Use of Integra in oral reconstruction: a case series.

OBJECTIVE: Small intraoral defects are usually reconstructed using skin autografts. However, the goal of this research was to describe an alternative to classic techniques using artificial dermis (Integra) in the reconstruction of these types of injuries. MATERIALS AND METHODS: Four patients with small intraoral lesions in different locations underwent resection. The created defects were covered with a bilayer of Integra; then, a chlorhexidine stent cure (Laboratorios Salvat, Barcelona, Spain) was applied. The patients were followed up daily during the first week to detect any signs of infection, dehiscence, or loss of the lamina. Thereafter, they were followed up once a week for 1 month. RESULTS: None of the patients presented with infections or loss of the dermis. When the silicon sheet was detached, granulation tissue was detected, with complete re-epithelialization of the lesion in the postoperative weeks 3 to 4. CONCLUSIONS: The use of the Integra allowed for the rapid reconstruction of slight intraoral defects while preventing the morbidity associated with classic techniques. In this study, no complications were observed.

[XXV Anniversary of the Endoscopy-Lithiasis-Laparoscopy (LEL) Working Group]. / XXV Aniversario del Grupo de Trabajo de Endoscopia-Litiasis-Laparoscopia (LEL).

INTRODUCTION: The purpose of this article is to describe the structural vicissitudes and content changes experienced by our Work Group, LEL over the last twenty-five years. MATERIALS AND METHODS: The compiled material comes from three sources: the author's experiences; the iconography provided by the co-ordinators; and the data obtained from programmes, letters, etc. This material has been analyzed and organized into six stages and the following has been highlighted in each of these: specific data from each day; key structural data; and the most relevant facts during the period. RESULTS: Various proposals have been made as a result of the Group's activity: to formally record the endoscopy techniques for the lower urinary tract and extend them to the upper urinary tract: URS and percutaneous surgery, the comprehensive treatment of lithiasis, the defence of our own techniques (such as UTR versus alternatives), as well as to provide an expert opinion on new technologies (laser in urology), and to replace open surgery techniques with others belonging to the Group: PNL and laparoscopy. CONCLUSIONS: For 25 years, the LEL Work Group has stayed active and closely united. It has participated in both internal and external structural changes prompted by the appearance of spectacular new developments that have emerged over this period of time: endoscopic access to the upper urinary tract; comprehensive treatment of lithiasis; and alternatives to traditional surgeries (percutaneous surgery, laparoscopic surgery).

XXV Aniversario del Grupo de Trabajo de Endoscopia-Litiasis-Laparoscopia (LEL) / XXV anniversary of the endoscopy-lithiasis-laparoscopy (LEL) working group

Introducción: El objetivo de este artículo es relatar los avatares estructurales y cambios de contenido, vividos por nuestro Grupo de Trabajo, LEL durante veinticinco años. Material y métodos: El material recopilado proviene de tres fuentes: las vivencias y experiencias del autor, la iconografía proporcionada por los coordinadores y, los datos obtenidos de programas, cartas, etc. Este material ha sido cribado y ordenado en seis etapas y se ha procedido a señalar en cada una de ellas los datos específicos de cada jornada, los datos claves estructurales y los hechos más relevantes durante el periodo. Resultados: Como consecuencia de la actividad del Grupo se han conseguido varios propósitos: protocolizarlas técnicas endoscópicas del Aparato Urinario Inferior y prolongarlas al Aparato Urinario Superior: URS y cirugía percutánea, el tratamiento integral de la Litiasis, la defensa de técnicas propias (como la RTU frente alternativas)así como peritar las nuevas tecnologías (láser en Urología) y sustituir técnicas de cirugía abierta por otras pertenecientes al Grupo: NLP y Laparoscopia. Conclusiones: Durante 25 años el Grupo de Trabajo LEL, se ha mantenido cohesionado y activo, participando en cambios internos estructurales y externos, motivados por la aparición durante este periodo, de espectaculares novedades: acceso endoscópico al Aparato Urinario Superior, tratamiento Integral de la Litiasis y alternativas a cirugías clásicas (Cirugía Percutánea, Cirugía Laparoscópica) (AU)

