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OBJECTIVES: To study and review the etiopathogenic hypothesis for endometriosis and theclinical features, diagnosis and treatment of bladderendometriosis.METHODS/RESULTS: We report two cases and review the international bibliography, collecting the casespublished by Spanish authors.CONCLUSIONS: Bladder endometriosis is a rarepathological entity, but its diagnosis should be consideredin fertile women with urinary tract symptoms duringmenstruation. Diagnosis is obtained by various imaging tests (ultrasound, CT scan, MRI), and is confirmed with cystoscopy and biopsy. The treatment may be surgical (TUR, partial cystectomy) and/or medical (hormonal).
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OBJECTIVES: To determine if p53expression in patients with infiltrative bladder cancer is a prognostic factor on clinical staging and cancer specific survival.METHODS: Immunohistochemical analysis of p53 in 34 patients (33 males and 1 female) undergoing radical cystectomy for infiltrative bladder cancer, with a mean follow-up of 16 months.RESULTS: p53 overexpression was detected in 18patients (64%). In the p53 positive group two patients were stage T1G3, 18 patients T2, 1 patient T3, and 2 patients T4. In the negative group a better correspondence between TUR and cystectomy stage was found, with stage worsening only in 3 patients. On follow-up, p53 positive patients showed worse outcomes due to their worsestages, although no statistical differences were found (p = 0.24). In the group of patients following a bladder sparing protocol (n = 6), p53 negative patients had complete remission of the disease.CONCLUSIONS: We see significant differences on understaging/more aggressive local outcome in p53 positive patients, with no greater mortality in this group. P53 expression does not contraindicate the inclusion of a patient in a bladder sparing protocol, although larger studies would be necessary to confirm these results.
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OBJECTIVES: To analyze the correlation between preoperative variables in patients with kidney cancer and subsequent finding of bad prognosis factors.METHODS: Retrospective cohort study reviewing the charts of all patients undergoing surgery at the HIBA between June 1988 and April 2003. 555 patients were included, registering age, gender, and clinical presentation. Pathology reports were classified following WHO for histology, Furhman for tumor grade, and AJCC for tumorstage. Intrarenal disease was defined as tumors ≤ T2; the rest of the tumors were considered extrarenal. Statistical analysis was performed using the Statistic 7 Software, performing Students t test, proportions comparison test, chi-square test, and odds ratio.RESULTS: Mean age was 58.8 years (r: 20-94), 388 (69.9%) patients were males and 167 (30.1%) females. 209 (37.7%) were smokers or ex-smokers. 256 (46.1%) tumors were incidentally diagnosed, 299 (53.9%) were symptomatic. The right kidney was affected more often (54.6%), and 2.3% were bilateral synchronic tumors. Grade II was the most frequent grade (62.2%). T1 was the predominant TNM with 273 patients (49.2%). Mean tumor size was 6.7 cm, with 5.54 cm for the intrarenal tumors and 8.67 cm for the extrarenal (Student t test p > 0.00001). 49.6% (127) of the 256 asymptomatic patients have extrarenal tumors, in comparison with only 26.4% (79) of the 299 symptomatic patients (chi-square p > 0.00001). Ninety-two (44%) of the 209 smokers had extrarenal tumors in comparison with 114 (32.9%) of the non-smokers.CONCLUSIONS: We may say that patients having a symptomatic renal tumor have between 2 and 3 times more probability to have non organ-confined disease at the time of surgery. This also increases, although in smaller amounts, between smokers and older than 70 years patients. The presence of a tumor greater than 7 cm almost triplicates of the possibility of extrarenal involvement.
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OBJECTIVES: To establish the trend of the bladder cancer adjusted mortality and its correlation with tobacco consumption in different Spanish AutonomicCommunities over a 15 year period.METHODS: We evaluate the trends of mortality ratesassociated with bladder cancer between January 1st 1989 and December 31st 2002 in the geographic area of Spain, as well as the tendency of tobaccoconsumption. Demographic and mortality data were obtained from the National Institute of Statistics, and consumption data were obtained from the Commissionerfor the Tobacco Market in the Spanish Economics and Finances Ministry. We calculate the average number of cigarettes (1 package = 20 cigarettes) consumed per person; we also calculate bladder cancer adjustedmortality rates, presented as number of deaths for that cause per 100.000 persons year, and the ratio betweennumber of packages of cigarettes consumed and adjustedmortality rate. We determine the yearly percentageincrease over the whole period of study for both themortality rate and tobacco consumption, and evaluate their correlation by the Spearman’s coefficient.RESULTS: Mean adjusted bladder cancer mortality rate over the period of study was 9.4 deaths per 100.000 habitants year, and mean tobacco consumption was 109.7 packages per person year. There has been a 2.05% yearly increase of bladder cancer associated mortality, mean cigarette consumption has diminished 1.3% per year. The Spearman’s test did not show any correlation between both factors (p = 0.722).CONCLUSIONS: Despite preventive measures fortobacco addiction in our country, there is an important continuous consumption. The increase in the incidence of bladder cancer does not seem to be related with highertobacco consumption currently, therefore it may be relatedwith other genetic or environmental factors.
