Cristián Palma

PATOLOGIA PREINVASORA DEL CERVIX

Se presenta una revision de la bibliografica y se comentan los principales aspectos epidemiologicos y clinicos de la patologia preinvasora del cervix. La historia natural de esta enfermedad revela la presencia de un fenomeno dinamico de progresion persistencia y regresion de lesiones intraepiteliales en las cuales el virus papiloma humano juega un rol preponderante. Se resalta el rol actual de la colposcopia en el manejo de una citologia alterada. Se revisa los resultados del manejo colpohistologico de un frotis atipico demostrando un 9% de lesiones de alto grado para los ASCUS y de 25% para los ASC-H. Finalmente se presentan las alternativas terapeuticas y se analizan los resultados de la escision con asa grande en pacientes portadoras de NIE III demostrando un 89% de curacion

Seminoma de testículo abdominal en un paciente adulto: reporte de un caso

Resumen Objetivo Presentar un nuevo caso de Seminoma de Testiculo Abdominal en un paciente adulto y una revision de la literatura Observacion clinica Presentamos a un paciente de 30 anos con criptorquidia, que luego de consultar por dolor abdominal en el servicio de urgencias, es diagnosticado un Seminoma de testiculo abdominal Discusion La incidencia de cancer testicular en testiculos no descendidos es de 3 a 48 veces mayor que en la poblacion general. La existencia de testiculos no descendidos en la poblacion adulta es rara en los paises desarrollados debido a la practica sistematica de orquidopexia electiva antes de los 2 anos de vida y orquiectomia en pacientes postpuberes con testiculos no descendidos. A pesar de estas medidas de prevencion, aun se encuentran casos aislados de tumores testiculares abdominales en adultos

Estudio prospectivo que compara la litotricia extracorpórea y la ureteroscopia en el tratamiento de la litiasis de uréter distal

Resumen Objetivos Comparar los resultados en el manejo de la litiasis de ureter distal entre la litotricia extracorporea (LEC) y ureteroscopia (URS) y asi evaluar la mejor alternativa de tratamiento en esta afeccion. Material y metodos Un total de 104 pacientes con diagnostico de litiasis de ureter distal, que requerian tratamiento quirurgico. Se realizo un enrolamiento y seguimiento prospectivo. Se utilizo en LEC un litotriptor Modulix SLX Storz, en la URS se utilizo un ureteroscopio semirrigido Storz 33 cm, diametro de 7,5 a 9,5 Fr, optica 6°. Del total de pacientes, 54 fueron a LEC y 50 a URS, y 62 eran varones y 42, mujeres, con una edad promedio de 49,72 anos para LEC y de 52,16 anos para URS. En la LEC el promedio de tamano fue 8,29 mm y en la URS, de 8,96 mm. Se establecio una significacion estadistica p Resultados El tiempo del procedimiento para la LEC, separado por sexo, fue de 55 min en el caso de los varones y de 45 min en las mujeres. Para la URS fue de 80 min para los varones y de 55 min para las mujeres. El tiempo de hospitalizacion promedio para la LEC fue de 4,8 h (todos los procedimientos ambulatorios). En el caso de la URS, fue de 22 h. Las complicaciones en el caso de la LEC fueron del 7% y para la URS, del 7,9%. De los pacientes tratados por LEC, el 74,3% presento stone free a los 30 dias, a diferencia de la URS, que presento un porcentaje de stone free del 92,3% (p Conclusiones Basados en los resultados de este estudio, la URS es el metodo mas adecuado para el manejo de la litiasis de ureter distal, tanto en resultados de stone free como en la falta de significacion en la comparacion de complicaciones.

Overexpression of CYP19A1 aromatase in Leydig cells is associated with steroidogenic dysfunction in subjects with Sertoli cell-only syndrome

