OBJECTIVES: It has been demonstrated that abdominal high-pressure and the use of C02 pneumoperitoneum induce changes of the cardiovascular and respiratory systems, attributable to two factors: changes of the cardiac output(CO) and hypercarbia. Other modifications derived from these facts include changes of the systemic vascular resistances (SVR), blood pressure (BP), central venous pressure (CVP), vascular changes like modifications of the renal blood flow (RBF), carotid flow (CF), portal flow, and hepatic artery flow (HAF). Our objective is to analyze the hemodynamic modifications induced by pneumoperitoneum on renal blood flow, carotid flow, portal flow and hepatic artery flow in a porcine experimental model.METHODS: We compared two groups of pigs: CONTROL group (n = 10) and LAPAROSCOPIC group (n = 10), undergoing open or laparoscopic nephrectomy respectively. In every case, catheters were inserted into the right external jugular vein and femoral artery and cardiac output, CVP, blood pressure and systemic vascular resistances (calculated as RVS = (BP/CVP)x 80/CO); these measurements were taken at the following times: baseline, 5, 30, 60 min. and postoperatively. Renal blood flow, carotid flow, portal flow and hepatic artery flow were registered by means of an electromagnetic probe around the vessel 30 minutes after the start of surgery.RESULTS: Comparative analysis shows: an increase of cardiac output in the laparoscopic group, the difference which was maximal at 30 minutes (4.33+ 0.73 vs. 8 .54+ 1.26 l/min., p < 0,001); a descent of the systemic vascular resistances (1118.81+ 302.52 vs. 663.37+ 81.45 dynes .s.cm5, p < 0.001) and an increase of blood pressure (66.5+ 11.52 vs. 80.25+ 2.49 mm Hg in the laparoscopic group. Flow analysis showed an increase of the carotid artery flow (125.73+ 41.69 vs. 291.7+ 51.52 ml/min., p < 0.001) and a decrease of portal flow (973.67+ 131.70 vs. 546.83+ 217.53 ml/min., p = 0.001) and hepatic artery flow (278.00+ 94.71 vs. 133.33+ 112.32 ml/min., p = 0.03) in the laparoscopic group. There were no significant differences in renal blood flow with the volume expansion used.CONCLUSIONS: Laparoscopic nephrectomy conditions an increase of carotid flow, probably secondary to the increase of cardiac output, and also a diminishment of hepatic perfusion, both arterial and portal. Nevertheless, volume expansion and the limitation of intra-abdo minal pressure to 12 mm Hg enable to maintain similar renal blood flow in both groups.
OBJECTIVES: To evaluate the need to perform renal ultrasound (US) in adult patients with acute pyelonephritis (APN). METHODS: A Review of the bibliography in the data bases PubMed and Cochrane Collaboration about the use of the ultrasonography in the evaluation and diagnosis of APN. RESULTS: Thirty-seven papers were found, but only 5 fulﬁlled the requirements for analysis. Four hundred and sixty three patients diagnosed of APN were revised, 449 (97%) of whom got US. Between 171 ultrasonographic ﬁndings, only in 52 (11.5%) cases US ﬁndings changed initial diagnosis to complicated APN that could lead to surgery. CONCLUSION: The low incidence of ultrasonographic ﬁndings does not justify the practice of renal US to every patient with APN. In patients with persistent fever longer than 72 hours, antecedents of anomalies of the urinary tract, antecedents of renal lithiasis, pregnancy, atypical clinic or diabetes mellitus, there is a higher incidence of pathological US ﬁndings that justify a change in the therapeutic approach. Further prospective clinical studies are needed to conﬁrm these conclusions.
OBJECTIVES: To evaluate and review the Fournier´s gangrene clinical presentation, initial APACHE II score and integral treatment of patients affected in HECMNSXXI.METHODS: Retrospective, descriptive and cross-sectional study in 40 patients with Fournier´s gangrene diagnosis, accepted for treatment in HECMNSXXI who gather inclusion criteria, from February 1996 to February 2006. RESULTS: Patients were between 21 and 93 yr old. In total 39 men and 1 woman were recruited. The most common etiologic factor was urethral stricture in 40% of patients. escherichia coli was detected in 42.5 % of the cultures, and represented the most common pathogen. Initial Apache II score was more commonly between 10 and 14 points (35%). 6 patients died (15%) all of them with and Apache II score above 25 points. 55% of patients were affected by diabetes mellitus. All patients with Fournier´s Gangrene received a triple antibiotic schema from admittance day, associated with emergency surgical dèbridement in the whole group. CONCLUSIONS: Aggressive and multidisciplinary treatment is mandatory in all the patients affected by Fournier´s gangrene. We recommend utilisation of the APACHE II score as very useful tool to determine the prognosis.
