Evaluación de los indicadores de calidad asistencial de la Asociación Española de Urología en un programa de trasplante renal / Evaluation of the Spanish Urological Association quality care indicators in a kidney transplantation programme

Introducción: Los indicadores muestran la presencia de un fenómeno y su intensidad. Evalúan el nivel de calidad asistencial, identificando situaciones de mejora potencial. Nuestro objetivo es evaluar los indicadores de calidad asistencial de 2013 y 2014 del área de trasplante renal de nuestro servicio. Material y método: Revisamos 88 y 106 trasplantes renales, y 47 y 66 extracciones realizados durante 2013 y 2014. Evaluamos los indicadores de calidad asistencial elaborados por la Asociación Española de Urología, analizando los resultados con el programa SPSS v 21.0. Resultados: Tiempo de isquemia fría (TIF) medio 14,96h en 2013 y 18,07h en 2014; TIF≤18h en 53% y 56% de riñones de donante cadáver. Tasa de fístula urinaria precoz relevante de 1,14% y 2,83% cada año; tasa de trasplantectomía precoz por complicación vascular 3,41% y 2,83%. Supervivencia global del paciente al primer año del 100% para ambos periodos; supervivencia de injerto al primer año del 95% y 94,34%. Porcentaje de trasplante de donante vivo del 14,77% y 17,92%, siendo laparoscópicas el 92,31% de extracciones de vivo en 2013 y 68,42% en 2014. Médicos en formación (MIR) como primer cirujano en el 6,67% y 12,64% de trasplantes, y en el 55,88% y 19,14% de extracciones de cadáver. Conclusiones: Durante el periodo evaluado se cumplieron todos los estándares de calidad asistencial en trasplante renal, salvo el TIF en ambos años y participación de MIR en implante renal únicamente en 2013. Este análisis promociona mejoras en la calidad asistencial, pudiendo trabajar sobre puntos débiles detectados

Introduction: Indicators show the presence of a phenomenon and its intensity. They assess the level of quality care and identify potential situations for improvement. Our objective is to assess the 2013 and 2014 quality care indicators of our department's kidney transplantation area. Material and method: For 2013 and 2014, we reviewed 88 and 106 kidney transplants and 47 and 66 extractions. We evaluated the quality care indicators developed by the Spanish Urological Association, analysing the results with the SPSS v 21.0 programme. Results: The mean cold ischaemia time (CIT) was 14.96hours in 2013 and 18.07hours in 2014. The CIT was ≤18h in 53% and 56% of cadaveric donor kidneys in 2013 and 2014, respectively. The rate of relevant early onset urinary fistulae was 1.14% and 2.83% for each year. The rate of early transplantectomy due to a vascular complication was 3.41% and 2.83% for 2013 and 2014, respectively. Overall patient survival at 1 year was 100% for both periods, and graft survival at 1 year was 95% and 94.34% for 2013 and 2014, respectively. The rate of living-donor transplantation was 14.77% and 17.92%, and 92.31% and 68.42% of the living-donor extractions were laparoscopic for 2013 and 2014, respectively. Resident medical interns were the first surgeon in 6.67% and 12.64% of the transplantations and in 55.88% and 19.14% of the cadaveric extractions during 2013 and 2014, respectively. Conclusions: During the evaluated period, all quality care standards in kidney transplantation were met, except for CIT in both years and resident medical intern participation in kidney implantation in 2013. This analysis promotes improvements in quality care, highlighting weak spots that need work

Evaluation of the Spanish Urological Association quality care indicators in a kidney transplantation programme. / Evaluación de los indicadores de calidad asistencial de la Asociación Española de Urología en un programa de trasplante renal.

INTRODUCTION: Indicators show the presence of a phenomenon and its intensity. They assess the level of quality care and identify potential situations for improvement. Our objective is to assess the 2013 and 2014 quality care indicators of our department's kidney transplantation area. MATERIAL AND METHOD: For 2013 and 2014, we reviewed 88 and 106 kidney transplants and 47 and 66 extractions. We evaluated the quality care indicators developed by the Spanish Urological Association, analysing the results with the SPSS v 21.0 programme. RESULTS: The mean cold ischaemia time (CIT) was 14.96hours in 2013 and 18.07hours in 2014. The CIT was ≤18h in 53% and 56% of cadaveric donor kidneys in 2013 and 2014, respectively. The rate of relevant early onset urinary fistulae was 1.14% and 2.83% for each year. The rate of early transplantectomy due to a vascular complication was 3.41% and 2.83% for 2013 and 2014, respectively. Overall patient survival at 1 year was 100% for both periods, and graft survival at 1 year was 95% and 94.34% for 2013 and 2014, respectively. The rate of living-donor transplantation was 14.77% and 17.92%, and 92.31% and 68.42% of the living-donor extractions were laparoscopic for 2013 and 2014, respectively. Resident medical interns were the first surgeon in 6.67% and 12.64% of the transplantations and in 55.88% and 19.14% of the cadaveric extractions during 2013 and 2014, respectively. CONCLUSIONS: During the evaluated period, all quality care standards in kidney transplantation were met, except for CIT in both years and resident medical intern participation in kidney implantation in 2013. This analysis promotes improvements in quality care, highlighting weak spots that need work.

