Adenomectomía laparoscópica: 10 años de experiencia / Laparoscopic adenomectomy: 10 years of experience

Introducción: Los síntomas del tracto urinario inferior secundarios al aumento del volumen prostático están asociados con la edad, y se están volviendo más prevalentes por el aumento de la esperanza de vida. Presentamos nuestra experiencia con la adenomectomía laparoscópica transperitoneal para el manejo de la obstrucción infravesical de origen prostático. Materiales y métodos: Se realizó una revisión retrospectiva de los pacientes sometidos a una adenomectomía laparoscópica entre 2005 y 2015. Se registró la edad, el flujo máximo y el residuo posmiccional pre y posquirúrgicos, el tiempo quirúrgico, el sangrado operatorio, el peso y la anatomía patológica, los días de sondaje y hospitalización y las complicaciones. Resultados: Se incluyeron 80 pacientes con una edad media de 70 años. El Qmáx medio prequirúrgico fue 8,21 ml/s y el posterior 22,52 ml/s. La media del residuo posmiccional previo fue 91,4 ml y el posterior 14,2ml. El tiempo quirúrgico medio fue 137,7 minutos. Fue necesaria la conversión a cirugía abierta en un caso por lesión intestinal. El sangrado intraoperatorio medio fue 227,6 ml. La estancia hospitalaria media fueron 5,46 días, y el tiempo de sondaje 4,86 días. Tuvimos 13 complicaciones que se registraron según el sistema Clavien-Dindo, siendo 3 de gravedad. El peso medio de la pieza quirúrgica fue 80,02 g. La anatomía patológica mostró hiperplasia benigna en 75 casos y cáncer de próstata en los 5 restantes. Conclusión: La adenomectomía laparoscópica es una técnica segura, reproducible y con los mismos resultados funcionales de la cirugía abierta. Nuestra serie muestra que este abordaje es útil, seguro y con una baja tasa de complicaciones

Introduction: Lower urinary tract symptoms secondary to increased prostate volume are associated with ageing and are becoming more prevalent due to increased life expectancy. We present our experience with transperitoneal laparoscopic adenomectomy for the management of bladder outlet obstruction caused by benign prostatic enlargement. Materials and methods: We performed a retrospective review of patients who underwent laparoscopic adenomectomy between 2005 and 2015. We recorded age, maximum flow and postvoid residual urine (preoperative and postoperative), surgical time, operative bleeding, weight and pathology, complications and duration of catheterisation and hospitalisation. Results: We included 80 patients with a mean age of 70 years. The mean preoperative and postoperative Qmax was 8.21 mL/s and 22.52 mL/s, respectively. The mean preoperative and postoperative postvoid residual urine was 91.4 mL and 14.2 mL, respectively. The mean surgical time was 137.7 min. Conversion to open surgery was necessary in one case due to intestinal injury. The mean intraoperative bleeding was 227.6 mL. The mean hospital stay was 5.46 days, and the catheterisation time was 4.86 days. There were 13 complications, which were recorded according to the Clavien-Dindo system, 3 of which were severe. The mean weight of the surgical specimen was 80.02 g. Pathology showed benign hyperplasia in 75 cases and prostate cancer in the remaining 5. Conclusion: Laparoscopic adenomectomy is a safe, reproducible technique with the same functional results as open surgery. Our series shows that this approach is useful and safe and has a low rate of complications

Laparoscopic adenomectomy: 10 years of experience. / Adenomectomía laparoscópica: 10 años de experiencia.

INTRODUCTION: Lower urinary tract symptoms secondary to increased prostate volume are associated with ageing and are becoming more prevalent due to increased life expectancy. We present our experience with transperitoneal laparoscopic adenomectomy for the management of bladder outlet obstruction caused by benign prostatic enlargement. MATERIALS AND METHODS: We performed a retrospective review of patients who underwent laparoscopic adenomectomy between 2005 and 2015. We recorded age, maximum flow and postvoid residual urine (preoperative and postoperative), surgical time, operative bleeding, weight and pathology, complications and duration of catheterisation and hospitalisation. RESULTS: We included 80 patients with a mean age of 70 years. The mean preoperative and postoperative Qmax was 8.21mL/s and 22.52mL/s, respectively. The mean preoperative and postoperative postvoid residual urine was 91.4mL and 14.2mL, respectively. The mean surgical time was 137.7min. Conversion to open surgery was necessary in one case due to intestinal injury. The mean intraoperative bleeding was 227.6mL. The mean hospital stay was 5.46 days, and the catheterisation time was 4.86 days. There were 13 complications, which were recorded according to the Clavien-Dindo system, 3 of which were severe. The mean weight of the surgical specimen was 80.02g. Pathology showed benign hyperplasia in 75 cases and prostate cancer in the remaining 5. CONCLUSION: Laparoscopic adenomectomy is a safe, reproducible technique with the same functional results as open surgery. Our series shows that this approach is useful and safe and has a low rate of complications.

