[Cryosurgery in the management of prostate cancer]. / Criocirugía en el tratamiento del cáncer de próstata.

This article reviews the current status of the prostatic cryosurgery in the management of patients with prostate cancer. Recent advances in cryoablative technology have allowed to treat these patients successfully with decreased morbidity. Using transrectal high-resolution ultrasound imaging, prostate cryotherapy is delivered with multiple ultrathin (17-gauge) cryo-needles, via percutaneous transperineal approach. The extent of freezing can be precisely controlled and monitored with thermic devices, tissue destruction is monitored with real-time visualization of the prostate and surrounding structures, and urethral warming is used to avoid urethral sloughing. However, the results with the second and third-generation cryosurgical equipment will have to be confirmed by means of prospective and randomized trials, because up to now we only have data based on retrospective analyses, which are very heterogeneous. The ability of prostate-specific antigen (PSA) to predict long-term outcome after cryotherapy for localized prostate cancer is not well known because experience with this treatment modality is still limited; however, it seems that a PSA value of 0.5 ng/ml or less after 6 months or longer after cryotherapy would be associated with a high probability (greater than 95%) of negative post-treatment biopsy. Cryosurgery could also be an option of treatment for men with recurrent local disease who have undergone radiotherapy or radical prostatectomy. We have to keep in mind possible complications (incontinence, impotency, urethrorectal fistula or bladder outlet obstruction. The favorable side effect profile and preliminary oncologic and funtional results could suggest that cryosurgery will have a role in the minimally invasive management of selected patients with prostate cancer.

[Ruptures of double-J ureteral catheter. Our experience and review of the literature]. / Roturas de catéter ureteral doble-J. Nuestra experiencia y revisión de la literatura.

Ureteral double-J stents are currently being used widely in numerous urologic indications. Side effects are infrequent and usually related to the act of insertion per se. Complications with long-term indwelling stents are mainly due to stent incrustation and more rarely to spontaneous breakage. We report 3 cases of stent multiple fragmentation after and indwelling period superior to 22 months without evidence of stent incrustation. We reviewed the literature and analyzed the different etiologic factors that are thought to be involved. We believe that radiologic control post-insertion and stent substitution after an indwelling period of three months are mandatory.

[Extracorporeal shock-wave lithotripsy in the treatment of calculi in horseshoe kidneys. Our experience]. / Litotricia extracorpórea por ondas de choque en el tratamiento de la litiasis en riñones en herradura. Nuestra experiencia.

Thirty-one (31 renal units (RU) were treated with extracorporeal shock wave lithotrity (ESWL) in 27 patients with lithiasis in horseshoe kidneys (HK). Treatment was done in an out-patients environment and in two thirds of cases the patient was placed in prone-decubitus. An average of 2.42 sessions per patient (range 1-8) were performed freeing 15 RU, 10 with removable residues, and failure in 6:3 with non-removable residues in all asymptomatic cases, 2 where fragmentation was insufficient and 1 renal annulment post-ESWL. Overall, results were "good" in 80.6% cases, with a significant relationship between size of lithiasis and therapeutical results. Thus, for < or = 2 cm calculi the result was good in 100% cases but a greater number of cleaning were required in those < 1 cm (62.5 vs 46.15%). On the contrary, "therapeutic failures" were limited to just > 2 cm calculi. It can therefore be concluded that most patients with lithiasis in HK, specifically when calculi are < 2 cm, can be treated primarily and in monotherapy with ESWL.

[Lithiasis of the transplanted kidney: therapeutical potential]. / Litiasis en el riñón trasplantado: posibilidades terapéuticas.

OBJECTIVES: The formation of calculus in the transplanted kidney is an uncommon complication. Metabolic derangements, infectious or obstructive processes, factors related with the surgical technique and the presence of ureteral catheters have been implicated in its etiopathogenesis. The therapeutic possibilities have changed in the last decade. The different factors related with stone formation in the transplanted kidney, the indications and treatment utilized in each case are analyzed. METHODS: We analyzed the cases of lithiasis following renal transplantation in our series of 800 renal transplants. The metabolic anomalies and other associated lithogenic factors in 5 cases that required treatment are described. RESULTS: All 5 patients were treated by ESWL. Complete resolution of the lithiasis was achieved in 4 cases whose kidney graft is currently stone free with preserved renal function, except one patient with hyperuricemia and hyperuricosuria who is again on hemodialysis for chronic rejection. In the fifth case fragmentation of the caliceal stone was not achieved after 4 sessions of ESWL. Subsequem ultrasound control evaluations have disclosed no changes in stone size or location. CONCLUSIONS: In our view, the approach to renal lithiasis in the transplanted kidney is similar to that of patients with solitary kidney, although stone size for treatment by ESWL should be limited to 2 cms. If stone size is between 1 and 2 cms, placement of a double-J catheter prior to ESWL is recommended, whenever possible. For stones larger than 2 cms, percutaneous nephrolithotomy is more effective and has less complications. Surgery is reserved for those patients in whom these techniques are unamenable or have failed.

