Los Carcinomas Renales estadio T1 clínico (< 7,0 cm) son frecuentes (aproximadamente entre 30- 40.000 casos por año en los Estados Unidos). Aproximadamente el 20 % son benignos, el 60% parecen ser carcinomas de células renales (CCR) relativamente indolentes, y sólo un 20 % muestran características histopatológicas potencialmente agresivas. Las opciones de manejo incluyen nefrectomía radi- cal (NR), nefrectomía parcial (NP), ablación térmica (TA) y vigilancia activa (VA).
Early diagnosis of upper urinary tract tumors is not easy. The development of endoscopic equipment has expanded the group of patients candidates for minimally invasive treatment. Only by providing accurate tumor staging and grading can clinicians decide which patients should be offered conservative therapies. We need diagnostic methods that allow us to make an early and accurate diagnosis for these lesions, as well as safe follow-up. Our proposal is to present a review of the most used diagnostic method, their features, and future diagnostic tools. The diagnostic arsenal requires further improvement. Only through accurate diagnosis, we will be able to safely provide conservative treatment. Developing new diagnostic techniques seem to move us closer to this goal even more. We propose a working algorithm on the management of these lesions.
OBJECTIVES: To test two interventions aiming at improving the compliance of primary health care physicians with an agreed-on protocol of referrals to a urology department.METHODS: Joint formative meetings (every six months) were celebrated throughout a 24-month period. Also a counseling telephone line was implemented. 18.088 referrals were analyzed. The effect of both expositions was tested comparing basal data (T0) with the performance at 6, 12, 18 and 24 months later (T1, T2, T3 and T4, respectively). An additional comparison was conducted to approach the results 1 year after the study ended (T5).RESULTS: 61.7% of the referrals at baseline complied with the protocol. A significant improvement was detected at T1 (compliance 73.4%, RR with respect to T0 1.19, 95% CI 1.14- 1.23). At T2, 73.7% of referrals were adequate (RR with respect to T0 1.19, 95% CI 1.15-1.24).The percent of adequate referrals at T3 remained stable (73.4%, RR with respect to T0 1.18, 95% CI 1.15-1.23). Nevertheless, adequacy of referrals by the end of the second year (T4) significantly decreased (67.3%, RR with respect to T0, 1.09, 95% CI 1.05-1.12). Adequacy at T5 was almost identical to the basal (64.4%, RR with respect to T0, 1.04 95% CI 1.04-1.07).CONCLUSIONS: Learning activities can be effective in improving the quality of referrals from primary care to one urology department. Stopping the activities entails an immediate return to the basal standards.
OBJECTIVES: Ta bladder tumors constitute 53% of primary bladder neoplasms, 70% of them being low-grade (G1). These tumors present a 15-38% chance of recurrence during the first year. The aim of this paper is to identify the predicting factors of the first recurrence in a series of TaG1 primary bladder tumors.METHODS: We have retrospectively analyzed patients who were diagnosed with TaG1 primary bladder tumor by transurethral resection between 2004 and 2012. We established their tumor grade and pathological stage according to the WHO’s classification guides for 1973 and 2004 as well as 2009’s TNM. Those patients who were diagnosed before 2009 did not receive any adjuvant treatment. Those who were diagnosed later on received 40 mg of endovesical Mitomycin C during their immediate post operative period as their only treatment. We define recurrence as the presence of tumor after the first cystoscopy and relapse-free survival (RFS) as the period of time (in months) until the first recurrence appeared. Follow up constitutes the period of time (in months) until the last check-up or first recurrence.We also analyzed different variables: age, gender, smoking habits, muscular representation in the sample, size of the tumor (> or < 1 cm), multiple or single tumors and adjuvant treatment. The survival analysis was performed by the Kaplan-Meier method, using the long-rank test to evaluate the differences between groups.RESULTS: 68 patients were included in the study (73.5 % men, 75% smokers). The average age was 61.9 years (the median being 58.5). Average follow up was 33.2 months (median 28.4). 35.3% of patients experienced recurrence. Average RFS was 19.2 ± 12.7 months (median 13.5). The majority of tumors were of a single nature (77.9%), with a size of less than 1 cm (55.9%) and with muscle representation (52.9%). 57.4% of patients did not receive adjuvant treatment. Only the absence of adjuvant treatment was associated with recurrence in uni and multivariate analysis (p<0,001), with a relative risk of 17,5 IC95% (7,6-30,2).CONCLUSION: The absence of adjuvant therapy with Mitomycin C is the only factor that, in a statistically significant way, increases the risk of recurrence, regardless of demographic factors and the characteristics of the tumor.
