Fístula arterioileal: experiencia en un hospital terciario y revisión de la literatura / Arterial-ileal fistula: experience from a tertiary referral center and literature review

Introducción y objetivo: la fístula entre la arteria ilíaca y el conducto ileal (Bricker) es una patología con un elevado riesgo vital. El objetivo de este artículo es dar a conocer esta entidad, describir su presentación, sus métodos diagnósticos y su tratamiento basados en los casos en un hospital terciario y en la revisión de la literatura. Material y métodos: presentamos los casos de fístulas arterioileales ocurridos en nuestro centro entre 2016 y 2020. Se realizó una exhaustiva revisión de la literatura publicada hasta la fecha mediante la búsqueda en PubMed de artículos publicados entre 1971 y 2020, incluyendo las palabras claves “arterial ileal conduit fistula” y seleccionando únicamente los artículos en español e inglés. Resultados: se identificaron 4 casos en nuestro centro. Se reconocieron en la búsqueda bibliográfica 13 artículos que describían 16 casos de fístulas arterioileales. La mayoría compartía factores comunes de riesgo y el abordaje quirúrgico fue mayoritariamente la cirugía abierta. El abordaje adecuado parece ser la combinación de cirugía abierta y endovascular, efectiva en 3 de nuestros 4 casos. Conclusión: la fístula entre la arteria ilíaca y el conducto ileal es una complicación infrecuente y grave, con una mortalidad en torno al 44 %. Resulta difícil de diagnosticar, salvo que exista alta sospecha clínica, con pocos casos descritos en la literatura. Es fundamental tener en cuenta la historia clínica previa del paciente. (AU)

Introduction and objective: the presence of a fistula between the iliac artery and the ileal conduit is a live-threatening condition that must be known and, therefore, suspected after a massive bleeding through the ileal conduit. The objective of this article is to present the arterial-ileal fistula, describe its presentation, diagnostic methods, and treatments, based on the cases presented in a tertiary referral center and literature review. Material and methods: all cases of arterial-ileal fistulas collected at our center from 2016 through 2020 are presented here. A comprehensive literature review published to date was also conducted based on a search for articles published from 1971 through 2020 on the PubMed database with the keywords “arterial ileal conduit fistula”, including studies only published in English and Spanish languages. Results: a total of 4 cases were identified in our center. A total of 13 articles describing 16 cases of arterial-ileal fistula were identified from the medical literature, most of them with some risk factors in common. The approach followed was mainly open surgery. The proper treatment seems to be a combination between open surgery and endovascular approaches, which turned out to be effective in 3 of our 4 cases. Conclusion: a fistula between the artery and the ileal conduit is a rare but serious complication, with a 44% mortality rate. It is difficult to diagnose unless there is clinical suspicion involved, with only a few cases reported in the medical literature. We should consider the patient’s pathological history to identify this entity. (AU)

Quality of Life in Women after Deep Endometriosis Surgery: Comparison with Spanish Standardized Values.

The quality of life (QoL) of women who have been surgically treated for endometriosis may be severely impaired. Therefore, QoL can be a determining factor in the recovery of these patients. The aims of this study were to evaluate if the QoL of women surgically treated for deep endometriosis differs from a healthy age-matched population from Catalonia (Spain) and to analyze the QoL of these women considering concomitant events. This is an observational cross-sectional study, where 112 women (between 18 and 48 years old), with endometriosis treated by surgery at Hospital Universitario La Paz (Madrid, Spain), were enrolled to assess the QoL using the second version of the 12-item short form (SF-12) questionnaire. The QoL in these women were tested against a reference population of healthy women using a standardized one-sample comparison method. In addition, the QoL was compared according to the pathophysiology and type of surgery. In women with endometriosis, the physical health component, but not mental health component, was positively correlated with age (r = 0.19; p-Value = 0.048). In addition, physical (20.3 ± 29.2) and social functions (29.7 ± 38.3) and the overall physical health component (37.8 ± 19.4) were significantly lower than the reference population. On the contrary, the body pain (64.1 ± 41.2), emotional role (62.5 ± 42.2), mental health (54.4 ± 26.0), vitality (59.3 ± 31.2), and the overall mental health component (59.4 ± 26.6) had significantly higher scores than the reference. The anatomical compartment of endometriosis, reintervention, bowel nodule resection, and fertility preservation did not show statistical differences in QoL. Women with deep endometriosis had worse physical and social functions, and the overall physical health, compared to the norm in Spanish women. Bodily pain, emotional role, vitality, and the overall mental health improved. These areas could be considered protective factors in this disease. Considering the importance of QoL in adjustments in mental and physical health, it would be necessary to improve these areas of QoL in women surgically treated for deep endometriosis.

