Estudio anatómico aplicado a la hernioplastia endoscópica totalmente extraperitoneal / Anatomic study applied to endoscopic totally extraperitoneal hernioplasty

Objetivo. El espacio preperitoneal de la región inguinal, tal y como se observa en la cirugía endoscópica totalmente extraperitoneal (TEP), puede presentar dificultades de compresión en los cirujanos no familiarizados con esta técnica. El objetivo de este trabajo es contribuir a la descripción de las fascias y espacios anatómicos de la región inguinal posterior como se aprecian en la reparación endoscópica TEP, unificar y simplificar conceptos y favorecer el aprendizaje del procedimiento.Pacientes y métodos. Desde 1996 han sido intervenidos mediante procedimiento TEP 250 pacientes, en los que se han efectuado 280 reparaciones. Además de la experiencia práctica, se han analizado los vídeos de 20 intervenciones grabadas, efectuando una revisión bibliográfica y consiguiendo un consenso terminológico entre los autores.Resultados. Para operar en el espacio adecuado, la fascia transversalis debe quedar en el techo del espacio de trabajo y la fascia preperitoneal en el suelo.La fascia espermática interna es una dependencia de la fascia preperitoneal que engloba a conducto deferente y vasos espermáticos en su trayecto hacia el anillo inguinal profundo; debe abrirse en el caso de las hernias indirectas. La identificación, sencilla, de vasos epigástricos inferiores, tracto iliopúbico y ligamento de Cooper permite las necesarias referencias anatómicas para efectuar la técnica con seguridad.La creación de un gran espacio preperitoneal desperitonizado permite la ubicación de una gran malla que tapiza y rebasa suficientemente todas las áreas débiles de la región inguinocrural. Mención especial requiere la identificación de zonas de riesgo, las cuales se sitúan todas mediales al ligamento de Cooper y caudales al tracto iliopúbico.Conclusiones. Un conocimiento preciso de la anatomía de la región inguinal preperitoneal es necesario para la ejecución correcta de la reparación TEP.Lo anterior, junto con el seguimiento estricto de una serie de pasos quirúrgicos, puede contribuir a la difusión del procedimiento (AU)

Hepatectomía en 4 pacientes con litiasis intrahepática / Hepatectomy in four patients with intrahepatic lithiasis

Introducción. La litiasis intrahepática, muy frecuente en países del sudeste asiático, es rara en países europeos y se asocia a estenosis y dilataciones de los radicales biliares, lo que puede obligar a realizar resecciones hepáticas para su resolución definitiva.Pacientes y método. Presentamos 4 pacientes con litiasis intrahepática que requirieron una hepatectomía para su resolución. En un caso se asoció a enfermedad de Caroli del lóbulo hepático derecho que precisó hepatectomía derecha, y los 3 casos restantes presentaron estenosis de radicales segmentarios del lóbulo hepático derecho y precisaron segmentectomías para su resolución. La litiasis intrahepática se manifestó clínicamente por un cólico hepático en un caso y una colangitis aguda en 3 casos. La exploración preoperatoria e intraoperatoria fundamental para el diagnóstico fue la ecografía. Las exploraciones radiológicas (tomografía computarizada, resonancia magnética y técnicas con contraste, preoperatorias e intraoperatorias) fueron importantes para el diagnóstico definitivo.Resultados. No existió mortalidad intraoperatoria ni postoperatoria. Dos pacientes presentaron un absceso subfrénico resuelto con drenaje radiológico. No ha recurrido la litiasis intrahepática tras un seguimiento medio de 29 meses (rango, 17-38).Conclusiones. La hepatectomía resuelve definitivamente aquellos pacientes con litiasis intrahepática cuando existen estenosis y/o dilataciones lobares o segmentarias. Si preoperatoriamente no se sospecha la litiasis intrahepática, los pacientes pueden requerir varias intervenciones para su resolución definitiva. (AU)

[Abscess of seminal vesicle: conservative treatment]. / Absceso de vesícula seminal: tratamiento conservador.

