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Mujer de 31 años, gestante de 25 semanas, que consulta en el servicio de Urgencias de nuestro centro, por presentar cuadro de crisis renoureteral derecha de 3 días de evolución que no cede con la administración oral de paracetamol.
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OBJECTIVES: The objectives of this work are two: first, to evaluate the resistance of Escherichia coli to several antibiotics and their trends over a six-year period in strands isolated in urine samples from patients receiving health-care in general practitioner offices in our environment; and second, to evaluate if empirical treatment regimens commonly accepted in our country would be applicable in our environment depending on the results of this study.METHODS: We analyzed the urine cultures positive for Escherichia coli obtained from samples collected at the 10 primary health care centers of the health-care area of El Bierzo and Laciana (Leon, Spain) between the years 2002 and 2007. In vitro resistances of these germs to several common use antibiotics were determined: fosfomycin, nitrofurantoin, tobramycin, cefuroxime, cefixime, amoxicillin-clavulanic acid, cotrimoxazole, ciprofloxacin, norfloxacin, and ampicillin. The existence of statistically significant (p<0.05) differences in sensitivity, comparing the years 2002 and 2007, including all antimicrobials except cefixime, was analyzed by the chi-square test. For cefixime we compared the results between 2002 and 2005.RESULTS: An increase of the resistance of Escherichia coli isolated in urine to all antimicrobials under study has occurred, except for nitrofurantoin, being the differences statistically significant in most cases. Nevertheless, resistances to fosfomycin and nitrofurantoin have remained below 6% throughout the study period. Resistances to tobramycin and cefuroxime were slightly over 10% and cefixime below 3.4%, although in the last one we only have data until 2005. Resistances to amoxicillin-clavulanic acid, initially low, have progressively increase reaching 20.6% in 2007. The same has happened for cotrimoxazole, ciprofloxacin, norfloxacin and ampicillin, passing 32% in 2007 in the first three cases and 62% in the last one.CONCLUSIONS: Variations in bacterial resistance patterns for Escherichia coli obliges to have an updated knowledge of them to adapt general empirical treatment uses to each specific health-care area.
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OBJECTIVES: The presence of intravesical foreign bodies is exceptional; it is not a common emergency. Most foreign bodies have a sexual-erotic origin, although we cannot forget others such as elements left by the surgeon in the surgical field. We performed a bibliographic review on the topic.METHODS: We performed a PubMed (MEDLINE) electronic bibliographic search with the mesh terms “foreign-body migration” [MESH] AND “Urinary Bladder” [MESH] and bibliographic citations. We performed a bibliographic review establishing a classification depending on the origin and diagnosis, as well as treatment.Most publications are case reports. We described the most frequent presentation which was the same than we have in our Center.RESULTS: We found a total of 122 works, nine of which were reviews; we selected 20 works. Although most are case reports, the reviews establish a classification depending on the origin: so, they refer to those foreign bodies directly introduced into the bladder: 1. By the patient: hairpins, safety pins, pencils, copper wires, hairs; 2. Accidentally: bullets; 3. Iatrogenic: fragments of bladder or ureteral catheters, staples, sutures. Foreign bodies migrated from other places: urological, gynecological, gastrointestinal, or vascular origin. We established a diagnostic and therapeutic algorithm.CONCLUSIONS: Bladder foreign bodies are not as frequent as it is believed. Most are found incidentally. Lower urinary tract symptoms are the most frequent, as the antecedent of manipulation by the patient or others in the genital-urologic sphere. The treatment of choice is extraction using the least invasive and most simple method for the patient.
