J. Palou Redorta

The Role of Antibiotics in the Treatment of Chronic Prostatitis: A Consensus Statement

Practical guidelines for the diagnosis and treatment of chronic prostatitis are presented. Chronic prostatitis is classified as chronic bacterial prostatitis (culture-positive) and chronic inflammatory prostatitis (culture-negative). If chronic bacterial prostatitis is suspected, based on relevant symptoms or recurrent UTIs, underlying urological conditions should be excluded by the following tests: rectal examination, midstream urine culture and residual urine. The diagnosis should be confirmed by the Meares and Stamey technique. Antibiotic therapy is recommended for acute exacerbations of chronic prostatitis, chronic bacterial prostatitis and chronic inflammatory prostatitis, if there is clinical, bacteriological or supporting immunological evidence of prostate infection. Unless a patient presents with fever, antibiotic treatment should not be initiated immediately except in cases of acute prostatitis or acute episodes in a patient with chronic bacterial prostatitis. The work-up, with the appropriate investigations should be done first, within a reasonable time period which, preferably, should not be longer than 1 week. During this period, nonspecific treatment, such as appropriate analgesia to relieve symptoms, should be given. The minimum duration of antibiotic treatment should be 2–4 weeks. If there is no improvement in symptoms, treatment should be stopped and reconsidered. However, if there is improvement, it should be continued for at least a further 2–4 weeks to achieve clinical cure and, hopefully, eradication of the causative pathogen. Antibiotic treatment should not be given for 6–8 weeks without an appraisal of its effectiveness. Currently used antibiotics are reviewed. Of these, the fluoroquinolones ofloxacin and ciprofloxacin are recommended because of their favourable antibacterial spectrum and pharmacokinetic profile. A number of clinical trials are recommended and a standard study design is proposed to help resolve some outstanding issues.

Vesicorenal Reflux and Upper Urinary Tract Transitional Cell Carcinoma after Transurethral Resection of Recurrent Superficial Bladder Carcinoma

AbstractOf 288 patients with superficial transitional cell carcinoma of the bladder vesicorenal reflux developed after transurethral resection in 26 per cent. This proportion was higher (77 per cent) when we considered only those tumors located near the ureteral orifices. There was a statistically significant relationship (p less than 0.001) between the development of upper urinary tract tumors and vesicorenal reflux (20 per cent of the patients with reflux and 0.9 per cent without reflux had a tumor), which corresponds to a 22-fold greater risk in the former group. Close followup is advised, since 1 of 5 patients with reflux after transurethral resection may have upper urinary tract transitional cell carcinoma.

Bladder Neoplasms after Nephroureterectomy: does the Surgery of the Lower Ureter, Transurethral Resection or Open Surgery, Influence the Evolution?

OBJECTIVE Nephroureterectomy is the treatment of choice for tumors of the upper urinary tract (UUTT). In 1952, a modified version of this technique was described, involving endoscopic detachment of the ureter followed by nephroureterectomy with a single lumbar incision. We reviewed a retrospective survey to assess whether UUTT patients treated with nephroureterectomy with no prior history of bladder tumor had different rates of incidence or different sites of bladder recurrence according to the specific technique employed. METHODS Patients were divided into group A, 87 patients who underwent a double incision nephroureterectomy and group B with 58 patients with prior detachment of the ureter. In both groups, incidence was calculated for two variables (bladder tumor recurrences and homolaterality of such recurrences) and chi-square tested. RESULTS Bladder tumor was diagnosed at follow-up in 39% of patients in group A and 34.5% in group B, with no statistically significant difference (N.S.). Bladder tumor recurrences were homolateral to UUTT in 50% of group A cases and 55% of group B cases (N.S.). CONCLUSIONS Although this is a retrospective survey of two asynchronous groups, given the similar nature of the UUTT cases in both groups and the fact that no statistically significant differences have been found, it is reasonable to conclude that nephroureterectomy with prior endoscopic detachment of the ureter is a safe and radical procedure.

