Enrique Broseta

Are Urology Residents Ready to Treat Premature Ejaculation After Their Training

INTRODUCTION The management of premature ejaculation (PE) among urology residents (URs) in the era of standard definition and new treatments is unknown. AIM To determine how future urologists currently address PE and to review their adherence to guidelines. METHODS A specifically designed survey on the preferred approaches to the treatment of PE was given to residents during the Eighth European Urology Education Programme. The results were tabled, and descriptive statistics were used to analyze differences in practice patterns. MAIN OUTCOMES MEASURES The responses are compared with clinical guidelines and recommendations. RESULTS A total of 360 URs attended the recommendation course, and 140 answered the survey (response rate: 38.8%). Seventeen (12.1%) of the respondents considered PE to be a very common sexual dysfunction, 62 (44.3%) considered PE to be frequent, 33 (23.6%) considered this condition uncommon, and 28 (20%) did not consider PE to be a dysfunction. Regarding incidents, 67 residents (47.9%) treated one patient per week. To assess PE, 132 (94.3%) used sexual history, 37 (26.4%) used physical examination, 38 (27.1%) used questionnaires, and 4 (2.9%) used laboratory testing. The preferred initial management strategy for PE was psychological/behavioral therapy for 65 (46.4%) residents. Topical anesthetic, andrological referral, and prescription of selective serotonin reuptake inhibitors (SSRIs) on demand were favored by 34 (24.3%), 19 (13.6%), and 8 (12.9%) of the respondents, respectively. Other options were psychiatric referral, which was preferred by two (1.4%) respondents, and prescription of daily SSRIs, which was preferred by two (1.4%) respondents. The preferred secondary treatment for patients who did not improve initially was prescription of SSRIs for on demand, which was 46 (32.9%) respondents. In cases where patients had concomitant erectile dysfunction (ED), 16 (11.4%) URs treated only the ED and 60 (42.9%) treated both conditions. CONCLUSIONS The majority of URs follow the established guidelines for diagnosis of PE, but not for treatment. The URs have an insufficient medical education in sexual medicine.

Urodynamic findings in amyotrophic lateral sclerosis patients with lower urinary tract symptoms: Results from a pilot study

To determine lower urinary tract symptoms (LUTS) prevalence and urodynamic findings in amyotrophic lateral sclerosis (ALS) patients treated in our hospital.

Local Treatment of Penile Prosthesis Infection as Alternative to Immediate Salvage Surgery

Introduction Penile prosthesis (PP) is the established treatment for patients with erectile dysfunction (ED) who do not respond to phosphodiesterase inhibitors and intracavernosal injections. In general, these devices have been largely successful but there are not free of serious complication such as PP infection (PPI). PPI requires immediate surgical removal or salvage rescue of the PP. Aim In this report, we present two clinical cases with inflatable PP (IPP) treated locally with antibiotic and high pressure irrigation and then avoid the PP removal or salvage rescue. Methods We present two patients with PPI in our institution and literature review. Main Outcome Measures Resolution of the two cases. Results Patient A (A) was 44 years old and patient B (B) 51 years old presented PPI after three weeks (A) and eight weeks (B). Both patients were diabetic. Physical exploration revealed an open scrotal incision at its margin with a clear discharge. The rest of the incision and scrotum were clean and dry. They had not scrotum pain/tenderness or systemic/septic symptoms. The bacterial culture of the incisional drainage revealed a Staphylococcus aureus (A) and Staphylococcus epidermidis (B). In both cases, we performed an excision of the tissue around the pump with a high pressure pulsed irrigation (Interpulse; Stryker Corp, Kalamazoo, MI, USA). For the irrigation we used three different solutions that included povidone-iodine, antibiotics (gentamicin plus vancomicin), and hydrogen peroxyde. Finally, we performed a multilayered surgical closure with the use of aspirate drainage over 24 hours and intravenous antibiotics. The patients had a total resolution of its symptoms after 20 months (A) and 36 months (B), and the IPP worked properly. Conclusion This treatment could be an option for to perform specific patients with local IPP infection without systemic symptoms instead of surgical removal.

Fitoterapia en Urología. Evidencia científica actual de su aplicación en hiperplasia benigna de próstata y adenocarcinoma de próstata

OBJECTIVE To evaluate the usefulness of phytotherapy in the treatment of the benign prostatic hyperplasia (BPH) and prostatic adenocarcinoma (ADCP). ACQUISITION OF EVIDENCE Systematic review of the evidence published until January 2011 using the following scientific terms: phytotherapy, benign prostate hyperplasia, prostatic adenocarcinoma, prostate cancer and the scientific names of compounds following the rules of the International Code of Botanical Nomenclature. The databases used were Medline and The Cochrane Library. We included articles published until January 2011 written in English and Spanish. We included studies in vitro/in vivo on animal models or human beings. Exclusion criteria were literature not in English and Spanish or articles with serious methodological flaws. SYNTHESIS OF THE EVIDENCE We included 65 articles of which 40 met the inclusion criteria. BPH: the most studied products are serenoa repens and pygeum africanum. There are many studies in favour of the use of phytotherapy but its conclusions are inconsistent due to the small number of patients, the lack of control with placebo or short follow-up. However the use of these products is common in our environment. ADCP: there is no evidence to recommend phytotherapy in the treatment of the ADCP. There are works on prevention but only at experimental level so there is no evidence for its recommendation. CONCLUSIONS The scientific evidence on the use of phytotherapy in prostatic pathology is conclusive not recommend ing the use of it for BPH or the ADCP.

