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Horseshoe kidney is the most common renal fusion anomaly. Its peculiar anatomical characteristics increase the risk of lithiasis formation and always entails a surgical challenge for its treatment.We present the cases of men with horseshoe kidneys diagnosed by CT one case of alarge pyelic lithiasis with others of a smaller size in the calyces, and the other of a big solitary lithiasis in renal pelvis. RESULTS: We performed a laparoscopic pyelolitectomy to remove the pyelic lithiasis and we used a flexible cystoscope through a trocar to extract the calyceal stones. The postoperative period was uneventful without evidence of urinary leakage or residual lithiasis. CONCLUSIONS: The laparoscopic approach to lithiasisis a suitable alternative in especially complex cases such as horseshoe kidney. The use of a flexible cystoscope allows to navigate through the renal cavities and extract the lithiasis which cannot be accessed through laparoscopic instruments, improving the efficiency of this approach.El riñón en herradura constituyela anomalía de la fusión más frecuente. Sus características anatómicas incrementan la formación de litiasis y dificultan su resolución. MATERIAL Y MÉTODOS: Presentamos dos varones con riñones en herradura diagnosticados mediante TC abdominal en un caso de litiasis piélica de 5 cm y en el otro de una litiasis en pelvis renal con otras caliciales más pequeñas. Realizamos una pielolitectomía laparoscópica extrayendo las litiasis piélicas utilizamos introducimos un cistoscopio flexible por un trocar para extraer las litiasis caliciales. RESULTADOS: El postoperatorio cursó sin incidencias y retiramos el catéter doble jota 3 semanas después sin evidenciar fuga urinaria ni litiasis residual, encontrándose los pacientes 6 meses después sin litiasis. CONCLUSIONES: El abordaje laparoscópico de la litiasis constituye una alternativa en los casos complejos como en el riñón en herradura. Utilizar un cistoscopio flexible permite navegar en las cavidades renales aumentando la eficacia del abordaje.

Advanced prostate cancer (PC) is a frequent entity. The objectives of this paper are the presentation of a sample of patients with PC undergoing treatment with androgen deprivation therapy (ADT) in usual clinical practice and the determination of parameters associated with the development of resistance to castration (CRPC).Multicenter, observational, retrospective study that analyzes patients treated with ADT from January 2016 to January 2017. Descriptive analysis of the most relevant clinical variables and univariante analysis and progression times by Kaplan-Meier test.Sample of 952 patients. At PC diagnosis median age 74 years. Median PSA at PC diagnosis 23 ng/ml, when begining ADT 20.2 ng/ml. 80.2% of patients were biopsied at PC diagnosis: 28.2% Gleason score group 1, 38.7% groups 2 and 3 and 33.1% groups 4 and 5. Initial treatment of PC: 75.9% ADT, radical prostatectomy 8.4% and radiotherapy 15.1%. Of the 952 patients, 281 (29.6%) fulfilled CRPC criteria.In this group 21.7% achieved undetectable PSA (group in which it was 59.9%. Increased probability of progression to CRPC in: PSA30ng/ml at PC diagnosis (p=0.000, OR 2.78), Gleason score group 4-5 (p=0.000, OR 2.33), and not to reach undetectable PSA after ADT (p0.001, OR 3.32). The initial ADT group presents progression to metastatic CRPC more rapidly in unfavourable histology and when not reached undetectable PSA after ADT.We present a sample of patients with advanced PC in treatment with ADT that shows heterogeneity in usual clinical practice. In our sample, elevated PSA at PC diagnosis, unfavorable histology and failure to achieve a PSA0.1 ng/ml after ADT is presented as an indicator of progression to the CRPC stage.El cáncer de próstata (CP) avanzado es una entidad frecuente. Los objetivos de este trabajo son la presentación de una serie de pacientes con CP en tratamiento con Terapia de Deprivación Androgénica (TDA) en práctica clínica habitual y la determinación de parámetros asociados al desarrollo de resistencia a la castración (CPRC).MATERIAL Y MÉTODOS: Estudio multicéntrico, observacional, retrospectivo que analiza pacientes tratados con TDA desde enero 2016 hasta enero 2017. Análisis descriptivo de las variables clínicas más relevantes, análisis univariante y supervivencia libre de progresión mediante test Kaplan-Meier.Muestra 952 pacientes. Al diagnóstico del CP edad mediana 74 años. Mediana de PSA al diagnóstico de CP 23 ng/ml, al inicio TDA 20,2 ng/ml. El 80,2% de pacientes tenían biopsia al diagnóstico del CP: 28,2% grado pronóstico Gleason grupo 1, 38,7% grados 2 y 3 y 33,1% grados 4 y 5. Tratamiento inicial del CP: 75,9% TDA, prostatectomía radical 8,4% y radioterapia 15,1%.De los 952 pacientes, 281 (29,6%) cumplían criterios de CPRC. En este grupo el 21,7% alcanzó PSA indetectable (0,1 ng/ml) con la TDA 20,2 frente al grupo no CPRC en el que lo alcanzaron el 59,9%. Encontramos mayor probabilidad de progresión a CPRC en pacientes con PSA al diagnóstico de CP30 ng/ml (p=0,000, OR 2,78), grado pronóstico Gleason grupos 4-5 (p=0,000, OR 2,33) y en aquellos que no alcanzan PSA indetectable tras TDA (p0,01, OR 3,32) variables que se relacionan con los tiempos de progresión a CPRC y especialmente al estadio metastásico.Se presenta una serie de pacientes CP avanzado en tratamiento con TDA que muestra heterogeneidad de características y de manejo según práctica clínica habitual. En nuestra serie el PSA elevado al diagnóstico, histología desfavorable y no alcanzar un PSA0,1 ng/ml tras la TDA se presentan como indicadores de progresión a estadio CPRC.