Prostatectomía radical robótica: revisión de nuestra curva de aprendizaje

Resumen Prostatectomia radical robotica: revision de nuestra curva de aprendizaje Objetivo Presentamos los primeros casos de nuestra serie de prostatectomia radical robotica con Da Vinci (PRRdaV), que corresponden a la curva de aprendizaje (CA) del cirujano que se ha iniciado en la tecnica. Metodos Se revisan los 20 primeros pacientes sometidos a PRRdaV y realizados por un cirujano experto, sin entrenamiento laparoscopico previo, pero con amplia experiencia en prostatectomia radical retropubica y perineal (HV). Se analiza: tiempo operatorio, perdidas hematicas, tasa de conversion, complicaciones intra y postoperatorias, estancia hospitalaria y dias de sonda vesical. Tambien: las tasas y la localizacion de los margenes positivos, asi como los resultados funcionales con un seguimiento medio de 10 meses. Resultados La media de tiempo operatorio fue de 140 minutos (100-211) y la perdida hematica media de 180 mL (80- 360), no requiriendo transfusion sanguinea en ningun caso. No se presentaron complicaciones intraoperatorias, y tampoco ninguna reconversion. Como acontecimientos postoperatorios solo destaca una retencion aguda urinaria tras retirada de sonda vesical. La estancia hospitalaria media fue 3,35 dias (3-5). Se obtuvieron 6 casos con margenes quirurgicos positivos (30%). La localizacion mas frecuente fue postero-lateral. Dieciocho de los 20 pacientes (90%) son completamente continentes de forma precoz, 2 (10%) requirieron utilizar una compresa de seguridad durante los 6 primeros meses por incontinencia leve de esfuerzo que se resolvio espontaneamente. De los 20 casos, 2 de ellos (10%) presentaban disfuncion erectil preoperatoria; de los 18 restantes, 12 (66.6%) conservaban potencia en el momento de la revision y 6 (33.4%) presentaron disfuncion erectil postoperatoria. Conclusiones La prostatectomia radical mediante cirugia robotica se ha demostrado claramente ventajosa (excelente maniobrabilidad para una tecnica minimamente invasiva, postura mas comoda y anatomica, vision tridimensional y corta curva de aprendizaje). Una amplia experiencia quirurgica previa en cirugia abierta y/o laparoscopica, acortan de forma significativa esta curva de aprendizaje de la PRRdaV.

Nefrectomía parcial laparoscópica transperitoneal en el tratamiento del tumor renal

Resumen La cirugia laparoscopica constituye una tecnica quirurgica que el urologo debe incorporar a su armamentario quirurgico. Su realizacion intenta simular los pasos quirurgicos de la cirugia abierta, asi como sus indicaciones. La nefrectomia parcial laparoscopica es una tecnica compleja que implica para su desarrollo una experiencia amplia en el manejo de las tecnicas endoscopicas. Presentamos nuestra experiencia de 35 nefrectomias parciales laparoscopicas transperitoneales con una media de seguimiento de 25 meses. El tiempo medio de cirugia fue de 200 minutos, el sangrado de 190 cc, y la estancia media de cinco dias. Se han objetivado dos sangrados postoperatorios, ninguna conversion y en dos casos se informo de margenes positivos, optandose por una actitud conservadora.

Significance of Collagenase 3 (Matrix Metalloproteinase 13) in Invasive Bladder Cancer: Correlation with Pathological Parameters

Purpose: To determine if collagenase 3 expression is associated with stage progression and prognosis of bladder cancer. Patients and Methods: Immunohistochemical staining for collagenase 3 was carried out on serial sections from specimens of 42 patients (32 males and 10 females) who underwent radical cystectomy for bladder cancer (median follow-up, 67.2 ± 5.99 months). Results: Immunohistochemical expression of collagenase 3 was detected in 13 (31%) patients. Pathological stage was pT2 in 12 (28.57%) patients, pT3a in 7 (16.6%), pT3b in 21 (50%) and pT4 in 2 (4.76%). Four tumours (9.52%) were grade II and 38 (90.47%) were grade III. Stage and tumours >3 cm in size were associated with bladder cancer progression-free survival and overall survival. We did not find any statistical differences with collagenase 3 expression related with stage and size. Conclusions: Immunohistochemical expression of matrix metalloproteinase 13 in invasive bladder cancer is not useful as marker for transformation and invasion. These findings should be evaluated in large multicentre prospective trials.

