Estado actual y evolución del manejo de la patología funcional y del suelo pélvico en los hospitales de la Comunidad de Madrid / Evolution and current status of the management of functional and pelvic floor pathology in the hospitals of the Community of Madrid

Introducción y objetivo Las disfunciones del suelo pélvico (DSP) incluyen un amplio número de patologías sujetas a una alta variabilidad en su manejo según los medios y capacitación de los centros y sus profesionales. El objetivo del estudio es constatar y describir la variabilidad clínica en el manejo de las DSP en los servicios de Urología de los centros sanitarios públicos de la Comunidad de Madrid, así como la dotación de medios disponibles en la actualidad en dichos centros. Material y métodos Encuesta realizada en septiembre de 2021 dirigida a facultativos especialistas en Urología Funcional de los hospitales públicos de la Comunidad de Madrid. Esta se basa en una encuesta realizada en 2011 por Díez et al. con la misma finalidad. Se analizaron las características asistenciales de los distintos centros y el manejo de las principales patologías funcionales del suelo pélvico. Se compararon los resultados con los de la encuesta de 2011 para las preguntas equiparables. Resultados El número de Unidades de Suelo Pélvico (USP) ha aumentado notablemente en los últimos 10 años. El uso de dispositivos ajustables en el tratamiento de la IUE masculina se ha extendido en los centros encuestados. La colposacropexia laparoscópica/robótica se ha convertido en el tratamiento de referencia del prolapso de órganos pélvicos (POP). Conclusiones Las USP multidisciplinares son el modelo a seguir para el manejo de las DSP. Se constata la variabilidad en el manejo de la incontinencia urinaria, POP, el síndrome de dolor vesical y la neuropatía del nervio pudendo (AU)

Introduction and objective Pelvic floor dysfunction (PFD) includes a large number of pathologies subjected to a significantly varied management, depending on the hospitals’ resources and educational levels of their professionals. The aim of this study is to determine and describe the clinical variability in the management of PFD in the urology departments of the public health centers of the Community of Madrid, as well as the resources currently available in these centers. Material and methods The survey was carried out in September 2021 and was addressed to physicians specialized in functional urology in the public hospitals of the Community of Madrid. This survey is based on the one performed in 2011 by Díez et al. for the same purpose. The characteristics of the healthcare services provided in the different centers and the management of the main functional pathologies of the pelvic floor were analyzed. The results were compared with those of the 2011 survey for equivalent questions. Results The number of Pelvic Floor Units (PFUs) has remarkably increased in the last 10 years. The use of adjustable devices in the treatment of male SUI has become widespread in the centers included in the survey. Laparoscopic/robotic sacrocolpopexy has become the gold standard treatment for pelvic organ prolapse (POP). Conclusions Multidisciplinary PFUs represent the reference framework for the management of PFD. Variability in the management of urinary incontinence, POP, bladder pain syndrome and pudendal nerve neuropathy is recognized (AU)

Evolution and current status of the management of functional and pelvic floor pathology in the hospitals of the Community of Madrid.

INTRODUCTION AND OBJECTIVE: Pelvic floor dysfunction (PFD) includes a large number of pathologies subjected to a significantly varied management, depending on the hospitals' resources and educational levels of their professionals. The aim of this study is to determine and describe the clinical variability in the management of PFD in the urology departments of the public health centers of the Community of Madrid, as well as the resources currently available in these centers. MATERIAL AND METHODS: The survey was carried out in September 2021 and was addressed to physicians specialized in functional urology in the public hospitals of the Community of Madrid. This survey is based on the one performed in 2011 by Díez et al. for the same purpose. The characteristics of the healthcare services provided in the different centers and the management of the main functional pathologies of the pelvic floor were analyzed. The results were compared with those of the 2011 survey for equivalent questions. RESULTS: The number of Pelvic Floor Units (PFUs) has remarkably increased in the last 10 years. The use of adjustable devices in the treatment of male SUI has become widespread in the centers included in the survey. Laparoscopic/robotic sacrocolpopexy has become the gold standard treatment for pelvic organ prolapse (POP). CONCLUSIONS: Multidisciplinary PFUs represent the reference framework for the management of PFD. Variability in the management of urinary incontinence, POP, bladder pain syndrome and pudendal nerve neuropathy is recognized.