Urosepsis is an underdiagnosed entity with high morbidity and mortality and significant associated costs. The delay in diagnosis leads to an increased risk of multiorgan failure and death. Although its prognosis is better than that of other sepsis, the mortality rate is 20 - 40%.Describe the obstructive uropathy cases (OU) that are complicated by severe sepsis (SS) and identify early biomarkers of SS.Observational and prospective study of 65 patients with urgent high OU. All patients were evaluated at three different times (0, 24 and 48 hours). An SS predictor model has been constructed and a multivariate risk analysis has been carried out.64.61% (n=42) developed SS (NSS: n=13). The only statistically significant variables in the 3 moments evaluated and that obtained a good area under the curve [AUROC (0.70)] were the elevation of neutrophils, procalcitonin, and decrease of bicarbonate. At the time of patient admission, the variable that best predicted SS was the elevation of procalcitonin (AUROC:0.919). SS risk factors (p0.005) were the history of cancer immunosuppression, and/or urinary tract surgeries, complete UO and high blood values of lactate, potassium and decrease of bicarbonate. The potassium-lactate combination on admission predicted SS with a probability function of 0.805.There is an analytical profile maintained over the time characteristic of SS that allows anearly identification of patients with OU subsidiary of been complicated with SS.INTRODUCCIÓN: La Sepsis urinaria obstructiva (SUO) es una entidad infradiagnosticada con una elevada morbimortalidad e importantes costes asociados. El retraso en su diagnóstico condiciona un mayor riesgo de fracaso multiorgánico y fallecimiento. Aunque su pronóstico es mejor que el de otros focos de sepsis, su mortalidad es del 20 - 40%.Describir los cuadros de uropatía obstructiva (UO) que se complican con sepsis grave (SG) e identificarlos biomarcadores diagnósticos de SG en la UOde forma precoz.MATERIAL Y MÉTODOS: Estudio observacional y prospectivo de 72 pacientes con UO alta ingresados de manera urgente en el Servicio de Urología del Hospital Clínico Universitario de Valladolid. Todos los pacientes del estudio fueron evaluados en tres momentos diferentes (0, 24 y 48 horas). Se ha creado un modelo predictor de SG y se ha realizado un análisis multivariante de riesgo.El 64,61% de los pacientes (n=42) desarrolló SG (NSG: n=13). Las únicas variables estadísticamente significativas en los tres momentos evaluados y que obtenían una buena área bajo la curva [AUROC (0,70)] fueron la elevación de neutrófilos y procalcitonina y la disminución de bicarbonato. En el momento del ingreso la variable que mejor predecía SG fue la elevación de procalcitonina (AUROC: 0,919). Los factores de riesgo de SG (p0,05) fueron los antecedentes de cáncer, la inmunosupresión y/o cirugías de vías urinarias, la UO completa y los valores elevados en sangre de lactato y potasio y la disminución del bicarbonato en la gasometría venosa. La combinación potasio-lactato al ingreso predecía SG con una función de probabilidad de 0,805.Existe un perfil analítico, mantenido en el tiempo, característico de SG que permite la identificación precoz de los pacientes con UO subsidiarios de complicarse con SG.

Congenital penile curvature (PCC) is a disorder caused by an alteration in the embryonic development of the urethra and the corporacavernosa, which causes difficulty in penetration, requiring surgical correction when inter course is impossible.To analyze the results of the surgical treatment of the IPC by means of rotation of the corpora cavernosa (RCC) described and modified by Shaeer. PATIENTS AND METHODS: Ten patients diagnosed with PCC with impossibility to inter course, were operated in a period of 36 months. Prior to the intervention,we applied the IIEF-5 questionnaire, measured the length of the penis and the angle of curvature throughself-photographs in three projections. By subcoronal approach,we perform denudation of the penis. On both sides of the urethra we incised Buck's fascia and released the neurovascular bundle from the ventral to the dorsal side. We generate an artificial erection evidencing the curvature. On the dorsal aspect of both corpora cavernosa, we made two incisions in the external longitudinal layer of the tunica albuginea. We sutured the internal and external edges of both incisions together with a 4/0 non-reabsorbable monofilament continuous suture, checking the correction of the curvature by means of an artificial erection. The patients were discharged the day after the intervention. The penile length and curvature were determined in the sixth month, and the IIEF-5 questionnaire. For the comparison of means we used the Mann-Whitney U test. RESULTS: The mean age was 26.8 years. The average follow-up was 20.7 months (12-31) and the median was 24. Before the intervention, the average curvature was 68.5° (50-90°); the average length 14.2 cm (10-18) and the IIEF-5 of 21. After surgery, the average length was 13.7 cm, the residual curvature the IIEF-5 of 25. There were no statistically significant differences between pre and postoperative penile length,(p=0.08). Nine patients assured that they would under go the same intervention again. CONCLUSIONS: RCC is an effective therapeutic alternative to the techniques of plication or lengthening of the tunica albuginea for the treatment of PCC, main tainingits long-term results.INTRODUCCIÓN: La incurvación peneana congénita (IPC) es un trastorno originado por una alteración en el desarrollo embrionario de la uretra y los cuerpos cavernosos, que condiciona dificultad para la penetración, precisando corrección quirúrgica cuando imposibilita el coito. OBJETIVO: Analizar los resultados del tratamiento quirúrgico de la IPC mediante rotación de los cuerpos cavernosos(RCC) descrita y modificada por Shaeer. PACIENTES Y MÉTODOS: Diez pacientes diagnosticados de IPC con imposibilidad para el coito, fueron intervenidos en un período de 36 meses. Previo a la intervención aplicamos el cuestionario IIEF-5, medimos la longitud del pene y el ángulo de incurvación mediante autofotografías en tres proyecciones. Mediante abordaje subcoronal realizamos el denudamiento del pene. A ambos lados de la uretra incidimos la fascia de Buck y liberamos el paquete vasculonervioso desde la cara ventral hasta dorsal. Generamos una erección artificial evidenciando la incurvación. En la cara dorsal deambos cuerpos cavernosos realizamos dos incisiones longitudinales en la capa longitudinal externa de la túnica albugínea. Suturamos los bordes internos y externosde ambas incisiones entre sí con una sutura continuade monofilamento irreabsorbible de 4/0, comprobando mediante una erección artificial la corrección de la incurvación. Los pacientes fueron dados de alta al día siguiente de la intervención. Al sexto mes se determinaron la longitud e incurvación peneanas, y el cuestionario IIEF-5. Para la comparación de medias utilizamos el test de la U de Mann-Whitney. RESULTADOS: La edad media fue 26,8 años. El seguimiento promedio fue 20,7 meses (12-31) y la mediana 24. Antes de la intervención la incurvación media fue 68,5° (50-90°); la longitud media 14,2 cm (10-18) yel IIEF-5 de 21. Tras la intervención la longitud media fue 13,7 cm, la incurvación residual 25. No existieron diferencias estadísticamente significativas entre la longitud peneana pre y postquirúrgica,(p=0,08). Nueve pacientes aseguraron que volverían asometerse a la misma intervención. CONCLUSIONES: La RCC constituye una alternativa terapéutica eficaz a las técnicas de plicatura o alargamiento de la túnica albugínea para el tratamiento de la IPC, manteniendo sus resultados a largo plazo.

