OBJECTIVES: Urethral pathology hasalways been an interesting topic for study, being presentin texts from 600 years B.C, where wood and metallicdilators are described. First external urethrotomiesappear in the Jewish-Muslim period, and Francisco Diazdescribes in 1588 the treatment of the prostate in hisbook “Tratamiento de las carnosidades de la verga”.With Civiale and Maisoneuve, between 1700 and1800, appears the description of the urethrotome, andfinally in the middle XIX century starts the search foradequate tissues to replace urethra.METHODS: We review all articles on the topic of urethralpathology from authors from Valencia in that period, mainly published in the journal “Revista Valenciana deCiencias Médicas”.RESULTS: We emphasize the use of bulbs and soundsin the approach to urethral stenosis by several authors,with their advantages and limitations. We also emphasizethe description of external urethrotomy by Prof. Molla.Finally, we point out the treatment of a posterior urethrafracture by tunneling reported by Dr. AlfredoTramoyeres.CONCLUSIONS: Despite not being a topic with a highvolume of publications, it has always interested authors.We describe all treatments, and sound insertion anddilation techniques as first option.
OBJECTIVES: To report the first consolidatedresults of the technical variation of the bladder-capsuleplasty, a complement of the well-known trans-cervicalhemostatic adenomectomy.METHODS: We analyze 65 recent consecutive patientswith BPH undergoing surgery by such technique withfollow-up between 6-48 months, analyzing the parameterswhich in this type of operation are significant to evaluate quality.RESULTS: We evaluated bleeding, transfusions, surgicalwound complications, postoperative discomfort, numberof days with catheter, and hospital stay; also reoperationsand morbidity-mortality, which show a notable improvementin comparison with what appears to be typical of thisoperation, considered the most aggressive approachfor the surgical treatment of BPH.CONCLUSIONS: We report a personal modificationof the transcervical hemostatic adenomectomy, publishedin 1974, after an experience of more than 1000operations: the bladder-capsule plasty. The changesintroduced in this 65 cases make us consider, even inpresent times, open surgery for BPH as the best solutionfor the obstructive problem in selected cases, with thelowest reoperation rates, and improving on factors suchas “invasiveness” and “higher cost” which have beenhistorically attributed to it.
OBJECTIVES: To report three cases ofatherosclerotic embolic vascular disease with clinicalpresentation in the lower urinary tract. This disease is notfrequent; it mainly affects the skin, kidneys and skeletalmuscle. Other organs of the urinary tract are rarelyaffected and they are exceptionally the clinical site ofdebut without previous known involvement of otherareas. METHODS/RESULTS: The first patient presented withhematuria associated with an ultrasound/cystoscopicalimage suspicion for neoplasia. Pathologic report of thetransurethral resection chips showed polypoid cystitiswith some small size arteries occupied by cholesterolneedles, associated with inflammation, ulcers andhematic extravasation. The second patient underwentcystoprostatectomy for a transitional cell carcinomaand, incidentally, numerous cholesterol emboli werefound, mainly in the lamina propria, but also in otherlayers of the bladder wall, prostate, urethra, verumontanum, and one seminal vesicle; this two latter siteshave not being reported in previous publications. Thethird patient showed the embolus within a prostatebiopsy core.CONCLUSIONS: This unfrequent disease may presentas a bladder or prostatic process and be diagnosed bybiopsy of these organs. It may simulate a bladder neoplasiaon ultrasound or cystoscopy and should be includedamong related or etiologic entities of polypoid cystitis,a well-known simulator of neoplasia.