[Urogenital alterations in hereditary and sporadic neurodegenerative ataxias]. / Alteraciones urogenitales en las ataxias neurodegenerativas hereditarias y esporádicas.

INTRODUCTION: Sporadic and hereditary ataxias (HA) represent a group of clinically and genetically heterogeneous syndromes characterized by spinocerebellar degeneration producing a motoneuron coordination disorder. In these diseases urinary and sexual symptoms are commonly associated to the neurological alterations. OBJECTIVE: To define the prevalence of functional low urinary tract symptoms in an ataxic population and to compare them with the symptomatology control a group of in healthy subjects. PATIENTS AND METHODS: An observational, descriptive, transversal study of 491 subjects recruited from the HA regional associations of Spain was conducted. In addition, a case-control study of prevalent ataxic patients and healthy subjects matched by sex and age was also performed. RESULTS: Among 195 patients included, 138 (70.8 %) had Friedreich ataxia (FA) and 57 (29.2 %) non-Friedreich ataxia (nFA). Global mean age was 32.3 years in FA and 43.7 in nFA patients (p < 0.05). Combined irritative and obstructive symptoms were present in 48.7 %, only irritative in 16.4 % and obstructive in 15 % of patients. Erectile dysfunction in 30.3 % (p < 0.01) and decreased libido in 13.4 % (p < 0.01), were the most common sexual problems. CONCLUSIONS: In HA, urinary symptoms are present in 80 % of patients, with mainly irritative symptoms in 2/3 of them. A complete urodynamic evaluation in symptomatic patients is recommended in order to characterize potential neurogenic vesico-urethral dysfunction. Even though sexual dysfunction may be related to neurological causes, additional etiologic organic factors should be excluded.

Alteraciones urogenitales en las ataxias neurodegenerativas hereditarias y esporádicas / Urogenital alterations in hereditary and sporadic neurodegenerative ataxias

Introducción. Las ataxias hereditarias (AH) y esporádicas comprenden un grupo de síndromes clínica y genéticamente heterogéneos, caracterizados por un trastorno variable de coordinación motora secundario a degeneración espinocerebelosa. Cabe esperar, como en otras enfermedades neurológicas, que junto al cuadro clínico neurológico se asocien síntomas urinarios y sexuales. Objetivo. Conocer la prevalencia de síntomas urinarios y sexuales en una población definida de pacientes atáxicos respecto a un grupo control de sujetos sanos. Pacientes y métodos. Estudio observacional, descriptivo, de corte transversal sobre una muestra de pacientes atáxicos pertenecientes a las asociaciones regionales de AH en España. Los sujetos a estudio fueron evaluados mediante un cuestionario de síntomas. Se trata de un estudio comparativo caso-control sobre una serie de casos prevalentes de sujetos atáxicos y un grupo control de población sana, pareado por sexo y edad. Conceptualmente se investiga la situación clínica referida a abril de 2002, aunque la recogida de información se prolongó durante 6 meses. Resultados. En abril de 2002 estaban asociados en España 491 pacientes atáxicos. Disponemos de datos sobre 195 pacientes, de los que 138 (70,8 %) eran ataxias de Friedreich (AF) y 57 (29,2 %) ataxias no Friedreich (NF). Edad media global de la AF era de 32,3 años frente a los 43,7 años de las NF (p < 0,05). En su evolución presentaron síndrome urinario mixto el 48,7 %, síntomas urinarios irritativos el 16,4 % y síntomas urinarios obstructivos el 14,9 %. Los trastornos sexuales más frecuentes en varones fueron disfunción eréctil (30,3 %) (p < 0,01) y disminución del deseo sexual (13,4 %) (p < 0,01). Conclusiones. En las AH neurodegenerativas pueden presentarse síntomas urinarios leves o moderados en un alto porcentaje de pacientes, predominando los síntomas urinarios irritativos. Recomendamos estudio urodinámico completo en pacientes sintomáticos con objeto de caracterizar la posible disfunción neurógena vesicouretral. Aunque la disfunción sexual puede atribuirse a fenómeno neurológico, existen otros factores orgánicos involucrados en su patogenia, lo que implica un enfoque multidisciplinar