Several observational studies have showed a combination of lower testosterone (T) to LH ratio and higher estradiol (E2) to T ratio in secretory infertile men compared to men with normal spermatogenesis, suggesting a steroidogenic dysfunction of Leydig cells (Lc) that may involve increased aromatase activity. Low T/LH ratio is associated with Lc hyperplasia, which together with LH hyperstimulation may represent compensation for impaired T production. Aromatase expression and oestrogen production are mainly detected in Lc of the testis, although Sertoli and germ cells also contribute to testicular aromatase activity. The aim of this study was to assess the transcriptional expression of CYP19A1 (aromatase) in isolated Lc of subjects with Sertoli cell‐only syndrome (SCOS) and signs of Lc impairment. Nineteen patients with SCOS and 10 controls with normal spermatogenesis who had medical indication of testicular biopsy for sperm retrieval were studied. Leydig cells were isolated by Laser Capture Microdissection (LCM) and CYP19A1 mRNA expression was quantified by SYBR® Green‐based qPCR. In addition, testicular T and E2 and serum hormonal levels were measured. Relative to control group, CYP19A1 was overexpressed more than twofold in 10/19 cases (2.3–12.2‐fold increase), showing a significant increment in cases with low T/LH ratio (T/LH < 2) compared to cases with T/LH ≥ 2 (p = 0.038, REST®). Moreover, Rq data for CYP19A1 had a direct correlation with testicular levels of E2 and the E2/T ratio (r = 0.869; p < 0.001 and r = 0.633; p = 0.005). In summary, Lc from infertile patients with signs of Lc dysfunction overexpressed aromatase and showed an increment of testicular E2. Our results suggest that increased expression of aromatase in Lc leads to higher E2 production and may account for the functional impairment of the Lc in patients with SCOS.

Concordance of renal stone culture: PMUC, RPUC, RSC and post-PCNL sepsis—a non-randomized prospective observation cohort study

IntroductionBetween 5 and 10% of patients undergoing percutaneous nephrolithotomy (PCNL) develop postoperative sepsis 1, 2. Strategies to prevent infectious complications are based on information provided by preoperative midstream urine cultures (PMUC). The aim of this study is to evaluate the concordance of the microbiologic findings of PMUC, cultures of the renal stone (RSC) and urine obtained directly from the renal pelvis (RPUC) in patients undergoing PCNL.Materials and methodsThis is a multicenter prospective study. The study included all patients who underwent PCNL from May 2013 to July 2015 in three academic hospitals. All patients underwent a PMUC. Samples for RPUC were obtained by renal puncture for PCNL. Stone fragments extracted during the procedure were sent for culture (RSC). Clinical variables, stone configuration, burden and microbiology reports of cultures were recorded. We analyzed concordance between cultures and association with infectious complications.ResultsOne hundred and twenty-two patients underwent PCNL. Twenty-four percent had positive culture, 3.2% (4/122) PMUC, 14.7% (18/122) RPUC and 13.9% (17/122) RSC. Positive PMUC demonstrated multidrug-susceptible Escherichia coli and Staphylococcus aureus, while RPUC showed multidrug-resistant pathogens and/or fungus. Seven patients (5.7%) developed postoperative infectious complications prior to discharge. There was a weak correlation between PMUC and intraoperative urine cultures (RPUC and RSC). Concordance rate between RPUC and RSC was 83.3%. The most common isolated pathogens were multidrug-resistant bacteria or fungus.ConclusionsPMUC did not reflect the microbiological environment found in stones and urine directly obtained from the renal pelvis. Patients with postoperative infectious complications had negative PMUC with positive RPUC or RSC. RPUC and RSC can help guide prompt and appropriate antibiotic treatment for patients who develop postoperative infectious complications after PCNL.

Leydig cell dysfunction is associated with post-transcriptional deregulation of CYP17A1 in men with Sertoli cell-only syndrome

