Extracorporeal shockwave lithotripsy in the management of urinary stones: New concepts and techniques to improve outcomes.

Objective: Extracorporeal shockwave lithotripsy (SWL) currently plays an important role in the treatment of urinary tract lithiasis. The purpose of this article was to describe new concepts and procedural strategies that would improve results using SWL as a treatment for urolithiasis, thereby achieving better clinical practice. Methods: A systematic review process was carried in PubMed/PMC from January 2003 to March 2023. A narrative synthesis of the most important aspects has been made. Results: The important recommendations for the adequate selection of the candidate patient for treatment with SWL are summarized, as well as the new strategies for a better application of the technique. Aspects about intraoperative position, stone localization and monitoring, analgesic control, machine and energy settings, and measures aiming at reduced risk of complications are described. Conclusion: To achieve the therapeutic goal of efficient stone disintegration without increasing the risk of complications, it is necessary to make an adequate selection of patients and to pay special attention to several important factors in the application of treatment. Technological development in later generation devices will help to improve current SWL results.

Modelo de gestión de la condición crónica litiásica (Kaiser Permanente) / Healthcare management protocols for chronic stone disease (Kaiser Permanente)

INTRODUCCIÓN: La enfermedad litiásica (EL) presenta una evolución crónica en un alto porcentaje de pacientes. Teniendo en cuenta el alto coste sanitario asociado al tratamiento de esta patología, deberían adaptarse y utilizarse enfoques y estrategias de cronicidad de forma similar a otras enfermedades crónicas. Uno de los modelos aplicados para la gestión de estas enfermedades con importante repercusión en el consumo de recursos sanitarios es el modelo de Kaiser Permanente. MATERIAL Y MÉTODOS: Para el desarrollo de este proyecto de gestión de la enfermedad litiásica se realizó una implementación en tres fases diferentes: Fase 1: identificación de la población objetivo del programa y diseño del modelo de asignación de riesgo. Se consideraron como factores de riesgo, la clasificación del paciente en el modelo CRG (clasificación de grupos de riesgo o carga de morbilidad) como predictor de mayor consumo de recursos, factores de riesgo anatómicos, factores de riesgo litógenos y factores hereditarios asociados a la litiasis. Fase 2: clasificación de los pacientes según riesgo y aplicación de medidas específicas. Las medidas de intervención dependerán del nivel de riesgo asignado: bajo, intermedio o alto riesgo. Fase 3: análisis de indicadores y resultados. RESULTADOS: La aplicación del modelo permitió diseñar el algoritmo y dibujar la pirámide de Kaiser: El 59% de los pacientes se asignaron al grupo de bajo riesgo y el 41% correspondían a pacientes de riesgo alto (36,5%) o muy alto (4,5%). Los resultados preliminares obtenidos a dos años de seguimiento muestran una reducción de la recidiva litiásica global en un 42,2% cuando se comparó con un grupo control (seguimiento clásico). La adherencia global del grupo intervención fue de un 96,4% y la satisfacción de los pacientes incluidos en el programa fue de 9,93/10, superiores estadísticamente al grupo control. CONCLUSIÓN: El modelo de gestión poblacional basado en la pirámide de Kaiser Permanente es factible como modelo de gestión de la condición crónica litiásica. La implantación de este modelo ha demostrado de forma preliminar su eficiencia en pacientes crónicos

INTRODUCTION: Stone disease is a chronic condition in a high percentage of patients. Due to the high healthcare costs associated with the treatment of this pathology, chronicity approaches and strategies should be adapted and used in a similar way to other chronic diseases. One of the models applied for the management of these diseases with a significant impact on the consumption of health resources is the Kaiser Permanente model. MATERIAL AND METHODS: A chronic stone disease management project was developed and carried out in three different phases: Phase 1: identification of the target population of the program and design of the risk allocation model. The risk factors considered were CRG model (classification of risk groups or burden of morbidity) as a predictor of greater consumption of resources, anatomical risk factors, lithogenic risk factors, and hereditary factors associated with lithiasis. Phase 2: classification of patients according to risk and application of specific measures. The intervention measures will depend on the level of risk assigned: low, intermediate or high risk. Phase 3: analysis of indicators and results. RESULTS: An algorithm of risk allocation was designed, and a Kaiser pyramid drawn. A total of 59% of the patients were assigned to the low-risk group and 41% corresponded to high-risk (36.5%) or very high-risk patients (4.5%). Preliminary results obtained at two years of follow-up show a reduction in global stone recurrence by 42.2% when compared with a control group (classic follow-up). The overall adherence of the intervention group was 96.4% and the satisfaction of the patients included in the program was 9.93/10. CONCLUSIONS: A management model for chronic stone disease based on the Kaiser Permanente pyramid is feasible. The implantation of this model has preliminarily demonstrated its efficiency in chronic patients

