H. Villavicencio

Fournier’s Gangrene: A Monographic Urology Center Experience with Twenty Patients

Background: Fournier’s gangrene (FG) is a fatal synergistic infectious disease with necrotizing fasciitis of the perineum and abdominal wall along with the scrotum and penis in males and the vulva in females. The aim of this study was to share our experience in the management of this infectious disease. Methods: A retrospective chart review was performed in 20 patients with a diagnosis of FG between January 1991 and December 2007. Patient’s age, source and predisposing factors, microbiological findings, duration of hospital stay, treatment modalities, and outcome were analyzed. Results: The mean age of the patients was 53.9 ± 9.56 (range 23–71) years. The source of gangrene was urinary in 5 patients, perirectal in 5, cutaneous in 1, and unknown in 9 patients. The main predisposing factors included diabetes mellitus in 9 patients (45%) and immunosuppression in 5 patients (25%). The mean duration of hospital stay was 39 ± 10 (range 6–62) days. Although early intervention and intensive treatment were carried out, 4 patients died with an overall mortality of 20% as a result of septicemia complications. The mortality rate was higher in elderly patients and those with diabetes mellitus, but it was not statistically significant. Regarding the mortality rate, duration of symptoms, number of debridements, culture results and source of infection were not found to be significant factors. Conclusions: FG is still a severe disease. Management of this infectious entity must be aggressive. Despite the use of contemporary effective antibiotic treatment, aggressive debridements, and state-of-the-art intensive-care conditions, FG still has high mortality and morbidity rates.

Robotic-assisted kidney transplantation: our first case.

AbstractPurposeKidney transplantation is the preferred treatment for patients with end-stage renal disease. In order to reduce the morbidity of the open surgery, a robotic-assisted approach has been recently introduced. According to the published literature, the robotic surgery allows the performance of kidney transplantation under optimal operative conditions while maintaining the safety and the functional results of the open approach.nMethodsWe present the case of a mother donating to her daughter affected by end-stage renal disease (ESRD) due to Alport disease (creatinine: 353xa0umol/l; GFR: 13xa0ml/min per 1.73xa0m2).nResultsA robotic-assisted kidney transplant (RAKT) was successfully performed. Surgical time was 120xa0min with 53xa0min for vascular suture. The estimated blood loss was <50xa0cc. The kidney started to produce urine intra-operatively with a rate of 250xa0cc/h, which remained constant over the next hours. During the first postoperative day, the patient was ambulating and started oral intake. Pain was minimal, and no analgesia was required after 48xa0h. Serum creatinine improved progressively to 89xa0umol/l on postoperative day 3. No surgical complications were recorded, and the patient was sent home on postoperative day 5.ConclusionWe present the first Spanish transperitoneal pure RAKT from a living-related donor. We believe this is the second pure robotic-assisted kidney transplantation case performed in Europe. We believe that the potential advantages of RAKT are related to the quality of the vascular anastomosis, the possible lower complication rate and the shorter recovery of the recipients.

Hemangioma of the Prostatic Urethra: Holmium Laser Treatment

Urethral hemangiomas are benign vascular tumors that are found in perimontanal prostatic localization and less frequently in the urethra. Although different urethral procedures have been postulated for its treatment, the best results are achieved using lasers. A patient who underwent endoscopic holmium laser treatment for such hemangiomas is presented. Total disappearance of the lesions without any complications was achieved.

Robotic kidney transplantation: one year after the beginning

IntroductionKidney transplantation (KT) is the preferred treatment for patients with end-stage renal disease (ESRD). To reduce the morbidity of the open surgery, a robotic-assisted approach has been recently introduced. Our aim is to evaluate surgical and functional results on 17 cases of robotic-assisted kidney transplantation (RAKT) performed at the same institution.Materials and methodsFrom July 2015 to June 2016, we performed 17 cases of RAKT from living donors in pre-emptive patients, who underwent laparoscopic nephrectomy. A prospective pilot study was made at Fundació Puigvert (Barcelona), evaluating functional and surgical outcomes. In this series, we considered the functional results, surgical outcomes and complications rates.ResultsSeventeen patients successfully underwent RAKT, in particular surgical console time was 181xa0min (150–200) with vascular suture time 42xa0min (32–48), and estimated blood loss <70xa0ml. Overall ischemia time was 98.9xa0min (84–140). No patient was converted to open transplantation. No major surgical intra-operative complications were observed. The mean post-operative serum creatinine level 160xa0μmol/L (81–479). We reported a case of delayed graft function (DGF), one case of graft arterial thrombosis and one case of intraperitoneal hematoma. No anastomosis revision and wounds infections occurred.ConclusionRAKT with regional hypothermia appears to be a safe surgical procedure in a properly selected group of patients. The potential advantages of RAKT are related to the quality of the vascular anastomosis, the possible lower complication rate and the shorter recovery of the recipients.