Tratamiento conservador del carcinoma renal de novo sobre injerto renal / Conservative treatment of de novo renal carcinoma on kidney graft

Introducción: El carcinoma renal de novo en el trasplante renal es una situación poco frecuente pero no excepcional, de mucha trascendencia por la potencial mortalidad del receptor o pérdida del injerto. El objetivo de nuestro trabajo es conocer el manejo y evolución de estos tumores en nuestra unidad de trasplante renal. Material y métodos: Analizamos los casos de tumor renal de novo entre los trasplantados de los últimos 17 años en nuestra unidad de trasplante renal, detectando 3 casos de carcinoma de células claras y uno de carcinoma papilar sobre el injerto. Se realizó seguimiento desde el punto de vista oncológico y de función renal, y se analizó la respuesta a cambios en la inmunosupresión. Resultados: En todos los casos se practicó tumorectomía, precisándose en el paciente con carcinoma papilar trasplantectomía posteriormente. En ningún caso hubo complicaciones quirúrgicas relevantes. Además, se realizó conversión a un inhibidor de señales de proliferación o inhibidor de la mTOR y retirada completa de anticalcineurínicos. Con un seguimiento medio de 43,5 meses (15-61) los 3 pacientes con carcinoma de células claras sobreviven con buena función del injerto y sin datos de recidiva tumoral. El paciente con carcinoma papilar realiza seguimiento en otro centro hospitalario. Conclusiones: La cirugía conservadora, junto con la conversión a un inhibidor de señales de proliferación, parecen ser una opción segura para el tratamiento de tumores primarios en injerto renal, ofreciendo buenos resultados oncológicos y en cuanto a función renal a corto y medio plazo

Background: De novo renal carcinoma in kidney transplants is an uncommon but not exceptional condition and is of significant importance due to the potential for recipient mortality and graft loss. The aim of our study was to determine the management and outcome of these tumors in our Kidney Transplantation Unit. Material and methods: We analyzed cases of de novo kidney tumors among patients who underwent transplantation in the last 17 years in our Kidney Transplantation Unit. We detected 3 cases of clear cell carcinoma and 1 case of papillary carcinoma on the graft. We conducted follow-up on the tumor and renal function and analyzed patient responses to changes in immunosuppression. Results: Tumorectomy was performed in all cases, and subsequent transplantectomy was required for patients with papillary carcinoma. None of the patients had relevant surgical complications. We also changed the patients’ regimen to a proliferation signal inhibitor or mTOR inhibitor and completely withdrew all anticalcineurin agents. With a mean follow-up of 43.5 months (15-61), the 3 patients with clear cell carcinoma survived with good graft function and with no evidence of tumor recurrence. The patient with papillary carcinoma underwent follow-up at another hospital center. Conclusions: Conservative surgery along with conversion to a proliferation signal inhibitor appears to be a safe option for treating primary tumors in kidney grafts and offers good oncological and renal function results in the short and medium term

Conservative treatment of de novo renal carcinoma on kidney graft.

BACKGROUND: De novo renal carcinoma in kidney transplants is an uncommon but not exceptional condition and is of significant importance due to the potential for recipient mortality and graft loss. The aim of our study was to determine the management and outcome of these tumors in our Kidney Transplantation Unit. MATERIAL AND METHODS: We analyzed cases of de novo kidney tumors among patients who underwent transplantation in the last 17 years in our Kidney Transplantation Unit. We detected 3 cases of clear cell carcinoma and 1 case of papillary carcinoma on the graft. We conducted follow-up on the tumor and renal function and analyzed patient responses to changes in immunosuppression. RESULTS: Tumorectomy was performed in all cases, and subsequent transplantectomy was required for patients with papillary carcinoma. None of the patients had relevant surgical complications. We also changed the patients' regimen to a proliferation signal inhibitor or mTOR inhibitor and completely withdrew all anticalcineurin agents. With a mean follow-up of 43.5 months (15-61), the 3 patients with clear cell carcinoma survived with good graft function and with no evidence of tumor recurrence. The patient with papillary carcinoma underwent follow-up at another hospital center. CONCLUSIONS: Conservative surgery along with conversion to a proliferation signal inhibitor appears to be a safe option for treating primary tumors in kidney grafts and offers good oncological and renal function results in the short and medium term.

Pairs of kidneys transplanted from the same donor: is there any difference?