Consenso sobre el impacto clínico de la nueva evidencia científica disponible sobre hiperplasia benigna prostática / Consensus on the Clinical Impact of the New Scientific Evidence Available on Benign Prostatic Hyperplasia

Objetivos: Explorar la opinión técnica de un panel experto y alcanzar un consenso de criterio profesional en relación con la más reciente evidencia científica en hiperplasia benigna de próstata (HBP) en los ámbitos del diagnóstico, de los criterios de progresión, del tratamiento médico y del tratamiento quirúrgico. Material y métodos: Revisión sistematizada de la literatura de los últimos 10 años en HBP por medio de un comité científico y elaboración de un cuestionario de 64 preguntas repartidas en tres áreas estratégicas: a) diagnóstico y estratificación de los pacientes con HBP atendiendo a los factores de riesgo de progresión; b) novedades en el tratamiento médico; y c) nuevas aportaciones en el tratamiento quirúrgico y mínimamente invasivo en HBP. Se seleccionó un panel de 50 urólogos destacados en el conocimiento de la HBP repartidos por toda la geografía nacional, instaurando para el estudio la metodología Delphi mediante la aplicación de dos encuestas sucesivas on line. Resultados: Los 50 expertos consultados completaron las dos rondas del cuestionario. En la primera se apreció un consenso de criterio en 50 de las 64 cuestiones analizadas, logrando en la segunda ronda un consenso en 59/64 ítems (92,5%) que incluyen aspectos de morbilidad de los síntomas del tracto urinario inferior (STUI), pruebas diagnósticas necesarias en la evaluación inicial del especialista, estratificación de los pacientes en relación con el riesgo de progresión, estrategias de terapia médica escalonada y de combinación en pacientes con riesgo de retención aguda de orina (RAO) o cirugía y de las indicaciones de terapia quirúrgica y el papel de los nuevos tratamientos menos invasivos. Conclusiones: En una patología de alta prevalencia, como la HBP, donde hemos asistido en los últimos años a cambios de calado en todo su espectro, la consecución de un elevado consenso al que han contribuido un amplísimo número de especialistas de referencia en esta patología, será de gran importancia para el manejo clínico habitual de esta enfermedad (AU)

Objectives: To study the technical opinion of an expert panel and reach a consensus of professional criterion in relation to the most recent scientific evidence in Benign Prostatic Hyperplasia(BPH) in the scopes of diagnosis, progression criteria, medical treatment and surgical treatment. Material and methods: Systematized review of the literature of the last 10 years in BPH by means of a scientific committee and elaboration of a 64-question questionnaire divided into three strategic areas: 1.- Diagnosis and stratification of the patients with BPH considering the progression risk factors. 2.-Novelties in the medical treatment and 3.- New contributions in the surgical and minimally invasive treatment in BPH. A panel of 50 urologists standing out for their knowledge in BPH distributed throughout the national geographic area was chosen, establishing the Delphi methodology for the study through the application of two successive online surveys. Results: The 50 experts consulted completed the two groups of the questionnaire. In the first, a consensus of criterion was observed in 50 out of the 64 questions analyzed, achieving a consensus in 59/65 (92.5%) in the second round, which included aspects of morbidity of the lower urinary tract symptoms (LUTS), diagnostic tests necessary in the initial evaluation of the specialist, stratification of the patients in relation to the risk of progression, strategies of step-by-step medical therapy and combination in patients with risk of Acute Urinary Retention(AUR) or surgery and of the indications of surgical therapy and the role of new less invasive treatments. Conclusions: In a condition of the high prevalence of BPH, in which we have seen important changes in its entire spectrum in recent years, the obtaining of an elevated consensus to which a large number of reference specialists in this condition have contributed will be of great importance for the usual clinical management of this disease (AU)

[Consensus on the clinical impact of the new scientific evidence available on benign prostatic hyperplasia]. / Consenso sobre el impacto clínico de la nueva evidencia científica disponible sobre hiperplasia benigna prostática.

