[Hand-assisted laparoscopic nephrectomy]. / Nefrectomia laparoscópica mano-asistida.

INTRODUCTION AND OBJECTIVES: To present the number of cases of hand-assisted laparoscopic nephrectomy. This study evaluates our results and difficulties of starting a progresive programme of laparoscopy. MATERIAL AND METHOD: Between november 2003 and november 2005, 35 hand-assisted laparoscopic nephrectomies were carried out, of a total of 45 laparoscopic nephrectomies. 22 radical nephrectomies, 3 simple nephrectomies and 10 nephroureterectomies. The average age of patients was 66 years (47-89). On average, they were overweight (IMC 28,3), with approximately 38% being obese. ASA 2.3 (1-4). The tumors measured 4.8cm on average, and 80% of these were T1. In 28.6% of the cases, they had previously undergone abdominal surgery. RESULTS: One was undertaken in 2003, 17 in 2004, and 17 in 2005. The surgery time was 140 minutes, 130 minutes (80-210) in radical nephrectomies, 135 minutes (120-150) in simple nephrectomies and 163 minutes (80-240) in the nephroureterectomy. Patients began an oral diet 1.7 days later, and were able to get up 1.7 days later. In the case of obese patients, they began an oral diet 2.3 days later and were able to get up (2.4 days) later than those non obese cases. (1.5 and 1.4 days respectively). The average stay has been 5.8 days (3-15). The average stay of the cases without complications was 4.2 days and those that encountered complications 9.7 days. In no cases was there a need for a blood transfusion. In 11.4% we had major complications with an average stay of 11.7 days. In 5.7% of cases there were reconversions, and 5.7% of cases were reoperated. 17.1% had minor complications, with an average stay of 8.8 days CONCLUSIONS: The advantage of hand-assisted nephrectomy is that it allows one to begin a laparoscopy, with a reduced learning time, and with satisfactory results, allowing the incorporation of laparoscopy surgery in hospitals with a reduced annual volume.

Nefrectomía laparoscópica mano-asistida / Hand-assisted laparoscopic nephrectomy

Introducción y Objetivos: Presentamos nuestra casuística de nefrectomías laparoscópicas mano-asistidas. Se valoran nuestros resultados y las dificultades del inicio de un programa progresivo de laparoscopia. Material: Desde noviembre 2003 hasta noviembre 2005 se han realizado 35 nefrectomías laparoscópicas Mano-asistidas, de un total de 45 nefrectomías laparoscópicas. 22 nefrectomías radicales, 3 nefrectomías simples y 10 nefroureterectomías. Media de edad 66 años (47-89). Tenían una media de sobrepeso (IMC 28,3); 38% eran obesos. ASA 2,3 (1-4). Los tumores tenían 4,8 cm de tamaño medio; 80% eran T1. El 28,6% habían sido operados previamente de cirugía abdominal. Resultados: Se realizaron 1 en 2003, 17 en 2004, y 17 en 2005. El tiempo quirúrgico ha sido 140 minutos, 130 minutos (80-210) en nefrectomías radicales, 135 minutos (120-150) en nefrectomías simples y 163 minutos (80-240) en nefroureterectomías. Los pacientes iniciaron dieta oral en 1,7 días y se levantaron en 1,7 días. Los obesos iniciaron la dieta (2,3 días) y se levantaron (2,4 días) más tarde que los no obesos (1,5 y 1,4 días respectivamente). La estancia media ha sido 5,8 días (3-15); en los no complicados 4,2 días y en los que han tenido complicaciones 9,7 días. En ningún caso se trasfundió. Hemos tenido 11,4% de complicaciones mayores con EM de 11,7 días. Un 5,7% de reconversiones y 5,7% de reoperaciones. Y 17,1% de complicaciones menores, con EM de 8,8 días. Conclusiones: La nefrectomía mano-asistida es una técnica que por sus ventajas permite un inicio en la laparoscopia, con menor curva de aprendizaje, y resultados satisfactorios, permitiendo incorporar la cirugía laparoscópica a hospitales con un menor volumen anual