OBJECTIVES: The aim of this study was to compare the evolution of the first kidney in relation to the second kidney transplanted from the same donor, focusing on the impact that a longer cold ischemia time may have as an independent variable. MATERIAL AND METHODS: The study included 44 pairs of kidneys transplanted from the same donor between February 2008 and October 2010, divided into Groups 1 and 2 according to the graft placement order. The variables analyzed were age, sex, comorbidities, number of transfusions, length of hospital stay, maximum peak PRA, immunologic incompatibility, ischemia time, delayed graft function (DGF), presence of rejection, creatinine clearance at first week, at 3 months and at 1 year, and vascular and tract complications in each group. RESULTS: The mean cold ischemia time was 15.6 hours in Group 1 and 20.1 hours in Group 2 (P < .001). The average recipient age was 52.79 years in Group 1 and 54.52 years in Group 2, with an equal sex ratio in the two groups; an average of 2.06 PRC were transfused prior to transplantation in Group 1 and 0.93 PRC in Group 2; the average length of stay was similar in the two groups. Major DR incompatibility was only found in Group 2 (P < .03). Creatinine clearance at first week, DGF and acute rejection showed worse results in Group 2, but these differences were not significant. Vascular complications were present in 4.5% and 2.3% of Groups 1 and 2, respectively, and tract complications were 6.8% and 11.4%. CONCLUSIONS: A greater tendency to DGF, early rejection and tract complications were found in the group with longer ischemia time, although the difference was not statistically significant. Larger series will be necessary to confirm our results.

Peripheral afferent nerve stimulation for treatment of lower urinary tract irritative symptoms.

OBJECTIVES: To assess the efficacy of posterior tibial nerve stimulation for treatment of lower urinary tract irritative symptoms (urgency, frequency, urge incontinence and pelvic pain). PATIENTS AND METHODS: 51 female patients with a mean age of 55 years were enrolled in the study. The patients presented with the following symptoms: Frequency/urgency 26 patients (50.98%), urge incontinence 22 (43.13%) and interstitial cystitis 3 patients (5.88%). The technique consists in administering low voltage electric stimulation via a 3-5cm needle placed above the tibial malleolus. Patients received weekly stimulations of 30 minutes for a 10-week period. Quality of life questionnaires and voiding diaries before and after treatment were completed. Moreover, the results were evaluated by patients. The variables analysed include: daytime and nighttime voiding frequency, daytime and nighttime voiding volume, daytime and nighttime leakage episodes and hypogastric pain. RESULTS: A statistically significant improvement was seen in all variables, especially remarkable in relation to frequency/urgency, impact on women quality of life and hypogastric pain, being less marked in relation to leakage episodes and voiding volume. CONCLUSIONS: Afferent nerve stimulation offers an alternative treatment for managing lower urinary tract irritative symptoms. However, it would be advisable to confirm the results obtained by means of long-term randomized, follow-up studies.

[Urinary lithiasis secondary to indinavir in an HIV-positive patient]. / Litiasis urinaria secundaria a Indinavir en enfermo HIV positivo.

OBJECTIVE: Indinavir is a protease inhibitor used in the treatment of HIV with a lithogenic capacity as a urological side effect. The pathogenesis, diagnosis and treatment of indinavir urolithiasis are briefly reviewed. METHODS: A 37-year-old male, seropositive for HIV on treatment with indinavir, lamiduvine and zidovudine, consulted for colicky left lumbar pain, nausea, vomiting and dark urine for the past three days. RESULTS: Patient evaluation showed a nonfunctioning left kidney and ureterohydronephrosis of unknown origin. URS showed a yellowish, friable material with a mucinous appearance that occupied the entire lumen of the ureter. Fragmentation was achieved with the lithotriptor probe. Six months later the patient had fully recovered and was asymptomatic. CONCLUSIONS: The incidence of protease inhibitor-induced urolithiasis is increasing. This condition should be distinguished from uric acid calculi whose treatment will aggravate the indinavir urolithiasis.

[Biofeedback as a therapeutic alternative in uncoordinated miction]. / El biofeedback como alternativa terapéutica en la micción no coordinada.

The Hinman Syndrome is known as an involuntary unsconscions contraction of the periurethral sphincter during micturition once neurologic disease and anatpmical obstruction are rejected. We report a case of a 23 years old man who was diagnosed of suffering from this syndrome. After the proper studies and left nephroureterectomy for ureterohydronephrosis secondary to long term massive vesicoureteral reflux, we proceeded to treat him with biofeedback and autocatheterisms. Six months after, the patient was asymptomatic with normal micturitions without residue.

[Unstable detrusor: usefulness of biofeedback]. / Detrusor inestable: utilidad del biofeedback.