OBJECTIVES: To study the efficacy and safety of the Perigee® System for the treatment of anterior vaginal prolapse in our experience with a medium term follow-up.METHODS: Prospective analysis on 48 consecutive patients with stage II-IV cystocele diagnosed from June 2006 until June 2009 using the Pelvic Organ Prolapse Quantitation classification without other associated prolapses. All diagnoses were done by a single urological specialist and follow-up is between 3 to 6 years. The questionnaire Patient Global Impression of Improvement was carried out before surgery, at the first follow up checking at one month, and at 6 and 12 months. The variables evaluated were age, presence of obesity, parity, prior hysterectomy, ASA class and stage of prolapse. RESULTS: The result, evaluating the questionnaire Patient Global Impression of Improvement, was cured or improved in 40 (83.3%) patients and 87.5% according to the Pelvic Organ Prolapse Quantitation, with a recurrence rate of 6.25%. Intraoperative complications were observed in 12.5% of the patients, postoperative in 4.2% and 41.5% after hospital discharge, pain being the most common complication (16.6%). The key variables for procedural failure were age 65 years >, obesity, parity ≥ 2, prolapse stage ≥ III and prior hysterectomy (p <0.05).CONCLUSIONS: In our series the Perigee® System allows anatomic repair with less morbidity, hospital stay and recovery time.
Type 1 Portuguese Familial Amyloid Polyneuropathy was first observed in 1939 and described in 1951 by Corino Andrade. FAP is a rare autosomal dominant disease caused by a mutant gene in chromosome 18, characterized by a variant transthyretin in which valine is substituted for methionine at position 30 (ATTR V30M), affecting mainly young adults. ATTR V30M positivity does not imply disease, but the disease is only present with ATTR V30M in serum. The clinical manifestations of FAP on the pelvic floor and genitourinary system are frequent at early disease onset. Phenotypic diversity can depend on modulating agents in the deposition of the mutant TTR, such as incomplete penetration and environmental influence. Functional vesicourethral disorders appear to be primarily at the bladder filling phase, namely diminished bladder sensation, and associated with a decrease in detrusor contractility during the emptying phase. Unbalanced voiding takes place in this context, with high post-void residuals, increasing the rate of co-morbidity, namely recurrent urinary tract infections and chronic renal failure.This study describes the lower urinary tract dysfunctions in ATTR V30M positive carriers, particularly during the asymptomatic period and early stages of the disease , and additionaly it describes its association with the clinical evolution of the disease. In the preliminary phase of the study, the lower urinary tract dysfunction in FAP-women may present itself as an early manifestation in asymptomatic patients. Uroflowmetry and the evaluation of post-voiding residual volume are non-invasive and low cost tests that should be done during routine initial evaluation. Reduced bladder sensation and poor detrusor contractility may be considered initial markers of FAP. The neurogenic factor (bladder afferent neurons) appears to be mechanical in nature with myogenic repercussions. This further aggravates the bladder underactivity secondary to pelvic efferent parasympathetic neuropathy and amyloid infiltration in the bladder wall. Early diagnostic and therapeutic intervention may avoid secondary end stage renal disease.
OBJECTIVE: To demonstrate that the deep infiltration of the pudendal nerve guided by tomography is a good treatment option for patients with refractory neuralgia.METHOD: Two cases of pudendal neuralgia are presented, both expressed mainly with pain in the perineal and gluteal areas. Both cases had changes in the skin and one with urinary symptoms. A deep trans-gluteal infiltration guided by CT scan was performed, administering bupivacaine 0.25% with 80 mg methylprednisolone.RESULTS: In women, after infiltration, there was a decrease in pain from 6 to 3. In man infiltrations were performed monthly, completing 4. He reported pain reduction from 8 to 2.CONCLUSIONS: Pudendal Neuralgia diagnosis is unknown. The most common cause is inflammation of adjacent structures to the nerve frequently caused by falling. Diagnosis is mainly clinical. Trans-gluteal infiltration guided by CT scan is an effective option in treatment.