[Sarcomatoid renal carcinoma]. / Carcinoma renal sarcomatoide.

Study of 250 pieces from nephrectomies performed in our service due to renal carcinoma, 10 (4%) of which where of the sarcomatoid histological variant. In 2 of the 10 cases, tumour was confined within the renal capsule at the time of surgery. These were the only cases where no disease progression was seen after treatment. A survival study using the Kaplan-Meter method was conducted. Median survival of patients with sarcomatoid pattern was 6 months, showing a significant difference with that obtained in other histological patterns. DNA content of tumoral cells was assessed by flow cytometry, which displayed a diploid pattern in 7 patients and aneuploid in 3. The 2 cases with no disease progression were diploid. We conducted nuclear cytomorphometry studies which showed significant differences in the mean nuclear perimeter between progressive and non-progressive tumours.

[Extracorporeal shockwave lithotripsy in single kidneys. Our experience]. / Litotricia extracorpórea por ondas de choque en monorrenos. Nuestra experiencia.

Forty patients with renal lithiasis in single kidney were treated with extracorporeal shock wave lithotrity in our unit. Nine patients required emergency urinary by-pass, because of original picture of obstructive anuria, and in another 21 cases a double-J catheterism was conducted as prophylaxis prior to lithotrity. Treatment was carried out with analgesia and ambulatory, except for 10 patients with calculi of less than 10 mm where by-pass was not performed, and who were kept in preventive hospitalization for 24 hours. Average of sessions per patients was 1.59 (range 1-7). After 6 months follow-up there are 24 free renal units (60%), 12 (30%) with debris that can be expelled, failure in 4 (10%): 2 with debris that can be expelled and 2 which were not fragmented. Renal function has not deteriorated during follow-up, except for 2 patients with obstructive uropathy, that subsequently normalized following resolution of the condition. No significant differences were found in the treatment of calculi of less than 10 mm with or without double-J. ESWL is considered to be the choice approach for lithiasis in patients with one single kidney, due to is efficacy and low morbidity, safety in the ambulatory environment, even for calculi of less than 10 mm with no urinary by-pass.

[Scrotal verrucous carcinoma]. / Carcinoma verrucoso escrotal.

Cancer of scrotum is of interest, despite its relative infrequency, because of its historical importance (was the first known occupational cancer) and also of its aggressive behavior. We report a rare case of verrucous carcinoma in a 67 years old man, without recrudescence six months after surgical treatment.

[Urologic manifestations in patients with acquired immunodeficiency syndrome]. / Manifestaciones urológicas en pacientes con el síndrome de inmunodeficiencia adquirido.

In order to know the incidence and nature of urological conditions in the Acquired Immunodeficiency Syndrome, a revision was made of 223 clinical histories from patients admitted to our hospital between 1998 and 1992. Some 24.6% developed urological conditions with prevalence of unspecific urinary infections, though several types of specific infections, immunological, neoplastic, neurourological and nephrological changes were also found as well as other conditions not caused by the disease, such as renal lithiasis. We noted that, although involvement of urinary tract in AIDS is not well defined, its frequency is high, since up to one fourth of patients are affected by different disorders.

[Adrenal gland carcinoma. Clinical, pathologic, and therapeutic study]. / Carcinoma suprarrenal. Estudio clínico, patológico y terapéutico.