Introduction and objectives: To present the number of cases of hand-assisted laparoscopic nephrectomy. This study evaluates our results and difficulties of starting a progresive programme of laparoscopy. Material and Method: Between november 2003 and november 2005, 35 hand-assisted laparoscopic nephrectomies were carried out, of a total of 45 laparoscopic nephrectomies. 22 radical nephrectomies, 3 simple nephrectomies and 10 nephroureterectomies. The average age of patients was 66 years (47-89). On average, they were overweight (IMC 28,3), with approximately 38% being obese. ASA 2.3 (1-4). The tumors measured 4.8cm on average, and 80% of these were T1. In 28.6% of the cases, they had previously undergone abdominal surgery. Results: One was undertaken in 2003, 17 in 2004, and 17 in 2005. The surgery time was 140 minutes, 130 minutes (80-210) in radical nephrectomies, 135 minutes (120-150) in simple nephrectomies and 163 minutes (80-240) in the nephroureterectomy. Patients began an oral diet 1.7 days later, and were able to get up 1.7 days later. In the case of obese patients, they began an oral diet 2.3 days later and were able to get up (2.4 days) later than those non obese cases. (1.5 and 1.4 days respectively). The average stay has been 5.8 days (3-15). The average stay of the cases without complications was 4.2 days and those that encountered complications 9.7 days. In no cases was there a need for a blood transfusion. In 11.4% we had major complications with an average stay of 11.7 days. In 5.7% of cases there were reconversions, and 5.7% of cases were reoperated. 17.1% had minor complications, with an average stay of 8.8 days Conclusions: The advantage of hand-assisted nephrectomy is that it allows one to begín a laparoscopy, with a reduced learning time, and with satisfactory results, allowing the incorporation of laparoscopy surgery in hospitals with a reduced annual volume

[Usefulness of the dynamic sentinel node technique in patients with penile carcinoma]. / Utilidad de la técnica del ganglio centinela dinámico en pacientes con carcinoma de pene.

OBJECTIVE: To explain and analyse when and how to use the new staging technique used in patients with squamous carcinoma of the penis, through the procedure of dynamic biopsy of the sentinel lymph node. PATIENTS AND METHODS: We demonstrate the technical application of the dynamic biopsy of the sentinel lymph node, in a 40-year-old patient, diagnosed as suffering from squamous carcinoma of the penis. We use preoperative lymphatic visualization through lymphogammagraphy, together with intraoperative detection through gamma scanning, in order to detect and identify the sentinel lymph node. CONCLUSIONS: We consider the dynamic biopsy of the sentinel node by the individual pattern of the lymphatic drainage as a new applicable Nuclear Medicina technique. It is an extremely useful technique in order to achieve early dissemination, by allowing us to identify patients with sub-clinic lymphatic spread, who will be candidates to regional lymphatic dissection.

Utilidad de la técnica del ganglio centinela dinámico en pacientes con carcinoma de pene / Utility of dynamic sentinel lymph node procedure in patients with carcinoma of the penis

OBJETIVO: Explicar y analizar, cuándo y cómo realizar la nueva técnica de estadiaje utilizada en los pacientes con carcinoma escamoso de pene, mediante el procedimiento de biopsia dinámica del ganglio centinela. MATERIAL Y MÉTODOS: Exponemos la aplicación de la técnica de biopsia dinámica de ganglio centinela en un paciente de 40 años, diagnosticado de carcinoma escamoso de pene. Mediante combinación de la visualización linfática preoperatoria mediante linfogammagrafía, con la detección intraoperatoria con sonda gamma, se logra detectar e identificar el ganglio centinela. CONCLUSIONES: Consideramos la biopsia dinámica del ganglio centinela, por el patrón individual de drenaje linfático, como una nueva exploración aplicable de Medicina Nuclear. Se trata de una técnica de gran utilidad en la detención precoz de diseminación, permitiendo la identificación de pacientes con afectación linfática, clínicamente inadvertida, que puedan y deban ser subsidiarios de disección regional linfática (AU)

[Cystic nephroma. Report of 5 cases]. / Nefroma quístico. A propósito de 5 casos.

OBJECTIVE: To report 5 cases of cystic nephroma and review the clinical, diagnostic and therapeutic aspects. METHODS: From 1974 to 1988, 5 cases of cystic nephroma were diagnosed at our hospital. Patient evaluation included IVP and renal US, and occasionally ascending urography, fine needle aspiration biopsy and CT. The cyst was removed through a lumbar incision in 4 patients and nephrectomy in one patient. RESULTS: The patients were followed by yearly ultrasound/urography for 1 to 15 years. No evidence of local recurrence or metastatic disease has been found. CONCLUSIONS: Cystic nephroma is an uncommon, benign kidney disease whose etiology is unknown. Although new imaging techniques are available, surgical excision and histologic analysis of the tumor are the only effective methods to distinguish benign from malignant cystic lesions of the kidney. Because it is a benign lesion, surgery must be conservative. Complete excision of the cyst is advocated. We found a well-encapsulated, noninfiltrating lesion that permitted surgical excision without difficulty in most of our cases. Herniation of some cysts into the urinary tract is a characteristic radiological sign.

