Management of male anterior urethral strictures in adults. Results from a national survey among urologists in Spain. / Manejo de la estenosis de uretra anterior del varón. Resultados de una encuesta nacional entre urólogos que ejercen en España.

INTRODUCTION AND OBJECTIVE: Assessment of urethral stricture (US) management seems important to evaluate the quality of attention and plan educational interventions. We aim to investigate the practice patterns on diagnostic and therapeutic approaches to adult male anterior US among urologists in Spain. MATERIALS AND METHODS: 23-question on-line survey conducted among all members of AEU (Spanish Urological Association). Demography data and practices on evaluation and treatment of US were included. 1737 invitation letters sent by email, with 21.7% response rate. Data were prospectively collected during 2016. Descriptive analysis and univariate comparisons conducted using X2 test. Statistical significance considered when P≤.05. RESULTS: Responders were mainly from Tertiary and Teaching University Hospitals. 63.2% treated≥10 patients/year with US. Retrograde urethrogram (RUG) was the commonest diagnostic tool followed by uroflowmetry (UF), and internal urethrotomy under direct vision (DVIU) the most frequent treatment. 84.4% limited DVIU for US≤1.5cm. 62.3% performed≤5 urethroplasties/year. Anastomotic urethroplasties were performed by 75.7% and graft repairs by 68.9%. Dorsal grafting was preferred rather than ventral. Non-transecting techniques were used by 23.9%. UF was the most common follow-up tool. 88.4% felt that referral units were required. Tertiary hospitals used Patient Reported Outcome Measure (PROM) questionnaires more frequently than secondary centres. High-volume urologists were more likely to use non-transecting techniques and to choose urethroplasty as first choice procedure. CONCLUSIONS: Male anterior US in Spain are treated by many urologists, mainly using endoscopic procedures. RUG is preferred for diagnosis, and UF for follow-up. A high percentage of urologists perform urethroplasties, mainly anastomotic repairs, but in low volume.

Nontraumatic posterior urethral stenosis. / Patología estenótica no traumática de la uretra posterior.

INTRODUCTION: Posterior urethral stenoses and contractures are complications after treatment of benign prostatic hyperplasia (BPH), localised prostate cancer (PCa), and orthotopic neobladder formation, compromising prognosis and functional outcomes. OBJECTIVES: To identify factors related to aetiology, prevention and treatment of non-traumatic posterior urethral stenosis and contractures. ACQUISITION OF EVIDENCE: Review of the published evidence related to posterior urethral stenosis and contractures after PCa treatment, BPH therapies and orthotopic neobladder formation. PubMed database search with English and Spanish papers considered. Cohort studies, case series, prospective and retrospective studies and review papers were included. SYNTHESIS OF EVIDENCE: Posterior urethral stenoses and contractures are common, leading to significant morbidity. A worsening on voiding quality should rise some concerns. Careful surgical and/or radiotherapic techniques prevent their development. Endoscopic therapies are the initial approach, with complex urethroplasties often required. Subsequent urinary incontinence, the most important sequelae, may need artificial sphincters. CONCLUSIONS: Non-traumatic posterior urethral stenoses could be important complications, potentially compromising the outcomes of initial therapy. They could require complex surgeries leading to urinary incontinence.

Traumatic lesions of the posterior urethra. / Lesiones traumáticas de la uretra posterior.

INTRODUCTION: The posterior urethral lesions are associated with pelvis fractures in 5-10% of cases. The posterior urethra is attached to the pelvis bone by puboprostatic ligaments and the perineal membrane, which explains why disruption of the pelvic ring can injure the urethra at this level. OBJECTIVES: To identify suspected cases of posterior urethral trauma and to perform the diagnosis and its immediate or deferred management. ACQUISITION OF EVIDENCE: Search in PubMed of articles related to traumatic posterior urethral lesions, written in English or Spanish. We reviewed the relevant publications including literature reviews and chapters from books related to the topic. SYNTHESIS OF THE EVIDENCE: With patients with pelvis fractures, we must always rule out posterior urethral lesions. The diagnostic examination of choice is retrograde urethrography, which, along with the severity of the condition, will determine the management in the acute phase and whether the treatment will be performed immediately or deferred. Early diagnosis and proper acute management decrease the associated complications, such as strictures, urinary incontinence and erectile dysfunction. CONCLUSIONS: Despite the classical association between posterior urethral lesions and pelvic fractures, the management of those lesions (whether immediate or deferred) remains controversial. Thanks to the growing interest in urethral disease, there are an increasing number of studies that help us achieve better management of these lesions.

