HEPARIN AS AN ANTIBACTERIAL COATING ON BIODEGRADABLE URETERAL STENTS: EXPERIMENTAL STUDY OF BRAIDSTENT®-H

INTRODUCTION

The aim of this study is to assess the effectiveness of heparin to inhibit the development of early bacteriuria as a coating for biodegradable ureteral stents.

MATERIAL AND METHODS

The BraidStent®-H biodegradable stent, whose heparin coating is incorporated by dip coating, was chosen for this study. Twenty-four swine were randomly divided into two groups: 12 animals underwent unilateral placement of the BraidStent®-H and 12 were fitted with a standard double-j stent (DJS). Bacteriuria is comparatively analyzed over time by consecutive urine sampling at 0, 1, 3, 6, 12, 24 and 48 hours. In addition, the concentration of heparin released in vitro in artificial urine at 0, 3, 6, 12, 24, 48, 72, 92 and 120 hours is determined via ELISA.

RESULTS

BraidStent®-H generates a significantly lower bacteriuria rate than a DJS at 6 and 12 hours. Heparin coating shows a significant delaying effect on the onset of bacteriuria, reaching 100% of the animals at 48 hours, compared to the DJS, which takes place at 6 hours. ELISA results reveal the presence of heparin in urine for a total of 72 hours. The coating does not affect the degradation of the device, which is completed at 6 weeks.

CONCLUSIONS

Heparin evidences an effective inhibition of early bacteriuria, showing its potential as an antibacterial coating for biodegradable ureteral stents. Future studies should focus on the development of long-term heparin coatings for biodegradable materials.

Predictive factors of infectious complications in the postoperative of percutaneous nephrolithotomy

OBJECTIVE

Infectious complications (IC) following percutaneous nephrolithotomy surgery (PCNL) can be life-threatening. Our objective was to analyse preoperative predictors of IC in PCNL.

MATERIALS AND METHODS

A total of 203 patients who underwent PCNL were included in a prospective study between January 2013 and February 2016. A postoperative IC was defined as urinary infection/pyelonephritis, systemic inflammatory response syndrome or sepsis. The variables analysed were age, gender, number, size(cm) and side of stone; Hounsfield units,diabetes (insulin dependent or not), preoperative culture, isolated bacteria, multitract, bodymass index and surgical time (min). A multivariate forward stepwise (logistic regression) was performed.

RESULTS

IC occurred in 30 patients (14.8%): 9 (4.4%) had urinary infection, 14 (6.9%) systemic inflammatory response syndrome and 7 (3.5%) sepsis. In addition, 13 (43.3%) had negative preoperative urine culture, 15 (50%) positive and in 2 (6.7%) was not available. On the logistic regression analysis, stone size (cm), insulin dependent diabetes and female sex were independently associated with increased risk of IC (odds ratio [OR] 1.03, 14.6 and 7.8, respectively; P=.0001).

CONCLUSIONS

Patients with large stone burdens, insulin diabetes condition and female gender, should be counselled properly regarding postoperative infection risks and closely followed up to diagnose IC (specially sepsis) soon enough. Negative preoperative urine culture seems not reliable enough to exclude an infectious complication according to our results.

Is extracorporeal shock wave lithotripsy a current treatment for urolithiasis? A systematic review

INTRODUCTION

Technological advances have prompted a change in the management of urolithiasis. Endourological techniques are gaining importance because they are highly effective treatments. The aim of this study was to answer the question of whether extracorporeal shock wave lithotripsy (ESWL) is still a competitive alternative compared with other therapeutic modalities.

ACQUISITION OF EVIDENCE

We conducted a literature search of articles published in the past 5 years. We identified 12 randomized and comparative studies and assessed the methodology and results of the study variables. We performed a narrative synthesis of the included studies. To summarise the variables, we used the mean and standard deviation for continuous variables and absolute numbers and percentages for the qualitative variables.

ANALYSIS OF THE EVIDENCE

Of the studies reviewed, 7 evaluated the various treatments for nephrolithiasis and 5 evaluated the treatments for ureteral lithiasis. At the renal level, a stone-free rate of 33.33-91.5% at 3 months was reached with ESWL, while a rate of 90.4-100% was achieved with the other endourological techniques, without finding statistically significant differences in the studies. At the ureteral level, a stone-free rate of 73.5-82.2% at 3 months was reached with ESWL, while a rate of 79-94.1% was achieved with the other endourological techniques, without finding statistically significant differences in the studies.