OBJECTIVES: To study the technical opinion of an expert panel and reach a consensus of professional criterion in relation to the most recent scientific evidence in Benign Prostatic Hyperplasia (BPH) in the scopes of diagnosis, progression criteria, medical treatment and surgical treatment. MATERIAL AND METHODS: Systematized review of the literature of the last 10 years in BPH by means of a scientific committee and elaboration of a 64-question questionnaire divided into three strategic areas: 1.- Diagnosis and stratification of the patients with BPH considering the progression risk factors. 2.-Novelties in the medical treatment and 3.- New contributions in the surgical and minimally invasive treatment in BPH. A panel of 50 urologists standing out for their knowledge in BPH distributed throughout the national geographic area was chosen, establishing the Delphi methodology for the study through the application of two successive online surveys. RESULTS: The 50 experts consulted completed the two groups of the questionnaire. In the first, a consensus of criterion was observed in 50 out of the 64 questions analyzed, achieving a consensus in 59/65 (92.5%) in the second round, which included aspects of morbidity of the lower urinary tract symptoms (LUTS), diagnostic tests necessary in the initial evaluation of the specialist, stratification of the patients in relation to the risk of progression, strategies of step-by-step medical therapy and combination in patients with risk of Acute Urinary Retention (AUR) or surgery and of the indications of surgical therapy and the role of new less invasive treatments. CONCLUSIONS: In a condition of the high prevalence of BPH, in which we have seen important changes in its entire spectrum in recent years, the obtaining of an elevated consensus to which a large number of reference specialists in this condition have contributed will be of great importance for the usual clinical management of this disease.

Fístula uretrocavernosa por fractura penena / Urethrocavernous fistula due to penile fracture

La fractura de pene con laceración de la uretra se presenta con dolor y hematoma, detumescencia, fallo en la erección y uretrorragia. Describimos el tercer caso publicado en la literatura de fistula uretrocavernosa por fractura peneana ocurrida durante el coito (AU)

Penile fracture with urethral laceration usually presents with pain and haematoma, detumescence, erectile failure and blood loss through urethral meatus. We describe the third published case of urethrocavernous fistula following blunt penile trauma sustained durind sexual intercourse (AU)

[Urethrocavernous fistula due to penile fracture]. / Fistula uretrocavernosa por fractura penena.

Penile fracture with urethral laceration usually presents with pain and haematoma, detumescence, erectile failure and blood loss through urethral meatus. We describe the third published case of urethrocavernous fistula following blunt penile trauma sustained durind sexual intercourse.

[Transurethral treatment of massive hematuria post retropubic adenomectomy]. / Tratamiento por vía transuretral de la hematuria masiva postadenomectomía retropúbica.

INTRODUCTION AND OBJECTIVES: to evaluate the frequency of reoperation caused by massive hematuria in the postoperation of open prostatectomy in benign prostatic hyperplasia (BHP) at our hospital. At the same time, we also want to evaluate the effectiveness and possible secondary effects of using transurethral approach to solve this surgical complications. MATERIAL AND METHODS: we analyzed retrospectively 540 open surgeries in benign prostatic hyperplasia, carried out from 1998 to 2005. We evaluated effectiveness, average surgery time and complications in case of endoscopic review. RESULTS: a reoperation was necessary in 2.5% of all 540 cases. In all the cases reoperated, hemorrhage was controlled using transurethral approach. Average surgery time was 37 minutes and secondary effects observed were not important. CONCLUSIONS: transurethral approach is a simple and effective technique in the treatment of massive hematuria after open prostatectomy in BPH. Surgery time spent is acceptable, and early and delayed complications observed have been few and cannot, in our opinion, be imputed only to this tech-

Tratamiento por vía transuretral de la hematuria masiva postadenomectomía retropúbica / Transurethral treatment of massive hematuria post retropubic adenomectomy

Introducción y objetivos: Evaluar la frecuencia de reintervención por hematuria postadenomectomía en nuestro centro al igual que la efectividad y los posibles efectos secundarios del abordaje transuretral como tratamiento resolutivo en el postoperatorio inmediato. Material y métodos: Se analizaron retrospectivamente 540 adenomectomías retropúbicas realizadas en el periodo 1998-2005. Se evaluó la efectividad, el tiempo quirúrgico medio de reintervención y las complicaciones en los casos en que se realizó la revisión endoscópica. Resultados: En un 2,5% del total de adenomectomías retropúbicas fue necesaria por hematuria la revisión endoscópica. En todos estos casos se logró por esta vía el control hemostático. El tiempo quirúrgico medio fue de 37 minutos y los efectos secundarios observados insignificantes. Conclusiones: La vía transuretral es una técnica simple y eficaz en el tratamiento de la hematuria masiva postadenomectomía retropúbica. El tiempo quirúrgico empleado es aceptable y las complicaciones observadas a largo plazo son mínimas y no pueden atribuirse únicamente a dicha técnica