OBJECTIVE: To report a case of primary bladder endometriosis treated with laparoscopic partial cystectomy.METHODS: We report the case of a 38 year old woman presenting with cyclic catamenial pain and hematuria who was diagnosed of bladder endometriosis by means of cystoscopy and MRI. Partial cystectomy using a laparoscopic approach was performed and symptoms disappeared.RESULTS: We report a well-documented case of primary bladder endometriosis and the laparoscopic approach used for its treatment. A review of the concept and the therapeutic alternatives are presented.CONCLUSIONS: Bladder endometriosis must be in mind when cyclic catamenial symptoms of pain and hematuria are present. When diagnosed, the laparoscopic approach must be considered the preferential option.
OBJECTIVE: To report a case of large chylous ascytis as a late complication of a laparoscopic nephrectomy for renal tumor.METHODS: A 62 year old patient was admitted with general deterioration and abdominal distension due to chylous ascites. Abdominal ultrasound and CT led to the diagnosis. Paracentesis confirmed the presence of a large peritoneal chylous fluid effusion.RESULTS: The patient was treated by punction and placement of a percutaneous drainage. A large amount of lymphatic fluid was obtained after punction with a progressive decrease. Medical treatment included low sodium and low fat diet, together with medium chain fast absorbing triglycerides, protein supplements, diuretics and somatostatin analogues (octeotride). The patient’s progress was satisfactory after several days of treatment.CONCLUSIONS: Chylous ascites is a rare complication of laparoscopic nephrectomy, but it has a favorable course if managed conservatively. Meticulous clipping of the retroperitoneal lymph vessels is recommended to prevent the formation of chylous ascites, especially when discharging the renal vascular pedicle during nephrectomy or extensive lymphadenectomy.
OBJECTIVE: To report a case of a bladder cavernous hemangioma, as well as the main features of its diagnosis and treatment.METHODS: A 74 year old patient, regular smoker, presented with total macroscopic hematuria of moderate intensity with large rounded clots. On physical examination the patient`s mucous membranes color was normal, and digital rectal examination showed a normal size prostate with fibroelastic consistency.RESULTS: An abdominal ultrasound was performed showing a slight bladder bottom thickening in addition to free clots and a homogeneous and normal prostate. Cystoscopy confirmed the presence of a sessile violet-colored rounded retrotrigonal tumor, 2 cm in diameter and 0.5 in height; it was immediately resected. The pathological study reported cavernous hemangioma. Patient’s evolution has been satisfactory.CONCLUSIONS: Bladder cavernous hemangioma is a rare cause of hematuria, and transurethral resection of the small size lesions constitutes an effective option as a definitive surgical treatment.
OBJECTIVE: Gross hematuria in the immediate postoperative radical prostatectomy is a rare complication. According to different series reviewed, significant bleeding after this surgery appears between 0.5-1.5% of the cases.METHODS: 58 year old male with localized prostate cancer who underwent open radical prostatectomy with preservation of the neurovascular bundles and a left accessory pudendal branch. In the 4th postoperative day patient presented severe hematuria and urethral bleeding requiring continuous bladder irrigation and blood transfusion. Given the persistence of bleeding despite conservative measures CT-angiography was performed demonstrating active bleeding at a bulbar artery from the left internal pudendal artery without associated pelvic hematomaRESULTS: Given the findings selective embolization was performed with absorbable material stopping the bleeding. Three months later the patient maintains urinary continence and erectile function with tadalafil.CONCLUSIONS: Urethral bleeding after radical prostatectomy is a rare complication the cause of which is distal to the urinary sphincter unrelated to the pelvic vessels. The performance of CT angiography and subsequent embolization is the treatment of choice, avoiding open surgical revision, with less morbidity.