Estudio poblacional de casuística y morbimortalidad de la prostatectomía radical en España

IntroductionThere is no population-based study that accounts for the number of radical prostatectomies (RP) carried out in Spain, nor regarding the morbidity and mortality of this intervention.Our objective is to study the morbidity and mortality of RP in Spain from 2011 to 2015 and to evaluate the geographic variation.Material and methodsWe designed a retrospective observational study of all patients submitted to RP in Spain during five consecutive years (2011-2015). The data was extracted from the «Conjunto Mínimo Básico de Datos» (CMBD).We have evaluated geographic variations in terms of morbidity and hospital stay, and the impact of the mean annual surgical volume for each center on these variables.ResultsBetween 2011-2015, a total of 37,725 RPs were performed in 221 Spanish public hospitals. The mean age of the series was 63.9 ± 3.23 years. Of all RPs, 50% were performed through an open approach, and 43.4% have been operated on in hospitals with < 500 beds. We observed an important variability in the distribution of the cases operated on in the different regions. The regions that perform more RPs are Andalusia, Catalonia, Galicia, and Madrid. Our study shows a complication rate of 8.6%, with hemorrhage and the need for transfusion being the most frequent (5.3 and 4%, respectively). There are significant differences in bleeding rates and hospital stay among regions, which are maintained after adjusting for patient characteristics and type of hospital. When studying the annual surgical volume of each hospital, we find that the impact on the rate of hemorrhage or transfusion is linear; however, hospital stay remains stable at around 5 days from 60 RPs/year.ConclusionsIn national terms, morbidity and mortality rates after RP are comparable to those described in the literature. This study reveals a clear dispersion in the hospitals that carry out this intervention, showing clear differences in terms of morbidity and hospital stay between the different regions.     

Seguimiento oncológico después de cistectomía radical basado en patrones de recidiva tumoral y sus factores de riesgo

ContextFollowing cystectomy, approximately 50% of patients will present tumour recurrence. A recurrence may be local, systemic or occur in the urethra or upper urinary tract.ObjectiveTo analyse the characteristics, risk factors and outcomes of patients with tumour recurrence following cystectomy so as to subsequently propose a cancer follow-up protocol.Acquisition of evidenceAnalysis of original articles and reviews related to tumour recurrence and follow-up after radical cystectomy for urothelial tumour. Articles were obtained from Pubmed searches.Summary of the evidenceSystemic and local recurrences following cystectomy appear in 20%-35% and 5%-15% of cases, respectively. Some 80%-90% are diagnosed in the first 3 years, with the majority concentrated in the first 24 months. Common factors related to an increased risk of local and systemic recurrence are a pathologic stage ≥ pT3, the presence of positive margins and the extension of the lymphadenectomy. The incidence of recurrence in the upper urinary tract and urethra is 2%-6% and 4%-6%, respectively. Both types of recurrence may appear late and share risk factors such as signs of multifocal disease, a history of non-muscle-invasive bladder cancer, multiplicity, presence of ISC, urinary tract tumours and prostatic urethral tumours. Tumours in the distal ureteral cystectomy specimen and tumours in the prostatic urethra are also risk factors related to the appearance of tumours in the urinary tract and urethra, respectively.ConclusionUnderstanding the natural history of urothelial bladder carcinoma and the risk factors related to the appearance of tumour recurrence following cystectomy are essential for designing an appropriate follow-up protocol. The follow-up of patients with risk factors for local or systemic recurrence will achieve maximum efficiency during the first 3 years. The follow-up should be extended for patients with risk factors for presenting upper urinary tract or urethral tumours.     

