María Fernanda Lorenzo-Gómez

Factores de riesgo de fracaso de la corrección quirúrgica de la incontinencia urinaria de esfuerzo mediante cinta suburetral transobturatriz

OBJECTIVE To identify risk factors leading to treatment failure in a sample of 302 women with stress urinary incontinence (SUI) treated by transobturator vaginal tape (TOT) with a medium follow-up of 4 years (range 1-6). MATERIAL AND METHODS A population based cohort study with prospectively data from 302 women, aged 41-81 years underwent TOT between April 2003-November 2010. Data were collected by validated questionnaire on urinary incontinence, the International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF), and clinical data-records. Continence was achieved in 262 (Group A) and 40 continued with incontinence (Group B). We investigated the relationship between age, SUI evolution time, type and number of childbirths (eutocic, dystocic, nulliparous, multiparous status) and medical and/or surgical backgrounds. The ICIQ-SF questionnaire was used to describe whether the surgery outcomes were successful or not. RESULTS Group A were younger (p=0.0001), had less SUI evolution time (p=0.017); more eutocic childbirths (p=0.000018). Group B had more dystocic childbirth (p=0.022), previous tension free vaginal tape (TVT) or TOT (p=0.03.), antidepressant-anxiolytic drugs (p=0.003), antihypertensive drugs (p=0.0005), type 1 diabetes (p=0.02), arterial hypertension (p=0.0007), respiratory diseases (p=0.025). Differences were not found with regard to nulliparous (p=0.701), multiparous status (p=0.42), obesity (p=0.18), intestinal disorders (p=0.59), oophorectomy (p=0.19), caesarean (p=0.17), prolapse surgery (p=0.29), hysterectomy (p=0.57), allergies (p=0.48), arthritis (p=0.22), arthrosis (p=0.44), depression (p=0.74), type 2 diabetes (p=0.44), smoking patterns (p=0.28), fibromyalgia (p=0.47). CONCLUSIONS Elderly women, with long evolution SUI, dystocic delivery, previous TVT or TOT appear as independent risk factors associated to TOT failure. These factors may make the indication of another surgical approach recommendable.

Comparison of sublingual therapeutic vaccine with antibiotics for the prophylaxis of recurrent urinary tract infections.

Objective: To compare the clinical impact of a prophylactic treatment with sublingual immunostimulation in the prevention of recurrent urinary tract infections (rUTIs) with the use of antibiotics. Material and Methods: Retrospective cohort study evaluating the medical records of 669 women with rUTIs; 339 had a 6-month prophylaxis with antibiotics and 360 a 3-month prophylaxis with a sublingual bacterial preparation (MV 140-Uromune®). The time frame after the prophylaxis-period until the appearance of a new infection (assessed by uroculture) was scored and followed during 1 year. The absolute risk reduction (ARR) and number needed to treat (NNT) were also calculated. Results: All patients treated with antibiotics experienced a new UTI during the scoring period of 12 months, being 19 days the median number of days free of UTIs (range 5–300). In the group treated with the bacterial preparation, 35 (9.7%) patients experienced an UTI in the same period. Kaplan-Meier curves comparing the accumulated survival (disease-free time) between both groups were significant different (P < 0.0001). The absolute risk reduction (ARR) was 90.28% (87.18–93.38) and the number needed to treat (NNT) 1.1 (1.1–1.1). Conclusions: These results suggest that the treatment with this bacterial preparation significantly reduces the incidence of rUTIs, arising as an effective strategy to reduce the frequency of rUTIs. It reduces antibiotic consumption, matching the current recommendations due to the raise of antimicrobial resistance. Randomized, double-blind and placebo-controlled, clinical trials are needed to establish, more accurately, the clinical impact of this bacterial preparation in patients with rUTIs.

PDE-5 inhibitors in monotherapy versus combination therapy in a sample of 1200 patients with erectile dysfunction

