Nefroureterectomía y desinserción transuretral láser-endoscópica en decúbito lateral sin cambio de posición: adaptación progresiva al abordaje por retroperitoneoscopia / Laparoscopic nephroureterectomy with laser endoscopic transuretral disinsertion in lateral decubitus: progressive adaptation to retroperitoneocopic approach

Introducción: La técnica de desinserción ureteral con rodete vesical continúa su evolución. Presentamos la técnica láser-endoscópica transuretral combinada con abordaje trans y retroperitoneal laparoscópicos en decúbito lateral, sin reposicionamiento del paciente para carcinomas uroteliales del tracto urinario superior. Materiales y métodos: Presentamos 3 nefroureterectomías laparoscópicas, una trans y 2 retroperitoneales. La desinserción se realizó en decúbito lateral utilizando un cistoscopio flexible y una fibra de 365 μ de laser Holmio. La técnica endoscópica se adaptó progresivamente a los abordajes retroperitoneoscópicos de 3 puertos y puerto único. Antes de la manipulación laparoscópica del riñón el uréter fue clipado por debajo del tumor, iniciándose posteriormente la técnica endoscópica. Ambos abordajes se combinaron simultáneamente. Resultados: Se lograron nefroureterectomías con desinserción endoscópica del rodete vesical en bloque, garantizando un sistema cerrado, comparable con la técnica abierta. El segundo caso precisó reconversión por problemas técnicos y prolongación del tiempo quirúrgico. No se diagnosticaron recidivas durante el seguimiento. Conclusión: Los resultados alcanzados son comparables con los de la cirugía abierta y la técnica garantizó el cumplimiento de los principios oncológicos. Permitió la desinserción en decúbito lateral evitando el reposicionamiento del paciente, ahorrando tiempo quirúrgico. Los resultados reflejaron los beneficios de la cirugía mínimamente invasiva en todos los casos

Background: The ureteral disinsertion with bladder cuff technique continues to evolve. We present the endoscopic laser transurethral technique combined with a transperitoneal and retroperitoneal laparoscopic approach in lateral decubitus, without patient repositioning, for treating urothelial carcinomas of the upper urinary tract. Materials and methods: We present 3 laparoscopic nephroureterectomies: 1 transperitoneal and 2 retroperitoneal. Disinsertion was performed in lateral decubitus using a flexible cystoscope and a 365-μm holmium laser fiber. The endoscopic technique was progressively adapted to 3-port and single-port retroperitoneoscopic approaches. Before laparoscopic handling of the kidney, ureter was clamped below the tumour. The endoscopic technique was then started. Both approaches were simultaneously employed. Results: Nephroureterectomies were achieved performing en bloc endoscopic disinsertion of the bladder cuff and ensuring a closed system comparable to open technique. The second case required reconversion due to technical problems and extension of the surgical time. No relapses were diagnosed during follow-up. Conclusion: Results are comparable to open surgery, technique ensured compliance to oncology principles, enabled disinsertion in lateral decubitus and avoid patient repositioning saving surgical time. The results reflect the benefits of minimally invasive surgery in all cases

Profilaxis antibiótica "dirigida" por cultivos rectales antes de la biopsia prostática transrectal: reducción de complicaciones infecciosas y costes de atención sanitaria / Rectal culture-directed antibiotic prophylaxis before transrectal prostate biopsy: Reduced infectious complications and healthcare costs

