Desarrollo y validación de una herramienta de entrenamiento y evaluación para la nefrectomía radical laparoscópica

Introduction

Laparoscopic radical nephrectomy(LRN) is a cornerstone in managing renal cancer and small renal masses. Twenty-first century surgical training faces challenges, thus must be efficient and safe so surgeons attain relevant skills, protecting patients and operative outcomes. This study aimed to systematically develop a tool for training and assessment in LRN and validate the developed tool for use by trainee urologists.

Dislocación testicular. aportación de 2 nuevos casos y revisión de la literatura

We report 2 new cases of testicular luxation. A review of current literature is made. Testis was located inguinal after scrotal trauma in both cases. Early close reduction was unsuccessfully. A delayed reduction was found in one case at the moment of surgery. A surgical replacement of the testis was carried out in the other patient. Follow-up control revealed a benign course in bothTesticular dislocation is a rare complication after scrotal trauma (only 152 cases reported). Physician have to be aware of this possibility following perineal trauma. Oftenly a surgery reduction is required     

Profilaxis de la hernia incisional y utilización de mallas. Revisión narrativa

Incisional hernias are a very common problem, with an estimated incidence around 15-20% of all laparotomies. Evisceration is another important problem, with a lower rate (2.5-3%) but severe consequences for patients. Prevention of both complications is an essential objective of correct patient treatment due to the improved quality of life and cost savings.This narrative review intends to provide an update on incisional hernia and evisceration prevention. We analyze the current criteria for proper abdominal wall closure and the possibility to add prosthetic reinforcement in certain cases requiring it. Parastomal, trocar-site hernias and hernias developed after stoma closure are included in this review.     

Evolución y pronóstico a medio y largo plazo de los tumores vesicales superficiales

ObjetivesTo evaluate the outcome of 551 patients with superficial transitional cell carcinomas of the bladder. To determine prognostic factors in these patients by means of the log-rank analysis of the Kaplan-Meier curves and a multivariate analysis with Cox regression model for the disease free survival (DFS), time to progression to infiltrating lesions (TTP) and overall survival (OS)Material and methodsBetween 1983 and 1998 we have seen 551 patients with superficial transitional cell carcinomas of the bladder in our Hospital. Fifteen patients included in this series had been diagnosed in other hospitals before 1983. The clinical records were actualized between 1998 and 2000 and only 21 patients were lost to follow-up (3,8%). The mean follow-up time was 6,2 years (median time: 5,3). One hundred and eleven patients (20%) died with a mean of 4,5 years (median time 3,4). Four hundred and forty patients were still alive on completion of the study with a mean follow-up time of 6,6 years (range 2-24 years; median 5,7)ResultsFour hundred and fifty-nine patients were men (83%) with a mean age of 64 years and 92 were women (17%) with a mean age of 70 years. In 347 patients there was only one tumour (63%). The tumours were stage Ta in 79 cases (14%), T 1 in 431 (78%) and Tis in 41 (7%). The histological grade was G 1 in 406 cases (74%), G 2 in 96 (17%) and G 3 in 33 (6%)There were recurrences in 253 patients (46%) with a mean time of 2.2 years. The DFS was 55% at 5 years, 44% at 10 years and 38% at 15 years. The multivariate analysis has shown a negative prognostic influence on DFS of the presence of multiple tumours (RR 1.4 CI 1.19-1.69), increasing age (analysed as a continuous variable) and the sex (being worse for females; RR 1.2 CI 0.98-1.52)In 40 patients (7.3%) the tumour became infiltrative in a mean of 3.3 years. The TTP was 93% at 5 years, 91% at 10 years and 90% at 15 years. The negative prognosticators in the multivariate analysis were G 3 tumour (RR: 5.1 CI 2.7-9.6), the group of tumours Ta-T 1 G 3 or multiple T 1 G 2 or Tis (RR 4.6 CI 2.6-7.9) and the age>70 years (RR 2.14 CI 1.2-3.7)Thirthy-one patients (5.6%) died of the tumour in a mean time of 4.6 years. The OS was 95% at 5 years, 93% at 10 years and 91% at 15 years. Significant prognosticators in the multivariate analysis for OS were the group of risk tumours Ta-T 1 G 3 and multiple Tis or T 1 G 2 (RR 5 CI 2.7-9) and age>70 years (RR 4.56 CI 2.2-8.8)ConclusionsThe recurrence rate is very high in all the patients, but the risk is highest when the tumours are multiple. The risk of progression is low, but still exits even in patients with tumours of low malignant potential. The highest risk is associated with Ta-T 1 G 3 of Tis or multiple T 1 G 2     

Lesión de los cuerpos cavernosos por arma de fuego. Presentación de un caso y revisión de la literatura

Rupture of the corpora cavernosa is a very rare lesion. It occurs most commonly during intercourse. A far more exceptional cause is a gunshot wound; in this case, there are frequently concomitant lesions to other structures. We present the case of a man who suffered a lesion to the corpora cavernosa due to a gunshot and underwent emergency surgery. We reviewed existing literature and verified that the first step in managing a genital gunshot wound is to stabilise the patient, following which we should surgically explore the affected area.     