Neumoencéfalo,coma y convulsiones después de una cirugía de descompresión lumbar

We describe a patient with pneumocephalus following lumbar decompression surgery who presented altered mental status at time to awake of anesthesia and the patient was admitted in intesive care unit in mechanical ventilation. The patient has not eye-opening response, no verbal response and motor response only withdraw in response to pain (7 points on Glasgow coma scale). Then, the patient experienced a generalized tonic-clonic seizure. Immediate cranial computed tomography (CT) images were performed. Cerebral pneumocephalus was present in CT, imaging revealed a voluminous pneumocephalus responsible for a significantspace-occupying effect on the frontal and parietal lobes, lateral ventricles and quadrigeminal plate cistern.Anti-epileptic therapy (diazepam and levetiracetam) and neurological monitoring were initiated. At 12 postoperative hours repeat CT scanning showed pneumocephalus were completely improved to minimal quantity and only limited to frontal lobe. The consciousness is impaired, and a generalized tonic-clonic seizure was present. Electroencephalogram showed continuous epileptiform activity and phenytoin IV was administered in continuous infusión. Four hours later the level of consciousness gradually improved, and the patient was right in eye opening, verbal and motor responses. A few hours later the patient was extubated, and no neurological deficits were present. Pneumocephalus should be considered in the differential diagnosis when evaluating a patient with altered mental status following lumbar surgery.     

Prostatectomía radical robótica: análisis después de 100 casos en la fundació puigvert

ObjectiveWe present the 100 first robotic radical prostatectomy with Da Vinci (RRPdaV), corresponding to the first experience in Spain.methodsWe reviewed the first 100 patients that underwent transperitoneal RRPda performed in Fundació Puigvert between July 2005 and January 2007. All cases were performed by 5 surgeons, being the learning curve for all of them. We analyzed surgical time, blood loss, conversion rate, intra and postoperative complications, hospital stay and days of bladder catheterization. Also, rates and location of surgical margins, as well as functional outcomes with an average follow up of 10.3 months.ResultsMean operating time was 180 minutes (100-310) and blood loss 210 mL (100-390). Blood transfusion was required in 2 cases. There were no intraoperative complications and neither any conversion to open surgery. There were 3 outstanding postoperative events, a compartmentalize syndrome, an acute urinary retention after removal of urethral catheter, and a paresthesias due to brachial plexus compression. Mean hospital stay were 3.7 days. (2-21). We had 21 cases of positive surgical margins (21%). The most frequent location was posterior lateral. 69 of 100 patients (69%) reached early (<3 months) total continence, 91% achieved in 9 months, and remaining 9% required use of at least one pad. Concerning to sexual function, 13 of 100 patients (13%) had preoperative erectile dysfunction, of remaining cases, 62% preserved potency at review, and 38% had postoperative erectile dysfunction.ConclusionsRRPDAv is a safe and reproducible procedure, and offers promising oncological and functional results with a minimal invasive technique. In spite of include the learning curve of 5 surgeons; we obtain an excellent rate of continence, and an acceptable sexual function. The individual improvement, with more experience, and a longer follow-up, will allow to value evolution of the technique, and it results.     

Residuo posmiccional y síntomas de disfunción de vaciado en mujeres con prolapso de órganos pélvicos antes y después de la cirugía vaginal. Estudio de cohortes multicéntrico

ObjectivesThe present study evaluates the impact of vaginal surgery for pelvic organ prolapse (POP) on voiding dysfunction (VD) symptoms and post-void residual (PVR) one year after the intervention.Material and methodsEpidemiological, longitudinal, prospective study. Thirty-nine gynecology units included women with symptomatic POP grade 2 or higher according to the Pelvic Organ Prolapse Quantification (POP-Q) system, who would undergo surgery for vaginal prolapse (CIRPOP-IUE study). Sociodemographic and clinical variables were collected before and after the intervention. At both visits, patients completed the ‘Epidemiology of Prolapse and Incontinence Questionnaire’ (EPIQ) and ‘Pelvic Floor Distress Inventory’ (PFDI-20) questionnaire. PVR volume was measured by bladder catheterization immediately after spontaneous urination.ResultsVD symptoms were present in 50% cases before the intervention. PVR was measured in 277 women of which 116 (41.87%) were > 50 ml and 42/277 (15.2%) were > 100 ml. Objective and subjective reduction in VD symptoms was observed one year after the intervention. Mean PVR volume was reduced with statistical significance, from a mean (SD) of 66.4 (68.9) ml to 48.3 (51.3) ml. The number of patients who reported difficulty in emptying and sensation of incomplete emptying on the EPIQ and PFDI-20 questionnaires also decreased.ConclusionsIn general, improved voiding functions were observed in the CIRPOP-IUE study through a decrease in specific VD symptoms and a reduction in mean PVR volume.     