Introduction: The purpose of this article is to describe the structural vicissitudes and content changes experienced by our Work Group, LEL over the last twenty-five years. Materials and methods: The compiled material comes from three sources: the author’s experiences; the iconography provided by the coordinators; and the data obtained from programmes, letters, etc. This material has been analyzed and organized into six stages and the following has been highlighted in each of these: specific data from each day; key structural data; and the most relevant facts during the period. Results: Various proposals have been made as a result of the Group’s activity: to formally record the endoscopy techniques for the lower urinary tract and extend them to the upper urinary tract: URS and percutaneous surgery, the comprehensive treatment of lithiasis, the defence of our own techniques (such as UTR versus alternatives),as well as to provide an expert opinion on new technologies (laser in urology), and to replace open surgery techniques with others belonging to the Group: PNL and laparoscopy. Conclusions: For 25 years, the LEL Work Group has stayed active and closely united. It has participated in both internal and external structural changes prompted by the appearance of spectacular new developments that have emerged over this period of time: endoscopic access to the upper urinary tract; comprehensive treatment of lithiasis; and alternatives to traditional surgeries (percutaneous surgery, laparoscopic surgery) (AU)

[Lasers in urology]. / Láser en urología.

UNLABELLED: The objective of this article is to quote under the form of a document the opinions expressed by the participants of the round table "Lasers in Urology Today" (january 2006). The material and method used is the compilation of critical and updated notions on the usefulness of lasers in urology, supplemented by bibliographic references, a limited iconography. The results achieved by lasers today enable us to state that: Holmium laser is the choice treatment for in situ lithotripsy; however, it has not significantly improved previous results when treating urologic tumours and stenoses. Nowadays we have two types of lasers: KTP and HoL, which obtain results similar to surgery regarding BPH, but with reduced morbidity. The usefulness of laser in laparoscopic surgery is still under development. CONCLUSION: Lasers in Urology Today play an active role in in situ lithotripsy (HoL), and a competitive one in BPH surgery (KTP and HoL). Regarding the rest of indications, i.e. tumours, stenoses, laparoscopic surgery, etc., further studies and enough follow-up times are still needed.

[Treatment of benign prostatic hypertrophy: present situation and future prospects]. / Tratamiento de la H.B.P. realidades presentes y perspectivas futuras.

Review article offering an up-to-date view and a forecast for the future evolution of a disease which over the last few years has been the subject of increasingly scientific thoroughness. It deals with the natural history of the disease and the application of basic knowledge from other fields. It establishes the importance of a therapeutic evaluation of the results obtained with alternative medical and surgical approaches in the management of this entity. This review of benign prostate hyperplasia analyses the present realities and the future perspectives of the disease. It includes the most important contributions from international consensus and recommendations, and evaluation of the impact of drug treatment, the discredit of alternative options, the contribution of basic sciences to the understanding of the development of prostate cancer and the future of surgical management (TUR) and its alternatives.

Tratamiento de la H.B.P. Realidades presentes y perspectivas futuras / Management of BPH: present realities and future perspectives

Artículo de revisión que ofrece una visión de presente y una predicción evolutiva de futuro de una patología sometida en los últimos años a una progresiva rigurosidad en su evaluación científica. Se aborda secuencialmente la historia natural de la enfermedad, la incorporación a esta patología de conocimientos básicos que proceden de otras disciplinas y se establece la trascendencia de la valoración terapéutica de los resultados alcanzados con las alternativas médicas y quirúrgicas para el abordaje de esta patología. El análisis de esta revisión de la hiperplasia prostática benigna se establece a partir de las realidades presentes en esta patología y las perspectivas de futuro e incluye las contribuciones más relevantes procedentes de las recomendaciones y consensos internacionales, evaluación del impacto del tratamiento farmacológico, descrédito de los tratamientos alternativos, contribución de las ciencias básicas a la comprensión de la evolución de la neoplasia prostática y al futuro del tratamiento quirúrgico (RTU) y sus alternativas (AU)

Bladder neoplasms after nephroureterectomy: does the surgery of the lower ureter, transurethral resection or open surgery, influence the evolution?

OBJECTIVE: Nephroureterectomy is the treatment of choice for tumors of the upper urinary tract (UUTT). In 1952, a modified version of this technique was described, involving endoscopic detachment of the ureter followed by nephroureterectomy with a single lumbar incision. We reviewed a retrospective survey to assess whether UUTT patients treated with nephroureterectomy with no prior history of bladder tumor had different rates of incidence or different sites of bladder recurrence according to the specific technique employed. METHODS: Patients were divided into group A, 87 patients who underwent a double incision nephroureterectomy and group B with 58 patients with prior detachment of the ureter. In both groups, incidence was calculated for two variables (bladder tumor recurrences and homolaterality of such recurrences) and chi-square tested. RESULTS: Bladder tumor was diagnosed at follow-up in 39% of patients in group A and 34.5% in group B, with no statistically significant difference (N.S.). Bladder tumor recurrences were homolateral to UUTT in 50% of group A cases and 55% of group B cases (N.S.). CONCLUSIONS: Although this is a retrospective survey of two asynchronous groups, given the similar nature of the UUTT cases in both groups and the fact that no statistically significant differences have been found, it is reasonable to conclude that nephroureterectomy with prior endoscopic detachment of the ureter is a safe and radical procedure.

