Influencia de la curva de aprendizaje en el diagnóstico del cáncer de próstata mediante biopsia ecodirigida / Influence of learning curve in the diagnosis of prostate cancer by ultrasound guided biopsy

OBJETIVO: Analizar si existe una curva de aprendizaje hasta lograr realizar biopsias prostáticas ecodirigidas de alta calidad que permitan efectuar el diagnóstico de cáncer de próstata con eficacia, teniendo en cuenta el resultado anatomopatológico de las muestras. MÉTODOS: Se revisaron retrospectivamente los datos de las 790 biopsias de próstata ecodirigidas realizadas en nuestro servicio entre mayo de 2009 y diciembre 2012 por cuatro cirujanos de modo consecutivo. Se revisaron los siguientes datos: cirujano que la realizaba, fecha de realización, edad del paciente, PSA, tacto rectal, ecografía, volumen prostático, número de cilindros recogidos y resultado anatomopatológico de la biopsia. Los cirujanos eran médicos internos residentes de urología en su primer año en nuestro servicio. Para el análisis estadístico se agruparon las biopsias en bloques de 25 y 75 casos realizados por cirujano, ordenados cronológicamente. Para valorar la influencia de la curva de aprendizaje en el diagnóstico se realizó un análisis univariante y multivariante entre las distintas variables y el resultado anatomopatológico. RESULTADOS: La mediana de edad fue 67 años (42-90). Fueron positivas para cáncer de próstata 300 biopsias (38%). En el análisis univariante respecto a la tasa de detección de cáncer, las variables cirujano, PSA, tacto rectal, resultado ecográfico, volumen prostático, número de cilindros y grupos de 75 mostraron diferencias estadísticamente significativas, esta última mostró un porcentaje de 32% en las primeras 75 biopsias realizadas por los cirujanos y 43,2% en el último grupo. No las mostraron las variables edad (p = 0,11) y grupos de 25 pacientes (p = 0,07). En el análisis multivariante, sin embargo, únicamente fueron estadísticamente significativas las variables PSA, tacto rectal, volumen prostático y grupos de 75 pacientes, esta última con una OR de 1,35 (IC95% 1,09 - 1,66). CONCLUSIONES: Los resultados obtenidos en nuestro estudio muestran que sí influye el número de procedimientos realizados, es decir la experiencia del cirujano, para alcanzar una rentabilidad diagnóstica óptima en las biopsias de próstata ecodirigidas

OBJECTIVE: To analyze if there is a learning curve to get to perform high quality ultrasound guided prostate biopsies that enable to effectively perform the diagnosis of prostate cancer, taking the pathological result of the samples into consideration. METHODS: We retrospectively reviewed data from 790 ultrasound-guided biopsies performed consecutively in our center between May 2009 and December 2012 by four surgeons. We reviewed the following data: Surgeon, date of intervention, patient age, PSA, rectal digital examination (DRE), ultrasound, prostate volume, number of cores obtained, pathology result of the biopsy. The surgeons were residents in Urology in their first year in the department. For statistical analysis the biopsies were grouped in blocks of 25 and 75 cases performed by a surgeon, in a chronological order. To evaluate the influence of the learning curve on diagnosis we performed univariate and multivariate analysis between the different variables and pathological report. RESULTS: Median age was 67 years (42-90). 300 biopsies (38%) were positive for prostate cancer. On univariate analysis, regarding cancer detection rate, the variables surgeon, PSA, DRE, ultrasound result, prostate volume, number of cores and groups of 75 showed statistically significant differences, this latter showing 32% in the first 75 biopsies and 43.2% in the last group. The variables age (p = 0.11) and groups of 25 patients (p = 0.07) did not show differences. Nevertheless, on multivariate analysis only PSA, DRE, prostate volume and groups of 75 patients were statistically significant, this latter with an OR of 1.35 (95%CI 1.09-1.66). CONCLUSIONS: The results obtained in our study show that the number of procedures performed, namely surgeon experience, does have an influence to achieve an optimal diagnostic yield in ultrasound guided prostatic biopsies

[Influence of learning curve in the diagnosis of prostate cancer by ultrasound guided biopsy]. / INFLUENCIA DE LA CURVA DE APRENDIZAJE EN EL DIAGNÓSTICO DEL CÁNCER DE PRÓSTATA MEDIANTE BIOPSIA ECODIRIGIDA.