Homogenizing the Teaching of Engaged Medical Examinations to Large Numbers of Students: the Experience of the Digital Rectal Examination.

This project aims to complement and homogenise the teaching of indications and technique of digital rectal examination (DRE) through the use of simulators, and subsequently analysed the level of satisfaction with the training and skills acquired. The students were distributed into small groups. One of the workshop's coordinators synthesised indications and procedures of DRE. A teaching video was made with all the contents and was distributed between the trainers. During the workshop, trainers explained the indications and the method of performing the DRE. Then, the selected clinical cases were presented, followed by the DRE by specific simulators. Once the students had completed each exploration, the trainers explained each case and discussed it with students. The following week, an anonymous questionnaire was given to participants to evaluate the workshop. Of the 232 participating students, 53 (23%) responded to the questionnaire. The overall level of satisfaction was higher than 98% (score 4-5), reaching 100% in the evaluation of the practical contents, and 93% of the students would recommend the continuity of the workshop in the next courses. The DRE workshop was well received among medical students, with a high degree of voluntary participation and response rate to the subsequent survey. With this project, we have achieved a greater homogenisation of teaching within the subject of Urology, and greater confidence for the students when facing their future clinical practice.

Chemotactic Responses of Xanthomonas with Different Host Ranges.

Xanthomonas citri pv. citri (Xcc) (X. citri subsp. citri) type A is the causal agent of citrus bacterial canker (CBC) on most Citrus spp. and close relatives. Two narrow-host-range strains of Xcc, Aw and A*, from Florida and Southwest Asia, respectively, infect only Mexican lime (Citrus aurantifolia) and alemow (C. macrophylla). In the initial stage of infection, these xanthomonads enter via stomata to reach the apoplast. Herein, we investigated the differences in chemotactic responses for wide and narrow-host-range strains of Xcc A, X. euvesicatoria pv. citrumelonis (X. alfalfae subsp. citrumelonis), the causal agent of citrus bacterial spot, and X. campestris pv. campestris, the crucifer black rot pathogen. These strains of Xanthomonas were compared for carbon source use, the chemotactic responses toward carbon compounds, chemotaxis sensor content, and responses to apoplastic fluids from Citrus spp. and Chinese cabbage (Brassica pekinensis). Different chemotactic responses occurred for carbon sources and apoplastic fluids, depending on the Xanthomonas strain and the host plant from which the apoplastic fluid was derived. Differential chemotactic responses to carbon sources and citrus apoplasts suggest that these Xanthomonas strains sense host-specific signals that facilitate their location and entry of stomatal openings or wounds.

Teaching Urology to Undergraduates: A Prospective Survey of What General Practitioners Need to Know.

BACKGROUND: Higher education training in Medicine has considerably evolved in recent years. One of its main goals has been to ensure the training of students as future adequately qualified general practitioners (GPs). Tools need to be developed to evaluate and improve the teaching of Urology at the undergraduate level. Our objective is to identify the knowledge and skills needed in Urology for the real clinical practice of GPs. METHODS: An anonymous self-administered survey was carried out among GPs of Primary Care and Emergencies which sought to evaluate urological knowledge and necessary urological skills. The results of the survey were exported and descriptive statistics were performed using IBM SPSS Statistics version 19.0. RESULTS AND LIMITATIONS: A total of 127 answers were obtained, in which 'Urological infections', 'Renal colic', 'PSA levels and screening for prostate cancer', 'Benign prostatic hyperplasia', 'Hematuria', 'Scrotal pain', 'Prostate cancer diagnosis', 'Bladder cancer diagnosis', 'Urinary incontinence', and 'Erectile dysfunction' were rated as Very high or High formative requirements (>75%). Regarding urological skills, 'Abdominal examination', 'Interpretation of urinalysis', 'Digital rectal examination', 'Genital examination', and 'Transurethral catheterization' were assessed as needing Very high or High training in more than 80% of the surveys. The relevance of urological pathology in clinical practice was viewed as Very high or High in more than 80% of the responses. CONCLUSIONS: This study has shown helpful results to establish a differentiated prioritization of urological knowledge and skills in Primary Care and Emergencies. Efforts should be aimed at optimizing the teaching in Urology within the Degree of Medicine which consistently ensures patients' proper care by future GPs.

Assessment of Multilocus Sequence Analysis (MLSA) for Identification of Candidatus Liberibacter Solanacearum from Different Host Plants in Spain.