Upper tract transitional cell carcinoma following cystectomy for bladder cancer.

PURPOSE: We assessed the incidence of upper urinary tract tumors (UUTTs) after cystectomy for invasive or superficial transitional cell carcinoma (TCC) of the bladder. The risk factors, patients' characteristics and evolution of those who developed UUTTs are analyzed. MATERIALS AND METHODS: From August 1980 to February 1994, 568 radical cystectomies were performed for TCC of the bladder: in 469 instances (82.5%) due to invasive tumor (T2-T4), and in 99 cases (17.5%) for superficial tumor (Ta, T1, Tis). All patients were followed for at least 5 years or until death. A retrospective study of patients who developed UUTTs has been performed. A revision of bladder tumor and UUTT characteristics, and the intervals between both is also evaluated. RESULTS: 26 patients (4.5%) developed UUTTs: 11 of the 99 patients cystectomized for superficial TCCs (11.1%); 6 of the 392 patients with primary invasive TCC (1.5%), and 9 of the 77 (11.6%) patients with invasive tumors and a prior history of superficial TCC. The interval to the development of UUTT was higher after cystectomy for superficial tumor. TCCs of the bladder that subsequently developed UUTTs were high grade in 84%, multifocal in 80%, or had carcinoma in situ in 65%, tumor in the prostatic urethra in 52%, and involvement of the distal ureter in 57%. Twenty-two UUTTs (84%) were located in the calyces or the renal pelvis, 3 were bilateral (11.5%), 14 multiple (58%) and 4 superficial (16%). With a median follow-up time of 18 (range 3-103) months, 14 patients (53.8%) died of tumor, 2 were alive with disease, 2 were lost for follow-up, and 8 (30%) were alive and free of disease. CONCLUSIONS: We found that patients cystectomized for superficial or invasive TCC with a prior history of superficial TCC have a higher incidence of UUTTs. These cases require follow-up with annual urography or loopography.

[Prostatic cysts of the midline: management and follow-up]. / Quistes prostáticos de la línea media: manejo y seguimiento.

OBJECTIVE: To analyze the presenting features, diagnosis and management of uncommon cystic lesions located at the midline of the prostate. METHODS: From 1990 to 1999, 8 patients with medial prostatic cyst were treated in our hospital. Vesicorenal ultrasound evaluation was the first procedure that was performed and was diagnostic in most of the cases. Only those patients that underwent surgery required admission to hospital. RESULTS: The most common presenting features were irritative and obstructive voiding syndromes. Treatment achieved cure or clinical improvement. CONCLUSIONS: Vesicorenal ultrasound assessment is the first procedure that should be considered in the diagnosis of this disease. Before ascribing the symptoms to a prostate cyst, other urological conditions with more prognostic relevance should be excluded. Treatment should be instituted only in the symptomatic patients and should be individualized according to the characteristics of each case.

[Cytoscopic follow-up of initial G3T1 bladder tumors treated with BCG]. / Seguimiento cistoscópico de los tumores vesicales G3T1 iniciales tratados con BCG.

OBJECTIVE: To evaluate the cystoscopic findings during initial follow-up, the anatomopathological correlation of tumor endoscopic features and the results of standard control multiple biopsy performed 6 months after TUR in patients with G3T1 transitional carcinoma treated with BCG. METHODS: 114 patients with G3T1 bladder tumor (52% associated with Cis) were treated with 81 mg Connaught BCG intravesical instillations weekly for 6 consecutive weeks. Follow-up was performed with cystoscopy and cytology at 3 months, and cystoscopy and standard multiple biopsy at 6 months. The endoscopic findings were described as normal bladder, macroscopically tumorous lesion or erythematous lesion. RESULTS: During the first 6 months of follow-up superficial recurrence was found in 16% and 5% showed progression to muscle invasion. Tumor recurrence or progression was found in 61% and 39% at 3 and 6 months, respectively. Most of the macroscopically tumorous lesions resulted in a tumor at 3 and 6 months in 56% and 64%, respectively, and the remaining lesions were mainly inflammatory granulomas produced by BCG therapy. Twenty biopsies of erythematous areas detected only one case of Cis (5%) and 98 standard multiple biopsies of endoscopically normal mucosa detected 10 cases of Cis (overall, 3 at 3 months and 7 at 6 months); all cases were preceded by initial Cis except in one case. CONCLUSIONS: Cystoscopy performed at 3 months is very useful since it detected 61% of the superficial recurrences and 66% of the cases with progression to muscle invasion during the first 6 months. Routine biopsy of erythematous areas detected during cystoscopy is of little value since a large number of these biopsies are unnecessary in view of its diagnostic yield (5%). Since 90% of the Cis detected during the first 6 months of follow-up were patients with Cis in the initial tumor, it would be appropriate to perform standard multiple biopsy for control only in this subgroup of patients if the sensitivity of cytology is low in high grade tumors or Cis.