The nested variant of bladder transitional cell carcinoma: Review of 12 cases and review of the literature.

OBJECTIVES: The nested variant of bladder transitional cell carcinoma is extremely rare and has a different biological behavior to other bladder tumors. The aim of this study is to analize if their behavior is as aggressive as has been described in the literature. MATERIAL AND METHOD: Review of 12 diagnosed cases with nested variant of bladder transitional cell carcinoma and analysis of demographic characteristics, clinical presentation, tumor characteristics, treatment options, analysis of recurrence and cancer-specific survival between January 1997 and December 2010 in our hospital. RESULTS: 50% of the cases had a pathologic stage ≥T2, with grade of differentiation G2 (50%) or G3 (50%). After the pathological result of the TUR (transurethral resection) Bladder, 5 cases underwent radical cystoprostatectomy, 3 a second TUR bladder and 4 cases with treatment chemotherapy and/or radiotherapy (RT). Five out of 12 cases (41.7%) died due to bladder cancer and 3 died (25%) of other causes (urinary sepsis, respiratory failure, renal failure). With a median follow up of 40 months, the overall survival was 50% and cancer-specific survival of 65.6%. CONCLUSIONS: The nested variant of bladder transitional cell carcinoma is a disease with an advanced-stage presentation, with high recurrence and mortality rates despite the use of different treatments. So far there is not a clinical practice guideline for this variety of urothelial tumor.

[Renal graft outcome in patients with combined heart-kidney transplantation]. / Trasplante cardio-renal. Evolucion del injerto renal.

INTRODUCTION: Improvement in surgical and organ preservation techniques and immunosuppressive therapy has permitted multiorganic transplants in patients needing both heart and kidney organs in a synchronous or asynchronous way. OBJECTIVES: To review our results in renal transplants in those patients with both heart and kidney transplants. MATERIAL AND METHOD: Retrospective study of the 7 patients with heart and kidney transplants performed in our Hospital. We have reviewed patients main characteristics, heart and renal failure causes, renal graft and patient outcome and complications related to renal transplant. RESULTS: Between 1985 and 2006 we performed 411 heart transplants; in 7 out of those 411 patients (1.7%) we performed 9 renal transplants, 2 simultaneously and 7 non-simultaneously. All patients were male; their average age at heart transplant was 51.3+/-12.2 years (24-60); the causes of the heart transplant were dilated myocardiopathy in 4 cases (57.2%), rheumatic cardiopathy in 1 (14.3%) and ischemic cardiopathy in 2 (28.5%). The average age at renal transplant was 57.5+/-11.2 years (32-68); the causes of the end renal failure were cyclosporine nephrotoxicity in 3 cases (33.3%), nephroangiosclerosis in 1 (11.1%), chronic interstitial nephropathy in 2 (22.2%), membranoproliferative glomerulonephritis in 1 (11.1%) and chronic rejection in 2 (22.2%). In the 2 simultaneous heart-kidney transplants cold ischemia was 4 hours long, immediate diuresis was seen in 1 case (50%) and there were no complications related to the kidney transplants. The time between the heart and kidney transplants in the 7 non-simultaneous heart-kidney transplants was 105.9+/-51.8 months (23-201 months), cold ischemia was 20.3+/-1.5 hours (18-22) and there was immediate diuresis in 5 cases (71.5%); 2 patients had no complications, 2 cases had acute renal rejection episodes, 1 case of perirenal haematoma, 1 renal polar infarction, lymphocele, 1 case of wound infection, 1 urinary infection and 2 pulmonary infections. Medium follow-up is 52.2+/-33.9 months (12-93); all patients are alive with functioning grafts with creatinine level of 1.8+/-0.43 mg/100 (1.4-2.4). Two renal grafts were lost due to chronic rejection 138 and 270 days after the kidney transplants. The immunotherapy was based on mycophenolate mofetil acid and tacrolimus, though it varied. CONCLUSIONS: The final renal failure associated to cardiopathies needing or having needed heart transplant does not preclude the transplants of both organs.