From 1973 to 1991, 13 patients [4 females (30%) and 9 males (70%)] were diagnosed with adrenal carcinoma at our hospital. The mean age at the time of diagnosis was 47.4 years (range 29 to 72 yrs). Eleven patients (85%) presented with abdominal symptoms and 8 (61%) with paraneoplastic syndrome. At the time of diagnosis, 3 (23%) had clinical or radiological signs of metastasis. Five patients (38.5%) had regional involvement and 5 (38.5%) had localized disease. The preoperative imaging studies disclosed an abnormal IVP in 8 of 13 patients (61%); 7 of 10 (70%) had an abnormal ultrasound scan and the CT scan was abnormal in 9 out of 9 patients (100%). Seventy-three percent of the tumors were classified as anaplastic or poorly differentiated carcinoma and 27% as differentiated carcinoma. Complete surgical excision was performed in 8 cases and op'DDD was administered in 4 cases. The five-year survival rate was 30%. We can conclude that early diagnosis, staging and histopathology have a significant effect on survival and surgical excision is the only treatment associated with medium or long-term survival.

[Risk of suffering from a second primary neoplasm in patients with bladder tumor]. / Riesgo de padecer una segunda neoplasia primaria en pacientes con tumor vesical.

An evaluation was made on the risk of having a second primary neoplasia following vesical tumor diagnosis. All patients attended the 'Hospital La Fe' and had been diagnosed between 1984 and 1993. A total of 238 vesical tumours were studied, 45 (15.9%) with associated second neoplasia; in 34 cases the vesical tumour was the first one to be diagnosed. The number of tumors seen was compared to expected figures, according to the appropriate incidence rates by age, sex and tumour type, taken out from the Spanish section of the 1987 edition of "Cancer Incidence in Five Continents". An increase over the expected values of second neoplasias for lung, prostate, kidney and bone cancer was found. Sixty percent developed concurrently (within 6 months from initial diagnosis). Most vesical tumours were infiltrant, thus conditioning both the prognosis and the second neoplasia. The likely factors implied in this phenomenon are discussed.

[Is radical surgery indicated in patients with infiltrating bladder carcinoma and involved regional lymph nodes?]. / Está indicada la cirugía radical en los pacientes con carcinoma vesical infiltrante y ganglios regionales afectos?

To evaluate the efficacy of radical vesical surgery in Infiltrant Vesical Carcinoma affecting the regional nodes, a retrospective study of a group of 75 patients who underwent radical cystectomy and lymphadenectomy was conducted. Based on the degree of node affectation patients were classified as follows: 49 pN(-) (65.3); 22 pN(+) (29.3); and 4 pN(x) (5.3) in which the pathological anatomy was inconclusive. In the pN(-) group, 8 (8.16%) died during the immediate postoperative due to surgical complications. Of the remaining 45, 5 cases were lost to follow-up; 31 (63.26%) died (all of them as a result of the tumour (M+)); whereas 9 (18.36%) are still alive and disease-free. Overall mean survival is 35.91% 10.3 months (4-65 months). Of them, 3 (13.6%) were lost while in poor performance status; 13 (59.09%) died for neoplasia-related causes (M+), and only one (4.5%) is alive and disease free. In this group, neoadjuvant chemotherapy was used in 10 cases, neoadjuvant radiotherapy in 4 and adjuvant radiotherapy in 5. Local relapse was seen in 8 (36.6%) cases. In our experience, a clear improvement in quality of live and mean survival at one year (up to 65 months) was noted in patients with Vesical Infiltrant Carcinoma and regional node affectation. Such situation encourages the use of radical surgery when faced, during surgical examination, with node infiltration by neoplastic cells.

[Lymphocele as a complication of renal transplantation]. / Linfocele como complicación del transplante renal.

Lymphoceles are a complication of renal transplantation surgery. The source of this lymphatic collections is the lymph draining through the lymphatic vessels located in the transplanted kidney sinus and surrounding the iliac vessels of the receptor. The main etiological factor is the surgical technique used when dissecting these structures for graft placement. Several factors have been suggested as favouring their occurrence, acute rejection being highlighted as one. This paper reviews a series of 517 renal transplantations performed in our service, with a lymphocele incidence of 5.2% (28). Using a log regression model, the influence of age, sex, time in dialysis, presence of tubular acute necrosis in the graft following placement, acute rejection and immunological regime, for the appearance of lymphocele were analyzed. Age and lack of acute tubular necrosis were the only two factors selected by the model. Also, clinical signs and symptoms as well as therapy instituted were analyzed, emphasizing that puncture-drainage and instillation of iodine povidone was 100% effective.

Spontaneous rupture of a neobladder.