To evaluate the associationbetween anogenital distance (AGD), as a biomarker ofprenatal androgen milieu, and risk of prostate cancer(PCa).A case-control study was conducted on260 men attending a university hospital where theyunderwent physical and andrological examination andcompleted a brief questionnaire. PCa patients were confirmedby biopsy of the tumor. Controls were men withoutPCa attending the urology outpatient clinic for routineexaminations. Two variants of AGD [from the anus to theposterior base of the scrotum (AGDAS) and to the cephaladinsertion of the penis (AGDAP)] were measured.Unconditional multiple logistic regression was used toestimate the association between AGD measurementsand presence of PCa, and Odds Ratios and 95% confidenceintervals (CI) were calculated.Cases showed significantly shorter AGDAPand AGDAS than controls. Subjects with AGDAP andAGDAS in the lowest compared to the upper tertile were2.6 times (95% CI 1.2-5.6) and 3.2 times (95% CI 1.5-6.9) more likely to have PCa, respectively.We found that shorter measurementsof both distances (AGDAS and AGDAP) were associatedwith higher risk of PCa. A previous study reportedsimilar results, showing that longer AGDAP was associatedwith lower risk of PCa, but this relationship was notfound for AGDAS, as it was in our study with a largersample size.Evaluar la asociación entre la distancia anogenital (AGD) como biomarcador de la ventana androgénica prenatal y el riesgo de padecer cáncer de próstata (PCa).MATERIAL Y MÉTODO: Estudio de casos y controles realizado en 260 pacientes. Todos los pacientes fueron sometidos a examen físico y andrológico y completaron un breve cuestionario. Los pacientes con PCa tenían diagnóstico histológico por biopsia prostática. Los controles fueron varones sin sospecha de PCa que acudieron a la consulta externa de Urología para exámenes rutinarios. Se midieron dos variantes de AGD [del ano a la base posterior del escroto (AGDAS) y del ano a la inserción dorsal del pene (AGDAP)]. Se utilizóanálisis de regresión logística múltiple para estimar la asociación entre las medidas de AGD y la presencia de PCa. Se calcularon Odds Ratios (ORs) e intervalos de confianza (IC) 95%.Los casos mostraron unas AGDAP y AGDAS significativamente más cortas que los controles.Los pacientes con AGDAP y AGDAS en el tercil inferior comparado con los pacientes del tercil superior mostraron 2,6 (IC 95% 1,2-5,6) y 3,2 veces (IC 95% 1,5-6,9) más riesgo, respectivamente, de padecer PCa.Encontramos que las medidas acortadas de ambas AGDs se asociaron con un mayor riesgo de padecer PCa. Un estudio previo obtuvo resultados similares, mostrando que una AGDAP alargada se asoció con un menor riesgo de padecer PCa, pero noobservó ninguna relación con respecto a la AGDAS, como sí objetivamos en este estudio con un mayor tamaño muestral.

Urethrorrhagia after radicalprostatectomy(RP) is very uncommon, regardless of the surgicalapproach used. Arterio-urethral fistula formation betweeninternal pudendal artery branches(IPA) and bulbarurethra is an exceptional finding.We report what we consider the first series oftwo cases (one has already been published) of urethrorrhagiaafter open retropubic RP due to urethrovascular fistulaformation with its origin in the IPA or in one of its terminalbranches.Both cases were diagnosed with contrast-enhancedCT, confirmed with arteriography, and they weretreated with superselective transarterial embolization(STE)with spongostan. After 5 years, the first case maintainserectile function using tadalafil on demand. The other caseis in the 2nd postoperative month.Severe urethrorrhagia after RP is an exceptionalcomplication. The existence of an arterio-urethralfistula must be considered when both urethrorrhagia andabnormal bulbar enhancement in CT are present. Arteriographyallows to confirm the diagnosis, most frequently involvingIPA distal branches. STE is an effective and safetreatment.La uretrorragia tras prostatectomía radical (PR) es muy infrecuente, independientemente del abordaje quirúrgico utilizado. La formación de fístulas arterio-uretrales entre ramas de la arteria pudenda interna (API) y la uretra bulbar, es un hallazgo excepcional.MATERIAL Y MÉTODOS: Presentamos la primera serie de 2 casos (uno ya publicado) de uretrorragia tras PR retropúbica abierta debidos a la formación de una fístula vascular con origen en la API o una de sus ramas terminales. RESULTADOS: Ambos casos fueron diagnosticados mediante TC con contraste intravenoso, confirmados con arteriografía, y tratados con embolización transarterial supraselectiva (STE) con espongostán. Tras 5 años, el primer caso conserva la función eréctil con tadalafilo a demanda. El 2º caso se encuentra en el 2º mes postoperatorio.CONCLUSIÓN: La uretrorragia severa tras PR es una complicación excepcional. Se debe sospechar la presencia de una fístula arterio-uretral ante la coexistencia de uretrorragia y realce bulbar anómalo en la TC, que suele ser la prueba de elección en el enfoque diagnóstico. La arteriografía permite confirmar los hallazgos, que suelen interesar a ramas dislates del territorio de la API. La STE es un tratamiento efectivo y seguro.