[Healthcare management protocols for chronic stone disease (Kaiser Permanente).] / Modelo de gestión de la condición crónica litiásica (Kaiser Permanente).

INTRODUCTION: Stone disease is a chronic condition in a high percentage of patients. Duento the high healthcare costs associated with the treatment of this pathology, chronicity approaches and strategies should be adapted and used in a similar way to other chronic diseases. One of the models applied for the management of these diseases with a significant impact on the consumption of health resources is the Kaiser Permanente model. MATERIAL AND METHODS: A chronic stone disease management project was developed and carried out in three different phases: Phase 1: identification of the target population of the program and design of the risk allocation model. The risk factors considered were CRG model (classification of risk groups or burden of morbidity) as a predictor of greater consumption of resources, anatomical risk factors, lithogenic risk factors, and hereditary factors associated with lithiasis. Phase 2: classification of patients according to risk and application of specific measures. The intervention measures will depend on the level of risk assigned: low, intermediate or high risk. Phase 3: analysis of indicators and results. RESULTS: An algorithm of risk allocation was designed, and a Kaiser pyramid drawn. A total of 59% of the patients were assigned to the low-risk group and 41% corresponded to high-risk (36.5%) or very high-risk patients (4.5%). Preliminary results obtained at two years of follow-up show a reduction in global stone recurrence by 42.2% when compared with a control group (classic follow-up). The overall adherence of the intervention group was 96.4% and the satisfaction of the patients included in the program was 9.93/10. CONCLUSIONS: A management model for chronic stone disease based on the Kaiser Permanente pyramidis feasible. The implantation of this model has preliminarily demonstrated its efficiency in chronic patients.

INTRODUCCIÓN: La enfermedad litiásica (EL) presenta una evolución crónica en un alto porcentaje de pacientes. Teniendo en cuenta el alto coste sanitario asociado al tratamiento de esta patología,deberían adaptarse y utilizarse enfoques y estrategias de cronicidad de forma similar a otras enfermedades crónicas. Uno de los modelos aplicados para la gestión de estas enfermedades con importante repercusión en el consumo de recursos sanitarios es el modelo de Kaiser Permanente.MATERIAL Y MÉTODOS: Para el desarrollo de este proyecto de gestión de la enfermedad litiásica se realizó una implementación en tres fases diferentes: Fase 1: identificación de la población objetivo del programa y diseño del modelo de asignación de riesgo. Se consideraron como factores de riesgo, la clasificación del paciente en el modelo CRG (clasificación de grupos de riesgo o carga de morbilidad) como predictor de mayor consumo de recursos, factores de riesgo anatómicos, factores de riesgo litógenos y factores hereditarios asociados a la litiasis. Fase 2: clasificación de los pacientes según riesgo y aplicación de medidas específicas. Las medidas de intervención dependerán del nivel de riesgo asignado: bajo, intermedio o alto riesgo. Fase 3: análisis de indicadores y resultados.RESULTADOS: La aplicación del modelo permitió diseñar el algoritmo y dibujar la pirámide de Kaiser: El 59% de los pacientes se asignaron al grupo de bajo riesgo y el 41% correspondían a pacientes de riesgo alto (36,5%) o muy alto (4,5%). Los resultados preliminares obtenidos a dos años de seguimiento muestran una reducción de la recidiva litiásica global en un 42,2% cuando se comparó con un grupo control (seguimiento clásico). La adherencia global del grupo intervención fue de un 96,4% y la satisfacción de los pacientes incluidos en el programa fue de 9,93/10, superiores estadísticamente al grupo control.CONCLUSIÓN: El modelo de gestión poblacional basado en la pirámide de Kaiser Permanente es factible como modelo de gestión de la condición crónica litiásica. La implantación de este modelo ha demostrado de forma preliminar su eficiencia en pacientes crónicos.