STUDY QUESTION Is the expression of steroidogenic enzyme 17α-Hydroxylase/17,20-Lyase (CYP17A1) down-regulated in Leydig cells (LCs) of men with spermatogenic failure and compensated impairment of LC function, i.e. a low testosterone to LH (T/LH) ratio? SUMMARY ANSWER Although the transcriptional expression of CYP17A1 is increased, its protein expression is decreased, in isolated LCs of men with spermatogenic failure and reduced serum T/LH. WHAT IS KNOWN ALREADY Primary spermatogenic defects have been associated with functional and morphological abnormalities of LCs, characterized by decreased serum testosterone (T) levels, decreased T/LH, increased 17β-estradiol (E2) and E2/T ratio, and larger clusters of LCs (LC hyperplasia). CYP17A1 is a key enzyme in the testosterone pathway and has been implicated in the steroidogenic lesion produced by E2 stimulation. STUDY DESIGN, SIZE, DURATION We studied 18 azoospermic patients with Sertoli cell-only syndrome (SCOS) and signs of LC dysfunction (cases) and 10 obstructive azoospermic/oligozoospermic men with normal spermatogenesis (controls). The SCOS patients were sub-grouped into 9 cases with T/LH <2 and 9 cases with T/LH ≥2. All of the men underwent testicular biopsy for sperm retrieval at the Reproductive Unit of a University Hospital. PARTICIPANTS/MATERIALS, SETTING, METHODS The transcriptional expression of CYP17A1 and SF-1 (steroidogenic factor 1) was quantified by SYBR®Green-based qPCR in LCs isolated by laser capture microdissection (LCM), and relative expression to the control pool was assessed. CYP17A1 protein expression was semi-quantified by indirect immunofluorescence (IFI) using Image-Pro Plus v7.0 (Media Cybernetics) in testicular tissue. FSH and LH serum concentrations, and serum and intratesticular T (ITT) and E2 (ITE2) were measured by IRMA and RIA, respectively. MAIN RESULTS AND THE ROLE OF CHANCE Relative CYP17A1 mRNA expression was increased in cases with T/LH <2 compared to cases with T/LH ≥2, by a mean of 3.3-fold (P = 0.002). No corresponding increase in protein expression was found; in fact, CYP17A1 immunostaining intensity assessed by the Integrated Optical Density (IOD) parameter was lower in the cases with T/LH <2 compared to controls (P = 0.008). Relative SF-1 mRNA expression was similar in both case subgroups. CYP17A1 mRNA expression correlated with ITE2 and intratesticular E2/T (r = 0.536; P = 0.026 and r = 0.542; P = 0.016, respectively), while an inverse association was observed for ITE2 and protein level expression (r = -0.421; P = 0.05). LARGE SCALE DATA Not applicable. LIMITATIONS REASONS FOR CAUTION We should interpret the results of the semi-quantification of immunofluorescent staining by Image-Pro Plus software with caution, because it is a semi-quantitative method that may have certain difficulties regarding the disposition of protein in the cells. However, it is not influenced by variations in the number of cells that express the protein, as could be the case of western blot analysis in testicular tissue. WIDER IMPLICATIONS OF THE FINDINGS Dysfunctional LCs of men with SCOS show post-transcriptional deregulation of CYP17A1, with increased mRNA and decreased protein expression, which may be modulated by increased ITE2 levels. In addition, transcriptional expression of CYP17A1 was not associated with changes in SF-1 mRNA expression. STUDY FUNDING/COMPETING INTEREST(S) This work was supported by the National Fund for Scientific and Technological Development (FONDECYT) of Chile to A.C. [grant number 1120176]. The authors declare no conflict of interest.

Acumulación de adipocitos en el cuerpo cavernoso: primera evidencia clínica e implicaciones fisiopatológicas en la disfunción eréctil

OBJECTIVES Animal models have shown that erectile dysfunction is associated with adipocyte accumulation under tunica albugínea, which could be involved in venous leakage and loss of penile rigidity. In the current sudy, we compared the histology of the penile sub-albuginean region of drug-refractory erectile dysfunction patients undergoing penile prosthesis implantation with potent patients with Peyronies disease undergoing curvature correction procedures. MATERIALS AND METHODS Seventeen refractory erectile dysfunction patients and fourteen potent patients with Peyronies disease were recruited. Sub-albuginean tissue samples were taken in each surgery. An expert uropathologist analysed each section. A bivariate analysis was performed. Multivariate logistic regression was used to calculate adjusted odds ratios; P value<.05 was considered significant. RESULTS Eleven patients (11/17) in the case group presented cavernous fat cell accumulation, while only one patient (1/14) in the control group presented this finding (P<.05). Adjusted odds ratio for erectile dysfunction was 40.72; 95% CI 2.28-727.29 (P=.012). CONCLUSIONS Different studies have shown that androgen disruption could be involved in penile structural changes, leading to trabecular smooth muscle apoptosis and trans or de-differentiation into adipocytes. This is the first prospective study in humans to report an association between erectile dysfunction and sub-albuginean adipocyte accumulation. Venous leakage secondary to this phenomenon could be a factor in the pathophysiology of erectile dysfunction, especially in patients that do not respond to medical therapy.