Introduction. Sporadic and hereditary ataxias (HA) represent a group of clineally and genetically heterogeneous syndromes characterized by espinocerebellar degeneration producing a motoneuron coordination disorder. In these diseases urinary and sexual symptoms are commonly associated to the neurological alterations. Objective. To define the prevalence of functional low urinary tract symptoms in an ataxic population and to compare them with the symptomatology control a group of in healthy subjects. Patients and methods. An observational, descriptive, transversal study of 491 subjects recruited from the HA regional associations of Spain was conducted. In addition, a case-control study of prevalent ataxic patients and healthy subjects matched by sex and age was also performed. Results. Among 195 patients included, 138 (70.8 %) had Friedreich ataxia (FA) and 57 (29.2 %) non-Friedreich ataxia (nFA). Global mean age was 32.3 years in FA and 43.7 in nFA patients (p<0.05). Combined irritative and obstructive symptoms were present in 48.7 %, only irritative in 16.4 % and obstructive in 15 % of patients. Erectile dysfunction in 30.3 % (p < 0.01) and decreased libido in 13.4 % (p < 0.01), were the most common sexual problems. Conclusions. In HA, urinary symptoms are present in 80 % of patients, with mainly irritative symptoms in 2/3 of them. A complete urodynamic evaluation in symptomatic patients is recommended in order to characterize potential neurogenic vesico-urethral dysfunction. Even though sexual dysfunction may be related to neurological causes, additional etiologic organic factors should be excluded

[Treatment approach for vesicogenital fistula. Retrospective analysis of our data]. / Planteamiento terapéutico de las fístulas vesicogenitales. Análisis retrospectivo de nuestra serie.

The vesicogenital fistula are abnormal communications between female genitalia and urinary bladder. We recorded all the vesicogenital fistula diagnosed since 1986, analyzing aetiology, treatment applied, complications and results. Total number of fistula have been 20 (18 vesicovaginal and 2 vesicouterine). The distribution in vesicovaginal fistula was iatrogenic in 15 cases (83%) and tumoral in 3 cases (17%). Vesicouterine fistula were due to cesarean. The initial treatment of the iatrogenic fistula was conservative using foley catheter. Twenty percent of the patients were cured with this treatment (3 cases). Surgical repair was necessary for the other patients, using different surgical approach according to the type of the fistula, intensity and patient age. It was successful in 91% of the patients. The results shows that simple surgical approach generate less morbidity and the early intervention is not less efficient.

[Fibroepithelial polyps of the upper urinary tract: their diagnostic evaluation and treatment in pediatrics]. / Polipos fibroepiteliales del tracto urinario superior: evaluación diagnóstica y tratamiento en pediatría.

OBJECTIVE: To establish the diagnostic criteria, analyze the histological patterns of benign and malignant ureteral and renal pelvic polyps in pediatric patients and discuss the best treatment option based on the final diagnosis. METHODS/RESULTS: The literature is reviewed with special reference to the diagnostic and therapeutic aspects of fibroepithelial polyps of the upper urinary tract in pediatric patients. An additional case with benign cytological and radiological findings is described. The patient underwent partial pyeloureteral resection. Histological analysis of the surgical specimen confirmed a fibroepithelial polyp. CONCLUSIONS: We emphasize the importance of adequate preoperative evaluation, precise identification of the base of the lesion for a correct choice of the surgical approach, and the advantages of complete segmental resection and reanastomosis over simple excision of the polyp.

[Urothelial carcinoma of the upper urinary tract. Survival and prognostic factors]. / Carcinomas uroteliales del tracto urinario superior. Supervivencia y factores pronósticos.