CONCLUSION

There is a lack of homogeneity among the published studies. ESWL is a minimally invasive treatment that with an appropriate technique and patient selection achieves high effectiveness, thus maintaining an important role at this time.

Analysis of the safety profile of treatment with a large number of shock waves per session in extracorporeal lithotripsy

OBJECTIVE

To assess the safety of increasing the number of waves per session in the treatment of urolithiasis using extracorporeal lithotripsy.

MATERIAL AND METHODS

Prospective, comparative, nonrandomized parallel study of patients with renoureteral lithiasis and an indication for extracorporeal lithotripsy who were consecutively enrolled between 2009 and 2010. We compared group I (160 patients) treated on schedule with a standard number of waves/session (mean 2858,3±302,8) using a Dornier lithotripter U/15/50 against group II (172 patients) treated with an expanded number of waves/session (mean, 6728,9±889,6) using a Siemens Modularis lithotripter. The study variables were age, sex, location, stone size, number of waves/session and total number of waves to resolution, stone-free rate (SFR) and rate of complications (Clavien-Dindo classification). Student's t-test and the chi-squared test were employed for the statistical analysis.

RESULTS

The total rate of complications was 11.9% and 10.46% for groups I and II, respectively (P=.39). All complications were minor (Clavien-Dindo grade I). The most common complications were colic pain and hematuria in groups I and II, respectively, with a similar treatment intolerance rate (P>.05). The total number of waves necessary was lower in group II than in group I (P=.001), with SFRs of 96.5% and 71.5%, respectively (P=.001).

CONCLUSION

Treatment with an expanded number of waves per session in extracorporeal lithotripsy does not increase the rate of complications or their severity. However, it could increase the overall effectiveness of the treatment.

[De novo urological neoplasms in kidney transplant patients: experience in 1,751 patients]

INTRODUCTION

Immunosuppressive treatment promotes development of neoplasms in kidney transplant patients. Cancer prevalence in these patients is 4 to 5 times higher as compared to the general population. Tumors are also known to behave more aggressively in transplant patients.

OBJECTIVE

To perform a descriptive analysis of de novo urological tumors in kidney transplant patients and to analyze patient survival.

MATERIALS AND METHODS

A retrospective study was conducted in 1751 transplant patients from January 1980 to December 2006. Patients in whom the tumor occurred in the first year after transplantation were excluded. The primary variables considered included sex, age at transplant, age at cancer diagnosis, site, clinical stage, treatment, and outcome. A Chi-square test was used for univariate statistical analysis. Survival was assessed using the Kaplan-Meier method.

RESULTS

Twenty-nine de novo tumors (1.6%) were diagnosed in the 1751 transplanted patients, with a median follow-up of 35.28 months (2-121) from tumor diagnosis. Tumors were found in 24 males (82%) and 5 females (18%). Median age at transplantation was 50.8 (17-70) years, and median age at tumor diagnosis was 56.4 (19-79) years. Eleven patients (38%) were diagnosed with prostate cancer, seven (24%) with bladder tumors, 4 (60%) with non-muscle invasive tumors, and 3 (40%) with muscle invasive tumors. A renal adenocarcinoma in the primitive kidney was diagnosed in 6 patients (20%). Five patients (18%) were detected a tumor in the transplanted kidney. Median survival was 75 months for patients with bladder tumors, 82 months for prostate cancer, 59 months for tumors in the native kidney, and 86 months for graft tumors.

CONCLUSIONS

In our series, de novo urological tumors in kidney transplant recipients were more common in males. Prostate cancer is the most common tumor and renal cell carcinoma of the native kidney has the worst survival rate.