Liberibacter is a bacterial group causing different diseases and disorders in plants. Among liberibacters, Candidatus Liberibacter solanaceraum (CLso) produces disorders in several species mainly within Apiaceae and Solanaceae families. CLso isolates are usually grouped in defined haplotypes according to single nucleotide polymorphisms in genes associated with ribosomal elements. In order to characterize more precisely isolates of CLso identified in potato in Spain, a Multilocus Sequence Analysis (MLSA) was applied. This methodology was validated by a complete analysis of ten housekeeping genes that showed an absence of positive selection and a nearly neutral mechanism for their evolution. Most of the analysis performed with single housekeeping genes, as well as MLSA, grouped together isolates of CLso detected in potato crops in Spain within the haplotype E, undistinguishable from those infecting carrots, parsnips or celery. Moreover, the information from these housekeeping genes was used to estimate the evolutionary divergence among the different CLso by using the concatenated sequences of the genes assayed. Data obtained on the divergence among CLso haplotypes support the hypothesis of evolutionary events connected with different hosts, in different geographic areas, and possibly associated with different vectors. Our results demonstrate the absence in Spain of CLso isolates molecularly classified as haplotypes A and B, traditionally considered causal agents of zebra chip in potato, as well as the uncertain possibility of the present haplotype to produce major disease outbreaks in potato that may depend on many factors that should be further evaluated in future works.

Xanthomonas citri subsp. citri and Xanthomonas arboricola pv. pruni: Comparative analysis of two pathogens producing similar symptoms in different host plants.

Comparative studies in Xanthomonas have provided a vast amount of data that enabled to deepen in the knowledge of those factors associated with virulence and Xanthomonas plant interaction. The species of this genus present a wide range of host plants and a large number of studies have been focused to elucidate which mechanism are involved in this characteristic. In this study, comparative genomic and phenotypic analysis were performed between X. citri subsp. citri (Xcc), one of the most studied pathogens within Xanthomonas, and X. arboricola pv. pruni (Xap), a pathogen which has aroused great interest in recent time. The work was aimed to find those elements that contribute to their host divergence despite the convergence in the symptoms that each species cause on Citrus spp. and Prunus spp., respectively. This study reveals a set of genes that could be putatively associated with the adaptation of these pathogens to their hosts, being the most remarkable those involved in environmental sensing systems such as the case of the TonB-dependent transporters, the sensors of the two-component system and the methyl accepting chemotaxis proteins. Other important variants were found in processes related to the decomposition of the cell wall as could be appreciated by their dissimilar set of cell-wall degrading enzymes. Type three effectors, as one of the most important factors in delineating the host specificity in Xanthomonas, also showed a different array when comparing both species, being some of them unique to each pathogen. On the other hand, only small variations could be connected to other features such as the motility appendages and surface adhesion proteins, but these differences were accompanied by a dissimilar capacity to attach on host and non-host leaf surface. The molecular factors found in this work provide the basis to perform a more in-depth functional analyses that unveil those actual factors associated with pathogenesis and host specificity in Xcc and Xap.

Effect of Soft Tissue Techniques on Headache Impact, Disability, and Quality of Life in Migraine Sufferers: A Pilot Study.

OBJECTIVE: To determine the efficacy of suboccipital inhibitory techniques in people with migraine compared with a control treatment based on myofascial trigger point (MTrP) therapy and stretching. DESIGN: A randomized, double-blind controlled pilot trial was conducted. SETTINGS/LOCATION: University research laboratory. SUBJECTS: Forty-six adults diagnosed with migraine with over 6 months duration. INTERVENTIONS: Participants were randomized to receive either combined MTrP therapy and stretching (control group) or the control treatment plus suboccipital soft tissue inhibition (experimental group). Treatment was applied on four occasions over 8 weeks (one every 15 days), with a duration of 30 minutes per session in the experimental group and 20 min in the control group. OUTCOME MEASURES: The impact of headache was assessed with the Headache Impact Test (HIT-6), disability by the migraine disability assessment (MIDAS), and quality of life by the Short Form Health Survey (SF-36). Both groups were assessed at baseline and 1 week immediately after the end of treatment. RESULTS: The amount of change of the HIT-6 score and MIDAS scores were significantly different between groups (p < 0.05), although the SF-36 scores were not. The change in the HIT-6 score and MIDAS scores was greater in the experimental group. Both groups showed a reduction on the HIT-6 score (p < 0.001), MIDAS scores (p < 0.05), and SF-36 physical subscale, whereas the SF-36 mental subscale improved only in the experimental group (p < 0.001). CONCLUSION: Soft tissue techniques based on MTrP therapy and stretching were helpful for improving certain aspects of migraine, such as the impact and disability caused by the headache, and the frequency and intensity of headache; however, when combined with suboccipital soft tissue inhibition, the treatment effect was larger.