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OBJECTIVES: The monohydrate calcium oxalate lithiasis (MCO) is divided in two groups depending on the morphologic-crystal structure: papillary (anchorage point on a renal papilla lesion) and cavity (formed in a cavity with low urodynamic capacity). The minimal differences between urinary biochemistry of MCO makers in comparison with healthy population suggests that other factors different than urine biochemistry (professional activity, dietetic habits, systemic diseases) may be related with lithogenesis. The objective of this work is to study such factors, and compare them in both groups of MCO lithiasis (papillary and cavity).METHODS: We study 40 patients with MCO lithiasis (20 patients papillary and 20 patients cavitary). Medical history was performed (family history of lithiasis; associated diseases such as high blood pressure, diabetes, hyperuricemia, hypercholesterolemia, peptic ulcer disease; dietetic survey to evaluate phytate consumption; professions with high-risk of exposure to toxic agents); 24-hour urine biochemical tests, two-hour urine (pH), and serum biochemical profile were performed. Statistical analysis was performed using student’s t test and chi-square.RESULTS: There is a high prevalence of family history of renal lithiasis (45%) without differences between groups. There are not differences in urine or blood biochemical tests. There is a low consumption of phytate-containing foods in both groups, without significant differences. There is a trend to a greater exposure to cytotoxic agents in the papillary group (45%) vs. the cavity group (25%). Hypertension and hyperuricemia are more prevalent in the cavity MCO group (α = 0.025 and α = 0.010, respectively). Peptic ulcer disease is more prevalent in the papillary MCO group (α = 2.025). There are no significant differences in prevalence of hypercholestero-lemia or diabetes mellitus between groups.CONCLUSIONS: Papillary MCO calculi are associated with a deficit of crystallization inhibitors (phytates), and disorders of the epithelium covering the renal papilla (cytotoxic agents exposure, peptic ulcer disease). Cavity MCO calculi are associated with a deficit of crystallization inhibitors (phytates) and a greater amount of heterogeneous nucleants (organic material induced by diseases such as hypertension, hyperuricemia, hyperglycemia, and hypercholesterolemia).
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OBJECTIVES: Vesicoureteral reflux (VUR) is detected in 30-50% of pediatric patients diagnosed of urinary tract infection (UTI). Multiple clinical trials have compared the results of conservative management against surgical therapy. The introduction of a thirdalternative in 1984 (endoscopic approach) hasdramatically modified the management of VUR. Theobjective of our work is to analyze the factors influencing the favourable outcome of the endoscopic treatment of VUR.METHODS: Retrospective and prospective cohort studyanalyzing 90 patients with grades III and IV VUR treated endoscopically over the last eight years. 184 patients undergoing endoscopic management were selected from a group of 550 patients (735 VUR renal units) with the diagnosis of VUR over the study period, . All patients underwent VCUG or galactose-based sonocystography to obtain the diagnosis. DMSA scintigram was used to evaluate renal damage. Data about gender, age, UTI, bilateralism, renal damage, voiding dysfunction,outcomes, complications, and recurrences were registered. A new factor was defined: ureteral dilation independentfrom the international classification. This factor wasevaluated by a single pediatric urologist blinded for the international classification results. Data analysis wasperformed using the chi square test and Fischer exact test; a multiple logistic regression analysis was alsoperformed. Statistical significance was established at p < 0.05. SPSS 11.0 software was employed for data analysis.RESULTS: Boys/girls ratio was 2.91. Bilateral VUR appeared in 44.4% of the cases. UTI was the presenting diagnosis in 64 cases; the diagnosis was prenatal in 21 cases (with a male predominance 5.2: 1). We found a strong correlation between renal scarring at the time of diagnosis and voiding dysfunction (p< 0.01). Cure rate after first injection was 64%. Although univariate analysisshowed a strong correlation between cure and first injection,bilaterality, voiding dysfunction, initial nephropathy, and ureteral dilation grade, on multivariate logisticregression the only significant factor to predict treatment response was the existence of severe ureteral dilation in comparison with mild dilation (p < 0.001; odds ratio 0.045, 95% confidence interval 0.01-0.16). Renal damageprogression was specially detected in those patients with voiding dysfunction (p = 0.053), bilaterality (p = 0.034) and severe ureteral dilation (p < 0.001).CONCLUSIONS: A direct relation between cure rate after endoscopic treatment of grade III and IV reflux and severity of ureteral dilation was demonstrated. Other relevant factors implied in the endoscopic resolution of VUR include the existence of voiding dysfunction,bilateral reflux and renal damage determined by DMSA at the time of initial diagnosis. Gender, age, and number of infections during follow up have no influence in the probability of cure of grade III and IV VU reflux treated with subureteral injection of biocompatible substances.