Introducción: La biopsia prostática transrectal ecográficamente dirigida (BPTE) se asocia a complicaciones infecciosas (CI). Las CI están relacionadas con un incremento de la prevalencia de bacterias ciprofloxacino-resistentes (BCR) en la flora rectal. Estudiamos las CI ocurridas en 2 grupos. Grupo de profilaxis antibiótica «dirigida» (GPD) vs. grupo de profilaxis empírica (GPE). Evaluamos el impacto económico que supone la profilaxis antibiótica «dirigida» (PD). Material y métodos: El GPD se estudió prospectivamente (junio 2013-julio 2014). Se recogieron cultivos rectales (CR) antes de BPTE y se sembraron en medios selectivos con ciprofloxacino para determinar la presencia de BCR. Los pacientes con bacterias sensibles recibieron ciprofloxacino. Pacientes con bacterias resistentes recibieron PD según antibiograma del CR. El GPE se estudió retrospectivamente (enero 2011-junio 2009). El CR no se realizó y todos los pacientes recibieron ciprofloxacino como profilaxis. Las CI ocurridas en ambos grupos se registraron en un periodo no superior a 30 días después de BPTE (historia clínica electrónica). Resultados: Trescientos pacientes fueron sometidos a BPTE, 145 recibieron PD y 155 PE. En el GPD, 23 pacientes (15,86%) presentaron BCR en CR. Solo un paciente (0,7%) experimentó ITU. En el GPE, 26 pacientes (16,8%) experimentaron múltiples CI (incluidas 2 sepsis) (p < 0,005). El coste total estimado, incluido el manejo de las CI, fue de 57.076 € con PE vs. 4.802,33 € con PD. El coste promedio/paciente con PE fue de 368,23 € vs. 33,11 € con PD. La PD logró un ahorro total estimado de 52.273,67 €. Es necesario que 6 pacientes se sometan a PD para prevenir una CI. Conclusiones: La PD se asoció a un notable descenso de la incidencia de CI causadas por BCR y redujo los costos de atención sanitaria

Transrectal ultrasound-guided prostate biopsy (TUPB) is associated with infectious complications (ICs), which are related to a greater prevalence of ciprofloxacin-resistant bacteria (CRB) in rectal flora. We examined the ICs that occurred in 2 groups: A guided antibiotic prophylaxis (GP) group and an empiric prophylaxis (EP) group. We assessed the financial impact of GP.: Material and methods: The GP group was studied prospectively (June 2013 to July 2014). We collected rectal cultures (RCs) before the TUPB, which were seeded on selective media with ciprofloxacin to determine the presence of CRB. The patients with sensitive bacteria were administered ciprofloxacin. Patients with resistant bacteria were administered GP according to the RC antibiogram. The EP group was studied retrospectively (January 2011 to June 2009). RCs were not performed, and all patients were treated with ciprofloxacin as prophylaxis. The ICs in both groups were recorded during a period no longer than 30 days following TUPB (electronic medical history). Results: Three hundred patients underwent TUPB, 145 underwent GP, and 155 underwent EP. In the GP group, 23 patients (15.86%) presented CRB in the RCs. Only one patient (0.7%) experienced a UTI. In the EP group, 26 patients (16.8%) experienced multiple ICs (including 2 cases of sepsis) (P < .005). The estimated total cost, including the management of the ICs, was €57,076 with EP versus €4802.33 with GP. The average cost per patient with EP was € 368.23 versus €33.11 with GP. GP achieved an estimated total savings of € 52,273.67. Six patients had to undergo GP to prevent an IC. Conclusions: GP is associated with a marked decrease in the incidence of ICs caused by CRB and reduced healthcare costs

Laparoscopic nephroureterectomy with laser endoscopic transuretral disinsertion in lateral decubitus: progressive adaptation to retroperitoneocopic approach. / Nefroureterectomía y desinserción transuretral láser-endoscópica en decúbito lateral sin cambio de posición: adaptación progresiva al abordaje por retroperitoneoscopia.