OBJECTIVES: To perform a bibliographic review of the main features of cryotherapy as a therapeutic option in the managemente of prostate cancer and to report our initial experience.METHODS: We employed the Endocare Fast-Trac system (Medipro) with 2,4 mm needles implanted in a single maneouvre without rack or transrectal US transducer support. Two cycles of freezing -hawing were employed, with apex backward movement when necessary. Freezing cycle duration was between 7-10 minutes or more. The Onik maneouvre – injection of saline into the Denonvillier’s space—diminishes the risk of rectal injury and fistula allowing reaching posterior limits of the icaball beyond the prostatic capsule.RESULTS: We treated 20 patients. Follow-up was between 30-36 months. 58% of the patients had unilateral prostate cancer, 42% bilateral. In accordance to the classicdefinition 9 patients were classified as low risk of extraprostatic disease, 6 medium risk and 5 high risk; using number of positive cores as the criterion for risk 5, 6 and 9 were low, medium and high risk respectively. Perprotocol prostate biopsies were performed in18 patients 6, 12 and 24 months after treatment. Two patientsunderwent a second treatment due to persistence ofcancer cells in the 6-month biopsy (11%).3-month PSA nadirs after a total of 21 cryo treatments administered were <0,2 ng/cc in 15 cases (78,9%),< 0,5 ng/cc in 17 (89,4%) and ≤ 1.0ng/cc in 18 (94,7%); it was over 1 ng/cc in only 5,6%. 30 month PSA for the same cutoff values was 27.8%, 50.0%, 66.6% and 33.3%, respectively.Prostate cancer cells were detected in the 12-month biopsies of 5.5% cases. All 24-month biopsies were negative.COMPLICATIONS: we observed scrotal edema,hematoma, perineal pain and constipation which lasted 2-3 weeks. 1 patient suffered injury of the mucosa at the prostatic urethra, which did not result in rectal fistula and was treated with bladder catheter for 3 months. 4 patients had erectile dysfunction before treatment. All others presented erectile dysfunction after treatment; 3 of them (20%) recovered rigidity enough to have intercourse over the 30 month period.No urethral sloughing or acute urinary retention appeared and all patients are continent.CONCLUSIONS: Prostatic cryosurgery is an effective, minimally invasive procedure for the treatment of prostate cancer with very low surgical risk, low morbidity and almost null mortality.
OBJECTIVES: To establish the most relevantepidemiological features of the squamous cell carcinomaof the penis (absolute, adjusted and accumulated incidence,incidence density, and epidemic index), as well as itsrelated survival.METHODS: We included all patients with the diagnosisof squamous cell carcinoma of the penis in the healtharea No. VIII of Ciudad Real (90,000 inhabitant)between January 1981 and December 2003. Datafrom the national Institute of Statistics were used forpopulation adjustments. A Cox regression model wasapplied for survival analysis.RESULTS: The incidence of squamous cell carcinoma ofthe penis has increased over the last years (yearly increase5.86%) with a high mortality rate within the first year(median survival 407 days)CONCLUSIONS: it would be recommendable to intensifypreventive measures to try a stop the increase in incidence,as well as successful adjuvant treatments to increasecancer specific survival.
OBJECTIVES: The limitations of PSA to identify patients with prostate cancer prompted the definition of different parameters trying to increase specificity without reducing sensitivity. This paper studies the relationship of volume and presence of prostate cancer in sextant biopsies. METHODS: We collected the results of prostate biopsies performed to 6000 patients between 1994 and 2002. 861 of them underwent more than one biopsy, adding up for a total of 7127 biopsies. Various predictive models to identify factors related to positive biopsy were constructed.RESULTS: Mean prostate volume is 14.6 ± 66.2 cc for the first biopsy, increasing in successive biopsies to 85.17 cc. A high incidence of prostate cancer was observed in small prostates, reaching 67.2% of those with normal size (< 20 cc) and diminishing with theincrease of volume down to only 19.7% in those larger than 50 cc (p < 0.0001). In second biopsies ofpatients with PSA between 4 and 10 ng/ml and gland volume higher than 50 cc percentage of biopsies positive for cancer was below 10%. Multivariant logistic regression showed that PSA, volume and PSA density were related with positive biopsies, but not free/total PSA ratio.CONCLUSIONS: Standard PSA cutoffs are not adequate for a proper diagnosis of prostate cancer by ultrasound guided transrectal biopsy. Volume (BPH) has a significant influence in PSA values and results of the biopsy, so that it should be taken into consideration when indicating biopsies.
