Survey of satisfaction in hospitalized patients at a urology department.

OBJECTIVES: To assess the level of satisfaction with the care provided to hospitalized patients in the Department of Urology at 12 de Octubre Hospital and analyze demographic and clinical factors influencing satisfaction. METHODS: A cross-sectional study was carried out using the SERVQHOS questionnaire, delivered at the time of discharge. A data sheet for each patient was collected, which included if they undergone surgery, type of surgery and whether or not presented postoperative complications, rated by the Clavien scale. RESULTS: 479 surveys were collected, with a participation of 92%. 95.4% of patients rated their overall level of satisfaction with the care received as "satisfied" or "very satisfied". Top-rated aspects were the kindness of the staff and personalized attention. The worst rated issue was the condition of the rooms, but this did not influence perceived quality. Variables related to greater overall satisfaction were male gender, shorter hospital stay, knowing the name of the nurse, the information received and subjective factors such as personalized service and willingness to help. CONCLUSIONS: Our patients show a high level of satisfaction, which is mainly dependent on subjective factors. The negative issues related to the facilities do not mean lower satisfaction.

Grade 3a Clavien grade complication following percutaneous nephrolithotomy. Related factors and review of the literature.

OBJECTIVE: We review the literature about bleeding complications of percutaneous nephrolithotomy (PCNL) and the application of the modified Clavien system classification. METHODS: We present a 38 year old man who underwent left PCNL with acute severe hematuria during the immediate postoperatory time. We review the literature and analyze the usefulness of the modified Clavien system to grade perioperative complications. RESULTS: Conservative management was insufficient so we had to perform arteriography and superselective embolization to solve the acute arterial bleeding. According to Clavien's classification, our case would be included within the grade 3a group complications. CONCLUSIONS: The complications following a PCNL are not uncommon. However most of them are not severe. The modified Clavien system, used for classifying complications after performing PCNL, can be useful for reporting results in an objective and replicable way.

Factores relacionados con una complicación grado IIIa de Clavien tras una nefrolitotomía percutánea. Revisión de la literatura / Grade 3a Clavien grade complication following percutaneous nephrolithotomy. Related factors and review of the literature

OBJETIVO: Revisamos la literatura a propósito de las complicaciones hemorragicas derivadas de una Nefrolitotomia Percutánea (NLP) y la aplicación del sistema modificado de Clavien para su clasificación. MÉTODOS: Presentamos el caso de un varón sometido a una NLP izquierda que presentó de forma aguda durante el postoperatorio inmediato una hematuria severa y anemizante secundaria a un sangrado arterial. Revisamos la literatura al respecto y analizamos la utilidad del sistema de clasificación de Clavien para las complicaciones quirúrgicas. RESULTADOS: Mediante arteriografía y embolización percutánea supraselectiva del vaso sangrante se consiguió el control definitivo del sangrado arterial. Representado así una complicación grado IIIa según el sistema de Clavien. CONCLUSIONES: Las complicaciones tras una NLP, en su mayoría leves, no son infrecuentes. El sistema modificado de Clavien adaptado para clasificar las complicaciones tras una NLP puede ser de utilidad para notificar resultados de forma objetiva y reproducible

OBJECTIVE: We review the literature about bleeding complications of percutaneous nephrolithotomy (PCNL) and the application of the modified Clavien system classification. METHODS: We present a 38 year old man who underwent left PCNL with acute severe hematuria during the immediate postoperatory time. We review the literature and analyze the usefulness of the modified Clavien system to grade perioperative complications. RESULTS: Conservative management was insufficient so we had to perform arteriography and superselective embolization to solve the acute arterial bleeding. According to Clavie's classification, our case would be included within the grade 3a group complications. CONCLUSIONS: The complications following a PCNL are not uncommon. However most of them are not severe. The modified Clavien system, used for classifying complications after performing PCNL, can be useful for reporting results in an objective and replicable way

Healthcare-associated infections in a department of urology: incidence and patterns of antibiotic resistance.