Anogenital distance (AGD), the distance from the centre of the anus to the genitals, is a sexually dimorphic phenotype in mammals. Several experimental studies have demonstrated that AGD is a biomarker of prenatal androgen exposure during the masculinisation period of development. The objective of this study was to assess the relationship between AGD (as an indirect marker of prenatal hormonal environment) and severity of the surgical specimen and prostate cancer (PCa) prognosis.We conducted a cross-sectional study with a total of 119 PCa patients with confirmed biopsy of the tumour. Every participant underwent a physical examination where two variants of the AGD were assessed, a) from the anus to the cephalad insertion of the penis (AGDAP) and b) to the posterior base of the scrotum (AGDAS). To assess the association between both AGD and severity and PCa prognosis multiple logistic regression analysis was used.Longer AGDAS was significantly associated with biochemical recurrence and affected margins of the surgical specimen (OR: 2.5; IC 95%:1.2-5.5, and 2.8; IC 95%: 1.1-7.5, respectively).Our findings suggest that a higher prenatal androgen exposure, resulting in a longer AGD, is associated with worse prognosis of PCa.

The enhanced recovery after surgery program (ERAS) has become the base of perioperative management in various surgical specialties. However, limited data are available for radical cystectomy.We have analyzed 124 patients undergoing radical cystectomy. For retrospective analysis, the patients were divided into two groups:Group A (n=72) included patients whose surgery was performed before the introduction of the ERAS protocol; and Group B (n=52) included patients who were treated following the items included in the ERAS protocol. The main objective was to assess the length of hospital stay and the permanence in intensive care units (ICU). Other variables were the use of intraoperative blood products, fluid-therapy and medical and surgical complications.Hospital and ICU stay were significantly shorter (p〈0.001) in Group B for patients following the ERAS protocol, which led to reduce 7 hospitalization days and 25.7 hours of overall ICU stay. Regarding fluid replacement following the ERAS protocol, our study showed a statistically significant reduction in the total amount of fluid administered, both crystalloids and colloids, in Group B (p〈0.001). The need of blood transfusion was also lower in Group B with a statistically significant difference (p〈0.001). No statistical differences were observed regarding the incidence of surgical complications.Introduction of ERAS protocol in radical cystectomy decreases the length of hospital stay, permanence in critical care units, and the need for fluidtherapy and blood product transfusion. However, more and larger studies are needed to prove the efficacy of ERAS for patients undergoing radical cystectomy.

The intraoperative goaldirected fluid therapy (GDT) has become the base of perioperative management in the fast-track protocols. This program using technology to estimate cardiac output, with the aim of minimizing splanchnic hypoperfusion. However, there is insufficient evidence to confirm its application in radical laparoscopic cystectomy.In a retrospective study, we have included 52 patients that were scheduled for radical cystectomy. In group A (n=32) patients were treated following GDT. Group B (n=18) included patients before the GDT introduction in our practice. The main objective was to assess the length of hospital stay and the permanence in intensive care units. Other variables of the study were the use of intraoperative blood products, fluid-therapy and medical and surgical complications. Statistical analysis was performed using the Mann Whitney U test for non-parametric variables and the Chi-square test for qualitative variables. Fisher's exact test was used when the sample size required it.The average length of hospital stay was 13.4 SD (11.0-15.9) days in group A versus 11.6 SD (8.9-14.3) days in group B (p0.364) . The average stay in critical care unit was 25.4 hours (16.1-34.6) in group A versus 21.0 (14.9-27.1) hours in group B with no significant differences between groups. The use of blood products was 0.41 packed red blood cells in group A versus 0.49 in group B with no statistically significant differences. The average volume of crystalloid administered was 1145 ml in group A versus 2382 ml in group B (p0.001) . In group A 656 ml of colloids were administered versus 266 ml in group B (p0.001) . There were no statistically significant differences in the incidence of complications.The use of a Goal Directed Fluid Therapy in radical cystectomy is related to a greater use of colloids than crystalloids, although its implementation does not affect hospital stay length or postoperative complications. In a multimodal perioperative program a single factor, as it is for the GDT, has little effect as an independent variable, and the combination of strategies has, more likely, a greater effect.

To analyze surgery for renal cancer with venous thrombus at different levels, perioperative complications and prognostic factors associated to overall, cancer-specific and disease-free survival.Retrospective analysis of 42 cases of renal cancer with venous thrombus performed between 2005 and 2015. The level reached by the thrombus was established according to the Mayo Clinic classification. Postoperative complications were staged according to Clavien-Dindo classification.Most frequent in males. Mean age 65.7 years. 16.6% were tumors with level II thrombus. Subcostal approach was performed in 58.9%. Extracorporeal circulation with cardiac arrest and hypothermia was established in 2 patients. Resection of metastatic disease was performed in 3 patients during radical nephrectomy. Reoperation was 2.3% while, perioperative mortality was 4.7%. 30% presented with metastases at diagnosis. Twenty patients progressed at 15.5 months (3-55). Overall survival was 60 months. The cancer-specific mortality was 75%. Disease-free survival was 30% at 55 months.Surgical treatment of renal cancer with venous thrombus requires a multidisciplinary management. The surgical technique varies according to the level reached by the venous thrombus. Tumor stage is the most important prognostic factor. Thrombus level influences prognosis, with longer survival for patients with tumor thrombus confined to the renal vein (pT3a) in comparison to tumors with thrombus in the atrium (pT3c).

The aim of our study is to demonstrate that intravesical administration of the association chondroitin sulfate (CS) and hyaluronic acid (HA), according to our treatment schedule, is a benefit for women with recurrent urinary tract infections (RUTI), not only from a clinical point of view, but also reducing recurrences.This is a study of 28 women diagnosed with RUTI, with a positive culture, and compatible symptoms;frethey underwent treatment according to the protocol of intravesical instillations of the combination CS 2%-1 gr + HA 1.6%-800 mg. To evaluate the effectiveness of the treatment, symptoms improvement, reduction of the number of episodes of urinary tract infection and quality of life were considered.In our series, we can observe an improvement of the quality of life assessed by PG-I, 66% after 12 months. It was seen that 55.6% of the patient's urine cultures became negative, while 44.4% had episodes of urinary infection, but with lower baseline symptoms intensity.Patients included in the protocol of instillation improved significantly their quality of life; in addition, to a considerable extent new urinary infections were not presented, being milder when they presented.