Prediction of infection caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae: development of a clinical decision-making nomogram.

OBJECTIVE: This study aimed to assess the population at risk of infection by extended-spectrum beta-lactamase (ESBL)-producing organisms, using clinical criteria. MATERIALS AND METHODS: All urine cultures positive for Enterobacteriaceae in a Spanish hospital department from January 2010 to 2014 were reviewed. All isolates with ESBL-positive strains were collected, and isolates received during the first week of each month with ESBL-negative strains from symptomatic patients hospitalized or admitted to the emergency room. Multivariate analysis of the factors involved was undertaken and a nomogram developed to predict the probability of infection by ESBL-producing microorganisms. RESULTS: The study included 1524 patients with urinary tract infection (UTI): 416 ESBL-positive and 1108 ESBL-negative. In univariate analysis, risk factors were: male gender (p = 0.036), age (p < 0.0001), nursing home (p < 0.0001), previous antimicrobial therapy (p < 0.0001) or hospitalization (p < 0.0001), diabetes (p < 0.0001), chronic renal insufficiency (p < 0.0001), severe underlying disease (p < 0.0001), neoplasia (p = 0.0005), urological (p < 0.0001) and non-urological invasive procedure (p = 0.0003), recurrent UTI (p < 0.0001), urological (p < 0.0001) or abdominal surgery (p < 0.0001) and permanent urethral catheter (p < 0.0001). In multivariate analysis, the data set was split into a development cohort of 1067 patients and a validation cohort of 457 cases. A nomogram was developed to predict the probability of infection by ESBL-producing bacteria, which included seven variables: age (p < 0.0001), gender (p = 0.004), nursing home (p < 0.0001), previous antimicrobial therapy (p = 0.04) or hospitalization (p < 0.0001), recurrent UTI (p < 0.0001) and non-urological invasive procedure (p = 0.005). The discriminative accuracy was 0.79 (95% confidence interval 0.77-0.83). CONCLUSIONS: A nomogram was developed that predicts the risk of infection by ESBL-producing Enterobacteriaceae with reasonable accuracy. It could improve clinical decision making and enable more efficient empirical treatment.

[Complications of radical prostatectomy.] / Complicaciones de la prostatectomía radical.

OBJECTIVES: The aim of this article is to classify and describe the different types of complications of radical prostatectomy, their frequency of appearance, as well as the different factors that may influence their development. METHODS: A systematic review of the literature was carried out, based on the search of published articles between 2002 and 2015. RESULTS: Laparoscopic or robotic radical prostatectomy may require conversion into open surgery, and these cases are significantly associated with longer hospital stay and greater rate of complications. Vascular damage comprises from injuries to small and medium caliber vessels (Santorini plexus or epigastric vessels) to possible lesions of large vessels (iliac), although they are infrequent. The most common nerve injury is that of the obturator nerve, which can be treated in the case of a complete section, and in incomplete lesions, damage is usually reversible. Intestinal injury is one of the most serious complications because it could be lifethreatening. Rectal injury is a complication that needs a correct diagnosis and intraoperative treatment, since it may lead to the development of a secondary rectourethral fistula. Such fistulae in most cases require surgical treatment. Lymphocele is a characteristic complication of radical prostatectomy with pelvic lymphadenectomy, requiring treatment only in cases of complication. Anastomotic leakage is a frequent complication, and a prognostic factor for the later development of anastomosis stricture. Some of the factors that seem to influence the development of complications are associated comorbidity, anatomical factors, surgical approach and surgical experience, among others. CONCLUSIONS: It is crucial to know the potential complications of radical prostatectomy, as well as the associated risk factors, in order to avoid their appearance.