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OBJECTIVES: Proper treatment of neurogenic hyperactive detrusor muscle is responsible for several features essential for life such as renal function, and quality of life relevant issues such as urinary incontinence. Anticholinergic drugs allow treatment in most cases, but their failure in cases of refractory neurogenic hyperactive detrusor is a challenge. To evaluate the efficacy of detrusor injection of type A botulin toxin in patients with refractory neurogenic hyperactive detrusor, on the following urodynamic parameters: maximum cystoma- nometric capacity, detrusor compliance, reflex volume, maximum detrusor pressure and post void residual. METHODS: Prospective study in 16 patients with the diagnosis of neurogenic hyperactive detrusor refractory to anticholinergic therapy. Urodynamic studies were performed 30 and 60 days before the procedure and after at least two weeks from stopping anticholinergic therapy. 300 units of type A botulin toxin (BTX-A) were endoscopically injected in 30 punction sites, 10 units per ml each punction. Urodynamic control was performed 30 to 45 days after injection. RESULTS: Six of the 16 patients in the study where females and 11 males; mean age was 39.5 years (22 to 63 years). Urodynamic results: mean maximum capacity on cystomanometry before BTX A was 204.73 ml and after BTX-A 381.87 ml. Maximum detrusor capacity before was 91.46 H2O cm whereas post-treatment was 41.2 H2O cm. Mean final filling pressure was 68 H2O cm before treatment and 34 H2O cm after. Mean reflex volume was 111.33 ml before and 310.8 ml after. Finally, mean post void residual before BTX-A was 129.6 ml whereas post-BTX-A was 345.9 ml. CONCLUSIONS: The injection of 300 U of type A botulin toxin in the detrusor muscle has demonstrated to be effective and safe for the treatment of refractory neurogenic hyperactive detrusor. There were statistically significant differences in the urodynamic parameters before and after the injection. There were no significant adverse events.
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OBJECTIVES: Urinary incontinence is one of the main complications after radical prostatectomy (RP). Preoperative kinetic physiotherapy could be useful as a preventive treatment of these complication. The objective of this work is to demonstrate the usefulness of preoperative perineal kinetic physiotherapy for early recovery of urinary continence after radical prostatec-tomy.METHODS: Randomized controlled clinical trial. 38 patients were divided into groups of 19 before radical prostatectomy. The first group (K) received preoperative kinesic treatment whereas the second group (NK) did not (control group). Urinary continence was evaluated at 14, 30 and 60 days after catheter retrieval.RESULTS: There were not epidemiological or tumor bio-logy differences between groups. The percentages of continent patients in group K at 14,30 and 60 days were 47.36%, 47.36% and 78.9% respectively, whe-reas in the NK group where 47.36%, 47.36%, and 89.4% respectively (p > 0.05).CONCLUSIONS: Kinesic perineal exercises before ra-dical prostatectomy did not diminish the times of urinary continence recovery or its appearance.
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OBJECTIVES: The objective of this workis to analyze the treatment of staghorn calculi at ourDepartment of Urology. We have to know the recentdevelopment of endoscopic surgery (percutaneous renalsurgery) and external shock wave lithotripsy.METHODS: We reviewed the surgical management ofstaghorn calculi during the period between 1987 and2004.RESULTS: Percutaneous renal surgery was performedsuccessfully in 24.1% of the cases. Persisting residualfragments appeared in 75.9% and were treated byESWL or second endosco-pic surgery.CONCLUSIONS: Percutaneous renal surgery may beconsidered the technique of choice to treat staghorncalculi. Endoscopic surgery has good results and littlecomplications with low morbidity. In other cases thetreatment is combined therapy, percutaneous renal sur-gery and ESWL
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OBJECTIVES: Comprehensive evaluationof surgical procedures remains the cornerstone of qualitycontrol. Robotic surgery has become a popular surgicaloption in urology. We review the English medical li-te-rature on urological robot-assisted endoscopic surgery(URAES) in order to assess the trends of medical publica-tions regarding this subject METHODS: All Studies addressing URAES were inclu-ded. Information for this review was obtained by PubMed searches from 2003 to 2008. Keywords used inour search included: “robotic urologic surgery”, “roboticassisted urological surgery”. Only articles published inEnglish were included in this review.RESULTS: We identified 383 studies. 366 articles corres-ponded to clinical series of different to-pics regarding ro-botics in urology; 13 articles presen-ted comparisons ofrobotic surgery versus either pure laparoscopic or opensurgery in urological procedures such as radical cistec-tomy (1), radical prostatectomy (10) and pyeloplasty(2). Four studies corresponded to randomized controltrials, addressing robotic teleroun-ding (2), kidney per-cutaneous access (1) and camera holding devices forendoscopic surgery (1).CONCLUSIONS: URAES is an emerging surgical op-tion for urological operations like radical prostatectomy,pyeloplasty and radical cystectomy. There is lack of high-level evidence information to support the idea of roboticsurgery as the upcoming surgical gold standard in uro-logy. Surgical evolution will favour the potential benefitsof robotic technology, but there is need for design andperformance of prospective randomized trials in roboticurologic surgery in order to consolidate the applicationof this novel technology
