[Buccal mucosa urethroplasty in anterior urethral strictures]

Buccal mucosal graft can be used for succesfull repair in both pendulous and bulbar strictures.

MATERIAL AND METHODS

We present our experience with buccal mucosal graft repair in 8 patients with onlay patch that varies from 4 to 16 cm. in length. Three pendulous, two bulbar and three panurethral strictures were repaired. These patients were observed for 36 to 60 months.

RESULTS

No stricture recurrences were observed. Only one patient had lower lip paresthesia for six months.

[Testicular epidermoid cyst: uncommon lesion of difficult preoperative diagnosis]

Intratesticular epidermoid cysts are rare tumours that constitute one percent of all testicular masses. They are bening lesions that make differential diagnosis from malignant testicular tumours difficult. The absence of serum markers elevation and ultrasound imaging could support these lesions being bening epidermoid cysts, and in that case, conservative surgery is adequate. We present the case of a 22 years old patient who complains of a left testicular mass. In this case ultrasound diagnosis was non-specific and a left radical inguinal orchiectomy was performed.

[Usefulness of abdominal leak point pressure determination in the diagnosis of female urinary incontinence in the TVT era]

OBJECTIVE

To analyse our results about continence in the treatment of female urinary incontinence with the tension-free vaginal tape (TVT) procedure based on abdominal leak point pressure(ALPP).

PATIENTS AND METHODS

Retrospective study of the fifty two patients who had urodynamic study and abdominal leak point pressure determination and were operated on between 1999 and 2002 for stress urinary incontinence. We reviewed the data of clinical history, physical examination and urodynamic report, surgery, complications, and objective and subjective results. Those patients having ALPP > 100 are included in group 1, between 61 and 100 in group 2 and less than 60 in group 3.

RESULTS

There were 19 patients in group 1, 17 in group 2 and 16 in group 3. We found no difference between the three groups regarding age, delivery, menopause, hysterectomy, evolution, previous surgery, grade of cystocele, association of anterior colporraphy to TVT and type of anaesthesia. The Obrink clinical grade increased as the ALPP decreased (grade 3 in 26.32% of group 1, 31.58% in group 2 and 68.71% in group 3). 100% of patients in groups 1 and 2 were continent with effort and 93.75% in group 3. Complications, especially de novo instability or urgency-frequency episodes or persistence of instability in patients having mixed incontinence, caused a decrease in the satisfaction degree to 79% in group 1, 76.5% in 2 and 62.5% in 3.

CONCLUSIONS

Abdominal leak point pressure determination does not change our decision of perform a TVT procedure but permits us to differentiate one group in which results could be worse.

Tumores de urotelio superior

OBJECTIVE

To evaluate diagnostic techniques, treatment and follow-up in 94 patients affected of upper urinary tract tumor.

PATIENTS AND METHOD

From 1978 to december 2002 we operated 105 patients due to upper urinary tract tumor, although only 94 are valid for analysis. Mean age was 65 years and 85% were man. Haematuria was the most frequent symptom.

RESULTS

Urography (93%), ecography (77%) and CT (67%) were the most used diagnostic techniques. Pelvic tumor was the most frequent (71%) and total nephroureterectomy including bladder cuff the chosen treatment (76.4%). Previous or simultaneous bladder tumor was observed in 23% cases and delayed in 30%. With a mean follow-up of 76 months the patient survival is 53%.

CONCLUSIONS

Due to the high frequence of previous, simultaneous or delayed bladder tumors, the upper urinary tract tumor should be considered as a panurothelial disease, worsening the outcome of this kind of tumors.

[Corrective surgery of penile inward curvature]

OBJECTIVE

To evaluate the corporoplasty techniques performed on 59 patients to correct congenital penile curvature and Peyronie's disease.

PATIENTS AND METHOD

From april 1991 to december 2001, 39 Nesbit technique, 12 Ruiz-Castañé method and 8 Essed-Schröeder procedure were performed on forty-four congenital curvatures and fifteen Peyronie's diseases. The mean age was 24 years old. Trying to hide the knots, in all patients except five a nonabsorbable inverting sutures were placed.

RESULTS

The mean follow-up was 12 months. Postoperatively, 53 patients (86%) had satisfactory cosmetic and functional results. Four patients of five with absorbable sutures had residual curvature which needed another successful surgical correction. One patient complained of penile shortening, one of glans hypoaesthesia, one of foreskin oedema and five of palpable plication sutures. No differences were found depending on the applied surgical technique.

CONCLUSIONS

The results reported are in accordance with the literature showing a higher recurrence rate with the absorbable sutures. The outcome is very similar with the three described techniques.

[Synchronous renal oncocytoma and asymptomatic pheochromocytoma. Report of a case]

OBJECTIVE

To report a rare case of coexisting renal oncocytoma and pheochromocytoma. To our knowledge, only one such case has been reported in the literature.

METHODS

The findings of the imaging studies of this rare case and the unsuspected anatomopathological findings are presented.

RESULTS/CONCLUSIONS

Despite its very low frequency, coexisting renal ocnocytoma and pheochromocytoma should be taken into account in patients with synchronous renal and adrenal masses. Unfortunately, there are no radiological patterns that allow us to suspect this rare condition.

[Complications in a consecutive series of 133 cases of radical prostatectomy]

OBJECTIVE

To evaluate the surgical complications of radical prostatectomy in our hospital.

PATIENTS AND METHOD

From august 1991 to december 1999, 138 patients with clinically localized prostate cancer underwent Walsh technique radical prostatectomy. The follow-up is known from 133 patients with a mean age of 64.8% and a mean PSA of 17.6 ng/ml.

RESULTS

The mean follow-up is 43 months. Urinary fistula (9%), lymphatic leakage (5.22%) and rectal injury (2.2%) are the most common early complications. Urinary incontinence (27%), erectile dysfunction (98%) and urethrovesical junction stenosis (12%) are the delay complications. Only three patients have died due to prostate cancer. Our results are compared with another series.