Analysis of the Efficacy and Safety of Increasing the Energy Dose Applied Per Session by Increasing the Number of Shock Waves in Extracorporeal Lithotripsy: A Prospective and Comparative Study.

PURPOSE: To evaluate the efficacy and safety of increasing the energy dose in treating urinary lithiasis with extracorporeal lithotripsy through an expanded number of Shock Waves Per Session (SWPS). MATERIALS AND METHODS: a randomized, prospective, and comparative study was performed with patients with renal or ureteral lithiasis from 2011 to 2014. Two groups were studied: Group A (n = 136), treated with 3500 SWPS, and Group B (n = 171), subjected to an expanded treatment with 7000 SWPS. Patients were considered stone free when there was no lithiasis or it were less or equal to 4 mm after treatment. Variables related to the patient, stones, treatment, and complications were collected. RESULTS: The global SFR was 75.0% and 87.7% in Groups A and B, respectively (p = 0.004). In renal location, the SFR was higher in Group B (74.1% vs 90.7%, p = 0.003) regardless of the size. In the ureteral location, there were differences in the pelvic only (73.7% vs 95.2%). There were no differences in either the complication rate (27.2% vs 25.7%, p = 0.77), or the severity between the two groups. The variable "number of SWPS" was seen to be an independent predictor of the resolution of lithiasis, having the probability of resolving lithiasis 2.62 (CI 95% = 1.40-4.89) times greater when applying 7000 SWPS. CONCLUSION: In our study, increasing the energy dose applied through an expanded number of SWPS has been shown to be more effective than standard regimens with a similar safety profile. However, more clinical studies on different types of lithotripters are required to confirm these results.

[New strategies and protocols in SWL.] / Nuevas estrategias y protocolos en LEOC.

OBJECTIVE: An update of the new treatment strategies in extracorporeal lithotripsy as a valid therapeutic alternative in the management of urinary calculi. METHODS: We performed a search and review of the most recent literature which responded to the terms "best practices", "update", "optimization", "practice pattern" in lithotripsy. Only articles written in English or Spanish were selected. RESULTS: The use of a stepwise voltage ramping during extracorporeal lithotripsy with or without pause before the first rise of energy, a decreased delivery rates and the use of a higher number of shock waves per session are shown as alternatives to improve the effectiveness with optimum safety profile. CONCLUSIONS: Extracorporeal lithotripsy is still an effective and minimally invasive treatment, and it has an important role in the treatment of urolithiasis. New treatment strategies are being developed to increase the effectiveness with a similar safety profile.

Nuevas estrategias y protocolos en LEOC / New strategies and protocols in SWL

OBJETIVO: Actualizar las nuevas estrategias de tratamiento con litotricia extracorpórea (LEOC) como una alternativa terapéutica vigente en el manejo de la litiasis urinaria.MÉTODOS: Se ha realizado una revisión de la literatura más reciente cuya búsqueda respondía a los términos 'mejores prácticas', 'update', 'optimization', 'practicepattern' en litotricia. Sólo fueron seleccionadas aquellas escritas en lengua inglesa o española. RESULTADOS: La disminución de la frecuencia de liberación de las ondas de choque, la aplicación de un escalonamiento progresivo en la dosis aplicada con o sin pausa previo al primer ascenso de la energía, y la utilización de un mayor número de ondas de choque por sesión se muestran como alternativas que mejoran la efectividad con un perfil de seguridad óptimo para el paciente. CONCLUSIONES: La LEOC es un tratamiento efectivo y mínimamente invasivo, que mediante la aplicación de una técnica adecuada todavía tiene un papel relevante en el tratamiento de la litiasis urinaria. Nuevas estrategias de tratamiento en LEOC están siendo desarrolladas para aumentar la efectividad, sin incrementar los riesgos para el paciente

OBJECTIVE: An update of the new treatment strategies in extracorporeal lithotripsy as a valid therapeutic alternative in the management of urinary calculi. METHODS: We performed a search and review of the most recent literature which responded to the terms 'best practices', 'update', 'optimization', 'practice pattern' in lithotripsy. Only articles written in English or Spanish were selected. RESULTS: The use of a stepwise voltage ramping during extracorporeal lithotripsy with or without pause before the first rise of energy, a decreased delivery rates and the use of a higher number of shock waves per session are shown as alternatives to improve the effectiveness with optimum safety profile. CONCLUSIONS: Extracorporeal lithotripsy is still an effective and minimally invasive treatment, and it has an important role in the treatment of urolithiasis. New treatment strategies are being developed to increase the effectiveness with a similar safety profile

Central Body Fat Mass Measured by Bioelectrical Impedanciometry But Not Body Mass Index Is a High-Grade Prostate Cancer Risk Factor.

