Revista mexicana de urologia最新文献

Cystic nephroma is a renal lesion belonging to the group of mixed epithelial and mesenchymal tumors, together with other infrequent tumors, such as synovial sarcoma and mixed epithelial and stromal tumor. It is considered one of the rarest renal tumors, and up to the present date, fewer than 250 cases have been reported in the international medical literature.

A 24-year-old homosexual man with a smoking index of 2 had a past history of condylomatous perianal lesion resection. He presented with left renal colic that was medically managed. Physical exploration revealed left costovertebral angle percussion. Urinalysis reported a pH of 5.5, blood ++, and a scant quantity of yeasts. The patient was HIV negative. Tomography scan identified an incidental left renal lesion with a Bosniak III multicystic component (25.3 mm × 28.2 mm). Magnetic resonance imaging showed a complex cystic lesion. A left open partial nephrectomy was performed and the histopathologic study reported cystic nephroma. The patient had adequate postoperative progression and was released on the 4th day after surgery.

Cystic nephromas are rare lesions that are commonly diagnosed in the postoperative period because their radiologic characteristics are similar to complex cysts suggesting malignancy. Treatment is surgical and nephron-sparing surgery is preferred in young patients with a small lesion.

Cystic nephromas are rare tumors and it is a challenge to differentiate them from malignant renal tumors and thus manage them by sparing functioning renal units whenever possible.

Background

Preservation of neurovascular bundles is one of the most important aspects regarding functional outcomes during radical prostatectomy. The use of robotic-assisted laparoscopy has helped to improve preservation. Other strategies to improve nerve sparing have recently been used, including the use of intraoperative nerve monitoring, intrafascial and interfascial dissection, and the use of patches to accelerate nerve function recovery.

The aim of our report was to show new strategies for nerve sparing in robotic-assisted laparoscopic radical prostatectomy (RALRP), exemplified by a clinical case.

Clinical case

A 42-year-old African-American man with intermediate-risk prostate cancer and good preoperative erectile function underwent RALRP, with an emphasis on careful nerve sparing.

Conclusions

Functional results are greatly relevant when performing RALRP, given that they are expected to be better with this technology. Despite the magnified vision achieved during robotic-assisted surgery, nerve fibers of the neurovascular bundles can be missed. Therefore, adhering to careful intrafascial dissection is essential, aided by the use of nerve monitoring and amniotic membrane patches, for improving outcome with respect to continence and erectile function in these patients.

Background

Partial nephrectomy has become the standard surgical treatment for small renal masses under 7 cm, providing excellent oncologic and functional results.

Aim

To present the oncologic and functional results over a 10-year period in patients with stage cT1 lesions that underwent open or laparoscopic partial nephrectomy.

Material and methods

A retrospective, descriptive, observational study was conducted on 18 patients treated with partial nephrectomy within the time frame of 2005 to 2014. Surgery duration, surgical margins, and kidney function through scintigraphy and the R.E.N.A.L. score were analyzed.

Results

The mean follow-up period was 4.5 years and overall survival was 95.5%. Mean surgery duration was 3.2 h, 72.1% of the lesions were stage pT1a, the mean age of the patients was 61.7 years, and 16.7% of the cases presented with positive margins. Mean blood loss was 611 ml and 38.8% of the patients had a R.E.N.A.L. score of moderate complexity. There was only one death and it was not cancer-specific.

Discussion

Partial nephrectomy for small tumors is the treatment of choice. There was a 16% deterioration of kidney function with partial nephrectomy, results that are better than those reported in the literature for radical nephrectomy.

Conclusions

The results at 10 years were positive and the overall 10-year survival was determined by factors such as age, comorbidities, and the grade of cellular differentiation - not by the surgical technique. Our study suggests that partial nephrectomy performed by experienced surgeons provides adequate oncologic and functional results.

Background

The procedure of transrectal biopsy of the prostate (TRBP) is not exempt from complications. Between 1-6.9% of men that undergo TRBP present with adverse effects such as hematuria, hematospermia, dysuria, or fever, and 0.5%-5% will present with septicemia.

Aim

To evaluate erectile function in Mexican men that underwent TRBP.