Complicaciones de la prostatectomía radical / Complications of radical prostatectomy

OBJETIVOS: Clasificar y describir los distintos tipos de complicaciones asociadas a la prostatectomía radical, determinar su frecuencia de aparición, así como los diferentes factores que pueden influir en su desarrollo. MÉTODOS: Se ha realizado una revisión sistemática de la literatura, basada en la búsqueda de artículos publicados entre los años 2002 a 2015. Resultdos: La prostatectomía radical laparoscópica o robótica puede necesitar una conversión en cirugía abierta, y estos casos se asocian significativamente a mayor estancia hospitalaria y mayor tasa de complicaciones. Los daños vasculares comprenden desde lesiones en vasos de pequeño y mediano calibre (plexo de Santorini o vasos epigástricos) hasta posibles lesiones de grandes vasos (ilíacos), aunque son poco frecuentes. La lesión nerviosa más común es la del nervio obturador, que puede suturarse en caso de sección completa, mientras que en lesiones incompletas los daños son generalmente reversibles. La lesión intestinal es una de las complicaciones más graves, ya que ponen en riesgo el pronóstico vital del paciente. Por otro lado, la lesión rectal es una complicación que precisa de un correcto diagnóstico y tratamiento intraoperatorio, ya que puede desembocar en el desarrollo de una fístula recto-uretral o fístula recto-vesical secundaria. Dicha fístula en la mayoría de los casos requiere un tratamiento quirúrgico. El linfocele es una complicación característica de la prostatectomía radical con linfadenectomía pélvica, precisando tratamiento únicamente en casos de complicación. La fuga anastomótica es una complicación precoz frecuente, y de gravedad variable según los casos, además de ser un factor pronóstico para el desarrollo posterior de estenosis de la anastomosis. Algunos de los factores que parecen influir en el desarrollo de complicaciones son, entre otros, comorbilidad asociada, factores anatómicos, vía de abordaje y experiencia quirúrgica. CONCLUSIONES: Resulta fundamental un correcto conocimiento de las complicaciones asociadas a la prostatectomía radical, así como de los factores de riesgo relacionados, a fin de prevenir su aparición

OBJECTIVES: The aim of this article is to classify and describe the different types of complications of radical prostatectomy, their frequency of appearance, as well as the different factors that may influence their development. METHODS: A systematic review of the literature was carried out, based on the search of published articles between 2002 and 2015. RESULTS: Laparoscopic or robotic radical prostatectomy may require conversion into open surgery, and these cases are significantly associated with longer hospital stay and greater rate of complications. Vascular damage comprises from injuries to small and medium caliber vessels (Santorini plexus or epigastric vessels) to possible lesions of large vessels (iliac), although they are infrequent. The most common nerve injury is that of the obturator nerve, which can be treated in the case of a complete section, and in incomplete lesions, damage is usually reversible. Intestinal injury is one of the most serious complications because it could be life-threatening. Rectal injury is a complication that needs a correct diagnosis and intraoperative treatment, since it may lead to the development of a secondary recto-urethral fistula. Such fistulae in most cases require surgical treatment. Lymphocele is a characteristic complication of radical prostatectomy with pelvic lymphadenectomy, requiring treatment only in cases of complication. Anastomotic leakage is a frequent complication, and a prognostic factor for the later development of anastomosis stricture. Some of the factors that seem to influence the development of complications are associated comorbidity, anatomical factors, surgical approach and surgical experience, among others. CONCLUSIONS: It is crucial to know the potential complications of radical prostatectomy, as well as the associated risk factors, in order to avoid their appearance

Focal cryotherapy: step by step technique description.

INTRODUCTION AND OBJECTIVE: Focal cryotherapy emerged as an efficient option to treat favorable and localized prostate cancer (PCa). The purpose of this video is to describe the procedure step by step. MATERIALS AND METHODS: We present the case of a 68 year-old man with localized PCa in the anterior aspect of the prostate. RESULTS: The procedure is performed under general anesthesia, with the patient in lithotomy position. Briefly, the equipament utilized includes the cryotherapy console coupled with an ultrasound system, argon and helium gas bottles, cryoprobes, temperature probes and an urethral warming catheter. The procedure starts with a real-time trans-rectal prostate ultrasound, which is used to outline the prostate, the urethra and the rectal wall. The cryoprobes are pretested and placed in to the prostate through the perineum, following a grid template, along with the temperature sensors under ultrasound guidance. A cystoscopy confirms the right positioning of the needles and the urethral warming catheter is installed. Thereafter, the freeze sequence with argon gas is started, achieving extremely low temperatures (-40ºC) to induce tumor cell lysis. Sequentially, the thawing cycle is performed using helium gas. This process is repeated one time. Results among several series showed a biochemical disease-free survival between 71-93% at 9-70 month- follow-up, incontinence rates between 0-3.6% and erectile dysfunction between 0-42% (1-5). CONCLUSIONS: Focal cryotherapy is a feasible procedure to treat anterior PCa that may offer minimal morbidity, allowing good cancer control and better functional outcomes when compared to whole-gland treatment.