Introduction and objectives: to evaluate the frequency of reoperation caused by massive hematuria in the postoperation of open prostatectomy in benign prostatic hyperplasia (BHP) at our hospital. At the same time, we also want to evaluate the effectiveness and possible secondary effects of using transurethral approach to solve this surgical complications. Material and methods: we analyzed retrospectively 540 open surgeries in benign prostatic hyperplasia, carried out from 1998 to 2005. We evaluate the effectiveness, average surgery time and complications in case of endoscopic review. Results: a reoperation was necessary in 2.5% of all 540 cases. In all the cases reoperated, hemorrhage was controlled using transurethral approach. Average surgery time was 37 minutes and secondary effects observed were not important. Conclusions: transurethral approach is a simple effective technique in the treatment of massive hematuria after open prostatectomy in BPH. Surgery time spent is aceptable, and early and delayed complications observed have been few and cannot, in our opinion, be imputed only to this technique

Treatment of bladder stones without associated prostate surgery: results of a prospective study.

OBJECTIVES: To assess the effectiveness of noninvasive bladder lithiasis treatment without associated prostate surgery to know whether bladder lithiasis is an absolute indication for prostate surgery. METHODS: Fifty patients with bladder lithiasis were entered in a prospective trial and were treated with extracorporeal shock wave lithotripsy if lithiasis was smaller than 4 cm2. Independent of the presence or absence of bladder outlet obstruction, in no case was prostate surgery associated. The variables studied were the effectiveness of the treatment, changes in the International Prostate Symptom Score (IPSS), and the subsequent need for desobstructive prostate surgery. The statistical study was performed using Student's t test and the proportional hazards model. RESULTS: Bladder lithiasis was successfully eliminated in 93% of the cases (in 77% of them with a single extracorporeal shock wave lithotripsy session). The mean IPSS decreased from 17.7 to 9.7 points (P = 0.0001) after lithiasis elimination. After a mean follow-up of 22 months, a mere 8% of the patients needed subsequent prostate surgery because their IPSS had increased to 20 points or more. The sole prognostic factor for the need for ensuing prostate surgery was the pretreatment IPSS score (P = 0.042). CONCLUSIONS: Noninvasive management of bladder lithiasis with no associated prostate surgery is highly efficient and results in marked symptomatic improvement. Furthermore, the number of patients needing subsequent prostate surgery was very low at mid-term follow-up. Because of all of the above, the existence of bladder lithiasis is not an absolute indication for prostate surgery.

Prognostic value of cystocopically pseudotumoral lesions (inflammation/granuloma) in primary stage T1 grade 3 bladder tumors treated with BCG.

OBJECTIVE: The aim of this study is to find out whether the pseudotumoral lesions (inflammation/granuloma) seen at the follow-up cystoscopy performed three to six months after transurethral resection of primary stage T1 grade 3 bladder tumor and instillations of BCG therapy might have some prognostic value as far as recurrence and/or long term progression are concerned. MATERIAL AND METHODS: From the first group of one hundred and thirteen patients with primary stage of T1 grade 3 bladder tumor treated with 81 mg of BCG Connaught (weekly/during six weeks), those with recurrent tumor at the 3rd and 6th month were excluded, so we evaluated 99 patients. We identified 13 patients with cystoscopically pseudotumoral lesions. RESULTS: of the 13 cystoscopically pseudotumoral lesions, we observed recurrence in two cases (15%), while among the rest of the 86 patients, we observed 22 recurrences (26%) (p = 0.9; not significant). Concerning progression, eight cases were reported out of 86 patients (9%) within the cistocopically normal group. No cases of progression were reported among the 13 patients with cystoscopically pseudotumoral lesions. This difference was not statistically significant (p = 0.5). CONCLUSIONS: The patients with cystoscopically pseudotumoral lesions (inflammation/granuloma) are a reduced group (13%) with less tendency to recurrence and without progression, even though this relationship is not significant.

[Metastatic testicular carcinoma]. / Carcinoma metastásico testicular.

OBJECTIVE: To describe 11 cases of metastatic carcinoma of the testicular parenchyma presenting as a scrotal mass. METHODS: A descriptive and retrospective study of metastatic carcinoma of the testis was performed. Eleven cases of testicular metastasis from prostate cancer (7), renal adenocarcinoma (2), bladder carcinoma (1) and carcinoma of the pancreas (1) are presented. RESULTS: All the patients had multiple disseminated disease from their underlying condition, which is a sign of poor prognosis. CONCLUSIONS: Testicular metastasis from carcinoma is rare and frequently arises from adenocarcinoma of the prostate. Clinically, testicular metastases cannot be distinguished from primary tumors and generally affect males over 60 years old.