OBJECTIVES: To describe the incidence of germ cell testicular tumors in our Center, their characteristics and therapy results.METHODS: Retrospective study of 66 cases of germ cell testicular tumors diagnosed in the Health Area of Badajoz between 1993 and 2005.RESULTS: Mean age of the time of diagnosis was 32 years (range 16-80 years), presenting a younger age patients with non seminomatous germ cell tumors (NSGCT) (mean age 30 years). 86.5% of the patients did not have risk factors associated with the diagnosis of germ cell testicular tumor. Testicular mass was the most frequent symptom, and a higher proportion of tumors were located in the left testicle (51.5%). Non seminomatous germ cell tumors were the most frequent histological type (64.8%). Stage I (72%) was the most frequent stage in the group of seminomatous tumors, in comparison with 68.5% of non seminomatous tumors. Stages II-III appeared in 34.4% of the NSGCT and 28% of seminomatous, having worse prognosis.92% of the patients received adjuvant treatment with chemotherapy and/or radiotherapy, and curative surgery was the only treatment in the remainder 8%. Residual mass surgery was undertaken in five patients (stages IIa, IIc and IIIa). Eight of the 66 cases were lost for follow-up. Fifty-three of the 58 patients with follow-up are disease-free, 18 of them with more than five years of follow-up.CONCLUSIONS: An increased incidence of germ cell testicular tumors have been verified over last years, mainly NSGCT. Nevertheless, the diagnosis of advanced stages of the disease has diminished in favour of initial stages, which have a better prognosis for the patient. Oncologycal treatment protocols have high cure rates, although a long-term follow-up is needed due to the natural history of these tumors.
OBJECTIVES: To present to new cases of nephroblastoma or Wilms tumor diagnosed in adult age.METHODS: The first case we report is a 16-year-old female with the diagnosis of stage I nephroblastoma after radical nephrectomy for a right renal mass. She underwent systemic polychemotherapy. The second case is a 33-year-old female with the diagnosis of nephroblastoma after percutaneous biopsy of a right renal mass. Due to the presence of lymph node, hepatic and lung dissemination systemic polychemotherapy (ACTD-VCR-DOX) was given. Right nephrectomy with regional lymph node dissection and hepatic metastasis excision were performed after confirmation of mass reduction. After that, the patient continued receiving systemic polychemotherapy with the same drugs. After resection of a lung nodule which did not disappear, and after confirmation of tumoral presence CB and VP 16 were added.RESULTS: Both patients are disease-free after 58 and 46 months respectively.CONCLUSIONS: This type of tumor typical of childhood is extremely rare in adult age, and despite worse survivals and more aggressiveness are described, they may be treated with the same protocols used in children, following any of the two big co-operative groups: American NWTS or European SIOP.
OBJECTIVES: To evaluate the changes in voiding symptoms in female patients with stress urinary incontinence (SUI) undergoing transvaginal sling techniques over a five-year period in the Department of Urology at the University Hospital of Albacete.METHODS: Between November 2001 and December 2005 126 patients with SUI (mean age 57.09 years; 36-78) underwent transvaginal sling techniques (Sling in Fast, TVT, TOT). All patients were evaluated clinically and urodynamically.RESULTS: Average body mass index (BMI) was 28.14 kg/m2 (SD 4.66; 95% CI: 27.32-28.96). 92 patients (73%) presented between 2-4 previous pregnancies. 99 patients (80.9%) have had birth labour between 2 and 4 times. All of them were vaginal birth labours except 12 cases (9.5%) in which caesarean section had been performed. Daytime voiding frequency after surgery was over 120 minutes in 112 patients (88.9%). Night-time voiding frequency was equal or less than twice in 110 patients (87.3%). 104 patients (82.5%) presented at least two leaking episodes per day, and 105 patients (83.3 %) needed to wear one pad per day or less during the last week before follow-up visit. The number of urinary leak episodes per day diminished in 114 patients (90.5 %) with a mean decrease of 9.65 episodes ( 95 % CI : 8.56-10.79 ) (p <0 . 0001 ) . Ninety-four patients (76.4 % ) were completely dry .CONCLUSIONS : Development of new surgical techniques for the treatment of SUI have improved results and diminished the number of complications , an expression of which is the favourable evolution of voiding changes after surgery .
