[Urinary lithiasis treatment by laparoscopy. Combined techniques.] / Tratamiento de la litiasis con laparoscopia. Técnicas combinadas.

Over the last 30 years, the treatment of urinary lithiasis has changed dramatically. With the advent of extracorporeal lithotripsy and the advances on ureterorenoscopy and percutaneous nephrolithotomy, the need to turn to open and laparoscopic/robotic surgery has diminished. The objective of this article is to review the different indications for open and/or laparoscopic treatment of urinary lithiasis, to achieve its complete elimination with the less invasive possible means and trying to minimize the number of secondary procedures as well as complications.

Tratamiento de la litiasis con laparoscopia. Técnicas combinadas / Urinary lithiasis treatment by laparoscopy. Combined techniques

Durante los últimos 30 años, el tratamiento de la litiasis urinaria ha cambiado drásticamente. Con el advenimiento de la litotricia extracorpórea y los avances en la ureteroscopia, y la nefrolitotomía percutánea, la necesidad de recurrir a la cirugía abierta y laparoscópica/robótica ha disminuido. El objetivo de este artículo es la revisión de las diferentes indicaciones del tratamiento abierto y/o laparoscópico de la litiasis urinaria, para conseguir la eliminación completa de la misma con los medios menos invasivos posibles y tratando de minimizar el número de procedimientos secundarios así como las complicaciones

Over the last 30 years, the treatment of urinary lithiasis has changed dramatically. With the advent of extracorporeal lithotripsy and the advances on ureterorenoscopy and percutaneous nephrolithotomy, the need to turn to open and laparoscopic/robotic surgery has diminished. The objective of this article is to review the different indications for open and/or laparoscopic treatment of urinary lithiasis, to achieve its complete elimination with the less invasive possible means and trying to minimize the number of secondary procedures as well as complications

Bilateral obstructive uropathy secondary to giant periureteral diverticulum.

Bladder diverticula are herniations of the mucosa through the fibers of the bladder muscle connected by necks of variable amplitude. They are often asymptomatic, although they may lead to complications that require a surgical therapeutic approach. We report the case of a patient with bilateral obstructive uropathy secondary to a giant periureteral diverticulum that was treated by diverticulectomy and reimplantation of the left ureter in the bladder.

[Patient with late-start hypogonadism and sexual dysfunction]. / Paciente con hipogonadismo de origen tardío y disfunción sexual.

OBJECTIVES: Testosterone deficit syndrome (TDS)is a clinical and biochemical entity characterized by low testosterone levels and androgenic deprivation clinic, which can cause a decrease in the quality of life. However, today there are doubts about its diagnosis and therapeutic management. METHODS: Bibliographic review using the MedLine database and detailed presentation of one clinical case. RESULTS: Testosterone deficit syndrome is associated with metabolic syndrome (visceral obesity, arterial hypertension, diabetes mellitus and dyslipemia). Currently, the performance of TDS screening in all males over the age of 45 years is under discussion. We propose a diagnostic-therapeutic algorithm for the management of TDS and erectile dysfunction. CONCLUSIONS: The treatment of erectile dysfunction associated with late start hypogonadism follows the same steps tha other generic cases of erectile dysfunction.

Paciente con hipogonadismo de origen tardío y disfunción sexual / Patient with late-start hypogonadism and sexual dysfunction

OBJETIVO: El síndrome de deficiencia de testosterona (SDT) es una entidad clínica y bioquímica caracterizada por niveles bajos de testosterona y clínica de deprivación androgénica, que puede provocar una disminución de la calidad de vida, sin embargo hoy en día existen dudas sobre su diagnóstico y manejo terapéutico. MÉTODOS: Revisión bibliográfica mediante la base de datos de Pub Med y exposición detallada de un caso clínico. RESULTADOS: El síndrome de deficit de testosterona se asocia con el síndrome metabólico (obesidad visceral, hipertensión arterial, diabetes mellitus y dislipemia): en la actualidad se discute si hacer cribado del SDT en todos los varones mayores de 45 años. Proponemos un algoritmo diagnóstico-terapéutico para el manejo del SDT y la disfunción eréctil. CONCLUSIONES: El tratamiento de la disfunción eréctil asociada al hipogonadismo de origen tardío sigue los mismos pasos que en otros casos genéricos de disfunción eréctil (AU)

OBJECTIVES: Testosterone deficit syndrome (TDS) is a clinical and biochemical entity characterized by low testosterone levels and androgenic deprivation clinic, which can cause a decrease in the quality of life. However, today there are doubts about its diagnosis and therapeutic management. METHODS: Bibliographic review using the MedLine database and detailed presentation of one clinical case. RESULTS: Testosterone deficit syndrome is associated with metabolic syndrome (visceral obesity, arterial hypertension, diabetes mellitus and dyslipemia). Currently, the performance of TDS screening in all males over the age of 45 years is under discussion. We propose a diagnostic-therapeutic algorithm for the management of TDS and erectile dysfunction. CONCLUSIONS: The treatment of erectile dysfunction associated with late start hypogonadism follows the same steps the other generic cases of erectile dysfunction (AU)

Prognostic significance of circulating tumor cell count in patients with metastatic hormone-sensitive prostate cancer.