[Performance of antibiotic prophylaxis in our Urologic Department]. / Cumplimiento de profilaxis antibiótica en un Servicio de Urología.

INTRODUCTION: The rate of surgical site infection is a good indicator of the quality of care in surgical departments. Antibiotic prophylaxis represents a measure of proven efficiency in preventing the infection in a surgical site, and its fulfilment is a main goal in management contracts of health services. The efficiency of this preventive measure requires the existence of updated protocols and performance evaluation. OBJECTIVE: To evaluate the compliance of this antibiotic protocol in our Urology Department with the global analysis of the causes of inadequate prophylaxis and by procedures. MATERIAL AND METHODS: The Department of Preventive Medicine as an outside observer, through a retrospective study, analyzed 695 urological surgical procedures (inpatient and outpatient) during the years 2003 and 2006 for its annual assessment of compliance with the antibiotic prophylaxis protocol. Administration of non-indicated prophylaxis, non-administration of indicated prophylaxis and incorrect dosage are considered as inappropriate prophylaxis. RESULTS: The compliance of the protocol was appropriate in 83.16% of the operations. The cause of the most frequent inadequacy was an incorrect pattern in 15.3%. Within this incorrect pattern the main reason was the delay of administration of prophylactic antibiotic and to a lesser extent an incorrect length of the antibiotic regime. CONCLUSIONS: The percentage of compliance with the antibiotic protocol in our Urology Department is high. The evaluation detected two problems of a different nature and solution: to adapt the timing of antibiotics is a functional, structural and organizational problem to be resolved in accordance with the Anaesthesiology Department. The number of doses of antibiotics in open prostate surgery requires knowledge and strict adherence to the guidelines by the surgeons. The efficiency of antibiotic prophylaxis requires the existence of appropriated and updated protocols for the unifications of criteria among professionals to detect new problems as well as to find solutions for its adequate compliance.

[Emergency conservative surgery on a unique kidney with broken multiple angiomyolipoma]. / Cirugía conservadora de urgencia en monorrena por rotura de angiomiolipoma múltiple.

A case of retroperitoneal hemorrhage due to the rupture of a multiple angiomyolipoma in a female with a unique kidney is described. Hipovolemic shock was the first symptom, being possible to perform on her a successful conservative surgery. Etiology, diagnostic methods and treatment of the spontaneous retroperitoneal hemorrhage are discussed.

[Testicular epidermoid cyst: uncommon lesion of difficult preoperative diagnosis]. / Quiste epidermoide testicular: una rara entidad de dificil diagnostico preoperatorio.

Intratesticular epidermoid cysts are rare tumours that constitute one percent of all testicular masses. They are bening lesions that make differential diagnosis from malignant testicular tumours difficult. The absence of serum markers elevation and ultrasound imaging could support these lesions being bening epidermoid cysts, and in that case, conservative surgery is adequate. We present the case of a 22 years old patient who complains of a left testicular mass. In this case ultrasound diagnosis was non-specific and a left radical inguinal orchiectomy was performed.

[Comparative study between cystoscopy, urinary cytology, NMP-22 and a new method, bladder chek, in the follow-up of superficial bladder cell carcinoma]. / Estudio comparativo entre cistoscopia, citología urinaria, NMP-22 y un nuevo método, bladder chek, en el seguimiento del cáncer vesical superficial.

OBJECTIVE: The goal of this work tries to evaluate the utility of the qualitative determination of NMP-22 in the evaluation of the superficial bladder carcinoma in asymptomatic patients, comparing it with its quantitative determination, the cytology and the cystoscopy. MATERIALS AND METHODS: A simple of urine just voided was taken in 88 asymptomatic patient follow-up for superficial bladder cell carcinoma. This dose was distributed in 3 parts, for performed cytology, for determination of NMP-22, and 4 drops of the third part are added to device bladder chek. Later, we performed cystoscopy and transurethral resection in patients with a suspicion of bladder cancer. RESULTS: 26 patients had tumor relapse and 62 patients were free of disease. The sensitivity for the bladder chek was of 28%, 34.62% for NMP-22, 34.62% for cytology and 100% for cystoscopy. The specificity was of 93.55%, 80.33%, 87.10% and 87.10% respectively. The sensitivity by degree was 25 in G1, 28.57 in G2 and 50 in G3 for Bladder chek; 29.41, 42.86 and 50 for NMP-22; 23.53, 71.43 and 0 for cytology. The sensitivity by stages was 27.7 in Ta-1 and 50 in T2 for Bladder chek; 34.78 and 50 for NMP-22; 39.13 and 0 for the cytology. CONCLUSIONS: The low sensitivity of bladder chek invalidates it like alternative method to the cystoscopy in the follow-up of the superficial asymptomatic bladder cell carcinoma.