OBJECTIVE: To analyze the survival and the main prognostic factors in patients with transitional cell carcinoma of the upper urinary tract. METHODS: From 1983 to 1996, we treated 50 patients with transitional cell carcinoma of the upper urinary tract. Treatment was basically conservative except in those cases whose tumor stage or grade required a radical approach. Grading and staging were performed according to the 1992 TNM classification. Eighteen patients had died at one year mean follow-up., At the time the study was completed (June, 1997), 32 patients were alive with a mean follow-up of 4.9 years. Disease-free survival, overall and specific survival were analyzed according to sex, age, association with bladder tumors, localization, type of treatment, tumor size, number, histological grade and stage. RESULTS: The male-to-female ratio was 5:1. Patient mean age was 65.7 years. Association with bladder tumors was observed in 50%. Treatment was conservative in 40% and radical in 60%. The five- and ten-year disease-free survival rates were 69%, overall survival 61% and specific survival 71%. The univariate analysis showed the following to be unfavorable prognostic factors for survival: renal vs ureteral tumors, radical vs conservative treatment, high grade and stage tumors. The association of carcinoma in situ with other tumors of the upper urinary tract was also found to be an unfavorable factor for disease-free survival. The multivariate analysis associated T4 and G3 tumors with poor prognosis. CONCLUSIONS: Transitional cell carcinoma of the upper urinary tract was associated with bladder tumors in 50% of the cases. Low grade stage tumors demonstrated a high survival rate, therefore conservative treatment should be the first approach. High grade/ stage tumors were found to be unfavorable prognostic factors for survival.

[Evolution and prognostic factors of adenocarcinomas of the prostate metastasizing at diagnosis]. / Evolución y factores pronósticos de los adenocarcinomas de próstata metastásicos al diagnóstico.

OBJECTIVES: In 30-40% patients, prostate adenocarcinoma is diagnosed already in the metastatic phase, a percentage that will depend on the number of patients with localized cancer that we are unable to detect. Hormonal suppression is the most widely accepted therapeutical option, although there are doubts on the value of rescue treatment after the hormone-refractive stage. This paper analyses those parameters as well as the main prognostic factors in a series of 135 patients with metastatic prostate cancer at diagnosis. MATERIAL AND METHODS: Between 1983 and 1996, 414 patients were diagnosed with prostate adenocarcinoma in the Urology Unit. Móstoles Hospital, 135 of which (32.6%) were metastatic at the time of diagnosis and were managed as follows: 113 (84%) were treated with maximum androgenic blockade (MAB). 13 (9.6%) with orchiectomy and antiandrogens, 5 (3.7%) with various treatments, and only 4 received symptomatic treatment. Of those treated with MAB, 97 (72%) continued treatment after the hormone-refractive stage and 16 (12%) were given stramustine phosphate instead of the antiandrogen. Response monitoring was done basically by means of serial PSA determination. The parameters analyzed included survival and the following potential prognostic factors: age, performance status, metastatic bone pain, tumour diagnosis based on number of metastasis, prior PSA level, Gleason, local stage, M1 type at diagnosis based on the 1992 TNM classification, and response to the various treatment applied. RESULTS: Mean age: 72 years. Over an average of 25 (0-127) months, 80 (59%) patients have died; mean follow-up of patients alive at end of study: 24 months (3-111). Lost to follow-up: 6 patients (4.4%). Up to 1991, the proportion of patients with metastasis was 48%; since 1992, 24%. Percentage of patients diagnosed due to clinical manifestations of the metastasis (25 patients) over these two periods increased, mean age decreased and the proportion of patients with highly aggressive tumours increased. Mean overall survival, 26 months: influential prognostic factors: diagnosis due to metastasis and Gleason greater than 7; very poor prognosis for those receiving no hormonal therapy, with no differences between drug versus surgical treatment. Tumour-dependent mean survival, 32 months; influential prognostic factors: performance status, metastatic bone pain, diagnosis due to metastasis and Gleason greater than 7; very poor prognosis for those receiving no hormonal therapy. Progression-free interval, 19 months; influential prognostic factors: metastatic bone pain, PSA higher or lower than 90. Gleason greater than 7 and local stage: no differences between treatments. Mean survival after progression, 6 months; influential prognostic factors: diagnosis due to metastasis, M1b versus M1c patients: increased survival in patients rescued with stramustine phosphate. CONCLUSIONS: The proportion of prostate adenocarcinomas with metastasis at diagnosis shows a trend to decrease, although the percentage of patients who are diagnosed by the sings and symptoms of their metastasis is increasing. These patients should be treated with pharmacological or surgical hormone-suppression. Rescue treatment with stramustine phosphate prolongs survival. Influential prognostic factors: Gleason greater than 7, metastatic bone pain, tumour extent and previous PSA.