OBJECTIVE: To analyze the correlation between circulating tumor cell (CTC) levels and clinicopathologic parameters (prostate-specific antigen level, Gleason score, and TNM stage) in patients with metastatic hormone-sensitive prostate cancer (PCa) and to establish its prognostic value in overall survival (OS) and progression-free survival (PFS). MATERIALS AND METHODS: A prospective, 3-arm study was performed that included 30 patients with localized PCa; 30 patients with metastatic PCa, and 30 healthy volunteers. A single 7.5-mL peripheral blood sample was taken. The CTCs were isolated using an immunomagnetic method based on the CellSearch system. Kendall's tau and Spearman's rho coefficients of correlation were used. The multivariate Cox regression model addressed OS and PFS. RESULTS: The median follow-up was 42.9 months (interquartile range 27.14-49.5). A significant positive correlation was demonstrated between the CTC level and all tumor burden markers (prostate-specific antigen and T, N, and M stage; P <.001), except for Gleason score (tau = 0.16). A cutoff of ≥ 4 CTCs/7.5 mL was chosen to distinguish patients with a poor prognosis. These patients had a significantly shorter median OS and PFS (24 vs 45 months and 7 vs 44 months, respectively; P <.001). As the CTC level increased, the OS and PFS decreased. The risk of mortality and progression for the patients with ≥ 4 CTCs was 4.1 (P = .029) and 8.5 (P <.001) times greater. Multivariate analyses indicated that a CTC of ≥4 was an independent prognostic factor for PFS (hazard ratio 5.9, P <.005). CONCLUSION: The CTC count in peripheral blood could provide a method of staging PCa correctly and be of value when assessing the prognosis of metastatic hormone-sensitive PCa.

[Hereditary renal cancer]. / Cáncer de riñón hereditario.

Kidney cancer is the tenth most common cause of cancer death. There are a growing number of genes known to be associated with an increased risk of specific types of kidney cancer. People with Von Hippel-Lindau syndrome have about a 40% risk of developing multiple bilateral clear cell kidney cancers. They can also develop retinal and brain hemangioblastoma, kidneys or pancreas cysts, pheochromocytoma and endolymphatic sac tumor. Four phenotypes with different renal cancer and pheocromocitoma risk have been described depending on the germline mutation. Hereditary papillary renal cell carcinoma syndrome has type 1 papillary renal cell carcinomas associated with protooncogene c-MET germline mutations. Birt-Hogg-Dubé syndrome has FLCN gene mutations associated with fibrofolliculomas, lung cysts with a high risk for spontaneous pneumothorax, and a 15% to 30% risk of kidney cancer (most classified as chromophobe carcinoma, oncocytoma or oncocytic hybrid, but clear cell and papillary kidney cancers have also been reported). Histopathological findings such as oncocytosis and oncocytic hybrids are very unusual outside the syndrome. Hereditary leiomyomatosis and renal cell cancer syndrome shows mutations of Fumarate hydratase gene and cutaneous leiomyomata in 76% of affected individuals, uterine leiomyomata in 100% of females, and unilateral, solitary, and aggressive papillary renal cancer in 10 to 16% of patients. A specific histopathological change is eosinophilic prominent nucleoli with a perinucleolar halo. Tuberous sclerosis complex is one of the most prevalent (1/5.800) hereditary syndromes where renal disease is the second leading cause of death, associated with angiomyolipomas (70%), renal cysts, oncocytomas or clear cell cancer.