[Surgical aspects in the third and fourth kidney retransplant]. / Aspectos quirúrgicos en los terceros y cuartos retrasplantes renales.

INTRODUCTION AND OBJECTIVES: A quarter of patients waiting for kidney transplantation are patients with previous graft failure. Outcome of first and second renal transplant make these the gold standard for end renal stage disease, but this is not so clear in the case of third and further renal transplant, especially at the time of organ shortage. We revise our experience in patients with three or more kidney transplants focusing on surgical aspects and graft outcome. MATERIAL AND METHOD: 1364 renal transplants have been carried out in our centre since 1975 until December 2003. We have retrospectively revised the 34 patients with three renal transplants and the 5 with four. We analyse the surgical technique, surgical complications and graft outcome. RESULTS: Mean age was 42 years (21-65). Average mismatches between donor and recipient was 3.2. All kidneys, but one case of living donor, were harvested from cadaver donors, mostly in multiple organ-procurement. Average time from the last renal transplant was 5 years (3 days-17 years) and from the last transplant carried out in the iliac fossa reused until the new transplant was 9 years (3 days- 17.5 years). All implants were performed through an iterative lumboliliac incision (25 on the right side, 11 on the left one and in 3 cases where side was not registered). Mean average duration of the procedure was 166 minutes (100-300). Nephrectomy of previous graft at the moment of the implant was carried out in 13 patients (33%). Vascular anastomosis was made on the common iliac vessels (50%) or on the external ones (50%) in end to side way, Ureteroneocystostomy was performed in an extravesical way except in 1 patient with cutaneous diversion. Vascular complications were 4 haemorrages (1 patient died), 3 venous and 2 arterial thrombosis. We had an abscess secondary to intestinal fistulae. Other surgical complications were 4 lymphoceles, three of them needed surgical treatment, and one perirenal haematoma treated in a conservative way. No urological complications were seen. In total 6 grafts (15%) were lost due to surgical complications. Graft actuarial survival rate at 1 year was 65%, 40% at 5 and 28% at 10 years. CONCLUSIONS: Three and four renal transplant survival rates are shorter than first and second ones. Iterative access through lumboiliac incision is associated with a higher vascular complication rate, probably in these patients a transperitoneal access would be better. Multicentric studies with higher numbers of patients are needed to define more clearly which patients would benefit from multiple kidney retransplants.

[Renal cell carcinoma in crossed fused renal ectopia]. / Tumor renal en ectopia renal cruzada con fusión.

Crossed renal ectopia its a rare congenital malformation and in most cases it presents with fusion of both kidneys. Patients should be asynptomatic until 4a-5a decade and at that time they unfold urinary infection, urolithiasis, abdominal mass or pain that simulates a gastric disease. We report a case of renal cell carcinoma in a patient with crossed fused renal ectopia, showed in a Scan that was performed for gastric disease suspicion.

[Usefulness of abdominal leak point pressure determination in the diagnosis of female urinary incontinence in the TVT era]. / Utilidad de la determinación de la presión abdominal de fuga en el diagnóstico de la incontinencia de orina femenina en la epoca del TVT.