OBJECTIVE: To describe a case of primary seminal vesicle abscess that was managed conservatively. METHODS: Antibiotics, according to the urine culture and antibiotic profile, were administered for four weeks. Outpatient follow-up was carried out with digital rectal examination, urine culture and ultrasound. RESULTS: A favorable clinical response was observed at day three. The patient was discharged from hospital on day 7. DRE, urine culture and ultrasound findings were normal after 4 weeks. CONCLUSIONS: Primary abscess of the seminal vesicle can be successfully treated with antibiotics. Percutaneous drainage of the abscess should be reserved for those cases that do not respond to conservative management with antibiotics.

Invaginación intestinal en el adulto. Presentación de siete casos con énfasis en el diagnóstico preoperatorio / Intestinal invagination in the adult. Presentation of six cases with emphasis on preoperative diagnosis

Objetivo. La invaginación intestinal en el adulto es un proceso potencialmente grave que, por su infrecuencia fuera de la infancia, se diagnostica de forma habitual durante el acto quirúrgico indicado por un síndrome obstructivo mecánico. Presentamos una serie reciente de casos cuyo diagnóstico se obtuvo preoperatoriamente. Pacientes y métodos. Se han analizado los registros de todos los pacientes mayores de 18 años con el diagnóstico postoperatorio de invaginación intestinal tratados en nuestra institución entre 1996 y 2000.Resultados. En 4 años se intervinieron 7 pacientes, con una edad media de 40 años. Todos presentaron datos clínicos de obstrucción intestinal completa o parcial. El diagnóstico preoperatorio etiológico se efectuó en 6 casos, gracias a la realización frecuente de ecografía y tomografía computarizada. Todos los pacientes fueron intervenidos, 3 de forma urgente y 4 con carácter programado. Durante el acto quirúrgico se identificaron las lesiones causantes de la invaginación, 4 localizadas en el íleon terminal (divertículo de Meckel, seudotumor inflamatorio, pólipo fibroide, pólipo adenomatovelloso degenerado), dos en el ciego (ambos adenocarcinoma sobre pólipo) y, en el caso restante, un linfoma doble de yeyuno e íleon. Las intususcepciones fueron ileoileales en 3 casos, ileocólicas en 3 y doble yeyunoileal e ileocólica en el séptimo paciente. Se practicaron 3 hemicolectomías derechas, 2 resecciones ileales, una exéresis de divertículo de Meckel y, finalmente, una doble exéresis (yeyunal e ileocólica) en el caso del linfoma. No existió mortalidad. Conclusiones. La invaginación intestinal en el adulto es una entidad poco frecuente. Los síntomas son los de un cuadro obstructivo mecánico completo o parcial; en estos últimos, la evolución puede ser intermitente o crónica. La ecografía y la tomografía computarizada demuestran ser los métodos de diagnósticos preoperatorios más efectivos. En el adulto, aproximadamente la mitad de los casos se deben a una enfermedad maligna, por lo que la resección es el procedimiento de elección (AU)

[Can PSA density predict the response to alpha-blockers in benign prostatic hyperplasia?]. / Puede la densidad de PSA predecir la respuesta a los alfa-bloqueantes en la hiperplasia benigna de próstata?

INTRODUCTION AND OBJECTIVES: In BPH there is a growth of both glandular and stromal components. Most of adrenoceptors sites are in the fibromuscular stroma. So the higher is the stromal/epithelial ratio, the more effective will alpha-blockers be. There in an indirect way of stimating this ratio without performing a biopsy. Bearing in mind that PSA is produced by the prostatic epithelium, the lower PSA density (PSAd), the higher the stromal/epithelial ratio and the higher alpha-blocker activity. We pretend to study if PSAd is useful for predicting the response to alpha-blockers in BPH. MATERIAL AND METHODS: We studied 75 patients suffering from prostatism and diagnosed of bladder outlet obstruction secondary to BPH through IPSS symptom score, digital rectal examination, PSA, uroflowmetry, and transrectal ultrasound. All of them received Alfuzosin, 5 mg twice daily during 3 months, and then were evaluated again with IPSS and uroflowmetry. RESULTS: A statistically significant improvement was appreciated of the two studied parameters and in both groups of patient with regard to the pretreatment situation. A statistically significant better answer was also appreciated in the group of patient with smaller PSAd in comparison with the higher PSAd patients. CONCLUSIONS: Our results show that PDAd is usefu to estimate the stroma/epithelium ratio, and therefore the clinical response to alpha-blockers.

