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OBJECTIVE: The urologic cases presented for discussion to the Board of the San Carlos Royal College of Surgery (Madrid), created in 1787 by royal decree of King Carlos III for the education and training of surgeons attending the general population, are reviewed. Their contents and the stage of the art of urology in that period are analyzed.METHODS: 303 records in the archives of the Faculty of Medicine of the Complutensis University of Madrid, presented to the Board of the San Carlos Royal College of Surgery for discussion at their regular meetings on Thursday, during the period spanning 1788-1834, were reviewed. A complete list of urologic cases and a transcription of the description of a bladder procedure are presented.RESULTS: 69 urologic cases were found. Lithiasis was the most common, followed by voiding disorders that encompass all urethrovesical conditions. Complications, such as fistula and abscess, account for a large part of the cases reported, followed by testicular and scrotal pathology (basically hydrolece), veneral disease and their complications of stricture and infection. The surgical techniques mainly comprised lithotomy (with analysis of the different perineal approaches), bladder punction for retention, urethrotomy, circumcision and surgical treatment of hydrocele by castration or punction.CONCLUSIONS: The urologic cases reviewed by the Board of the San Carlos Royal College of Surgery were basically those of the most common conditions of that period, mainly lithiasis and voiding disorders arising from urethrovesical conditions and their complications, as well as diseases of the male genitalia. The surgical techniques focussed mainly on the description of stone removal by the perineal approach and castration or punction for hydrocele. The reports and reviews followed the principles of galenic and hippocratic medicine. The impact of European advancements were only observed in the latter stages. Undoubtedly, these records and reviews have made an outstanding contribution to the 18th and early 19th century Spanish medical literature.
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OBJECTIVE: The anatomic anomalies ofthe inferior cava and its collaterals, even though they donot normally show symptoms, can cause difficulties indifferent diagnostic and therapeutic procedures, such asthe percutaneous treatment by gonadal embolization ofthe varicocele.METHODS: We analyzed the incidence of one of theseanomalies, specifically the left circumaortic renal vein, ina series of 50 gonadal embolization procedures forsymptomatic varicocele.RESULTS: We found two cases (4%) of left circumaorticrenal vein in our series. Gonadal embolization was possiblein only one of the cases since the ostium of the gonadal veincould not be localized in the other case. In the first case,the gonadal ostium was in the paraaortic confluence of thevenous ring, and could be catheterized and selectivelyembolized.CONCLUSIONS: The presence of a circumaortic leftrenal vein can make it technically impossible to performembolization of the symptomatic varicocele.
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OBJECTIVE: To analyze the influence ofpersonal and histopathological factors as prognostic variables in the evolution of upper urothelial tumors submittedto radical surgery.METHODS: Multifactorial retrospective study of aseries of 61 patients submitted to radical surgery for upperurinary tract transitional cell tumors. Patient habits andhistopathological factors are analyzed. The statistical significance of the different factors wasanalyzed using the Pearson chi-square test for thequalitative variables, with analysis of the residuals andKaplan-Meier survival curves and statistical validation with the Mantel Cox test. The level of significance wasp < 0.05.RESULTS: A statistically significant correlation wasfound for tumor-related death and pathological stage,positive lymphadenectomy and positive lymphadenopathyon the CT (p < 0.05). The presence or absence of a historyof smoking was not available for all patients and wastherefore not evaluable. The most frequent reason forconsultation was hematuria (39%). Tumor growth wasmostly of the papillary type (79%), localization wasmostly in the renal pelvis (30%) and the most frequentprocedure was nephroureterectomy without endoscopicdetachment (60%). CONCLUSIONS: The pathological stage and a positivelymphadenectomy or the presence of positivelymphadenopathies on the CT were found to be prognosticfactors in urothelial tumors of the upper urinary tract.