Cáncer de riñón hereditario / Hereditary renal cancer

El cáncer de riñón es la décima causa más común de muerte por cáncer. Esta revisión analiza las características de los síndromes hereditarios más frecuentes asociados a un subtipo histológico de tumor renal específico, su prevalencia y penetrancia, test genéticos disponibles y programas de cribado/detección precoz y tratamiento recomendados. En el síndrome de Von Hippel-Lindau un 40% de los pacientes desarrollan carcinoma renal de células claras bilateral y multifocal. También son frecuentes el hemangioblastoma del SNC o retina, feocromocitomas y tumores del saco endolinfático. Se han descrito cuatro fenotipos clásicos de VHL en función de la mutación y un diferente riesgo de feocromocitoma o carcinoma de células renales. Se puede realizar test genético de diagnóstico de confirmación, diagnóstico prenatal o preimplantación. El cáncer papilar renal hereditario tiene múltiples carcinomas papilares bilaterales de subtipo histológico 1. El gen asociado es el proto-oncogen c-met. El síndrome de Birt-Hogg-Dubé por mutaciones en el gen FLCN combina múltiples tumores renales bilaterales de tipo oncocitoma, carcinoma cromófobo, tumor híbrido oncocítico y una minoría carcinoma de células claras renales. Se asocia a fibrofoliculomas cutáneos, quistes de pulmón y neumotórax espontáneo. Histológicamente, hay lesiones iniciales de oncocitosis o híbridos oncocíticos excepcionales fuera del síndrome hereditario. La leiomiomatosis hereditaria y cáncer de células renales por mutaciones del gen fumarato hidratasa tiene en un 15%de los pacientes un agresivo carcinoma papilar tipo 2, en un 75% leiomiomas cutáneos múltiples y en 100% leiomiomas uterinos. En el estudio histopatológico se observan unos macronúcleolos eosinófilos característicos. La Esclerosis tuberosa es uno de los síndromes hereditarios más frecuentes asociado a angiomiolipoma (70% de afectados),quistes renales, oncocitoma o carcinoma renal de células claras (AU)

Kidney cancer is the tenth most common cause of cancer death. There are a growing number of genes known to be associated with an increased risk of specific types of kidney cancer. People with Von Hippel-Lindau syndrome have about a 40% risk of developing multiple bilateral clear cell kidney cancers. They can also develop retinal and brain hemangioblastoma, kidneys or pancreas cysts, pheochromocytoma and endolymphatic sac tumor. Four phenotypes with different renal cancer and pheocromocitoma risk have been described depending on the germline mutation. Hereditary papillary renal cell carcinoma syndrome has type 1 papillary renal cell carcinomas associated with protooncogenec-MET germline mutations. Birt-Hogg-Dubé syndrome has FLCN gene mutations associated with fibrofolliculomas, lung cysts with a high risk for spontaneous pneumothorax, and a 15% to 30% risk of kidney cancer (most classified as chromophobe carcinoma, oncocytoma or oncocytic hybrid, but clear cell and papillary kidney cancers have also been reported). Histopathological findings such as oncocytosis and oncocytic hybrids are very unusual outside the syndrome. Hereditary leiomyomatosis and renal cell cancer syndrome shows mutations of Fumarate hydratase gene and cutaneous leiomyomata in 76% of affected individuals, uterine leiomyomata in 100% of females, and unilateral, solitary, and aggressive papillary renal cancer in 10 to 16% of patients. A specific histopathological change is eosinophilic prominent nucleoli with a perinucleolar halo. Tuberous sclerosis complex is one of the most prevalent (1/5.800) hereditary syndromes where renal disease is the second leading cause of death, associated with angiomyolipomas (70%), renal cysts, oncocytomas or clear cell cancer (AU)

[Nephron sparing surgery for the treatment of renal carcinoma in a functioning graft: case report]. / Cirugia conservadora de cancer renal en injerto funcionante: a proposito de un caso.

OBJECTIVE: We present nephron sparing renal surgery as a therapeutic option for the conservative treatment of renal cancer by reporting one case of de novo renal cell carcinoma (RCC) presenting in a functioning renal graft. METHODS/RESULTS: We describe one case of de novo RCC presenting in a functioning renal graft 51 months after transplantation. Tumorectomy was carried out with a margin of normal parenchyma and the base was free of tumor. Definitive pathologic study showed type I papillary renal cell carcinoma, Fuhrman grade 2, pathological stage I with free margins. There were not post operative complications and immunosuppression therapy was not modified. After almost three years of follow-up there is no evidence of tumor recurrence and an adequate renal function. CONCLUSIONS: Renal graft RCC is rare. Conservative surgery in selected patients may be a safe and effective technique when the tumor appears in a functioning graft, because it offers good oncological control and preserves renal function, avoiding transplant nephrectomy and the need of haemodialysis.

[En bloc transplantation of pediatric donor kidneys to adult receptors]. / Trasplante en bloque de riñones procedentes de donantes pediatricos en receptores adultos.

