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La presión innovadora forma parte de la utopía técnico-científica vigente y compromete por igual a cirujanos, pacientes, medios de comunicación e industria sanitaria. Ha hecho aflorar un nuevo tipo de aventurismo técnico con su yatrogenia acompañante que comporta riesgos innecesarios. Los personalismos, la persuasión industrial y la potenciación de las marcas hospitalarias, tanto públicas como privadas, han debilitado los valores y la ética profesional en un entorno en el que la tecnología está perdiendo coste/beneficio y los conflictos de interés han encendido muchas sospechas. Se impone una revisión crítica del culto tecnólatra y una valoración serena de los costes de nuestras intervenciones no solo en la esfera de lo económico sino también en lo que se refiere a la seguridad para los pacientes, a la sostenibilidad medioambiental y a la utilización más eficiente de nuestros dispositivos asistenciales.
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OBJECTIVES: Over 90% of all prostate cancer patients are diagnosed at a stage when the disease is organ-confined and potentially curable. Currently >60% of all prostate cancer surgeries in the United States are performed using the robotic approach. We review the current literature evaluating the technical advances to optimize continence recovery following robotic prostatectomy. METHODS: Recent studies suggest that the several technical nuances during robotic prostatectomy can result in earlier continence recovery in patients without compromising the oncologic outcome. The key is in delicate handling of tissues, reducing trauma, preserving support structures and restoring post-operative anatomy as close as possible to pre-operative anatomy. There should also be standardization in assessment of continence recovery. CONCLUSION: Much progress has been achieved in elucidating the anatomic, physiologic and neural basis of the male continence mechanism, resulting in novel adaptations of the conventional approach to radical prostatectomy with the aim of preserving continence and accelerating its return. Various principles for augmenting continence return have been proposed which have been evaluated in series of open, laparoscopic and robotic-assisted radical prostatectomy. Going forward, we foresee a paradigm shift from individual techniques toward a unified approach of interwoven principles aimed at preserving and augmenting the functional and innervative anatomy of the continence mechanism.
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OBJECTIVES: One of the main drawbacks of flexible urethrocystoscopy is the risk of urinary tract infection (UTI). In order to reduce this risk, antimicrobial prophylaxis has been considered, however there is not a unanimous view regarding indications, dosage, type of antibiotic, and so on. To clarify this uncertainty, we practiced a pilot and experimental study aimed at assessing the effectiveness of chemoprophylaxis with 3 grams of fosfomycin trometamol in the prevention of UTI after urethrocystoscopy.METHODS: Sixty patients were entered into a pilot randomized clinical trial between March and August 2011. Thirty patients were assigned to a control group without receiving any antibiotic dose, and the intervention group (30 patients) received 3 g fosfomycin trometamol. Ten days later urine culture and sediment analysis were performed in all patients. Significant bacteriuria was considered from > 105 CFU /ml. One month later a telephone survey was developed to assess urinary symptoms, and assistance to the family doctor. We estimated the cumulative incidence of bacteriuria, pyuria and microhematuria in both groups, and we compared the results using a strategy of analysis per protocol and intention to treat. RESULTS: The incidence of bacteriuria, pyuria and microhematuria in the control group was 10%, 23.3% and 26.7% respectively and in the intervention groups the values differed depending on the type of analysis. Considering only the 27 patients (per protocol analysis), the incidence would be 11.1%, 37.0% and 29.6% respectively. If we include the three patients who did not completed the study (per intention to treat analysis) and considering their results as negative, the results were 10%, 33.3% and 26.7% respectively. Finally, in the case the three cultures not performed in this group had produced a positive result, the impact would have been 20.0%, 43.3% and 36.7%. In any of the three cases, the differences with the control group were not statistically significant. CONCLUSIONS: In a selected population and with appropriate aseptic measures, antibiotic chemoprophylaxis does not appear to show a clinically relevant reduction in the incidence of UTI in patients undergoing flexible urethrocystoscopy.
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OBJECTIVES: Aging of the current population is an evident fact, and the surgical treatment of these patients is something we find in our daily practice. In this sense, all doubts that may arise when it comes to carrying out this technique in patients with important comorbidities appear to be cleared, as even patients with prior respiratory or heart disease benefit from the laparoscopic approach.METHODS: An analysis was carried out on a total of 99 patients over 70 years of age who underwent renal laparoscopic surgery, compared, on one hand, to 173 patients under 70 years of age undergoing the same procedure, and on the other, to 95 patients over 70 years of age who underwent open surgery. We collecteded and compared all complications described intraoperatively and in the immediate postoperative period, as well as hospital stay.RESULTS: Patients over 70 years of age have a greater comorbidity compared to patients under 70 (ICH 1.46 vs. 0.89 p<0.05), but there are no statistical differences in terms of intraoperative or postoperative complications, or mean hospital stay. When compared to patients over 70 years of age with a similar comorbidity who underwent classic surgery, (ICH 1.46 vs. 1.45), we found a lower rate of complications (12.2 vs. 28.4% transfusion, 1.4 vs. 4.0% fever, p<0.05) and a shorter hospital stay (4.9 vs. 7.1% p<0.002).CONCLUSION: Patient age does not seem to have a determining effect on complications or on the postoperative period of kidney disease when laparoscopy is used, which is why this method of treatment seems adequate in such cases.