Factibilidad y efectos de la prehabilitación en cirugía cardiaca. Estudio preliminar

Prehabilitation programs that combine exercise training, nutritional support, and emotional reinforcement have demonstrated efficacy as a strategy for preoperative optimization in abdominal surgery. The experience in cardiac surgery, one of those associated with greater morbidity and mortality, is anecdotal.ObjectiveEvaluation of the feasibility of a multimodal prehabilitation program and its effect on functional capacity in patients candidates for elective cardiac surgery.MethodsPilot study conducted from July 2017 to June 2018 in patients candidates to myocardial revascularization and/or valve replacement. The program consisted of: 1) supervised exercise training program, 2) breathing incentive exercises, 3) nutritional support, and 4) mindfulness training. An evaluation was carried out prior to the start of the program and at the end of it (preoperatively).ResultsAll patients except one who refused surgery, completed the program, which lasted an average of 45 days. No patients presented complications related to the program. The program induced a significantly increase in functional capacity measured by the six-minute walking test (510.7 +62 m vs 534.3 + 71 m, P = .007) and the chair test (13.2 + 4, 7 vs 16.4 + 7 repetitions, P = .02), as well as an increase in the level of physical activity measured by the Yale physical activity questionnaire (37.6 + 20 vs 54.2 + 27; P = 00029).ConclusionsMultimodal prehabilitation in patients candidates for elective cardiac surgery is feasible and it increases functional capacity preoperatively without being associated with complications. The presumed beneficial impact of this improvement on the incidence of postoperative complications and hospital stay, requires further investigation.     

Manejo anestésico en neurocirugía de paciente con síndrome de Eisenmenger y síndrome de Down. Reporte de un caso

Adults patients with congenital heart disease increasingly present for non cardiac surgery. The anesthetic management this type of patients in neurosurgery requires a meticulous surgical anesthetic planning. The need for urgent intervention, with the presence of a congenital heart disease evolved to Eisenmenger Syndrome, associated to a difficult airway, is a challenge for the anesthesiologist. The use of dexmedetomidine may be a valid alternative. We present the case of a patient with Down syndrome, and Eisenmenger syndrome who underwent drainage of brain abscess from the emergency department and was subsequently scheduled for reintervention. We compare the different anesthetic techniques used in both procedures, analyzing the implications they had on the main physiopathological alterations presented by the patient.     

Impacto del grado de cumplimiento de un protocolo ERAS en la recuperación funcional después de cirugía colorrectal

IntroductionCompliance to ERAS protocols is a process quality measure that is associated to better outcomes. The main objective of this study is to analyze the association between protocol compliance, surgical stress and functional recovery. The secondary objective is to identify independent factors associated to functional recovery.MethodsA prospective observational single-centre study was performed. Patients who had scheduled colorectal surgery within an ERAS program from January 2017 to June 2018 were included. We analysed the relationship between protocol compliance percentage and surgical stress (defined by C reactive protein [CRP] blood levels on postoperative 3^rd day), and functional recovery (defined by the proportion of patients who meet the discharge criteria on the 5^th PO day or before). Multivariate analysis was performed to asses independent factor associated to functional recovery.Results313 were included. For every additional percentage point of compliance to the protocol 3^rd day C reactive protein plasmatic level decreases 1,46 mg/dL and increases 7% the probability to meet the discharge criteria (p < 0.001 both). Independent factors associated to functional recovery were ASA III-IV (OR 0.26; 0.14-0.48), surgical CR-POSSUM score (OR 0.68; 0.57-0.83), early mobilization (OR 4.22; 1.43-12.4) and removal of urinary catheter (OR 3.35; 1.79-6.27), p < 0,001 each of them.ConclusionBetter compliance to ERAS protocol in colorectal surgery decreases surgical stress and accelerates functional recovery.     

