[Laparoscopic surgery training in pelvitrainer and virtual simulators]. / Aprendizaje de la cirugía laparoscópica en pelvitrainer y en simuladores virtuales.

Over the last few decades, there has been a rise in the number of minimally invasive techniques, such as arthroscopy, vascular radiology and our speciality, laparoscopy. Laparoscopy has resulted in a reduction in the damage caused during intervention, with the subsequent reduction in hospital stay, postoperative pain and infections. However, one disadvantage of these techniques is that they require a large investment in instruments and a long and costly training period. In the following chapter, we describe the laparoscopic training process of the medical residents from our Urology Service in the pelvitrainer and virtual simulator.

Aprendizaje de la cirugía laparoscópica en Pelvitrainer y en simuladores virtuales / Laparoscopic surgery training in pelvitrainer and virtual simulators

En las últimas décadas se han incrementado las técnicas quirúrgicas mínimamente invasivas, como la artroscopia, radiología vascular y en nuestra especialidad la laparoscopia. Con la laparoscopia se ha reducido el daño causado durante la intervención, con la consiguiente disminución del periodo de hospitalización, el dolor postoperatorio y las infecciones. Sin embargo estas técnicas presentan el inconveniente de requerir grandes inversiones en instrumental y un periodo de entrenamiento más largo y costoso. En el siguiente capítulo repasamos el proceso de aprendizaje laparoscópico realizado en el pelvitrainer y en el simulador virtual por parte de los residentes de nuestro Servicio de Urología

Over the last few decades, there has been a rise in the number of minimally invasive techniques, such as arthroscopy, vascular radiology and our speciality, laparoscopy. Laparoscopy has resulted in a reduction in the damage caused during intervention, with the subsequent reduction in hospital stay, postoperative pain and infections. However, one disadvantage of these techniques is that they require a large investment in instruments and a long and costly training period. In the following chapter, we describe the laparoscopic training process of the medical residents from our Urology Service in the pelvitrainer and virtual simulator

[Intraocular metastatic renal carcinoma presenting as progressive unilateral blindness]. / Carcinoma renal metastásico intraocular. Ceguera unilateral progresiva como forma de presentación.

Clear cell renal carcinoma is the most common histological type, representing 70-80% of all renal carcinomas. Metastases are already present in about 25-30% of patients at the time of diagnosis of renal cell carcinoma. Ocular metastasis is extremely rare.

[Giant stone in a Bricker urinary diversion. Obstruction uropathy as the presenting form]. / Litiasis gigante en derivación urinaria tipo Bricker. Uropatía obstructiva como forma de presentación.

Bowel is used in urological surgery to replace the bladder, either as a conduit to drain urine to the abdominal wall as a urinary stoma or refashioned to form a substitute bladder. Many factors contribute to stone formation, being urinary stasis, mucus production and bacteriuria the most important. Metabolic changes induced by exposure of segments of the alimentary tract to urine promote struvite, calcium oxalate and calcium phosphate stone formation. Generally, the majority of patients with stones in a urinary diversion can be treated with minimally invasive techniques. Open surgical removal is considered when other modality of treatments cannot be accomplished safely and expeditiously.

Prevalence of benign prostatic hyperplasia in Spanish men 40 years old or older.

PURPOSE: We estimate the prevalence of benign prostatic hyperplasia (BPH) according to symptoms as well as prostate obstruction determined by uroflowmetry and prostate size. MATERIALS AND METHODS: A cross-sectional study was performed at the autonomous community of Andalusia in 1,106 men 40 years old or older. The International Prostate Symptom Score (I-PSS) questionnaire was used to establish symptoms, abdominal and transrectal ultrasonography was done to measure prostate size and uroflowmetry was performed to measure urinary flow obstruction. RESULTS: The prevalence of moderate or severe symptoms was 24.94% and it increased with age. Of the 1,106 subjects 4.19% had severe prostatism, while 12.45% had poor quality of life (I-PSS greater than 3). Average prostate size was greater than 30 gm. in men 60 years old or older. Maximum urine flow was less than 10 and 15 ml. per second in 25.97 and 55.67% of the men, respectively. The prevalence of BPH, defined as I-PSS greater than 7, maximum flow less than 15 ml. per second and prostate size greater than 30 gm., was 11.77% (range 0.75 to 30 at ages 40 to 49 and greater than 70 years, respectively). CONCLUSIONS: The prevalence of BPH increases with age. Moderate prostatism is perceived as resulting in poor quality of life by young subjects and good quality of life by some older subjects. In some men there were symptoms and obstruction but no prostate enlargement. This percentage persists with age after 50 years, when the prevalence of BPH starts to increase.

[Cost-effectiveness comparative study of ceftriaxone verus cefotaxime in the treatment of complicated urinary infections]. / Estudio comparativo coste eficacia ceftriaxona versus cefotaxima en el tratamiento de las infecciones urinarias complicadas.