OBJECTIVE: To analyze if there is a learning curve to get to perform high quality ultrasound guided prostate biopsies that enable to effectively perform the diagnosis of prostate cancer, taking the pathological result of the samples into consideration. METHODS: We retrospectively reviewed data from 790 ultrasound-guided biopsies performed consecutively in our center between May 2009 and December 2012 by four surgeons. We reviewed the following data: Surgeon, date of intervention, patient age, PSA, rectal digital examination (DRE), ultrasound, prostate volume, number of cores obtained, pathology result of the biopsy. The surgeons were residents in Urology in their first year in the department. For statistical analysis the biopsies were grouped in blocks of 25 and 75 cases performed by a surgeon, in a chronological order. To evaluate the influence of the learning curve on diagnosis we performed univariate and multivariate analysis between the different variables and pathological report. RESULTS: Median age was 67 years (42-90). 300 biopsies (38%) were positive for prostate cancer. On univariate analysis, regarding cancer detection rate, the variables surgeon, PSA, DRE, ultrasound result, prostate volume, number of cores and groups of 75 showed statistically significant differences, this latter showing 32% in the first 75 biopsies and 43.2% in the last group. The variables age (p=0.11) and groups of 25 patients (p=0.07) did not show differences. Nevertheless, on multivariate analysis only PSA, DRE, prostate volume and groups of 75 patients were statistically significant, this latter with an OR of 1.35 (95%CI 1.09-1.66). CONCLUSIONS: The results obtained in our study show that the number of procedures performed, namely surgeon experience, does have an influence to achieve an optimal diagnostic yield in ultrasound guided prostatic biopsies.

Intrarenal pseudoaneurysm after percutaneous nephrolithotomy. Renal angiography and selective embolization.

OBJECTIVE: We present a case of intrarrenal pseudoaneuysm after percutaneous nephrolithotomy. The treatment was selective embolization of the pseudoaneurysm. We discuss the role of computerized angiotomography and angiography in these cases. We present a review of the related literature. METHODS: A computerized angiotomography (angio CT) was performed because of suspicion of a delayed vascular lesion after percutaneous nephrolithectomy. Faced with the findings of the angio CT an selective renal artery arteriography and selective embolization was performed. RESULTS: The angiotomography shows an enhanced nodular contrast in the lower third of the left kidney with a scarred area at this level suggestive of hemorrhage due to vascular lesion.Through puncture of the right common femoral artery, arteriography was performed on the left renal artery with, objectifying an amputated artery related to the bleeding situation in the calyx. After localization of the point of hemorrhage, the vessel was embolized with a 3 mm metallic microspiral GCD, 6 cm in length After embolization, the evolution of the patient was satisfactory. CONCLUSIONS: Intrarenal pseudoaneurysm is the most frequent cause of late bleeding after percutaneous nephrolithotomy. The most common symptom is hematuria that can be severe and require active treatment in order to inhibit the hemorrhage. In these cases, computerized angiotomography and angiography take on a very important diagnostic role, the latter offering the possibility to treat the hemorrhage through selective embolization of the pseudoaneurysm.

Pseudoaneurisma intrarrenal tras nefrolitotomía percutánea. Angiografía renal y embolización selectiva / Intrarenal pseudoaneurysm after percutaneous nephrolitotomy. Renal angiography and selective embolization

OBJETIVO: Presentamos un caso de pseudoaneurisma intrarrenal tras nefrolitotomia percutánea. El tratamiento en este caso fue la embolizacion selectiva. A partir de este caso discutimos la utilidad en el dignóstico de la angiotomografia computerizada y la angiografia renal. Realizamos una revisión de la literatura al respecto. MÉTODOS: Se realizó una angitomografía computerizada (angioTC) por sospecha de lesión vascular diferida tras la nefrolitectomía percutánea. Ante los hallazgos deangioTC, se realizó una arteriografía de la arteria renal izquierda y embolización selectiva de la lesión. RESULTADOS: La angiotomografía evidencia un realce nodular de contraste en el tercio inferior del riñón izquierdo con área hipocaptante a este nivel sugestiva de hemorragia por lesión vascular. Mediante punción de la arteria femoral común derecha, se realiza arteriografía de la arteria renal izquierda objetivando una arteria amputada que corresponde a la situación del sangrado al cáliz. Tras localización del punto de hemorragia se procedió a embolizar el vaso con una microespiral metálica GDC de 3mm y 6cm de longitud Tras la embolización, la evolución del enfermo fue satisfactoria. CONCLUSIONES: El pseudoaneurisma intrarrenal constituye la causa más frecuente de sangrado tardío tras nefrolitotomía percutánea. El síntoma más habitual es la hematuria que puede ser severa y precisar de tratamiento activo para cohibir la hemorragia. En estos casos, cobran un papel muy importante en el diagnostico, la angiotomografía computerizada y la angiografía, ofreciendo esta última la posibilidad de tratar la causa de la hemorragia mediante la embolización selectiva del pseudoaneurisma(AU)

