Robotic surgery in the management of complex pelvic endometriosis.

INTRODUCTION: Endometriosis consists in the proliferation of endometrial tissue outside of the uterine cavity, predominantly in the ovaries but also in the urinary bladder or bowel. About 10% of fertile women are affected and the main symptoms are pain, menstrual disorders and infertility. Surgery is the treatment option for those symptomatic patients in which medical treatment had no success. MATERIAL AND METHODS: We report on a case of a 43 - years - old patient without urologic personal history submitted to our office because of a grade - III right - hydronephrosis. The patient, with an endometriosis diagnosis since years, presents chronic pelvic pain with the daily necessity of strong opioids intake. CT scan revealed several endometriosis implants in the uterine wall and rectum that caused right ureteral entrapment. Renography revealed a 24% function in the right kidney. After right nephrostomy a multidisciplinary committee decided surgical intervention. With robotic approach, we performed an hysterectomy with right salpingo - oophorectomy; release, resection and right ureteral reimplantation; anterior resection of the rectum and protective ileostomy. Vaginal extraction of the specimen. In this video we show the key steps of the procedure. RESULTS: Total operative time: 330 minutes. Total bleeding: 250 cc. Nephrostomy removal: 4 th day. Urethral catheter removal: 5 th day. Patient was discharged in the 7 th day. Ureteral JJ - stent removal: 30 th day. CT urography reveals a permeable ureteral tract with no urine leakage. Renography shows a progressive improvement of the kidney function. CONCLUSIONS: Robotic surgery allows a correct handling of endometriosis, mainly in complex cases. It is a safe and reproducible technique with correct outcomes in selected patients. A multidisciplinary team is required.

[Experience with third, fourth and fifth kidney transplants and their complications.] / Experiencia en terceros, cuartos y quintos trasplantes renales y sus complicaciones.

OBJECTIVES: Kidney transplant may be a good choice to treat chronic renal failure even in patients with two or more previous renal grafts. However, there might be several surgical complications and other difficulties we have to deal with. The aim of this report is to analyze the third, fourth and fifth transplants performed in our center focusing on the surgical complications and graft and patient survivals. METHODS: We performed a retrospective analysis of the 73 third, fourth and fifth kidney transplants performed in our center between February 1975 and December 2015. Statistical analysis has been performed with IBM SPSS 23.0 software. RESULTS: 62 patients received a third graft, 10 received a fourth one and one patient received a fifth graft. The median age of the recipients was 48 years, while for donors it was 50. Median cold ischemia time was 21 hours. Transplantectomy was not necessary in 49.31% of the cases. In 59.7% of the cases the graft vessels were anastomosed to the external iliac vessels. There were 21 cases of relevant postoperative complications (27.4% of the total grafts). Vascular thrombosis appeared in 5.5%. After 49 months of follow-up, the 1-, 3-, and 5-year graft survival were 64.3%, 56.16% and 50.69%, respectively. CONCLUSIONS: A new renal transplant in patients with two or more previous grafts is feasible, being necessary to individualize the cases. In spite of being more complex operations than previous transplants with a higher complication rate, we can obtain both acceptable graft and patient survival outcomes with an appropriate approach.

Utilización de cadáveres para la enseñanza de la intubación orotraqueal / Use of corpses for teaching orotracheal intubation

A propósito de una consulta realizada por un profesional, relacionada con la práctica de intubación orotraqueal de cadáveres con fines formativos, el Comité de Ética Asistencial (CAE) del Hospital Universitario Marqués de Valdecilla ha considerado de especial relevancia la contextualización del proceso, tanto a nivel temporal como de infraestructura (tipo de centro sanitario); y sus principales reflexiones y conclusiones, se pretenden dar a conocer. Primero, que existe un vacío legal a este respecto, que provoca interpretaciones legales sin base fundada. Segundo, se recomienda que atendiendo al principio de autonomía de las personas, así como a la dignidad de las mismas, se debiera obtener un consentimiento informado para la realización de dichas prácticas; y, en el caso de no poder obtenerse, se recomienda que el alumno se abstenga de realizar el procedimiento (AU)

With regard to a query raised by a professional, related to the practice of the orotracheal intubation of bodies for training purposes, the Healthcare Ethics Committee (HEC) of the Hospital Universitario Marqués de Valdecilla has considered the contextualisation of the process to be particularly relevant, both in terms of time and infrastructure (type of health centre); and it is intended to publicise its main reflections and conclusions. First, there is a legal loophole in this respect, leading to legal interpretations which are not well-founded. Second, it is recommended that by following the principle of individual autonomy and the dignity of individuals, it should be possible to obtain informed consent to carry out such practices. In the event that the informed consent cannot be obtained, it is recommended that students refrain from performing the procedure (AU)