OBJECTIVES: Analysis of all pediatric donor en bloc transplants to adult receptors performed in our department. METHODS: Retrospective analysis of 73 en bloc kidney transplants and 497 adult transplants performed in our centre from 1990 to 2004. Mean follow-up was 50.23 months (10.18-89.05 months). All patients received the same immunosuppression, although it evolved with time. RESULTS: There were significant differences in terms of nonfunctioning kidneys and delayed graft function, more frequent in pediatric en bloc and adult transplants, respectively. Pediatric kidneys provided better renal function and less proteinuria. Patient and graft survivals were similar in both groups. One and five-year graft survivals were 83.56% and 8 1.47% for pediatric donor kidneys, and 91.50% and 86.99% for adult donor kidneys. Vascular complications were the most frequent cause of graft loss for the en bloc transplants. CONCLUSIONS: Pediatric donor en bloc transplants have an excellent survival and function in the middle and long-term. Vascular complications are the main cause of pediatric donor graft loss. The adoption of a pediatric donor en bloc transplant program increases the transplant activity.

Cirugia conservadora de cancer renal en injerto funcionante: a proposito de un caso / Nephron sparing surgery for the treatment of renal carcinoma in a functioning graft: case report

Objetivo: A propósito de un caso de cáncer de células renales (CCR) de aparición de novo en un injerto renal funcionante se presenta la cirugía conservadora del cáncer renal como alternativa terapéutica. Métodos/Resultados: Se realiza la descripción de un caso de CCR de aparición de novo en un injerto renal funcionante después de un periodo de latencia de 51 meses. Se practicó tumorectomía con margen de parénquima sano y base libre de afectación tumoral. El diagnóstico histopatológico definitivo fue un carcinoma papilar renal tipo I, grado 2 de Fuhrman, estadio I con márgenes sin afectación tumoral. No existieron complicaciones postoperatorias, y no se modificó la inmunosupresión. En el seguimiento a casi tres años no hay evidencia de recidiva tumoral, manteniéndose una adecuada función renal. Conclusiones: El CCR del injerto renal es poco frecuente. La cirugía conservadora del CCR en pacientes adecuadamente seleccionados puede ser una técnica segura y efectiva cuando éste asienta en un injerto renal funcionante, proporcionando un correcto control oncológico y manteniendo una adecuada función renal, evitando la trasplantectomía y la necesidad de hemodiálisis (AU)

Objective: We present nephron sparing renal surgery as a therapeutic option for the conservative treatment of renal cancer by reporting one case of de novo renal cell carcinoma (RCC) presenting in a functioning renal graft. Methods/Results: We describe one case of de novo RCC presenting in a functioning renal graft 51 months after transplantation. Tumorectomy was carried out with a margin of normal parenchyma and the base was free of tumor. Definitive pathologic study showed type I papillary renal cell carcinoma, Fuhrman grade 2, pathological stage I with free margins. There were not post operative complications and immunosuppression therapy was not modified. After almost three years of follow-up there is no evidence of tumor recurrence and an adequate renal function. Conclusions: Renal graft RCC is rare. Conservative surgery in selected patients may be a safe and effective technique when the tumor appears in a functioning graft, because it offers good oncological control and preserves renal function, avoiding transplant nephrectomy and the need of haemodialysis (AU)

Trasplante en bloque de riñones procedentes de donantes pediátricos en receptores adultos / En bloc transplantation of pediatric donor kidneys to adult receptor

OBJETIVOS: Análisis evolutivo de los trasplantes renales realizados con órganos procedentes de donantes infantiles implantados en bloque a receptores adultos. METODOS: Análisis retrospectivo de 73 trasplantes renales en bloque y 497 trasplantes adultos realizados en nuestro centro entre 1990 y 2004. El seguimiento medio fue de 50,23 meses (10,18-89,05 meses). Todos los pacientes recibieron la misma terapia inmunosupresora, si bien ésta evolucionó con el tiempo. RESULTADOS: Se objetivaron diferencias en cuanto a la no función y la disfunción inicial del injerto que fueron mayores en los bloques pediátricos y los trasplantes adultos, respectivamente. Los bloques ocasionan mejor función renal y menor proteinuria. Las supervivencias del paciente y del injerto fueron similares en ambos grupos. Las supervivencias del injerto al año y 5 años fueron del 83,56 % y 81,47 % en los trasplantes de riñones infantiles en bloque; y del 91,50 % y 86,99 % en los trasplantes de riñones procedentes de donantes adultos. Las complicaciones vasculares son la causa más común de pérdida del injerto en bloque. CONCLUSIONES: Los bloques pediátricos presentan una excelente supervivencia y función a medio y largo plazo. Las complicaciones vasculares representan la principal causa de pérdida del injerto pediátrico. La adopción de un programa de trasplante infantil en bloque permite aumentar la actividad trasplantadora (AU)