[PSA and hK2 in the diagnosis of prostate cancer]

Serum markers for prostate carcinoma are widely applied for the purpose of early detection of cancer and the differentiation between benign and malignant disease, for the pre-treatment staging of detected prostatic cancers, and for the monitoring of prostate cancer after curative or palliative therapies. Since its discovery in 1979, serum PSA has been the most powerful marker of prostate cancer, but, when used alone, PSA is not sufficiently sensitive or specific to consider it an ideal tool for the early detection or staging of prostate cancer. To optimize the use of PSA, the concepts of PSA velocity, PSA density, and age-related PSA values were developed. Moreover, the molecular forms of PSA, especially the percentage of free PSA, seem to be useful tools for the detection of prostate cancer in men with slightly elevated total PSA. Human kallikrein 2 (hK2), a serine protease closely related to PSA that also is expressed predominantly in the prostate, is a new complementary marker to PSA for early detection of prostate cancer. In this review, we examine PSA testing and its effectiveness in the diagnosis of prostate cancer. Further, we also evaluate recent literature regarding the use of hk2.

[Incidental renal cancer in young adults: clinical and histopathological findings]

OBJECTIVE

to evaluate the clinical and pathological renal cancer (CR) characteristics in our series of tumours, analyzing its impact in the group of age less than 40 years.

MATERIAL AND METHODS

We studied 294 patients with CR. The pathologic characteristics were analyzed and DNA ploidy pattern of the surgical pieces were done in 252 patients. The patients were divided in two groups based on age, greater or less to 40 years, well then clinical and pathologic characteristics were compared between.

RESULTS

Of all patients, 26 of 294 patients (8,94%) were included in the young age group (less to 40 years). We did not found differences between both groups comparing stage, tumoral volume, treatment realized or DNA ploidy pattern, but in nuclear grade with more aggressive tumours in young people (p=0,0018), without differences in recurrence-free survival or actuarial disease specific survival rate.

CONCLUSIONS

The findings in our study indicate that the natural history and outcome of the RC is similar in both older and younger patients. Therefore, in our opinion, the management of CR in young people should be established with independence of the age.

[Indications, results and techniques of permanent prostate brachytherapy for localized prostate cancer]

INTRODUCTION AND OBJECTIVE

Prostate brachytherapy is a first-line therapeutic approach for localized prostate cancer in selected patients. We present our experience in brachytherapy and a thorough review of the literature.

MATERIALS AND METHODS

A review of the literature and evaluation of patient's selection was done. Furthermore the implantation technique, oncological results according to the different risk groups and acute and chronic complications were also analyzed.

RESULTS

The biochemical relapse-free 10 year survival rate was 87-96% in low risk tumours and 63-86% in intermediate risk tumours. A total of 3-24% underwent urinary retention that required TURP in 0-8,7%. Other complications were urinary incontinence in 0-6,7%, proctitis in 0-15,5%, erectile dysfunction in 6,3-30%, rectal ulcer/fistula in 0-5,4%.

CONCLUSIONS

Prostate brachytherapy is a safe and effective treatment in low and intermediate risk patients with prostate cancer.

[Leiomyoma of renal pelvis]

Renal leiomyoma are uncommon mesenchymal tumours, which can arise from any organ of the genitourinary tract with smooth muscle cells. The diagnostic imaging techniques available can not differentiated easily leiomyoma from other malignant renal masses. Since preoperative diagnosis cannot be made, management usually involves radical nephrectomy as in the case described. After treatment, prognosis is excellent.

[Renal cancer in elderly: clinical and histopathological findings]

OBJECTIVE

to evaluate the clinical and pathological characteristics of the CCR in our series of tumors, analyzing its impact in the group of age greater than 65 years.

MATERIAL AND METHODS

300 patients with renal adenocarcinoma (CCR) were studied. In 252, ploidy pattern of DNA and pathologic characteristics of the surgical pieces were done. According to the criteria of the Spanish Society of Geriatrics, the patients were divided in two groups based on the age, greater and smaller of 65 years. The clinical and pathologic characteristics were compared between both groups.

RESULTS

103 of the 300 patients (33.3%) were included in the geriatric group. We did not found differences between both groups comparing stage, tumoral volume or treatment realized, but found differences in DNA ploidy pattern, recurrences and survey.

CONCLUSIONS

The RCC in the elderly has a few clinical and pathological characteristics similar to the rest of patients in our series. Nevertheless differences exist in the average and actuarial survival, which is minor in the patient of more than 65 years, cause the percentage of detected aneuploidies and number of recurrences in not confined tumors in this group of age.

Evaluación del estudio pT3a de la actual clasificación TNM del cáncer renal

OBJECTIVE

We assessed the prognostic value of a stage pT3a diagnosis based on perirrenal fat infiltration.