OBJECTIVES: The association of stress urinary incontinence secondary to urethral hypermobility and lower urinary tract obstruction in the same patient with cystocele is rare, and even represents a contradiction. The objective of our work is to treat to define the characteristics that identify this entity, in comparison with isolated stress urinary incontinence or lower urinary tract obstruction in patients with cystocele.METHODS: We performed a retrospective study in 1168 cases of cystocele in which urodynamic studies were performed. All patients underwent history and neurological and uro-gynecologycal physical examination. The urodynamic study included uroflowmetry, cystomanometry, voiding pressure/flow tests and voiding cystourethrograms. All data were collected in an Excel 2000 database and statistical analysis was performed with the SPSS software. RESULTS: A- General data: 25 cases qualified for the study in group I (isolated stress urinary incontinence with urethral hypermobility); 24 cases in group II (lower urinary tract obstruction); and 14 cases in group III (astress urinary incontinence associated with lower urinary tract obstruction). The proportion of each group in the whole group of cystoceles corresponded to a 4/1/0.05 ratio respectively. Mean age was 58.4 years for group I, 68.2 for group II and 71.2 for group III. A Statistically significant lower age was demonstrated for group I (p < 0.0005). B-The symptom “sensation of vaginal lump” was less frequent in group I (32%). A significant difference was demonstrated (p = 0.02). C- Group I showed a lower increase of daily voiding frequency (32%), p = 0.02. D- Group I showed less night-time voiding frequency (1 episode)(p < 0.04).E-Urinary incontinence with cough was less frequent in group I (84%) (p = 0.0004). F- Group I had more bladder capacity (243.6 ml) (p < 0.05).G-Group I showed less urethral resistances (URA = 37.9 cm H2O) (p = 0.01). H- W80-W20 was higher in group I: 1.3 W/m2 (p < 0.05). I-The symptom “sensation of vaginal lump appeared more often in group II (70.8%) (p = 0.02). J-Radiological degree of cystocele was greater in group II (1.7) (p< 0.05). K- Detrusor hyperactivity was more frequent in group III (64.3%) (p = 0.00009). L- No significant differences were found between groups II-III when comparing type of obstruction. CONCLUSIONS: The group of isolated stress urinary incontinence (group I) is characterized by a younger age, less frequency of sensation of vaginal lump, less daily frequency and nocturia, and urodynamic data of greater bladder capacity, lower urethral resistance and normal detrusor contractility. The group of isolated lower urinary tract obstruction (group II) could be characterized by a more frequent sensation of vaginal lump and increase of the radiological cystocele. The group of stress urinary incontinence associated with lower urinary tract obstruction had a higher percentage of cases of detrusor hyperactivity. All these data might enable a proper identification of different risk elements in the groups.
OBJECTIVES: To share our experienceperforming laparoscopic pyeloplasty and our contribu-tions to this surgery.METHODS: Between March 2004 and January 2006we have performed 12 laparoscopic pyeloplasties in12 patients. We modified our technique as we founddifficulties during operations. By the only modificationof patient position we have achieved a significant im-prove in our technique.RESULTS: We describe how we performed the operationin the first cases and how we do it today, with the newposition. We also describe the advantages observed.CONCLUSIONS: With our technique we achieve animportant surgical time reduction, improvements in safetyand reduction of surgical complications
OBJECTIVE: To report the case of a patient with the diagnosis of locally advanced renal carcinoma.METHODS: We present in the case in a clear and well illustrated way (pictures). We report the case of a female patient with a very big renal carcinoma, with local extension, who underwent nephrectomy through a lumbar approach and received chemotherapy and immunotherapy.RESULTS: Despite radical surgery, chemotherapy and immunotherapy the tumor had rapid evolution locally and systemically, as a demonstration of its high aggressiveness.CONCLUSIONS: Renal carcinoma is considered the tumor with a high tendency to have metastases. The prognosis depends on size, stage and grade, determining factors for patient survival. Although there are new therapeutic options (immunologic), surgery continues being the main therapeutic tool. Continuous regular follow-up enable us detection and timely treatment of any event (local or systemic recurrence).