Experiencia en terceros, cuartos y quintos trasplantes renales y sus complicaciones / Experience with third, fourth and fifth kidney transplants and their complications

Objetivos: El trasplante renal puede ser una buena opción terapéutica en la insuficiencia renal terminal, incluso en los pacientes con dos o más injertos previos. Sin embargo, pueden existir una serie de dificultades y complicaciones quirúrgicas a las cuales el equipo de trasplante debe enfrentarse. El objetivo de este artículo es revisar los terceros, cuartos y quintos trasplantes realizados en el Hospital Universitario Marqués de Valdecilla (HUMV) analizando las dificultades quirúrgicas, sus complicaciones y la supervivencia de injertos y pacientes. Método: Revisión retrospectiva desde Febrero de 1975 hasta Diciembre de 2015 que incluye 73 trasplantes (3º,4º y 5º) realizados en el HUMV. El estudio estadístico ha sido realizado con el programa informático IBM SPSS versión 23.0. Resultados: 62 pacientes han recibido un tercer trasplante, 10 de ellos posteriormente han recibido un cuarto y 1 única paciente ha recibido un quinto. La mediana de edad de los receptores fue 48 años y la de los donantes 50. La mediana de isquemia fría fue de 21 horas. No fue necesaria la trasplantectomía de los injertos previos en un 49,31 % de los casos. En un 59,7% de los casos se pudieron anastomosar los vasos del injerto a los vasos iliacos externos del receptor. Se registraron un 27,4% de complicaciones postquirúrgicas relevantes, con un 5,5% de trombosis en los vasos de los injertos. Tras una mediana de seguimiento global de 49 meses la supervivencia del injerto a 1, 3 y 5 años fue del 64,3%, 56,16% y 50,69% respectivamente. Conclusión: A pesar de ser necesario individualizar los casos, un nuevo trasplante en pacientes con dos o más injertos renales previos, sigue siendo una opción terapéutica a considerar. Aunque pueden ser cirugías complejas y de alto riesgo de complicaciones, con un manejo óptimo y cirujanos expertos se pueden obtener cifras de supervivencia de injerto aceptables (AU)

Objectives: Kidney transplant may be a good choice to treat chronic renal failure even in patients with two or more previous renal grafts. However, there might be several surgical complications and other difficulties we have to deal with. The aim of this report is to analyze the third, fourth and fifth transplants performed in our center focusing on the surgical complications and graft and patient survivals. Methods: We performed a retrospective analysis of the 73 third, fourth and fifth kidney transplants performed in our center between February 1975 and December 2015. Statistical analysis has been performed with IBM SPSS 23.0 software. Results: 62 patients received a third graft, 10 received a fourth one and one patient received a fifth graft. The median age of the recipients was 48 years, while for donors it was 50. Median cold ischemia time was 21 hours. Transplantectomy was not necessary in 49.31% of the cases. In 59.7% of the cases the graft vessels were anastomosed to the external iliac vessels. There were 21 cases of relevant postoperative complications (27.4% of the total grafts). Vascular thrombosis appea-red in 5.5%. After 49 months of follow-up, the 1-, 3-, and 5-year graft survival were 64.3%, 56.16% and 50.69%, respectively. Conclusions: A new renal transplant in patients with two or more previous grafts is feasible, being necessary to individualize the cases. In spite of being more complex operations than previous transplants with a higher complication rate, we can obtain both acceptable graft and patient survival outcomes with an appropriate approach (AU)

Paratesticular cellular angiofibroma with atypical (bizarre) cells: case report and literature review.

We report the extremely unusual occurrence of a cellular angiofibroma (CAF) with atypical (bizarre) cells in the spermatic cord. We present a 63-year-old man, who was referred to the Urology Service with a six-month history of a slowly growing painless nodule in the right inguino-scrotal area. The clinical impression was that of a lipoma. The mass was locally excised. Gross examination showed a well-circumscribed neoplasm attached to the spermatic cord and measuring 5cm in the greatest dimension. Microscopic examination of the tumor showed the appearance of CAF with scattered severely atypical (bizarre) cells distributed throughout the lesion. By immunohistochemistry, atypical cells showed diffuse expression of p16, CDK-4, CD34 and vimentin. Keratin AE1/AE3, S-100 protein, p53, and epithelial membrane antigen were negative. The patient is free of disease two months after tumor excision. To the best of our knowledge, this is the third case of CAF with atypical (bizarre) cells occurring in the paratesticular area. Pathologists should be aware of this morphological variation of CAF to avoid misdiagnosis and over-treatment.