Duodenopancreatectomía cefálica y tutorización externa del conducto de Wirsung. Resultados de una serie de 80 casos consecutivos

IntroductionThere is controversy regarding the ideal pancreaticojejunostomy technique after pancreaticoduodenectomy. Many authors consider the external Wirsung stenting technique to be associated with a low incidence of fistula, morbidity and mortality. We analyse our experience with this technique.Patients and methodsA retrospective analysis of the morbidity and mortality of a series of 80 consecutive patients who had been treated surgically over a 6.5-year period for pancreatic head or periampullary tumors, performing pancreaticoduodenectomy and pancreaticojejunostomy with external Wirsung duct stenting.ResultsMean patient age was 68.3 ± 9 years, and the resectability rate was 78%. The texture of the pancreas was soft in 51.2% of patients and hard in 48.8%. Pylorus-preserving resection was performed in 43.8%. Adenocarcinoma was the most frequent tumor (68.8%), and R0 was confirmed in 70% of patients. Biochemical fistula was observed in 11.2%, pancreatic fistula grade B in 12.5% and C in 2.5%, whereas the abdominal reoperation rate was 10%. Median postoperative hospital stay was 16 days, and postoperative and 90-day mortality was 2.5%. Delayed gastric emptying was observed in 36.3% of patients, de novo diabetes in 12.5%, and exocrine insufficiency in 3. Patient survival rates after 1, 3 and 5 years were 80.2, 53.6 and 19.2%, respectively.ConclusionsAlthough our low rates of postoperative complications and mortality using external Wirsung duct stenting coincides with other more numerous recent series, it is necessary to perform a comparative analysis with other techniques, including more cases, to choose the best reconstruction technique after pancreaticoduodenectomy.     

Luces y sombras de la duodenopancreatectomía cefálica laparoscópica

IntroductionLaparoscopic pancreaticoduodenectomy (PD) is not widely accepted, and its use is controversial. Only correct patient selection and appropriate training of groups experienced in pancreatic surgery and laparoscopy will be able to establish its role and its hypothetical advantagesMethodsOut of 138 pancreatic surgeries performed in a two-year period (2017-2019), 23 were laparoscopic PD. We evaluate its efficacy and safety compared to 31 open PD.ResultsThere were no cases of B/C pancreatic or biliary fistula, nor any cases of delayed gastric emptying in the laparoscopic group, but hemorrhage required one reoperation. The conversion rate was 21% (five cases): one due to bleeding, and the remainder for non-progression. The converted patients showed no differences compared to those completed by laparoscopy. There were no differences between laparoscopic and open PD in surgical time, postoperative complications, reintervention rate, readmissions or mortality. R0 resection in tumor cases was 85% for laparoscopy and 69% in open surgery without statistical significance. The postoperative hospital stay was shorter in the laparoscopic PD group (eight vs. 15 days).ConclusionsIn a selected group, laparoscopic PD can be safely and effectively performed if carried out by groups who are experts in pancreatic surgery and advanced laparoscopy. The technique has the same postoperative results as open surgery and is oncologically adequate, with less hospital stay. Proper patient selection, a step-by-step program and a lax and early conversion prevents serious operating accidents.     

Síntomas de tramo urinario inferior y síndrome de apnea obstructiva del sueño: evolución urodinámica antes y después de un año de tratamiento con presión continua positiva de la vía aérea

ObjectiveTo report the clinical evolution and the urodynamic behaviour of several lower tract urinary symptoms in patients with obstructive sleep apnea syndrome before and after the treatment with continuous positive airway pressure (CPAP) devices.MethodsA prospective study was performed; patients with recent diagnosis of sleep apnea confirmed by nocturnal sleep polygraphy and absence of medical urological past history. In order to discard important lower urinary tract conditions, urological examinations were previously performed. Urinary symptoms were evaluated using the IPSS and OAB-V8 validated questionnaires, three-day Bladder Diary and invasive urodynamic examinations with a gap of one year before and one year after using the CPAP.Results84 urodynamic studies were carried out in 43 patients. The IPSS score decreased by 3.58 points. The OAB-V8 score decreased by 2.87 points. Nocturia episodes decreased to one per night. The percentage of patients with nocturnal polyuria went down to 26%. The bladder compliance significantly increased (97.39 vs 200.40 ml/cm H2O). The presence of detrusor overactivity decreased from 11 (before CPAP) to 5 patients (after CPAP).ConclusionThe proper treatment with CPAP showed a statistical and clinical improvement of several LUTS with limited urodynamic modifications.     

