OBJECTIVE: In the Spanish health system, General Practitioners (GPs) play a key role in regulating the flow of patients to hospital care. Most of patients with BPH can be managed throughout the evolution of the disease exclusively by the GPs. METHODS: A pre-experimental study was carried out in two periods, before (pre-test) and after (post-test) of the dissemination of a management protocol for patients with BPH. The protocol was trialled in the health area of Villarrobledo and included all referrals to the urology clinic for BPH from Primary Care. We analyzed the appropriate referrals according with the criteria set forth in the protocol and compared the complementary tests through statistical study (descriptive, a bivariate, multi-variate analysis and rate calculation) using version 21 of the SPSS. RESULTS: Referral rate decreased after the application of the protocol but did not increase the rate of appropriated referrals. Patients referred after setting forth protocol by GPs that assisted to the education program were younger. There were referred less patients with elevated PSA and more patients with clinical progression. These GPs used less test to achieve diagnosis. The GPs who did not attend were significantly younger, mainly women, with no previous specific training in BPH and without a full time GP position. CONCLUSIONS: The implementation of a protocol has reduced the referral rate, but it has not improved the appropriate referrals. More research is required to understand the determinants of inequalities in referral from primary care.
OBJECTIVE: To determine the prevalence of Urinary Incontinence (UI) in a hospitalization unit. METHODS: Descriptive cross-sectional study, with pa- tients in a hospitalization unit in Ferrol. The prevalence, the type of UI, the UI assessment and the impact of UI on daily life were estimated with the questionnaires: IU-4 (by sex), the severity tool ICIQ-SF and the IIQ. RESULTS: 302 patients participated in the study. The prevalence of UI was 41.4%. Regarding the type of incontinence, 35% suffer stress UI, 27% urge UI, 14.6% mixed UI, 8.8% functional UI and 2.2% Reflex UI. We can affirm that being a woman is a risk factor for UI [p<0.001; OR 5.0-95% CI (2.8-8.9)]. On the other hand, medium physical activity is objectified as a protective factor to suffer UI (p=0.003). CONCLUSION: The impact on the quality of life of the UI is high. Establishing more real data of predictive factors may help to identify patients. Using standardized methods of study such as validated questionnaires when assessing our patients is also of interest. The need to manage UI should be reinforced as a priority for nursing professionals, not only during hospital admissions, but also at the community level or in emergencies, due to the high prevalence described.
OBJECTIVE: Perform a detailed anatomo-pathological analysis of consecutive surgical specimens in men with clinically very low risk prostate cancer ac-cording to National Comprehensive Cancer Network (NCCN) criteria. MATERIALS AND METHODS: The study included 799 prostate cancer patients who underwent radical prosta-tectomy between January 2005 and December 2013. We identified 81 consecutive patients with clinically very low risk prostate cancer. The slides of the patients who fulfilled the inclusion criteria were re-reviewed. The parameters studied were: pathological stage, histological grade by Gleason score (GSS), margins involve-ment, tumor percentage (PT), and number of apparently independent tumor foci (FT).RESULTS: The patients had organ-confined tumors in almost all of them (pT2: 97.5%). Most of the cancers studied were bilateral (pT2c: 67.9%), multifocal (FT≥2: 88.8%), with a low tumor percentage (PT<10%: 80.2%) and with a low Gleason Score (GSS≤6: 91,3%). Non-confined disease: 2.5%, all cases extra-prostatic extension (pT3a). GSS>6: 8,6%, all cases GSS7(3+4). CONCLUSIONS: The NCCN criteria for very low risk prostate cancer help to make a good selection of non-aggressive tumors and are a useful tool for including patients in an active surveillance program.
The ERAS (Enhanced Recovery After Surgery) protocol, originated in the 1990s when two groups of researchers presented different proposals to improve the postoperative evolution of patients undergoing elective surgery. In 2001, the ERAS group was organized, consisting of different surgery units from northern Europe (Scotland, Sweden, Denmark, Norway, and the Netherlands). This group made a consensus that they called the ERAS project, characterized by a multimodal reha- bilitation program for surgically operated patients on a scheduled basis. The protocol includes a combination of preoperative, intraoperative, and postoperative strategies based on scientific evidence. That improves the recovery and functionality of patients after the surgical event minimizes the response to surgical stress. Besides, this action on factors involved in the biological response to aggression impacts postoperative complications and decreases hospital stay and hospitalization costs. The professionals in charge of the patient are responsible for three key elements that affect the outcome after surgery: the first is the control of stress reactions to surgery, the second is fluid therapy, and the third is analgesia. The trimodal approach leads to improving the results in urological surgery, such as radical cystectomy.