OBJECTIVE: To present a case of infantile myofibromatosis of visceral location and a review of the literature.METHOD/RESULTS: We report the case of an 11-year-old Caucasian girl hospitalized for abdominal tumorous mass, weight loss and lack of appetite. Physical examination showed: cutaneous-mucous paleness and a painless, palpable tumorous mass of 8-10cm in the right abdominal flank, of firm consistency with defined edges and extending past the midline. Blood test showed hemoglobin 90 mg/l and erythrocyte sedimentation rate of 130 mm/hour. Chest x-ray and bone study were normal, while abdominal x-ray showed intratumorous calcification, intravenous urographyc showed light displace downwards and outwards of the right kidney. Ultrasound showed a solid echogenic mass with a diameter of 11cm in the right abdominal flank, above and extending towards the lower portion of the right kidney. Surgical treatment for possible neuroblastoma was initiated, during which various tumorous growths were observed in the mesocolon, the largest measuring 7cm, which were removed. Macroscopic examination showed whitish well-defined tumorous growths of firm consistency, with focal calcifications. Microscopic examination showed a proliferation of fibroblastic type cells, with some areas having smooth muscle cell characteristics. Diagnosis was myofibromatosis.CONCLUSIONS: Infantile myofibromatosis is the most common fibrous disorder of infancy and childhood, more commonly found between birth and two years of age, may also appear later in life. Etiology is unclear, but certain studies report estrogen involvement in its pathogenesis. Clinical symptoms depend on the location and extension of the lesion and age at presentation. Spontaneous relapse may occur. Prognosis is good in the absence of visceral damage, although generalized congenital myofibromatosis with visceral damage is associated with high mortality, especially in the first months of life, due to its destructive capacity, obstruction of vital organs, growth inhibition or infection. Urologic concerns include possible infiltration of genito-urinary organs (kidney, corpus spongiosum) and its association with urologic abnormalities. Ultrastructural and immunohistochemical studies show that the tumor is composed of myofibroblasts, with estrogen receptors, displaying vimentin and smooth muscle actin immunoreactivity.Strict follow up is recommended in patients with congenital myofibromatosis to avoid or detect possible complications that may be life-threatening (Bone survey, abdominal-pelvic ultrasound, echocardiogram, chest-abdominal CT and biopsy). The treatment of choice is surgical removal, with extensive excision to avoid possible relapse
OBJECTIVE: To report one case of late metastasis of a clear cell carcinoma treated by radical surgery. METHODS/RESULTS: Patient with history of radical nephrectomy and lymphadenectomy six years before presenting with regional lymph node metastasis in a follow-up diagnostic test. After treatment with immunotherapy, stopped because of intolerance, surgery of the metastatic lymph node mass was decided. CONCLUSIONS: Renal cancer is an unpredictable tumor in terms of oncological behaviour, so that it may metastasize any time in its evolution, even after radical surgery and several years free of disease. Surgery for the metastases of renal cancer is a good therapeutic option, with good long-term results, when they are isolated and accessible to surgery.
OBJECTIVE: To report one case of intratesticular varicocele, infrequent pathology (2% of the cases), with a series of ultrasound peculiarities: testicular atrophy and associated parenchymal abnormalities, in a 24-year-old patient with left testicular pain.METHODS: Ultrasound showed severe left varicocele, mixed type, with the regular extratesticular component and dilated subcapsular and mediastinum vessels, with turbulent flows increasing with Valsalva’s manoeuvre, as well as an alteration of the ultrasound pattern of the parenchyma, with hypoechoic and hypovascular areas and diminished testicular size.DISCUSSION/CONCLUSIONS: Intratesticular varicocele is a rare pathology more frequent in the left testicle, which is frequently associated with extratesticular varicocele. The presence of testicular atrophy and associated parenchymal abnormalities has been rarely described in the literature. Clinically they show features overlapping the extratesticular types.