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OBJECTIVES: We performed a study including 120 patients with the diagnosis of varicocele (testicular Doppler ultrasound), from June 2004 to July 2006, analyzing the following variables: surgical time, hospital stay, postoperative analgesic requirements, complications and return to social-working activities.RESULTS: 120 patients between 18 and 42 years of age underwent surgery. Mean surgical time was 25.07 minutes. A minority of the patients were discharged the following day (difficulties with transportation), the rest were treated as outpatient. Almost no postoperative analgesic drugs were employed, only three patients required pain treatment. Only three minor complications appeared during or after surgery. All patients had a fast recovery back to their social-working activities (between 15 and 21 days).CONCLUSIONS: We consider laparoscopic ligation of spermatic veins may be considered an effective method for the treatment of patients with varicocele. It is the treatment of choice for bilateral varicocele, obese patients, after the failure of conventional techniques, in patients with history of inguinal surgery, and when simultaneous laparoscopic treatment of other pathologies is necessary. We also emphasize the importance it plays as training in the learning curve for the development of this technique.
Case Report
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OBJECTIVE: Primary renal neuroendocrine tumor (NET) is a very rare neoplasia with a higher frequency of appearance in horseshoe kidney (HK). From 1966, when Resnick published the first case, approximately 2 of each 10 new cases appear in kidneys with this malformation. From the diagnosis of a case of primary NET in a HK, we calculated the relative risk of their presentation as associated entities.METHODS: 63-year-old male with the incidental diagnosis of an 8 cm solid renal mass in the isthmus of a HK. At the time of diagnosis there were no signs of local-regional extension of the primary neoplasia neither metastasis. The patient underwent nephrectomy and pathologic study confirmed the diagnosis of NET. After a systematic review using multiple search platforms (Blackwell, Ovid, Proquest, PubMed, Science Direct, and Wiley) our case is No. 11 of NET in HK from a total of 57 renal NET.RESULTS: Despite its very low frequency, 19.3% of NET present in HK. Using 1/400 as the incidence of HK in general population, the calculated relative risk in HK is 77 times greater than that of a normal kidney.CONCLUSIONS: The relative risk of presentation of NET in HK is enormously superior than that of general population.This diagnosis must be suspected in patients with HK, mainly if the tumor is located in the renal isthmus. Due to its potentially aggressive clinical course and poor response to other therapies, measures for improvement of surgical treatment must be considered priority
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OBJECTIVE: To show the clinical management of rhabdomyolysis secondary to laparoscopic surgery and how clinical treatment may be enough for adequate resolution.METHODS: Laparoscopic nephrectomy is a routine technique, which may have associated morbidity. We present one case of rhabdomyolysis which presented as gluteal pain and functional impotency, together with skin lesions, acute renal failure and elevated muscle enzymes.RESULTS: In our case, the patient had a satisfactory outcome with medical treatment. We perform a bibliographic review in which we identify multiple risk factors, such as body mass index, surgical time, position during operation with lateral decubitus and 40-60º flexion. Prevention is the most important factor to avoid acute renal failure secondary to myoglobin.CONCLUSIONS: Prevention, early detection, and immediate start of therapeutic measures are essential for the good resolution of rhabdomyolysis after surgery.
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OBJECTIVE: We report one case of gonadal stromal testicular tumor and perform a bibliographic review.METHODS/RESULTS: We present the case of a 42-year-old male patient consulting for a painless right testicular mass. Orchiectomy was performed and the patient underwent follow-up.CONCLUSIONS:Nonspecific sexual cord tumors are extremelyrare, with slow growing and benign behaviour, presentingpositive staining for various markers.