CONCLUSIONS

The morbidity of radical prostatectomy is very similar to the compared series. Urinary incontinence and erectile dysfunction are the most worrying complications which the patient must know to have the opportunity to choose another therapeutic option.

[Leydig cell tumor. Report of 2 cases and review of the literature]

The Leydig cell tumor is the most frequent of non-germ cell tumors of the testis. Clinical findings depend on the age of presentation. We present two cases of Leydig Cell tumors of the testis, diagnosed in a 8 years old child with isosexual precocity, and a 42 years old adult with Gynaecomastia. After reviewing the existing literature on this uncommon pathology we consider that the iconography presented is very interesting for furthering the knowledge on this subject.

[Correlation between imaging findings and anatomopathologic results in radical prostatectomy. Data from our series]

OBJECTIVE

To analyze the diagnostic methods utilized in prostate cancer and the preoperative information on the extent of the tumor, and compare these results with those obtained from anatomopathological analyses of the radical prostatectomy specimen.

METHODS

Data on the radical prostatectomies performed during the study period were obtained from the Admissions and Clinical Records services and were analyzed using the SPSS statistical analysis software for Windows.

RESULTS

From 1991 to 1998, 109 radical prostatectomies were performed. Evaluation by transrectal US was carried out in 89 patients (81.6%) and detected a tumor (unilateral or bilateral) in 77, for a sensitivity of 86% (CI 78.8-93.2). A CT study was performed in 94 patients and was positive in 25, for a sensitivity of 26.5% (CI 17.6-35.4). The sensitivity for transrectal US and CT were 4.17% and 3.33% for capsular involvement, 5.88% and 5.26% for seminal vesicle involvement, and 0% and 0% for node involvement, respectively.

CONCLUSIONS

Transrectal ultrasound is a reliable diagnostic imaging method, although it has a low sensitivity when used to determine the extent of the tumor. In our series, the radiological methods showed a low sensitivity when they were utilized to determine the extent of the prostate cancer. Routine preoperative assessment by CT can be obviated in prostate cancer.

[Mucinous adenocarcinoma of the prostate. Report of a new case]

OBJECTIVE

To describe a case of mucinous adenocarcinoma of the prostate, an uncommon variant of prostatic carcinoma of which few cases have been reported in the literature. This tumor type is briefly reviewed with special reference to the controversial issues that remain unresolved due to the small number of cases.

METHODS/RESULTS

A case of mucinous adenocarcinoma of the prostate is presented. An extraprostatic origin had been discarded. The diagnosis was made by DRE, transrectal US and histological confirmation by transrectal biopsy. PSA values were normal. Studies to determine the extent of the lesion showed advanced locoregional dissemination. Surgery was therefore not indicated and hormonal therapy was administered. Patient outcome was poor with no apparent clinical response to hormone blockade. Radiotherapy was attempted. The patient rapidly became worse and died.

CONCLUSIONS

Mucinous adenocarcinoma of the prostate is characterized by the presence of significant amounts of extra and intracellular mucin. Its clinical features are not unlike those of classical adenocarcinoma and in general terms, it is considered to carry a worse prognosis and refractory to hormone therapy.

[Incidence of priapism at the Marqués de Valdecilla University Hospital in Santander]

OBJECTIVE

Our experience in the management of priapism, its etiology, blood gas changes, treatment and outcome are presented.

METHODS

The records of patients that had been treated at the Urology services of our hospital over the last 8 years were reviewed. During this period, patients with erectile dysfunction were treated according to a protocol.

RESULTS

There were 9 episodes of priapism in 8 patients; all cases were low flow and the patients were aged 37-71 years. The duration of the prolonged erection ranged from 4 to 72 hours. Of these 9 cases, the etiology was intracavernosal PGE in 7, after trazodone administration in one case, and unknown in one case. Intracavernosal metoxamine was administered in all cases with excellent results, except one case that required a saphenous-cavernosal shunt and another case that was initially treated with adrenalin also with good results.

CONCLUSIONS

Since intracavernosal agents have been utilized in the treatment of erectile dysfunction, priapism has become a more frequent urological emergency. Although a lower incidence has been reported for PGE, the dose should be well adjusted to avoid a higher incidence.

[Trazodone-induced priapism]

We present a 41 years old male, treated with trazodone because of depression. He was seen at our Andrology unit for a 72 hours evolutioned priapism. We review the literature and submit this paper for publication because it is an uncommon pathology.

[Massive lymphatic involvement secondary to prostatic adenocarcinoma]

Prostatic carcinoma may be diagnosed by the clinic manifestations or by the symptoms for locoregional disemination and distance metastasis. The lymphatic system is the first metastatic station, which is affected in a high percentage of cases. Event it may simulate lymphoproliferatives process and it si uncommon the lymphatic macroaffectation at first. In theses cases, the histologic and immunohistochemical study by the determination of prostatic specific antigen in lymph nodes can provice the diagnosis. Treatment of these tumors is palliative with hormonotherapy. Prognosis is bad with a low survival at five years.

[NMP-22 in the diagnosis of bladder cancer]

OBJECTIVE

To evaluate the usefulness of the NMP-22 test in the diagnosis of bladder cancer; to calculate the ideal cutoff and to compare the results among NMP-22, voided urine cytology and cystoscopy.

MATERIAL AND METHODS

166 patients having clinical suspicious of bladder cancer or in follow-up due to a previous one. The exclusions criteria were: other urological conditions, radiotherapy in the last three months, systemic chemotherapy in the last month, recent vesical trauma or indwelling catheter. Prior cystoscopy a recent voided urinary sample was sent to the pathology and biochemistry laboratory to perform cytology and NMP-22. A TUR was performed in patients with bladder tumour. The cutoff was calculated with ROC curves. For each test we calculate sensitivity, specificity, positive and negative predictive value. We use the McNemar test to compare the results, all of which are expressed with a confidence interval of 95%.