OBJECTIVE: To analyse our results about continence in the treatment of female urinary incontinence with the tension-free vaginal tape (TVT) procedure based on abdominal leak point pressure(ALPP). PATIENTS AND METHODS: Retrospective study of the fifty two patients who had urodynamic study and abdominal leak point pressure determination and were operated on between 1999 and 2002 for stress urinary incontinence. We reviewed the data of clinical history, physical examination and urodynamic report, surgery, complications, and objective and subjective results. Those patients having ALPP > 100 are included in group 1, between 61 and 100 in group 2 and less than 60 in group 3. RESULTS: There were 19 patients in group 1, 17 in group 2 and 16 in group 3. We found no difference between the three groups regarding age, delivery, menopause, hysterectomy, evolution, previous surgery, grade of cystocele, association of anterior colporraphy to TVT and type of anaesthesia. The Obrink clinical grade increased as the ALPP decreased (grade 3 in 26.32% of group 1, 31.58% in group 2 and 68.71% in group 3). 100% of patients in groups 1 and 2 were continent with effort and 93.75% in group 3. Complications, especially de novo instability or urgency-frequency episodes or persistence of instability in patients having mixed incontinence, caused a decrease in the satisfaction degree to 79% in group 1, 76.5% in 2 and 62.5% in 3. CONCLUSIONS: Abdominal leak point pressure determination does not change our decision of perform a TVT procedure but permits us to differentiate one group in which results could be worse.

[Upper urinary tract tumours]. / Tumores de urotelio superior.

OBJECTIVE: To evaluate diagnostic techniques, treatment and follow-up in 94 patients affected of upper urinary tract tumor. PATIENTS AND METHOD: From 1978 to december 2002 we operated 105 patients due to upper urinary tract tumor, although only 94 are valid for analysis. Mean age was 65 years and 85% were man. Haematuria was the most frequent symptom. RESULTS: Urography (93%), ecography (77%) and CT (67%) were the most used diagnostic techniques. Pelvic tumor was the most frequent (71%) and total nephroureterectomy including bladder cuff the chosen treatment (76.4%). Previous or simultaneous bladder tumor was observed in 23% cases and delayed in 30%. With a mean follow-up of 76 months the patient survival is 53%. CONCLUSIONS: Due to the high frequence of previous, simultaneous or delayed bladder tumors, the upper urinary tract tumor should be considered as a panurothelial disease, worsening the outcome of this kind of tumors.

[Corrective surgery of penile inward curvature]. / Cirugía correctora de la incurvación peneana.

OBJECTIVE: To evaluate the corporoplasty techniques performed on 59 patients to correct congenital penile curvature and Peyronie's disease. PATIENTS AND METHOD: From april 1991 to december 2001, 39 Nesbit technique, 12 Ruiz-Castañé method and 8 Essed-Schröeder procedure were performed on forty-four congenital curvatures and fifteen Peyronie's diseases. The mean age was 24 years old. Trying to hide the knots, in all patients except five a nonabsorbable inverting sutures were placed. RESULTS: The mean follow-up was 12 months. Postoperatively, 53 patients (86%) had satisfactory cosmetic and functional results. Four patients of five with absorbable sutures had residual curvature which needed another successful surgical correction. One patient complained of penile shortening, one of glans hypoaesthesia, one of foreskin oedema and five of palpable plication sutures. No differences were found depending on the applied surgical technique. CONCLUSIONS: The results reported are in accordance with the literature showing a higher recurrence rate with the absorbable sutures. The outcome is very similar with the three described techniques.

[Complications in a consecutive series of 133 cases of radical prostatectomy]. / Complicaciones de una serie consecutiva de 133 casos de prostatectomía radical.

OBJECTIVE: To evaluate the surgical complications of radical prostatectomy in our hospital. PATIENTS AND METHOD: From august 1991 to december 1999, 138 patients with clinically localized prostate cancer underwent Walsh technique radical prostatectomy. The follow-up is known from 133 patients with a mean age of 64.8% and a mean PSA of 17.6 ng/ml. RESULTS: The mean follow-up is 43 months. Urinary fistula (9%), lymphatic leakage (5.22%) and rectal injury (2.2%) are the most common early complications. Urinary incontinence (27%), erectile dysfunction (98%) and urethrovesical junction stenosis (12%) are the delay complications. Only three patients have died due to prostate cancer. Our results are compared with another series. CONCLUSIONS: The morbidity of radical prostatectomy is very similar to the compared series. Urinary incontinence and erectile dysfunction are the most worrying complications which the patient must know to have the opportunity to choose another therapeutic option.

[Leydig cell tumor. Report of 2 cases and review of the literature]. / Tumor de células de Leydig. Aportación de dos casos y revisión de la literatura.