OBJECTIVES: To evaluate the results of the outpatient surgical treatment of genuine female stress urinary incontinence (SUI) over a five year period since the integration of the Department of Urology in the Ambulatory Surgery Unit at our hospital “Consorcio Hospital General Universitario de Valencia” (CHGUV). METHODS: Between January 2000 and December2004 26 patients (ages 49-78; mean age 69.8 yr.) with the diagnosis of SUI underwent tension-free suburethral mesh sling (TVT) outpatient operations under local anesthesia-sedation at the ambulatory surgery unit of the CHGUV. All patients had clinical and urodynamic evaluation, excluding those presenting genital prolapse or non compliance with the social requirements forambulatory surgery. Previous anti-incontinence surgery was not an exclusion criterion. We evaluate inclusion and discharge criteria, results and satisfaction degree measured by a questionnaire. RESULTS: 22 patients (85%) had genuine SUI and 4(15%) had mixed UI with predominance of the stresscomponent. 54% (14 ) of the patients were ASA I, 31%. 8) ASA II, and 15% (4) well compensated ASA III. Operation tolerance under local anesthesia (20-30 ml 1% lidocaine) was good in all patients, having used additional sedation-analgesia (propofol-remifentanil IV perfusion) in 10 of them (38%). Mean operative time was 30 minutes (25-45) and stay at the unit discharge was 100 min. (80-140). All patients were discharged the same day. None of them required readmission or presented urinary retention after catheter removal. SUI disappeared in all of them. Three patients presented postoperative urge incontinence responsive to oral anticolinergic drugs. Our results are similar to thoseobtained with epidural anesthesia and hospital admission, being the degree of satisfaction with treatment higher than 95%. CONCLUSIONS: The development of new, revolutionary systems for the treatment of SUI has simplified the surgical treatment of this entity, so that we can say a high percentage of patients may be included in an ambulatory surgery program, significantly improving cost-efficacy without diminishment of health-care quality or patientsatisfaction.
OBJECTIVES: To study patient satisfactionand complications appeared in a series of patients witherectile dysfunction undergoing implant of penileprosthesis.METHODS: Retrospective study of all patients undergoing surgical treatment for erectile dysfunction by penile prosthesis implant between 1993 and 2003. Collected data included patient age at the time of surgery, previous treatment, and significant medicalhistory. We reviewed the models of prosthesis employed,incisions, and complications appeared. Finally, aquestionnaire was elaborated to establish the level ofpatient satisfaction.RESULTS: 24 prostheses were implanted between1993 and 2003. Mean patient age was 56.6 ±7.56 years (36-63), median 59.5 yr. Penile-scrotalincision was employed in 13 (54.16%) patients,suprapubic incision in 6 (25%) and subcoronal incisionin 1 (4.16%). Type of prosthesis: semirrigid AMS 6009 (37.5%), semirrigid AMS 650 10 (41.66%); the twocomponent hydraulic prosthesis AMS Ambicor was used only in one case.Six (25%) patients presented complications. 16.66%were minor, cavernositis, pain, hematoma or prosthesisextrusion. Prosthesis extraction was necessary in 2(8.33%) cases. 13 (54.16%) patients responded to thetelephone survey. 85% of them use their prosthesis.54% percent refer adequate self-satisfaction and partnersatisfaction (well satisfied/much satisfaction).23% not too bad, and the remainder 23% bad or very bad.CONCLUSIONS: Despite the highest rate of postoperative complications, penile prosthesis is adequately accepted by patients with erectile dysfunction, even malleable models. Patient satisfaction is high, being higher in partners. Most patients would desire to undergo surgery again if they were in the same situation.