Evaluation of Adult Acute Scrotum in the Emergency Room: Clinical Characteristics, Diagnosis, Management, and Costs.

OBJECTIVE To evaluate the clinic characteristics, diagnosis, management, and costs of the adult acute scrotum in the emergency room (ER). Acute scrotum is a syndrome characterized by intense, acute scrotal pain that may be accompanied by other symptoms. It is usual in children and commonly found as well in adults, with different causal pathologies between these groups. METHODS Between November 2013 and September 2014, 669 cases of adult acute scrotum who presented to our ER were prospectively analyzed. Patients under 15 years of age were excluded. Patient age, reason for consultation, investigations performed, final diagnosis, management, and costs were evaluated. For the statistical analysis, the Mann-Whitney, Kruskal-Wallis U, and chi-square tests were used. RESULTS A total of 669 cases of acute scrotum were analyzed. The mean age at presentation was 40.2 ± 17.3 years. The most presented diagnoses were orchiepididymitis (28.7%), epididymitis (28.4%), symptoms of uncertain etiology (25.1%), and orchitis (10.3%). Diagnostic tests were carried out in 57.8% of cases. Most cases were treated as outpatients (94.2%), with 5.83% admitted and 1% undergoing surgical treatment. Overall, 13.3% of patients represented to the ER. Abnormal results in blood and urine tests were more common among older patients and infectious pathologies. The average cost generated by an acute scrotum ER consult was 195.03€. CONCLUSION Infectious pathologies are the most common causes of acute scrotum at ER. Abnormal blood and urine tests are unusual and are more common in older patients and infectious pathologies.

Onco-TESE: obtención de espermatozoides tras orquiectomía radical por tumor testicular y azoospermia

OBJECTIVE There is the possibility of diagnosing azoospermia in cases of testicular tumours in patients who wish to preserve fertility. Our objective is to present a technique for obtaining spermatozoa from testicles with ex vivo tumours in order to preserve fertility in these patients. MATERIAL AND METHODS A 34-year-old patient was referred for azoospermia. The physical examination revealed a node in the lower pole of the left testicle. In the scrotal ultrasound, the testicle presented disperse microcalcifications and a 1-cm hypoechoic mass in the lower pole. The tumour markers were negative, and the CT showed no distant disease. Left radical orchiectomy was performed, along with the placement of a testis prosthesis. Bench surgery was then performed, with extraction of the seminiferous tubules in the upper pole. RESULTS Of the submitted samples, 4 progressive and 1 nonprogressive motile spermatozoa were identified per field. Two samples were cryopreserved. The pathological report indicated the presence of a seminoma measuring 1.3 × 1 cm, with free margins and with no invasion of the rete testis (stage I). An assisted reproduction technique (intracytoplasmic sperm injection) was performed on the patients partner with the frozen spermatozoa, which resulted in pregnancy and the subsequent birth of a healthy child. CONCLUSION We propose this technique as the method of choice for obtaining spermatozoa from patients who simultaneously present azoospermia and testicular tumours and who wish to preserve their fertility.

Fitoterapia en Urología. Evidencia científica actual de su aplicación en urolitiasis, dolor pélvico crónico, disfunción eréctil e infecciones urinarias

OBJECTIVE To assess the usefulness of phytotherapy in urolitiasis, urinary tract infections, erectile dysfunction (ED) and chronic prostatitis/chronic pelvic pain (CP/CPP). ACQUISITION OF THE EVIDENCE Systematic review of the evidence published until January 2011 using the following scientific terms:phytotherapy, urinary lithiasis, Chronic prostatitis, chronic pelvic pain, erectile dysfunction, urinary tract infection, cystitis and the scientific names of compounds following the rules of the International Code of Botanical Nomenclature. The databases used were Medline and The Cochrane Library.We included articles published until January 2011 written in English and Spanish. We included studies in Vitro/in vivo on animal models or human beings. Exclusion criteria were literature not in English and Spanish or articles with serious methodological flaws. SYNTHESIS OF THE EVIDENCE We included 86 articles selecting 40 that met the inclusion criteria. In Urolitiasis there are few works in humans. The phytate has its main use as prevention and in reducing the growth of residual fragments after extracorporeal shock wave lithotripsy (ESWL). In CP/CPP the only compound that has shown effectiveness was the extract of pollen in a field of multimodal treatment. In DE ther is no evidence for the use of herbal medicine.Most of the works have limitations in the design or low sample size. In urinary tract infections most of the products are diuretics .There is only evidence for the cranberry as prevention in young or pregnant women. It must not be used as a treatment for urinary tract infections. CONCLUSIONS Phytotherapy is usefull in repeat urinary tract infections and the CP/CPP. It has some role in the urolitiasis and lacks useful in the DE.