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OBJECTIVE: Ultrasound-guided transrectal biopsy of the prostate is generally considered to be well-tolerated and with few complications. The results of a prospective study that evaluated patient and biopsy performer's perception of the foregoing aspects are presented. METHODS: The records of 305 consecutive patients submitted to ultrasound-guided transrectal biopsy were analyzed. Aspects of the physical examination and biopsy performer's assessment of patient tolerance were recorded in 290 cases. 264 patients filled out a questionnaire on different aspects of the test. A telephone interview was carried out to obtain data on side-effects and complications of the biopsy procedure. Patient and biopsy performer's perception of tolerance and complications of ultrasound- guided transrectal biopsy were analyzed. RESULTS: Biopsy could not be performed in 1% of the cases due to pain. Before biopsy 34.5% of the patients thought the procedure would be painful, while only 6.8% sustained this view after biopsy. Insertion of the transducer and punction were considered to be painful by 8% and 12.9% of the patients, respectively, and 2.9% considered anesthesia should be used for the procedure. Tolerance of biopsy punction remained unchanged throughout the procedure in 53.2% and became worse as the test proceeded in the remaining patients. Anxiety and increased anal tone were found to be the only factors that had an impact on tolerance. The complications were: fever > 38°C (0.7%), rectal bleeding that required admission to the observation ward (1%), hematuria (51.1%), hemospermia (21.3%), difficulty in voiding (2.5%) and urinary retention (0.3%). Moderate vagal reactions were the most common immediate complications (2.4%). CONCLUSIONS: Ultrasound-guided transrectal biopsy is generally well-tolerated and with few complications. Rectal bleeding is the complication that most frequently requires management and causes more anxiety to patients, but infection is the most severe.
Case Report
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OBJECTIVE: To present two cases of intrascrotal lithiasis associated with hydrocele and the results of the crystallographic study.METHODS: Three intrascrotal calculi in two patients aged 72 and 75 years that underwent surgery for hydrocele were analyzed. Two 2-mm. calculi were incidentally discovered during surgery for a right hydrocele in one patient. An ultrasound scan of the other patient showed a left hydrocele with a free-floating, round, hyperechoic, 6-mm. calculus, with posterior acoustic shadow. None of the patients had a previous history of trauma. The 3 calculi were white and smooth, but turned yellow and rough after removal. Scanning electron microscopy and x-ray dispersion studies were performed.RESULTS: All 3 calculi had a center comprised of hydroxyapatite and white organic matter, and an exterior of yellow organic matter. The mineral portion of the center of the 6-mm. calculus and one of the 2-mm. calculi was composed of 33% phosphorus and 67% calcium, and the other 2-mm. calculus contained 32% phosphorus and 68%calcium by x-ray dispersion analysis.CONCLUSIONS: Intrascrotal lithiasis is rare. In the two cases described herein, we observed abundant organic matter, particularly on the stone surface, and hydroxyapatite, particularly in the center. Among the possible etiologic causes, the deposit of organic matter in the presence of high oversaturation of calcium phosphates and absence of cystallization inhibitors, can initiate calcification and the subsequent collection of organic matter makes the process irreversible.
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OBJECTIVE: The aim of this clinicoepidemiologic study is to determine the frequency, risk factors, morbidity and socioeconomic impact or urolithiasis in the general population of a Caribbean, subtropical rural area.METHODS: A representative sample of 1,504 subjects were randomly selected from the general population of 15,591 inhabitants in the area whose health services were provided by the Policlinico Julio Trujillo using the two-stage and equal probability functions with 95% CI. After informed consent was obtained, a survey was conducted to identify the subjects in the sample that had developed urolithiasis at some time or another. All subjects with a history of urolithiasis were included in a second survey to obtain the data required to complete the study.RESULTS: The prevalence rate was found to be similar to the 2.52% prevalence estimated worldwide. Urolithiasis was more common in the 20-29 years age group for both genders, and prevalent in the caucasians (3.2%) and male gender (3.2%). 36.8% of the subjects that had developed urolithiasis at some time or another had a family history of urolithiasis. Urinary tract infection, arterial hypertension, ischemic heart disease and diabetes mellitus were frequently associated with this condition. The incidence of stone formation was higher for the hottest period. High intake of food rich in oxalic acid, carbohydrates, proteins-purines and dairy products and low intake of fluids were closely linked with lithiasis. 97.2% s had one and 78.3% had more than one episode of nephric colic. 68.4% had one and 61.5% more than one recurrence of urolithiasis. 15.7% required surgery and 42.1% required hospitalization. Only 42.1% of the cases had unspecific medical treatment. No case had specific treatment.CONCLUSIONS: The behavior of urolithiasis in this rural population is the same as that reported in other studies for urban areas. It showed a high frequency, similar risk factors, high morbidity and important socioeconomic impact. Only half of the patients received treatment that is considered to be the least costly.