OBJECTIVES: Analysis of all pediatric donor en bloc transplants to adult receptors performed in our department. METHODS: Retrospective analysis of 73 en bloc kidney transplants and 497 adult transplants performed in our centre from 1990 to 2004. Mean follow-up was 50.23 months (10.18-89.05 months). All patients received the same immunosuppression, although it evolved with time. RESULTS: There were significant differences in terms of nonfunctioning kidneys and delayed graft function, more frequent in pediatric en bloc and adult transplants, respectively. Pediatric kidneys provided better renal function and less proteinuria. Patient and graft survivals were similar in both groups. One and five-year graft survivals were 83.56% and 8 1.47% for pediatric donor kidneys, and 91.50% and 86.99% for adult donor kidneys. Vascular complications were the most frequent cause of graft loss for the en bloc transplants. CONCLUSIONS: Pediatric donor en bloc transplants have an excellent survival and function in the middle and long-term. Vascular complications are the main cause of pediatric donor graft loss. The adoption of a pediatric donor en bloc transplant program increases the transplant activity (AU)

[Renal transplantation in donors over 60 years of age]. / Trasplante renal en receptores mayores de 60 años.

OBJECTIVES: To evaluate the impact of receptor's advanced age on kidney transplant outcomes. METHODS: We reviewed all transplants performed between January 1990 and December 1999. Among 570 patients receiving grafts, 115 patients were 60 years or older at the time of transplantation. We compared this group with receptors younger than 60 years. We studied possible prognostic variables and compared patient and graft outcomes. RESULTS: Mean age 63.81 (typical deviation (TD): 2.96). Mean follow-up time for elderly receptors was 41.6 months (TD: 26.58). 55.7% patients were males (p: 0.4). The most frequent cause for end stage renal disease was unknown etiology in group 1 and glomerular in the younger group (p: 0.01). 42% patients older than 60 years presented initial graft dysfunction, in comparison to 28.1% among younger than 60 (p: 0.006). Three-year graft survival was 90.42% for receptors 60 years old or older compared to 88.72% for group 2, without significant differences (p: 0.5). The most frequent graft loss etiology was patient death. (67.7%). (p = 0.005). Patient survival was 81.01% in group 1 and 95.25% in group 2, being differences significant (p < 0.001). CONCLUSIONS: Renal grafts in receptors over the age of 60 years show a greater incidence of delayed graft function, although it doesn't seem to influence final graft survival. The most frequent cause for graft loss is receptor's death. Receptor's age does not represent a contraindication for transplant.

Trasplante renal en receptores mayores de 60 años / Kidney transplant in receptors over the age of 60

OBJETIVO: Evaluar el impacto de la edad avanzada del receptor en la evolución del trasplante renal. MÉTODO: Se examinaron los trasplantes realizados entre Enero de 1990 y Diciembre de 1999. Trasplantamos a 570 pacientes, de éstos 115 pacientes tenían 60 años o más cuando recibieron el trasplante. Comparamos este grupo con los receptores menores de 60 años. Estudiamos las posibles variables pronosticas y comparamos la evolución de los pacientes y de los injertos. RESULTADOS: Edad media 63,81 (DT: 2,96). El tiempo medio de seguimiento de los receptores mayores fue 41,6 meses (DT: 26,58). El 55,7 por ciento eran varones (p: 0,4).La causa más frecuente de insuficiencia renal en el primer grupo fue la no filiada, en los jóvenes, la glomerular (p: 0,01). El 42 por ciento de los mayores de 60 años presentaron disfunción inicial del injerto, frente al 28,1 por ciento de los menores (p: 0,006). El porcentaje de injertos funcionantes en los receptores de 60 años o mayores a los 36 meses era del 90,42 por ciento, frente al 88,72 por ciento en los menores de dicha edad, sin ser significativa la diferencia (p: 0,5). La causa más frecuente de pérdida del injerto fue la muerte del paciente. (67,7 por ciento).(p: 0,005). La supervivencia de los pacientes del primer grupo fue del 81,01 por ciento y del 95,25 por ciento en los menores de 60 años, con una diferencia significativa (p<0,001). CONCLUSIONES: El injerto renal en los receptores mayores de 60 años presenta una mayor disfunción inicial, esto no parece influir en la supervivencia final del mismo. La causa más frecuente de su pérdida es la muerte del receptor. La edad del receptor no representa una contraindicación para el trasplante (AU)