OBJECTIVE: Healthcare-associated infections (HAIs) constitute a potentially severe complication which implies higher costs. A full knowledge of their microbiological characteristics and risk factors is of paramount importance for adequate management. The purpose of this study was to carry out an analysis of HAIs in patients admitted to a department of urology. MATERIAL AND METHODS: Between November 2011 and October 2012, a prospective observational study was carried out analysing HAIs in patients admitted to the urology department of a tertiary care university hospital in Spain, reviewing the incidence and types of HAIs, the microorganisms isolated and patterns of resistance to antibiotics. Risk factors for HAIs were also evaluated. RESULTS: HAIs were seen in 110 (6.5%) out of 1701 patients. Hypertension, a higher American Society of Anesthesiologists (ASA) score and surgery showed a statistical association with a higher risk of HAIs, and patients who underwent radical cystectomy had a high incidence of HAIs (10 out of 14). The most common HAIs were urinary tract infections (66.1%), followed by surgical site infections (16.5%), intra-abdominal abscesses (10.4%) and venous catheter-associated bacteraemia (6.1%). The most frequently isolated microorganisms were Escherichia coli (31.8%), then Enterococcus (17.6%) and Pseudomonas (12.9%). Escherichia coli showed resistance rates of 48.1% for ampicillin/amoxicillin plus ß-lactamase inhibitor, 51.9% for fluoroquinolones, and 33.3% were extended-spectrum ß-lactamase-producing E. coli. Pseudomonas aeruginosa showed a resistance rate of 36.4% for fluoroquinolones and carbapenems. CONCLUSIONS: HAIs usually occur in patients with risk factors. Radical cystectomy is associated with a high incidence of HAIs. Microorganisms associated with HAIs show high rates of resistance, which must be taken into account when selecting appropriate antibiotic therapy.

Implementing an action protocol on prostatic disease in primary care and impact on referrals to urology.

OBJECTIVES: To determine the impact of implementing a joint action protocol on prostatic disease on the referrals to Urology from Primary Care in a health care area. METHODS: We drafted a protocol for managing patients consulting for clinical signs and symptoms associated to benign prostatic hyperplasia (BPH) and to test PSA in asymptomatic males. At the same time, three e-mail addresses were opened for consultations generated from Primary Care, and joint sessions were carried out in the primary health care centers. We measured the impact of the protocol by assessing the adequacy of prostatic disease referrals to Urology, as well as by determining the course of the total number of referrals in three peripheral specialized health care centers (PSHCC). RESULTS: From January 2011, a better compliance to the referrals to Urology protocol for prostatic disease has been produced, going from 47% (assessment prior to implementing the protocol) to 64%. These results are especially good when we consider referrals associated to PSA, which went from a compliance of 33% to 84%. Regarding the course of the referrals to Urology, the referral rate (referrals per 1000 inhabitants) has decreased by 15% (from 13,8 to 11,7). CONCLUSIONS: The collaboration between Urology and Primary health care, by means of implementing joint protocols, and also by establishing new communication channels (e-mail, joint sessions), achieves a better adequacy of patients referred for prostatic disease, as well as a reduction in the total number of referrals.

Implantación de un protocolo de actuación en patología prostática en atención primaria e impacto en las derivaciones a urología / Implementing an action protocol on prostatic disease in primary care and impact on referrals to urology

OBJETIVO: Determinar el impacto sobre las derivaciones a Urología desde Atención Primaria, de un protocolo de actuación conjunta en patología prostática en un área sanitaria. MÉTODOS: Se elaboró un protocolo para el manejo del paciente que consulta por clínica relacionada con hiperplasia prostática y para la realización de PSA en varón asintomático. Al mismo tiempo, se abrieron tres direcciones de correo electrónico para consultas generadas desde Atención Primaria y se realizaron sesiones conjuntas en los Centros de Salud. Medimos el impacto del protocolo valorando la adecuación de las derivaciones a Urología por patología prostática, así como determinando la evolución del número total de derivaciones en tres centros de especialidades periféricas. RESULTADOS: Desde enero de 2011, se ha producido una mejor adecuación de las derivaciones a Urología por patología prostática, que han pasado de un 47% de adecuación (valoración previa a la implantación del protocolo) a un 64%. Estos resultados son especialmente buenos cuando consideramos las derivaciones relacionadas con el PSA, que han pasado de un 33% a un 84% de adecuación. En cuanto a la evolución de las derivaciones a Urología, la tasa de derivación (derivaciones por 1000 habitantes) ha descendido en un 15% (de 13,8 a 11,7). CONCLUSIONES: La colaboración entre Urología y Atención Primaria, mediante la implantación de protocolos conjuntos, así como estableciendo nuevos medios de comunicación (correo electrónico, sesiones conjuntas), consigue una mejor adecuación de los pacientes derivados por patología prostática, así como una disminución en el número total de derivaciones (AU)