Renal lithiasis is known for its high incidence and prevalence, but mainly for its morbidity and recurrence. Despite a good indication and appropriate surgical treatment, the essential problem, the origin of the formation of the stones, generally persists and it is not uncommon that patients suffer multiple treatments and discomfort secondary to ancillary measures normally used to prevent complications. It is widely known, for consistency, that a prophylactic treatment with general or, in a smaller group of patients, specific measures are appropriate to diminish recurrences. Nevertheless, prophylaxis is not usually used by many urologists and, on top of that, in the majority of those cases when it is taken into consideration, it is the patient who fails for inadequate treatment compliance. It is very important, in any of our conversations with the urinary lithiasis' patient in relation with the disease, that the urologist provides a proper and detailed information about all its features, from diagnosis to active treatment and possible complications and, of course in those cases where prophylaxis is going to be essential to avoid new unpleasant episodes of pain and associated surgical interventions, emphasizing that improving his/her quality of life depends, to a great extent, on the patient himself. In this article, considering the existing evidence and personal experience, we intend to detail those behaviors we should take into consideration to facilitate the patient both therapeutic decisions and a positive attitude towards his/her disease, with the aim to control it in the best possible way.

To analyze if there is a learning curve to get to perform high quality ultrasound guided prostate biopsies that enable to effectively perform the diagnosis of prostate cancer, taking the pathological result of the samples into consideration.We retrospectively reviewed data from 790 ultrasound-guided biopsies performed consecutively in our center between May 2009 and December 2012 by four surgeons. We reviewed the following data: Surgeon, date of intervention, patient age, PSA, rectal digital examination (DRE), ultrasound, prostate volume, number of cores obtained, pathology result of the biopsy. The surgeons were residents in Urology in their first year in the department. For statistical analysis the biopsies were grouped in blocks of 25 and 75 cases performed by a surgeon, in a chronological order. To evaluate the influence of the learning curve on diagnosis we performed univariate and multivariate analysis between the different variables and pathological report.Median age was 67 years (42-90). 300 biopsies (38%) were positive for prostate cancer. On univariate analysis, regarding cancer detection rate, the variables surgeon, PSA, DRE, ultrasound result, prostate volume, number of cores and groups of 75 showed statistically significant differences, this latter showing 32% in the first 75 biopsies and 43.2% in the last group. The variables age (p=0.11) and groups of 25 patients (p=0.07) did not show differences. Nevertheless, on multivariate analysis only PSA, DRE, prostate volume and groups of 75 patients were statistically significant, this latter with an OR of 1.35 (95%CI 1.09-1.66).The results obtained in our study show that the number of procedures performed, namely surgeon experience, does have an influence to achieve an optimal diagnostic yield in ultrasound guided prostatic biopsies.

Laparoscopic pyeloplasty (LP) is the treatment of choice for ureteropelvic junction obstruction (UPJO). We present the 3-trocars LP technique with several considerations and practical advices.Several maneuvers to optimize exposure and simplifying the implementation of the operation were showed. A total of thirteen patients with UPJO and criteria for surgical treatment were included, and were operated using the 3 trocars LP technique. Demographic data, perioperative and follow-up were collected retrospectively.Mean operative time was 132 minutes. No conversion to open surgery was registered and additional trocar insertion was not required. Neither perioperative complications nor postoperative complications were reported. Three patients needed ureteral stenting preoperatively for pain. Five patients required flexible nephroscopy with CO2 for extraction of calyceal stones. The pain was controlled in all cases.The LP is a feasible and safe technique for the surgical correction of UPJO, and maneuvers presented in this study simplify the procedure and may be applied in other laparoscopic procedures.

Small cell carcinoma of the bladder shows low incidence and poor survival; thus, treatment algorithms based on randomized studies are unavailable. The aim of the present study is to review our case series.Observational retrospective study of 10 patients diagnosed with small cell carcinoma of the bladder between 2006 and 2013.Mean age was 65.7 years; There was only one female in the cohort. In all cases hematuria was the fist symptom. 4 cases presented high-grade papillary urothelial carcinoma with small cell carcinoma. Radical cystectomy was performed in 40% patients, in combination with chemotherapy, radiotherapy or both. Median survival was 330 days (IC 95%: 40.757- 619.243) and only one patient showed complete response.Even when small cell carcinoma of the bladder is a low incidence tumor, its prognosis is worse than that of urothelial carcinoma. Although further randomized studies are needed to best define treatment, this study shows that survival at local stages is optimized by neoadjuvant chemotherapy, followed by radical resection, as the literature suggests.

Ta bladder tumors constitute 53% of primary bladder neoplasms, 70% of them being low-grade (G1). These tumors present a 15- 38% chance of recurrence during the first year. The aim of this paper is to identify the predicting factors of the first recurrence in a series of TaG1 primary bladder tumors.We have retrospectively analyzed patients who were diagnosed with TaG1 primary bladder tumor by transurethral resection between 2004 and 2012. We established their tumor grade and pathological stage according to the WHO's classification guides for 1973 and 2004 as well as 2009's TNM. Those patients who were diagnosed before 2009 did not receive any adjuvant treatment. Those who were diagnosed later on received 40 mg of endovesical Mitomycin C during their immediate post operative period as their only treatment. We define recurrence as the presence of tumor after the first cystoscopy and relapse-free survival (RFS) as the period of time (in months) until the first recurrence appeared. Follow up constitutes the period of time (in months) until the last check-up or first recurrence. We also analyzed different variables: age, gender, smoking habits, muscular representation in the sample, size of the tumor (or1 cm), multiple or single tumors and adjuvant treatment. The survival analysis was performed by the Kaplan-Meier method, using the long-rank test to evaluate the differences between groups.68 patients were included in the study (73.5% men, 75% smokers). The average age was 61.9 years (the median being 58.5). Average follow up was 33.2 months (median 28.4). 35.3% of patients experienced recurrence. Average RFS was 19.2 ± 12.7 months (median 13.5). The majority of tumors were of a single nature (77.9%), with a size of less than 1 cm (55.9%) and with muscle representation (52.9%). 57.4% of patients did not receive adjuvant treatment. Only the absence of adjuvant treatment was associated with recurrence in uni and multivariate analysis (p0,001), with a relative risk of 17,5 IC95% (7,6-30,2).The absence of adjuvant therapy with Mitomycin C is the only factor that, in a statistically significant way, increases the risk of recurrence, regardless of demographic factors and the characteristics of the tumor.