[Vesical endometriosis after cesarean section: diagnostico-therapeutic aspects]. / Endometriosis vesical tras cesárea: aspectos diagnóstico-terapéuticos.

Endometriosis is a benign condition with an aggressive behaviour defined by the presence of ectopic endometrial tissue, outside the uterus. It occurs in 15-20% women with child bearing potential. Most commonly it affects organs such as the ovaries, uterine ligaments, fallopian tubes, rectum and the cervico-vaginal region. Involvement of the urinary tract, however, is rare. It can be seen in just about 1% cases, vesical location being the most frequent of these presentations (84% cases). We describe one case of vesical endometriosis that developed after a cesarean section. The intra-operative findings confirmed the existence of infiltration of the detrusor muscle and the vesical mucosa by endometrial tissue from the area of the uterine incision. A discussion of the different diagnostic and therapeutic options is also included.

[Clinical course of superficial transitional carcinoma of the bladder without poor prognostic factors]. / Evolución clínica de los carcinomas transicionales superficiales de vejiga sin factores pronóstico desfavorables.

OBJECTIVES: Surface carcinoma of the bladder shows a high incidence of tumour recurrence that require frequent examinations associated to potential morbidity. This paper analyses our series of patients with vesical tumours with no known unfavourable clinical prognostic factors, aiming to detect low risk groups where it may be feasible to change the usual follow-up criteria. MATERIAL AND METHODS: Between 1983 and 1996, 503 patients with vesical cancer, 388 of which 388 were primarily surface tumours, were monitored. The study analyzed 24 patients with surface transitional carcinoma with no unfavourable prognostic factor, i.e. Ta tumours, grade 1, single, under 1 cm, negative urine cytology and multiple negative vesical biopsies. This group was then compared to a control group comprising all other patients with surface tumours in our series (364 patients), and the prognostic factors were assessed based on the disease-free interval, progression-free interval, and overall and tumour-specific survival. Also the recurrence-free interval from the first endoscopic control at 3 months after transurethral resection, were studied according to Parmar's criteria. RESULTS: With a mean follow-up of 53 months, 37% patients in the study group have relapsed versus 41% in the control group (n = 0.9), after 2 years on average. Actuarial curves in the control group reveal statistical significance for higher degree tumours recurrence. No grade progression has occurred in the study group versus 9% in the control group. No patient evolved to T2 versus 5% in the control group; also in this group, 5% patients died because of their tumour versus none in the study group. The 24 patients in the study belong to group 1 in Parmar's low risk, while the remainder of patients in the control group ranked according to these criteria have demonstrated an unfavourable statistical significance (p < 0.01) in patients with early relapse. CONCLUSIONS: Good results obtained in the evolution of patients with surface tumours with no unfavourable prognostic factors are due to the strict monitoring they undergo in order to detect early relapses. However, 37% of recurrences in this group does not allow to modify the usual follow-up schedule. In our experience, Parmar's criteria does not contribute any benefit over classical criteria to evaluate prognostic factors in surface vesical cancer.

[Meconial hydrocele]. / Hidrocele meconial.

Presentation of one case of meconial hydrocele, a very infrequent disease that should be taken into account in all newborns presenting intrascrotal mass. Ultrasonography performed to a 29 year-old female during the 36th week of pregnancy, demonstrated in the fetus the presence of an enlarged right hemiscrotum with homogenous material inside, which was diagnosed as an intrascrotal haematoma due to a likely intrauterine spermatic cord torsion. After eutocic delivery, within one month from birth the newborn developed signs and symptoms which were compatible with acute scrotum and the emergency surgical exploration showed meconial hydrocele secondary to patency of peritoneal-vaginal duct with associated inguinal hernia. The causes, forms of presentation, differential diagnoses and therapeutical options of meconial peritonitis, a rare condition with favourable evolution in most cases, are analyzed showing that, under certain circumstances, treatment is controversial.

[Epidemiologic indicators of adenocarcinoma of the prostate. Results on 436 patients]. / Indicadores epidemiológicos del adenocarcinoma de próstata. Resultados sobre 436 pacientes.