RESULTS

The ideal cutoff was 6 U/ml. We have a global sensitivity of 82.75% for NMP-22 and 67.9 for cytology (p = 0.0118); the specificity was 80% and 94.12% respectively (p = 0.0018). By grade the sensitivity was 72.22% G1, 70.97% G2 and 100% G3 for NMP-22 and 44.44%, 58.06% and 90.62% for cytology. By stage it was 68.42% Ta, 83.33% T1 and 100 T2 or more for NMP-22 and 36.84%, 75% and 85.71% for cytology. With the cystoscopy we obtained a 100% sensitivity and 89.41% specificity.

CONCLUSIONS

The NMP-22 is a useful test for the diagnosis of bladder cancer; is more sensitive and less specific than cytology. We think it can replace the cytology in the diagnosis and follow-up of bladder cancer. The ideal cutoff is 6 U/ml.

[Retroperitoneal benign schwannoma. Report of a new case]

The schwannoma is a tumor resulting from the Schwann cells of neural shwath, being its retroperitoneal localization quite unusual. This tumor is clinically unspecified and in most of the cases it originates symptoms coming from the compression of the close structures when its localization is retroperitoneal. Its diagnosis is quite often fortuitous being confirmed by anatomopathological study afterwards. The treatment is surgical radical exeresis with subsequent followup. We report a new case of this uncommon retroperitoneal pathology in a female patient showing a nonspecific clinic. Two years after the surgery she remains asymptomatic without any radiological evidence of recidive.

[Bellini's carcinoma. Our experience]

OBJECTIVE

To present our experience with Bellini duct carcinoma, a rare form of renal adenocarcinoma with well-defined histological, cytogenetic and immunohistochemical characteristics. The literature is reviewed.

METHODS/RESULTS

We reviewed the records of 430 patients with renal tumor that had been treated over a 10-year period. Only 6 cases with Bellini duct carcinoma were found. The mean age was 60 years, all patients were male and hematuria and lumbar pain were the most common clinical manifestations. Diagnosis was made by imaging techniques (US, urography, CT). The definitive diagnosis was based on the histological and immunohistochemical findings following nephrectomy. The one-year and three-year survival rates were 50% and 0%, respectively, indicating the aggressive nature of this variant of renal adenocarcinoma.

CONCLUSIONS

Bellini duct carcinoma is an uncommon variant of renal carcinoma with nonspecific clinical features. It is a very aggressive tumor type whose treatment is only by nephrectomy and the outcome is poor.

[Fournier's gangrene after vasectomy]

OBJECTIVE

An uncommon case of Fournier's gangrene following vasectomy is described.

METHODS/RESULTS

A 35-year-old male with no remarkable previous history, who underwent vasectomy in another hospital, developed a clinical picture compatible with Fournier's gangrene 7-8 days later. The patient required wide, aggressive surgical debridement on several occasions with broad spectrum antibiotic coverage. After a long stay at the hospital, the patient was finally discharged and referred to another hospital for plastic surgery.

CONCLUSIONS

Fournier's gangrene is a polymicrobial infection of the perineoscrotal region that manifests as a rapidly progressive necrotizing fasciitis. Most of the cases have a predisposing and/or triggering factor. Fournier's gangrene following vasectomy is uncommon. The morbidity and mortality in this severe complication depend on early diagnosis and aggressive surgical management.

[Comparative study of BTA stat test, NMP-22, and cytology in the diagnosis of bladder cancer]

OBJECTIVE

To compare the sensitivity and specificity of the BTA stat test, NMP-22 and voided urine cytology in the diagnosis of bladder cancer.

METHODS

The study comprised 100 patients or follow-up or with a suspicion of bladder cancer. A voided urine sample was obtained and alliquoted in three samples for the BTA stat test, NMP-22 and cytology. The patients were subsequently evaluated by cystoscopy and TUR was performed when cancer was suspected. The bladder cancer was classified according to TNM stage and WHO grade. The McNemar test was utilized to compare the results. The cut-off level used for NMP-22 was 10 U/ml. ROC curves were plotted to determine the NMP-22 values for optimal sensitivity and specificity in our seires.

RESULTS

Two patients were excluded from the study. The overall sensitivity was 76.47% for cytology, 78.43% for the BTA stat test and 84.31% for NMP-22 (p = n.s.). The specificity was 91.49%, 87.23% and 87.23% respectively (p = n.s.). By grade and stage, NMP-22 showed the best results followed by the BTA stat test and lastly cytology, although the differences were not significant. The ideal cut-off for NMP-22 in our series was 6 U/ml and not the generally recognized 10 U/ml.

CONCLUSIONS

NMP-22 is superior to the BTA stat test and cytology in the diagnosis of bladder cancer, although the differences were not significant. The ideal cut-off in our series was 6 U/ml. The BTA stat test has the advantage of being easy to perform and provides the results in 5 minutes. In our view, NMP-22 and BTA stat test can replace cytology in the diagnosis of bladder cancer.

[The BTA stat test in the follow-up for bladder cancer]

OBJECTIVE

To evaluate the utility of the BTA stat test in the follow-up of asymptomatic patients with superficial carcinoma of the bladder.

METHODS

In 122 asymptomatic patients on follow-up for superficial bladder carcinoma, a sample of recently voided urine was obtained prior to cystoscopy and BTA stat test and cytology were performed. Thereafter we performed cystoscopy and TUR in those patients suspected of having recurrent bladder carcinoma.

RESULTS

51 patients had bladder cancer and 71 were tumor free. The sensitivity was 60.78% for the BTA stat test, 45% for cytology and 98% for cystoscopy. The specificity was 87.32%, 94.36% and 90.14%, respectively. The positive predictive value and negative predictive value were 77.5 and 75.6, 85.16 and 70.5, and 87.7 and 98.46, respectively for each test. The sensitivity by grade was 23% for G1, 71.4% for G2 and 92.8% for G3 for the BTA test versus 15.3%, 37.5% and 85.7% for cytology. The sensitivity by stage was 46.6% for Ta, 52% T1 and 100% for T2-4 and Tis for the BTA test versus 26.6%, 40% and 80% for cytology.

CONCLUSIONS

The BTA stat test is superior to cytology in the follow-up of patients with bladder cancer. However, it has a low sensitivity in G1 and Ta and T1 tumors, therefore cystoscopy cannot be avoided.