[Brucellar orchiepididymitis]. / Orquiepididimitis brucelosa.

The brucellosis is an unusual entity whose incidence has diminished due to the improvement in preventive measures. We have carried out a retrospective study of all the patients admitted in our service between 1996 and 1998, with diagnosis of orchitis. Two of the 31 patients admitted for this reason presented a final diagnosis of brucellar orchiepididymitis. Both patients presented clinic of affectation from the general state accompanied by resistance to habitual antibiotic treatment. The patient's epidemic antecedents, accompanied by the suitable clinical evolution took to the suspicion of orchiepididymitis of brucellar etiology, with change in the antibiotic rule. The diagnosis of the process was obtained by means of serologic tests and blood cultures.

[Simple syringocele of Cowper's glands]. / Siringocele simple de la glándula de Cowper.

OBJECTIVE: To describe an additional case of simple syringocele of Cowper's glands and review the literature. METHODS: An additional case of simple syringocele of Cowper's glands is presented and the literature over the last 10 years is reviewed. RESULTS/CONCLUSIONS: The treatment most commonly utilized is marsupialization to the urethra by endoscopy. The foregoing was performed in our patient with satisfactory results.

[Malignant melanoma of the penis]. / Melanoma maligno de pene.

OBJECTIVE: To report a case of malignant melanoma of the penis, a rare malignant neoplasm whose aggressive behaviour carries a poor prognosis. METHODS: A 58-year-old male consulted for a pigmented elevated lesion in the balanopreputial sulcus. The biopsy was positive for melanoma. Complementary studies did not demonstrate disseminated disease. RESULTS: Partial resection of the penis and bilateral inguinal lymphadenectomy were performed. Histological analysis showed two positive nodes in the same lymphatic chain. Interferon was administered for 6 months. The patient remains disease-free at 35 months' follow-up. CONCLUSIONS: Although surgery is the treatment of choice, adjuvant therapy (chemotherapy and immunotherapy) should be considered in those patients without localized disease.

[Urologic complications in renal transplantation. Study of 250 cases]. / Complicaciones urológicas en el trasplante renal. Estudio en 250 casos.

OBJECTIVE: The aim of this study is value the incidence of urological complications (fistulae and estenosis) in our serie of renal transplant, to analyze the variables that can influence in their appearance and the treatments used. Likewise, to value the follow-up of theses patients and the survival of the renal graft and of the patient. MATERIAL AND METHODS: 250 renal transplants are carried out between july of 1985 and october of 1998. The relationship among the variables you makes by means of the test chi 2 of Pearson and the test of Fisher; the contrasts of stockings with the t of Student; the survival of the organ and of the patient, by means of the analysis of curved of survival according to the method of Kaplan and Meier; and the comparison among curved of survival was carried out with the test of Cloth and Cox. RESULTS: Of the 250 transplants, 46 patients suffered for complications, 29 urinary fistulae (11.6%) and 21 estenosis (8.4%). The most frequent localization in both complications was the union uretero-vesical. The presence of urinary fistulae didn't influence negatively in a significant way nor over the survival of the implant (p < 0.211), neither over the patient's survival. The estenosis appearance was related in a significant way with the donor's age (p < 0.02). The estenosis presence was not related in a significant way neither with the survival of the implant neither with that of the receiver. CONCLUSIONS: The incidence of urological complications was of 18.4% (11.6% estenosis and 8.4% fistulae). The most frequent localization was the union uretero-vesical. The presence of estenosis correlated with the increase of the age of the donors. The technique of reimplante ureteral didn't influence in the results in a significant way. We don't find any relationship between the appearance of urological complications and the patient's survival.

[Malignant neoplasms of the penis]. / Neoplasias malignas del pene.