OBJECTIVES: To determine the impact of implementing a joint action protocol on prostatic disease on the referrals to Urology from Primary Care in a health care area. METHODS: We drafted a protocol for managing patients consulting for clinical signs and symptoms associated to benign prostatic hyperplasia (BPH) and to test PSA in asymptomatic males. At the same time, three e-mail addresses were opened for consultations generated from Primary Care, and joint sessions were carried out in the primary health care centers. We measured the impact of the protocol by assessing the adequacy of prostatic disease referrals to Urology, as well as by determining the course of the total number of referrals in three peripheral specialized health care centers (PSHCC). RESULTS: From January 2011, a better compliance to the referrals to Urology protocol for prostatic disease has been produced, going from 47% (assessment prior to implementing the protocol) to 64%. These results are especially good when we consider referrals associated to PSA, which went from a compliance of 33% to 84%.Regarding the course of the referrals to Urology, the referral rate (referrals per 1000 inhabitants) has decreased by 15% (from 13,8 to 11,7). CONCLUSIONS: The collaboration between Urology and Primary health care, by means of implementing joint protocols, and also by establishing new communication channels (e-mail, joint sessions), achieves a better adequacy of patients referred for prostatic disease, as well as a reduction in the total number of referrals (AU)

Tratamiento hormonal en la recidiva bioquimica tras prostatectomía radical / Hormonal treatment in biochemical recurrence after radical prostatectomy

Hasta la fecha el papel de la HT en la recidiva bioquímica, su inicio, esquema y duración permanecen en controversia dada la ausencia de ensayos randomizados que analicen la supervivencia del paciente sometido a esta terapia tras fracaso bioquímico. La hormonoterapia mediante el empleo de análogos LH-RH resulta en este escenario la medida más frecuentemente empleada en la práctica clínica. Sin embargo el sustento científico de la misma es bastante endeble. Implica extrapolar los beneficios de la HT precoz vs diferida, vista en otros estadios de la enfermedad (generalmente avanzada), a un paciente asintomático con exclusivo aumento del PSA, que tendría en muchos casos una larga historia natural hasta el desarrollo de metástasis y con el impuesto añadido de los efectos secundarios bien conocidos actualmente. Probablemente los pacientes con Gleason >8 y TDPSA < 12 meses sí pudieran beneficiarse de un tratamiento hormonal precoz, sobre todo si son jóvenes (grado 2c). En muchos otros casos donde no se contemple un tratamiento local como RT, la decisión de HT precoz o tardía debe ser cuidadosamente valorada y comentada con el paciente. Las alternativas de tratamiento hormonal con preservación de función sexual, como el bloqueo intermitente, monoterapia con antiandrógenos o la suma de un 5- ARI con antiandrógeno, deben ser valoradas con cautela ante la escasez de información a largo plazo aunque éste parece un atractivo escenario para su empleo(AU)

To date, the role of hormonal therapy (HT) after biochemical failure, when to initiate it, the therapeutic scheme and duration remains controversial due to the absence of well designed randomized trials analyzing the overall survival of patients. In clinical practice, the most widely spread treatment in this scenario is hormonal therapy with LH-RH analogues. However, the scientific support for this issue is very weak. We are extrapolating the benefits proven for early vs delayed HT in advanced prostate cancer, to asymptomatic patients presenting just an increase in PSA. These patients usually have a long time disease-history until development of metastasis. It should also be noticed the harmful secondary effects acquired with the time of employment of hormotherapy. Probably patients suffering a Gleason score >8 and PSA doubling time <12 months could obtain a benefit from an early castration treatment, even more if they are young (grade 2c). Except in selected cases of local treatment as radiotherapy, the decision for early or delayed hormonal therapy should be taken carefully with patient consensus. The alternatives for hormonal treatment to preserve sexual function, as intermittent treatment, antiandrogen monotherapy, or antiandrogen plus 5 alpha reductase inhibitors, are very attractive in this scenario. However due to the short time experience with these modalities of treatment should be evaluated with caution(AU)

Testicular tumors: residual retroperitoneal mass surgery after chemotherapy;Is it possible to predict their histology?

OBJECTIVES: We present our series of residual retroperitoneal mass surgery after chemotherapy. We evaluate possible preoperative parameters that can predict the retroperitoneal mass histology. Survival and relapse rates were also evaluated. METHODS: We reviewed sixty resections of residual retroperitoneal masses of testicular tumours after chemotherapy performed at our department between 1995 and 2007. We evaluate the relationship between histology of the retroperitoneal mass and possible risk factors, such as outcomes after chemotherapy, which was evaluated as changes in the size of the retroperitoneal mass, and negativization of serum tumor markers. We also evaluate histology and size of the primary testicular cancer. RESULTS: The histology of retroperitoneal mass was necrosis or fibrosis in 25 (42%) cases, teratoma in 29 (48%) and viable tumor in 6 (10%). The size of the retroperitoneal mass decreased after the chemotherapy in 62% cases; moreover negative serum tumor markers were found in 87%. Elevated values of human chorionic gonadotropin were associated with viable cells in the retroperitoneal mass (p=0.014) and, the presence of teratoma in the primary tumor may be associated with teratoma in the retroperitoneal mass histology (p=0.002). However, no other preoperative factors that predict the residual mass histology were found. Repeated resections of retroperitoneal masses were required in four patients and 9 patients died during follow-up. CONCLUSIONS: We cannot determine preoperative parameters that accurately predict the histology of retroperitoneal masses. Therefore, resection of residual retroperitoneal masses after chemotherapy in non-seminomatous germ cell tumours must be performed.

