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OBJECTIVES: To perform a comparative evaluation of three types of continuous bladder irrigation catheters with the aim of determining which of them allows greater irrigation solution inflow and bladder outflow.METHODS: We compared three types of three-way catheters, 22F in caliber, being the material the main difference between them: latex, silicone, or polyvinyl.RESULTS: The polyvinyl catheter showed significant differences both in inflow and outflow in comparison with the other two types of catheters (p =0,000, ANOVA test with Sheffe’s post hoc). Additionally, the latex catheter showed a significant outflow decrease with the insufflation of the self retentive balloon.CONCLUSIONS: The polyvinyl catheter, due to material rigidity, is the one that allows better bladder irrigation
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OBJECTIVES: White light cystoscopy is the current standard for the diagnosis of bladder cancer and monitorization for recurren-ce. Recent studies suggest that porphyrin based fluorescence cystoscopy may im-prove endoscopic detection of bladder tumors. We aimed to evaluate the improvement that hexaminolevulinate fluorescence cystoscopy could lead in bladder cancer detection and treatment at one single centre.METHODS: Between September 2006 and September 2007 a total of 39 patients with known or suspected bladder cancer underwent bladder instillation with 50 ml 8 mM hexaminolevulinate (HAL) for 1 hour. The bladder was inspected using white light cystoscopy (WLC), followed by blue light (fluorescence) cystoscopy (BLC). Papillary and suspicious lesions were resected for histological examination. Mean age was 70.1 years (50-86). Thirty patients were male (76.9%) and 9 female (23.1%). The tumor characteristics were: 18% primary tumors, 51% recurrences and 30% control cystoscopies. 24 patients had previously received some treatment (9 MMC and 15 BCG). Only 7 patients had previous positive urine cytology.RESULTS: All papillary lesions visualized with WLC were confirmed by BLC (18 patients). From these, 17 have positive biopsies (6 pTaG1, 9 pT1G1-3, 1 pT2, 1 CIS). In 15 patients (38.4%) we found at least 1 lesion more with BLC. In this group 8 cases (20.5%) had positive histological diagnosis (3 pTaG1, 2 pT1G3, 3 CIS). In five patients (13%) post-TUR therapeutic management has changed by using BLC (BCG vs MMC). All four patients with CIS were diagnosed by BLC. There was no evidence of local or systemic side effects due to HAL in the postoperative time.CONCLUSIONS: Our results suggest there is an improvement in the diagnosis of papillary and flat lesions in bladder cancer by using HAL fluorescence cystoscopy. This has changed the management in the postoperative period (MMC vs BCG) in 13% of the patients. Obviously, we need more patients to assess our data and long term follow-up to analyze the impact in terms of tumor recurrence and progression
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OBJECTIVES:To study paratesticular malignant fibrous histiocytomas (FHM) from the clinical, histological, immunohistochemical and histogenetic, point of view. METHODS: Through Medline and not index-linked search of international scientific literature we have found a total of 77 cases of paratesticular FHM that globally create diagnostic, terminological and therapeutic problems.RESULTS: We include the case number 78 of FHM of spermatic cord, that presents a few special characteris-tics (not described before) of cutaneous fistula and infiltration of an inguinal leiomyoma, with histologi-cal and immunohistochemical confirmation. We performed a conceptual review of this type of tumours, including the evaluation of contradictions and reclassifications that has undergone from its first description, which causes that they are underestimated and their real prevalence in international series is very variable: from 7 to 37 % of paratesticular sarcomas. Also, the fact of their low incidence has determined the lack of protocols for diagnosis and treatment. CONCLUSIONS: Paratesticular tumours, although infrequent, have a high rate of malignancy. The FHM concept has varied throughout the last 15 years. Today, this term is synonymous of pleomorphic undiffe-rentiated sarcoma and has been an exclusion diagnosis (Vimentin [+] / CD 68 [+] - occasionally - without ultrastructural differences), reserving the infla-mmatory subtype for which they have an inflammatory and histiocytic component. The accomplishment of an intraoperatory biopsy is essential in this location, since it is even difficult to know preoperatively, if a lesion is benign or malignant. The differential diagnosis is only solved after microscopic and inmunohistochemical study. Leiomyoma next to this location (inguinal) could be diagnosed and confused with a nodule of the main FHM. Their immunophenotype allowed us to diag-nose it not only as leiomyoma (myogenic markers were positive -non skeletal muscle-), but also to observe the infiltration by the FHM.