Transformación maligna secundaria de teratomas testiculares: serie de casos y revisión de la literatura

BackgroundTeratomas are a spectrum of neoplasms that can undergo malignant transformation. In the World Health Organization (WHO) classification of tumors, this entity was classified as «teratoma with somatic-type malignancy», was defined as a malignant neoplasm of non-germinal phenotype that originates in a teratoma.Materials and methodsWe present a serie of nine cases of testicular teratomas with secondary malignant transformation. From January 1995 to December 2011, we found a total of 306 cases of testicular tumors. Mixed germ cell tumors were the most frequently diagnosed malignancy with 45.7%.ResultsTeratoma with secondary malignant transformation, represented 2.9% of all germinal tumors. Five cases originated within a mixed germ cell tumor, two cases from mature teratomas, and two from immature teratomas. The predominante malignant somatic component were sarcomas; two cases of chondrosarcoma, one rhabdomyosarcoma, and one case showing foci of chondrosarcoma and rhabdomyosarcoma. The case of osteosarcoma is notable for its rarity. Two cases showed epithelial malignancy in the form of an adenocarcinoma, and finally, two cases were primitive neuroectodermal tumors. At the time of diagnosis, five patients had metastases.ConclusionThe transformation of germ cell tumors to somatic type malignancies is rare. The malignant component can originate from any of the three germ lines. These tumors are resistant to standard chemotherapy for a germ cell tumor and the clinical stage is the most important prognostic factor. At our institution, the malignant component that appeared most frequently was chondrosarcoma.     

Impacto de la resección no planificada y la reintervención de sarcomas de partes blandas en su pronóstico

IntroductionUp to 40% of all initial operations for soft tissue sarcoma (STS) are unplanned, which would leave residual macroscopic tumor in more than 50% of the cases. The effect this has on local recurrence rate, metastases rate and survival has never been fully established, due to the lack of randomized studies.MethodsRetrospective review of patients with STS treated in our unit between January 2001-January 2016. We classified them whether they had been treated by initial planned or unplanned operation. Outcomes were compared in both groups globally and stage-matched. Endpoints were local recurrence and distant metastases.ResultsTwenty-three patients of STS underwent a planned excision and 16 an unplanned excision, 13 of them underwent further re-excision. 40% of patients with planned excision had an advanced stage in regard to the unplanned excision group which presented earlier stages. 77% of patients with unplanned excision had residual tumor identified after surgical re-excision. Local recurrence rate in the unplanned excision group was considerably higher 73,5% vs. 43,8%. Metastases rate was lower in planned excision group, 45,5% vs 56,3% (P > .05). The recurrence pattern in the unplanned excision group was unstable, with worse outcomes in earlier stages.ConclusionThe unplanned excision of a soft tissue sarcoma may compromise disease local control, with higher rates of local recurrence and metastases, and worse functional out- comes, despite further oncological treatment. We need to recognize the clinical features for malignancy risk in soft tissue lumps for a safe diagnosis to avoid inadequate resections.     

Terapia de privación de andrógenos en el cáncer de próstata localizado. Situación actual y tendencias futuras

IntroductionProstate cancer (PCa) has been recognized as an androgen-sensitive disease since the investigations from Huggins and Hodges in 1941. Thanks to these findings, they received the Nobel Prize in 1966. This was the beginning of the development of androgen deprivation therapy (ADT) as treatment for patients with PCa.ObjectiveTo summarize the current indications of ADT in localized PCa.Evidence acquisitionWe conducted a comprehensive English and Spanish language literature research, focused on the main indications for ADT in localized PCa.Evidence synthesisNowadays, the indications for ADT as monotherapy in localized PCa have been limited to specific situations, to patients unwilling or unable to receive any form of local treatment if they have a PSA-DT < 12 months, and either a PSA > 50 ng/mL, a poorly differentiated tumor, or troublesome local disease-related symptoms. ADT can be used in combination with local treatment in different scenarios. Although neoadjuvant treatment with ADT prior to surgery with curative intent has no clear oncological impact, as a future sight, PCa is a heterogeneous disease, and there could be a group of patients with high-risk localized disease that could benefit.ConclusionsWe need to optimize the treatment with ADT in localized PCa, selecting the patients accordingly to their disease characteristics. Given that the therapeutic armamentarium evolves day by day, there is a need for the development of new clinical trials, as well as a molecular studies of patients to identify those who might benefit from an early multimodal treatment.     