[Evolution from Percutaneous nephrolithotomy to Mini-PCNL in supine position on the treatment of complex renal calculi: feasibility study.] / Evolución de nefrolitotomía percutánea estándar a mini­NLP en posición supino en el tratamiento de la litiasis renal compleja: estudio de viabilidad.

OBJECTIVES: Mini-PCNL is a potentially less invasive technique than standard percutaneous nephrolithotomy (PCNL). We present our experience and results comparing both approaches in large burden complex renal calculi. METHODS: Prospective non randomized study comparing PCNL (24/26F nephroscope; Group A) and Mini-PCNL (15/18F; Group B) perioperative and postoperative results, in 40 (20 each group) consecutive patients between 2013 and 2014. We analyze demographic data, hemoglobin drop, urine culture, stone characteristics, operative time, puncture, number and size of the tract, disintegration energy sources, nephrostomy placement, hospital stay, stone free rate and Clavien-Dindo complications. RESULTS: Evolution has shown growth for Mini-PNL, with the last 17 consecutive cases performed by this approach. No preoperative differences in laterality, age, gender or ASA were found; but there were differences in BMI (median Group A: 26.35 kg/m2; Median Group B: 33.05 kg/m2, p = 0.008). Median calculi surface area (SA = length × width × π × 0.25) was higher for mini-PNL (6.69 cm2 vs 14.14; p=0.003). The operative time was longer for mini-PNL (120 vs 162.5 min, p = 0.03). Only one case (5%) required transfusion in NLP 24/26F. Mini-PCNL was associated with tubeless technique (55%) (p = 0.022), which explains lower 24 h postoperative pain, after surgery, measured by VAS (p =0.0004). The hospital stay was equivalent (median: 2 days; p=0.8). Both techniques showed efficacy (SFR at 3 months 80%). There were no statistically significant differences between the number and severity of complications between groups (Group A: 15%, 66.7% Clavien II, Group B: 15%; 66.7% Clavien II, p = 1). CONCLUSIONS: Mini-NLP can manage kidney stones and even large staghorn calculi without nephrostomy in a high percentage of patients. The technical evolution towards a small caliber approach maintains the effectiveness of the procedure without impacting its safety, with benefits perceived by patients such as less postoperative pain.

Evolución de nefrolitotomía percutánea estándar a mini-NLP en posición supino en el tratamiento de la litiasis renal compleja: estudio de viabilidad / Evolution from Percutaneous nephrolithotomy to Mini-PCNL in supine position on the treatment of complex renal calculi: feasibility study

OBJETIVO: Mini-NLP es una técnica con menor potencial de invasividad que nefrolitotomía percutánea convencional (NLP). Se presenta una experiencia que compara los resultados de ambos abordajes en pacientes con litiasis complejas y/o de gran tamaño. MÉTODOS: Estudio prospectivo no aleatorizado, que compara resultados perioperatorios y postoperatorios de NLP a través de nefroscopio 24/26F (Grupo A) y Mini-NLP 15/18F (Grupo B) en 40 pacientes (20 cada grupo) consecutivos intervenidos entre 2013 y 2014. Se analizan datos demográficos, analíticos y microbiológicos, características de la litiasis renal, tiempo operatorio, sitio de punción, número de trayectos, tipo de fragmentación, colocación de nefrostomía, estancia hospitalaria, tasa de aclaramiento litiásico, eficacia y complicaciones según clasificación Clavien-Dindo. RESULTADOS: La evolución ha sido creciente para Mini-NLP, realizándose con este abordaje los últimos 17 casos consecutivos. No se detectaron diferencias preoperatorias en lateralidad, edad, sexo o ASA; pero sí en IMC (mediana Grupo A: 26,35 kg/m2; mediana Grupo B: 33,05 kg/m2, p = 0,008). La mediana de superficie litiásica (SC=longitud X anchura X π X 0,25) fue mayor en mini-NLP (6,69 vs 14,14 cm2; p = 0,003). El tiempo operatorio fue mayor en mini-NLP (120 vs 162,5 min; p = 0,03). Solo se transfundió 1 caso (5%) en el grupo de NLP 24/26F. Mini-NLP se asoció a técnica tubeless (55%) (p = 0,022), lo que explica menor puntuación EAV de dolor a las 24h de la cirugía (p = 0,0004). La estancia hospitalaria fue equivalente (mediana: 2 días; p = 0,8). Ambas técnicas presentaron una eficacia (SFR a los 3 meses) del 80%. No existieron diferencias estadísticamente significativas entre el número y severidad de las complicaciones entre ambos grupos (Grupo A: 15%, 66,7% Clavien II; Grupo B: 15%; 66,7% Clavien II; p=1). CONCLUSIONES: Mini-NLP permite tratar litiasis renal de gran tamaño e incluso litiasis coraliformes, sin necesidad de nefrostomía en un porcentaje alto de pacientes. La evolución técnica hacia un abordaje de calibre reducido mantiene la eficacia del procedimiento sin impactar la seguridad del mismo y con ventajas percibidas por los pacientes como es menor dolor postoperatorio