Complicaciones infecciosas tras biopsia prostática transrectal. Análisis de nuestra experiencia / Infectious complications after transrectal ultrasound-guided prostatic biopsy. Analysis of our experience

OBJETIVO: Establecer la tasa de complicaciones infecciosas derivadas de la realización de una biopsia prostática transrectal ecodirigida (BPTRE), identificar su perfil microbiológico y los factores de riesgo relacionados.MÉTODOS: Diseñamos un estudio prospectivo no aleatorizado donde se incluyeron 220 pacientes sometidos a BPTRE en nuestro centro entre Abril y Septiembre de 2008. Los criterios de inclusión fueron: tacto rectal sospechoso, PSA >10ng/ml y en aquellos con PSA 4-10 ng/ml se tiene valora el cociente PSA libre/total. Los criterios de exclusión empleados fueron: ser portador de catéter urinario, administración de tratamiento antibiótico la semana previa a la realización de la biopsia, manipulación de la vía urinaria en el mes previo a la biopsia, alergia a quinolonas y riesgo de endocarditis, incumplimiento de la pauta de profilaxis antibiótica y pérdida de seguimiento.Analizamos la relación entre ser diabético, inmunodeprimido, ITU o prostatitis previas y urocultivo prebiopsia positivo con la aparición de fiebre, disuria o bacteriuria tras la biopsia.RESULTADOS: La edad media fue de 69,5 años (+/-7,9), el PSA total medio 12,7ng/ml (+/-28,7), el volumen prostático medio 50,6cc (+/-29,6) y el número medio de cilindros obtenidos por biopsia 13,5 (+/-1,7).El 25% de los pacientes tenía disuria tras la biopsia, el 3,2% fiebre, el 4,5% bacteriuria. El E.coli fue el patógeno más frecuentemente hallado en los urocultivos pre y post biopsia.No encontramos relación estadísticamente significativa entre la aparición de disuria y la fiebre con la condición de diabético, inmunosupresión, ITU o prostatitis previas, volumen prostático y número de cilindros obtenidos en la biopsia.Únicamente la existencia de un urocultivo prebiopsia positivo y una biopsia con más de 14 cores, demostraron tener asociación estadísticamente significativa con la existencia de bacteriuria tras la biopsia, p=0,007 y p= 0,018 respectivamente. CONCLUSIONES: Nuestra tasa de complicaciones infecciosas fue similar a la descrita para otras series. La existencia de un urocultivo prebiopsia positivo y obtener más de 14 cilindros por biopsia demostró tener relación estadísticamente significativa con la existencia de bacteriuria tras la biopsia. El E.coli fue el patógeno más frecuentemente aislado (AU)

OBJECTIVES: To establish the rate of infectious complications derived from the use of transrectal ultrasound-guided prostate biopsy (TRUS), identify its mi-crobiological profile and related risk factors.METHODS: We designed a prospective non-randomi-zed study in which we enrolled 220 patients undergoing TRUS biopsy at our centre between April and September 2008. The inclusion criteria were: suspicious digital rectal exa-mination, PSA >10 ng/ml, and free/total ratio of PSA is assessed in patients with PSA 4-10 ng/ml. The exclu-sion criteria were: having an indwelling urinary catheter, the administration of antibiotic treatment in the week before the needle biopsy, manipulation of the urinary tract in the month prior to the needle biopsy, allergy to quinolones and risk of endocarditis, failure to comply with the anti-biotic prophylaxis regimen and loss to follow-up.We analyzed the relationship between diabetes, immunodepression, previous UTI or prostatitis and positi-ve pre-biopsy urine culture with the appearance of fever, dysuria or bacteriuria following needle biopsy.RESULTS: Mean age was 69.5 years (+/-7.9), mean total PSA 12.7ng/ml (+/-28.7), mean prostate volu-me 50.6 cc (+/-29.6) and mean number of cores ob-tained by needle biopsy 13.5 (+/-1.7). 25% of the patients had dysuria following needle biopsy, 3.2% fever and 4.5% bacteriuria. E.coli was the pathogen most frequently found in pre- and post-biopsy urine cultures.No statistically significant relationship was found bet-ween the appearance of dysuria and fever and being diabetic, having immunosuppression, previous UTI or prostatitis, prostate volume and number of cores obtai-ned in the biopsy.Only the existence of a positive pre-biopsy urine culture and biopsy with more than 14 cores proved to have a statistically significant association with the existence of bacteriuria following biopsy, p=0.007 and p= 0.018, respectively. CONCLUSIONS: Our rate of infectious complications was similar to that described in other series. The existence of a positive pre-biopsy urine cul-ture and obtaining more than 14 cores per biopsy was related, with statistical significance, to the existence of bacteriuria following the biopsy. E.coli was the most frequently isolated pathogen (AU)

Tumores testiculares: cirugía de masas retroperitoneales residuales tras tratamiento quimioterápico; ¿es posible predecir su histología? / Testicular tumors: residual retroperitoneal mass surgery after chemotherapy; ¿is it possible to predict their histology?