Correlation Between Confocal Laser Endomicroscopy (Cellvizio®) and Histological Grading of Upper Tract Urothelial Carcinoma: A Step Forward for a Better Selection of Patients Suitable for Conservative Management

BACKGROUNDnDespite the recent growing interest in the conservative management of upper tract urothelial carcinoma (UTUC), the diagnostic process is still a challenge for the risk of tumor undergrading. Real-time confocal laser endomicroscopy (CLE) provides in vivo microscopic images of tissues using a low-energy laser light source.nnnOBJECTIVEnTo describe our initial experience with CLE for the real-time characterization of UTUC.nnnDESIGN, SETTING, AND PARTICIPANTSnFourteen flexible ureteroscopies (f-URS) were performed at our center with CLE for UTUC. Lesions were preoperatively identified at computed tomography-intravenous urography. Cellvizio system was used during f-URS to perform CLE on the targeted lesions. Biopsies were then performed.nnnINTERVENTIONnf-URS with CLE.nnnOUTCOME MEASUREMENTS AND STATISTICAL ANALYSISnSurgeons CLE readings (low-grade/high-grade/carcinoma in situ [CIS]) were documented in the operation notes. A dedicated genitourinary pathologist-blinded to the surgeon reading-examined all specimens. A third person collected prospectively the CLE readings and the histopathological reports. Cohens Kappa analysis was performed to test interobserver agreement.nnnRESULTS AND LIMITATIONSnThe mean diameter of tumors at computed tomography scan was 26mm (range, 5-50mm). In eight patients, CLE allowed to obtain images compatible with low-grade UTUC, in five patients with high-grade UTUC, and in one case with CIS. We found correspondence between the CLE images and the final histopathological results in seven out of seven cases of low-grade UTUC (100%), in five out of six cases of high-grade UTUC (83%), and in one out of one case of CIS (100%). Substantial agreement was found at interobserver agreement (k=0.64) between CLE and histological reading. No complications and/or limitations related to the use of CLE were recorded.nnnCONCLUSIONSnCLE is a promising new technology in providing a reliable real-time histological characterization of UTUC lesions. Ideal targets might be UTUC patients potentially candidates for conservative management.nnnPATIENT SUMMARYnWe believe that a conservative treatment for low-grade upper tract urothelial carcinoma is an option that must be considered. The diagnostic process is still lacking of accurate tools. In this study, we find that confocal laser endomicroscopy, using the Cellvizio system, seems to help the clinician to have a real-time histological characterization of upper tract urothelial carcinoma lesions. This could better select patients for a conservative treatment.

Treatment Strategy for Newly Diagnosed T1 High-grade Bladder Urothelial Carcinoma: New Insights and Updated Recommendations

CONTEXTnHigh-grade T1 (T1HG) bladder cancer (BCa) has a very high likelihood of disease recurrence and progression to muscle invasion. Radical cystectomy is considered the best chance at cure, albeit with a high risk of morbidity, and is overtreatment for some patients. Treatment with bacillus Calmette-Guerin (BCG) allows bladder preservation but may risk disease progression.nnnOBJECTIVEnTo systematically review the current literature on the management of T1HG BCa and provide updated treatment recommendations.nnnEVIDENCE ACQUISITIONnMedline, EMBASE, and Epub Ahead of Print databases were searched in November 2017 to identify observational cohort studies and controlled trials, between 1946 and 2017, associated with diagnosis, treatment, and prognosis of T1HG BCa.nnnEVIDENCE SYNTHESISnClinical understaging and/or persistence of disease is not uncommon at initial transurethral resection (TUR); thus, a second re-TUR is recommended for cases with T1HG BCa. Patients electing a bladder preservation approach should undergo induction BCG therapy followed by a maintenance schedule, while patients with several high-risk features should consider immediate cystectomy and those with BCG-refractory or BCG-unresponsive disease should be considered for early cystectomy. Current phase I/II clinical trials for T1HG patients may offer future bladder preservation therapy approaches.nnnCONCLUSIONSnT1HG tumours are heterogeneous in nature and challenging to treat. Bladder preservation with BCG induction and maintenance, or radical cystectomy is the current standard treatment modality of choice for these tumours. Promising therapies for BCG-unresponsive disease are currently under investigation.nnnPATIENT SUMMARYnPatients with high-grade T1 bladder cancer are at a high risk of tumour recurrence and progression, requiring more aggressive treatment such as bladder removal. Bladder preservation therapies are available (and new therapies are being tested in clinical trials); however, patients should be aware that currently bladder removal is considered the best opportunity for cancer cure.

Endoscopic approach of the overinfected urachal cyst

The overinfected urachus cyst presents itself in quite different forms. In spite of the accuracy of ultrasound and abdominal CT scan, sometimes the diagnosis of this urachal abnormality is imprecise and even misleading. This article describes the transvesical endoscopic drainage of an infected urachal cyst with optimum result upon the treatment of this condition.

Diagnóstico de las fistulas urinarias.

El diagnostico de las fistulas urinarias viene orientado inicialmente por el cuadro clinico, debiendo tener en cuenta los factores etiologicos que puedan estar relacionados (cirugia, manipulacion via urinaria, radioterapia, cuerpo extrano, neoplasia, etc.), prosiguiendo con la realizacion de las exploraciones complementarias necesarias, para intentar llegar al diagnostico definitivo de la localizacion del trayecto fistuloso. Dado que tanto desde el punto de vistaclinico, como desde el punto de vista de exploraciones complementarias, el diagnostico sera muy distinto dependiendo de los organos que se hallen comunicados, creemos que la distribucion mas logica para clasificar este tema es segun afectacion de organo urinario en primer termino y el organo extraurinario en segundo termino.