Prospective, randomized, multicenter study in 267 patients with complicated urinary infection from 9 hospitals nationwide. Drug treatment was either Ceftriaxone 1 g once daily parenterally or Cefotaxime parenteral 1 g 8 hourly for a minimum of 7 days. Patients were clinically, analytically and microbiologically evaluated before and after treatment to assess the efficacy and tolerance of both drug products. To evaluate treatment cost, we used the price of both drugs and the material required for their administration (syringe and disposable needle). 119 patients were excluded from the cost-efficacy evaluation and 148 remained in the study (75 assigned to treatment with Ceftriaxone and 73 to Cefotaxime). Clinical efficacy of treatment was 93% and 87.6% for Ceftriaxone and Cefotaxime respectively (p > 0.05). Cost per patient was 27,347 pesetas for Ceftriaxone and 34,490 for Cefotaxime (p < 0.05).

[Penile prosthesis. Implantation under local anesthesia]. / Prótesis de pene. Implantes bajo anestesia local.

UNLABELLED: We report our motivation, technique, results and the current status of penile prosthesis implantation under local anesthesia at our institution. The lack of anesthetists to cope with the surgical demands and the conflicting views on the priority assigned to the different pathologies prompted us to seek an alternative approach. TECHNIQUE: Anesthetic blockade with mepivacaine (2%) for the pudendal nerve branches (dorsal and perineal, in some cases; cavernous, in the first one) responsible for penile innervation, and anesthetic blockade of the genitofemoral and ilioinguinal nerves that innervate the scrotum and its contents. Of the five patients, 80% had excellent and 20% had good tolerance of the procedure. The definition of the foregoing categories are discussed herein. Currently, we have no waiting list or conflicts relative to treatment priorities. We reserve the technique for patients with anesthetic contraindications, as case number five.

[An arteriovenous fistula as a complication of percutaneous nephrostomy]. / Fístula arteriovenosa como complicación de la nefrostomía percutánea.

Percutaneous nephrostomy has emerged as a substitute for surgical nephrostomy. The complication rate is low, hematuria being one of the most common. Treatment should be conservative while possible since the clot plays an important role in the tamponade of hemorrhage. Arteriovenous fistulas following percutaneous nephrostomy are rare. Diagnosis is by arteriography and treatment is by selective embolization.

[Lymphatic staging by laparoscopic surgery]. / Estadiaje ganglionar mediante cirugía laparoscópica.

Lymphadenectomy is mandatory in vesical and prostatic tumours for a precise staging of candidates to radical surgery. Presentation of our series of 18 ilioobturative lymphadenectomies between May 1992 and February 1993, performed in 14 prostate carcinoma and 4 vesical tumours. As most interesting results, the average number of nodes removed, which was 8, and the discovery of nodular affectation in 5 cases, understaged by the non-invasive procedures, are highlighted; likewise, the reduction in surgery duration up to the current frame of 80 to 120 minutes must be emphasized. Mortality due to the procedure was null. We believe that laparoscopic lymphadenectomy should be the choice technique in the staging of tumoral dissemination in the ilioobturative domain.

[Laparoscopic exeresis of a completely duplicated kidney]. / Exéresis laparoscópica de riñón con duplicidad completa.

During the '80s, laparoscopy in general has undergone an enormous boom as representative of minimally invasive surgery, urology standing out in that progression as the specialty leading the endoscopic approach both for the tradition and profusion of techniques developed. In Spain, major scope laparoscopic surgery started with lymphadenectomy in which we are the second Spanish and first Andalusian group to perform it. The experience accumulated by our group has allowed us to perform and present one case of laparoscopic nephrectomy, this being the first time in Andalusia and second in Spain that an Urology Unit develops this technique, the distinct feature being the presence of complete duplicity of the kidney. The procedure had no peri or post-operative complications and the patient was discharged four days later. We conclude that although presently the indications of renal exeresis for this procedure are limited, these will soon be expanded thanks to the urologists' concern, the accumulation of experience and the improvement of the instrumentarium.

[Local anesthesia in the surgical management of hydrocele and cysts of the spermatic cord]. / La anestesia local en el tratamiento quirúrgico del hidrocele y quiste de cordón espermático.

Traditional management of vaginal fluid collections has always been surgery. The benignancy of this disease does not correspond with the morbidity caused by the anaesthetic techniques used. Over the last few years, sclerotherapy has become increasingly attractive as an alternative to hydrocelectomy. Indications are, nonetheless, restricted, presenting a relapse rate which varies according to the substance used and the operating team. The study proposes the use of local anaesthetics for the surgery of vaginal fluid collections so as to minimize the immediate postoperative period and thus the hospital stay. Between May and October 1991, 55 patients, 49 with hydrocele (4 bilateral) and 6 with sperm cord cyst, were treated in our Unit. Patients were monitored in the theatre (EKG, blood pressure and oximeter) to supervise their life constants, and 2% Mepivacaine (10-20 cc) was infiltrated into the sperm cord and the area of scrotal wall to be cut. Surgical techniques range from dissection to scission of the bag until partial eversion, requiring the use of reabsorbable suture and a careful haemostasis to avoid drainage. Anaesthetics tolerance has been highly satisfactory in 52 patients (94%), good in one patient (2%) and unsatisfactory in two cases (4%). Recorded complications include: severe bradycardia and hypotension in one case (2%), persistent right renoureteral pain in one case (2%), scrotal haematoma in 5 cases (9%) and suture dehiscence in another patient (2%). It is concluded that surgical management of vaginal collection with local anaesthetics is feasible, and reduces the immediate postoperative period also avoiding morbidity derived from a more aggressive anaesthetic technique.