Mielolipoma extraadrenal perirenal: aportación de un caso y revisión de la literatura

Resumen El mielolipoma extra-adrenal es raro, son tumores benignos compuestos de material hematopoyetico y tejido graso. Pero, estos tumores pueden presentarse con hemorragia, aunque suelen ser asintomatico. Generalmente se descubren de forma casual con el estudio de otras patologias. Presentamos el caso clinico de un paciente que a raiz de estudio de dolor lumbar se diagnostica de mielolipoma pararrenal.

Historia de la robótica: de Arquitas de Tarento al Robot da Vinci. (Parte II)

HISTORY OF ROBOTICS: FROM ARCHYTAS OF TARENTUM UNTIL DA VINCI ROBOT. (PART II) Robotic surgery is a reality. In order to to understand how new robots work is interesting to know the history of ancient (see part i) and modern robotics. The desire to design automatic machines imitating humans continued for more than 4000 years. Archytas of Tarentum (at around 400 a.C.), Heron of Alexandria, Hsieh-Fec, Al-Jazari, Bacon, Turriano, Leonardo da Vinci, Vaucanson o von Kempelen were robot inventors. At 1942 Asimov published the three robotics laws. Mechanics, electronics and informatics advances at XX th century developed robots to be able to do very complex self governing works. At 1985 the robot PUMA 560 was employed to introduce a needle inside the brain. Later on, they were designed surgical robots like World First, Robodoc, Gaspar o Acrobot, Zeus, AESOP, Probot o PAKI-RCP. At 2000 the FDA approved the da Vinci Surgical System (Intuitive Surgical Inc, Sunnyvale, CA, USA), a very sophisticated robot to assist surgeons. Currently urological procedures like prostatectomy, cystectomy and nephrectomy are performed with the da Vinci, so urology has become a very suitable speciality to robotic surgery.

Incidentally Detected Renal Angiomyolipoma with Tumour Thrombus into the Inferior Vena Cava

A right-renal angiomyolipoma with tumour thrombus into the inferior vena cava was incidentally detected. This is the ninth published case of its type and the second incidental case. Presence of a thrombus does not imply invasive disease, but the tumour then is often bigger than 6 cm and radical surgery is mandatory.

[Evolution of open versus laparoscopic/robotic surgery: 10 years of changes in urology].

Abstract Introduction Laparoscopic surgery has been increasingly used in urology in recent years. Laparoscopy has been performed at our center since 2001. Changes over time in the indication of open versus laparoscopic/robotic surgery, hospital stay, and learning curve are reviewed. Materials and methods A retrospective review of our database from 1997 to the end of 2007. A total of 3622 procedures were performed during this time (endoscopic procedures were excluded): 67,75% open, 26,17% laparoscopic, 2,29% perineal, and 3,78% robotic surgeries. Of these, 83,79% were performed in males and 16,20% in females. Mean patient age was 58,8 years. Data from the study period, including mean hospital stay and changes over time in operating time as a function of the learning curve, were analyzed and compared to data for the last 12 months of the study period. Results The percentages of all surgical procedures performed using a laparoscopic approach in the 1997–2006 versus the last 12 study months were as follows: nephrectomy, 31,8% versus 74,7%; living donor nephrectomy, 93% versus 100%; nephroureterectomy, 28,1% vs. 93,4%; partial nephrectomy, 31,3% vs 87%; and radical prostatectomy, 17,6% versus 73,5% including laparoscopic and robotic approaches. Shorter mean hospital stays and operating times were also seen. Conclusions Use of the laparoscopic approach has greatly increased in the 10-year period studied. In renal surgery, few indications remain for open surgery. In prostate surgery, introduction of robotic surgery in 2005 and learning of laparoscopy by several of our urologists have dramatically changed the therapeutic approach. Gradual incorporation of laparoscopic surgery has led to a decreased hospital stay and to a shortening of the learning curve.