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OBJECTIVES: Due to the absence ofrandomized studies, the Spanish Reemex Working Group started a registry to analyze and review the resultsof a large group of patients with mid-term and long-termfollow-up to obtain conclusions based on clinicalexperience.METHODS: A registry of 715 patients who underwent surgical intervention for insertion of the SUI readjustable prosthesis Reemex TRT (tension free readjustable tape) in 15 Spanish hospitals (40% urology departments,60% gynecology departments). The registry was established to evaluate the safety and efficacy of the sling adjustabilityconcept in the surgical treatment of female SUI. The SpanishWorking Group was able to evaluate results of theReemex system in 683 patients of a total of 715. Mean age was 59.9 yr. (range 21-87) with a mean follow-up of 23 months (6-93). The group includes: 30.2% patients with mixed incontinence, 73.1% patients with urodynamicintrinsic sphincteric deficit, 35.7% patients with previous history of failed surgical interventions for urinaryincontinence, and 54.3% previous pelvic floor associatedoperations. All patients were evaluated preoperatively with history, physical examination and urinaryincontinence questionnaire. Each follow-up visit included incontinence questionnaire, physical examination and stress test.RESULTS: Cure rate was 92.2%, with 6.9% improvement and 0.9% failures. Readjustment was performed in 416 patients (60.9%) as a second phase of surgery over the following 24-48 hours, before hospital discharge. 80 patients (11.7%) were readjusted in the mid- or long-term (between 6 and 8 months after surgery). The level of support of the sling was successfully reduced in three patients between 6 and 14 months after surgery. No other patient suffered voiding difficulties in the long-term. 1.7% of the patients needed extraction of the tensor due to persistent abdominal wall seroma. 0.8% presented vaginal extrusion of the sling.CONCLUSIONS: The Reemex system is a minimallyinvasive technique with consistent results and evenimproved in heterogeneous groups of patients including intrinsic sphincter defficiency, reoperations, mixedincontinence and associated pathologies.
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The application of laparoscopy as a surgical technique in Urology has enabled to expand the therapeutic options for various pathologies. The treatment of urinary lithiasis localized in the renal pelvis is one of them. We report a laparoscopic pyelolithotomy, describing the operation step-by-step, from patient positioning and trochar insertion to drainage tube insertion and closure. The objective of this article is to show the technique, presenting it as an alternative option.
Case Report
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OBJECTIVES: To report one case of partial androgen insensitivity syndrome.METHODS: The patient underwent history and physical examination, blood tests, hormone determinations, androgen stimulation and suppression tests, nuclear chromatin and karyotype, imaging and endoscopic tests, exploratory laparoscopy with gonadal biopsy and bilateral orchyectomy, and subsequent genital plasty.RESULTS: We report the case of a phenotypically female patient with genital ambiguity, with a dorsally curved peniform clitoris and a urogenital sinus with partial labia fusion. Blood tests, hormonal determinations, and androgen stimulation-suppression tests were all normal. Both ultrasound and laparoscopy showed absence of internal genitalia. The biopsy showed testicles with relative Leydig cell hyperplasia and slight basal membrane thickening. The cosmetic and functional results were completely satisfactory with normal sexual intercourse.CONCLUSIONS: The reinforcement of the generic role after genital plasty provided satisfactory identification and sexual performance.