OBJETIVO: Presentamos nuestra serie de cirugías de masas retroperitoneales residuales postquimioterapia, evaluando aquellos parámetros que pudieran predecir su histología y mostramos la evolución tras la cirugía.MÉTODOS: Revisamos retrospectivamente 60 cirugías de masas retroperitoneales residuales tras quimioterapia, secundarias a tumores testiculares de células germinales realizadas en nuestro servicio entre 1995 y 2007. Estudiamos la relación entre la histología de la masa y sus posibles factores predictores, tales como: la respuesta a la quimioterapia valorada como reducción del tamaño de la masa retroperitoneal y evolución de los marcadores tumorales, la anatomía patológica y el tamaño del tumor primario.RESULTADOS: La histología de las masas residuales fue necrosis/fibrosis en 25 (42%) casos, teratoma en 29 (48%) y tumor viable en 6 (10%). La quimioterapia consiguió reducir el tamaño de la masa en el 62% de los casos, se logró negativización de los marcadores en el 87%. Aunque valores más altos de gonadotropina coriónica humana se asocian con masas que contienen células viables (p=0,014) y la presencia de teratoma en el tumor primario puede orientar hacia la histología de la masa retroperitoneal (p=0,002), no encontramos otros factores preoperatorios predictivos de la histología de la masa residual. En 4 pacientes fueron necesarias varias cirugías ante la existencia de recidiva y 9 pacientes fallecieron durante el seguimiento.CONCLUSIONES: No encontramos claros factores predictores de la histología de la masa retroperitoneal. Por tanto, en los tumores germinales no seminomatosos debe realizarse una completa resección quirúrgica de las masas retroperitoneales residuales tras el tratamiento quimioterápico(AU)

OBJECTIVES: We present our series of residual retroperitoneal mass surgery after chemotherapy. We evaluate possible preoperative parameters that can predict the retroperitoneal mass histology. Survival and relapse rates were also evaluated. METHODS: We reviewed sixty resections of residual retroperitoneal masses of testicular tumours after chemotherapy performed at our department between 1995 and 2007. We evaluate the relationship between histology of the retroperitoneal mass and possible risk factors, such as outcomes after chemotherapy, which was evaluated as changes in the size of the re-troperitoneal mass, and negativization of serum tumor markers. We also evaluate histology and size of the primary testicular cancer.RESULTS: The histology of retroperitoneal mass was necrosis or fibrosis in 25 (42%) cases, teratoma in 29 (48%) and viable tumor in 6 (10%). The size of the retroperitoneal mass decreased after the chemotherapy in 62% cases; moreover negative serum tumor markers were found in 87%. Elevated values of human chorionic gonadotropin were associated with viable cells in the retroperitoneal mass (p=0.014) and, the presence of teratoma in the primary tumor may be associated with teratoma in the retroperitoneal mass histology (p=0.002). However, no other preoperative factors that predict the residual mass histology were found. Repeated resections of retroperitoneal masses were required in four patients and 9 patients died during follow-up.CONCLUSIONS: We cannot determine preoperative parameters that accurately predict the histology of retroperitoneal masses. Therefore, resection of residual retroperitoneal masses after chemotherapy in non-seminomatous germ cell tumours must be performed(AU)

Biopsias de saturación para la detección de cáncer de próstata: efectividad, seguridad y factores predictivos / Saturation biopsies for prostate cancer detection: effectiveness, safety and predictive factors

OBJETIVO: Determinar la rentabilidad y seguridad de las biopsias de saturación para la detección del cáncer de próstata (CaP), e identificar variables relacionadas con la presencia del tumor.MÉTODOS: Revisamos de forma transversal y retrospectiva 144 biopsias de saturación (enero/06-julio/09). Los criterios de inclusión fueron: al menos 2 sets de biopsias sin evidencia de malignidad y cifras de Antígeno Prostático Específico (PSA) > 10 ng/ml o cinética de PSA sugestiva de malignidad (velocidad > 0,75 ng/ml/año) y pacientes con atipias en biopsia/s previa/s. Las variables analizadas fueron: edad, tacto rectal sospechoso (TRS), PSA total, cociente PSA libre/total, volumen prostático, densidad de PSA, anatomía patológica previa, número de cilindros obtenidos y complicaciones. Se analiza estadísticamente mediante test de CHI-2, t de Student y regresión logística(AU)

