Laparoscopic latero-abdominal colposuspension: Description of the technique, advantages and preliminary results

INTRODUCTION

There are currently various fixation or suspension techniques for pelvic organ prolapse (POP) surgery. Laparoscopic colposacropexy is considered the gold standard. We present the surgical steps of the laparoscopic latero-abdominal colposuspension (LACS) technique and the preliminary results obtained.

MATERIAL AND METHODS

Patients with anterior and/or apical compartment symptomatic POP undergoing LACS are included. The Baden-Walker scale, the Overactive Bladder Questionnaire-Short Form (OAB-q SF), the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) and the Patient Global Impression of Improvement (PGI-I) scale were used to assess the degree of prolapse, urinary filling and sexual symptoms and the level of satisfaction before and after surgery, respectively. Conventional laparoscopic material and a polyvinylidene fluoride (PVDF) mesh were used.

RESULTS

Eighteen patients were included with a minimum follow-up time of 6months. The mean surgical time was 70.3±23.8min. Anatomic correction of prolapse was seen in all cases. Only one recurrence was detected. High levels of patient satisfaction were achieved.

CONCLUSION

LACS allowed the anatomical reconstruction of the pelvic floor and proved to be a minimally invasive, fast, effective, safe and reproducible technique. More series are needed to evaluate its role against laparoscopic colposacropexy.

[Inverted papilloma of the upper urinary tract]

Inverted papilloma of the upper urinary tract is a rare tumor and generally considered to be a benign. We present two cases of benign ureteral inverted papilloma. They were discovered after to study a upper urinary infection and a gross hematuria respectively. Both cases appear to be associated with asynchronous and synchronous bladder carcinoma, so it is very important a strict follow-up.

[Malignant retroperitoneal schwannoma]

We present an uncommon case of retroperitoneal malignant schwannoma diagnosed accidentally. The clinical, diagnostic and therapeutic features are discussed.

[Ureteral obstruction secondary to Rosai-Dorfman disease]

Ureteral obstruction can be secondary to a lot of reason. We present a uncommon case report of ureteral obstruction to Rosai-Dorfman disease. The form of clinic presentation is described, the diagnostic methods used and the therapeutic management.

Papiloma invertido vesical con recidiva en uretra prostática

Urothelial inverted papilloma is usually a solitary lesion with rare recurrences. Its behaviour is unclear, its potential for recurrence or progression is not well-known. We present a case of inverted papilloma of the bladder with recurrence in prostatic urethra after four years of follow-up. We review etiology, clinical presentation, diagnose, treatment and the present discussion about its malignancy ability.

[Calcified retroperitoneal liposarcoma]

Case report of a retroperitoneal liposarcoma pleomorfico with calcification in diagnosed in our hospital. We comment on its clinical characteristics, diagnostic methods and treatment. We likewise comment the possible differential diagnoses.

Enfermedad poliquística del adulto en riñón en herradura

A case report of kidney polycystic and horseshoe kidney coincidence in the same patient. They are two congenital associated renal diseases uncommon for urologists. The form of clinic presentation is described, the diagnostic methods used and the therapeutic management.

[Observational study of therapy compliance in the treatment of uncomplicated urinary tract infections of the urinary tract with 500 mg ciprofloxacin suspension]

OBJECTIVE

To evaluate patient compliance with 500 mg. ciprofloxacin oral suspension therapy for uncomplicated tract infections.

METHOD

Open, non-comparative, multicenter study of 87 patients of both sexes. Mean age was 67.5 years. Duration of treatment ranged from 3 to 10 days.

RESULTS

The degree of compliance with treatment was satisfactory in 82.7% of the cases.

CONCLUSION

The characteristics of the 500 mg ciprofloxacin oral suspension (easy to take, easy to use, etc.) facilitate patient compliance with the treatment prescribed for uncomplicated urinary tract infections.

[Metastasis priapism. Report of 4 new cases and review of the literature]

OBJECTIVE

Four additional cases of malignant priapism or priapism secondary to penile metastasis from urogenital tumors are presented and the literature is reviewed.

METHODS

Chest and abdominal radiological evaluation, cavernosal and abdominal US, abdominal and pelvic CT and MRI, and cavernosal biopsy were performed for the localization and staging of the primary tumor.

RESULTS

Conservative palliative management achieved a survival of only a few months in three of the patients with tumor dissemination to adjacent vital organs. Radical surgery was performed in one patient with tumor localized to the genital area. Currently, this patient has no clinical symptoms, although the follow-up is only 4 months.

