The Occidental thinking is basicallybinary, based on opposites. The classic logic constitutesa systematization of these thinking. The methods ofpure sciences such as physics are based on systematicmeasurement, analysis and synthesis. Nature is describedby deterministic differential equations this way.Medical knowledge does not adjust well to deterministicequations of physics so that probability methods areemployed. However, this method is not free of problems,both theoretical and practical, so that it is not oftenpossible even to know with certainty the probabilities ofmost events. On the other hand, the application ofbinary logic to medicine in general, and to urologyparticularly, finds serious difficulties such as the imprecisecharacter of the definition of most diseases and theuncertainty associated with most medical acts.These are responsible for the fact that many medicalrecommendations are made using a literary languagewhich is inaccurate, inconsistent and incoherent.The blurred logic is a way of reasoning coherently usinginaccurate concepts. This logic was proposed by LoftiZadeh in 1965 and it is based in two principles: thetheory of blurred conjuncts and the use of blurred rules.A blurred conjunct is one the elements of which have adegree of belonging between 0 and 1. Each blurredconjunct is associated with an inaccurate property orlinguistic variable. Blurred rules use the principles ofclassic logic adapted to blurred conjuncts taking thedegree of belonging of each element to the blurredconjunct of reference as the value of truth.Blurred logic allows to do coherent urologic recommendations(i.e. what patient is the performance of PSA indicatedin?, what to do in the face of an elevated PSA?), or toperform diagnosis adapted to the uncertainty of diagnostictests (e.g. data obtained from pressure flow studies infemales).
OBJECTIVES/METHODS: Dr. VictorMollá Frambuena developed his practice in Valenciaduring his whole professional career, following the stepsof his father (the prestigious Professor Rafael MolláRodrigo), in the disappeared Red Cross Hospital wherehe became the first chairman of the department of urology.He published all his scientific work, which we analyze inthis article, in this city, mainly in the journal “CronicaMédica”.RESULTS/CONCLUSIONS: After an exhaustive search,we analyze all the data about his medical biographyand his scientific publications, this latter mainly in thejournal Cronica Medica from 1928 to 1938, the yearin which the last number was published.
OBJECTIVES: To remind the most relevantfeatures on the presenting clinical picture, diagnosisand treatment of this disease, which is not uncommonalthough many times is not suspected.METHODS: We review five cases of female urethradiverticula diagnosed in our department over the lastfive years. We describe the clinical picture, physicalexamination, diagnostic tests, as well as treatmentundertaken in each, comparing them with currentbibliography up to date. RESULTS: 1-Three out of five patients presented a tumorin the anterior vaginal wall; one had stress urinaryincontinence and the other recurrent urinary tract infection.2-The diagnostic methods employed were urethroscopy,retrograde and voiding urethrography, transvaginalultrasound, and pelvic MRI. The last two cases werediagnosed by MRI as the only diagnostic test. 3-Surgical treatment was chosen in all cases, being transvaginaldiverticulectomy the chosen operation. Onepatient underwent transurethral diverticulectomy with theSachse urethrotome for a post operative recurrence.CONCLUSIONS: Female urethra diverticulum is a clinicalentity many times underdiagnosed that should besuspected in every patient with chronic lower urinarytract symptoms. We have several available imagingtests which can confirm the working diagnosis, eitheralone or in combination, being MRI the newest.Surgical treatment has demonstrated to be curative, withthe transvaginal technique as the most effective andtherefore the one of choice.
OBJECTIVES: To evaluate the efficacy of the polypropilene mesh shaped in a T, with a circular area (to repair the cystocele) and an anterior extension (to function as a tension free sling), for the combined treatment of cystocele and urinary incontinence.METHODS: Retrospective study including 31 female patients with cystocele, with or without urinary incontinence, undergoing mesh repair. Mean age was 62.3 yr.(range 55-72). All patients were multiparous. Number of childbirths varied between 1 and 4. Mean follow-up was 23.5 months (range 12 to 29 months). 80% had grade III cystocele and 20% grade IV. 28 patients (90.3%) presented with urinary incontinence and 3 (9.67%) urgency without incontinence. 16 patients had previously undergone hysterectomy and another 6 surgery for urinary incontinence (2 Raz and 4 Burch operations). 11 patients (33.6%) needed a combination technique in the same operation: associated vaginal hysterectomy in 4 patients and posterior mesh colporrhaphy for grade III symptomatic rectocele in 7 patients.RESULTS: No patient had prolapse recurrence, 1patient needed clean intermittent catheterizations for 3 months, and 3 suffered de novo urgency (with good response to anticolinergic drugs). The worsening ofstress urinary incontinence (SUI) in one patient was solved by suburethral sling insertion; another patient who had prolonged postoperative vaginal bleeding requiringblood transfusions and subsequent mesh erosion of the vaginal wall (she underwent re-operation to cut off the mesh). 3 patients complained of intercourse discomfort which disappeared after an average of 3 months. No other remarkable intra or postoperative complications appeared.CONCLUSIONS: The polypropilene mesh associated with a sling is an effective treatment to repair cystocele with or without SUI, although long-term studies with a greater number of patients are required to validate the technique.