OBJECTIVES: To compare the results oftreatment of peyronie`s disease with propoleum, laser,and simultaneous propoleum-laser.METHODS: Prospective research. Twenty-eight patientswith Peyronie’s disease from the hospitals Freyre deAndrade,Fajardo, Clínico Quirúrgico y HabanaCampo were studied between May 2002 and August2003. They were divided into three groups:1) treatmentwith propoleum: 10 patients; 2) treatment with laser: 8patients; and 3) treatment with propoleum + laser: 10patients. A registered formula of Propoleum powderwas employed in daily 900 mg capsules over sixmonths. 30 sessions of laser were applied to the plaquedivided in periods of 10 sessions every 2 months.Study variables: age, race, date of disease start/ clinicalimprovement correlation, beginning of improvementafter treatment. Data were processed in a statisticalsoftware (Epinfo-6) and multivariate analysis with nonparametric methods was employed.RESULTS: Mean age was between 4th and 7th decadein all groups. Caucasian race was predominant. Thepropoleum-laser group achieved the greater diminishmentof the plaque among those with one or two years ofdisease evolution. Pain was not the main symptom inthese patients. The greater diminishment of the curvaturewas obtained in the propoleum groups, with a meandiminishment of 10.8 (propoleum only) and 10.3(Propoleum+ laser) in comparison to the laser groupwith a mean decrease of 8 and mean increase of12.6. Mean plaque diminishment measured clinicallywas 2.3 cm and 1.5 cm in the propoleum groups,respectively, and 1.2 cm in the laser group. Ultrasoundmeasurement mean diminishment was 2.3 mm and12.16 mm in the propoleum groups. The laser resultswere not comparable due to the low number of patientsin relation to the other groups.CONCLUSIONS: 1-best results appeared in the groupstreated with propoleum in patients with 1-2 years ofdisease. 2-Diminishment of the curvature angle, physicalor ultrasound measurement of the plaques was greaterin the propoleum groups. 3-After the start of treatment,the propoleum-laser group referred early improvements,and the propoleum group referred continuous progressiveimprovement; only a few patients in the laser group referredimprovement. 4- Treatment with propoleum was moreeffective and laser increased its action, being propoleumin monotherapy less complex in its application and witha better cost-benefit ratio
OBJECTIVES: Presentation of our initialexperience with the practice of the laparoscopic radicalprostatectomy through the extraperitoneal access (ELRP).We describe the proceeding and its technical difficulties,time consumption and complications.METHODS: From January to May 2005 we haveindicated 17 ELRP in our institution. Two of them wereperformed with the help of a mentor. We followed theBrussels technique but without preservation of the neurovascular bundles.RESULTS: Laparoscopic approach was indicated in 17patients, 8 of them were completed and 9 converted toopen surgery. Of the cases performed without externalaid (which are the analysed in this communication), 6were pure laparoscopic and 9 were permuted to open.Of the last 6, only one was not completed by laparoscopy.Mean operative time was 304 minutes (355 for thepure laparoscopy cases). Transfusion rate was 13%.Positive surgical margins were observed in 26% of thecases (16% of the complete laparoscopic procedures).There were not major complications. Not ileus wasobserved. In one case, bladder catheter had to bereplaced after 7 days because it was not properly placedduring surgery. Conversion to open surgery duringextraperitoneal laparoscopic proceeding is not verydifficult but previous surgical experience is required.CONCLUSIONS: ELPR is feasible in an institution likeours but is necessary a team with previous experiencein laparoscopic surgery and the aim of invest a bigeffort, specially regarding operative time. Initial learningcurve has not caused any important complication.
OBJECTIVE: Prostatic tumors are the most frequent malignant neoplasms in men, most of them being constituted by carcinomas; only 0,2% of malignant prostatic neoplasms are of mesenchimal origin. They are not well known, especially those of prostatic stromal phenotype. METHODS AND RESULTS: We report the case of a 20- year-old man with a prostatic stromal sarcoma. After total cystoprostatectomy a tumor measuring 8 cm could be seen, replacing almost the whole prostate. Microscopically a spindle cell neoplasia with moderate atypia and a high mitotic index entrapping few elongated prostatic ducts (adopting a phyllodes tumor morphology) was observed. CONCLUSION: The clinical behavior of these infrequent sarcomas is not well-established. Recurrences are not uncommon whereas lung and bone metastases have been described. Twelve months after surgery our patient is alive without evidence of disease.