Control group and maintenance treatment with bacillus Calmette-Guerin for carcinoma in situ and/or high grade bladder tumors.

PURPOSE: Intravesical instillations of bacillus Calmette-Guerin have demonstrated satisfactory results in the treatment of vesical carcinoma in situ and high grade superficial bladder tumors. We designed a protocol to evaluate the decrease in tumor recurrence with maintenance therapy. MATERIALS AND METHODS: Between June 1989 and May 1995 an initial course of 6 intravesical instillations of Connaught strain bacillus Calmette-Guerin was administered in patients with carcinoma in situ and/or high grade superficial bladder tumors. Six months later 131 disease-free patients were randomly assigned to a control group or a maintenance therapy group that received 6 instillations every 6 months (6 x 6) for a 2-year period. RESULTS: Of the 126 evaluable patients at a mean followup of 79 months there were no significant differences in recurrence nor progression. A total of 16 patients (26.2%) in the control and 10 (15.1%) in the maintenance group had superficial relapse at a mean of 24 and 20 months, respectively (p = 0.07). Eight patients underwent radical cystectomy due to bladder contraction in 1, high grade superficial recurrence in 4 and disease progression in 3. Of the 65 patients on maintenance therapy 22 (33.85%) completed the planned 2-year treatment. CONCLUSIONS: Six-month maintenance therapy in patients treated initially for carcinoma in situ and/or high grade superficial bladder tumors who are disease-free at 6 months did not significantly decrease recurrence or progression.

Polytetrafluoroethylene and autologous fat endoscopic injection for a prostato-perineal fistula.

PURPOSE: Prostato-perineal fistula is a rare abnormality. We present a simple endoscopic technique to manage this complicated problem. MATERIALS AND METHODS: We report on a 34-year-old man with a prostato-perineal fistula after multiple surgeries for imperforate anus. The patient underwent an endoscopic injection of polytetrafluoroethylene and autologous fat in the fistulous tract. RESULTS: Two endoscopic procedures with the injection of polytetrafluoroethylene and autologous fatty tissue around the prostatic urethral orifice were necessary to occlude the fistula. CONCLUSIONS: The endoscopic injection of polytetrafluoroethylene and autologous fat was an easy, well tolerated and long lasting solution in this patient.

Prognostic value of cystocopically pseudotumoral lesions (inflammation/granuloma) in primary stage T1 grade 3 bladder tumors treated with BCG.

OBJECTIVE: The aim of this study is to find out whether the pseudotumoral lesions (inflammation/granuloma) seen at the follow-up cystoscopy performed three to six months after transurethral resection of primary stage T1 grade 3 bladder tumor and instillations of BCG therapy might have some prognostic value as far as recurrence and/or long term progression are concerned. MATERIAL AND METHODS: From the first group of one hundred and thirteen patients with primary stage of T1 grade 3 bladder tumor treated with 81 mg of BCG Connaught (weekly/during six weeks), those with recurrent tumor at the 3rd and 6th month were excluded, so we evaluated 99 patients. We identified 13 patients with cystoscopically pseudotumoral lesions. RESULTS: of the 13 cystoscopically pseudotumoral lesions, we observed recurrence in two cases (15%), while among the rest of the 86 patients, we observed 22 recurrences (26%) (p = 0.9; not significant). Concerning progression, eight cases were reported out of 86 patients (9%) within the cistocopically normal group. No cases of progression were reported among the 13 patients with cystoscopically pseudotumoral lesions. This difference was not statistically significant (p = 0.5). CONCLUSIONS: The patients with cystoscopically pseudotumoral lesions (inflammation/granuloma) are a reduced group (13%) with less tendency to recurrence and without progression, even though this relationship is not significant.

Intravesical treatment of severe bacillus Calmette-Guerin cystitis.