[Foreign body as renal pseudotumor in a patient with renal polycystic kidney]. / Cuerpo extraño como pseudotumor renal en un paciente con poliquistosis renal.

OBJECTIVE: To report a case of granuloma due to a retained surgical sponge that mimicked a pseudotumor in a patient with autosomal dominant polycystic kidney disease. The appearance of retained surgical sponges on diagnostic imaging is reviewed. METHODS: Patient evaluation included renal ultrasound, magnetic resonance imaging (MRI) and arteriography. RESULTS: MRI provides characteristic features that permit preoperative diagnosis. CONCLUSIONS: In the presence of a mass or abscess in patients who have previously undergone surgery, a retained surgical sponge should be included in the differential diagnosis. MRI permits preoperative diagnosis.

[Etiopathogenesis and management of paraneoplastic fever and Stauffer syndrome in renal carcinoma]. / Etiopatogenia y manejo de la fiebre paraneoplásica y del síndrome de Stauffer en el carcinoma renal.

Some paraneoplastic syndromes as fever, cachexia, loss of weight or hepatic dysfunction, are relatively frequent in patients affected by a renal cell carcinoma (RCC). However their pathogeny has been unknown until a short time ago. The advances in immunology have permitted to identify the interleukin-6 as the responsible for these changes. In spite of our better knowledge, the treatment of these paraneoplastic syndromes, when persist after the removal of the tumor, continues being a challenge. We present the case of a patient with a renal cell carcinoma that began as a feverish syndrome, developing thereinafter a hepatic dysfunction or Stauffer's syndrome. The paraneoplastic symptoms persisted after removal of the tumor. No response to the administered treatment has been observed. The patient died two months after the surgery.

[Upper urinary tract tumors: results of treatment and follow-up]. / Tumores del tracto urinario superior: resultados del tratamiento y seguimiento.

OBJECTIVE: To present the results of treatment and follow-up of 105 patients with tumor of the upper urinary tract. METHODS: A retrospective study was conducted on 105 patients (88 male and 17 female; mean age 68.3 years) with tumor of the upper urinary tract that had been treated from 1975 to 1997. In total 114 functional units were treated, including recurrences and bilateral tumors. The sites of involvement were: ureter (49.9%), pelvis (41.2%) and the entire upper urinary tract (8.7%). Ninety-six percent were transitional cell carcinomas: 4.8% were well differentiated (GI), 68% moderately differentiated (G2) and 26.8% poorly differentiated (G3); 58.6% were superficial, while 41.3% showed tumor invasion into or beyond the muscle layer. Ninety-two of the 105 patients were followed. The SPSS program was employed for the statistical analysis. The survival was calculated by the Kaplan-Meier method and the differences by the log rank test. Multivariance analysis was performed using the Cox regression method. TREATMENT: 58% underwent radical nephroureterectomy, 30% were treated conservatively and 11.6% underwent partial resection of the upper urinary tract. Recurrence: 8.7% of the patients showed tumor recurrence. The recurrence rate after conservative surgery was 13.6% and was as high as 80% in the remaining ureter. Metastasis: 22.8% of the patients presented metastasis to the retroperitoneal lymph nodes, bone, liver and lungs. Survival: In the univariate analysis tumor stage, age, radical and conservative surgery were found to influence survival, while stage and surgery (radical or conservative) were found to be statistically important by multivariate analysis. CONCLUSIONS: The treatment of choice for high grade and stage transitional cell carcinoma is by radical surgery, whereas for the superficial and well differentiated tumors, conservative management can achieve similar survival rates while preserving the renal unit and upper urinary tract.

[Expression of protein p53 in superficial transitional carcinoma of the bladder with differing course]. / Expresión de la proteína p53 en carcinomas transicionales vesicales superficiales con distinta evolución.

OBJECTIVE: To determine the prognostic value of p53 protein expression in relation to progression of superficial bladder cancer. METHODS: A retrospective study was conducted in which p53 protein was determined in TUR fragments of 18 patients with superficial transitional cell carcinoma of the bladder with no evidence of tumor progression in the last 6 years and in 13 patients with superficial tumors that had become invasive. DO-7 monoclonal antibody was utilized (+if stained nuclei were more than 25%). RESULTS: Expression of p53 protein was found in 9 patients (50%) with bladder tumors that had not progressed and in 6 patients (46.1%) with bladder tumors that had become invasive (p = 0.83). CONCLUSION: Determination of p53 protein was not related with cancer progression in this series.