The spontaneous rupture of neobladder is an extremely rare entity of which there only exists one formerly reported case in the world literature. It is far more common after enterocystoplasty for augmentation (19 reported cases). We describe here the spontaneous rupture of a neobladder 8 months after performing cystectomy and bladder replacement by an enterocystoplasty in order to treat a bladder carcinoma. In this case the patient showed symptoms and signs of acute peritonitis. The diagnosis was carried out using a cystogram and the treatment consisted of a laparotomy with closure of the perforation and drainage of the peritoneal cavity.

[Prognostic factors in tumors of the upper urinary tract]. / Factores pronósticos de los tumores del tracto urinario superior.

Review of patients treated for tumours of the upper urinary tract (UUTT) in our hospital during the 1969-1992 period. The characteristics studied were: stage (TNM 1987), grade (OMS), associated vesical tumour, location of primitive tumour, size, number, surgery performed and presence of tumoral relapse. Cox's regression model was used for the analysis of prognostic factors with survival time as the response variable. The sample has 92 patients (78% men and 22% women), average age 64 years. The tumours were: 46 pyelitic, 36 ureteral and 10 mixed. Stage distribution was: 13 pTa (14%), 41 pT1 (45%), 16 pT2 (17%), 15 pT3 (17%), 3 pT4 (7%); grade distribution: 22 grade I (24%), 54 grade II (59%) and 16 grade III (17%) 48% cases presented associated vesical tumour and 15% relapsed. The sample's median survival was 81 months and survival probability at 5 and 10 years was 52% and 45%. A significant association with survival time was shown by: stage, grade, sex and renal annulment. The multivariant analysis selected: 1) stage; 2) renal annulment and 3) sex. The predictive power of staging is indisputable, thus becoming the first selected variable. Renal annulment and sex factors add independent information on evolution. The information provided by the tumour's grade highly correlates to that of the stage, and therefore it was not selected in the multivariant analysis.

[The risk of second primary neoplasm in prostatic cancer patients]. / Riesgo de padecer una segunda neoplasia primaria en pacientes con cáncer de próstata.

The risk of suffering a second primary neoplasia after bearing a prostate cancer has been evaluated. The study patients attended the Hospital La Fe and were diagnosed between 1984 and 1992. There was a total of 223 prostate neoplasias, 22 of which had associated a second neoplasia and in 12 cases, corresponding to seven tumoral locations, prostate cancer was the first pathology to be diagnosed. Tumours observed were compared to those expected, according to the incidence rates appropriate for each age group and tumoral type, taken from the Spanish section of "Cancer Incidence in Five Continents", 1987. An excess of second neoplasias for vesical, kidney, CNS, bone and lymphoma tumours was found. In most cases, the second tumour was diagnosed between 6 to 12 months after diagnosis of prostate cancer. The patient's prognosis is dependent of the second neoplasia. The possible mechanisms of these associations are discussed in the light of state-of-the-art knowledge.

[Antimicrobial prophylaxis in urologic endoscopic surgery: pefloxacin versus ceftriaxone]. / Profilaxis antimicrobiana en cirugía endoscópica urológica: pefloxacino versus ceftriaxona.

Prospective, randomized study in 96 patients undergoing urologic endoscopic surgery to assess the efficacy of two antimicrobials, pefloxacin and ceftriaxone, in the prevention of urinary tract infections. The disease most frequently prompting surgery was vesical tumour and prostate adenoma. All patients had sterile pre-operative urine. Drugs were given endovenously two hours prior surgery in one single dose. Prophylactic efficacy was measured through urine culture before removal of the catheters. Incidence of bacteriuria greater than 100,000 colonies/ml was 20% for the pefloxacin group compared to 15.2% for ceftriaxone. These differences were not statistically significant (Squared-chi test). These results show that pefloxacin is as effective as ceftriaxone in the prophylaxis of endoscopic urological surgery. A single dose schedule was not entirely suitable to reduce post-operative bacteriuria.

[Surgical wound infection in renal transplant recipients]. / Infección de herida operatoria en trasplantados renales.

Between 1980 and 1991, 504 transplantations were performed in our hospital. All patients received pre-surgical therapy with antibiotics. The total incidence of surgical wound infection was 15 cases (3%). After reviewing all parameters that could have been involved in the development of these infections, it become apparent that diabetes mellitus, more than one transplant in the same patient, development of haematoma in the wound and presence of urinary fistulae were statistically significant (p < 0.05). On the other hand, the use of the different immunosuppressive regimes (azathioprin and cyclosporin) and acute tubular necrosis showed no statistical significance (p > 0.05); also, no relationship was found between infection and acute graft rejection.