Material and methods

A total of 324 patients underwent TRBP. All the patients were evaluated through the International Index of Erectile Function (IIEF-5) questionnaire. All patients that had a positive result for cancer and that presented with erectile dysfunction at the initial evaluation were excluded from the study. Ninety-three patients were included and were evaluated with the IIEF-5 before the biopsy and at 4, 12, and 24 weeks after TRBP.

Results

At the baseline IIEF-5 evaluation, 100% of the 93 patients were potent. At post-TRBP week 4, the mean IIEF-5 score was 22 points (range: 11-25). Significant difference was found when the groups were evaluated (P = .001), given that > 30% presented with some grade of erectile dysfunction, compared with the baseline evaluation. At week 24, only 7.25% of the patients presented with some grade of erectile dysfunction.

Conclusions

After TRBP, the decrease in the IIEF-5 scores and the presence of erectile dysfunction was temporary and transitory, having a greater effect during the first month after the procedure. There was improvement after the first month and an almost complete recovery at 6 months.

Renal cell carcinoma represents 2-3% of all cancers and is the most frequent solid lesion of the kidney. Incidental diagnosis through imaging studies is approximately 50%, and the majority of those cases are asymptomatic. Management is based on radical surgical treatment and postoperative follow-up through imaging techniques is essential for detecting local or systemic recurrence.

A 60-year-old man had a past history of left radical nephrectomy due to renal tumor 10 years earlier. Clinical manifestation was painless, gross hematuria. CT-urography revealed right ureteropelvic ectasia with a lesion occupying the distal third of the ureter that produced a negative filling defect. Endoscopic revision, lesion excision, and adjuvant treatment based on the tyrosine kinase inhibitor, sorafenib, were carried out.

This clinical case underlines the importance of strict follow-up in patients with renal tumors when there is no clear knowledge as to the metastatic behavior and predictable tumor dissemination routes in renal cell carcinoma.

Background

We describe herein 2 cases of germ cell tumors with somatic malignant transformation (SMT), a rare phenomenon with a low survival rate.

Case 1

A 53-year-old man had a one-month progression of pain and hardening in the left testis. He was diagnosed with a tumor and underwent radical orchiectomy (RO). The histopathology report stated: teratoma with SMT into neurogenic sarcoma and rhabdomyosarcoma. The patient developed retroperitoneal disease and was treated with chemotherapy. The retroperitoneal tumor progressed and grew and so surgical exploration was carried out, identifying an unresectable tumor. A biopsy was taken and the result was a high-grade fusiform rhabdomyosarcoma extending to the greater omentum.

Case 2

A 45-year-old man was a user of NSAIDs. He underwent RO and retroperitoneal tumorectomy in 2004 that reported germ cell tumor at both sites. He received chemotherapy and adjuvant radiotherapy. In 2014 he was referred to our institution and a PET-CT scan identified a 3 × 4 cm intercaval-aortic tumor. Tumor markers were normal. Tumorectomy of 80% of the tumor (R2) was performed, reporting fusocellular sarcoma. Three cycles of doxorubicin/ifosfamide and radiotherapy were administered. The patient remained under surveillance with a 16 mm intercaval-aortic tumor. He presented with upper gastrointestinal bleeding and died.

Conclusions

SMT of germ cell tumors is rare and insufficiently understood.

Aim

To present the first year experience of the robotic surgery project at the Hospital Central Militar that consisted of 55 consecutive cases of robotic-assisted laparoscopic radical prostatectomy.

Methods

With the incorporation of the robotic surgery system in November 2014 to November 2015, the same surgeon (JGCS) performed a total of 55 radical prostatectomies. In the present retrospective study, the following preoperative data were analyzed: ECOG, ASA risk, BMI, associated morbidities, previous radiotherapy, history of TURP, IPSS, erectile function, urinary continence index, PSA, prostatic volume, Gleason score, initial staging, and clinical stage. The intraoperative variables were: type of access, surgery duration, conversion rate, bleeding, blood transfusions, complications, type of anastomosis, and time with bladder catheter. The postoperative variables analyzed were: positive margins, biochemical recurrence, urinary continence, and erectile function.

Results

The mean age of the patients was 68 years and the mean PSA value was 7.80 ng/ml. In 50.9% of the cases, the Gleason score was 6 (3 + 3). Mean surgery duration was 270 min and mean estimated blood loss was 512 ml. Mean hospital stay and time with catheter was 5.9 and 8 days, respectively, and the positive margin rate was 18.1%. The rates for continence and potency at the follow-up at one, 3, 6, and 12 months were 41.8%, 78%, 88%, 100% and 29%, 41%, 68%, 66%, respectively.