OBJECTIVE: To assess the behaviour and management of these uncommon neoplasias. MATERIAL AND METHODS: Between March 1975 and July 1999, a total of 95 malignant neoplasias of the penis were diagnosed and treated by our unit. Patients mean age was 62 years (28 to 87 years). A retrospective analysis of any associated lesions, biological behaviour of the various neoplasias, as well as therapies used is carried out. RESULTS: The squamous carcinoma of the penis (SCP) is the most frequent pathohistological entity entailing 78 cases (82%), followed by verrucous carcinoma (VC) 13 cases (13.5%), basal cells carcinoma 1 case, and melanoma, lymphoma and penile metastasis 1 case each. There is a significant presence of associated lesions with marked predominance of phimosis. The most frequent reason for the call is an injury of the penis (74 cases; 78%). Treatment was mainly partial penectomy (51 patients; 53.7%), followed by conservative treatment in 28 cases (30%). Inguinal lymphadenectomy was performed in 13 patients (14%), due to either a positive nodular biopsy or a persistent adenopathy following antibiotic therapy. CONCLUSIONS: Neoplasias showing superior biological behaviour are basal cell carcinoma of the penis, and verrucous carcinoma. Prognosis in SCP is based on pathological status and node involvement. Patients with pT1 tumours showed no metastatic adenopathies after follow-up regardless of cytological grading, and are therefore candidates to watchful waiting with regular monitoring. Melanoma of the penis is a highly aggressive tumour due to its high metastatic capacity with a poor prognosis.

[Squamous carcinoma of the penis]. / Carcinoma escamoso de pene.

OBJECTIVE: To present our experience with squamous cell carcinoma of the penis. METHODS: We reviewed our series of 73 squamous cell carcinoma of the penis over the last 23 years. Patient mean age was 65.7 years. All lesions had been previously biopsied. Patient records were reviewed for a history of phimosis and related lesions. The histological, clinical and therapeutic aspects, and survival are analyzed. RESULTS: Most of the squamous cell carcinoma of the penis were superficial lesions (pT1). Treatment was by partial penile resection in 42 cases, total penile resection in 9, and emasculation in 2 cases. Conservative surgery was performed in 20 cases (tumor excision in 14 and posthectomy in 6 cases). Lymphadenectomy was performed in 11 patients. Eight patients received radiotherapy to the inguinal region. The rate of recurrence after surgery was 11% (8 cases). Five of the 8 patients with tumor recurrence had been treated by conservative surgery. The 5-year survival rate was 78%. CONCLUSIONS: Penile cancer is uncommon and accounts for less than 1% of tumors in the male in our setting. A higher incidence has been found in men with phimosis, poor hygiene and low sociocultural level. Partial penile resection is the treatment of choice for the primary lesion. The outcome is worse in patients with invasive tumor, poor cell differentiation, ulceroendophytic morphology, and above all in patients with metastatic adenopathy. Radiotherapy provided no benefits, made inguinal evaluation difficult and increased the morbidity in some cases. Patients with pT1 tumor and good cell differentiation showed no metastatic adenopathy during follow-up. Patient follow-up is fundamental to detect recurrence or metastatic adenopathy and to institute treatment immediately.

[Bladder compression by collateral veins]. / Compresión vesical por colaterales venosas.

Many space-filling injuries (e.g. haematoma, abscess, aneurysm, lymphocele, neoplasia etc.) may result in extrinsic compression of the bladder. We contribute one case report of compression of the bladder from collateral venous circulation in a patient who came for a left varicocele.

[Intraperitoneal bladder perforation in emphysematous cystitis]. / Perforación vesical intraperitoneal en el transcurso de una cistitis enfisematosa.

Contribution of one case report of a 69-year old diabetic male patient with neurogenic bladder. The patient developed emphysematous cystitis and peritonitis secondary to intraperitoneal perforation of the bladder. Emphysematous cystitis is an uncommon clinico-radiologic entity more frequent in diabetic and female patients and the elderly. Early diagnosis and treatment may avoid a fatal outcome. The paper includes a review of this condition.

[Basal cell carcinoma of the penis]. / Carcinoma basocelular de pene.