Gross hematuria in the immediate postoperative radical prostatectomy is a rare complication. According to different series reviewed, significant bleeding after this surgery appears between 0.5-1.5% of the cases.58 year old male with localized prostate cancer who underwent open radical prostatectomy with preservation of the neurovascular bundles and a left accessory pudendal branch. In the 4th postoperative day patient presented severe hematuria and urethral bleeding requiring continuous bladder irrigation and blood transfusion. Given the persistence of bleeding despite conservative measures CT-angiography was performed demonstrating active bleeding at a bulbar artery from the left internal pudendal artery without associated pelvic hematomaGiven the findings selective embolization was performed with absorbable material stopping the bleeding. Three months later the patient maintains urinary continence and erectile function with tadalafil.Urethral bleeding after radical prostatectomy is a rare complication the cause of which is distal to the urinary sphincter unrelated to the pelvic vessels. The performance of CT angiography and subsequent embolization is the treatment of choice, avoiding open surgical revision, with less morbidity.

To present a series of four cases of Gartner cysts and their clinical presentation. A bibliographic review was performed.The series consisted of 4 women, mean age 39, who complained of a bulge at the anterior vaginal wall, associated with a variety of urinary symptoms.Surgical removal was performed in all cases. The pathological studies confirmed the diagnosis of Gartner cyst. There were no recurrences in the long-term follow-up.Vaginal wall cysts are rarely found in common urological practice. Gartner cysts arise as a consequence of the Gartner duct (mesonephric remainder) obstruction and they are located in the anterior or lateral wall of the vagina. They may be associated with renal and ureteral anomalies. Differential diagnosis with other vaginal cysts can only be made by histological studies. The correct treatment is the entire removal through a vaginal approach.

To analyze the characteristics, etiology and treatment of a series of patients with spontaneous retroperitoneal hemorrhage from renal causes.We retrospectively reviewed patients diagnosed of spontaneous retroperitoneal hemorrhage between 2006 and 2011. All patients consulted for back pain and the diagnosis was made by computed tomography (CT) and /or magnetic resonance (MR). All patients were treated surgically.The series includes 8 patients. Six cases had renal mass and associated hematoma and 2 presented only perirenal hematoma. Six patients underwent total nephrectomy, one underwent partial nephrectomy, and one just drainage of the hematoma.The pathological study showed 4 cases of renal angiomyolipoma (one associated with multiple small renal carcinomas), 2 cases of renal carcinoma and 1 case of hemorrhagic renal infarction.Renal masses are the main cause of Wunderlich syndrome and CT is the diagnostic procedure of choice. Surgical treatment is preferred in patients with renal mass diagnosed and cases of hemodynamic compromise.

To analyze the outcomes, predictors of success and predictors of need for hospital admission in our series of patients who underwent ureteroscopy (URS) as a major outpatient surgery (MOS) procedure.We carried out a retrospective analysis of 402 patients who had undergone semi-rigid URS for ureteral calculi as a MOS procedure in our center between 2004 and 2012. Patients with previous DJ catheter were excluded. We classified the calculi according to their location (lumbar, pelvic, iliac), size (or1cm) and number (single or multiple). Follow-up was done by plain X-ray of the abdomen and ultrasound one month after surgery. The procedure was considered successful when patients were free from the treated calculi or had ureteral fragments3 mm one month after surgery. Univariate and multivariate analyses were carried out to identify the factors involved in success and hospitalization not being required.A total of 269 patients were included. The majority of the stones were single (92.2%),1 cm in size (76.6%), pelvic (62.1%), and left-sided (57.2%). 89.6% of the procedures were performed as MOS and 82.2% were considered to be successful. In the multivariate analysis, left-sided (p0.001) and pelvic location of the calculi (p=0,01) were found to be independent predictors for the success of the procedure In terms of hospital admission, the only independent predictor was the presence of intraoperative complications ( p=0.006).Left-sided and pelvic locations were the independent predictors for the success of the URS. A lack of intraoperative complications was the independent predictor for not requiring hospitalisation.

To evaluate the usefulness of the Memorial Sloan Kettering Cancer Center (MSKCC) nomogram for prediction of recurrence probability in our series of patients who have undergone radical cystectomy for bladder cancer.397 patients underwent radical cystectomy for bladder cancer between 1986 and 2005. 165 patients were excluded:21 due to exitus in the immediate postoperative period, 32 due to previous radiation therapy, 6 due to neoadjuvant chemotherapy, 5 due to inability to complete follow-up, 15 that did not undergo lymphadenectomy and 86 who were alive at the time of review with less than 5 years of follow-up. Patients were classified into recurrence risk groups: organ-confined tumors (pT0-2 pN0 ), extra-bladder involvement (pT3-4 pN0) and lymph node involvement (pN+). Survival analysis was performed using the Kaplan-Meier method. Five-year recurrence-free survival by risk groups in our series was compared with the one estimated using the MSKCC nomogram using a ROC curve.We analyzed 232 patients. Follow-up in patients who died of cancer was 25 ± 25 months. For alive patients and those who died of other causes, follow-up was 120 ± 39 months. Pathology studies revealed 42.7% organ-confined tumors , 33.2% with extra-bladder involvement and 24.1% with lymph node involvement. The five-year recurrence free survival analysis according to the Kaplan-Meier method stratified by risk groups was: pT0-2 76%, pT3-4 51%, pN+ 31%. The probability of recurrence free survival according to the MSKCC nomogram in the same risk groups was: 85% ± 5%, 62% ± 10% and 25% ± 13%, respectively. The area under the ROC curve was 0.795 (95% CI 0.739-0.852) CONCLUSION: In our series, the MSKCC nomogram constitutes a useful tool for predicting 5-year cancer free survival in patients who undergo radical cystectomy.