Conclusions

The results of our initial experience with robotic radical prostatectomy are promising. We have been able to put robotic-assisted laparoscopic radical prostatectomy into practice at our hospital in a safe and reproducible manner with a minimum of adverse results.

The most frequent site of excretory system rupture that is secondary to obstruction, usually arising from stone disease, is the renal fornix. Forniceal rupture and the formation of retroperitoneal fluid collections are rare forms of retroperitoneal fibrosis. Presented herein is the case of a man in the fith decade of life that came to the Emergency Service because of abdominal pain. Computed tomography scan of the abdomen and pelvis revealed a slightly enhanced retroperitoneal soft tissue lesion that extrinsically enveloped and compressed the right ureter. A second image of lower density was observed in the excretory phase that proved to be a urinoma secondary to rupture of the ipsilateral renal fornix. A double-J catheter was placed to decompress the excretory system and systemic steroid therapy was given, with good response. Retroperitoneal fibrosis is an uncommon disease characterized by the development of inflammation and fibrosis in the retroperitoneal space. We describe herein 2 forms, idiopathic and secondary, the former being more frequent. Current evidence has associated the idiopathic variant with IgG4-related diseases.

Aim

To compare the results of transcutaneous posterior tibial nerve stimulation vs. darifenacin for the treatment of refractory overactive bladder in women.

Material and methods

A quasi-experimental clinical trial was conducted on 30 women diagnosed with refractory overactive bladder. Twenty-two patients received 7.5 mg of oral darifenacin daily and 8 patients had 12 30-min weekly sessions of transcutaneous electrostimulation of the posterior tibial nerve. The patients kept a 3-day urinary diary, underwent pad tests, and the quality of life Bladder Control Self-Assessment Questionnaire and International Consultation on Incontinence Questionnaire were applied at the baseline, at 6 weeks, and at 12 weeks of the study.

Results

At 6 weeks, the patients treated with darifenacin presented with a reduction in urinary frequency (8.27 vs. 11.5, p = 0.236), in nocturia (1.36 vs. 4.25, p = 0.017), and in incontinence episodes (1.32 vs. 3.62, p = 0.041), compared with the patients that received stimulation treatment. In regard to the quality of life questionnaires, at 6 weeks the patients that received darifenacin treatment had a lower score on the self-assessment questionnaire (7.13 vs. 10.14, p = 0.045). In relation to the pad test, after comparing the measurements at the beginning and end of treatment, there was reduced urine leakage in grams with darifenacin (69.32 vs. 2.09, p = 0.041) and with stimulation (42.25 vs. 2.62, p = 0.012), with no statistical significance between the 2 groups (p = 0.753).

Conclusions

Darifenacin was superior to transcutaneous stimulation of the posterior tibial nerve in relation to symptom reduction, urine leakage, and questionnaire scores at 6 weeks. There was no statistically significant difference between the 2 groups at 12 weeks.

Background

Urinary tract infections are a leading cause of medical consultations in Mexico and the growth of antimicrobial resistance results in increased morbidity and rising costs.

Aim

To make an economic evaluation of ceftibuten as treatment for uncomplicated urinary tract infections in adults, from the perspective of the Mexican private health system.

Methods

A cohort-based decision-making model was developed to compare ceftibuten with TMP-SMX, ciprofloxacin, and cefalexin. Effectiveness was measured using local susceptibility rates of Escherichia coli. Costs were obtained from official market value data and converted to 2014 USD values. Incremental analysis was employed to determine if ceftibuten was a worthwhile investment on the part of the private health system in Mexico.

Results

The total expected cost per patient for ciprofloxacin was $116 USD and the corresponding costs for TMP/SMX and cefalexin were $92.40 USD and $74.80 USD, respectively. Ceftibuten had a lower expected cost ($34.50 USD) and a higher percentage of therapeutic success (99.4%), compared with ciprofloxacin 21%, cefalexin 41%, and TMP/SMX 31.7%.

Conclusions

Even though ceftibuten has a higher market price than other antimicrobials in Mexico, it can represent possible savings by avoiding the costs associated with undesirable results due to antimicrobial resistance to E. coli.