OBJECTIVE: To evaluate the association between body fat mass distribution measured by bioelectrical impedanciometry (BEI) and high-grade prostate cancer (HGPC). METHODS: We prospectively analyze 323 patients who underwent prostate biopsy. BEI was performed prior to biopsy. Prostate cancer (PC) was stratified according to D'Amico classification. For univariate analysis, Student t test was done. For multivariate analysis, bivariate logistic regression was performed using PSA, body mass index (BMI), percentage central body fat, percentage total body fat, and visceral fat as explicative variables for the diagnosis of HGPC. RESULTS: PC was found in 134 patients. Thirty seven (27.2%) were HGPC. This group had higher age, PSA, and percentage central body fat (p = 0.001, p = 0.001, p = 0.04). BMI showed no association with HRPC. Age, PSA, and percentage central body fat (OR 1,123, 95% CI 1,022-1,233, p = 0.001) were independent risk factors. CONCLUSIONS: Central body fat measured by BEI could explain the association between obesity and HGPC better than BMI suggesting the use of this technique to study body fat distribution.

Impacto en la calidad de una vida de los pacientes con catéter doble J / Impact in the quality of life of the patients with double J catheter

OBJETIVO: Los catéteres doble J se usan frecuentemente para permitir la diuresis entre riñón y vejiga, pero su presencia tiene un importante impacto en la calidad de vida (CdV) de los pacientes. Nuestro objetivo en este trabajo es describir dicho impacto y recoger aquellas medidas que pueden paliar los síntomas relacionados con su uso. MÉTODOS: Se ha realizado una búsqueda de artículos en las fuentes bibliográficas Cochrane library, Uptodate, Pubmed, Tripdatabase, seleccionando publicaciones entre 2000-2015 y las guías europeas EAU 2016. Se seleccionaron aquellos estudios que evaluaron la calidad de vida con catéteres doble J y las posibles soluciones. RESULTADOS: Se incluyeron 6 estudios cualitativos sobre calidad de vida, 6 ensayos clínicos sobre nuevos diseños en catéteres doble J, y 3 revisiones sistemáticas. La mayoría de los estudios utilizaron el cuestionario USSQ de calidad de vida. Se describen los principales problemas, siendo los mas frecuentes e importantes los síntomas de llenado y dolor. Entre las posibles soluciones se encuentran modificaciones en diseño y composición del catéter y sobre todo el uso de alfa-bloqueantes y anticolinérgicos para mejorar la CdV. CONCLUSIÓN: Los catéteres doble J presentan una importante repercusión sintomática y deterioro en la CdV lo cual hace necesario una indicación adecuada, limitar su duración y utilizar todas aquellas medidas tecnológicas y farmacológicas para paliar sus efectos

OBJECTIVE: Double J ureteral stents are frequently used to allow free diuresis from the kidney to the bladder, but their presence has a major impact on patient`s quality of life (QoL). Our aim is to describe such impact, and to describe possible solutions that can alleviate the symptoms associated with their use. METHODS: Systematic search in bibliographic sources including Cochrane library, UpToDate, Pubmed, Tripdatabase, selecting publications between 2000-2015, and also the EAU European guidelines (2016). Studies that assessed QoL with double J stents and possible solutions were selected. RESULTS: We included 6 qualitative studies on QoL, 6 clinical trials of double J catheters new designs, and 3 systematic reviews. Most studies used the USSQ (QoL) questionnaire and main problems are described, being storage symptoms and pain the most frequent and important. Possible solutions include modifications in design and composition of the catheter and specially, the use of alpha-blockers and anticholinergics to improve QoL. CONCLUSION: Double J stents have an important symptomatic impact that impairs QoL. They should be used under appropriate indication; their duration should be limited and we must employ all the technological and pharmacological approaches to mitigate their effects

Microureteroscopy in Children: Two First Cases.