OBJECTIVE: To conduct a populational study by analyzing the major epidemiological indicators in a group of 436 patients with prostate adenocarcinoma. MATERIAL AND METHODS: The population reference for the study involves a total of 396,294 people, of which 197,500 are male. Between 1983 and 1996, 436 patients were diagnosed with prostate adenocarcinoma in the Urology Service of Mostoles Hospital. Gleason Index has been used to determine the histological grade, while the 1992 TNM rating was used for staging purposes. Gleason rating is known for 395 patients, distribution being as follows: 26.6% with Gleason 2, 3 or 4; 44.6% with 5, 6 or 7 and 28.9% with 8, 9 or 10. T1 tumours accounted for 21.1% cases; T2: 45.6%; T3: 22.2% and T4: 11%. There were 58.3% M0: 32.8% M1 and 8.9% Mx tumours. Approach for local disease: radical prostatectomy or radiotherapy. Approach for disseminated disease; hormonal blockade. Deaths: 130 (29.8%); cancer related deaths: 91 (70%). Mean follow-up of survivors: 3.4 years (0.25-14 years). Major variables analyzed: age, incidence, prevalence, mortality, Gleason's evolution and overall and specific survival. RESULTS: Mean age: 71.3 years. Prior to 1990 there were 55.5% patients under 70 years old; in 1995-96 there are 39.4%. Incidence has increased up to 36.5% per 100,000 people/year in 1996. Mean mortality in 1993-1996: 5.6 per 100,000 people/year. Prevalence in 1996: 155 per 100,000 people/year. Family background for prostate cancer: 8%. Incidence of second tumours: 10.5%. Increased proportion of patients with moderate to high versus low Gleason grades. Overall survival at 5 years: 53%, at 10 years: 33%. Tumour related survival at 5 years: 65%; at 10 years: 48%. Older age, higher PSA, higher Gleason, advanced stages and metastasis are all unfavourable prognostic factors for both overall and specific survival (p = 0.000). Significant prognostic factors in multivariate analysis have been a higher Gleason grade and non metastatic tumour at diagnosis. CONCLUSIONS: Incidence of prostate adenocarcinoma has increased in our milieu, reaching 36.5 per 100,000 people/year in 1996, far from the figures in the US. Actual mortality in our series is somehow lower than data published in other national series. This condition shows very high prevalence rates which results in increasingly growing and highly significant economic costs.

[Bladder pseudosarcoma in pediatrics: clinico-pathological features and treatment]. / Pseudosarcoma vesical en pediatría: aspectos clínico-patológicos y tratamiento.

OBJECTIVES: To review the most common clinical signs and symptoms of inflammatory pseudotumor of the bladder in children and to distinguish this benign lesion from malignant neoplasms such as rhabdomyosarcoma and leiomyosarcoma. METHODS: Two cases os pseudosarcomatous tumor of the bladder in children are described. In the first patient, the tumor had appeared spontaneously in a 9-year-old boy. The second had developed in a 6-year-old girl and was considered to be reactive to prior surgery. The literature is reviewed and data from 16 cases of inflammatory pseudotumor of the bladder in patients under 16 years of age are also presented. RESULTS: The mean age at presentation was 8 years. The male-to-female ratio was 3:1. Hematuria (56%), dysuria (37%) and abdominal pain with a palpable mass (18%) were the most commonly described clinical manifestations. Tumor size ranged from 3 to 10 cm and they were frequently located in the lateral walls and base of the bladder. Histological analysis showed an inflammatory pseudosarcomatous reaction. Immunohistochemical analysis showed moderate staining for vimentin, mild staining for focal muscle actin and negative for keratin and S-100 protein. Patients were treated by local resection (7 pts), partial cystectomy (5 pts), radical cystectomy (2 pts) and pelvic exenteration (2 pts). The mean follow-up was 34 months. All patients that had been followed (14/16) were reported to be free of disease with no evidence of recurrences or metastases. CONCLUSIONS: Inflammatory pseudotumor of the bladder is an unusual benign tumor that is very rare in children. Long-term follow-up confirms the benign nature of the lesion and conservative management is therefore advocated. However, given its histological similarity to malignant tumors, a close follow-up is recommended.