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OBJECTIVE: To compare the morbidity of conventional inguinal lymphadenectomy for epidermoid carcinoma of the penis using ligation versus ultrasonic sealing of the lymph nodes with Ligasure(TM). METHODS: 29 cases of carcinoma of the penis are analyzed; 8 underwent superficial and deep inguinal lymphadenectomy using the conventional procedure for ligation of lymph nodes (4 cases) and ultrasonic ligation with Ligasure(TM) (4 cases). The early and late complications are analyzed. RESULTS: The operating time was found to be significantly shorter in patients treated with Ligasure(TM), no lymphoceles were observed and lymphedema was reduced. CONCLUSIONS: The use of Ligasure(TM) for sealing the lymphatic vessels in inguinal lymphadenectomy for carci- noma of the penis appears to have the advantages of a shorter operating time and reduced complications in comparison with conventional ligation.
Case Report
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OBJECTIVE: To present a case of a 16-year-old male patient with primary enuresis refractory toconservative treatment.METHODS / RESULTS: Radiologic and urodynamictests revealed posterior urethral valves that were treatedby transurethral fulguration. The patient was cured ofboth enuresis and infravesical obstruction and remainsdisease-free 3 years after the operation with no impact onhis sexual function.CONCLUSIONS: Posterior urethral valves are veryrarely diagnosed in adolescents and adults. Very fewcases have been published in the literature. To ourknowledge, the case described herein is the first casepresenting with persistent primary enuresis.
Case Report
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OBJECTIVE: Two cases of extra-adrenal nonsecretory retroperitoneal paraganglioma in male patients arepresented. The first case had intermittent vascular claudication inlower limbs and the second one was an incidental finding duringstaging of a lymphoma. METHODS: Both cases were studied using imaging techniques(US, CT and MRI) and histological and immunohistochemicalanalyses.RESULTS: The imaging techniques demonstrated solidhomogeneous retroperitoneal masses intimately adhered to theabdominal aorta in the first case and located in the left upperhemiabdomen (in front of the left kidney) in the second one.Histological analysis showed a proliferation of spindle cells withcuboid cytoplasm arranged in solid nests, with typicalimmunohistochemical findings of paraganglioma.CONCLUSIONS: Extra-adrenal retroperitoneal paragangliomaare rare tumors, particularly the non-secretory variant. The onlyreliable criteria for malignancy are extensive capsular invasion anddistant metastases.
Case Report
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OBJECTIVE: To present a case of transitional cell carcinoma of the bladder with diffuse intrasinusoidal metastases to the liver that presented as fulminant hepatic failure. METHODS / RESULTS: A 65-year-old patient who presented at the emergency department of this hospital with fever and pain in the right hypochondrium and flank is described. Three months previously the patient had undergone operation in our department for a recurrence of a tumor affecting the bladder and urethra (Tis of the bladder and T1 GII of the prostatic urethra). The blood tests on admission were practically normal but showed alterations from the twelfth day onwards, suggesting acute liver failure in the differential diagnosis; the patient died 21 days later. The ultrasound and CT scans showed hepatomegaly with multiple heterogeneous areas which were not visible three months earlier and with no space- occupying lesions. At autopsy, the liver was found to be enlarged, with no macroscopic metastatic nodules. Microscopic examination revealed massive tumoral infiltration of the hepatic sinusoids with diffuse replacement of the hepatocytes. CONCLUSIONS: Secondary, metastatic liver cancer usually presents as multiple nodular lesions and only vary on very rare occasions as a diffuse infiltration leading to acute hepatic failure. This case provides the first description of the autopsy findings in a bladder transitional cell carcinoma with diffuse intrasinusoidal metastases to the liver.
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OBJECTIVE: To present 3 cases of primary abscessof the psoas muscle. The clinical features, diagnostic tests, treatmentand outcome are discussed.METHODS / RESULTS: Three patients that presented with feverand pain referred to the renal and/or iliac fossa are described.Physical examination showed psoas involvement in only one patient.Among the complementary tests performed, ultrasound demonstratedthe abscess in one of the cases; the definitive diagnosis was made bycontrast-enhanced CT. One of the cases was treated only withantibiotics while the other two cases were treated with CT-guidedpercutaneous drainage and appropriate antibiotic therapy.CONCLUSIONS: Psoas abscess is an uncommon pathologywhose presenting features are usually unspecific. CT with contrastenhancement is considered to be the technique of choice for thediagnosis and to corroborate the resolution of the condition. Recently,the use of CT or US-guided percutaneous drainage has replacedsurgery as the initial therapeutic approach for this condition.