To identify post-prostatectomy prognostic factors for biochemical recurrence (BR).We retrospectively analyze a series of patients with clinically localized prostate cancer who were treated with radical prostatectomy (RP)as monotherapy between 1996 and 2007, pN0-pNx, with a minimum of 12 months of follow-up. BR is considered to be persistence or elevation in PSA after RP greater than 0.4 ng/ml on the subsequent determination. Analyzed variables were Gleason Score, pathological stage, surgical margin involvement, capsular involvement, and perineural involvement. We performed univariate and multivariate analysis using the chi squared test and proportional Cox risk model in order to determine the variables associated with BR.We included 693 patients. Mean age was 63.5 years with a mean follow-up of 88.5 months. Mean PSA was 9.2 ng-ml. BR was observed in 218 patients, 43 due to biochemical persistence. More common pathological findings were Gleason score 7 (47.1%), and pathological stage pT2c (60.1%). Mean time to BR was 35.5 months with 91.2% occurring in the first 8 years. On multivariate analysis, Gleason score ≥ 7(4+3), pathological stage pT3b and positive surgical margin were independent predictors of BR.Gleason Score ≥ 7(4+3), positive surgical margins and pathological stage pT3 are independent prognostic factors associated with BR-free survival.

The performance of the urethrovesical anastomosis is one of the most difficult steps in urologic laparoscopy. Many different techniques have been developed to improve this step and, recently, new sutures such as the V-loc (R) barbed system have been created. In the present study we analyze the usefulness of this suture for diminishing the time employed for the anastomosis suture during the learning curve of laparoscopic radical prostatectomy.We performed a prospective comparative study between two groups. The first group included the first 50 cases of a novel surgeon using this barbed suture, and we compared these procedures with 50 consecutives cases of an experienced surgeon. We compared preoperative parameters, surgical and suturing times, as well as drain and catheter duration, and hospital stay.We did not find statistically significant differences in any pre or postoperative parameters between both groups. Although surgical time was lower in the control group this difference was not statistically significant. The time used to perform the suture was lower in the study group, and we found significant differences between both groups. Neither drain nor bladder catheter times were different between groups.In the absence of prospective randomized trials comparing barbed or not barbed running sutures, our study shows that the use of the V-loc® system improves the times needed for the urethrovesical anastomosis during the learning curve of laparoscopic radical prostatectomy.

Laparoscopic Radical Prostatectomy (LRP) is technically a very demanding procedure and potentially even more challenging in patients with previous transurethral resection (TURP). This study evaluates the impact of previous TURP on the short-term functional outcome of patients undergoing extraperitoneal LRP.Retrospective analysis of a prospectively collected database, comprising a single-surgeon cohort of 155 consecutive LRP cases, 19 of which had previous history of TURP. Demographics, clinical and functional outcomes were evaluated and compared among patients with and without previous TURP. Multivariate analysis was performed to identify potential variables independently associated with continence outcomes. Incontinence was defined as the need of more than 1 pad/day. Potency was defined as the ability for sexual intercourse with or without the use of phosphodiesterase inhibitors.Demographic and clinical variables were comparable among the two study groups. Neurovascular bundle preservation was possible in 26% and 37% of patients with and without previous TURP, respectively. No major complications were recorded and the incidence of minor complications was comparable. Overall continence rate at 3 months was 82,58%, for the entire cohort. Subset analysis demonstrated a 3-month continence rate of 73.7% vs. 83.8% (p0.05) in patients with and without TURP, respectively. Multivariate analysis demonstrated age, BMI and ASA were variables independently associated with continence outcomes. In the cohort of patients with previous TURP, 2 out of 7 undergoing preservation recovered erections, with a mean follow up of 15.5 months, comparable to the 30% achieved in patients without TURP and nerve sparing procedure.Laparoscopic Radical Prostatectomy in patients with previous TURP is feasible, with complication rates and short-term functional outcomes comparable to those in patients without previous resection.

Literature review of adenocarcinoma of the urachus in connection with two cases recently diagnosed and treated in our center.We report 2 cases of urachus Adenocarcinoma treated in our institution, both underwent extended partial cystectomy including excision of the urachus up to the umbilicus.Urachal adenocarcinoma is an exceptional tumor, of poor prognosis, the treatment of which is surgical (partial cystectomy), and the main predictors of disease-free survival are the degree of tumor differentiation and the free margins of the surgical specimen.

The inability to remove a bladder catheter due to impossible balloon removal is a situation with controversial management; there are no action guidelines and it is limited to individual experience in most cases. In this article, we review the techniques described for removing a urethral catheter and we share our experience with one case.A 70-year-old male with permanent bladder catheter was referred to the emergency department due to an inability to deflate the self-retaining balloon during routine change in his health centre.After unsuccessfully trying to puncture the balloon through the inflation channel previously cut above the valve, we punctured it via the suprapubic route under ultrasound guidance with a biopsy needle. Using this technique, we managed to rupture the balloon without free fragments, enabling the catheter to be changed without incident.There are various techniques for approaching this situation, the knowledge of which enables the urologist to resolve the problem by adapting to patient's characteristics and available resources. Suprapubic puncture of the self-retaining balloon is an easily reproducible technique with minimal complications and a lower rate of free fragments.

Radical Radiotherapy constitutes a useful therapeutic option for localized prostate cancer. Almost one third of prostate cancer patients choose this alternative to treat the disease. Despite modifications in the technique as intensity modulation, 3D conformational radiotherapy or computer-assisted brachytherapy, a significant percentage of these patients will show an increase in PSA values after radiation. Local relapse without distant disease and PSA less than 10 ng/ml are candidates for salvage therapy. Cryotherapy has already become a curative treatment option in this group of patients. Recent technological as well as surgical advances in salvage-cryotherapy have reduced dramatically complications and progressively increase the interest on this alternative.