RESULTADOS: La edad media fue de 66 años (DS±6,4), el PSA total medio 14,4 ng/ml (DS±12,6), el cociente medio PSA libre/total 0,09 (DS±0,09), el volumen prostático medio 61,6 cc (DS±27,4), la densidad media de PSA 0,27 (DS±0,26) y el número medio de cilindros obtenidos de 30,45 (DS±3,8).Diagnosticamos un 32% de adenocarcinoma prostático. La densidad de PSA fue mayor en el grupo con CaP, 0,39 (DS±0,36) frente a 0,21 (DS±0,18) en los pacientes sin cáncer (p=0,003). En el 58% de los pacientes con TRS se observó adenocarcinoma en la biopsia, frente a un 28% con TR normal (p=0,009). El volumen prostático medio del grupo con CaP fue de 52,5 (DS±24,7) frente a 66 (DS±27,7) del grupo sin cáncer (p=0,006).En el análisis multivariante, la densidad de PSA (p=0,02; IC 95% 1,36 - 37,36) es la única variable que predice de forma independiente la existencia de adenocarcinoma.Para el resto de variables analizadas, tanto en el análisis univariante como en el multivariante, no se hallaron diferencias estadísticamente significativas.La incidencia de complicaciones derivadas del procedimiento fue similar a la descrita en la literatura para otras series.CONCLUSIONES: La biopsia de saturación es efectiva y segura para determinar la presencia de cáncer de próstata. La densidad de PSA es el único factor que se han mostrado como variable predictiva independiente para el diagnóstico de tumor(AU)

OBJECTIVES: To determine the effectiveness and safety of saturation biopsies for prostate cancer detection of and to identify predictive variables for cancer.METHODS: We conducted a retrospective transversal study in which we analyzed 144 saturation biopsies (January ‘06 - July ‘09). Inclusion criteria: at least two sets of biopsies without evidence of malignancy and Prostate Specific Antigen (PSA) levels >10ng/ml or PSA kinetics suggestive of malignancy (rate >0.75ng/ml/year) and patients with atypia in a previous biopsy.The variables analyzed were: age, abnormal digital rectal examination (DRE), total PSA, free/total PSA ratio, prostate volume, PSA density, previous histopathology, number of cylinders obtained and complications. Statistical analysis was performed using the Chi-square test, Student’s t-test and logistic regression.RESULTS: Mean age was 66 years (SD ± 6.4), mean total PSA 14.4 ng/ml (SD ± 12.6), mean free/total PSA ratio 0.09 (SD ± 0.09), mean prostate volume 61.6 cc (SD ± 27.4), mean PSA density 0.27 (SD ± 0.26) and mean number of cylinders obtained 30.45 (SD ± 3.8).We diagnosed 32% of the patients with prostatic adenocarcinoma. We observed PSA density was higher in the prostate cancer group, 0.39 (SD ± 0.36), compared to 0.21 (SD ± 0.18) in patients without cancer (p=0.003). Adenocarcinoma was found in 58% of the biopsies in patients with suspicious DRE, compared to 28% with normal DRE (p=0.009). Mean prostate volume in the prostate cancer group was 52.5 (SD ± 24.7) compared to 66.0 (SD ± 27.7) in the group without cancer (p=0.006).In the multivariate analysis, the PSA density (p=0.02; 95% CI 1.36 - 37.36) was the only variable that independently predicted the presence of adenocarcinoma. No statistically significant differences were found in either univariate or multivariate analysis for the remaining variables analyzed. The incidence of complications was similar to that described in the literature for other series(AU)

CONCLUSIONS: Saturation biopsy is safe and effective for detection of prostate cancer. PSA density was the only factor that was shown to be independent predictive variable for tumor diagnosis(AU)

An unusual case of air within the bladder wall: bladder pneumatosis?

Emphysematous cystitis is a potentially life-threatening condition characterized by the amassing of gas within the wall of the bladder, as a result of infection by gas-forming organisms. However, the amassing of gas in the wall of the bladder does not always result from an infectious etiology. Here we report the case of a patient diagnosed with lung cancer and treated with chemotherapy, where there was air within the bladder wall accompanied by pneumoperitoneum. The presence of an infectious etiology was not clear, and the patient responded successfully to medical treatment. Although emphysematous cystitis is the most common diagnosis, the presence of gas within the wall of the bladder is a sign and not a disease per se. In our opinion, the case displays similar characteristics to those of pneumatosis cystoides intestinalis, and for this reason we refer to it as bladder pneumatosis.