BACKGROUND: The ureteral disinsertion with bladder cuff technique continues to evolve. We present the endoscopic laser transurethral technique combined with a transperitoneal and retroperitoneal laparoscopic approach in lateral decubitus, without patient repositioning, for treating urothelial carcinomas of the upper urinary tract. MATERIALS AND METHODS: We present 3 laparoscopic nephroureterectomies: 1 transperitoneal and 2 retroperitoneal. Disinsertion was performed in lateral decubitus using a flexible cystoscope and a 365-µm holmium laser fiber. The endoscopic technique was progressively adapted to 3-port and single-port retroperitoneoscopic approaches. Before laparoscopic handling of the kidney, ureter was clamped below the tumour. The endoscopic technique was then started. Both approaches were simultaneously employed. RESULTS: Nephroureterectomies were achieved performing en bloc endoscopic disinsertion of the bladder cuff and ensuring a closed system comparable to open technique. The second case required reconversion due to technical problems and extension of the surgical time. No relapses were diagnosed during follow-up. CONCLUSION: Results are comparable to open surgery, technique ensured compliance to oncology principles, enabled disinsertion in lateral decubitus and avoid patient repositioning saving surgical time. The results reflect the benefits of minimally invasive surgery in all cases.

Rectal culture-directed antibiotic prophylaxis before transrectal prostate biopsy: Reduced infectious complications and healthcare costs. / Profilaxis antibiótica «dirigida¼ por cultivos rectales antes de la biopsia prostática transrectal: reducción de complicaciones infecciosas y costes de atención sanitaria.

BACKGROUND: Transrectal ultrasound-guided prostate biopsy (TUPB) is associated with infectious complications (ICs), which are related to a greater prevalence of ciprofloxacin-resistant bacteria (CRB) in rectal flora. We examined the ICs that occurred in 2 groups: A guided antibiotic prophylaxis (GP) group and an empiric prophylaxis (EP) group. We assessed the financial impact of GP. MATERIAL AND METHODS: The GP group was studied prospectively (June 2013 to July 2014). We collected rectal cultures (RCs) before the TUPB, which were seeded on selective media with ciprofloxacin to determine the presence of CRB. The patients with sensitive bacteria were administered ciprofloxacin. Patients with resistant bacteria were administered GP according to the RC antibiogram. The EP group was studied retrospectively (January 2011 to June 2009). RCs were not performed, and all patients were treated with ciprofloxacin as prophylaxis. The ICs in both groups were recorded during a period no longer than 30 days following TUPB (electronic medical history). RESULTS: Three hundred patients underwent TUPB, 145 underwent GP, and 155 underwent EP. In the GP group, 23 patients (15.86%) presented CRB in the RCs. Only one patient (0.7%) experienced a UTI. In the EP group, 26 patients (16.8%) experienced multiple ICs (including 2 cases of sepsis) (P<.005). The estimated total cost, including the management of the ICs, was €57,076 with EP versus €4802.33 with GP. The average cost per patient with EP was €368.23 versus €33.11 with GP. GP achieved an estimated total savings of €52,273.67. Six patients had to undergo GP to prevent an IC. CONCLUSIONS: GP is associated with a marked decrease in the incidence of ICs caused by CRB and reduced healthcare costs.

Implantación laparoscópica de esfínter urinario artificial: una opción en el tratamiento de la incontinencia urinaria femenina recidivada / Laparoscopic implantation of artificial urinary sphincter: An option for treating recurrent female urinary incontinence

Introducción: El fallo de la cirugía anti-incontinencia oscila entre el 5-80%. En la actualidad no existe consenso sobre el uso del esfínter urinario artificial (EUA) como tratamiento de la incontinencia urinaria recidivada en la mujer. Varios autores han demostrado que el EUA es útil si se comprueba la deficiencia intrínseca del esfínter. Presentamos, a nuestro entender, el primer caso descrito en España sobre la implantación laparoscópica de un EUA como tratamiento de la incontinencia urinaria recidivada femenina. Material y métodos: Bajo anestesia general se colocó a la paciente en decúbito supino con ligero Trendelenburg y se comprobó el acceso a la vagina. Mediante un abordaje laparoscópico pélvico transperitoneal se desarrolló el espacio de Retzius y seguidamente los espacios laterovaginales hasta la fascia endopélvica. Para facilitar la disección del cuello vesical se introdujo una torunda en la vagina, realizando maniobras simultáneas de tracción y contratracción. Como puerta de entrada para el EUA se amplió la incisión del trocar inferior. Se ajustó el manguito periuretral y seguidamente se colocan: el reservorio y la bomba en el espacio latero-vesical y el labio mayor de la vulva respectivamente. Finalmente, se conectaron los 3 elementos del EUA y se cerró el peritoneo para aislarlo del intestino. Resultados: Tiempo operatorio: 92 min. Pérdida hemática estimada < 100 cc3. Estancia hospitalaria: 48 h. No ocurrieron complicaciones intra ni postoperatorias. El EUA se activó a las 6 semanas. A los 24 meses la paciente lo manipula adecuadamente y alcanzó continencia total. Conclusiones: La implantación laparoscópica del EUA es una técnica factible. Las maniobras transvaginales de tracción y contratracción pueden evitar lesiones intraoperatorias