OBJECTIVES: To evaluate the clinical and oncological results of perineal radical prostatectomy (PRP) as monotherapy.METHODS: We include our initial series of 115 consecutive patients with prostate cancer without neoadjuvant hormonal therapy undergoing perineal radical prostatectomy as monotherapy from November 92, when we decide to abandon laparoscopic lymphadenectomy in patients deemed at low risk of N+ (PSA =10 and Gleason score = 7 and organ confined or suspicion of minimal extra capsular extension on ultrasound). Functional results are compared with the first 115 consecutive patients in our own series of retropubic radical prostatectomy (RRP). No patient received adjuvant therapy and deferredintermittent androgen blockade was only applied when patients with biochemical progression reached a PSA of 4ng/ml.RESULTS: After a mean follow-up of 57.7 months (3-130) we obtained: global survival 98.3%, disease spe-cific 100%; biochemical progression 13.9% (16), pT 2 (5.2%), 32pT3a (21.8%), 7pT3b-pT4a (71.4%)).Incidence of positive margins 41.7% (52.1% unifocal with a progression rate of only 12%). 87% of thepatients did not need transfusion during or after surgery. Urinary continence was 96.5% and the probability of potency preservation was 34.7%. Among 16 patients with biochemical progression, only 4 required deferred intermittent androgen blockade (1 cycle in 3 patients and two in the remainder).CONCLUSIONS:PRP without lymphadenectomy as monotherapy offers excellent oncological and functional results equivalent to RRP, which favour the perineal approach: short-term operative times, lower transfusion rate, possibility of regional anesthesia, better tolerance with minimal analgesia requirements, and shorter hospital stay. Watchful waiting in the follow-up of patients in biochemical progression with a deferred intermittent androgen blockade regimen offers an excellent quality of life, with survivals similar to any other therapeutic option after this follow-up time.
OBJECTIVE: To describe the procedures and complications of bladder exstrophy closure, epispadias repair and bladder neck surgery to achieve urinary control. METHODS: Retrospective chart review of 11 patients with the exstrophy-epispadias complex.RESULTS: Early bladder closure is performed after birth with or without concomitant pelvic osteotomy. The preferred procedures are: the Cantwell-Ransley technique for epispadias repair, the Young-Dees-Leadbetter procedure for bladder neck reconstruction and ileocystoplasty with Mitrofanoff for bladder augmentation.CONCLUSIONS: Augmentation and continent diversion procedures can increase the functional capacity of the exstrophic bladder, and allow the vast majority ofpatients to achieve continence and preserve renal function. Bladder lithiasis is the most significant complication in these patients.
OBJECTIVES: To analyze the complicationsand morbidity during our learning curve of laparoscopicradical prostatectomy (LRP) and compare them withother published series.METHODS: We review the 25 first laparoscopic radicalprostatectomies performed in our department, evaluatingthe operative technique and other features such as surgicaltime, blood loss, complications and conversion to opensurgery. We also evaluate morbidity, postoperativehospital stay, and functional features such as potencyand continence.RESULTS: LRP was completed in 22 patients. Overallintraoperative complication rate was 32%. 3 caseswere converted to open surgery due to technical difficulties or intraoperative complications. We had complicationsin 4 patients, that were not severe (bladder injury 2cases, and epigastric artery injury another 2) andwhere solved without difficulties during the operation.The most severe intraoperative complication was relatedto the anesthesia procedure at the time of extubation ofa patient who required tracheotomy.There were no severe postoperative complications,being leakage from the anastomosis the most common(7 cases). All of them were managed conservatively,although this resulted in a mean hospital stay of 10.8days. 2 patients required endoscopic procedures in theimmediate postoperative time for bladder catheterrepositioning. All patients suffered erectile dysfunctionand the continence rate at 3 months was 77.2%.CONCLUSIONS: Although LRP is a long operation anddifficult during the learning curve, its complication rateis acceptable because they are not severe and can bemanaged in a relatively easy way
OBJECTIVES: Report a new case of renalangiosarcoma treated by surgery and adjuvant chemotherapywith bad results.METHODS: 72-year-old male undergoing right nephrectomyfor renal tumor. Pathology reports renal angiosarcoma.RESULTS: Three months after surgery patient refers lumbar painand hemoptysis and CT scan reveals the existence of multiplebone and lung metastasis; a regimen of systemic chemotherapywith Doxorrubicine+ Ifosfamide was started without response;he died two months later.CONCLUSIONS: Primary renal angiosarcoma is very rare,with less than 10 cases in the literature before 1998, and itis always associated with bad prognosis. Diagnosis is basedon immunohistochemical studies (antibodies against CD31,CD34 and factor VIII related antigen) to define the endothelialdifferentiation of the tumor. There is no experience to definethe best therapeutic strategy against this entity.