CONCLUSIONS

Malignant priapism is rare and usually secondary to GU tumors. The prognosis is poor since it generally indicates the presence of multiorgan metastasis. However, the prognosis is better for single metastasis, which is an indication for radical surgery.

[Trigonocervicoprostatomy. Indications and results from 100 case reports]

Trigonocervicotomy is a barely invasive technique for the treatment of infravesical obstruction, first introduced in the 60's by Turner-Warkic and Orandi. To achieve good results with this procedure, the selection criteria must take into account a series of parameters such as age, sexual activity, PSA, prostate weight (below 30 grams) and others. In addition to its low morbidity, a larger percentage of patients preserve ejaculation than with the use of other techniques, also the neck sclerosis rate being lower as seen in all our series and expertise. The efficacy of this technique was studied on 100 patients.

[The management of urinary candidiasis in cystectomized patients]

Presentation of eight cases of urinary candidiasis in patients who underwent radical cystectomy and were managed using by-pass of the urinary tract, oral antifungal therapy and solutions in the way of intermittent instillation through nephrostomy catheters.

[Management of the complications of ureterointestinal reimplantation in urinary diversion]

OBJECTIVE

To analyze our experience in the management of complications of ureteroenteric reimplantation in patients undergoing urinary diversion by endourological techniques or open surgery, in order to identify a useful algorithm that takes the oncologic prognosis into account, as well as the probability of success.

METHODS

A retrospective study was conducted on 136 patients who had undergone urinary diversion from 1987-1998. Of these, 126 had transitional cell carcinoma, two had infiltrating carcinoma, two had a benign condition and 6 had undergone urinary diversion for patient comfort without cystectomy. The following techniques were utilized: cutaneous ureteroileostomy or Bricker technique (104 patients), Mainz neobladder (10 patients), ileal neobladder (15 patients), colonic conduit (5 patients) and cutaneous ureter (2 patients).

RESULTS

Overall, 56 patients (41%) had some type of alteration at the ureteroenteric reimplantation site, but only 36 (26%) required intervention. The reimplantation techniques utilized were: the Bricker direct ureteroileostomy (26 patients), Le Duc (6 patients), Leadbetter (3 patients), and the direct cutaneous technique (1 patient). Patient mean age was 67 years (range 53-80). There were 35 males and one female. Seven patients required immediate reimplantation due to a persistent urinary fistula and 29 had late obstruction (more than 3 months), accounting for 21.3% of the cases undergoing urinary diversion. The antegrade endourological approach was utilized in 24 patients (5 nephrostomy alone and 19 stent or balloon dilatation). Dilatation was performed palliatively in 6 cases with extensive tumor spread. Permanent success was achieved in 5 cases (38%) and in spite of the initial success, there were 4 reobstructions. Open surgery was performed in 24 patients (66% of the complicated reimplantations); 5 of these patients had another pathology that warranted laparotomy, 7 required reimplantation early due to a fistula and two patients with a nonfunctioning kidney underwent nephrectomy. Ureteral replacement using the ileum was performed in 4 patients and direct reimplantation to the primary loop was performed in 6 patients. Good surgical results were consistently achieved.

CONCLUSIONS

The complication rate of ureteral reimplantation is high in patients undergoing urinary diversion. Endourology has an important role in these cases, particularly in patients with a poor prognosis. Surgery achieves the best results. Although they may entail difficulty, complex cases such as extensive ureteral necrosis can be managed successfully.

[Infiltrating bladder tumors associated with upper urinary tract tumors]

Analysis of the infiltrant tumours of the bladder diagnosed in our service between 1986-1996 both inclusive, with associated tumour of the upper tract during its evolution. From a total of 262 infiltrant transitional tumours of the bladder and 52 transitional tumours of the upper urinary tract, 8 patients were found to have both types of tumours in association, which accounted for 3.05% of all infiltrant vesical tumours. Mean age of our patients, all male, was 65. The pathological anatomy of the upper tract tumours was: 4 pT1 and 4 pT3. 75% presented relapsing tumours of the bladder, 50% had a background of bladder Cys, 87.5% were multifocal vesical tumours and 100% were larger than 3 cm. In addition, 62% cases were ipsilateral to the tumours of the upper urinary tract. It can therefore be concluded that for tumours of the bladder, multifocality, relapse, presence of vesical Cys and tumour size, are all concurring features when association of these two types of tumours occurs.

[Management of priapism induced by PGE1]

OBJECTIVE

To review the literature on priapism following intracavernous injection of PGE1, its management and the physiopathological mechanisms involved.

