[Management of distal ureter in laparoscopic nephroureterectomy]. / Abordaje del uréter distal en la nefroureterectomía laparoscópica.

INTRODUCTION: Nephroureterectomy is one of the procedures for which a laparoscopic approach is more clearly indicated. However, despite the long experience available, management of the distal ureter is still difficult. MATERIALS AND METHODS: Thirty-two laparoscopic nephroureterectomies were performed from November 2004 to December 2008. The procedure used was endoscopic resection of distal ureter and earlier ligation of the ureter in the laparoscopic time in 13 patients, a laparoscopic bladder cuff in 13 patients, and an open bladder cuff in 3 patients. RESULTS: Mean operating time was 221.53 min (125-315 min), and mean postoperative stay of 27 patients was 4.6 days. Conversion to open surgery and discontinuation of the procedure for local tumor progression were required in one patient each. Mean patient follow-up was 17.8 months. No local relapse or metastasis occurred in the ports. CONCLUSION: The most common procedures continue to be endoscopic resection and the open bladder cuff depending on indication. Any laparoscopic approach to upper urothelial tumors must strictly comply with oncological principles. The reported procedure is in our experience the fastest, most simple, and most effective for this purpose. In our opinion, the therapeutic algorithm provided is adequate for management of the distal ureter in laparoscopic nephroureterectomy.

[Evaluation and treatment of kidney penetrating wounds]. / Evaluation et traitement des plaies pénétrantes du rein.

Penetrating lesions of the kidney are less frequent than closed wounds. However, their incidence has increased these past decades, in relation with the augmentation of urban violence. The main causes of penetrating wounds are knives and firearms, with a related rate of renal lesions more important in the second case. The treatment of renal traumas has evolved these past years. Previously, surgical investigations were systematically indicated in most cases, which was associated with an elevated number of nephrectomies. Today, the development of new diagnostic imaging techniques available in most emergency units allows in certain cases the replacement of therapy by a strict follow-up of the patient, the objective being to preserve the kidney. The principal diagnostic investigation is CT scanning with injection of a contrast product, which is useful to adequately classify renal lesions and to make decision regarding the best first-line therapeutic management. In case of penetrating lesion, the first step is the evaluation of the haemodynamic condition of the patient. In case of haemodynamic instability, immediate surgical investigation is necessary. Conversely, if the patient is stable, CT with delayed imaging must be carried out. For grade I and II renal lesions, therapeutic abstention is recommended. Grade III and IV lesions associated with other intraperitoneal lesions that require emergency laparotomy must be surgically investigated and in these cases, reconstructive surgery or nephrectomy must be considered. Most grade IV lesions associated with a lesion of the renal hilus and grade V lesions must be referred to surgery. Minor renal lesions may not be treated; such cases necessitate a follow-up of the patient that should include successive assessments of the haemoglobin and the haematocrite, together with CT and ultrasonographic investigations aimed at the follow-up of lesion evolution and detection of potential urinomas or prolonged bleedings. The progressive decrease of the haematocrite and arteriovenous fistulae must be treated first by an embolization. Untreated patients with persistent urinary fistulae will undergo, if necessary, ureteral catheterization and percutaneous drainage of the urinoma.

Probability of prostate cancer as a function of the percentage of free prostate-specific antigen in patients with a non-suspicious rectal examination and total prostate-specific antigen of 4-10 ng/ml.

Our aim was to assess the usefulness of measuring the percentage of free prostate specific antigen (PSA) in serum in relation to reducing the number of prostate biopsies in men with benign prostate examinations and serum PSA levels between 4 and 10 ng/ml. The percentage of free PSA (Immulite) in serum was analyzed prospectively in 500 men, all of whom underwent ultrasound-guided sextant prostate biopsies. Cancer was detected in 21.4% (107/500) of the patients. Using a free PSA cutoff of < or = 23% as a criterion for performing prostate biopsy would have detected 94.4% of cancers, avoided 18.8% of benign biopsies and yielded a positive predictive value of 25.3%. The percentage of free PSA increased with prostate volume. Mean total PSA and mean free percent PSA values increased as patient age increased, influencing the calculation of cutoff values, sensitivity and specificity. PSA density had a sensitivity and specificity not significantly different than the percentage of free PSA. Measurement of the percentage of free serum PSA improves the specificity of prostate cancer detection in patients with elevated total serum PSA levels and benign prostate examinations.

[Conservative parenchymal surgery in kidney neoplasms]. / Cirugía conservadora de parénquima en neoformaciones renales.