The purpose of bladder augmentation using the gastrointestinal tract is to create a low-pressure and high-capacity reservoir, permitting suitable continence and voiding, preserving the upper urinary tract.To analyze the indications, complications and results of our series of augmentation enterocystoplasties.We retrospectively reviewed patients undergoing augmentation enterocystoplasty in our department between 1997 and 2010, both included. The indications were: Interstitial cystitis, neurogenic bladder and inflammatory bladder retraction. In all cases a cystography, urethrocystoscopy, urodynamic study and studies of each condition. Bladder release is performed by means of medial laparotomy and an extraperitoneal approach with bivalve opening to the urethral orifices. The bladder augmentation is performed with a 15-20 cm segment of detubularized ileum obtained at 20 cm from the ileocecal valve; in cases of kidney failure, a 7-cm gastric body wedge is added. The bladder catheter was removed following cystogram after 15 days. Monitoring was performed by means of ultrasound with postvoid residual, blood analyses, urine culture and voiding diary. We performed a descriptive study of the demographic characteristics, postoperative complications according to the Clavien classification and in the long term.We included 24 patients, 19 women and 5 men with a mean age of 48.5 years and a median of 47 (21-77). Mean follow up was 7.5 years with a median of 8 (1-11). The indications were: 7 interstitial cystitis, 8 bladder retraction and 7 neurogenic bladder. There were no intraoperative complications. The postoperative complications were 3 Clavien I, 2 type II, 2 IIIA and 1 IIIB. In the long term, 3 patients presented urinary incontinence, 2 mild metabolic acidosis, 5 required self-catheterization, 6 bladder stones, 2 febrile urinary tract infections and 1 stricture of the anastomotic mouth. In three cases, an ileogastrocystoplasty was performed without hydroelectrolytic impairment or impairment of kidney function.In selected patients, augmentation enterocystoplasty constitutes an efficacious therapeutic option in the treatment of lower urinary tract dysfunction with scant morbidity and few complications.

To review the presentation, diagnosis and treatment of primary renal lymphoma through a new case report.We report the case of a 73-year-old man who presented at AE with constitutional symptoms and weight loss of 9 kilograms over 3 monthsLaboratory analysis showed impaired renal function, anemia and hypercalcemia. Imaging tests showed a large solid mass in the right perirenal area with infiltration of the parenchyma and Gerota's fascia surrounding the hilum of the kidney, as well as a solid mass in the inferior pole of the left kidney. Pathology showed the presence of lymphoid-like monomorphic cells. After establishing the diagnosis of bilateral primary renal lymphoma it was decided to start treatment with CHOP-Rituximab-type combination chemotherapy.Primary renal lymphoma is a rare entity and the diagnostic technique of choice is CT. Definitive diagnosis is confirmed on histology. In view of its aggressive nature and poor prognosis, it is important to make an early diagnosis in order to start treatment promptly. The treatment of choice is systemic chemotherapy using a CHOP regimen.

To report two new cases of Ewing's sarcoma/primitive neuroectodermal tumor of the kidney, one of them with tumor thrombus in cava.Characterization of two new cases and literature review by PubMed search.We report the cases of two men diagnosed with primary renal Ewing's sarcoma, who have been treated with nephrectomy and adjuvant chemotherapy, being in complete remission to date.Ewing's sarcoma / primitive neuroectodermal tumor of the kidney is a rare condition that mainly affects young adults. The natural history of these tumors is the evolution towards metastatic disease and death. Treatment is multimodal, combining surgery and chemotherapy. The role of radiotherapy is not well established.

To evaluate the predictive factors for relapse in clinically localized squamous cell carcinoma of the penis undergoing surgical treatment.Forty-nine patients were diagnosed with cancer of the penis in our Service between 1999 and 2009. In the present study we excluded 18 subjects: 9 due to the presence of palpable adenopathies, 6 due to histological characteristics other than squamous cell carcinoma, two lost to follow-up, and one due to death at the time of diagnosis. Diagnosis was based on physical examination and biopsy findings. The primary lesion was treated by circumcision, partial surgery or total penectomy. Disease relapse was defined by lymph node or metastatic involvement after three months from surgery. Univariate and multivariate analysis were carried out using the chi-squared test and logistic regression to identify the factors involved in tumor relapse.Thirty-one patients were included in the study. Mean follow-up was 36 months (median 29). The histopathological study yielded the following profile: 55% pT1 cases, 32% pT2 cases and 13% pT3 tumors. Regarding histological grade, the distribution was G1: 29%, G2: 32%, G3: 39%. Recurrence and mortality rates were 38.7% and 35.5%, respectively. In the univariate analysis, location of the lesion (p=0.004), type of surgery (p=0.008), tumor stage (p=0.003) and cellular grade (p0.001)were significantly correlated to disease relapse. In the multivariate analysis, only cellular grade proved statistically significant (p=0.01).In our series, only histological grade could be regarded as an independent predictor of tumor relapse.

To analyze a new case of primary localized amyloidosis of the ureter, describing the differential diagnosis with ureteral tumors and its pathogenic mechanism.Description of the case of a male patient who presented clinical symptoms of renoureteral pain and hematuria and an image suspected of ureteral tumour undergoing laparoscopic nephroureterectomy. The pathological study confirmed amyloidosis of the ureter, AL by immunohistochemistry.This report further extends the slightly more than 50 published cases of primary localized amyloidosis of the ureter the clinical signs of which, pain and haematuria, are similar, showing stenosis and enlargement in an area of the ureteral wall on imaging techniques. In the majority of cases the diagnosis was obtained postoperatively, being necessary to exclude generalized and secondary affectation.Emphasis must be placed on the differential diagnosis of tumors of the ureter, especially in single-kidney patients, by using ureteroscopy and biopsy or preferably a careful cytological study. In our case a local inflammatory phenomenon could have been the basis of its pathogenesis.