OBJECTIVE: Mini-PCNL is a potentially less invasive technique than standard percutaneous nephrolithotomy (PCNL). We present our experience and results comparing both approaches in large burden complex renal calculi. METHODS: Prospective non randomized study comparing PCNL (24/26F nephroscope; Group A) and Mini-PCNL (15/18F; Group B) perioperative and postoperative results, in 40 (20 each group) consecutive patients between 2013 and 2014. We analyze demographic data, hemoglobin drop, urine culture, stone characteristics, operative time, puncture, number and size of the tract, disintegration energy sources, nephrostomy placement, hospital stay, stone free rate and Clavien-Dindo complications.RESULTS: Evolution has shown growth for Mini-PNL, with the last 17 consecutive cases performed by this approach. No preoperative differences in laterality, age, gender or ASA were found; but there were differences in BMI (median Group A: 26.35 kg/m2; Median Group B: 33.05 kg/m2, p = 0.008). Median calculi surface area (SA = length X width X π X 0.25) was higher for mini-PNL (6.69 cm2 vs 14.14; p = 0.003). The operative time was longer for mini-PNL (120 vs 162.5 min, p = 0.03). Only one case (5%) required transfusion in NLP 24/26F. Mini-PCNL was associated with tubeless technique (55%) (p = 0.022), which explains lower 24 h postoperative pain, after surgery, measured by VAS (p = 0.0004). The hospital stay was equivalent (median: 2 days; p = 0.8). Both techniques showed efficacy (SFR at 3 months 80%). There were no statistically significant differences between the number and severity of complications between groups (Group A: 15%, 66.7% Clavien II, Group B: 15%; 66.7%. Clavien II, p = 1). CONCLUSIONS: Mini-NLP can manage kidney stones and even large staghorn calculi without nephrostomy in a high percentage of patients. The technical evolution towards a small caliber approach maintains the effectiveness of the procedure without impacting its safety, with benefits perceived by patients such as less postoperative pain

Survival predictors in patients with prostate adenocarcinoma with hormonal blockade.

Ki-67 index and clinical-pathological factors such as the Gleason score and the presence of neuroendocrine differentiation have been used for predicting survival in patients with prostate cancer. We examined prostate tissue from 45 patients with advanced prostate cancer who were treated with maximal androgen blockade and analysed their cancer-specific survival (CSS). We assessed the Gleason index, performed an immunohistochemical analysis of Ki-67 (MIB-1) and determined the presence of neuroendocrine differentiation (chromogranin A). A survival study was conducted using Kaplan-Meier curves (log-rank test) and a Cox regression analysis. Twenty-four patients (53.3%) died from the disease, with a mean follow-up of 68.7±7.7 months (56.6% CSS at 5 years and 31.8% at 10 years). In the univariate analysis, survival was associated with an interquartile distribution of Ki-67 (0-5, 6-12%, 13-25%, >25%; log-rank, p=0.01), Gleason 5 (total index 9-10; log-rank, p=0.002) and the presence of metastases during the diagnosis (M1; log-rank, p=0.004) but not to cT category (T3-T4; log-rank, p=0.26) or neuroendocrine differentiation (immunohistochemically positive tumour cell nests; log-rank, p=0.46). The multivariate analysis revealed that a Ki-67 index ≤12% (HR, 0.22; p=0.0009) and the absence of metastases (M0) during diagnosis (HR, 0.17; p=0.0002) were protective factors in this population. In conclusion, Ki-67 proliferation index and the lack of metastases at diagnosis predict CSS in patients with advanced prostate cancer who undergo hormonal blockade. Neuroendocrine differentiation in tumour tissue had no prognostic value in this study.

Presence of Extracellular DNA during Biofilm Formation by Xanthomonas citri subsp. citri Strains with Different Host Range.