Comparación de los resultados después de flouroquinolonas y terapias de combinación en prostatitis crónica tipo iiiA

PurposeWe investigated retrospectively the clinical outcomes of the patients with type iii inflammatory chronic prostatitis, who were treated with fluoroquinolones with and without an α-blocker between 2009-2011.Material and methodsDiagnosis was established with medical history (symptoms presented longer than 3 months within previous 6 months), physical examination, Meares-Stamey test and the questionnaire of the NIH-CPSI. The responses to the treatment were assessed with uroflowmetry test and the questionnaire of NIH-CPSI at initial and after 4 weeks of the treatment. The patients with incomplete data and treatment and who treated with α-blockers and/or antibiotics in the period 4 weeks prior to the therapy started in our clinic and had any surgery of lower urinary tract previously were excluded. The patients were classified under 6 groups; group1 = ciprofloxacin, group2 = ofloxacin, group3 = levofloxacin, group4 = ciprofloxacin+tamsulosin, group5 = ofloxacin+tamsulosin, group 6 = levofloxacin+tamsulosin. Wilcoxon Signed Ranks and Kruskal Wallis test were used for comparison of results. Mann Whitney U test with Bonferroni correction made was used as posthoc (P < .05).ResultsThe median scores of NIH-CPSI decreased significantly in all groups (P < .05). Levofloxacin reduced the median total scores of NIH-CPSI more than ciprofloxacin and ofloxacin monotherapies. The combination therapies were better than antibiotic therapies alone and best result was obtained in levofloxacin + tamsulosin combination.ConclusionTamsulosin + fluoroquinolone (especially tamsulosin + levofloxacin) combinations yielded better results in both NIH-CPSI scores and peak flow rates.     

Sedentarismo y sobrepeso como factores de riesgo en la detección del cáncer de próstata y su agresividad

ObjectiveTo analyze the influence of sedentary (SE) and overweight (OW) in the risk of prostate cancer detection (CP) and aggressiveness.Material and methodWe performed prostate biopsy (PB) to 2,408 consecutive male, 5 ARIs untreated, because of elevated serum PSA above 4.0 ng/mL (91%) or suspicious digital rectal examination (9%). In all ultrasound guided PB, 10 cores were obtained plus 2 to 8 additionals, according to age and prostate volume. Physical activity was assessed using a survey (SE vs non-SE) and calculated body mass index (normal vs OW > 25 kg/cm²). The tumor aggressiveness was evaluated according to the Gleason score (high grade «HG»: Gleason> 7) and D’Amico risk (high risk «HR»: T > 3a or PSA > 20 or Gleason score > 7).ResultsWe found a significant association between SE (52.5%) and OW (72.9%), P < .001. The overall PC detection rate was 35.2%. In men with SE it was 36.7% and non-SE 33.6%, P = .048. The overall rate of AG tumors was 28.3%, 29.2% in men with SE and 27.1 in non-SE, P = .261. The overall rate of AR tumors was 35%, 39.7% in men with SE and 29.4% non-SE, P < .001. CP was detected in 38.1% of men with normal BMI and 34.3% in men with OW, P = .065. HG tumor rates were 18.1% and 31.4% respectively, P < .001 and AR tumor rates were 22.6% and 39.2% respectively, P < .001. Binary logistic regression showed that SE was an independent predictor of CP, OR .791 (95% CI: .625-.989), P = .030. SE and OW were independent predictors of HG: OR .517 (95% CI: .356-.752), P = .001, and OR 1.635 (95% CI: 1070-2497), p = 0.023. SE and OW were also independent predictors of HR: OR .519 (95% CI .349-.771), P = .001, and OR 1.998 (95% CI 1.281-3.115), P = .002.ConclusionsIn men who met criteria for prostate biopsy an association between sedentary and overweight exist. A sedentary lifestyle is associated with increased risk of PC detection while sedentary and overweight were associated with more aggressive tumors.     