MATERIAL AND METHODS

A series of 300 patients diagnosed of renal cell carcinoma (CCR) between 1992 and 2001 were retrospectively analyzed. Focusing on pT3a tumors as defined by perirrenal fat infiltration, a group of 92 patients (91,08%) regardless lymph node involvement (Nall) were included. Patients with distant metastases were excluded. In patients with pT3a Nall M0 tumors, tumour size was a significant parameter predicting survival. The most significant cut-off value for tumor size based on ROC curve was 5,5 cm. Therefore two groups were defined (up to 5,5 cm or greater than 5,5 cm) and actuarial survival were compared between both groups.

RESULTS

No significant differences were found comparing actuarial survival of selected pT3a and tumour size less than 5,5 cm with pT1 and pT2 tumors. After classifying selected pT3a less than 5,5 cm as pT1, multivariate analysis showed no differences regarding to prognostic variables before and after classification. Subsequently multivariate analysis showed that modified T stage was an independent significant predictor of cancer specific actuarial survival.

CONCLUSIONS

Perirrenal fat infiltration in renal cell carcinoma should not be used to assign T category. In our series grading tumors pT3a lesser than 5,5 cm as pT1/pT2 TNM stage does not affect their prognostic value.

Dislocación testicular postraumática

Testicular dislocation is an uncommon injury after blunt scrotal trauma (with only 150 cases reported) that must be properly diagnosed and treat in order to avoid a testicular atrophy. We presented a case report of traumatic dislocation of right testicle after a motorcycle accident. This type of testicular injury should be included in the whole evaluation of every polytrauma patient and usually requires a surgical treatment. The aim of this report is to clarify some aspects of the management of such rare entity.

[Endoscopic treatment of pielo-uretheral lithiasis with Holmium-YAG laser. Two years of experience]

OBJECTIVE

To show the efficiency and safety of Holmium laser in the treatment of pyeloureteral lithiasis, based on our own experience since the introduction of this source of energy in our department.

MATERIAL AND METHODS

From January 2002 to February 2004, we have carried out 198 ureterorenoscopies using Holmium laser to treat lithiasis located in the upper urinary tract. In all cases, a previous radiological study demonstrated the stone. Follow-up, where the efficacy of the treatment was assessed, was done with a scout x-ray after 3-4 weeks. We evaluated the localization and features of the lithiasis, technical aspects, results and complications of our series.

RESULTS

The most common localization of the lithiasis was the pelvic ureter (59%), with the number of treated cases in both the iliac and lumbar ureter being similar (16%). 70% of the lithiasis had a size between 0.5 and 1.5 cm, and 15% showed a diameter bigger than 1.5 cm. In 61.8% of cases, laser lithotripsy was carried out under spinal anaesthesia, being the average of the pulses used 2532 (confidence interval 95%), using a working power of 1 J in all cases. The overall efficacy of the procedure in terms of size and localization was 95.5%. The complication rate was scarce (2.19%).

CONCLUSIONS

Holmium laser lithotripsy is a very effective and safe procedure since in our experience it is 95.5% efficient for pyeloureteral lithiasis treatment and has a low rate of complications.

[Role of chronic prostatic infiltrate from specimens of prostate biopsy in total and free PSA determination]

PURPOSE

To analyze the influence in total serum PSA (PSA(t)) and free PSA (PSA(1)) of chronic inflammatory patterns from prostate biopsy specimens of non-symptomatic patients.

PATIENTS AND METHODS

518 non-symptomatic patients underwent ultrasonography and prostatic biopsy for PSA(t) > 4 ng/mL and/or DRE suspicious of malignancy. Those with a negative biopsy were divided into two subgroups: patients with benign prostatic lesions (LBP) and patients with chronic inflammatory signs (SIC).

RESULTS

456 patients (88.03%) were biopsied for elevated PSA(t) or/and DRE suspicious of malignancy in 62 patients (11.97%). Mean volume in patients with LBP was 54cc, while 51cc was the mean volume in patients with histological pattern of chronic inflammatory infiltrate. Mean PSA(t) in patients with LBP was 9.43 (IC 95% +/- 7.8) and 8.8 (IC 95% +/- 5.73) in SIC's group patients.