METHODS/RESULTS

The literature on PGE1-induced priapism available on Medline is reviewed and two cases treated at our hospital are described. The diagnostic and therapeutic algorithms are presented. The relationship between drug use and priapism is difficult to establish since patients with the same history who received the same dose of Alprostatil did not develop priapism.

CONCLUSIONS

Although infrequent, treatment must be instituted urgently since there is generally low flow.

[Congenital bilateral agenesis of the vas deferens associated with cystic fibrosis. A molecular genetic study]

OBJECTIVE

To analyze the association of congenital bilateral agenesis of the vas deferens and cystic fibrosis.

METHODS

Three azoospermic patients with surgically confirmed congenital agenesis of the vas deferens in whom a molecular genetics study had been performed to discard the more common mutations of cystic fibrosis are described and the literature reviewed.

RESULTS

All patients showed azoospermia. The molecular genetics study showed one of the patients to be a heterozygotic carrier of G542X and no other mutations like the remaining patients.

CONCLUSIONS

15% of patients with azoospermia have chromosomal anomalies. Recently, it has been reported that 50%-65% of patients with congenital bilateral agenesis of the vas deferens have mutations for the CFTR gene, with more than 400 reported. Patients with bilateral agenesis and their partners should be screened for cystic fibrosis prior to any in vitro fertilization techniques.

[Tumors of the upper urinary tract]

A series of 60 cases of tumours of the Upper Urinary Tract (UUT) diagnosed in our centre between 1987-1996 and affecting 57 patients is presented. Patient's mean age was 63.7 years, males being clearly predominant, 4:1, there was no predominant laterality and the preferential location was the renal pelvis. Fifty-two (52) out of all tumours were transitional, 1 was a fibroepithelial polyp and 2 were metastasis from prostate and colon cancers. Pathoanatomy of the remaining cases is not known since no surgery was performed, although the cytologic diagnosis has identified them as transitional tumours. Our series shows a significant association to other transitional tumours as demonstrated by the existence of 2 cases with a background of UUT tumours and other 31 cases associated to transitional tumour of the bladder. Haematuria was the predominant sign (54%) and UIV the leading examination technique. Nephroureterectomy was the most commonly used therapeutical approach. UUT appear to be highly predominant in our environment, with a clear male predominance and preferential location in the renal pelvis. Haematuria continues to be the most frequent presentation sign and UIV the exploratory technique offering better performance in the diagnosis. Also a high association was found to other types of transitional tumours, the diagnosis and follow up of which allowed us to diagnose a large number of tumours of the upper tract.

[Transitional cell carcinoma and renal cell adenocarcinoma: unusual case of association in the same kidney]

Presentation of one patient with a highly infrequent association of transitional cells carcinoma and renal cells adenocarcinoma synchronically developed in the same renal unit. There has been very few cases diagnosed up to now, and only around 25 have been described in the literature. There is a clear predominance of males versus females, with haematuria being the most frequent sign present in 90% cases. Elective complementary examination is CT and the choice treatment can be either nephroureterectomy or extended nephrectomy based on early suspicion of transitional cells carcinoma or renal cells adenocarcinoma.

[AIDS and HIV infections in urologic practice]

The infection caused by the Human Immunodeficiency Virus (HIV), a retrovirus, leads to a progressive decline and to the suppression of cell-mediated immunity favouring the development of opportunistic diseases and potentially fatal neoplasias which are practically innocuous in individuals with an intact immunologic system. The number of AIDS cases recorded in Spain until March 1997 was 45,132, with a revised mortality rate of 58%. Cases in Murcia total 713 up to October 1997, of which 217 patients are being monitored in the AIDS Unit in our centre, 414 individuals have died in the region. It is well know that about one third of patients with diagnosed AIDS or who are HIV carriers will develop some type of genitourinary lesion, either as a result of a renal disorder, concurrent or not with HIV, or any other condition directly related to the infection. This is a report on our Service's experience in the treatment of HIV patients with genitourinary symptoms that, in a total of 15 cases, required our intervention. Emphasis is placed on the incidence of nephrolithiasis secondary to therapy with protease inhibitors over the last few months following introduction of this new therapeutic tool, prostatitis due to salmonella, and inlaid cystitis among others.

[Non-urothelial neoplasm in patients with infiltrating bladder carcinoma]

OBJECTIVE

To analyze the incidence of non-urothelial neoplasms in patients with infiltrating bladder tumor submitted to radical surgery.

METHODS

A retrospective study was conducted in patients who underwent radical cystoprostatectomy for an infiltrating bladder tumor from 1987-1996. The pathological and follow-up data were analyzed.