OBJECTIVE: Perform a review on the di-agnosis and treatment of pheochromocytomas and ma-lignant paragangliomas.MATERIAL AND METHOD: A search was conducted in PubMed and Google Scholar of articles or clinical guides that referred to the diagnosis and treatment of these tumors.RESULTS: For the diagnosis of malignancy, a histological confirmation of a pheochromocytoma or paraganglioma should be provided, plus the presence of metastasis confirmed by images. Methanephrines are recommend-ed over other biochemical determinations. For staging, PET-CT with 18F-FDG or 18F-DOPA is preferred because of its greater sensitivity than conventional images. The 123I-MIBG scan should be requested when radiothera-py with 131I-MIBG is planned.For treatment, control of adrenergic symptoms through the use of α-blockers is recommended. Active surveil-lance was an option in selected patients with slowly progressive tumors. Surgical treatment improved OS (148 months vs 36 months p=<0.01). Therapy with 131I-MIBG was indicated in patients with positive scin-tigraphy, reporting a global survival of 50% at 5 years with variable tumor responses. Chemotherapy was pro-posed in rapidly progressive disease, reporting a medi-an overall survival of 6 years. Ablative therapies should be considered when there is a limited number of lesions, to achieve local tumor control and reduce the symptoms of excess catecholamines. External radiation therapy at high doses would be effective for patients with local symptoms due to their tumor burden. Prospective multi-in-stitutional clinical trials are needed to determine the true benefits of molecular therapies in these patients.CONCLUSIONS: We recommend a multidisciplinary approach in centers of high complexity to be able to offer the entire diagnostic - therapeutic arsenal available so far that they improve the survival and quality of life of these patients.
OBJECTIVES: The utility and importance of the 3-day Bladder Diary (3dBD) for the diagnosis and management of patients with Bladder Pain Syndrome (BPS) was analyzed.MATERIAL AND METHODS: Epidemiological, obser-vational, longitudinal and multicentric study, carried out under usual conditions of clinical practice. 37 Functional Urology and Urodynamics units included 329 women with BPS according to the criteria of the International So-ciety for the Study of Bladder Pain Syndrome (ESSIC). Of all patients included, 319 were evaluable (79 with new diagnosis and 240 in follow-up). Sociodemographic and clinical variables were collected together with vari-ables related to cystoscopy, biopsy and physical exam-ination and BPS diagnostic tests. Patients completed the “Bladder Pain/Interstitial Cystitis - Symptom Score” (BPIC-SS), “Patient Global Impression of Severity” (PGI-S) and “EuroQoL-5D-5L” (EQ-5D-5L) questionnaires besides of the 3dBD. Results of the 3dBD were described ac-cording to urinary symptoms and the symptoms reported through questionnaires, in addition their association was studied.RESULTS: In anamnesis, 74.9% of patients reported in-creased Urinary Frequency (UF), 59.6% urgency and 72.7% nocturia compared to 88.7%, 55.9% and 73.6% as reflected in the 3dBD. The highest correlation index-es (CI) were obtained between BPIC-SS and UF/24h (0.45) and between UF/24 h and PGI-S (-0.36) and EQ-5D-5L (-0.33). Mean voiding volume was higher in patients with better BPIC-SS score (163.72 (SD 68.02 ml) y 154.1 (SD 70.63 ml)), at 6 and 12 months.CONCLUSIONS: 3dBD has proven to be a useful and complementary tool to the anamnesis in the evaluation of the repercussion of pain in the micturition pattern and for the differential diagnosis of the symptoms of BPS pa-tients. It also allows to obtain complete and objective information about the symptoms. Although it is necessary to incorporate other tools that complete the clinical char-acterization of these patients.