Trastornos de la eyaculación

Resumen Las alteraciones de la eyaculacion constituyen un problema de consulta frecuente en urologia y en cierta medida, en la consulta general. Su importancia radica, ademas de su alta prevalencia, en el detrimento psicologico que repercute en la calidad de vida de los pacientes, sus parejas, y por constituir una posible causa de infertilidad. Dada la complejidad del control de la funcion eyaculatoria, las causas pueden ser multiples y por lo tanto es necesario un abordaje integral del bienestar biopsicosocial del paciente para lograr un manejo adecuado de esta afeccion. Por otro lado, si bien es imprescindible entender los aspectos fisiopatologicos de estas disfunciones para comprender su manejo, hay que hacer notar que su diagnostico es eminentemente clinico. Sobre este ultimo topico es que existe gran controversia, ya que existe variabilidad en la definicion de algunos de estos trastornos, lo que afecta la capacidad de deteccion del clinico, su manejo y tambien la calidad de los estudios clinicos que investigan su tratamiento. El tratamiento adecuado parte con un correcto diagnostico clinico y, como se dijo anteriormente, exige un abordaje multidisciplinario. De hecho es historicamente un campo compartido con la psiquiatria, incluyendo el DSM criterios estrictos para su diagnostico. Existen diversas terapias dependiendo del diagnostico de cada trastorno, las que van desde tratamientos farmacologicos hasta terapias psicologicas segun sea la situacion clinica.

Sub-Albuginean Adipocyte Accumulation is Associated with Erectile Dysfunction: First Clinical Evidence and Pathophysiological Implications

The aim of this study is to determine the presence of adipocyte accumulation under penile tunica albuginea in a group of refractory erectile dysfunction patients. Nine erectile dysfunction patients (case group) and eleven potent patients with Peyronie’s disease (control group) underwent penile prosthesis implantation and curvature correction surgeries, respectively. In both groups, sub-albuginean tissue samples were taken within the operative time. Groups were compared in terms of clinical characteristics, co-morbidities and presence of sub-albuginean adipocyte accumulation. Of the nine patients in the case group, eight presented cavernous fat cell accumulation, while only one patient in the control group presented this finding (p<0.05). A significant association (p<0.05) was found between adipocyte accumulation and erectile dysfunction (OR 35 CI 95% 1.98-1727.62). A similar association with chronic arterial hypertension was also found (OR 20 CI 95% 1.29-1008.46). This is the first human study to report an association between erectile dysfunction and penile sub-albuginean fat accumulation. Metabolic syndrome-related conditions could cause disruption in androgen homeostasis, leading to adipocyte accumulation. Venous leakage secondary to accumulation of fat under tunica albuginea could be an important element in the pathophysiology of erectile dysfunction, especially in metabolic syndrome patients that do not respond to medical therapy.

Extraño caso de polaquiuria

Un joven de 15 anos que vive en Santiago, Chile. Se presento con una historia de 6 meses de evolucion caracterizada por nicturia y polaquiuria. El examen fisico revelaba una gran masa de 10 cm de diametro en el hipogastrio. La ecotomografia informaba una gran masa retroperitoneal. En la resonancia nuclear magnetica (RNM) se observa una imagen hipointensa en T1 (A) e hiperintensa en T2 (B) de aspecto quistico homogeneo, de contornos bien definidos, cuyos septos y pared realzan tras la administracion de contraste endovenoso (C), la cual mide aproximadamente 11,2 x 8,8 x 8,9 cm. La lesion descrita contacta y desplaza la pared abdominal anterior produciendo un efecto similar en la vejiga y el sigmoides. Impresion radiologica: lesion quistica multiloculada en pelvis mayor, entre sus diagnosticos diferenciales se debe considerar quiste mesenterico, linfangioma, menos probablemente hidatico. En el acto quirurgico se encontro una gran masa adherida a la vejiga, vasos iliacos, desplazando ambos deferentes y ureteres con grandes cambios anatomicos. Anatomia patologica confirma quiste hidatidico (D). Chile es uno de los paises con la mayor incidencia de Equinococcus Granulosus, con aproximadamente 700 a 800 nuevos casos por ano. Se presenta en areas rurales del pais y afecta principalmente el higado (59-75%), pulmones (27%), rinon (3%), huesos (1-4%) y cerebro (1-2%).