RESULTS

Of 120 patients submitted to radical cystoprostatectomy for an infiltrating bladder tumor, 23 (19%) had an associated non-urothelial neoplasm: 14 (61%) were metachronous and 9 (39%) were synchronous. Two patients had two secondary tumors (9%).

CONCLUSION

We have found a high incidence of non-urothelial tumor in patients with infiltrating bladder tumor. By order of frequency, these were prostate cancer, gastrointestinal cancer, pulmonary cancer, etc. Studies have ascribed the association of prostate and bladder cancer to the deletion of suppressor genes.

[Inverted papilloma: presentation of 5 cases and review of the Spanish literature]

Vesical inverted papilloma (IP) is a transitional disease most commonly found in the bladder, representing a small percentage within the group of vesical neoformations. Although of benign behaviour, some authors advise that a relatively strict monitoring should be used considering its high rate of proliferative activity. It mainly affects males in their fifth to seventh decade, and it presents as any other transitional tumour. In about one fourth of the cases a transitional carcinoma becomes associated throughout its evolution, thus supporting the theory of periodic monitoring.

[Recurrent hydrocele in a patient with familial mediterranean fever]

OBJECTIVE

To report an uncommon case of familial Mediterranean fever with urological manifestations.

METHODS/RESULTS

A case of recurrent hydrocele in a patient with familial Mediterranean fever is described.

CONCLUSIONS

Although familial Mediterranean fever is characterized by an acute febrile stage and involvement of the serosa, it may manifest as recurrent hydrocele due to involvement of the urological serosa, as in the case described herein.

[Retroperitoneal liposarcoma. Apropos of 3 cases]

OBJECTIVE

Three additional cases of retroperitoneal liposarcoma are described, with special reference to the diagnostic utility of CT, although the definitive diagnosis can only be established anatomopathologically.

METHODS/RESULTS

Three cases of retroperitonel liposarcoma are described. Two patients had complained of the presence of an abdominal mass and discomfort and one patient had referred colic pain.

CONCLUSION

The prognosis of retroperitoneal liposarcoma is closely related to the histological type and involvement of the adjacent structures. The most common clinical feature is the sensation of an abdominal mass and discomfort.

[Changes in the caudal regression of fused Muller ducts: utriculocele. Three clinical forms of presentation]

Utriculocele is the engrossment of the prostate utricle with occlusion and/or cystic formation, sometimes including the ejaculatory conducts. We report three patients diagnosed with utriculocele with different presentation forms: hypospermia, haematuria and mictional syndrome, and the treatment used. Theories on their formation, clinical presentation forms described in the literature, diagnostic means, most frequent associations, and different therapeutic alternatives are all discussed as well as a revision of the reported cases.

[Eosinophilic cystitis]

Eosinophilic cystitis (EC) is a clinical-pathological entity characterised by the transmural infiltration of the bladder. It shows as an irritative mictional syndrome, though the most common sign is haematuria. Endoscopically it appears as an intravesical mass and is usually mistaken for a transitional tumour of the bladder. There has been many etiologies involved but not one single factor has been identified as responsible for the condition. Medical approach is the most appropriate initial treatment, but since the condition is so often mistaken with vesical tumoration, the first therapeutical attitude in most cases is Transurethral Resection (TUR) which, though more aggressive, is therapeutic, haemostatic and provides material for the pathoanatomical diagnosis.

[Usefulness of prostaglandin E1 in the diagnosis of corpora cavernosa fracture. Report of a case]

OBJECTIVE

To describe a case of rupture of the corpora cavernosa demonstrated by intracavernosal PGE1.

METHODS/RESULTS

Herein we describe a patient with fracture of the penis in whom the degree of injury could not be determined by questioning and clinical inspection. The artificial erection test with intracavernosal PGE1 was utilized to evaluate the ruptured corpora cavernosa.

CONCLUSION

Intracavernous PGE1 is useful in the diagnosis of rupture of the corpora cavernosa and has minimum side effects.

[Liver failure caused by flutamide]

Flutamide is a non-steroidal anti-androgen used in the treatment of prostate cancer, usually in combination with LHRH-analogs. Incidence of hepatotoxicity associated to Flutamide in the literature is very low and does not exceed 0.18%. Between February 1989 and December 1994, the FDA was reported 20 cases of patients who had died and 26 who had been hospitalized due to hepatotoxicity secondary to Flutamide. We contribute two cases of patients diagnosed with prostate adenocarcinoma following treatment with flutamide and LHRH-analogs who presented liver failure; one with signs and symptoms of acute hepatitis that recovered after discontinuation of the drug, and a second one who developed micronodular cirrhosis and later died of icteroascitic decompensation and hepatorenal syndrome. Including a review of the literature, the paper comments on the likely biological mechanisms for liver toxicity caused by Flutamide. The authors conclude that clinical and laboratory monitoring of patients who either will receive or are receiving treatment with Flutamide is necessary, and withdrawal of drug imperative as soon as certain symptoms of hepatic dysfunction become apparent.

