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OBJECTIVES: In the middle of the 20th century, Urology in Valencia was fully consolidated as a surgical speciality since Prof. Molla started it about the end of the 19th century; Dr. Felipe Alcala Santaella Nuñez stands out as the chairman of the Department of Urology of the “Hospital Provincial de Valencia”, after his father Dr.Rafael Alcalá Santaella. He achieved to form a group of renowned professionals, some of which still are in active practice.METHODS: We reviewed all his scientific work and the journals it was published in, mainly Archivos Españoles de Urología, through the Department of Medical History of the University of Valencia. His biography was recons-tructed using the “Biographic and Bibliographic History of Spanish Urology” by Drs. E. Maganto Pavón and M. Pérez Albacete, as well as direct interviews with family members.DISCUSSION: We emphasize the magnificent approach to the clinical presentations of tuberculosis he does in his doctoral thesis, analyzing its types by location, main features, and most adequate treatment. He also emphasized the importance of relapse in lithiasic patients and recommendations to be follow, as well as the condition of bladder neoplasias.CONCLUSIONS: We consider Dr.Felipe Alcalá Santae-lla Nuñez as a wide-experience-professional who made solid contributions to the regional urology in his times, thanks to his excellent surgical abilities and dedication.
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OBJECTIVE: To determine the incidence of congenital anomalies of the urinary tract in Colombia and study their association with maternal risk factors.METHODS: We performed a register based, case control study using the data from the ECLAMC (Colaborative Latinoamerican Study for Congenital Malformations) in Colombia, between June, 2001 and December, 2004. Positive Registries for any urological anomaly were selected. Calculations for the incidence of each abnormality were done. Odds ratio were estimated for 11 maternal variables.RESULTS: 83 positive registries were found. The established incidence was 0,43%. These anomalies accounted for 9,4% of the total of malformations. The obtained rate (x 10.000 births) for each anomaly was: hypospadias 17,7; chryptorchidism 13,3; hydronephrosis 2,6; cystic renal disease 2,6; undeterminate sex 2,6; unilateral renal agenesis 1,3; micropenis 1,9; bilateral renal agenesis 0,7; patent urachus 0,3. The risk for renal defects increased with preterm birth, odds ratio OR= 3,66; 95% IC [1,13-13,82] and maternal chronic disease OR= 6,18; 95% CI [1,09-34,98]. A determi-nistic association was found with consanguinity between the parents. The positive associations for genital defects were: low birth weight OR= 4,07; 95% CI [2,00-8,25], preterm birth OR= 3,80; 95% CI [1,87-7,72], presence of malformated individuals in the family OR= 2,30; 95% CI [1,02-5,25], and smoking during pregnancy OR= 5,36; IC [1,01-28,51]. A deterministic association was found with alcohol ingestion during pregnancy.CONCLUSIONS: The prevalence of anomalies of the urinary tract in Colombia is considerably lower in com-parison with european and northamerican statistics. The birth weight is the most important risk factor for anomalies like hypospadias and chriptorchidism. Consanguinity between the parents and alcohol ingestion during the pregnancy are determinant on the risk for renal and genital anomalies, respectively. Variables like smoking during pregnancy and chronic maternal disease must be deeply explored in the future to determine their role in the etiology of these defects.
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OBJECTIVES: The number of biopsy samples for a proper prostate cancer diagnosis has not yet been established. We report our experience with the10-sample extended biopsy.METHODS: We collected the results of a group of 222 patients undergoing extended ultrasound guided prostate biopsy with 10 samples. In addition to the sextant biopsies 2 extra samples were obtained from the dorsal-apex area on each lobe. Results of this group were compared with a control group of 552 patients undergoing sextant biopsy in 2002 with the same inclusion in criteria.RESULTS: 60 patients had cancer (27.15%). The extra samples gave the diagnosis in 5 out of 60 patients, 8.33% of the tumors and 2.25% of all patients. Control group showed cancer in 24.5%, not having the difference statistical significance. The incidence in prostates smaller than 20 cc was 69.2%, 11.6% in prostates bigger than 50 cc. 80% of the patients with prostate cancer only in the extra samples have a volume smaller than 35 cc. Multivariate logistic regression study for the probability of prostate cancer only showed association with serum PSA and prostate volume but not with the number of samples.CONCLUSIONS: The extended biopsy is not indicated as an initial diagnostic technique, being reserved for specific cases such as repeated biopsies in patients with high risk pathology reports. Neither it is indicated in the bigger volume prostates.