OBJECTIVES: To report one case of isosexualprecocious pseudopuberty in a 4-year-old boy caused by aninterstitial cell testicular tumor.METHODS: Physical exam, blood tests, hormonal determinations,adrenal suppression tests, bone age, orchiectomy and pathologicstudy of the specimen were performed.RESULTS: Physical examination showed a boy with muscledevelopment, acne; body, sexual and face hair correspondingto an older boy; with increased volume of the left testicle andinfantile contralateral testicle. Urinary 17-ketosteroids wereelevated and did not decrease after dexametasone. Boneage corresponded to an 11-year-old standard. Pathologic studyshowed an interstitial cell tumor. Puberty changes disappeared afterorchiectomy.CONCLUSIONS: This diagnosis should be taken intoconsideration in every case of accelerated sexual developmentin a boy with testicular tumor and without maturation of thecontralateral testicle.
OBJETIVES: To describe the clinicopathologicalcharacteristics of the scrotal bizarre leiomyoma in order toincrease our understanding, and avoid the possibility of erroneousdiagnosis and treatment.RESULTS: We report the case of a 43 year-old patient with apendulous nodular scrotal tumour, which after microscopicstudy could be seen to be of smooth muscular origin,corresponding, because of its peculiar histological characteristics,to the rare variety called atypical or symplasmic bizarre leiomyoma.CONCLUSION: Although it is a form of leiomyoma which isextremely infrequently found in the scrotum, it is necessary toknow it can occur and to know that we are dealing with abenign tumour that should be treated as such.
OBJECTIVES: Multilocular cystic nephroma is arare benign entity grouped among the cystic non-genetic diseases,which usually presents with a clinical picture and radiologicalfeatures indistinguishable from malignant neoplasias, makingimpossible to rule out malignancy preoperatively.METHODS: We report two cases of multilocular cystic nephromawhich were treated with different surgical attitudes despitetheir clinical and radiological similarities, because on thesecond case intraoperative pathologic study of the specimenwas performed.RESULTS: The diagnosis of multilocular cystic nephroma wasconfirmed in both cases, with the difference that radicalnephrectomy was performed in the first case whereas theintraoperative study of the tumor in the second allowed to performtumorectomy with renal parenchyma preservation.CONCLUSIONS: We consider that in the presence of amultiloculated renal mass of complex appearance and benignclinical behavior, the intraoperative study of the tumor willavoid performance of radical surgery.
OBJECTIVES: To report the 7th case of pararenalangiomyolipoma published in the world literature and toreview the international bibliography.METHODS: We report the case of a 46-year-old female withhistory of renal colic and a complex mass on radiologicaltests.RESULTS/CONCLUSIONS: Extrarenal retroperitonealangiomyolipoma is a rare pathology with no more than 7published cases. The diagnostic difficulty and radiologicalsimilarities with liposarcoma make surgery the treatment ofchoice.
OBJECTIVE: To describe the clinical conditions, the radiological findings and the management of a case of seminal vesicle abscess. METHODS: A 47-year old man presented with irritative voiding symptoms, fever, diminished ejaculated volume, hematuria and testicular pain. Diagnosis was made with digital rectal examination, ultrasound and CT. RESULTS: The patient was managed with antibiotic the- rapy alone for 4 weeks. Clinical and radiological reso- lution was achieved. CONCLUSIONS: Seminal vesicle abscess is a rare condition. Diagnosis is based on clinical data and radiological findings. Conservative treatment could be effective in selected cases.