[Impact of prostatic benign hyperplasia and prostatic inflammation on the increase of prostate specific antigen levels]

PSA is currently the best marker in the diagnosis and staging of prostate cancer, although it has a low specificity when trying to distinguish between BPH and prostate cancer. Between January 1994 and December 1995, 243 BPHs were diagnosed after prostate TUR and retropubic adenomectomy. A selection of 131 cases were analyzed based on PSA higher than 4 and normal rectal examination pre-surgery. After surgery PSA was determined again with a time interval from the earlier one ranging between 103-211 days, noting that in about 70% cases PSA levels were normalized and 64% of these also presented focused acute prostatitis, chronic prostatitis, prostate infarction, lithiasis or areas of abscess formation. In spite of a significant number of patients with high PSA levels, this elevation should be interpreted cautiously considering the large percentage of cases where posterior pathological anatomy is a sign of BPH. We believe that among the conditions that could justify such abnormal PSA elevations are those described of areas of chronic or acute prostatitis, prostate infarctions, areas of abscess formation and presence of intraprostate lithiasis.

[Cranial blind ureter: a new case]

One of the anomalies affecting the ureter is the blind bifid cranial ureter, which is truly an uncommon alteration. Clinical signs and symptoms are very ambiguous, and sometimes the condition is diagnosed accidentally while conducting an urographic examination. The aim of this paper is simply to contribute a new case to the existing literature.

[Wallstent prosthesis of unusual location caused by recurrent urethral stenosis following repeated urethroplasty]

Presentation of one case of relapsed urethral stenosis in a penoscrotal location where after several failed therapeutical approaches, the final decision was to place a Wallstent endoluminal prothesis. The patient underwent several endoscopic internal urethrotomies and urethroplasty in two occasions, developing complications: urethral calculi, hair follicles requiring cauterization, repeat infections and relapse urethral stenosis, which finally lead to the decision of fixing a intraluminal stent even if in an unusual location (penoscrotal). The result, 40 months after implantation, is both subjectively and objectively better, with a good mictional calibre and satisfactory erection which allows the patient to have sexual intercourse. The Wallstent prothesis can be the ultimate alternative in those cases of "ill-treated" urethra where other techniques fail.

[Intratumor and retroperitoneal massive hemorrhage caused by retroperitoneal liposarcoma]

Case report of a giant retroperitoneal liposarcoma which presented with a picture of acute abdomen resulting from a massive tumoral haemorrhage. Diagnosis was achieved by ECO and CT, and was confirmed by Pathological Anatomy. Treatment was surgical, performing tumour removal plus polar nephrectomy of the affected side. The patient evolution was favourable. The standard methods of diagnosis and prognostic factors are commented.

[Endourethral prosthesis in recurrent urethral stenosis. Long-term follow-up]

OBJECTIVES

To describe our experience with urethral stents in the treatment of recurrent strictures.

METHODS

From March 1991 to July 1992, 17 Wallstent and 1 Strecker self-expandable stents were implanted. Patient follow-up ranged from 11 to 40 months. The results were analyzed on the basis of the clinical, urodynamic, radiological and cystoscopic findings.

RESULTS

Of the 18 patients in whom a urethral stent had been implanted, 2 (11.1%) required removal of the stent, 1 patient was lost to follow-up, 2 had died during follow-up from causes unrelated with the procedure. At 40 months follow-up, late complications were observed in 8 patients (47%): intraprosthetic excrescence, erectile disorders, pollakiuria, lithiasis, episodes of RAO, or incontinence.

CONCLUSIONS

In our view, the implanted urethral stent is a valid alternative when other techniques are not feasible or have failed (dilatation, internal urethrotomy, urethroplasty...), but we should not forget the long-term complications.

[Ovarian vein syndrome]

The Ovarian Vein Syndrome has been the subject of controversy ever since first described as such by Clark in 1964. This is an uncommon entity within urologic sings and symptoms which appears as a recurrent nephritic colic coinciding with menstruation or during the immediately preceding days. The authors review a clinical case from our Urology Service, including some considerations on the case.