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OBJECTIVES: To study the clinical presentation, diagno-sis, treatment, and evolution of upper urinary tract tumours.METHODS: We carried out a retrospective study on the upper urinary tract tumours treated in our centre, HCU Valladolid, between 1994 and 2007.RESULTS: 65 tumours were diagnosed, although only 59 were valid for the study. Mean patient age was 68 years (interval between 46 and 88 years). 47 were men and 12 women. The most common symptom on presentation was hematuria (79,9%). Urography was the most frequently used diagnostic technique (96,6%) and nephroureterectomy with transurethral resection of the intramural ureter was the most common surgical treatment performed, carried out in 28 cases. 9 patients underwent percutaneous treatment with only one recurrence, and 2 patients received ureteroscopic treatment. 50,9 % of the lesions were classified as superficial tumours. The 5 and 10-year survival rates were 55 and 47%.CONCLUSIONS: Upper urinary tract tumours are an unusual disease characteristic of medium-advanced ages. Nowadays nephroureterectomy by open surgery or laparoscopy is the standard treatment. Con-servative endoscopic procedures have more and more importance and present excellent results in highly selected cases.
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OBJECTIVES: Classically, the diagnosis of ectopic ureter was done in grown up girls due to urinary incontinence, today the diagnoses are more precocious, which has partially changed treatment. The objective of this paper is to perform a review of our experience over the last years and to correlate it with the current type of presentation.METHODS: We studied all patients with the diagnosis of ectopic ureter in a period of 10 years, between 1997 and December 2006. Demographic characteristics, type of presentation, diagnostic tests performed, age at the time of diagnosis and treatment were all analyzed, altogether with the different techniques employed for treatment.RESULTS: We found 19 patients with this disease, 15 of them females. Type of presentation was febrile urinary tract infection in 13 patients, urinary incontinence in two, and prenatal diagnosis of hydronephrosis in 4. Sixteen children had double pyeloureteral systems and only three had single systems. In all cases the diagnosis was performed with renal-bladder ultrasound, urethrocystogram and endoscopic studies. Additional studies such as excretion pyelograms were performed in 8 patients at the start of the series and nuclear medicine tests in 17. Median age at the time of diagnosis was eight months. All patients underwent surgical treatment. In patients with double systems superior heminephroureterectomy wae performed in 8 patients, vesicoureteral reimplantation in three and pyelo-pyelic anastomosis in three cases with upper pole remnant function. In another two cases nephroureterectomy was performed due to the presence of reflux to the lower or system and severe renal compromise. In all three cases with single systems ureter reimplantation was performed.CONCLUSIONS: Currently prenatal suspicion and adequate study of urinary tract infections enable confirmation of ectopic ureter. Few children debut with urinary incontinence currently, due to the precocity of diagnosis. Treatment is always surgical, and basically depends on renal function, and the presence or absence of vesicoureteral reflux. Vesicoureteral reimplantation is performed preferentially in patients with ectopic ureter and a single system, and superior heminephrectomy in those with double systems, leaving the distal ureter of first option.
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OBJECTIVES: Laparoscopic radical cystectomy has been developed after the expansion of laparoscopic radical prostatectomy. This technique makes possible a minimally invasive approach to muscle-invasive bladder cancer with less blood loss and faster postoperative recovery. METHODS: From September 2004 to January 2007, 54 laparoscopic radical cystectomies were performed, 48 of them in stage T2, from which 43 (90%) were male and 5 (10%) female patients. Mean age was 64 years (27-88). Lymphadenectomy was carried out by laparoscopic approach in all cases, with a mean of 13 nodes obtained (4-24). Urinary diversion was done through the incision needed to extract the specimen in all cases but one that was completed completely intracorporeally; constructing a Bricker-type ureteroileostomy in 30 (62%) cases, orthotopic neobladder (Vesica Ileale Padovana) in 17 cases (35%), and cutaneous ureterostomy in 1 case (2%).RESULTS: Mean surgical time for the whole procedure was 287 minutes (180-480), 270 minutes for Brickertype derivation cases and 316 minutes for neobladder cases. Blood transfusion rate was 25%. Mean ileal paralysis was 5 days (2-10) with a mean hospital stay of 13 days (6-34) for Bricker cases and 16 days (8-30) for neobladder cases. Oncological control, after a mean follow-up of 10,8 months (0,4-30), showed a cancerspecific survival of 90% with a mean survival time of 28 months (95% CI 26-30). Global mean survival was 79% with a mean survival of 26 months (95% CI 23-29).CONCLUSIONS: Laparoscopic radical cystectomy is a feasible technique that offers some advantages. It allows excision with less blood loss and an easier postoperative period. Randomized studies should demonstrate these advantages to confirm this approach as the technique of choice. Urinary diversion performed through the laparotomy incision, necessary to extract the specimen, optimizes derivation results and whole surgical time without reducing the beneficial effects of the laparoscopic exeresis.