Presentation of results of treatment using Biofeedback in two conditions which quite frequently associate vesical instability and incontinence: 65 cases of enuresis and 39 of urinary stress incontinence in females. The method was effective and achieved disappearance of detrusor instability in 78.2% of enuretic cases and 58.9% of urinary stress female incontinence. Outcome for incontinence was less favourable since disappearance was only achieved in 70.5% of enuretics and 20.5% cases of female incontinence. A brief description of the method and instrumentation used is done, which can be easily conveyed to any electromiographic device with real time output. The paper substantiates the authors' views relative to the likely pathogeny of the instability in both processes and the mechanism of action of Biofeedback techniques.

[Bladder carcinosarcoma. A clinical case]. / Carcinosarcoma vesical. Caso clínico.

Presentation of a new case of vesical carcinosarcoma in a 49 year-old male patient. The tumour's pathoanatomical study showed an epithelial pattern of transitional and squamous cells and a sarcomatous pattern composed of rabdomiosarcoma, osteochondrosarcoma and pleomorphous indifferentiated sarcoma with giant multinuclear cells. Histogenesis, signs and symptoms, and treatment, as well as the need of performing an immunohistochemical study for its diagnosis are discussed.

[Giant müllerian cyst. An infrequent cause of palpable hypogastric mass]. / Quiste mülleriano gigante. Una causa infrecuente de masa hipogástrica palpable.

Due to its remarkable rarity, large volume and good post-operative evolution, the authors present one case of a cyst from Müller's duct debris, 18 x 16 cm in size, in a 22-year old male who presented with tangible mass in the hypogastrium and occasional nycturia. The size conditions the clinical symptomatology, although the are times such as this, when they can acquire a considerable volume and grow with practically no symptoms. Clinical history and diagnostic methodology are explained, pointing out the most relevant clinical criteria for proper differentiation from other entities, the complexity of differential diagnosis and the therapeutical procedure used.

[Ureteral revascularization in kidney transplantation. Report of a case]. / Revascularización ureteral en el transplante renal. A propósito de un caso.

We present uretero-pyeloplasty as a new surgical approach to stricture of the pyelo-ureteric junction in the transplant recipient. The foregoing is more frequently found in kidneys that are placed in the inverted anatomic position. The surgical procedure is performed without difficulty and at the same time permits us to evidence the presence of a new ureteral revascularization from the recipient after the interruption of vascular supply of the donor kidney.

[Oncocytic cell tumor. Problems, diagnosis, therapy]. / Tumor de células oncocíticas. Problemática, diagnóstico-terapéutica.

Renal oncocytoma is an uncommon tumor. At least 203 such cases have been reported. This urologic condition represents a diagnostic difficulty and because its natural history has not been elucidated, its treatment remains a controversy. Two recent cases of renal oncocytoma seen at our Urology Service prompted us to review the literature and analyze the diagnostic methods, therapeutic approach and its prognosis.

[Angiomyolipoma of the kidney. Comments on 3 recent cases]. / Angiomiolipoma renal. Comentarios sobre tres recientes observaciones.

We report another three cases of renal angiomyolipoma with different modes of presentation and treatment. Two cases are considered to be of particular interest; one patient presented chyluria in the course of the disease and Wunderlich's syndrome posteriorly, and in the other patient the presenting features were extrarenal. The diagnostic and therapeutic possibilities are discussed and attention is focussed on the conservative approach whenever possible.

[Echography and cytology versus cystoscopy in the follow-up of patients with superficial tumors of the bladder]. / Ecografía y citología versus cistoscopia en el seguimiento de los enfermos con tumores vesicales superficiales.

We present a prospective study on 100 consecutive patients diagnosed with superficial vesical tumour who have had a transurethral resection done on them. For the detection of relapses we use the echography-cytology association and confirm the findings observed by performing a cystoscopy. In view of the high rate of concordancy obtained we conclude by backing this association as a possible alternative to be applied in the control of specific patients with superficial vesical tumours.

[Echographic studies in renal transplant. Our experience]. / Los estudios ecográficos en el trasplante renal. Nuestra experiencia.

The present study briefly reports our experience in the evaluation of renal transplantation by conventional and pulsed Doppler ultrasound. We advocate the use of both imaging techniques in these patients because these are safe, reliable, easy-to-use, reproducible noninvasive imaging techniques that afford a high diagnostic yield.

[Angiodysplasia of the terminal ileum]. / Angiodisplasia del íleon terminal.

Angiodysplasia, a recently discovered disease, is a pathology of scant incidence in our environment and difficult to find because of the inconclusiveness of diagnostic proofs. The disease, generally related to adults and the elderly, and preferentially located in the large intestine, does not always manifest this way. The case we present is one of the youngest in the world literature and of ectopic localization in the terminal ileum. This confirms the enigmatic aspect of this pathology, which still has characteristics to be delimited. Its etiology, incidence and prevalence are unknown and there are no unanimous criteria for its classification or possible association with other pathologies.