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OBJECTIVES: Experimental data show the relationship between the area of injured urothelium and recurrence rates in superficial bladder cancer. Tumor cell adherence is increased by the exposure to the extracellularmatrix (ECM). Transurethral resection uncovers the ECM and might lead to recurrent tumors. The question ifrecurrences are increased by enlarged urothelium resectionareas is difficult to answer because there will be noprospective studies available. We investigated if deeperand larger urothelial injuries, which are caused by differentiated resections lead to higher recurrence and progression rates than regular resections of bladdertumors.METHODS:163 patients with superficial bladder cancerwere retrospectively evaluated. Sixty-six received a differentiated resection and 97 a regular one. We analyzed the recurrence and progression rates over a minimum of 48 months as well as tumor persistence in the second resection.RESULTS: Patients with differentiated resections of bladder tumors were found to have no higher incidence of tumor recurrence and progression but showed a significantly higher percentage of tumor free second resections.CONCLUSIONS: As a model of enlarged urotheliallesions the differentiated resection technique for superficialbladder cancer has no negative influence on recurrence or progression rates. It seems unlikely that the extracellularmatrix uncovered by resection is the main reason for the high recurrence rates. The significantly lower incidence of tumor persistence in the second resection favors the differentiated resection technique in the transurethral treatment.
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OBJECTIVES: To establish the prevalence of incidental prostate cancer after transrectal ultrasound guided prostatic biopsy and subsequent suprapubic prostatic adenomectomy and to compare it with a similar group of patients who did not underwent biopsy before surgery. To evaluate treatment, outcomes, and disease progression in patients with incidental prostate cancer.METHODS: Retrospective study of 549 suprapubicadenomectomy performed between 1996-2001 (6 yr.), comparing the group of patients with biopsies before surgery vs. the group of patients without biopsies.RESULTS: 291 (53%) patients did not undergo biopsy before adenomectomy. 258 (47%) underwent biopsies. 25 incidental prostate cancers were detected, 19 (76%) in the group of no biopsy and 6 (24%) in the biopsy group. 88% pT1a and 12%pT1b. Mean Gleason score 4.5 (3-7). 84% of the patients did not receive treatment (21) (“wait and see”); 8% (2) androgen blockade; 8% (2) finasteride (2). Three patients (12%) in the group of no biopsy had disease progression. Mean follow-up was 48.1 months (22-96). No case of cancer-specific mortality was detected.CONCLUSIONS: Global prevalence of incidental prostate cancer in our series of patients undergoing suprapubic prostatic adenomectomy was 4.55%. Prevalence was higher in the group of patients without previous biopsy (3.46%) than in the biopsy group (1.09%). Tumorprogression was 12% and cancer specific survival 100% after a mean follow-up of 48.1 months (22-92).Previous prostatic biopsy in patients with suspicionsdigital rectal examination or elevated PSA diminishes the prevalence of incidental prostate cancer. Watchful waiting may be a valid option in some cases.