[Laparoscopic testicular autotransplantation]. / Autotrasplante testicular laparoscópico.

The authors describe an experimental technique of endoscopic autotransplantation of the testis. Four trocars are utilized; one is placed at the level of the umbilicus, one in the right flank, another in the left flank, and one in the hypogastrium. Five or six cms of the epigastric vessels are dissected and sectioned. Then the spermatic vessels and released from the inguinal orifice up to their origin and sectioned. The testis is taken to the peritoneal cavity through the skin and the sustenaculum testis is sectioned. Both vascular pedicles are exteriorized through an incision at the level of the inguinal duct. Microvascular anastomosis is performed as in a routine procedure and the vessels are inserted into the abdomen again, the testis is taken to the scrotum and the inguinal duct is closed from inside.

[Laparoscopic ileal conduit]. / Conducto ileal laparoscópico.

The authors describe an experimental model for performing the Bricker procedure endoscopically. After placing the operating table in the Trendelenburg position, the trocars are inserted through the incisions at the level of the umbilicus, the right and left flanks and the hypogastrium. Both ureters are dissected free from the inferior pole of the kidney up to a short distance from the bladder, clamped and cut. The right flank incision is extended a few cms longitudinally and the right ureter and ileal loop are brought out through the incision. Once exteriorized, a segment of the ileum is separated and intestinal continuity reestablished. The right ureter is then attached to the distal end of the ileal segment. The other end of the loop is brought to the left flank and exteriorized together with the left ureter, as described above. Once the ureter has been attached, they are passed inside. The incisions are sutured and a stoma is created in the right flank. The authors recommend the application of this simple technique in the clinical setting.

[Dermatomyositis as paraneoplastic syndrome of bladder tumor]. / Dermatomiositis como síndrome paraneoplásico de tumor vesical.

The dermatomyositis is a connective tissue disease characterized by changes affecting both the skin and the muscle, appearing most frequently around the fifth and sixth decades and which association to a vesical tumour is very rare. This paper contributes one case of paraneoplastic dermatomyositis associated to infiltrant vesical tumour, presenting erythematous damage in face, nape of the neck and upper thorax, as well as periorbital heliotrope erythema and fingernails base and sides telangiectasia, all of which are typical signs of dermatomyositis.

[The use of the double-J catheter as urinary obstruction prophylaxis in lithiasis]. / Uso del catéter doble J como profilaxis de la obstrucción urinaria en patología litiásica.

Our experience in the use of the double-J catheter in the prevention and treatment of urinary obstruction in stone disease is presented. This retrospective study spans the period January, 1985 to June 1989. Fifty-five double-J catheters were placed in 51 patients (catheter replacement was required in 4). Catheter placement was done antegradely in 17, retrogradely in 34 and intraoperatively in 4 cases. The indications were for treatment post-ESWL in 45 patients, stone remnants following percutaneous nephrolithotomy in 1, post-ureteroscopy in 2, and after open surgery in 2 patients. Complications were observed in 24% of the cases, hematuria being the most common complication. The foregoing agrees with the 20-40% complication rate reported in the literature. Thus, we can conclude that the double-J catheter is well-tolerated and is a simple yet useful endourologic tool in the prevention and treatment of urinary obstruction in stone disease.

[Diagnostic evaluation of closed renal trauma]. / Evaluación diagnóstica de los traumatismos renales cerrados.

Renal traumatism is a relevant entity, its early and precise diagnosis having great weight in the initiation of appropriate treatment and its success. All 189 contained renal traumatisms seen in our service between 1981 and 1989, are studied. The purpose of the present work is to determine the diagnostic reliability of the different tests available, chiefly comparing echography versus urography, as well as CT. The method used is measurement of Sensitivity, Specificity and Predictive values, arranged by grades and compared using the squared-chi method (Fisher's exact test). Regarding the primary results we must emphasise the rejection of a void hypothesis in grades II and III with an error level lower than 0.01 for positive predictive values in echography vs. urography; as well as the high values of sensitivity and specificity of CT in high degree traumatisms. To conclude, those traumas where a complementary study is necessary urography may provide more information than echography; although in traumatisms where high degree lesions are suspected, CT will provided the most valuable information.