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OBJECTIVES: Testicular cancer affects young and fertile patients. Half of them are non seminomatous tumors. The management of this cancer in stage I includes: watchful waiting, chemotherapy and retroperitoneal lymph node dissection (RPLND). In the past,classic RPLND produced a high rate of anejaculation with the subsequent compromise to fertility. Currently, antegrade ejaculation is achieved in almost 90% of the cases with the modified technique. The objective of this work is to show the conservation of antegrade ejaculation and some surgical anal cortical features of the modified laparoscopic RPLND.METHODS: From January 2003 to July 2006 24 patients with non-seminomatous testicular tumors underwent modified laparoscopic RPLND. Patients were asked about preservation of antegrade ejaculation six weeks after surgery. We also analyze surgical and oncological variables in the series.RESULTS: All surgeries where successfully completed laparoscopically. Mean age 29.8 years (15-50). Antegrade ejaculation was preserved in 91.6% (22/24) of the patients. Mean surgical time was 122 minutes (90-215). Mean hospital stay was 1.7 days (1-4). Mean number of lymph nodes excised was 13 (5-22). Metastatic lymph node involvement was found in 29% of the patients (7/24). There were no surgical complications.CONCLUSIONS: Laparoscopic approach is as effective as the classic open technique to maintain antegrade ejaculation and subsequent fertility. Additionally, it has low morbidity, the advantages of a minimally invasive approach and oncological outcomes are similar to the classic approach. For these reasons the laparoscopic approach should be the technique of choice for patients in who decision to undergo surgical staging is taken.
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OBJECTIVES: We propose a modification to open nephroureterectomy.METHODS: By a single incision (lumbar incision) a percutaneous ligation-section of the finely dissected terminal ureter is performed.RESULTS/CONCLUSIONS: This technique offers a better quality of life in the immediate postoperative period, shortens the surgical time, and it has the advantage of being oncologically safe, avoiding a double surgery
Case Report
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OBJECTIVE: To describe one case of advanced prostate cancer first presenting with binocular diplopia due to retroorbital metastasis.METHODS: We present the case of a 54-year-old patient with the diagnosis of disseminated prostate cancer treated by complete androgen blockade.RESULTS: After the start of hormonal treatment, the patient initially improved although survival was limited.CONCLUSIONS: Orbital metastasis is an infrequent site for prostate cancer dissemination which implies a limited survival oscillating between 7,5-30 months. In our case survival was 10 months from diagnosis.
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OBJECTIVE: We report two cases of primary testicular lymphoma and performed a bibliography review about this pathology. METHODS/RESULTS: We describe two cases of primary testicular lymphoma in two male patients 69 and 61 yr. old respectively. In both cases, reason for consultation was in- crease of the right testicular size. After inguinal orchyectomy the diagnosis for the first case was large and medium T cell diffuse lymphoma, stage I (E)-A; three years after chemotherapy (R-CHOP) the patient is in complete remission. In the second case, the diagnosis was diffuse large B-cell lymphoma, and after receiving various chemotherapy regimens died 14 months after diagnosis. CONCLUSIONS: Testicular lymphoma is a very rare entity, despite being considered the most common testicular tumor in patients over the age of 60 years. Most of them are non-Hodgkin diffuse, intermediate or high grade of malignancy , B-cell immunophenotype, being T-cell exceptional. Prognosis is poor due to their high tendency to systemic dissemination. The treatment is based on orchiectomy, chemotherapy and radiotherapy, although there is not a standardized regimen
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OBJECTIVE: To report one case of unusual testicular metastasis from a renal origin.METHODS: 57-year-old patient with disseminated right renal cancer under treatment who presented bone metastasis and a painful nodule in the upper pole of the right testicle during his follow-up with medical therapy, making surgery necessary. The pathology result was clear cell adenocarcinoma.RESULTS: Six months later the patient continues under oral Sorafenib without evidence of new metastatic implants.CONCLUSIONS: Testicular secondary metastatic tumors account for less than 1% of old testicular tumors. In patients in the fifth and sixth decades, mainly if they are affected by other neoplasias, testicular masses use to be metastatic implants. The most frequent origin is prostate.