Introduction: The failure rate for anti-incontinence surgery ranges from 5% to 80%. There is not actual consensus on the use of artificial urinary sphincter (AUS) as treatment for recurrent urinary incontinence in women. Several authors have shown that AUS can be useful, if the intrinsic sphincteric deficiency is checked. We present the first case in Spain, to our knowledge, of laparoscopic implantation of AUS as treatment for female recurrent urinary incontinence. Material and methods: Under general anaesthesia, patient was placed in supine decubitus with slight Trendelenburg, access to the vagina was verified. Through a transperitoneal pelvic laparoscopic approach, Retzius space was opened and then the laterovaginal spaces up to the endopelvic fascia. To facilitate the dissection of the bladder neck, we inserted a swab into the vagina, performing simultaneous traction and countertraction manoeuvres. As an access port for the AUS, we widened the incision of the lower trocar. We adjusted the periurethral cuff and then placed the reservoir and the pump in the laterovesical space and the labia majora of the vulva, respectively. Lastly, we connected the 3 AUS elements and peritoneum was closed to isolate AUS from the intestine. Results: The surgical time was 92 min, the estimated blood loss was < 100 cc3 and the hospital stay was 48 h. There were no intraoperative or postoperative complications. The AUS was activated at 6 weeks. At 24 months, patient managed the AUS adequately and total continence was achieved. Conclusions: Laparoscopic implantation of AUS is a feasible technique. Transvaginal traction and countertraction manoeuvres can prevent intraoperative lesions

Laparoscopic implantation of artificial urinary sphincter: An option for treating recurrent female urinary incontinence. / Implantación laparoscópica de esfínter urinario artificial: una opción en el tratamiento de la incontinencia urinaria femenina recidivada.

INTRODUCTION: The failure rate for anti-incontinence surgery ranges from 5% to 80%. There is not actual consensus on the use of artificial urinary sphincter (AUS) as treatment for recurrent urinary incontinence in women. Several authors have shown that AUS can be useful, if the intrinsic sphincteric deficiency is checked. We present the first case in Spain, to our knowledge, of laparoscopic implantation of AUS as treatment for female recurrent urinary incontinence. MATERIAL AND METHODS: Under general anaesthesia, patient was placed in supine decubitus with slight Trendelenburg, access to the vagina was verified. Through a transperitoneal pelvic laparoscopic approach, Retzius space was opened and then the laterovaginal spaces up to the endopelvic fascia. To facilitate the dissection of the bladder neck, we inserted a swab into the vagina, performing simultaneous traction and countertraction manoeuvres. As an access port for the AUS, we widened the incision of the lower trocar. We adjusted the periurethral cuff and then placed the reservoir and the pump in the laterovesical space and the labia majora of the vulva, respectively. Lastly, we connected the 3 AUS elements and peritoneum was closed to isolate AUS from the intestine. RESULTS: The surgical time was 92min, the estimated blood loss was <100cc(3) and the hospital stay was 48h. There were no intraoperative or postoperative complications. The AUS was activated at 6 weeks. At 24 months, patient managed the AUS adequately and total continence was achieved. CONCLUSIONS: Laparoscopic implantation of AUS is a feasible technique. Transvaginal traction and countertraction manoeuvres can prevent intraoperative lesions.