OBJECTIVE: We present a case of intrarrenal pseudoaneuysm after percutaneous nephrolithotomy. The treatment was selective embolization of the pseudoaneurysm. We discuss the role of computerized angiotomography and angiography in these cases. We present a review of the related literature. METHODS: A computerized angiotomography (angio CT) was performed because of suspicion of a delayed vascular lesion after percutaneous nephrolithectomy. Faced with the findings of the angio CT an selective renal artery arteriography and selective embolization was performed. RESULTS: The angiotomography shows an enhanced nodular contrast in the lower third of the left kidney with a scarred area at this level suggestive of hemorrhage due to vascular lesion. Through puncture of the right common femoral artery, arteriography was performed on the left renal artery with, objectifying an amputated artery related to the bleeding situation in the calyx. After localization of the point of hemorrhage, the vessel was embolized with a 3 mm metallic microspiral GCD, 6 cm in length After embolization, the evolution of the patient was satisfactory. CONCLUSIONS: Intrarenal pseudoaneurysm is the most frequent cause of late bleeding after percutaneous nephrolithotomy. The most common symptom is hematuria that can be severe and require active treatment in order to inhibit the hemorrhage. In these cases, computerized angiotomography and angiography take on a very important diagnostic role, the latter offering the possibility to treat the hemorrhage through selective embolization of the pseudoaneurysm(AU)

Divertículo vesical de hutch: una entidad de infrecuente presentación en el adulto / Hutch bladder diverticula: a very uncommon entity in adults

OBJETIVO: Presentamos el caso de un paciente adulto al que se le diagnosticó tras estudio realizado de divertículo de Hutch. Señalar que se trata de un tipo de divertículo vesical congénito muy infrecuente en la infancia y excepcional en el adulto, siendo muy escasos los casos en adulto comunicados en la literatura. MÉTODOS: El paciente fue estudiado mediante Urografía Intravenosa y Cistouretrografia Miccional Seriada. Una vez evaluadas las pruebas complementarias y establecido un juicio diagnóstico, se revisa la literatura y las alternativas terapeuticas. RESULTADOS: La Urografía intravenosa demostró en la fase excretora una ureterohidronefrosis sin defectos de repleción sugestivos de litiasis a nivel ureteral distal. Por otro lado se observaba un afilamiento del uréter a su entrada en vejiga debido a la presencia de un divertículo vesical yuxta-meatal. Posteriormente se realizó una cistografía retrógrada que descartó reflujo vesicoureteral y mostró que el divertículo presentaba residuo elevado tras la micción. Dadas las características de nuestro paciente y la ausencia de reflujo vesicoureteral ipsilateral asociado; se decidió un tratamiento endoscópio con apertura de la boca del divertículo. La evolución fue satisfactoria. CONCLUSIONES: El divertículo paraureteral de Hutch es una entidad infrecuente, incluso en la infancia. Para el diagnóstico en estos pacientes resulta especialmente útil la cistouretrografía miccional seriada (CUMS). Los síntomas, complicaciones asociadas así como la presencia de reflujo determinaran el tipo de tratamiento a realizar(AU)

OBJECTIVE: We present the case of an adult patient diagnosed with Hutch diverticula after examination. Indications were of a type of congenital bladder diverticula very rare in children and unusual in adults, as very few cases in adults are addressed in the literature. METHODS: Intravenous Urography and Voiding Cystourethrogram (VCUG) were realized. RESULTS: The intravenous urography revealed ureterohydronephrosis in the excretory phase that did not have repletion defects suggesting lithiasis at distal urethra. On the other hand, a narrowing of the urethra was observed at the point of bladder entry due to the presence of a juxtameatal bladder diverticulum. Next a retrograde cystography was performed which ruled out vesicourethral reflux and revealed that the diverticulum presented elevated residuals after urination. As a result of our patient’s clinical characteristics and the absence of vesico-urethral reflux, we decided to perform an endoscopic surgical opening of the diverticula’s neck. CONCLUSIONS Hutch paraurethral diverticula is an very uncommon entity, even in infancy. The Voiding Cystourethrogram (VCUG) is especially useful in diagnosing these patients. In symptomatic cases surgical correction of the diverticula is required(AU)

Hutch bladder diverticula: a very uncommon entity in adults.

OBJECTIVE: We present the case of an adult patient diagnosed with Hutch diverticula after examination. Indications were of a type of congenital bladder diverticula very rare in children and unusual in adults, as very few cases in adults are addressed in the literature. METHODS: Intravenous Urography and Voiding Cystourethrogram (VCUG) were realized RESULTS: The intravenous urography revealed ureterohydronephrosis in the excretory phase that did not have repletion defects suggesting lithiasis at distal urethra. On the other hand, a narrowing of the urethra was observed at the point of bladder entry due to the presence of a juxtameatal bladder diverticulum. Next a retrograde cystography was performed which ruled out vesicourethral reflux and revealed that the diverticulum presented elevated residuals after urination. As a result of our patient's clinical characteristics and the absence of vesico-urethral reflux, we decided to perform an endoscopic surgical opening of the diverticula's neck. CONCLUSIONS Hutch paraurethral diverticula is an very uncommon entity, even in infancy. The Voiding Cystourethrogram (VCUG) is especially useful in diagnosing these patients. In symptomatic cases surgical correction of the diverticula is required.