[Retroperitoneal mass secondary to Bellini carcinoma]

Bellini Collecting Duct carcinoma is a rare and aggresive histological variety of renal adenocarcinoma which originates from the epithelium of the collecting tubule, with a well established histological, cytogenetic and inmunohistochemic characterization. It allows us to differenciate this tumor type from the rest of renal adenocarcinomas. There are 7 cases already published in the national literature. We introduce a new case with a particularity that is to show an unusual presentation form. It appears clinically without a specific urological symptomatology and radiologically it present a retroperitoneal mass shape with explains the patient's clinical manifestations.

[The results of open surgery in the ureteropelvic junction syndrome]

OBJECTIVE

To evaluate the efficacy of the Anderson-Hynes pyeloplasty in 47 patients with pelviureteric junction syndrome and to compare our results with the reported results for open surgery and other techniques.

METHODS

The records of 47 patients (21 males, 26 females) with pelviureteric junction syndrome treated at the Marqués de Valdecilla University Hospital from 1979-1997 were reviewed. Twenty-eight patients had right-sided involvement and two were bilateral. Mean age at the time of surgery was 35 years. Pain was the most common presenting feature (nephric colic, 28 pts; chronic lumbar pain, 11 pts).

RESULTS

The Anderson-Hynes technique was performed in 43 of the 47 patients. IVP showed good results in 74.5%.

CONCLUSION

In our experience the success rate achieved with the Anderson-Hynes technique is comparable to those reported elsewhere, which ranges from 65%-100%. Although currently there is considerably less experience with endoscopic and laparoscopic techniques, the results achieved to data appear to be similar to those of open surgery.

[Raz's technics in the surgical treatment of stress urinary incontinence in women]

OBJECTIVES

To analyze our results in the surgery of the stress urinary incontinence in women with the Raz's techniques, to assess the association among continence and factors like surgical technique, grade of incontinence and urethral pressure profile.

MATERIAL AND METHODS

We do a retrospective study of 88 operations in 81 patients between the first of January 1990 and the thirty-one of December 1998. We describe the patients, previous treatments, grade of incontinence ans urodynamics data. We analyze the pre and post-operative complications. The outcome is evaluated by the Kaplan-Meier method, and the results are compared by the log rank test.

RESULTS

11 patients had a previous surgery and 7 had done physiotherapy; the grade of incontinence was 1 in 7 patients, 2 in 56 and 3 in 18. There were neither significative difference between UPP and abdominal leak point pressure and grade of incontinence nor between those parameters and continence. We did the Raz 1 technique in 67 patients, Raz 2 in 3, Raz 3 in 18. There were no significant difference among them. There are a progressive loose in the continence rate along the two first years; after that the continence rates are stabilized about 75%. The complications rate was scarce, except for the postoperative urinary retention, that reached the 20.45%.

CONCLUSIONS

Our results are similar to those cited in the bibliography, mainly in the Spanish one. The highest rate of failure is in the two first years.

[Iatrogenic ureteral lesions in open surgery: review of 10 years]

OBJECTIVE

To carry out a revision of iatrogenic ureteral damage during open surgery occurred in our hospital over a 10-year period, to review the literature and to contrast the results.

MATERIAL AND METHOD

Between January 1987 and December 1996, 19 cases of iatrogenic ureteral damage were reported in 18 patients. Ureteral damage was the result of gynaecological surgery in 8 cases (42%), general surgery in 5 cases (26.5%), vascular surgery in 4 cases (21.1%) and urological surgery in 2 cases (10.5%). Four patients had been given radiotherapy. In 15 of the ureteral units involved, reconstructive open surgery was performed while the remaining 4 units received conservative therapy.

RESULTS

In 11 cases of open surgery the results were good, 2 cases are nephrostomy carriers and 2 underwent nephrectomy. Conservative treatment was resolutive in all instances.

CONCLUSIONS

Gynaecological and general surgery are the major causes of ureteral iatrogeny in our media. In more than half the cases, diagnosis is late. Radiotherapy was associated to late diagnosis in all cases. When diagnosed early, both surgical and conservative therapy achieve good results.

[Urethral diverticula in the male. Our experience over 10 years]

OBJECTIVE

To review our series of urethral diverticulum in the male, an uncommon condition whose etiology continues to be a subject of discussion. The clinical features, diagnostic methods and treatment are analyzed.

METHODS

A 10-year retrospective study was conducted at our hospital. The etiopathogenic factors, risk factors, presenting features, methods of diagnosis, treatment, postoperative and non-surgical complications (lithiasis, intradiverticular tumors...) were analyzed.

RESULTS

Only six cases of diverticulum of the male urethra were found and were mainly of acquired origin. Recurrent infection was the most common clinical presentation. Patients were evaluated by voiding and retrograde cystourethrography. All patients underwent surgery. Postoperative control evaluation was performed by cystourethrography. The surgical complication rate was low.

CONCLUSIONS

Diverticulum of the male urethra is an uncommon urological disease whose etiopathogenesis has as yet to be established, although it is accepted to be predominantly of acquired origin. Its clinical features are unspecific, for which reason it should be considered when making a diagnosis. Although transrectal ultrasound appears to be useful, diverticulum of the male urethra is usually diagnosed by conventional cystourethrography. Treatment is by endoscopic or open surgery, which achieves good results.