OBJECTIVES: To analyze retrospectively a series of 60 nephron sparing surgeries (NSS) in patients presenting with renal masses. MATERIAL AND METHODS: The clinical histories of 59 patients undergoing NSS between january 1978 and december 1997 were reviewed. 40 were males, the mean age 54.4 years (range 17-77 years). 10 (17%) had bilateral synchronous tumors, 15 (25%) had a solitary kidney and 3 a renal insufficiency. In 25 patients NSS was obligatory, while in 34 it was elective. 30 (50%) of the renal masses had been diagnosed incidentally. Overall, 49 kidneys underwent an enucleation and 11 a partial nephrectomy. RESULTS: The histopathological exam revealed 43 (71.6%) renal cell carcinomas (RCC), 2 (3.4%) urothelial carcinomas, 6 (10.2%) oncocytomas, 7 (11.6%) angiomyolipomas and 2 (3.4%) multilocular cystic nephromas. Among the RCC, 8 had < or = 3 cm, 22 between 3.1-5 cm, 10 between 5.1-8 cm and 3 more than 8 cm. 31 (72.1%) were well encapsulated and only 2 (4.6%) invaded the nearby parenchyma. 7 (16.2%) were pT1, 34 (79%) pT2 and 2 (4.6%) pT3. 39 (90.3%) were G1 or G2, and only 4 (9.3%) were G3. Two patients (3.3%) died perioperatively, both from the obligatory group. 3 (6.8%) of the patients with malignant tumors progressed and died, all with CCR and from the obligatory surgery group. Another 3 patients of this group developed local recurrences, but were rescued with iterative surgery (conservative in 1); 2 of these patients had sporadic CCR, another a von Hippel Lindau disease. None of the 34 patients who underwent elective NSS progressed, nor recurred locally and all are alive and disease free; only 14 (56%) of the 25 patients operated on by necessity survived, although 6 of them died of causes not related with the kidney tumor. The cancer specific survival at 58.3 months of follow-up (range 5-187 months) is 86.8% for the whole series, 100% for the elective NSS group and 68.7% for the obligatory NSS group. 19 (31.6%) patients developed complications, 14 among the obligatory group; two died (hemorrhage and sepsis). 3 patients presented acute renal failure, but none required dialysis; presently 4 (6.7%) patients have poor renal function and 1 requires dialysis. CONCLUSION: NSS affords good control of renal carcinoma; in the cases operated on electively, the 100% cause specific survival yielded by NSS supports the use of conservative surgery in patients with well delimited tumors and normal contralateral kidney.

Determination of the percentage of free prostate-specific antigen helps to avoid unnecessary biopsies in men with normal rectal examinations and total prostate-specific antigen of 4-10 ng/ml.

OBJECTIVE: To assess the usefulness of measuring the percentage of free prostate-specific antigen (PSA) in serum to reduce the number of prostate biopsies in men with serum PSA levels between 4 and 10 ng/ml and benign prostate examinations. MATERIALS AND METHODS: The percentage of free PSA (Immulite((R))) in serum was analyzed prospectively in 180 men with benign digital rectal examinations and total PSA serum levels of between 4 and 10 ng/ml. All patients underwent ultrasound-guided sextant prostatic biopsies. Sensitivity, specificity and positive and negative predictive values were calculated as well as the percent of patients in which biopsies could have been avoided for various cutoff values of the percentage of free PSA as an indicator for biopsy. Influence of age in the determination of cut points was evaluated. RESULTS: Cancer was detected in 22.2% (40/180) of the patients. Mean percentage of free PSA was 13.4% in patients with cancer and 18.9% in patients with benign prostatic hyperplasia (p = 0.001). Using a percentage of free PSA cutoff of 22% or less as a criterion for performing prostatic biopsy would have detected 95% of cancers, avoided 25% of benign biopsies and yielded a positive predictive value of 29% in patients who underwent biopsy. Mean percent of free PSA values increased as mean subject age increased, influencing the calculation of cut points, sensitivity and specificity. Leaving the cut point constant across all age groups will oblige older patients to undergo an increased number of unnecessary biopsies, although allowing for higher sensitivity in younger men. CONCLUSIONS: Measurement of the percentage of free serum PSA improves specificity of prostate cancer detection in patients with elevated total serum PSA levels and benign prostate examinations. Subject age seemed to influence the determination of optimal cut points.

Andrological implications of congenital posterior urethral valves in adults. A case of retained ejaculation and review in western literature.

This report is the second case in Western medical literature of retained ejaculation and subsequent sterility due to posterior urethral valves. A survey of this anomaly in adults is presented together with its andrological implications.