Utilidad del cociente psa-l/psa-t y la dpsa para la discriminación entre hipertrofia benigna de próstata y cáncer de próstata / Usefulness of free/total prostate-specific antigen (PSA) ratio and PSA density to enhance differentiation of benign prostatic hyperplasia from prostate cancer

OBJETIVO: Investigar la rentabilidad diagnóstica del cociente PSA-L/PSA-T y densidad de PSA, en el diagnóstico del cáncer de próstata en pacientes con cifras de PSA-T en la zona gris de decisión diagnóstica entre 4-10 ng/ml. Establecer el punto de corte para hacer el diagnóstico diferencial entre enfermedad benigna de la próstata y cáncer, con el fin de evitar biopsias innecesarias. MÉTODO: Estudio prospectivo realizado a 136 varones de edades comprendidas entre 54 y 87 años (media 70,6). Los pacientes acuden a la consulta de urología por síntomas urinarios. Se les solicita una prueba de PSA-T, PSA-L, cociente de PSA-L/PSA-T, se realiza tacto rectal y ecografía transrectal con biopsia en octantes, se mide el volumen de la próstata y se calcula la densidad de PSA. A 113 pacientes se solicita estudio anatomopatológico, encontrándose 82 casos de HBP y 31 de carcinoma de próstata en diferentes estadios. RESULTADOS: No se encontraron diferencias significativas entre el grupo de pacientes con HBP y CAP para el PSA-T, PSA-L, cociente PSA-L/PSA-T ni tacto rectal. La DPSA y el volumen de la próstata son significativamente diferentes p < 0,05 en los pacientes con HPB y CAP. Para una sensibilidad del 94% (78,5-99), el punto de corte para el cociente de PSA sería de 0,28 y la especificidad del 11% (5,2-19,8). Con una sensibilidad del 96,2% (80,3-99,4) el punto de corte obtenido para DPSA es de 0,109 y la especificidad de 25% (15,5-36,6).CONCLUSIONES: En pacientes con cifras de PSA-T entre 4 y 10 ng/ml el cociente PSA-L/PSA-T no tiene ventajas sobre el PSA-T en el diagnóstico precoz del cáncer de próstata. La DPSA puede mejorar la especificidad, sin comprometer el diagnóstico de CAP (AU)

[Usefulness of free/total PSA ratio and PSA density in distinguishing benign prostatic hypertrophy from prostatic cancer]. / Utilidad del cociente PSA-L/PSA-T y la DPSA para la discriminacion entre hipertrofia benigna de próstata y cáncer de próstata.

OBJECTIVE: To investigate the clinical significance of the free-to-total prostate-specific antigen ratio (f/tPSA) and PSA density (PSAD) for prostate cancer detection in patients with intermediate tPSA levels (4-10 ng/ml). To establish a cutoff to discriminate between benign prostatic disease (BPH) and prostate cancer (CaP), avoiding unnecessary biopsies. METHODS: This prospective study included 136 men, aged between 54 and 85 (mean 70.6) years old. Urinary tract symptoms were present in these patients. Serum samples were obtained to measure tPSA, fPSA, and f/tPSA; digital rectal examination and transrectal ultrasound eight-sector biopsies were performed. Prostate volume was measured and PSAD calculated. The pathologic study, carried out in 113 patients, showed 82 with BPH and 31 with prostate cancer in various stages. RESULTS: There were no significant differences between patients with BPH and CaP when comparing tPSA, fPSA, f/tPSA or digital rectal examination. PSAD and prostate volume were significantly different in patients with BPH and CaP. With a sensitivity of 94% (78.5-99), the f/tPSA cutoff was 0.28 with a 11% (5.2-19.8) specificity. With a sensitivity of 96.2% (80.3-99.4) cutoff for PSAD was 0.109 and specificity 25% (15.5-36.6). CONCLUSIONS: In patients whose tPSA level is between 4 and 10 ng/ml, f/tPSA has no advantages over tPSA measurement for early detection of prostate cancer. DPSA can improve specificities, without compromising the detection of CaP.