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OBJECTIVES: To evaluate the toxicity and outcomes of the allogeneic transplantation of peripheral blood hematopoietic stem-cells with low intensityconditioning (mini-alo Bone Marrow transplantationBMT) in metastatic renal cell carcinoma refractory to at least one line of systemic treatment.METHODS: From 30 patients submitted to the Sant Pau`s Hospital for immunotherapy between 1/2001 and 1/2003, six patients finally underwent mini-alo BMT within a clinical trial. Conditioning: Fludarabine: 30 minute IV infusion of 13 mg/m2 on days - 9, - 8, - 7, - 6 and - 5. Busulfan: 1 mg/kg (real weight) q 6 hours, PO on days - 6, -5, and - 4 (4 doses per day on days - 6 and - 5, and 2 doses only on day - 4, total number of doses 10).RESULTS: Two patients achieved partial response, one patient stabilized disease, and two patients hadprogression on days + 30 and + 60. Therefore, 2/3 patients surviving more than six months achieved partial response. One patient died on day + 30 after acute hepatic graft-versus-host disease. Complete chimerism was demonstrated in all patients.CONCLUSIONS: The mimni-alo BMT is feasible inpatients with metastatic renal cell carcinoma and providesobjective responses, although its efficacy should beconfirmed by phase III clinical trials.
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OBJECTIVES: The excision of the adrenal gland by laparoscopic approach is the gold standard for the treatment of adrenal tumors smaller than 6 cm. Most Brazilian centres favour the transperitoneal approach. The objective of the present prospective study was to show the intraoperative and postoperative results ofpatients undergoing adrenal laparoscopic surgery through a lateral retroperitoneal approach performed by an individual surgeon.METHODS: Between January 2000 and October 2004, 35 patients (16 males and 19 females) with adrenal lesions, including 4 Cushing’s syndrome, 4 Conn’s syndrome, 1 neuroganglioma, 4 pheochromocytoma,17 nonfunctioning adenomas,1 virilizing tumor, and 4cases of adrenal nodule after treatment of a non-adrenal primary neoplasia, prospectively underwent retroperitoneoscopic adenomectomy by one surgeon. We describesurgical times, estimated blood losses, time to oral intake,analgesic requirements, surgical complications andconversion rates, hospital stay and time to return to usual activities, comparing our results with other series in the literature.RESULTS: All procedures were successfully completed. Mean surgical time was 135 minutes, mean estimated blood loss 235 ml, mean time to oral intake 12 hours, no patient required analgesics after the second postoperativeday, mean hospital stay was 2 days, and mean time to return to usual life activities 3 weeks. There were two complications, one case of intraoperative hypercapnia and one case with postoperative pneumonia. Conversionto open surgery was not required in any case.CONCLUSIONS: Retroperitoneoscopic adrenalectomy may be performed effectively and safely, with a low complication rate, independently of the etiology of the lesion. The lateral retroperitoneoscopic access is anexcellent option for the minimally invasive treatment of the adrenal glands.
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OBJECTIVES: The cystic ectasia of the rete testis is a benign entity with a typical ultrasound appearance as a collection of small hypoechoic structures in the confluence of the mediastinum testis. The clinical importance of these entity remains on doing an adequate differential diagnosis with testicular neoplasias with a cystic component.METHODS: We retrospectively reviewed the database of the Ultrasound Unit in the Department of Urology looking for patients with a diagnosis of cystic ectasia of the rete testis over a six-year period.RESULTS: Three cases of cystic ectasia of the rete testis were diagnosed over the six-year period, in all the indication for ultrasound was testicular pain. Mean patient age was 62 years. No patient developed testicular tumor on follow-up.CONCLUSIONS: The knowledge of the ultrasound characteristics found in the cystic ectasia of the rete testis helps to make a proper diagnosis of this benign entity without the need of indication of testicular biopsy.