CONCLUSIONS

The presence of SIC has no significant influence in the eventual value of PSA(1) y PSA(t) in a selected population. As a result of that finding data from serum PSA can be reliably evaluated even in the presence of SIC in biopsy specimens.

Valor predictivo de progresión de la muscularis mucosae y del porcentaje de células G3 en tumores vesicales T1G3

INTRODUCTION AND OBJECTIVE

Vesical tumor T1G3 constitutes the border between the superficial tumor and the infiltrante tumor. Some of these tumors do not respond to BCG and progress, with cystectomy that present poor results, patients who would benefit from a precocious and aggressive treatment if we could identify them in an preinvasive stage. New predictive factors try to select to these tumors, being little the works that consider anatomo-pathological meticulous study (substanding of the T1 in T1a and T1b and percentage of present G3 cells in the tumor). Our objective is to analyze the value of these anatomo-pathological considerations like predictive factors of progression.

MATERIAL AND METHODS

Retrospective study of a series of 91 patient affection of vesical tumor T1G3 with initial treatment by means of RTU and BCG. We analyzed 12 variables. The new predictive factors: the level of invasion respect to muscularis mucosae and the percentage of G3 cells. By means of logistic regression analisys we establish the independent pronostic factors for tumoral progression.

RESULTS

A total of 31 patients presented infiltration of detrusor, passing away 17 of tumoral cause, after an average time of pursuit of 57.8 +/- 28.2 months. In 8 cases (9%) the substanding could not be determined. The rate of progression for T1a tumors was of 20% (8/40) and for T1b 53% (23/43). Presented independent predictive value of progression the multiplicity (odds: 7.26), the size (odds: 2.14), the presence of Cis (odds: 1.42) and the subestanding (odds: 6.81).

CONCLUSION

The substanding is a predictive factor of progression clinically useful in vesical tumors T1G3, reason why we considered habitual clinical introduction.

[Mucinous adenocarcinoma of the bladder]

Mucinous adenocarcinoma is a rare entity within the group of primary adenocarcinoma of the bladder which represent 0.5-2% of all malignant epithelial bladder tumours. In spite of the rarity of this tumoral type; it is a poor prognosis entity mainly due to its diagnosis especially in advanced stage of the disease. There is no general agreement on the treatment of adenocarcinoma of bladder. Not withstanding surgery would be the only curative treatment, although unfortunately, it is curative in just a few cases. We report six cases with mucinous adenocarcinoma of the bladder attended in our Department in the last ten years (january 1991-december 2001). In one of them a radical cystectomy was performed, while transurethral resection with or without adjuvant treatment was practiced in the other one. Only one patient is alive today, namely, the one where the tumour not invade the muscular tissue. These findings show the discouraging results of this entity closely intertwined with the pathologic stage.

[Evolution of microbial resistance to fluoroquinolones at a tertiary hospital]

Within the setting of a reference tertiary hospital such as Hospital La Fe, a retrospective study of major germs responsible for urinary infections and their susceptibility to fluoroquinolones was conducted between 1990-1998 in an attempt to quantify the increased resistance found in both in- and out-patients. The rationale for the study was the clinical evidence of resistance to those antimicrobials. E. coli continues to be the most frequently isolated micro-organism in all types of urinary infections in both intra-hospital (50%) and extra-hospital infections (63%), followed by E. faecalis, P. mirabilis, and Klebsiella. When ward patients are compared to patients in Intensive Care Units (ICUs) a number of differences become apparent as regard to the isolated micro-organisms. Current resistance to fluoroquinolones is about 23% for E. coli, 28% for E. faecalis, 6.5% for P. mirabilis, 5% for Klebsiella spp, 15% for Pseudomonas aeruginosa and 9% for Enterobacter spp. When these results are compared to those seen at the beginning of the '90s a highly significant increase is noted for E. coli (from 3 to 23%), E. faecalis (from 4.5 to 28%) and Pseudomonas aeruginosa (from 4 to 15%) with a much lower increase for the remaining micro-organisms. The reasons behind such an increase are numerous, the major one being the massive use of quinolones both in humans and animals, with variations based on age and geographic region. Generalisation of this major increase would lead to future use of fluoroquinolones based on susceptibility in culture, particularly in serious urinary infections.