The Leydig cell tumor is the most frequent of non-germ cell tumors of the testis. Clinical findings depend on the age of presentation. We present two cases of Leydig Cell tumors of the testis, diagnosed in a 8 years old child with isosexual precocity, and a 42 years old adult with Gynaecomastia. After reviewing the existing literature on this uncommon pathology we consider that the iconography presented is very interesting for furthering the knowledge on this subject.

[Correlation between imaging findings and anatomopathologic results in radical prostatectomy. Data from our series]. / Correlación de los hallazgos por imagen y resultados anatomopatológicos en la prostatectomía radical. Datos de nuestra serie.

OBJECTIVE: To analyze the diagnostic methods utilized in prostate cancer and the preoperative information on the extent of the tumor, and compare these results with those obtained from anatomopathological analyses of the radical prostatectomy specimen. METHODS: Data on the radical prostatectomies performed during the study period were obtained from the Admissions and Clinical Records services and were analyzed using the SPSS statistical analysis software for Windows. RESULTS: From 1991 to 1998, 109 radical prostatectomies were performed. Evaluation by transrectal US was carried out in 89 patients (81.6%) and detected a tumor (unilateral or bilateral) in 77, for a sensitivity of 86% (CI 78.8-93.2). A CT study was performed in 94 patients and was positive in 25, for a sensitivity of 26.5% (CI 17.6-35.4). The sensitivity for transrectal US and CT were 4.17% and 3.33% for capsular involvement, 5.88% and 5.26% for seminal vesicle involvement, and 0% and 0% for node involvement, respectively. CONCLUSIONS: Transrectal ultrasound is a reliable diagnostic imaging method, although it has a low sensitivity when used to determine the extent of the tumor. In our series, the radiological methods showed a low sensitivity when they were utilized to determine the extent of the prostate cancer. Routine preoperative assessment by CT can be obviated in prostate cancer.

[Incidence of priapism at the Marqués de Valdecilla University Hospital in Santander]. / Incidencia de priapismo en el Hospital Universitario Marqués de Valdecilla de Santander.

OBJECTIVE: Our experience in the management of priapism, its etiology, blood gas changes, treatment and outcome are presented. METHODS: The records of patients that had been treated at the Urology services of our hospital over the last 8 years were reviewed. During this period, patients with erectile dysfunction were treated according to a protocol. RESULTS: There were 9 episodes of priapism in 8 patients; all cases were low flow and the patients were aged 37-71 years. The duration of the prolonged erection ranged from 4 to 72 hours. Of these 9 cases, the etiology was intracavernosal PGE in 7, after trazodone administration in one case, and unknown in one case. Intracavernosal metoxamine was administered in all cases with excellent results, except one case that required a saphenous-cavernosal shunt and another case that was initially treated with adrenalin also with good results. CONCLUSIONS: Since intracavernosal agents have been utilized in the treatment of erectile dysfunction, priapism has become a more frequent urological emergency. Although a lower incidence has been reported for PGE, the dose should be well adjusted to avoid a higher incidence.

[Mucinous adenocarcinoma of the prostate. Report of a new case]. / Adenocarcinoma mucinoso de próstata. Aportación de un nuevo caso.

OBJECTIVE: To describe a case of mucinous adenocarcinoma of the prostate, an uncommon variant of prostatic carcinoma of which few cases have been reported in the literature. This tumor type is briefly reviewed with special reference to the controversial issues that remain unresolved due to the small number of cases. METHODS/RESULTS: A case of mucinous adenocarcinoma of the prostate is presented. An extraprostatic origin had been discarded. The diagnosis was made by DRE, transrectal US and histological confirmation by transrectal biopsy. PSA values were normal. Studies to determine the extent of the lesion showed advanced locoregional dissemination. Surgery was therefore not indicated and hormonal therapy was administered. Patient outcome was poor with no apparent clinical response to hormone blockade. Radiotherapy was attempted. The patient rapidly became worse and died. CONCLUSIONS: Mucinous adenocarcinoma of the prostate is characterized by the presence of significant amounts of extra and intracellular mucin. Its clinical features are not unlike those of classical adenocarcinoma and in general terms, it is considered to carry a worse prognosis and refractory to hormone therapy.