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OBJECTIVES: To have data about theindications, morbidity and mortality of the nephrectomyby the open approach, to obtain information that couldbe compared with the laparoscopic approach. To ourknowledge there is not a similar review in the Spanishliterature since this 60’s.METHODS: We analyzed 681 nephrectomies accountingfor a 5.7% of a total of 11.845 operative reportsregistered in our centre over the last 25 years. For outcomeanalysis, 93 cadaver donor nephrectomies were excluded.The analysis focuses on three well differentiated areas: kidney transplant surgery, nephrectomies for malignantdiseases, and nephrectomies for benign pathologiesincluding a very specific subgroup that includes theinfectious-inflammatory diseases. In parallel, we performeda bibliographic review in which more than 87,000 casesof open surgeries where referenced, adding the articlesabout laparoscopic nephrectomies published over thelast decade.RESULTS: Global mortality of the series (the first 30postoperative days) was 0.8%, mostly cases of transplantnephrectomies (4), and one upper urinary tract transitionalcell carcinoma. Significant morbidity appeared in 47cases (8%), 15 of which (2.5%) required reoperation,being intensive bleeding with hypovolemia of variableseverity the most frequent cause.The series includes non selected cases of a wide spectrumof pathologies. Any comparison with minimally invasiveapproaches should take into consideration, among otherparameters, selection of the cases
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OBJECTIVES: We report one case of adrenal myelolipoma in a female patient presenting with right lumbar pain over six months. METHODS: Diagnostic work included ultrasound, intravenous urography (IVU) and CT scan. RESULTS: The patient underwent right adenomectomy with the working diagnosis of adrenal myelolipoma. We describe the pathology report. CONCLUSIONS: Myelolipoma may present hematopoietic, fat and bone components. It continues being an incidental finding. Ultrasound and CT scan are effective diagnostic tests. Asymptomatic small tumors, smaller than 4 cm, may be monitored with watchful waiting. Symptomatic tumors greater than 4 cm should be extirpated because of the risk of spontaneous rupture with retroperitoneal bleeding. Bilateral adrenalectomy for big tumors implies medical replacement with hydrocortisone.
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OBJETIVES: To report the clinical characteristics, diagnosis and treatment of psoas abscess. METHODS/RESULTS: We report the case of a 77 year old female patient who was diagnosed of psoas abscess. Due to the unspecific symptoms, she was initially treated as a renal colic. Ultrasound was the test that oriented us to the diagnosis. Percutaneous drainage was effective, checking the resolution using CT Scan. CONCLUSIONS: Psoas abscess is an uncommon pathology the presenting features of which are usually unspecific. CT Scan is the astronomer diagnostic tests and percutaneous drainage has good results and is less aggressive therapeutic option for this disease.
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OBJECTIVES: Testicular microlithiasis,characterized by the existence of microscopic calcifications within the seminiferous tubules, is rare, generally anincidental finding during a scrotal ultrasound.METHODS: We report the case of a 45-year-old male without risk factors for the development of a germ celltesticular tumor with the diagnosis of bilateral testicularmicrolithiasis.RESULTS: The patient was followed yearly with testicular ultrasound, without evidence of germ cell tumor over a fouryear follow-up period.CONCLUSIONS: Although the clinical significance oftesticular microlithiasis is under debate due to the various controversies found in the literature about its association or not with testicular tumors, as well as the various protocols for initial management and adequate intervals for followup, it seems reasonable to perform an ultrasound yearly independently of the existence or not of associated risk factors.
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OBJECTIVES: To report a new case of asymptomatic capsular leiomyoma. METHODS: 68-year-old male asymptomatic patient who was diagnosed of solid mass after a radiological study (ultrasound and CT scan). RESULTS: The treatment of this neoplasia was radical nephrectomy, with an uneventful postoperative course and a pathology report of renal leiomyoma. CONCLUSIONS: Renal leiomyoma is a rare benign mesenchymal tumor that should be taken into consideration for the differential diagnosis of renal masses, because it would be an indication for nephron-sparing surgery; never- theless, due to the difficulties to differentiate it from renal cell carcinoma it is not rare that the diagnosis is achieved after histological study of the nephrectomy specimen.