[Asymptomatic renal carcinoma diagnosed based on synchronous metastasis in the thyroid gland]. / Carcinoma renal asintomático diagnosticado a partir de una metástasis sincrónica en tiroides.

Secondary tumors of the thyroid are very rare, being the kidney the most frequent place of the primary tumor. The majority of these metastases appear months or years after the primary renal tumor. We report the case of an asymptomatic renal carcinoma discovered after the histological analysis of a thyroidectomy piece. The treatment of the primary renal tumor was radical nephrectomy. Three years after diagnosis and treatment the patient is free of relapse.

[Leiomyosarcoma of the inferior vena cava. Apropos of a case]. / Leiomiosarcoma de cava inferior. A propósito de un caso.

Presentation of one case of inferior cava leiomyosarcoma in a 24-year old female patient, incidentally diagnosed after performance of ultrasound. The complementary examinations performed (CAT, NMR, arteriography) guided to a mass of suprarenal origin. During surgery, a tumour of the inferior cava vein was suspected and was later confirmed through the pathoanatomical study of the surgical piece. Review of the clinical and diagnostic aspects placing special emphasis on treatment.

[Rectorrhage as an unusual extrarenal complication after ESWL]. / Rectorragias como complicación extrarrenal poco habitual tras LEOC.

We report a case of rectorrhage due to an hematoma of sigmoid colon post ESWL in a patient with chronic hepatopathy and right ureteral calculus. We comment the clinic and endoscopical study, as well as the review of literature.

[Immunotherapeutic treatment for metastatic renal carcinoma]. / Tratamiento inmunoterápico para el carcinoma renal metastásico.

Immunotherapy management for advanced renal carcinoma has awaken a growing interest over the last few years. Based on Atzpodien's studies, in December 1994 a protocol was initiated in our centre for the treatment of metastatic renal carcinoma, using subcutaneous alpha interferon, subcutaneous Interleukin-2 and endovenous 5-Fluorouracil. The present report analyzes all six cases included in the protocol and their results.

[Tumors of the upper urinary tract: epidemiology, clinical, and diagnosis]. / Tumores del tracto urinario superior: epidemiología, clínica y diagnóstico.

OBJECTIVE: To review the epidemiological, clinical and diagnostic aspects of upper urinary tract tumors (UUTT). METHODS: The clinical records of 105 patients with UUTT were reviewed. There were 114 functioning units in total. Data on distribution according to sex, age at presentation, involved side, focality, localization, association with bladder tumor, risk factors, clinical features, radiological and histological findings were analyzed. Descriptive statistical analysis was performed and the means and frequency rates were estimated. RESULTS: Of the 105 patients, 88 (83.8%) were male and 17 (16.1%) were female, accounting for a male to female ratio of 5.1:1. The mean age was 68.3 +/- 10.5 years (range 24-88). The tumor involved the left side in 52 cases (49.5%), the right side in 49 cases (46.6%) and 4 cases (3.8%) had bilateral involvement; 84 (80%) were unifocal and 21 (20%) were multifocal. The pyelocaliceal region was compromised in 41.2% (47/114) of the functioning units, the lumbar ureter in 14% (16/114), the sacral ureter in 7% (8/114), the pelvic ureter in 28.9% (33/114) and the entire upper urinary tract in 8.7% (10/114). UUTT was associated with a bladder tumor in 60.9%. The bladder tumor and UUTT presented simultaneously in 26 cases (29.8%). The bladder tumor presented before the UUTT in 35 cases (40.2%) and in 26 cases (29.8%) it presented after. Smoking was found to be the most important risk factor. Hematuria was the most common reason for consultation (67.6%), followed by flank pain (23.8%), and 13.3% were asymptomatic. The most common urographic finding was a filling defect (46.4%), followed by loss of function (36.8%) and hydronephrosis (20.1%). Loss of renal function was observed in 66% of the cases with metastasis. Histologically, 99% were transitional cell carcinoma, basically moderately differentiated (68.8% grade II) and non infiltrating (58.6% pTa-pT1). CONCLUSIONS: Our findings are largely in agreement with the data published in the literature, although we have found a very high incidence of UUTT associated with bladder tumor in our series.