OBJECTIVE: Intravesical instillation of bacillus Calmette-Guerin (BCG) is an established treatment of carcinoma in situ and recurrent superficial bladder tumours. The inflammatory reaction due to BCG provokes cystitis of short duration as a frequent side effect. When the symptomatology is severe and long-lasting, different systemic treatments have been administered with varying degrees of efficacy. MATERIAL AND METHODS: We have studied the treatment of severe BCG cystitis with a anaesthetic anti-inflammatory solution administered by intravesical instillations to 16 patients. RESULTS: Good results were obtained in 94% of the cases, with immediate clinical improvement in terms of pain and urinary symptoms, and with no side effects. CONCLUSIONS: This treatment is inexpensive and easy to administer. We consider that it offers a useful option to solve an infrequent but very annoying problem for the patients.

[Intracranial metastasis in prostatic cancer]. / Metástasis intracraneales en cáncer de próstata.

The intracranial metastasis due to prostatic adenocarcinoma are quite rare, inside them, the ones placed in the parasellar region on the cranial base are exceptional. There are only 3 clinical cases found in the literature consulted, now we report here two more cases and we review the etiopathogenia, clinic presentation, diagnosis and treatment for this type of lesions. Usually there are very undifferentiated neoplasms, developed stages and with multiple metastasis at others levels. A patient with prostatic carcinoma known and neurological signs we should suspect the presence of intracranial metastasis. The diagnosis is made with image tests (basically with CT and MRI), being necessary in some cases the histological confirmation with a biopsy. Although the prognostic of these patients (less than 6 months in our cases) depends more of the evolutive stage of the illness than the type of treatment that the patients will be someated, we should establish it rapidly, on this way we can revert the neurological status and we will improve the quality of life of these patients.

[Initial superficial bladder tumors: our experience. Our criteria. Study Group of Bladder Tumors]. / Tumores vesicales superficiales iniciales: nuestra experiencia. Nuestro criterio. Grupo de Estudio de Tumores Vesicales.

OBJECTIVES: Evaluation of a homogeneous series of Superficial Primary TCC of the Bladder. Utility of randomized biopsies (BMN). Study of risk factors and risk groups as a basis for determining treatment and followup patterns. MATERIALS AND METHODS: Survey of 1,529 PSBT cases that underwent TURB and BMN, with a mean followup of 4.2 years. Strict statistical treatment: multivariate analysis using Cox logistic regression according to Kaplan-Meier curves. RESULTS: Tumor features of note: single tumor (65%), smaller than 1.5 cm (45%), high grade (G3: 26%), and high stage (T1: 64%). BMN showed associated CIS in 284 cases (19%). Main risk factors for recurrence were multiplicity, size > 3 cm and association with CIS. The main risk factor for progression was grade 3 (OR 19.9). Grade 3 and association with CIS were found to increase mortality risk. On the basis of this data, we grouped tumors according to low-, middle-, and high-risk, and established our proposed treatment and followup for each group. CONCLUSIONS: This multivariate analysis of a homogeneous cohort of 1,529 primary superficial bladder tumor cases allowed vs to determine risk groups for treatment and followup.

Upper urinary tract tumors after primary superficial bladder tumors: prognostic factors and risk groups.

PURPOSE: We evaluated the prognostic factors of primary superficial bladder cancer that may predict a metachronous upper urinary tract tumor. We also determined whether the incidence of upper urinary tract disease varies according to risk group based on primary superficial bladder tumor classification. MATERIALS AND METHODS: We studied disease evolution in a cohort of 1,529 patients with a primary superficial bladder tumor. To determine the prognostic factors of upper urinary tract cancer we performed multivariate analysis using Cox regression. Independent variables were grade, T stage, multiplicity, tumor size, carcinoma in situ association, previous or synchronous upper urinary tract tumor and intravesical instillation. We also performed the chi-square test and Kaplan-Meier survival analysis to assess the variable incidence of upper urinary tract tumors according to primary superficial bladder tumor risk group classification. RESULTS: The incidence of upper urinary tract cancer was 2.6%. The only factor prognostic for an upper urinary tract tumor was multiplicity (relative risk 2.7, 95% confidence interval [CI] 1.06 to 6.84). All patients with an upper urinary tract tumor had a previously recurrent primary superficial bladder tumor. In the low, intermediate and high risk groups the incidence of upper urinary tract cancer was 0.6% (relative risk 1), 1.8% (relative risk 3.1, 95% CI 0.4 to 23.9) and 4.1% (relative risk 8.3, 95% CI 1.1 to 61.6), respectively (chi-square and log rank tests p = 0.007 and p <0.05, respectively). CONCLUSIONS: A higher risk of upper urinary tract cancer must be expected in cases of multiple primary superficial bladder tumors. This finding supports the multicentricity theory of transitional cell carcinoma. Primary superficial bladder tumor classification by risk group is also useful for predicting the various risks of metachronous upper urinary tract cancer.