Can partial nephrectomy preserve renal function and modify survival in comparison with radical nephrectomy?

OBJECTIVE: To investigate whether radical nephrectomy (RN) and nephron-sparing surgery (NSS) for T1 renal cell carcinoma influence renal function, oncological outcome or survival rate. MATERIAL AND METHODS: A retrospective study was performed, including 290 nephrectomies for tumours of a diameter of less than 7 cm; 174 radical nephrectomies were compared to 116 nephron-sparing surgeries. Preoperative and pathological data were compared between the two groups. The glomerular filtration rate was estimated using the abbreviated Modification of Diet and Renal Disease (MDRD4) study equation. The evolution of renal function was analysed from 6 months to 4 years after surgery, and the oncological outcomes were evaluated by means of cancer and non-cancer survival curves. RESULTS: The results showed a major impairment in renal function in the RN group compared to those who underwent NSS (25 vs 7 ml/min/1.73 m², 6 months after surgery), a difference that was maintained over time. Moreover, patients undergoing RN had a greater chance of developing renal failure. Overall, the survival curves showed a higher mortality rate for the RN group (p = 0.034), although the cancer-specific mortality rate did not show any statistically significant differences (p = 0.079). CONCLUSIONS: For stage T1 renal cortical tumours, NSS should, whenever possible, be regarded as the primary therapeutic option, given that it obtains similar oncological outcomes to RN and preserves renal function, which seems to translate into a lower overall mortality rate.

Factors influencing the progression of renal damage in patients with unilateral renal agenesis and remnant kidney.

BACKGROUND: Although some studies have shown that the risk to develop proteinuria and renal insufficiency is increased in patients with a remnant kidney (RK) or unilateral renal agenesis (URA), other patients maintain normal renal function and negative proteinuria, and the reasons to explain these different outcomes are not known. METHODS: We performed a retrospective study of 54 patients with a severe reduction in renal mass (33 patients with URA and 21 with RK). Follow-up was 100 +/- 72 months. RESULTS: Twenty patients (group 1) showed normal renal function at presentation, whereas the 34 remaining (group 2) had proteinuria, and some of them renal insufficiency. Group 2 patients were older and had a higher blood pressure and BMI than group 1 patients. Eleven patients of group 1 remained normal throughout follow-up (group 1A), whereas the remaining 9 developed proteinuria/renal insufficiency (group 1B). BMI at presentation was significantly higher in group 1B: 27 +/- 3.6 kg/m(2) versus 21.6 +/- 2.6 kg/m(2), and BMI was the only factor statistically associated with the risk to develop proteinuria/renal insufficiency in group 1. Among group 2 patients, renal function remained stable in 20 (group 2A), and deteriorated (>50% increase of baseline serum creatinine) in the remaining 14 patients (group 2B). BMI at presentation and treatment with ACEI during follow-up were the only factors statistically associated with the risk for renal failure progression among group 2 patients. CONCLUSION: Overweight plays a fundamental role in the appearance of proteinuria and renal damage in patients with severe renal mass reduction.

Experiencia en el trasplante renal de cadáver con arterias reconstruidas ex situ / Experience with cadaveric kidneytransplantation with ex setu arterial reconstrution

OBJETIVOS: Revisamos nuestra experiencia en el trasplante renal de cadáver empleando injertos con anomalías arteriales previamente reconstruidas ex situ. MÉTODOS: Se revisan retrospectivamente los 20 casos realizados entre enero de 1989 y diciembre de 1994 para poder obtener un seguimiento mínimo de 5 años. Como control hemos utilizado un grupo de 73 pacientes trasplantados con injertos considerados 'ideales' durante el mismo periodo de tiempo. Ambos grupos fueron homogéneos respecto a todas las variables que se consideró que pudiesen influir en la evolución posterior del injerto. RESULTADOS: Los resultados observados han sido equivalentes a los del control en cuanto a incidencia de NTA (Necrosis Tubular Aguda), episodios de rechazo, cifras de creatinina, complicaciones quirúrgicas o reintervenciones. En cambio, se ha detectado una clara tendencia (25 por ciento de los casos) a desarrollar una estenosis de arteria renal (p=0,052). Estos últimos casos fueron diagnosticados por la aparición de una HTA de difícil control y fueron tratados de forma conservadora mediante angioplastia percutánea con buenos resultados funcionales en el 100 por ciento, aunque en el 80 por ciento fue necesaria más de una sesión. En ningún caso esta complicación dio lugar a la pérdida del injerto. CONCLUSIONES: Los injertos renales con arterias dañadas durante la extracción o como consecuencia de cambios patológicos tales como arteriosclerosis o aneurismas, son útiles para el trasplante previa reconstrucción en banco. No obstante, la mayor tendencia a desarrollar una estenosis arterial sintomática hace conveniente descartar sistemáticamente esta complicación en el seguimiento de estos pacientes pues, diagnosticada precozmente, no parece influir en la evolución del injerto cuando se trata a tiempo. El primer abordaje terapéutico debe ser la angioplastia transluminal percutánea, reservando la cirugía abierta para sus fracasos (AU)