BACKGROUND: Urinary stones disease is becoming more common not only in adults but also in children. Most cases are resolved with extracorporeal shock wave lithotripsy, but miniaturization of endoscopes has increased the use of ureteroscopy in resolving ureteral stones, most notably in children. CASE PRESENTATION: This presentation focuses on two cases of microureteroscopy. In both cases, the presence of lithiasis in the pelvic ureter was suspected to be the cause of ureter hydronephrosis, and a microureteroscopy was performed for treatment purposes. MicroPerc set 4.85F sheath was used to explore the pelvic ureter, thus avoiding the need to dilate the ureteral meatus or having to use the safety guide. Patients did not require a postoperative stent and were discharged within 24 hours of the procedure. CONCLUSION: Use of microureteroscopy proved satisfactory in the two cases of children and it allows diagnosis and treatment of ureteral pathology in pediatric patients.

Assessment of the Effectiveness, Safety, and Reproducibility of Micro-Ureteroscopy in the Treatment of Distal Ureteral Stones in Women: A Multicenter Prospective Study.

PURPOSE: The aim of this study is to assess the effectiveness, safety, and reproducibility of the micro-ureteroscopy (m-URS) in the treatment of distal ureteral stones in women. MATERIALS AND METHODS: A multicenter, prospective observational study was designed and conducted between March and December 2015. We included women having at least one stone in the distal ureter and being a candidate for surgical treatment using the 4.85F sheath of MicroPerc®. Patients with clinical criteria and/or laboratory analysis indicating sepsis or coagulation alteration were excluded. RESULTS: Thirty-nine women were operated in eight hospitals. The profile of the patients was fairly homogeneous among hospitals. Only differences were found in age, preoperative stent, and the result of the previous urine culture. Immediate stone-free status was achieved in 88.2% and 100% 7 days after the procedure. 97.4% of patients did not present any complication in the postoperative period, with only one case with complication Clavien II. Postureteroscopic Lesion Scale (PULS) in 76.9% of patients did not show any injury, 20.5% had lesions grade 1, and grade 2 lesions 2.6%. As for the reproducibility of m-URS between hospitals, statistical analysis of the results showed differences between all the centers participating in the study. CONCLUSIONS: m-URS is an effective, safe, and reproducible technique that minimizes surgical aggression to the ureteral anatomy. Satisfactory and comparable results to "conventional" ureteroscopy were obtained in the treatment of distal ureteral stones in women, although clinical trials are needed. The reduction of the ureteral damage may reduce secondary procedures and increase the cost-effectiveness of the procedure.

[Cancer of the penis. Our experience in 15 years]. / Cáncer de pene. Nuestra experiencia en 15 años.

OBJECTIVE: To review and analysis the diagnosis, treatment, evolution, and risk factors of the penis cancer. MATERIAL AND METHODS: We carried out a retrospective study between 1992 and 2007. We included 47 patients with penis cancer diagnose of treated in our service. We analyzed risk factors, symptoms, diagnosis and treatment. The staging was done according to the TNM classification, taking into account the physical exam, radiology and the surgical findings. The average time of follow-up was 50 months {range 12 to 120 months). For univariate statistical analysis the Chi-square test was used, and for the survival the method of Kaplan Meir. RESULTS: Mean age was 60 years (28-91 years), being 95% older than 50. At the diagnosis 16 patients (34%) had lymphatic nodes, being the most frequent location was unilateral inguinal nodes (62%). Of the 27 cases (57%) who underwent blood calcium check at the time of diagnosis, we found hypercalcaemia in 8 patients (30%). The surgical treatment was the gold standard treatment. The technique more frequently employed was the partial penectomy 25 (53%). 4 patients received radiotherapy as initial treatment. Lymphadenectomy was performed in 14 patients, mostly bilateral inguinal lymphadenectomy (8 patients). The pathology finding at 100% of the cases was squamous cell carcinoma (80% well differentiated). Regarding to the TNM, most of the patients had a clinical stage located: T1N0M0 23%, T2N0M0 27%. The most significant adverse prognostic factors were the presence of lymph nodes, clinical stage at the diagnosis and the degree of cell differentiation (p = 0001). At the last review 36 (76%) cases were free of disease. There were 11 (24%) cases that presented recurrence and were treated: 3 patients with radiotherapy, surgery was used in 7 patients and 1 patient with chemotherapy. Eleven patients died during follow up, 9 of these from disease progression. CONCLUSIONS: The carcinoma of the penis remains a rare malignancy in our centre. Hypercalcemia is a common finding when patients have lymph nodes. The most significant adverse prognostic factors were the presence of lymph nodes, clinical stage at the diagnosis and the degree of cell differentiation. The most effective treatment for cancer of the penis is surgery reserving chemotherapy and radiation therapy for the recurrence.

