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)

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.

[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