[Studer's type ileal neobladder. Study of complications and continence]

Analysis of early and late post-surgical complications in 44 cases of Studer's type bladder replacement due to carcinoma of the bladder performed over a 6-year period. Follow-up ranges between 6 months and 6 years. 4 patients died during the post-operative (9.09%): 1 myocardial infarction, 1 pulmonary embolism and 2 intestinal fistula. 28 patients (63.64%) had post-operative complications: 4 GI fistula (9.09%) 5 ileus (11.36%), 2 GI bleeding (4.54%), 1 ureteral fistula (2.27%), 1 ureteral stenosis, 6 urethro-intestinal fistula (13.36%), 1 tubular necrosis, 1 ruptured ureteral catheter, 5 wound infections (11.36%), 12 urine infections (27.27%), 6 sepsis (13.63%), 1 lymphocele, 1 evisceration and 2 eventrations. Repeat surgery was required in 6 cases. Within 6 months from discharge, 7 of 40 patients (17.5%) had some complication: 3 acute pyelonephritis, 4 episodes of acidosis-dehydration and 1 ureter stenosis. After 6 months, 7 of 38 patients (18.4%) had complications: 1 acidosis, 3 vesical lithiasis, 2 ureteral stenosis and 1 urethro-intestinal, plus 2 cases of chronic urinary retention. Daytime continence was 97.2% and nighttime continence 30%; after 6 months evolution, no further changes were seen.

[Female urethral diverticula. Our experience over 10 years]

OBJECTIVE

To review our series of urethral diverticulum in the female, an uncommon condition whose etiology continues to be a subject of discussion. The etiopathogenic hypotheses are briefly reviewed. The clinical features, current diagnostic methods and treatment are analyzed.

METHODS

A 10-year retrospective study was conducted at our hospital. The risk factors, presenting features and postoperative complications were analyzed.

RESULTS

Only six cases of diverticulum of the female urethra were found. Recurrent infection and the presence of a palpable mass were the most common clinical features. Diagnosis was made by voiding and retrograde cystourethrography and urethroscopy. All patients underwent surgery. Postoperative control evaluation was performed by cystourethrography.

CONCLUSIONS

Diverticulum of the female urethra is an uncommon urological disease which should be taken into account when making a diagnosis. Its etiopathogenesis has as yet to be established, although it is accepted to be predominantly of acquired origin and related with paraurethral gland pathology. Its clinical features are unspecific or it may cause florid urinary symptoms. Our patients were diagnosed by cystourethrography, although other diagnostic imaging techniques are currently available. Treatment is by surgery, which achieves good results and the complication rate is low.

[Usefulness of BTA Stat test (Bard) in the diagnosis of bladder cancer. Preliminary results and comparison with cytology and cystoscopy]

OBJECTIVE

The Bard BTA test is an immunochromatographic reaction to detect the bladder tumor antigen in patients with bladder cancer. The sensitivity, specificity and predictive values of this test are analyzed and compared with the standard methods of bladder cancer diagnosis (cystoscopy and cytology).

METHODS

In 120 patients with symptoms suggestive of bladder cancer or who came for follow-up control evaluation for bladder cancer, we performed the BTA test and cytology in a voided urine sample prior to cystoscopy. TUR and randomized biopsies were performed in patients with a suspicion of bladder cancer.

RESULTS

76 patients had bladder cancer and 44 were free of cancer. The sensitivity was 76.36% for the BTA test, 61.84% for cytology and 98.5% for cystoscopy. The specificity was 77.7% for the BTA test, 86.36% for cytology and 86.36% for cystoscopy. The positive and negative predictive values were 85.29% and 65.38%, 88.68% and 56.72%, and 91.5% and 97.4%, respectively, for each of the foregoing tests. The sensitivity by grade was 43.75% for G1, 78.38% for G2, 95.65% for G3 for the BTA test; 18.75%, 59.46% and 95.65% for G1, G2 and G3, respectively, for cytology. The sensitivity by stage was 53.8% for Ta, 76% for T1, and 100% for T2-4 and Tis for the BTA test, whereas the sensitivity for cytology was 23.08%, 62% and 100%, respectively, for the foregoing tumor stages.

CONCLUSIONS

The BTA test is simple, fast and useful in bladder cancer diagnosis. Our results show that the BTA test is superior to cytology.

[Tethered cord syndrome in the adult]

OBJECTIVES

To describe a case of tethered cord syndrome, with special reference to the diagnostic and therapeutic difficulties.

METHODS

A case of an adult patient with tethered cord syndrome after the complications post-TURP is described. The most relevant radiological and urodynamic features are presented.

CONCLUSIONS

The tethered cord syndrome in the adult has a wide variety of symptoms. The age of onset depends on the level of cord involvement and the precipitationg factors. The urological symptoms are as varied as the urodynamic features, therefore each case must be treated independently. Treatment is a controversy; untethering offers little benefit to the patients. The incidence of the tethered cord syndrome in the adult may be higher than the reported incidence, particularly in patients with progressive and unexplained neurological, orthopedic or urological symptoms.

[Role of nitric oxide in warm ischemia of the transplanted kidney]

OBJECTIVE

Nitric oxide (NO) is a gas considered to have two roles: cytoprotective, derived from its vasodilating and anti-platelet aggregation effects, and cytotoxic, due to its free oxygen radical. It is produced by NO synthase; nitrites and nitrates are its end products. We investigated the role of NO in ischemia-perfusion injury.

METHODS

For the study, we utilized dogs weighing 15 to 25 kg. Autotransplantation of the left kidney and right nephrectomy were performed. Group I comprised 9 dogs submitted to renal autotransplantation; group II comprised 6 dogs submitted to renal autotransplantation after 24 h cold ischemia; group III comprised 6 dogs submitted to renal autotransplantation after 24 h cold ischemia and subsequent warm ischemia of 30 min; group IV comprised 9 dogs submitted to renal autotransplantation after 24 h cold ischemia and 60 min warm ischemia.

RESULTS

A significant fall in nitrite levels was observed in dogs that had some type of surgical injury. Nitrate levels increased significantly in dogs that had warm ischemia. At 30 min reperfusion, a significant increase in the production of constitutive enzyme was observed in all groups. A significant increase in inducible enzyme at 30 min reperfusion was observed in the first three groups and no inducible enzyme was produced in the group that had more injury from ischemia (group IV).

CONCLUSION

Nitrites are markers of the injury produced by surgery. Nitrates clearly express the injury to the organs caused by warm ischemia-reperfusion. The cNOS enzyme increases after surgery in response to surgical insult or stress. The iNOS enzyme increases in the kidneys that have suffered ischemia and are viable. Non-viable kidneys express no enzymatic activity (cNOS, iNOS).