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OBJECTIVES: Giant hydronephrosis, defined as the presence of a liquid volume over 1000 ml within the urinary collector system, is a rare clinical entity, the diagnosisof which is an excellent exercise because it lacks of a definedclinical presentation.METHODS/RESULTS: We report the case of a 66-year-old male under study for a suspicious digestive tumor due to a long lasting clinical picture with severe cachexia, asthenia, anemia , constipation, and abdominal mass. Radiological tests showed a great right hydronephrosis secondary to a culculus in the ureteral-pelvic junction. Simple nephrectomy was performed, evacuating 7800 ml of serous-hematicliquid from the pyelocalicial system. A histological diagnosisrevealed the presence of multiple foci of transitional cellcarcinoma and renal cell carcinoma associated. We reviewthe diagnostic and therapeutic features in the literature.CONCLUSIONS: Giant hydronephrosis represents adiagnostic dilemma. It may present as an asymptomatic process, with clinical features of abdominal organscompression (bowel or urinary obstruction) or simulateabdominal tumors, massive ascites, or cystic retroperitoneal lesions. Simple nephrectomy is the treatment of choice in most cases, due to the advanced deterioration of the renal unit. Nevertheless, in some cases, in compromised patients, percutaneous drainage may be necessary as previous or definitive treatment to avoid changes in the hemodynamicbalance secondary to the sudden abdominal decompression.
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OBJETIVE: Metanephric Stromal Tumors (MST) are pediatric renal neoplasms not very common in adults. This study revises its classification, incidence and evolution and also some specific characteristics of the casesdiagnosed in adults.METHODS: We present two cases of MST diagnosed in adults of 72 and 77 years old respectively. Abdominal pain due to a more than 4Kg. mass was the initial presentationin both cases. The tumors were completely resected. Four and ten years after excision patients are alive without disease.RESULTS: Characteristic histologic features include aproliferation of fusocellular cells with alternating cellularity that imparts a nodular appearance and onion-skin cuffing around entrapped renal tubules or vascular structures. No mitoses or atypia was found but extensive necrosis and fibrosis were present. A majority of stromal cells werevimentine and CD-34 positive. Stains for CK and EMAhighlighted entrapped native tubules. Both cases werepreviously classified as mesoblastic nephromas. According to the 2002 ONS classification of tumours of the urinary system, they have been revised and re-classified as MST.CONCLUSION: MST are pediatric benign tumors exceptionallydiagnosed in adults. Metanephric stromal tumors are dividedinto 3 categories based on the presence of epithelial cells, stroma and epithelial cells plus stromal. Complete excision is the treatment of choice and the prognosis is excellent.
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OBJECTIVES: Metanephric adenoma is arelatively unfrequent asymptomatic embryogenic renal tumor which is generally diagnosed by an abdominal diagnostic tests indicated for other reasons. Differential diagnosis with benign and malignant tumors has to be performed.METHODS/RESULTS: We report one case of metanephric adenoma with intense necrotic-hemorrhagic and cystic changes with a size not previously referred in the literature.CONCLUSIONS: Cystic and hemorrhagic changes inbenign renal tumors make differential diagnosis with malignant tumors mandatory. Surgery is necessary in almost all cases and histologic study will give the diagnosis.
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OBJECTIVES: To report the case of a patient diagnosed with tuberous sclerosis complex (TSC), describe its clinical features, diagnosis, and to attract attention on the fact that after 40 years of follow-up, the patient has presented practically all the manifestations described in the literature.METHODS: A 42 year-old man diagnosed with TSC presented the emergency department due to left lumbar pain and self-limited gross hematuria. On clinicalexamination patient was haemodynamically stable, but with decrease in haemoglobin (6.8g/ dL). Abdominal CT scan showed a 20 cm diameter heterogeneous mass in the left kidney suggesting hemorrhage of anangiomyolipoma.RESULTS: Left radical nephrectomy was performed and the pathological study of the surgical specimen confirmed the diagnosis of angiomyolipoma. Inmunohistochemical staining was positive with HMB-45.CONCLUSIONS: To recommend that patients with TSC be evaluated by a multidisciplinary group of clinicians, including urologists, neurologists and dermatologists. As patients with TSC survive into adulthood they will require more intervention by the urologist. CT scan is usually enough for the diagnosis of angiomyolipomas. Complete nephrectomy is appropriate when the whole kidney has been replaced by angiomyolipoma. The identification of molecular markers (HMB-45) facilitates histopathological diagnosis.