OBJECTIVE: To describe the ultrasound characteristics, vascularization pattern (colour Doppler ultrasound) and possible histogenesis of one case of synchronic uniesticular seminoma and teratocarcinoma as independent tumor nodules, histologically different, in a 19-year-old patient with testicular mass for eight months.METHODS: Conventional ultrasound, colour Doppler ultrasound, and high resolution Doppler angiogram were performed, analyzing vascular flows. After resection of the tumor, macroscopic and histological sections were related with ultrasound images.RESULTS: The patient showed three independent, well limited, tumoral nodules in the right testicle: two of them heterogeneous, 20 and 33 mm in diameter, with cystic areas and calcifications. The third nodule was solid, hypoechoic and homogeneous, 26 mm in diameter. All nodules presented an increase in vascularization with low resistance arterial flows. Histologically the first two nodules were teratocarcinomas (predominantly mature teratoma and embryonal carcinoma) and the third classic seminoma.CONCLUSIONS: Although seminoma and mixed germ cell tumors are common, their presentation in the same testicle as independent nodules with different histologies is a rarely referred case in the literature, which allows us to apply a histogenetic and ultrasound-pathologic correlation model in seminomatous and nonseminomatous tumors. The presence of cystic cavities and gross calcifications is highly correlated with teratoma. In our case there are not significant differences in the vascularization pattern with Doppler ultrasound
OBJECTIVE: To present and analyze one case of sacral agenesis with distal lumbar vertebral dysraphism, and to highlight the most relevant elements found in a bibliographic search.METHODS: We describe the clinical characteristics of an adult patient with sacral agenesis, the diagnostic-therapeutic urological management and her outcome over four years of follow-up. A bibliographic search was also performed including review of all articles published over the last 16 years; we briefly include the most relevant elements.CONCLUSIONS: Sacral agenesis, as a local regional expression of “caudal regression syndrome” almost invariably produces functional involvement of the bladder and recurrent urinary tract infection, although the evolution may be benign like present case. This does not exempt from the unavoidable need of proper initial morphological-functional diagnosis, periodic follow-up and treatment.
OBJECTIVE: Congenital arteriovenous fistulas are an exceptional clinical feature. Although they are frequently asymptomatic, their presentation as severe hematuria pose an excellent diagnostic exercise and often immediate therapeutic action.METHODS/RESULTS: We report the case of a 75-year-old female patient presenting with severe hematuria producing anaemia, high blood pressure and congestive heart failure. Image tests revealed right ureteral-hydronephrosis with bladder blockage by blood clots. The endoscopic study (cystoscopy and ureterorenoscopy) alerted about the origin of the hematuria from the right kidney, finally requiring nephrectomy as definitive treatment. Pathology revealed the presence of a round formation with multiple vascular channels, arterial and venous, in the pyelocalicial submucosa, with focal epithelial erosion, compatible with congenital arteriovenous fistula. We review the diagnostic and therapeutic features in the literature.CONCLUSIONS: Renal congenital arteriovenous fistulas represent a diagnostic dilemma. They may present asymptomatic or condition clinical features derived from the shunt and high cardiac output (hypertensive cardiopathy and congestive heart failure) or from the erosion and acute hemorrhage into the urinary tract (severe renal hematuria). Treatment should be conservative with embolization or supraselective sclerosis. Nevertheless, in cases of big fistulas, post embolization revascularization, or hemodynamic instability nephrectomy is an excellent option.
OBJECTIVE: To state the scarce incidence of this prostatic pathology and the relative confusion with terminology applied to the presence of intraprostatic melanin pigments.METHODS/RESULTS: 66-year-old patient with elevated serum PSA with the diagnosis of prostatic blue nevus after biopsy.CONCLUSIONS: This diagnostic finding has not clinical or prognostic significance. They are benign lesions that must not be confused with other similar more aggressive lesions.
OBJETIVE: Anomalies of the urachal remnant are rare. Urachal cysts are usually asymptomatic, however, when they become infected, they can mimic a wide variety of intra-abdominal pathologies. We present two patients in which an urachal cyst was found.METHODS: Two male patients 25 and 38 years old respectively underwent laparoscopic resection of an urachal remnant. In one of the cases the urachal remnant was complicated by infection. Opportune clinical and radiologic diagnose was made in both cases and complete excision of the urachal remnant was carried out by laparoscopic means.RESULTS: The procedures were performed without complications and follow up showed excellent results. Both patients presented very short convalescence with rapid recovery. CONCLUSIONS: The treatment of choice for urachal pathology is the complete excision of the complicated lesion. For this matter laparoscopic surgery assures surgical results comparable to conventional surgery adding the advantages of a minimally invasive approach.