Experiencia en trasplante renal con donantes infantiles / Our experience with transplantation of children kidneys

OBJETIVO: Evaluar la idoneidad del empleo de riñones procedentes de donantes infantiles en el trasplante renal del adulto. MÉTODOS: Revisamos nuestra experiencia en el trasplante renal de cadáver con donantes infantiles (< 15 años) entre 1989 y 1994, para obtener un seguimiento al menos de 36 meses. Hemos estratificado a los pacientes (N=43), en un grupo A de donantes menores o iguales a 6 años (N=13), un grupo B que incluye a los mayores de 6 años (N=30) y un grupo C correspondiente a un control de pacientes trasplantados con donantes de edades ideales en el mismo periodo de tiempo (N=73). Los 3 grupos fueron homogéneos en cuanto a las variables demográficas consideradas de influencia salvo por la presencia de una mayor incidencia de hipotensión del donante en el grupo B. RESULTADOS: Los pacientes del grupo A han tenido un número de episodios de rechazo que ha triplicado al control (p=0,019). Asimismo, en este grupo hemos obser vado una mayor incidencia de complicaciones quirúrgicas, preferentemente vasculares (trombosis arterial, rotación renal), con respecto al control (p=0,039). Cuando de este grupo A excluimos del análisis a los dos injertos procedentes de donantes menores de 12 meses trasplantados en bloque, no encontramos una mayor incidencia de complicaciones quirúrgicas vasculares o urológicas respecto al control. Tampoco hemos detectado diferencias entre los 3 grupos respecto a la estancia media, función renal (creatininemia), supervivencia del injerto o del paciente. CONCLUSIÓN: Los injertos mayores de 6 años se comportan igual que los injertos de edades ideales. Asimismo, los mayores de 12 meses pueden ser trasplantados individualmente con excelentes resultados. Debemos esperar a disponer de una serie más amplia para confirmar y tratar de explicar la alta incidencia de rechazo agudo en los donantes menores de 6 años. (AU)

Compatibilidad HLA y reexposición antigénica. Influencia en la evolución del retrasplante renal de cadáver / HLA compatibility and antigenic re-exposure : influence on the outcome of second cadaveric renal transplants

OBJETIVOS: En el momento actual se conocen algunos factores predictivos de la evolución del retrasplante renal de cadaver, en especial su relación con la respuesta del receptor frente al primer injerto. Sin embargo, la influencia de la compatibilidad HLA y de la repetición de las mismas incompatibilidades entre el receptor y sus dos donantes es materia de controversia. Conocer la importancia relativa de estos factores en la supervivencia del segundo trasplante renal de cadaver constituye el principal objetivo del presente estudio. MÉTODO: Realizamos un estudio retrospectivo sobre un total de 80 pacientes sometidos a un segundo trasplante renal de cadáver, bajo protocolos de inmunosupresión basados en el empleo de ciclosporina (CyA), entre los años 1985 y 1995 en el Hospital 12 de Octubre de Madrid. Se recogieron las características y evolución de primer y segundo trasplantes, así como los referidos al donante y receptor. Todas las variables consideradas fueron empleadas para constuir un modelo de análisis multivariante de la supervivencia del segundo injerto (regresión de Cox), evaluando la importancia de la compatibilidad HLA global y específica de cada locus, así como de la reexposición antigénica, sobre su evolución. RESULTADOS: El seguimiento medio de los segundos trasplantes fue de 56ñ10 meses (12-133). El estudio multivariante demostró el incremento en la supervivencia del retrasplante cuando donante y receptor compartían al menos 3 antígenos HLA. Además, la compatibilidad para los locus A y DR tiende a mejorar la evolución, aunque sin alcanzar el rango de significación estadística. No obstante, el dato de mayor interés es que la repetición de incompatibilidades HLA entre el donante y sus dos receptores mejoró significativamente la supervivencia del retrasplante renal de cadáver (p=0,006).CONCLUSIONES: Nuestra experiencia confirma los beneficios de la política de asignación de injertos renales en virtud del grado de compatibilidad HLA también en el caso de retrasplante. Demuestran también que la reexposición antigénica no empeora necesariamente la evolución del segundo injerto renal en la era CyA (AU)