Vivencias y emociones profesionales en el proceso de donación y trasplantes de órganos. Una revisión sistemática

IntroductionThe objective was to explore, discuss and synthesize the emotional experiences of health professionals during the process of organ procurement and transplantation.MethodsA systematic review was made in Medline, Science Direct and the Virtual Library of the Andalusian Public Health System, selecting 16 original articles for inclusion in the review, with qualitative evaluation and narrative synthesis.ResultsThe results revealed the main use of qualitative methodology, and 4 emergent themes were identified: working in organ procurement and transplantation; the transition of professional roles; emotional experiences; and, coping strategies and emotional management. This systematic review revealed the complex and diverse character of professionals’ emotional experiences as well as the importance of the interpersonal relationship.ConclusionsIntense emotional experiences related to the sense of responsibility, the work challenge and coping strategies based on reward searching explained important contradictions and tensions about professional roles and functions, especially during the donation interview.     

Pronóstico y predictores de mortalidad de los pacientes ancianos críticos

Objectives

to evaluate mortality of patients ≥ 80 years admitted to the Surgical Intensive Care Unit (SICU), global hospital mortality and factors related to it.

Uso de Twitter® y sus implicaciones en las reuniones y congresos de la Asociación Española de Cirujanos

Introduction

The use of web 2.0 tools and especially Twitter is in full expansion. Twitter has jumped from the personal field to the professional with great success, joining as a means of regular dissemination in scientific congresses.

Utilidad del cociente psa-l/psa-t y la dpsa para la discriminación entre hipertrofia benigna de próstata y cáncer de próstata

objectiveTo investigate the clinical significance of the free-to-total prostate-specific antigen ratio (f/tPSA) and PSA density (PSAD) for prostate cancer detection in patients with intermediate tPSA levels (4-10 ng/ml). To establish a cutoff to discriminate between benign prostatic disease (BPH) and prostate cancer (CaP), avoiding unnecessary biopsiesMethodsThis prospective study included 136 men, aged between 54 and 85 (mean 70,6) years old. Urinary tract symptoms were present in these patients. Serum samples were obtained to measure tPSA, fPSA, and f/tPSA; digital rectal examination and transrectal ultrasound eight-sector biopsies were performed. Prostate volume was measured and PSAD calculated. The pathologic study, carried out in 113 patients, showed 82 with BPH and 31 with prostate cancer in various stagesResultsThere were no significant differences between patients with BPH and CaP when comparing tPSA, fPSA, f/tPSA or digital rectal examination. PSAD and prostate volume were significantly different in patients with BPH and CaP. With a sensitivity of 94% (78,5-99), the f/tPSA cutoff was 0,28 with a 11% (5,2-19,8) specificity. With a sensitivity of 96,2% (80,3-99,4) cutoff for PSAD was 0,109 and specificity 25% (15,5-36,6)ConclusionsIn patients whose tPSA level is between 4 and 10 ng/ml, f/tPSA has no advantages over tPSA measurement for early detection of prostate cancer. DPSA can improve specificities, without compromising the detection of CaP     

Hipertensión arterial en el paciente quirúrgico. Adecuación de la medicación y criterios de suspensión

Arterial hypertension (AHT) is a modifiable risk factor for cardiovascular diseases, which may have an impact on perioperative complications, depending on the organ damage suffered by the patient. The perioperative management of treatment of arterial hypertension, is a mainstay in the preoperative assesment prior to any intervention. It doesn’t seem reasonable to delay surgery solely due to blood pressure values, although for patients with BP > 180/110 mmHg, the decision to perform scheduled surgeries should be carefully assessed.     

Implante de prótesis peneana: indicaciones y abordaje penoescrotal

Inflatable penile prosthesis was developed in 1973 as a definitive treatment for erectile dysfunction. Since then these prosthetic devices underwent huge modifications, and scientific and technologic advances were accomplished, improving reliability, longevity and the surgical outcomes. Surgical implantation of a penile prosthesis may be considered in patients with erectile dysfunction who do not respond to pharmacotherapy or who prefer a permanent solution to their problem. According to the 2019 EAU Guidelines, regardless of the indication, prosthesis implantation has one of the highest satisfaction rates (92-100% in patients and 91-95% in partners) among the treatment options for erectile dysfunction based on appropriate consultation. The penoscrotal handling is the most common approach accounting for >80% of inflatable penile prosthesis placed worldwide. Most frequent complaints and dissatisfaction with inflatable penile prosthesis are related to technical issues or poor surgical outcomes such as the final length of the penis. There is an urgent need to improve the patient awareness in inflatable penile prosthesis in the preoperative arena, including the high expectation management, and an effort to select the proper patients for definitive treatment.