Cáncer de pene. Nuestra experiencia en 15 años / Cancer of the penis. Our experience in 15 years

Objetivos: Revisión y análisis de los factores de riesgo, diagnóstico, tratamiento y evolución del cáncer de pene. Material y Métodos: Realizamos un estudio descriptivo retrospectivo desde 1992 hasta el 2007, en el que se incluyeron 47 pacientes con diagnóstico de cáncer de pene tratados en nuestro servicio. Se analiza factores de riesgo, síntomas, diagnóstico, tratamiento, y evolución de los pacientes. El estadiaje clínico y anatomopatológico se hizo acorde a la clasificación TNM, teniendo en cuenta el examen físico, pruebas de diagnóstico por imagen y hallazgos de la pieza quirúrgica. El tiempo medio de seguimiento es de 50 meses (rango 12 a 120 meses).Para el análisis estadístico univariante se utilizo la prueba de Chi-cuadrado, y para el análisis de la supervivencia el método de Kaplan Meir. Resultados: La edad media de los pacientes fue de 60 años (28-91 años), siendo el 95% de ellos mayores de 50.Presentaron adenopatías al diagnóstico 16 pacientes (34%) siendo las más frecuente (62%) las adenopatías unilaterales inguinales. Ningún caso presentó metástasis a distancia. De los 27 casos (57%) a los que se les realizó calcio en sangre al momento del diagnostico, encontramos hipercalcemia en 8 (30%). El tratamiento fue quirúrgico en la mayoría (95%), siendo la técnica más empleada la penectomía parcial en 25 (53%). En 4 sujetos se decidió la radioterapia como tratamiento inicial. A 14 se les realizó una linfaadenectomía, siendo la técnica más frecuente la inguinal bilateral profunda (8 pacientes). Respecto al estadio TNM, la mayoría de pacientes presentaron un estadio clínico localizado: T1N0M0 23 %, T2N0M027%. El diagnóstico anatomopatológico en el 100% de los casos fue carcinoma epidermoide (80% fue bien diferenciado) En la última revisión 31 casos (76%) estaban libres de enfermedad. Hubo 11 (24%) casos que presentaron recidiva y fueron tratados: 3 con radioterapia, 7 cirugía de rescate y 1 de ellos con quimioterapia. Los factores pronósticos adversos más importantes son la presencia de adenopatías, el estadio clínico al diagnóstico y el grado de diferenciación celular (p=0,001) Once pacientes fallecieron a lo largo del seguimiento, 9 de los cuales por progresión de la enfermedad. Conclusiones: El carcinoma de pene sigue siendo una enfermedad maligna poco frecuente en nuestro medio. Los factores pronósticos adversos más importantes son la presencia de adenopatías, el estadio clínico al diagnóstico y el grado de diferenciación celular. El tratamiento más eficaz del cáncer de pene es quirúrgico, reservando la quimioterapia y radioterapia para adyuvancia o terapia de rescate. La hipercalcemia es un hallazgo frecuente cuando los pacientes presentan adenopatías (AU)