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OBJECTIVE: We report one case of ovarian metastasis secondary to a renal clear cell carcinoma.METHODS/RESULTS: 52-year-old consulting for metrorrhagia with the initial diagnosis of primary ovarian carcinoma. Tumor dissemination work up tests reported a renal mass suggestive of ovarian metastasis. Surgery included hysterectomy, double annexectomy, and radical nephrectomy. Final diagnosis was renal clear cell carcinoma with ovarian metastasis.CONCLUSIONS: Metastases to the ovary pose a diagnostic problem in their interpretation, especially when they show a similar histology to the primary ovarian tumor. Due to therapeutic and prognostic implications, it is very important to differentiate if it is a primary ovarian tumor or a metastasis from a renal carcinoma.
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OBJECTIVE: Differential diagnosis of a testicular mass includes inflammatory conditions,malignant tumors and traumatic lesions, including hematomas and hematocele.METHODS/RESULTS: We report two cases of chronic hematocele. We discuss the clinico-radiologic characterisc and differential diagnosis.CONCLUSION: Hematocele is difficult to diagnose preoperatively because its symptoms may mimic cysts or neoplasms.
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OBJECTIVE: To issue the existence of a va-riety of angiomyolipoma, named epithelioid, with differenthistological and clinic properties.METHODS: We report the case of a 17-year-old female,with Bourneville’s disease, who was discovered to have asolid renal mass suggestive of carcinoma in a control CTscan, adjacent to other smaller masses identified as angio-myolipomas.RESULTS: After several tumorectomies, the suspicious mass,4 cm in size, was diagnosed as epithelioid angiomyolipo-ma, with immunohistochemical confirmation of capacity forHMB45, and negative vimentin and keratin.CONCLUSIONS: Despite the possibility of coexistence ofadenocarcinoma and angiomyolipoma, the existence of anepithelioid variety cannot be discarded, mainly in patientswith phakomatosis. The indications for surgery are the samethan for the rest of renal masses. Nevertheless, follow-upcriteria must be stricter due to the possibility of torpid out-come in terms of dissemination of this infrequent variety ofangiomyolipoma
Case Report
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OBJECTIVE: To report one case of me-lano-ma of the glans penis.METHODS/RESULTS: We present the case of a patientdiagnosed and treated in our department describing diag-nosis and therapeutic management.CONCLUSIONS: Melanoma of the penis is an uncommonpresentation form of this kind of cutaneous tumor. We es-pecially emphasize its diagnosis, clinical presentation andtherapeutic management due to its prompt metastatic disse-mination requiring early diagnosis and treatment
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OBJECTIVE: To present a previously unreported long term complication of percutaneous nephrolithotomy for exclusive renal stone.METHODS/RESULTS: A 30-years-old woman underwentpercutaneous nephrolithotomy for a obsrtuctive pelvic stone, through inferior calix access achieving a stone free status. During the procedure occurred an inadvertent pelvis perforationan, but the early evolution was otherwise uneventful. Patient was asymptomatic during the follow-up. However, a urinary ultrasound disclosed important pielocalyceal dilation, and further investigation demonstrated extensive proximal ureteral stricture. Resumen.- OBJETIVO: Presentar una complicación a largo plazo no comunicada previamente de la nefrolitectomía percutánea en el tratamiento de la litiasis renal única.MÉTODOS/RESULTADOS: Mujer de 30 años con litiasis piélica obstructiva que fue sometida a nefrolitectomía percutánea a través de un acceso por cáliz inferior, consiguiendo la resolución. Durante la intervención hubo una perforación de pelvis inadvertida; la evolución temprana fue, por lo demás, sin complicaciones. La paciente permaneciera sintomática durante el seguimiento. Sin embargo, una ecografía de aparato urinario descubrió una importante dilatación pielocalicial, y las pruebas diagnósticas posteriores demostraron una estenosis ureteral proximal larga.CONCLUSIONES: Las estenosis ureteral pueden aparecer rara vez como complicaciones tardías de la nefrolitectomía percutánea. Realizamos una revisión de la literatura sobre esta complicación tan poco común y discutimos la posible etiología y medidas preventivas.Keywords: Percutaneous nephrolithotomy. Ureteral stricture.Palabras clave: Nefrolitectomía percuténea. Litiasis renal.CONCLUSION: Ureteral stricture may rarely occur as a late complication of percutaneous nephrolithotomy. A review of the literature of this quite uncommon complication was performed and the authors discuss the possible etiology and preventive measures