Función eréctil después de cistectomía con preservación neurovascular

ObjectivesTo study the utility of neurovascular preservation for postoperative erection in radical cystectomy.Materials and methodsRetrospective analysis of 44 cystectomies performed at our center between January 2006-December 2009 in men < 65 years. In 11 cases a neurovascular preservation was done. We analyzed age, BMI, indication for surgery, urinary diversion, use of i-PDE5 or alprostadil, and daytime and nighttime continence. Erection Hardness Score (EHS) was used to assess erectile function.ResultsSpontaneous postoperative erectile function in preservation group was 44,4% EHS 4, 33,3% EHS 3 and 22,3% EHS 1 (achieving EHS 3 or 4 with alprostadil). In the non preservation group, 4,5% achieved EHS 4 spontaneously. The other 95,5% had EHS 0 (4,5% achieved EHS 3 with tadalafil 20 mg and 9% with intracavernous injections). Variables age (P = .001) and nerve-sparing surgery (P < .001) were related to postoperative erectile function recovery. In the multivariate analysis, nerve-sparing surgery remained statisticaly significant.ConclusionsThe functional results in preserving cystectomy are promising. The preservation should be considered in young patients without erectile dysfunction.     

Dexmedetomidina en el manejo de la vía aérea difícil con fibrobroncoscopio en paciente despierto afecto de síndrome de Klippel-Feil

Klippel-Feil Syndrome is a disease characterised by congenital fusion of cervical vertebra, which leads to cervical limitation and instability. In these cases, the best option is the orotracheal intubation with the fibre-optic bronchoscope with the patient awake. The advantage is that cervical movements that could lead to neurological damage are minimised. In these patients, adequate sedation, together with instillation of local anaesthetic in the pharynx and hypopharynx, is the key to reducing patient discomfort and achieving successful orotracheal intubation. Dexmedetomidine is a selective α2- adrenergic receptor agonist that produces sedation and analgesia at the locus coeruleus without producing respiratory depression, as well as maintaining patient collaboration. The case is presented of a patient with Klippel-Feil Syndrome and difficult airway management, who was given a dexmedetomidine infusion at 0.6 μg/kg/h as sedation for an awake fibre-optic endotracheal intubation.     

Uso de retractor Alexis en cirugía de tiroides y paratiroides

In thyroid and parathyroid surgical procedures, good visibility of the thyroid gland is essential. This is traditionally achieved by means of traction sutures of the dermo-plastysmal flaps to the drapes of the operative field, producing tension and even damage to the skin. The Alexis^® retractor ring improves exposure and facilitates stable access to the thyroid, protecting the skin from injury during the intervention.     

Colecistectomía laparoscópica en régimen de cirugía mayor ambulatoria en un hospital comarcal: resultados iniciales de una serie de 110 casos

IntroductionThe aim of our study was to analyze the reliability of laparoscopic cholecystectomy (LC) in an Ambulatory Surgery unit, in order to encourage its use and achieve better management of health resources.Material and methodRetrospective study of 110 patients operated on for LC between September 2004 and November 2008. The selection criteria were: absence of prior supramesocolic abdominal surgery, no previous admission for acute cholecystitis, absence of stones in the bile ducts and normal liver function tests, no intake of oral anticoagulants or antiplatelet agents and ASA I-II. All patients were operated using a previously established Major Ambulatory Surgery (MAS) protocol.ResultsThe patients included 81 women and 29 men, with a mean age of 51.03 years (range 24–77), of which 57 had a medical and / or surgical history.The overall morbidity was 6.36% with a mortality of 0%. The conversion rate was 0.9%. A total of 87 patients (79.1%) were discharged at 6 h after surgery, thus fulfilling the criteria of the MAS system. The mean overall hospital stay was 1.49 days (median 0). The reoperation rate WAS 1.81% and the rate of readmission after discharge was0.9%.ConclusionsThe performance of outpatient laparoscopic cholecystectomy is feasible and safe. It should be integrated into the activities of Major Ambulatory Surgery, ensuring careful selection of patients and interest by surgeon who performs it.