Polyorchidism: the case in a young male and review of the literature

5 created a four-group anatomical classification of polyorchidism based on testis embryology. Group one consists of polyorchidism with no vas deferens or epididymis in the supernumerary testis. Group two includes the testes that share these two mentioned structures with the ipsilateral testicle. The third is formed by testes with their own epididymis and sharing the vas deferens. Finally, group four corresponds to supernumerary testes with their own annexes. 5 We report a 14-year-old male patient, with unremarkable medical or surgical history, who arrived to the emergency room with right testicular pain. The patient reported an acute testicular pain that awaked him at night and disappeared spontaneously. He did not report the presence of lower urinary tract symptoms or scrotal trauma. Physical examination revealed left and right testicles normal in size, position and firm in consistency. No varicocele was palpable on either side. Vasa, epididymis, and penis were unremarkable. In the right scrotum a 1 cm painless mass was palpable. A scrotal ultrasound revealed a rounded structure of 1 cm of diameter with clear limits, located in the right hemiscrotum adjacent to the lower pole of the right testis and presenting the same echogenicity and Doppler intensity as the testis. Scattered micro-calcifications were seen in both testicles. Testicular tumor markers profile showed lactate dehydrogenase (LDH), alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (β-hCG) in normal levels. Magnetic resonance imaging (MRI) confirmed the diagnosis with a left normal testicle with maximum diameters being approximately 3.5 cm and normal epididymis. Two testicles were identified on the right side; the larger one was approximately 3.2 cm, and a second one, completely independent testicle, measuring 1.35 cm long, was found adjacent to the larger one. Each testicle seemed to show its own epididymis. The presence of a 6 mm cyst on the head of the epididymis of the larger right testicle was also reported. In conclusion, diagnosis was polyorchidism with

Aplicación de la metodología Lean healthcare en un servicio de urología de un hospital terciario como herramienta de mejora de la eficiencia

OBJECTIVE To describe the application of the Lean methodology as a method for continuously improving the efficiency of a urology department in a tertiary hospital. MATERIAL AND METHODS The implementation of the Lean Healthcare methodology in a urology department was conducted in 3 phases: 1) team training and improvement of feedback among the practitioners, 2) management by process and superspecialisation and 3) improvement of indicators (continuous improvement). The indicators were obtained from the Hospitals information systems. The main source of information was the Balanced Scorecard for health systems management (CUIDISS). The comparison with other autonomous and national urology departments was performed through the same platform with the help of the Hospitals records department (IASIST). A baseline was established with the indicators obtained in 2011 for the comparative analysis of the results after implementing the Lean Healthcare methodology. RESULTS The implementation of this methodology translated into high practitioner satisfaction, improved quality indicators reaching a risk-adjusted complication index (RACI) of 0.59 and a risk-adjusted mortality rate (RAMR) of 0.24 in 4 years. A value of 0.61 was reached with the efficiency indicator (risk-adjusted length of stay [RALOS] index), with a savings of 2869 stays compared with national Benchmarking (IASIST). The risk-adjusted readmissions index (RARI) was the only indicator above the standard, with a value of 1.36 but with progressive annual improvement of the same. CONCLUSIONS The Lean methodology can be effectively applied to a urology department of a tertiary hospital to improve efficiency, obtaining significant and continuous improvements in all its indicators, as well as practitioner satisfaction. Team training, management by process, continuous improvement and delegation of responsibilities has been shown to be the fundamental pillars of this methodology.

Clinical profile of motor neuron disease patients with lower urinary tract symptoms and neurogenic bladder

INTRODUCTION Lower urinary tract symptoms (LUTS) are frequent in motor neuron disease (MND) patients, but clinical factors related to them are unknown. We describe differences in LUTS among MND phenotypes and their relationship with other clinical characteristics, including prognosis. METHODS For this study, we collected clinical data of a previously published cohort of patients diagnosed with classical amyotrophic lateral sclerosis (cALS), progressive muscular atrophy (PMA) or primary lateral sclerosis (PLS) with and without LUTS. Familial history was recorded and the C9ORF72 expansion was analysed in the entire cohort. Patients were followed-up for survival until August 2016. RESULTS Fifty-five ALS patients (37 cALS, 10 PMA and 8 PLS) were recruited. Twenty-four reported LUTS and neurogenic bladder (NB) could be demonstrated in nine of them. LUTS were not influenced by age, phenotype, disability, cognitive or behavioural impairment, or disease progression, but female sex appeared to be a protective factor (OR=0.39, p=0.06). Neither family history nor the C9ORF72 expansion was linked to LUTS or NB. In the multivariate analysis, patients reporting LUTS early in the disease course tended to show poorer survival. CONCLUSIONS In this study, LUTS appear to be more frequent in male MND patients, but are not related to age, clinical or genetic characteristics. When reported early, LUTS could be a sign of rapid disease spread and poor prognosis. Further prospective longitudinal and neuroimaging studies are warranted to confirm this hypothesis.