Review
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OBJECTIVES: The microbubbles enhanced ultrasound contrast is a novel technique that informs us in real time of renal perfusion and microcirculation.METHOD: We reviewed the literature about its use in the study of renal masses in order to show their actual clinical performance in this condition. RESULT: This technique is useful in the differential diagnosis of pseudotumors, characterization and monitoring of small renal masses, the study of complex renal cysts and controlling the progression of renal masses that underwent ablative treatments. Like any diagnostic technique has some limitations on usage; its rapid contrast wash, being operator-dependent, require some experience and need special software to be correctly interpreted.CONCLUSSIONS: The microbubbles enhanced ultrasound contrast is a useful and economic technique for the study and differential diagnosis of the renal masses.
Case Report
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OBJECTIVE: We report a case of supernumerary testis, a rare anomaly with only around 100 cases reported in the literature.METHODS: We describe the case of a 26-year-old man who consulted for a left paratesticular tumor. Physical examination and ultrasound showed a 2-cm nodular lesion over the left epididymis. The lesion was confirmed as supernumerary testis by surgical examination and biopsy and was subsequently excised, given the malignancy potential.RESULTS: The supernumerary testis was evaluated using two standard classifications, one assessing function and embryological development, and the other assessing topography, anatomy, and reproductive potential.CONCLUSIONS: The differential diagnosis for an intrascrotal mass should include the possibility of a supernumerary testis; hence, surgical examination and biopsy are necessary. Supernumerary testes should be excised in the case of pain, dysplasia, or in situ carcinoma, or whenever the biopsy is inconclusive.
Case Report
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OBJECTIVE: To present a case of giant adrenal carcinoma associated with renal vein and inferior vena cava (IVC) thrombus. Up to now, there is no similar case reported in the national literature.METHODS: 75 year old woman with signs of virilization. CT-scan showed an 18 cm adrenal mass with venous thrombus and possible pulmonary metastases. The working diagnosis was primary suprarenal carcinoma. RESULT: Due to elderly age and advanced stage, including metastasis, we decided to not perform surgery, and initiate chemotherapy. CONCLUSIONS: Adrenal Cancer is an infrequent and very aggressive tumor. Surgery is the only curative treatment. In advanced stages chemotherapy is recommended, but with poor results.
Case Report
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OBJECTIVE: To report a rare case of penile paraffinoma caused by the subcutaneous or intra-urethral injection of foreign substances containing long-chain saturated hydrocarbons. These were injected in order to increase the penis size which generated a chronic granulomatous inflammatory reaction. This is a rare practice in the western world.METHODS: We present the case of a 32-year-old Bulgarian male who presented with a two-year history of elastic, slightly painful penis swelling after subcutaneous liquid paraffin injection. The proposed treatment was excision of the affected tissue and penile reconstruction in a two-stage procedure. RESULTS: The operative procedure was successful and the patient had good aesthetic and functional results. Paraffin and other materials injected into the penis can produce many complications. Foreign body granuloma, skin necrosis, penile deformity, chronic and unhealed ulcer, painful erection, and the inability to achieve a satisfactory sexual relationship are some of the resulting complications. Intralesional or systemic steroids have been used in primary sclerosing lipogranuloma resulting in the disappearance of the granuloma, but in our opinion the treatment of choice should be radical excision, and, if necessary, secondary reconstruction of the penis.CONCLUSION: The injection of foreign substances to enhance penis size is currently an unjustifiable practice. However, it is still carried out, especially in Eastern Europe and Asia. In most cases surgical treatment is needed to treat the complications and the best modality seems to be radical excision together with follow-up.
Case Report
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OBJECTIVE: Transurethral resection (TUR) is highly effective in the local control of superficial bladder cancer. However, the recurrence rate can reach 80% of the cases. Adjuvant intravesical chemotherapy may decrease significantly tumor recurrence. We describe a bladder adverse reaction to mitomycin C as adjuvant therapy for non-invasive bladder cancer.METHODS: Three patients with diagnosis of pTa G1 urothelial carcinoma were treated by TUR plus an instillation of 40 mg. of mitomicin C. A month later, the patients were attended for dysuria and hematuria. Cystoscopy and bladder biopsy were performed in all cases.RESULTS: Multiple sessile lesions suspicious of tumor recurrence were found on cystoscopy. The histopathological diagnosis disclosed the existence of severe atypia of the urothelium and stromal changes similar to those observed after radiotherapyCONCLUSIONS: Adjuvant intravesical chemotherapy with mitomycin C may cause local reactions with macroscopic patterns similar to tumoral recurrences.
Case Report
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OBJECTIVE: To present a case report of crossed fused renal ectopia treated with percutaneous nephrolithotomy at our hospital and to perform a literature review.METHODS/RESULTS: We present the case of a male with renal calculi in a crossed ectopic and fused kidney, treated satisfactorily with percutaneous nephrolithotomy in a onestage surgery through an upper pole access.CONCLUSIONS: Percutaneous nephrolithotomy is a minimally invasive procedure with good results and low morbidity in this kind of patients. It is technically demanding and requires surgeon´s ability and experience.