[Bacteriologic assessment of the lower urinary tract and genital area in patients with recurrent urinary tract infections]. / Valoración bacteriológica del tramo urinario inferior y área genital en las pacientes con infecciones urinarias de repetición.

OBJECTIVE: The pathogens responsible for urinary infection originate from the digestive tract prior passage through the genital region. Samples were obtained from this region in an attempt to identify women with these pathogens. We have analyzed the most frequently colonized areas of the genital region in order to develop a method for obtaining samples. Risk factors were evaluated by determining the relationship of the samples with factors implicated in the pathogenesis of recurrent infection. METHODS: Samples were obtained from 146 women of all ages that consulted for recurrent urinary tract infection. The samples from the genital region (perimeatal vulva, vagina, urethral and intraurethral meatus) and urine obtained through a catheter were cultured. RESULTS: The overall incidence of positive samples was 41%; 23% of the patients showed urinary infection (urine obtained by catheterization) at the time the samples were taken. The vaginal samples were the most frequently colonized and the intraurethral samples were the most sensitive when compared with the urinary samples. The sensitivity, specificity, positive and negative predictive values of these two samples were the same as those of the other samples together. In regard to colonization, a difference was found only between menopausal and premenopausal women, and in proportion to the duration of the history of infection. CONCLUSIONS: The study shows that it is unnecessary to obtain various samples; vaginal and intraurethral smears are sufficient. Menopausal women who referred two symptomatic episodes a year were found to be at a higher risk for vaginal infection, and in proportion to the number of years they have had recurrent infection.

[Clinical trial of the effect of urethral catheter on the etiology of urethral stenosis following transurethral resection of the prostate]. / Ensayo clínico sobre el efecto de la sonda uretral en la génesis de la estenosis uretral post-resección transuretral de próstata.

OBJECTIVE: To analyze the effect of the urethral catheter and urethral secretions in the development of urethral stricture post-transurethral resection of the prostate (TURP). METHODS: A clinical study was conduced on 109 patients treated by TURP. The patients were randomly assigned to one of the following groups: A (suprapubic catheter), B (urethral catheter), C (urethral cleansing). The incidence of urethral stricture in the different groups was compared using the chi-square test and survival was analyzed by the Kaplan Meier method. RESULTS: 5 patients were lost to follow-up (4.5%). The median number of days the catheter was indwelling was one day for group A, and 4 days for groups B and C. The overall incidence of urethral stricture was 4.3%; by groups the incidence was 3.8% for group A, 3% for B and 5.9% for group C. The differences were not statistically significant. CONCLUSION: The study showed no statistically significant differences in the incidence of post-TURP urethral stenosis in patients with a suprapubic or urethral catheter. Furthermore, urethral stenosis was not less frequent in patients in whom urethral cleansing was performed.

[Analysis of 895 consultations for hematuria in the emergency department in an urology unit]. / Analyse de 895 consultations pour hématurie dans le département des urgences d'un service d'urologie.

OBJECTIVE: To study efficacy of our diagnostic approach in patients with haematuria, as well as the information provided by the different tests. PATIENT AND METHODS: The computerization of our emergency department, and the study of the data base have permitted us to study retrospectively 722 cases of hematuria seen at our center over a period of 10 months. The relation between the benign or malignant etiology of the hematuria, and the presence or absence of associated symptoms and the intensity of the hematuria is shown, as well as the relation between the intensity of the hematuria and the decrease in the hemoglobin rates detected. RESULTS: Fifty eight percent of the 722 patients, 39% of them due to neoplasm. The intensity of had one symptom only hematuria was significantly superior in the patients with the final diagnosis of neoplams. The accomplishment of reactive strip, basic imaging techniques and urine sediment has permitted in our series to direct the diagnosis in 67.3% of patients. Cystoscopy has shown great efficacy in diagnosing the cases of monosymptomatic hematuria with normal radiological studies. CONCLUSION: Monosymptomatic hematuria deserves a work-up to rule out malignancy. Reactive strip, urine sediment, KUB and ultrasonography allow to direct the diagnosis in most cases.

[Ureteral obstruction secondary to intrapelvic migration of methyl methacrylate following total hip replacement]. / Obstrucción ureteral secundaria a la migración intrapélvica de metilmetacrilato tras colocación de prótesis total de cadera.

We report an uncommon case of ureteral obstruction arising from the cement utilized to fix a total hip prosthesis. The pathophysiological mechanisms that may cause urinary tract involvement in this type of surgery are discussed.