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OBJECTIVE: To report a case of choriocarcinomaof the bladder during the different periods of its evolution. Theanatomopathological study showing dedifferentiation of a transitionalcell tumor is presented and the histogenesis of this rare tumor isdiscussed. METHODS: A case of a rapidly progressing transitional celltumor of the bladder that dedifferentiated into choriocarcinoma ispresented. The pathological findings of the first resections of thetransitional cell tumor that progressed to choriocarcinoma arepresented and the histogenesis is discussed.RESULTS / CONCLUSIONS: Choriocarcinoma of the bladder isvery rare, highly malignant and carries a poor prognosis. Its originis widely accepted to be in the dedifferentiation of a transitional celltumor. The use of immunohistochemistry and the positivity of HCGsupport the diagnosis.
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OBJECTIVE: Retrovesical cystic lesions are uncommon, although its incidence is growing due to the use of current diagnostic techniques. Its clinical features are unspecific and can mimic other conditions of the lower urinary tract making the differential diagnosis of this disease entity is difficult. A case of appendiceal mucocele, an unusual retrovesical lesion, is presented METHODS / RESULTS: A 9 x 14 cm right retrovesical cystic lesion suggestive of a seminal vesicle cyst was detected in a 57-year-old patient with pollakiuria. The patient was symptomatic, therefore surgical exploration was performed and the lesion was resected. The histological analysis of the surgical specimen demonstrated an appendiceal mucocele with no signs of atypia. The literature is reviewed, with special reference to the diagnostic and therapeutic aspects of this lesion.CONCLUSIONS: We underscore the need to utilize the diagnostic armamentarium (transrectal US, CT, MRI, deferens vesiculography, urethrocystoscopy, colonoscopy, opaque enema, IVP, etc.) to identify retrovesical cystic lesions. Preoperative diagnosis is necessary in appendiceal mucocele to avoid rupture during the surgical procedure and prevent peritoneal pseudomyxoma. Occasionally, however, the definitive diagnosis of these retrovesical lesions can be made only by punction biopsy or surgical exploration.
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OBJECTIVE: To report a case of ureteroplastyusing the vermiform appendix.METHODS: Herein we describe a patient who underwent partialresection of the ureter due to a neoplasm. The ureteral defect wasrepaired using the vermiform appendix. The surgical technique andthe results achieved are presented and the literature is brieflyreviewed.RESULTS / CONCLUSIONS: The few cases reported in theliterature and the case described herein show the utility of thevermiform appendix for ureteral substitution in specific cases wherethis procedure is indicated.
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OBJECTIVE: To review the main features of femaleurethral cancer, the only genitourinary neoplasm with a predilectionfor women, the ratio being 4:1. Female urethral cancer is anuncommon neoplasm that accounts for only 0.02% of all cancersfound in women.METHODS: A case of female urethral cancer in a 52-year-oldwoman is presented.RESULTS / CONCLUSIONS: Female urethral cancer is anuncommon neoplasm. The clinical pathologic stage is the bestpredictor of the disease-free survival rate. For patients with Ta-2N0M0 tumors, multimodality therapy may not be required. Forpatients with T3-4N0M0 tumors, the best results are obtained withmultimodal radiation and chemotherapy with surgical resection.
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OBJECTIVE: To describe a surgical optionin the resection of the distal third of the ureter and bladdercuff.MATERIAL AND METHOD: Three nephroureterectomieswere performed by the extraperitonealaccess. The first was performed in a patient withvesicoureteral reflux, recurrent urinary infection andchronic renal failure; and two nephroureterectomies wereperformed for the treatment of upper urinary tracttransitional cell cancer.RESULTS: Nephrectomy, according to the techniquedescribed by Gill, and treatment of the distal ureter weredone based on the principles of open surgery, with exposureof the kidney by enlargement of one of the portals,sectioning the ureter, insertion of a catheter in the ureterantegradely of and eversion of the ureter endoscopically,followed by the removal of the bladder cuff.CONCLUSION: Among the techniques utilized for thisprocedure, we believe that the technique described herein presents some advantages because it does not require anincision for the removal of the distal ureter, it is easy toperform and provides more comfort to the patient after thesurgery. Furthermore, only materials used by the urologistin routine practice are required and there is nocontamination of the surgical space by neoplastic cells.