OBJECTIVES: To report the rare case of apatient with a ureteral polyp.METHODS: We describe the case of a 55-year-old femalepatient receiving care at the Celia Sanchez ManduleyUniversity Hospital in Manzanillo, Cuba, who was fortuitously diagnosed of a fibroepithelial polyp of the right ureterduring the work up and treatment of an ovarian tumor.RESULTS: This case is the first of its kind in this hospital after22 years, which confirms the rarity of ureteral tumors, specifically those of benign etiology. The absence of symptoms,specifically hematuria and pain, does not correspond to thereviewed articles. The chosen treatment was exeresis of thepolyp at its base and frozen biopsy, followed by re-establishment of the urinary passage, as various authors recommend. Currently the endoscopical approach is recommended for its multiple advantages.CONCLUSIONS: We conclude that this disease is veryrare, may have a symptomatic course and the treatment ofchoice is surgery with very good results.
OBJECTIVE: To evaluate: i. long-term efficacyof tamsulosin in the control of lower urinary tractsymptoms (LUTS) suggestive of benign prostatic obstruction(BPO) using the I-PSS questionnaire, ii. the frequency ofcomplications related to the disease, and iii. short andlong-term tolerability of tamsulosin.METHODS: A total of 2.921 patients with LUTS suggestiveof BPO for more than 6 months and total IPSS>7 treated with tamsulosin (Omnic®) in real lifepractice conditions in Spain entered an observationalprospective multicentre clinical study. Efficacy wasprimarily assessed by changes from baseline to endpointin I-PSS symptoms score (total, irritative and obstructive),and secondarily by the appearance of diseasecomplications, and urinary flow measurements. Safetywas assessed recording every suspected adverse reaction,blood pressure changes and laboratory data on months6 and 12. Evolution in time of free flow and sonographicalevaluation of the prostate were also obtained in 663(22.7%) and 1346 (46.1%) cases, respectively, and the use of previous and concomitant medication wasalso analysed.RESULTS: After 6 and 12 months total I-PSS, irritative,and obstructive symptoms were significantly reducedwith the use of tamsulosin 0,4 mg once daily. At 1 yearfollow-up total I-PSS score, irritative symptoms, andobstructive symptoms were reduced in 8.2, 3.5 and4.8 points (46%, 45% and 48% improvement), respectively(p< 0.0001). The proportion of patients seriouslysymptomatic (total I-PSS score 20-35) was reduced from34.8 % at the start of the study to 8% at 6 months and2.9% at 12 months. Mean QoL also significantly improvedafter 6 and 12 months of treatment. Average score QoLindex was reduced from 4.1 to 1.86 after 12 months(2.24 points, 55% improvement) (p< 0.0001). Qmaxalso significantly improved after 6 and 12 months oftreatment (p< 0.0001). The good tolerability profile oftamsulosin has been confirmed after 6 and 12 monthsof treatment.CONCLUSIONS: Therapeutic intervention with tamsulosin0,4 mg once daily is effective in all parameters analysed(I-PSS questionnaire and flow study), very well toleratedand safe in the short-term (6 and 12 months) in patientswith LUTS suggestive of BPO. Long-term data specificallyregarding the decrease in prostate volume and the evolutionof the BPH condition will be welcome.
OBJECTIVE: We review “in vivo”methods most commonly used for the investigation ofdetruso-sphincteric pharmacological response. Wecompare this information with the procedures used inour Institution for these purposes.METHODS: The medical databases MEDLINE, EMBASEand Pascal Biomed were searched to identify articles onthis subject. The methods used have been criticallyanalyzed and compared with the methods used in ourexperiments.RESULTS: The “in vivo” dynamic investigation ofvesico-sphincteric function began at our Institution in thelate 70s. Methods for the study of vesical or urethraldynamic behaviour have been devised to be appliedindependently or simultaneously. Great difficulties havebeen encountered, both in our experience and in thework of revised authors, in the integrated investigationof Lower Urinary Tract function. Methods to overcomethese drawbacks have been proposed.CONCLUSIONS: Methods for “in vivo” studies ofphysiological and pharmacological detruso-sphinctericfunction are presented and compared with currentprocedures found in the literature. It is highlighted thatan integrated method for the simultaneous study ofvesico-sphincteric function is a difficult challenge yet tobe taken up.