[Renal tumors smaller that 3 cm]

OBJECTIVES

To analyze the characteristics of renal adenocarcinoma less than 3 cm in size and to determine the therapeutic approach in these tumors.

METHODS

286 cases with a histological diagnosis of renal adenocarcinoma that had undergone surgery at our hospital over the last 25 years were reviewed.

RESULTS

The study showed 11 cases had renal tumors less than 3 cm in size. Six had been incidentally diagnosed. Two patients presented metastasis during the course of the disease and one patient had massive lymph node invasion (N3) at the time of diagnosis. Seven patients had a low tumor stage and grade.

CONCLUSION

Renal tumors less than 3 cm in size have been considered to have a low potential for malignancy. However, the availability of more sophisticated diagnostic imaging techniques have led to earlier detection of renal masses, when the tumor is of a smaller size. Therefore determining whether the tumor is benign or malignant should be based exclusively on the histopathological findings. Treatment of this type of lesions is by surgery and performing a partial nephrectomy should be considered.

[Nuclear area versus nuclear grade in the prognosis of renal carcinoma. Long-term results]

Fürhman's nuclear grading was used to compare the prognostic value of nuclear morphometry (represented by the nuclear area) in 95 renal adenocarcinomas treated by radical nephrectomy with a 11 to 25 years follow-up. The morphometric study was conducted by measuring 100 randomly selected nuclei, with a x1000 MOP-Videoplan morphometer and a light chamber adapted to a microscope. Based on the nuclear area, 2 prognostic groups were made up, one for area values below 35 microns2 and another one for areas over 35 microns2. The nuclear grade was reassigned in all cases according to Fürhman's rating, assembling G1-2s as low grade and G3-4s as high grade for statistical convenience. Staging was done using Tonson's classification; stage II was divided into III-A (venous involvement) and III B + C (presence of adenopathy). The survival analysis was included in the sample overall analysis and in each stage. Survival showed significant differences between groups with areas over and below 35, and between high and low grade. Only 2 cases in stage III B + C and none in stage IV had areas below 35. When comparing survival between under 35 and low grade cases, and between over 35 and high grade cases, no significant difference was obtained. It was therefore conclude that, although nuclear morphometry is a good prognostic factor in renal carcinoma, it contributes little to nuclear grading and it has the drawback of being too elaborate.

[Satellite intrarenal tumor nodules in renal carcinoma. Therapeutic implications]

OBJECTIVES

To analyze the incidence of tumoral satellite nodules in renal carcinoma, study the main features of the primary tumor and establish an approach to determine the risk of multicentricity.

METHODS

We analyzed 286 radical nephrectomies due to renal carcinoma. Twenty-nine cases (10.13%) that had intrarenal tumoral nodules were chosen; 5 cases (17.2%) had adenoma and 24(82.8%) had carcinoma. All but one case with von Hippel Lindau disease were sporadic tumors. The main features of the principal tumor (size, cellular type, architectural features, grade and stage) in both groups with and without nodules, were analyzed and compared.

RESULTS

The mean diameter was 7.89 +/- 4.091 cm (range 3.5-20) for the tumor and 0.85 +/- 0.65 cm (range 0.1-3) for the nodule. The mean tumor diameter was not significantly different from that of the group with no nodules (mean tumor diameter 8.16 +/- 3.58, range 2-25). Ten cases had only 1 nodule (34.48%), 4 had 2 (13.79%), 2 had 3 (6.89%), 3 had 4 (10.34%) and 10 had 5 or more nodules (34.48%). The mean age was 56.89 +/- 11.46 (range 22-76); 24 were males (82.75%) and 5 females (17.14%); 14 cases were located in the right (28.27%) and 15 in the left side (51.72%). The foregoing data were not significantly different from those of the group with no nodules. Nineteen cases had clear cell, 5 granular, 4 mixed and 1 had the fusiform cell type. Seventeen cases were grade 2 (68%) and 8 cases grade 3 (32%); there were no G1 or G4. Ten were Robson stage I (34.48%), 2 were stage II (6.89%), 11 stage III (37.93%) and 6 stage IV (20.68%). Three cases had local recurrence (10.34%). No differences were observed for survival between the two groups. A 3 cm nodule was diagnosed preoperatively in only one case. Assuming the following criteria of a localized tumor, stage I, with a diameter less than 5 cm for performing elective nephron-sparing surgery, only 8 of the 43 cases that met the foregoing criteria had nodules (16.18%). Of these, 4 (2 of which were adenomas) had a single nodule (9.3%). If the criterion of low grade (G1-G2) tumor is also considered, only 5 of the 27 cases that met the foregoing additional criterion had nodules (14.7%).

CONCLUSIONS

When nephron-sparing surgery is performed, it should be remembered that there is an approximately 10% risk of leaving tumor nodules of small size in the kidney which may cause local recurrence. Consequently, these patients should be followed very closely.

[Incidental versus clinical renal adenocarcinoma: comparative study (1970-1994)]

A revision has been made of 286 renal adenocarcinoma treated in the Urology service at the Hospital marqués de Valdecilla, Santander, during the period from January 1970 through December 1994, dividing the study in two groups based on diagnosis being incidental or clinically suspected, and comparing the following parameters: 5-year intervals incidence, age, gender, intrarenal location, tumoral diameter, histology, nuclear grade, tumour stage and survival. The objective was to analyze the possible differences between renal cell neoplasias diagnosed based on clinical behaviour and those diagnosed incidentally over a 25 year period. Of the 286 renal adenocarcinomas, 217 (77.5%) were symptomatic at diagnosis, 63 (22.5% were found accidentally, while presentation in 6 cases is unknown. The percentage of incidental diagnosis increases gradually from 0% during the 1970-75 period to 44.2% from 1990 to 1994. No significant differences were found between incidental and clinical cases with regard to gender, age at presentation, affected side or intrarenal location of the tumours. The tumoral diameter of incidental cases was 6.74 +/- 3.31 cm, and 8.53 +/- 3.66 in the clinical ones, the difference being significant (p < 0.001). Nuclear grade is lower in incidental cases than in clinical ones, with a significant difference (p < 0.01). Asymptomatic tumours occur with higher proportion at low Robson stages, 60.3% stage I vs. 30.5% of symptomatic cases (p < 0.001). A comparison of survival shows the existence of significant differences (p < 0.001) between incidentalomas and clinical adenocarcinomas, the significance in this differences fading when both groups are compared based on the stage. Relative to suspected cases, incidental tumours present less size, lower nuclear grade, lower stage and better survival, all these differences being highly significant. No significant differences are seen in survival between incidentalomas and symptomatic ones when compared by stage at tumour presentation.