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OBJECTIVES: We report a clinical case of inverted papilloma of the anterior male urethra.METHODS/RESULTS: 40-year-old male without significant past medical history presenting with dysuria and referring three episodes of urethral bleeding. Preliminary studies included voiding cystourethrogram (VCUG) which revealed a filling defect in the anterior urethra. Urethrocystoscopy was performed under anesthesia, with resection of the tumor. Pathologic study reported a urethral inverted papilloma.CONCLUSIONS: Inverted papillomas of the male urethra are rare. The most frequent clinical manifestations are dysuria and hematuria, although they may present with urethral bleeding when located in the anterior urethra. Diagnosis is based on clinical symptoms, ultrasound, endoscopy and VCUG which enable detection of urethral filling defects. The treatment of choice is transurethral resection of the lesion. Annual endoscopic control is recommended after surgery.
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OBJECTIVES: We report one case of solitary fibrous tumor of the tunica vaginalis, a benign paratesticularlesion.METHODS: Surgical exploration with intraoperative biopsy and excision of the lesion was undertaken, leaving the testicleand epididymis undamaged.RESULTS: Intraoperative biopsy revealed the presence of fibrous tissue without malignant cellularity. Pathological diagnosis on the surgical specimen was solitary fibroustumor of the tunica vaginalis. The patient remains asymptomaticand disease-free one year after treatment.CONCLUSIONS: Almost all testicular masses are malignant,but in order to avoid a non-indicated orchyectomy, one should be cautious with the finding of a paratesticular lesion of probable benign nature on ultrasound or during surgery.
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OBJECTIVES: Syphilis is a systemic disease the course of which follows successive clinical stages. Central nervous system and spinal cord involvement on late phases may lead to bladder dysfunction. We report one case of neurosyphilis with associated bladder hyperreflexia.METHODS/RESULTS: 51-year-old male with the diagnosis of neurosyphilis consulting for voiding disorders withevidence of detrusor hyperactivity of neurogenic etiology on the urodynamic study.CONCLUSIONS: The differential diagnosis of neurogenicbladder in patients with psychiatric or neurological symptoms should include neurosyphilis. Etiologic diagnosis is obtained by cerebrospinal fluid examination, and the diagnosis of bladder dysfunction by urodynamic study.
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OBJECTIVES: Ureteral endometriosis is a rare entity which may produce urinary tract obstruction with subsequent loss of renal function if treatment is not under- taken early due to its asymptomatic but locally aggressive course. METHODS/RESULTS: We report one case of intrinsic ureteral endometriosis with unilateral renal failure (renal atrophy) and unresectable periureteral fibroinflammatory thickening involving vascular or visceral structures. CONCLUSIONS: We emphasize the diagnostic and therapeutic importance of a high degree of clinical suspicion about this entity, mainly in patients with history of genital endometriosis.
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OBJECTIVES: To report a rare clinical case ofsolitary pararenal fibrous tumor, analyzing its pathologicalcharacteristics and prognosis by a bibliographic review.METHODS/RESULTS: We present the case of a 36-year-old male consulting for right flank colic pain, which wasdiagnosed of a solid mass in the lower pole of the rightkidney and underwent right radical nephrectomy. Patholo-gical study of the surgical specimen showed the presenceof a solitary pararenal fibrous tumor.CONCLUSIONS: Solitary fibrous tumor is a rare neopla-sia, being its pararenal localization even rarer. It is a tumorwith benign behavior in up to 90% of the cases. The immu-nohistochemical study is the key to diagnosis
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OBJECTIVES: To report a new case of bladder leiomyoma in an adult.METHODS: 64-year-old female patient consulting for a four-month hematuria diagnosed of a bladder intraluminal tumor on ultrasound during a routine gynecologic revision. Cystoscopy confirmed the presence of the tumor. Transurethral resection was indicated.RESULTS: Pathology reported a definitive diagnosis of leiomyosarcoma. Anterior pelvic exenteration was subsequently performed. On one year follow-up there is no evidence of disease.CONCLUSIONS: We emphasize the rarity of these neoplasias. We comment on their main characteristics, pointing out the importance of immunohistochemical staining for the definitive histological diagnosis. We refer the therapeutic options described in the literature.
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OBJECTIVES: We report herein the clinical,histological, and immunohistochemical features of a case of sarcomatoid chromophobe renal cell carcinoma.METHODS/RESULTS: A 59-year-old woman referred a two-month history of constant right flank pain, andhematuria. A right radical nephrectomy was performed. Gross pathologic examination showed a tumor located in the lower part of the kidney with two different aspects.Histologically, the tumor was composed of two intermixeddistinct morphologic components: a chromophobe renal cell carcinoma and a high-grade spindle cell sarcoma. CONCLUSION: Our case represent a typical sarcomatoidchromophobe cell carcinoma. This unusual renal cancer has the potential to behave aggressively and tometastasize.