[Primary transitional carcinoma of the prostatic ductus]

Primary prostate transitional cell carcinoma is a very rare tumour originating in the transitional epithelial cells of the intraprostate periurethral ductus. Only 17 of 829 patients diagnosed with prostate carcinoma were found to have the transitional cell variety. Eight (8) of those had pure transitional cell carcinoma and 9 a mixed presentation of acinar adenocarcinoma and transitional cell ductal carcinoma. Bladder origin of the tumour was ruled out in all cases. We report a retrospective study on the clinical behaviour of prostate transitional cell carcinoma. Compared to acinar carcinomas, few differences were found when age, symptoms, physical findings and imaging diagnosis were evaluated. Clinical presentation, DRE, PSA, metastatic spread and presence of supravesical obstructive uropathy where also studied to establish a diagnosis. Radiotherapy was the most frequently used therapeutical approach. Mean survival is 26.6 months (4-60 months) and there has been 11 death up to now. Compared to acinar forms, this tumour shows a hormone-resistant, aggressive biological behaviour with poor prognosis. Early diagnosis and radical surgery are the only options available to increase life expectancy for these patients.

[Infravesical obstructive uropathy secondary to extreme vulval atrophy]

Lower urinary tract obstruction in women is an uncommon condition resulting from multiple either organic or functional disorders. This paper contributes one case of obstructive uropathy secondary to presence of almost complete vulvar synechia due to extreme genital atrophy, a rare entity that may appear in postmenopausal women. Partial and incomplete vulvar fusion usually occurs in significant postmenopausal atrophies, sometimes associated to urethral meatus stricture; this, however, has no significant repercussion on urination dynamics. No other comparable case was found in the reviewed literature.

[Mucinous prostate adenocarcinoma initially presented as an intestinal subocclusive picture]

Mucinous prostate adenocarcinoma is an infrequent tumour, with no more that 50 cases described to date. This paper contributes a new case of the entity. Rather than on the rarity of the tumour, the interest in our case focuses in the unusual nature of its clinical presentation. It initially appeared as a presumable rectoanal neoplasia but the pathoanatomical examination discovered the prostatic origin of the tumoration.

[Comparative study of pure epidermoid carcinoma of the bladder and transitional cell carcinoma with squamous or mixed differentiated foci]

INTRODUCTION

The epidermoid bladder carcinoma is an infrequent tumour in our environment accounting for 5-8% of total vesical tumours, but is not so uncommon to find foci of squamous differentiation within a transitional carcinoma. We conducted a comparative study between these two histologic forms and analyzed the pattern of their clinical behaviour.

MATERIAL AND METHODS

Retrospective study on a total of 32 cases of epidermoid carcinoma diagnosed between 1986-1996 that following histological confirmation were divided into two groups; plain epidermoid carcinoma (PEC), 11 cases; and transitional carcinoma with foci of squamous differentiation (MEC), 19 cases. After further review 2 cases were excluded.

RESULTS

PEC appears in older patients. Both tumoral forms are more frequent in males, the male/female ratio being lower in PEC. Presence of irritative factors is significantly associated to PEC (P < 0.01) and smoking to MEC. Presentation signs are similar in both groups, and haematuria is the most frequent sign. Most usual location in both groups was the trigone, which caused uni/bilateral hydronephrosis in over 50% patients. At the time of diagnosis all PECs were invasive versus only 86% in the MEC group.

TREATMENT

PEC group underwent the following procedures: 4 radical cystectomies, 2 cystectomies plus radiotherapy, 3 palliative TUR and 2 TUR with radiotherapy. In the MEC group there were 3 radical cystectomies, 2 cystectomies plus radiotherapy, 1 cystectomy with previous chemotherapy, 8 palliative TUR, 2 TUR with endovesical chemotherapy, 1 TUR with systemic chemotherapy, 1 TUR with radiotherapy and 1 systemic chemotherapy. Mean survival was 12.5 months (0-43) in PEC and 26.55 (0-96) in MEC. Disease-free time in PEC and MEC was 5 months (0-37) and 10.25 (0-70) respectively. Only one patient achieved 5-year survival.

CONCLUSION

Epidermoid carcinoma both plain and mixed is an aggressive tumour with poor prognosis and short survival. 100% PECs in our series are invasive at diagnosis, and no statistically significant differences were found in survival and disease-free time between both histological variants. Cystectomy remains the choice therapy.