Objective: To review and analysis the diagnosis, treatment, evolution, and risk factors of the penis cancer. Material and Methods: We carried out a retrospective study between 1992 and 2007. We included 47 patients with penis cancer diagnose of treated in our service. We analyzed risk factors, symptoms, diagnosis and treatment. The staging was done according to the TNM classification, taking into account the physical exam, radiology and the surgical findings. The average time of follow-up was 50 months (range 12 to 120 months). For univariate statistical analysis the Chi-square test was used, and for the survival the method of Kaplan Meir. Results: Mean age was 60 years (28-91 years), being 95% older than 50.At the diagnosis 16 patients (34%) had lymphatic nodes, being the most frequent location was unilateral inguinal nodes (62%).Of the 27 cases (57%) who underwent blood calcium check at the time of diagnosis, we found hypercalcaemia in 8 patients (30%).The surgical treatment was the gold standard treatment. The technique more frequently employed was the partial penectomy 25 (53%). 4patients received radiotherapy as inicial treatment. Lymphadenectomy was performed in 14 patients, mostly bilateral inguinal lymphadenectomy (8 patients).The pathology finding at 100% of the cases was squamous cell carcinoma (80% well differentiated). Regarding to the TNM, most of the patients had a clinical stage located: T1N0M0 23%, T2N0M0 27%.The most significant adverse prognostic factors were the presence of lymph nodes, clinical stage at the diagnosis and the degree of cell differentiation(p = 0001).At the last review 36 (76%) cases were free of disease. There were 11 (24%) cases that presented recurrence and were treated: 3 patients with radiotherapy, surgery was used in 7 patients and 1 patient with chemotherapy. Eleven patients died during follor up, 9 of thes from disease progression. Conclusions: The carcinoma of the penis remains a rare malignancy in our centre. Hypercalcemia is a common finding when patients have lymph nodes. The most significant adverse prognostic factors were the presence of lymph nodes, clinical stage at the diagnosis and the degree of cell differentiation. The most effective treatment for cancer of the penis is surgery reserving chemotherapy and radiation therapy for the recurrence (AU)

Prognostic value of p53, Ki-67, microstaging and microvessel density in pT1G3 bladder tumors: creation of risk groups for progression.

OBJECTIVE: New predictive factors for bladder tumor progression have been analyzed in many publications, often with contradictory results. Very few papers have referred specifically to T1G3 tumors. Our objective was to find new, clinically useful markers which either alone or in association with classical prognostic factors would allow the early selection of the correct therapeutic approach. MATERIAL AND METHODS: This was a retrospective study of 83 patients with T1G3 bladder tumors who were initially treated with transurethral resection + bacillus Calmette-Guérin therapy, with a minimum follow-up period of 3 years. We analyzed eight variables. New factors considered were: the level of submucosal invasion; microvessel density; and immunostaining for Ki-67 and p53. Independent prognostic variables for progression were established using logistic regression analysis, and risk groups were created from mathematical models. RESULTS: Five variables were determined as unfavorable: tumor multiplicity; tumor size >3 cm; carcinoma in situ; T1b substage; and p53 positivity. The first three factors predicted progression in only 32% of cases, while the addition of the new prognostic factors (T1b substage and p53 positivity) increased this rate to 65%. We established four risk groups, with rates of progression of 67% and 100% in the high-risk and very high-risk groups, respectively. For inclusion in these groups, both new predictive factors had to be unfavorable; if either one were absent then the three classical factors had to be present. CONCLUSIONS: Microstaging and p53 positivity have a prognostic value for predicting progression in T1G3 tumors, providing 33% more information than that obtained with classical prognostic factors alone. The application of mathematical models identifies risk groups and allows the use of an early and more aggressive treatment.

Tratamiento de la litiasis renal cálcica. LEOC, NLP, cirugía abierta / Treatment of renal calcium stones: ESWL, PNL, open surgery

OBJETIVO: El objetivo del siguiente trabajo es una revisión y exposición, tanto de nuestra experiencia como de la literatura y del tratamiento actual de la litiasis renal cálcica. MÉTODOS: Se evalúan los resultados e indicaciones terapéuticas con los siguientes resultados y conclusiones. RESULTADOS/CONCLUSIONES: La litiasis piélica es la indicación ideal de la LEOC con tasas de resolución que fluctúan del 33 al 90 por ciento, influyendo sobre todo el tamaño del cálculo y también su composición. En la litiasis calicial los resultados son superponibles a la litasis piélica, excepto en los situados en cáliz inferior, en la que la tasa global de resolución completa oscila del 50 al 75 por ciento, mientras que con el tratamiento con NLP se alcanzan cifras del 90 por ciento, además cuando el ángulo infundíbulo-piélico es menor de 90º la tasa de resolución es aún menor. En la litiasis intradiverticular la tasa de resolución oscila entre el 4-58 por ciento obteniéndose los mejores resultados cuando el cálculo es pequeño y el cuello del divertículo es visible en la urografía. La litiasis coraliforme es la más compleja y por tanto la que más dificultades ofrece en el tratamiento con LEOC, sólo en el coraliforme tipo I su tratamiento con ondas de choque ofrece unos buenos resultados con un 72 por ciento de limpieza y una media de 3,5 sesiones por paciente (AU)