[Cystic adenocarcinoma of the kidney. Apropos of 18 cases]

OBJECTIVES

To analyze the main epidemiological, clinical and pathological features of cystic renal carcinoma in comparison with those of solid tumors. To determine the reliability of the preoperative diagnostic methods to distinguish these cysts from other cystic renal disease.

METHODS

The study comprised 286 carcinomas that had been treated over a period of 25 years. These cases were divided into two groups; 268 solid tumors and 18 cystic lesions. We analyzed patient age at onset, sex, tumor location and intrarenal status, clinical features, tumor size, cellular type, grade, stage and survival rate. In the group with cystic lesions, we analyzed the diagnostic methods used and the diagnosis made preoperatively.

RESULTS

6.29% were cystic carcinomas. There were no differences between the solid and cystic lesions except for the slightly larger size of the latter (9.88 cm versus 8.01 cm). No significant differences were found for survival. The IVP and arteriograms only disclosed an expansive renal process suggestive of a neoplasm in 9 and 3 cases, respectively. Ten cases were evaluated by US and 13 by CT, which revealed a complicated cystic lesion. The fine needle punction aspiration biopsy, which was done in 3 cases, was negative. On the basis of the findings, a diagnosis of cystic carcinoma was made in 11 cases and multilocular cystic nephroma in 3 cases. The older cases that had been seen when US or CT were unavailable had been diagnosed as having renal carcinoma.

CONCLUSIONS

Similar results, with special reference to the high rate of false negatives of the cytological study, have been reported in the literature.

[Computerized axial tomography (CAT) and echography (US) of multilocular cystic nephroma]

OBJECTIVES

To determine the sensitivity and specificity of computed tomography and ultrasound in the diagnosis of multilocular cystic nephroma.

METHODS

Four cases with a pathologically confirmed diagnosis of cystic nephroma were reviewed.

RESULTS

These four cases had a predominantly cystic mass with thin walls located in the lower pole of the kidney. Both techniques had a sensitivity of 100% for renal masses but a low specificity since they failed to distinguish multilocular cystic nephroma from other cystic lesions.

CONCLUSIONS

A presumptive diagnosis of multilocular cystic nephroma can be made on the findings of these noninvasive diagnostic imaging techniques. The definitive diagnosis, however, is by anatomopathology.

[Review of 42 cases of penile carcinoma]

OBJECTIVES

42 cases of penile carcinoma were retrospectively analyzed to determine the overall survival and the influence of treatment and inguinal lymph node metastasis on survival.

METHODS

The clinical records of 42 patients with penile carcinoma that had been treated at our hospital over a 17-year period were reviewed, with special reference to the epidemiological aspects, diagnosis, staging, treatment and overall survival.

RESULTS

The overall 5 and 10-year survival were 73% and 43%, respectively. Inguinal dissection was performed in 24% of the patients. The overall survival was better in those with no lymph node involvement.

CONCLUSIONS

Following local surgery of penile cancer, inguinal lymphadenectomy of palpable nodes is recommended to improve survival, if antibiotic treatment is not effective. Randomized and cooperative studies are necessary to assess the efficacy of prophylactic lymph node dissection and its influence on survival.

[Atypical forms of renal carcinoma]

This is a comparative study of the various subtypes of renal carcinoma (divided according to their microscopic features in classic, papillary, Bellini's, sarcomatoid, chromophobe, small cells) on the 286 renal carcinomas removed in the Valdecilla Hospital over the last 25 years. For each type of presentation, age, gender, location, intrarenal status, tumoral diameter, clinical signs and symptoms, presence of metastasis, Fuhrman's core grade, Robson stage and survival, have been analyzed. No cases of small cells or chromophobe tumours were seen. Of the total 286 renal tumours, 253 (88.64%) showed a classical pattern, 21 (7.34%) were papillary, 10 (3.49%) sarcomatoid, and 2 (0.69%) Bellini's carcinomas. In the analysis by mean age at presentation, distribution by sex, involvement site and intrarenal location, no statistically significant differences were found between the different tumoral subtypes. In our series, the sarcomatoid type presents a larger average tumoral diameter than both the papillary and the classical ones (p < 0.01, p < 0.001, respectively). The most frequent clinical manifestation in all tumoral types was haematuria. The sarcomatoid tumours showed a statistically significant trend to present with higher core grade (G4) and higher tumoral stage (E IV) than papillary and classical tumours. Overall survival at 3 years was 72% for the papillary type, 65% for the classical and 22% for the sarcomatoid subtype, the latter being significantly worse than the first two (a < 0.001).

[Substitutive orthotopic ileocystoplasty. The Studer's technique]

OBJECTIVES

The results of the Studer enterocystoplasty technique is analyzed, with special reference to the early and late complications and urinary continence.

METHODS

We reviewed the records of 20 patients that underwent bladder substitution according to the Studer technique due to bladder carcinoma from 1990-1993. Patient follow-up ranged from 6-36 months. The ureteroileal anastomosis was done by the single stitch technique onto a tubularized ileal chimney.