Xanthomonas citri subsp. citri (Xcc) A strain causes citrus bacterial canker, a serious leaf, fruit and stem spotting disease of several Citrus species. X. alfalfae subsp. citrumelonis (Xac) is the cause of citrus bacterial spot, a minor disease of citrus nursery plants and X. campestris pv. campestris (Xc) is a systemic pathogen that causes black rot of cabbage. Xanthomonas spp. form biofilms in planta that facilitate the host infection process. Herein, the role of extracellular DNA (eDNA) was evaluated in the formation and stabilization of the biofilm matrix at different stages of biofilm development. Fluorescence and light microscopy, as well as DNAse treatments, were used to determine the presence of eDNA in biofilms and bacterial cultures. DNAse treatments of Xcc strains and Xac reduced biofilm formation at the initial stage of development, as well as disrupted preformed biofilm. By comparison, no significant effect of the DNAse was detected for biofilm formation by Xc. DNAse effects on biofilm formation or disruption varied among Xcc strains and Xanthomonas species which suggest different roles for eDNA. Variation in the structure of fibers containing eDNA in biofilms, bacterial cultures, and in twitching motility was also visualized by microscopy. The proposed roles for eDNA are as an adhesin in the early stages of biofilm formation, as an structural component of mature bacterial aggregates, and twitching motility structures.

Two-Port Laparoscopic Reconstructive Surgery of the Urinary Tract with Reusable Umbilical System (Hybrid Less): A Proof of Concept Study.

OBJECTIVES: We compared perioperative results and complications of reconstructive surgery of the urinary tract performed using a multichannel platform through the umbilicus and one additional 3.5-mm with a cohort of patients simultaneously treated with conventional 4-port laparoscopy. MATERIALS AND METHODS: Matched-pair study comparing perioperative outcomes, postoperative visual analogue pain scale (VAPS) and morbidity of 2-port (n = 20) and 4-port (n = 10) laparoscopic reconstructive urological surgery. Preoperative and perioperative data compared included demographics, type of surgery, operative time, blood loss, decrease in serum hemoglobin, operative complications, length of stay and postoperative complications according to Clavien-Dindo classification. RESULTS: There was no significant difference between groups regarding age, gender, body mass index, American Society of Anesthesiologists score, type of surgery, operative time, operative complications and intraoperative or postoperative transfusion. Estimated blood loss was lower using reduced-port approach. VAPS at postoperative day one was significantly lower for 2-port approach and so was the length of stay. Patient satisfaction with the wound was higher for 2-port surgery. Differences were not observed in number and severity of postoperative complications. CONCLUSIONS: Urological reconstructive operations can be safely performed using the hybrid laparoendoscopic single-site umbilical approach, resulting in lower blood loss, higher patient satisfaction and lower postoperative pain, which also facilitate earlier hospital discharge, than the same reconstructive procedures performed through multiport conventional laparoscopy.

Two-Port Approach Compared to Standard Laparoscopic Radical Cystectomy.

BACKGROUND AND OBJECTIVES: Two-port laparoscopic radical cystectomy (LRC) using a multichannel platform through the umbilicus and one additional 10-mm in the right iliac fossa has been recently described. We compare the perioperative and early results of this technique with a cohort of patients simultaneously treated in our institution with four-port LRC and a 7 to 10 cm midline incision. MATERIALS AND METHODS: A matched-pair study comparing perioperative outcomes, postoperative visual analog pain scale (VAPS), and morbidity of two-port (n=30) and four-port (n=30) LRC. Preoperative and perioperative data analyzed and compared included demographics, type of urinary diversion, operative time, blood loss, transfusion requirements, decrease in serum hemoglobin, operative complications, analgesic needs, length of stay, number of nodes removed, and other pathologic information. Complications in the first 3 months were evaluated according to the Clavien-Dindo classification. RESULTS: There was no significant difference between the two groups regarding patient age, gender, body-mass index, American Society of Anesthesiologists (ASA) score, Charlson comorbidity index, tumor stage, percent of positive nodes, positive margin rate, number of nodes retrieved, proportion of neobladders, secondary carcinoma in situ, incidental prostate cancer, or need of systemic chemotherapy. Median operative time was 20 minutes higher in the two-port procedure, but this difference was not statistically significant (p=0.2). Estimated blood loss and differential hemoglobin change were lower in the two-port technique (each p=0.03), but no difference was detected regarding the intraoperative or postoperative transfusion rate. Length of hospital stay was also equivalent. Differences were not observed either in the number or severity of complications. VAPS at days 2, 3, and 5 was significantly lower for two-port LRC (p<0.01). CONCLUSIONS: Two-port LRC performed through an umbilical platform and an accessory 10-mm port seems technically equivalent to standard four-port LRC. Perioperative outcomes regarding hospital stay and complications are tantamount. Diminished blood loss and, especially, less postoperative pain favor the reduced-port approach in this complex urologic minimally invasive procedure.