OBJECTIVES: To report a new case of bladder leiomyoma.METHODS: A 20 mm tumor of the right lateral wall of the bladder was incidentally found in a pelvic ultrasound study of a 29-year-old female. The cystogram showed the presence of a filling defect in the same side. Cystoscopy showed a right lateral wall tumor with normal mucosal cover. RESULTS: With the working diagnosis of bladder leiomyoma, transurethral resection of the bladder tumor was performed, and pathology confirmed the diagnosis. Postoperatively, the patient developed a calcareous plaque on the resection area which was treated by transurethral resection of the plaque and leiomyoma remainders and subsequence urine acidification. CONCLUSION: Although it is a rare tumor, in certain circumstances it is possible to establish the working preoperative diagnosis with a high index of suspicion. On the other hand, due to the benign character of the process, conservative surgery (transurethral resection in this case) offers excellent results.
OBJECTIVES: Bladder leiomyoma is a raretumor, its frequency being estimated below 1%.METHODS: We report the case of a 17-year-old malepatient presenting with hematuria and lower urinarytract irritative symptoms whose work up discovered twosmall bladder tumors.RESULTS: After TUR of the lesions the diagnosis of bladderleiomyoma was established; no recurrences haveappeared on follow-up.CONCLUSIONS: Bladder leiomyoma is a benigntumor, therefore surgery should be the most conservative.Bibliographic review of the Spanish urologic journalsshows that this is the youngest patient reported to date.
OBJECTIVES: To report one case of spermatic cord rabdomyosarcoma in an adult patient.METHODS: We report the case of a 36-year-old male presenting with a painful left inguinal scrotal mass.RESULTS: Left radical orchiectomy was performed with excision of the mass. Pathology showed a spermatic cord rabdomyosarcoma. The patient received several cycles of systemic chemotherapy.CONCLUSIONS: Spermatic cord rabdomyosarcoma is a rare tumor derived from the undifferentiated mesoderm. It rarely appears after the second decade of life. Local-regional recurrence after surgery is very frequent. There are adjuvant treatments, the indication and use of which couldn’t be included in proper protocols due to the low incidence of this tumour in adults.
OBJECTIVES: To report one case of cavernoushaemangioma in the upper urinary tract.METHODS/RESULTS: 29-year-old female presentingwith right renal colic whose IVP showed UPJ obstruction.Dismembered pyeloplasty was performed and pathologyreported a cavernous haemangioma as the cause ofstenosis.CONCLUSIONS: Cavernous haemangioma, a rareupper urinary tract pathology, should be considered inthe differential diagnosis of causes of UPJ obstruction.
OBJECTIVES: Varicocele is a relativelyfrequent entity; in most cases venous dilation only involvesthe extratesticular portion, but 2% of the cases presentintratesticular dilation. We report one case of leftintratesticular varicocele.METHODS/RESULTS: We report the case of a 25-yearold male patient referred for study of left testicular pain,whose work up only found left intratesticular varicocele.CONCLUSIONS: Intratesticular varicocele is an infrequententity which can be associated with testicular pain, scrotalmass and infertility or may be asymptomatic. Thediagnosis is established by Doppler ultrasound; ifsymptomatic, it may be treated by spermatic veinligation.
OBJECTIVES: The ovarian metastasis bya gastrointestinal cancer is called Krukenberg tumor.We report a case of metastasis to the testis andepididymis by gastric cancer that can be the analoguein male.METHODS: A patient, submitted to total gastrectomy fora poorly differentiated gastric adenocarcinoma (TNMstage: pT3 GIII N+ M1) developed one year later apainful swelling of the right hemiscrotum and groin. Thepalpation revealed a painful mandarine-like massconglobated in the right testis and epididymis, with afurther mass at the external inguinal-ring and multiplelittle nodes along the spermatic cord. An inguinal orchifuniculectomy was performed and the histologicaltests described a poorly differentiated, microtubularadenocarcinoma, infiltrating the connective tissue, withoutspreading to the testis, that was properly structured. Theatypical tumor formations expressed carcinoembryonalantigen, but were negative for -HCG and PSA. Theimmune-histochemical results confirmed the diagnosis ofan adenocarcinoma.RESULTS/CONCLUSION: The metastasis in testiclesand/or epididymus are rare and cannot be differentiatedclinically or by imaging procedures from a primary testicleneoplasia. Only the exact anamnesis of previous tumorsand the age can provide some indications. The therapy ofchoice is however represented by inguinal orchifuniculectomy