OBJECTIVE: Ureteroscopic lithotripsy (URS) is the current standard choice of treatment for both ureteral and adequate renal stones. Although it is known to be a safe procedure, postoperative febrile urinary tract infection (UTI) is not rare. Especially in diabetic pa-tients, rate of urinary tract infection is higher. Therefore, we aimed to describe the risk factors for UTI following URS in diabetics.MATERIALS AND METHODS: Between January 2017 and April 2019, 546 patients who underwent uretero-scopic lithotripsy for ureteral and/or renal stones were included. A matched-pair analysis was performed to compare postoperative UTI rates between diabetics and nondiabetics. We retrospectively reviewed the medical records including age, gender, BMI, comorbidities, UTI history, hemoglobin A1c (HbA1c), operating time, stone size and hounsfield unit (HU), preoperative hydro-nephrosis, ureteroscopic methods and ureteral stenting. Logistic regression analysis was done to determine the risk factors for postoperative UTI in diabetics.RESULTS: In diabetic patients rate of postoperative UTI was 29% (13/45). After matched-pair analysis within the group of non-diabetics, incidence was 11% (5/44) (p=0.04). In univariate analysis, preoperative ureteral stent, UTI history and HbA1c level were the risk factors for UTI after URS in diabetics. UTI history and HbA1c level were the independent risk factors for developing postoperative UTI in diabetic patients. HbA1c threshold 6.9% afforded 75% sensitivity and 67% specificity for predicting postoperative UTI in diabetics.CONCLUSIONS: Diabetic patients are under greater risk to develop postoperative UTI following URS. Those patients with UTI history and HbA1c level higher than 6.9% must be followed carefully.
OBJECTIVE: To compare miniaturized percutaneous nephrolithotomy (mini-PNL) and retrograde intrarenal surgery (RIRS) in children with 10-20 mm renal stones.MATERIALS AND METHODS: Between 2015 and 2019, 63 pediatric patients aged under 16 years who underwent mini-PNL and RIRS for the treatment of kidney stones sized 10-20 mm were analyzed retrospectively. The mini-PNL group (n=30) was defined as group 1 and the RIRS group (n=33) was defined as group 2. Peri-operative data including stone-free rate, operative time, fluoroscopy time, hospitalization time, number of anesthesia sessions, complication rates, and cost-effec-tiveness were analyzed. RESULTS: The mean age was 8.09±5.49 years in group 1 and 5.75±4.56 years in group 2. The stone-free rate was not different at the first (80.0% vs. 57.6%) and third month (93.3% vs. 90.9%) follow-up in group 1 and group 2. The mean hospitalization, operative, and fluoroscopy times were statistically significantly longer in group 1. The mean number of anesthesia sessions for patients was 1.20±0.40 in group 1 and 2.15±0.44 in group 2 (p=0.00). Minor complication rates were not different and no major complications were observed in either group. The cost per patient was calculated as 365.97 Euros in group 1 and 698.64 Euros in group 2 (p=0.001).CONCLUSIONS: This study suggested that RIRS was an effective alternative treatment method for 10-20 mm kidney stones in children, with comparable stone-free and complication rates. RIRS has a shorter operative time, fluoroscopy time, hospital stay than mini-PNL, with a similar stone-free rate for 10-20 mm kidney stones in children. However, mini-PNL is cheaper and allowed a lower need for anesthesia sessions.
OBJECTIVE: Renal cell carcinoma is con-stantly associated with calcification, but ossification is ex-tremely scarce. METHOD: We retrospectively analyzed two cases with clear cell renal cell carcinoma with osseous metaplasia. RESULTS: We criticized the oldest case of woman whose a 32x31mm irregular renal mass with calcifications and we also mentioned about a diffusely calcified mass of 90mm of a 68-year-old male patient. The histopathological exam-inations of both were reported as clear cell carcinoma with metaplastic bone formation. CONCLUSION: Although there are no definitive data on prognosis and follow-up due to the low number of cases; this entity usually occurs with early stage disease and a favorable prognosis as in our cases. While the prognostic importance of osseous metaplasia existence in renal cell carcinoma is controversial, such that can safely be man-aged with nephron sparing surgery in appropriate cases. As the number of cases and follow-up periods increased; more definitive information will be obtained.
OBJECTIVE: To assess the importance of long-term close follow-up in patients with breast carcinoma.MATERIALS AND METHODS: To present a case reportRESULTS: A case of a 55-year-old woman with history of lobular carcinoma of the breast is presented. She received neoadjuvant treatment, surgery and complementary chemo-therapy and radiotherapy. In radiologic imaging studies, multiple bone metastases were diagnosed. The patient consulted for left lumbar pain. Radiologic studies revealed left hydronephrosis secondary to soft tissue lesion in pyelo-ureteral junction with renal functional impairment. A biopsy performed using an endoscopic approach (ureteroscopy), diagnosed a metastasis of breast carcinoma in the ureter.CONCLUSION: Metastatic lesions in the ureter are ex-tremely rare, even less frequent the ones with breast origin with around ten cases published worldwide. With the pre-vious diagnosis of breast carcinoma, the probable ureteral compromise should be considered especially in patients with clinical and radiological symptoms of urinary tract ob-struction. A well-timed and proper diagnosis may influence in prognosis and survival.