RESULTS

The median age was 57.2 +/- 11.86 yrs (range 33-73). The preoperative stay for intestinal preparation ranged from 1-29 days (median 4.4 +/- 5.84) and the postoperative stay ranged from 1-60 days (median 26 +/- 11.44). The average operating time was 5.30 +/- 0.7 hours (range 4.15-7). There were two postoperative deaths; one from acute myocardial infarction and the other from pulmonary embolism. Three patients died from tumor progression during follow-up and one from leg ischemia 17 months postoperatively. Early complications: 2 cases of prolonged ileus, 1 wound infection, 7 urinary infections, 1 low debit intestinal fistula which resolved with parenteral nutrition, 3 patients had leakage at the ileourethral anastomosis which resolved with prolonged catheter drainage of 3-15 days, 1 hemorrhage from acute lesions to the gastric mucosa, 3 fascial dehiscence and 1 ureteroileal fistula that required reimplantation into the neobladder. Late complications: 1 ureteroileal stenosis that progressed to renal atrophy, 1 enterourethral stenosis that resolved with internal urethrotomy and 2 cases of severe metabolic acidosis and dehydration that resolved with fluid therapy. No differences were observed between the creatinine, pH and ion levels preoperatively and during follow-up. Continence was assessed in 17 cases: 100% were continent during the day, 41.2% were continent during the night, 4 had occasional nocturnal leakage and 6 required collecting devices during the night.

CONCLUSIONS

The Studer technique provides good results and quality of life to patients undergoing cystectomy. Although it carries a high morbidity, conservative management will suffice in a high percentage of cases.

[Stress urinary incontinence. Our experience with its treatment using the transvaginal colposuspension technique (Raz I and II)]

Presentation of our experience in the surgical treatment of urinary stress incontinence, with transvaginal colposuspension techniques, specifically those described by S. Raz and known as Raz I and Raz II. Over a 24-month period, 25 transvaginal colposuspensions (22 Raz I and 3 Raz II) were performed. The results achieved were 21 patients (84%) have recovered, while 4 (16%) remain incontinent, 3 of them referring improvement and 1 without improvement, after a follow-up of 12 to 36 months. With regard to complications, there has been 5 cases (20%) of postoperative retention, one vesical perforation while passing the needles, and a vesicle perforation during vaginal dissection of the retropubic space.

[Papillary adenocarcinoma of the rete testis. Report of a case]

OBJECTIVES

Another case of adenocarcinoma of the rete testis is described and the literature on this uncommon tumor type reviewed.

METHODS/RESULTS

The clinical features, pathological findings and treatment of adenocarcinoma of the rete testis in a 72-year-old male are presented.

CONCLUSIONS

Adenocarcinoma of the rete testis is a rare tumor type; few cases have been reported in the literature. Although treatment is primarily by surgery, recognition of new cases will provide further insight into this primary tumor of the rete testis.

[Clinical trial with intravesical alfa-2b interferon for the prevention of T1 transitional carcinoma of the bladder: preliminary results. Review of the bibliography]

OBJECTIVE

To assess the efficacy of 60 MU intravesical alpha-2b interferon (IFN) in preventing recurrence of transitional cell carcinoma of the bladder.

METHODS

A prospective, randomized double-blind study was conducted to assess the efficacy of 60 MU intravesical alpha-2b IFN compared to a control group. T1G2-G3 and the G1 recurrent tumors were included in the study (30 in each group). Instillation was started 2-3 weeks after complete TUR and administered once weekly for 12 weeks and once monthly thereafter for one year.

RESULTS

The distribution according to sex and age of the patient, tumor size, grade and classification as primary or secondary was the same for both groups. Multiple tumors were prevalent in the IFN-treated group. During the first year of follow up, the tumor recurrence rate was 23.3% for the IFN-treated group and 36.6% for the control group. At 22.4 months mean follow up, the rate of recurrence was 40% for the IFN-treated group and 46.6% for the control group. Of these recurrences, 8.3% of tumors in the IFN group showed progression in grade and/or stage versus 35.7% for the control group. The disease-free interval averaged 8.5 months; 10.5 for the treated group and 6.9 months for the control group. Local or systemic toxicity was negligible.

CONCLUSIONS

Alpha-2b IFN is well-tolerated at a dose of 60 MU. It prolongs the disease-free interval and while throughout the follow up period the recurrence rate is similar to that of the control group, it does seem to markedly slow progression in the grade and/or stage of the tumor.

[Epidemiologic study of the clinical features, diagnosis, and treatment of kidney trauma in Cantabria]

OBJECTIVE

This study reviews the clinical features, methods and treatment of renal trauma (RT).

METHODS

The epidemiological study was conducted using data from 340 cases of RT that had been treated in the Department of Urology of the Marqués de Valdecilla University Hospital in Santander. All the information was filed in a data base specifically for the purpose.

RESULTS

Statistical analyses of the data showed the incidence of the symptoms, diagnosis and treatment of RT.

CONCLUSIONS

Radiological and ultrasound evaluation are still fundamental for the diagnosis of RT. Only 4% of these patients have died. Abdominal, thoracic and cranial injuries cause the most severe lesions. Concerning treatment, only 17% of the cases with RT required surgery.

[Epidemiologic study of the factors influencing renal trauma in Cantabria]

OBJECTIVE

In this study, the most important factors that influence renal trauma (RT) were evaluated in patients that had suffered different types of accidents.

METHODS

Data from 340 cases of RT that were seen over a period of 15 years were obtained. This was performed in two stages: first, data were obtained during this time period; secondly, the patients were followed after discharge from hospital.

RESULTS

All this information was filed in a data base specifically for this purpose and were statistically analyzed to determine and quantify the types of RT and their incidence in relation to demographic and temporal factors, type of accident, etc.

CONCLUSIONS

Weekends, alcohol, age, road traffic accidents, type of road, etc., are the most important factors that influence the development of RT. The incidence of RT in Cantabria is similar to that of the US and European countries.

[Bladder pheochromocytoma]

OBJECTIVES

The present study reports on a case of paraganglioma of the urinary bladder and briefly reviews the literature.

METHODS/RESULTS

The patient presented with gross hematuria and no history of hypertension. The pathological findings were diagnostic of paraganglioma of the urinary bladder.

CONCLUSIONS

Extra-adrenal pheochromocytoma is uncommon. Although it usually presents with typical symptoms, these are also determined by tumor location. Currently, there are no anatomopathological criteria to distinguish the benign from the malignant form.