OBJECTIVE: To report an uncommon case of basal cell carcinoma of the penis. METHODS: A case of basal cell carcinoma of the penis is presented. This has been the only case of this tumor type detected in our setting. The literature is briefly reviewed. RESULTS/CONCLUSIONS: Basal cell carcinoma of the penis is rare. To date only 20 cases have been reported in the literature. To our knowledge, no case of distant metastasis has been documented. Diagnosis by gross examination may be difficult due to the broad polymorphism of this lesion and must be confirmed by histological analysis.

[Giant fibroepithelial polyp of the ureter]. / Pólipo fibroepitelial gigante del uréter.

OBJECTIVE: To report a case of giant fibroepithelial polyp of the ureter and review the literature with special reference to the diagnosis and treatment of this benign condition. METHODS: A young male patient with a nonfunctioning left kidney caused by a giant fibroepithelial polyp of the ureter is presented. The diagnostic methods and treatment options are discussed. RESULTS: Following the diagnosis of obstructive uropathy with loss of left renal unit function, a left nephroureterectomy was performed which revealed a giant polypoid mass. CONCLUSION: Fibroepithelial polyp of the ureter is a benign condition that is difficult to diagnose with current endoscopic techniques. Endoscopy should be the first therapeutic option if loss of renal function is not irreversible.

[Intramuscular ketorolac compared to subcutaneous tramadol in the initial emergency treatment of renal colic]. / Ketorolaco intramuscular frente a tramadol subcutáneo en el tratamiento inicial de urgencia del cólico renal.

OBJECTIVE: To compare the efficacy and safety of two analgesics (tramadol and ketorolac) for initial emergency treatment of renal colic. METHODS: A prospective study on 48 patients randomly assigned to treatment with ketorolac 30 mg i.m. and tramadol 1 mg/kg s.c. Pain intensity was evaluated by a simple analogic scale ranging from 0-4 (0 = no pain, 1 = mild, 2 = moderate, 3 = severe and 4 = very severe pain). Statistical analyses were performed with Student's test and the chi square test for numerical and qualitative data, respectively. RESULTS: No significant differences were found for the overall efficacy (> 80%) or side effects in both groups. However, a difference was found between both groups for pain score 15 minutes post-injection, which showed i.m. ketorolac to be more effective. CONCLUSION: Both ketorolac (30 mg i.m.) and tramadol (1 mg/kg s.c.) are effective in the initial treatment of renal colic. Both drugs have an efficacy greater than 80% when used separately and almost 100% when used in combination. The analgesic effect of ketorolac is observed earlier than that of tramadol.

[Management of obstructive uropathy in pregnancy]. / Manejo de la uropatía obstructiva en el embarazo.

INTRODUCTION: Obstructive uropathy in pregnant women is a relatively common condition. It can be difficult to assess due to the frequency with which physiologic dilation of the upper urinary tract is seen in pregnant women. PATIENTS AND METHOD: Over the past 3 years 40 pregnant women with symptomatic obstructive uropathy were seen in our service. RESULTS: Most pregnant women responded to conservative treatment (pain killers and antibiotics). In the remaining group, instrumentation was necessary through the urinary route: double J ureteral catheterism (10 patients: 6 due to uterine compression and 4 to lithiasis), percutaneous nephrostomy (4 patients: 2 due to ureteral catheter obstruction impossible to replace, and two due to urinary sepsis), or ureterorenoscopy (1 patient with lithiasis). CONCLUSIONS: The single most common cause for obstructive uropathy in our experience is ureteral compression due to a gravid uterus. Choice therapy in most cases is conservative treatment. When in spite of conservative treatment signs and symptoms persist, urinary by-pass with antibiotic prophylaxis must be performed. Ureterorenoscpy as a diagnostic and therapeutical approach should be taken into consideration in pregnant women with ureteral lithiasis. Incidence of pre-term labour was not higher than usual.

[Penile injuries: our experience]. / Traumatismos del pene: nuestra experiencia.

Trauma of the penis is relatively uncommon. Not many centres and even less urologists have extensive experience in the comprehensive management of this type of injury. Revision of the series accrued in our hospital over 20 years, in each case explaining the mechanism of occurrence, treatment applied and results obtained.