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OBJECTIVE: Primary bladder adenocarcino-ma is a rare entity. We performed a review of the literatureon this subject and present a clinical case.METHOD/RESULTS: A 74 year old female patient presentsto the emergency department with complaints of gross he-matúria not accompanied by lower urinary tract symptoms.Diagnostic work-up included renal and bladder ultrasound,cistoscopy and abdomino-pelvic C.T. scan. Metastatic disea-se was excluded. Trans-urethral resection revealed an invasi-ve adenocarcinoma. A gynaecologic origin was excludedby further gynaecologic examination and an anterior pelvicexanteration was performed. The bladder specimen showedprimary bladder adenocarcinoma, pT3aN0. At 6 months offollow-up, the patient does not present disease progressionor surgical complications.CONCLUSION: Primary bladder adenocarcinoma is rare.Unlike urothelial carcinoma, it responds poorly to chemo-therapy or radiotherapy. Radical Cistectomy offer the bestchance of long-term survival
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OBJECTIVE: Adenomatoid tumor of the epididymis is unfrequent, benign, with no malignant outcomes described.METHODS: We report five cases, with patient’s ages varying from 31 to 76 years, and tumor sizes from 6 to 30 mm. All patients underwent surgery with excision of the mass, some of them after several months of growing. In one of the cases the evolution reached six years.RESULTS: None of the cases presented recurrence or bad outcome after surgery. Pathology confirmed the benign adenomatoid character in all cases.CONCLUSIONS: Despite the clinical, ultrasound and physical examination findings suggest the localization in the epididymis and its benign character, surgical exploration is mandatory with surgical excision of the paratesticular mass.
Case Report
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OBJECTIVE: We report a new case of Sertoli cell testicular tumor with malignant characteristics.METHODS: 77-year-old male patient, suffering a general wasting syndrome presenting with a left solid testicular mass with the diagnosis of malignant Sertoli cell tumor after or-chyectomy, without local, regional or distant dissemination, and a benign outcome after 18 months of follow-up.RESULTS: Sertoli cell tumor or androblastoma is classified as non-germ cell tumor derived from the stroma of the sexual cords. There are three types depending on its cellular com-position: calcified big cell, sclerotic cell, and the most fre-quent of all, the classic type.CONCLUSIONS: Being the Sertoli cell testicular tumor rare, its malignant type is even rarer, accounting for not more than 10% of all. Despite the pathological characteristics related to malignancy, its posterior behaviour is unpredictable and not much known, the same than follow-up and treatment, because it is not sensible to cytostatic drugs. The existence of metastases continues to be the only valid parameter with prognostic value.
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OBJECTIVE: Two cases of Mondor’s disease and one case of non-venereal sclerosing lymphangitis of the penis are reviewed. We analyze the differences between both processes based on the existing literature about these pathologies. METHOD: Two clinical cases of Mondor’s disease and other one with non-venereal sclerosing lymphangitis are reported. RESULTS: Due to the spontaneous and good outcome of both pathologies, the diagnosis and follow-up are difficult in both processes. CONCLUSIONS: Doppler ultrasound has a great importance for the differential diagnosis between both processes. The treatment is based on steroidal anti-inflammatories as well as sexual abstinence.
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OBJECTIVE: To evaluate patients’ perception of pain and discomfort during DRE, the impact of discomfort on potential future screening compliance, and if emptying the bladder immediately before DRE reduces patient discomfort.METHODS: One-hundred patients undergoing DRE for prostate cancer screening answered an anonymous questionnaire regarding pain, urinary urgency and bowel urgency during DRE and its potential impact on future examination. Another group with 100 patients was randomized in two subgroups to analyze if urinating immediately before DRE reduces patient discomfort.RESULTS: Seventy-three (73%) patients reported moderate or higher discomfort for at least one of the domains evaluated: 61% complained of pain; 22% of urinary urgency; and 22% of bowel urgency. Emptying the bladder immediately before examination did not reduce pain (58% vs. 50%, p = 0.115), urinary urgency (22% vs. 16%, p = 0.151), or bowel urgency intensity (16% vs. 14%, p = 0.264). There was no difference in the number of patients that answered they will repeat the prostate exam next year (96% vs. 90%, p = 0.211) or in those that would encourage a friend that needs the prostate exam to do it (96% vs. 98%, p = 0.378).CONCLUSIONS: Pain and discomfort during DRE are not negligible but they do not affect intention to have a prostate exam in the future. Urinating immediately before examination does not significantly reduce the incidence of pain, urinary urgency, or bowel urgency during DRE.