OBJECTIVES To compare the effectiveness in the treatment of erectile dysfunction when using PDE-5 inhibitors (PDE5i), alprostadil (PG-E1) and testosterone (TES) in monotherapy or combination therapy. MATERIAL AND METHODS Observational multicentre retrospective study of men diagnosed and treated for ED between January 2008 and January 2014. Age, social and employment situation, pathological medical history, risk factors, usual treatments, IIEF-5 at the first consultation and at first and each 6 months follow-ups, physical examination, calculated total and free testosterone and received treatment were analysed. Descriptive statistics, one-way ANOVA analysis, Chi2 for qualitative data, t-test, Fishers exact test and Pearsons correlation coefficient were used; p < 0.05 is considered significant. RESULTS Average age was 58.61 years, SD5.02, average follow- up time 48.21 months, SD 6.21, range 6-174 months. Out of the patients 76.12% were married, 9.81% divorced/separated, 10.04% single, 4.03% widowed; 85.14% of the total in stable partnership but 66.16% were not accompanied by their partners. In total 844 patients received monotherapy (597 PDE5i; 62 PG-E1; 36 TES; 27 penile prosthesis; 121 psychotherapy/alternative therapies) and 357 combination therapy (167 PDE5i+TES; 124 PDE5i+PGE1; 66 PG-E1+TES). There was a homogeneous distribution between risk factors and medical history groups. Satisfactory response according to IIEF-5 was achieved for 72.33% of patients on PDE5i monotherapy, 46.65% of patients on PDE5i+PG-E1 combination therapy and 83.41% of patients on PDE5i+TES. CONCLUSIONS The best therapeutic success for ED in this series was achieved through a combination of testosterone+PDE-5 inhibitors without increasing morbidity and maintaining the response over time. Larger studies with longer follow-up will corroborate these findings.

Bilateral Renal Infarction in a Lupus Patient: An Unusual Pathology

Acute renal infarction is still an underdiagnosed pathology. Most cases are secondary to arterial embolism in patients with atrial fibrillation or other cardiac illnesses; however, a less known etiology is the vascular affection of systemic lupus erythematosus (SLE). Renal infarction in lupus patients normally appears with positive antiphospholipid antibodies or lupus anticoagulant in the context of an antiphospholipid syndrome (APS). This is characterized by a state of hypercoagulability potentially affecting all segments of the vascular bed with thrombosis. A differential diagnosis with lupus nephritis, a very common pathology in SLE patients, must be carried out. We have to suspect this pathology in patients with SLE and APS who come to the emergency department complaining of abdominal pains or a renal colic. We present the case of a 69-year-old woman who was diagnosed of bilateral segmental renal infarction in the context of recently diagnosed SLE with no other vascular manifestations.

Results of the surgical correction of urinary stress incontinence according to the type of transobturator tape utilized

OBJECTIVES To analyze the short and long term results of tapes of different materials used to treat stress urinary incontinence (SUI). A secondary objective was to evaluate the ability to adjust the tape after implantation. MATERIALS AND METHODS Retrospective chart review of 355 patients with SUI operated between March 2003 and October 2011. Eight different types of transobturator tapes were used: Gynecare TVT-O®, Monarc®, SAFYRE®, Contasure KIM®, I-Stop®, DynaMesh®, Aris® Bandellete and Swing-band®. Results and complications were recorded. RESULTS The mean age at operation was 61 years. Correction of SUI was achieved in 87.88% of cases. The best results were obtained with Contasure KIM® (98.26 % continence). The tape was well tolerated and was elastic enough to be able to be adjusted 48-72 hours after implantation without deformation. Slings with macropores and over lock stitches on the superior and inferior borders presented the lower rates of postoperative urinary retention, pain, perior postoperative bleeding and urinary tract infections. CONCLUSIONS Transobturator tension free tapes require a short operation time and have a low complication rate. The possibility of adjustment in the early postoperative period increases the success rate and reduces complications. Knotless meshes with macropores and over lock stitches appear to be better balanced, are quite resistant to stretching and deformation when readjusted after implantation and present a low infection rate.

Bladder Neck Rupture Following Perineal Bull Horn Injury: A Surgical Challenge

Pelvic-abdominal injuries caused by goring are serious lesions which require rapid diagnosis and urgent treatment in the context of a polytraumatized patient. The simultaneous rupture of both the bladder and the prostatic-membranous urethra occurs in 10%–29% of males with pelvic fractures but bladder neck injuries in adults are rarer. Unstable pelvic fractures, bilateral fractures of the ischiopubic branches (also referred to as fractures from falling astride) and the diastasis of the pubic symphysis are those that have the greatest likelihood of injuring both the posterior urethra and the bladder. We present a case of perineal bull horn injury with muscle laceration, bone fractures, scrotal avulsion and rupture of the bladder neck involving the right ureter which required two operations to be repaired.

Paraganglioma of Prostatic Origin

Introduction Paragangliomas are usually benign tumors arising from chromaffin cells located outside the adrenal gland. Prostatic paraganglioma is an unusual entity in adult patients, with only 10 cases reported in the medical literature. Case Report A 34-year-old male with a history of chronic prostatitis consulted for perineal pain. On digital rectal examination the prostate was enlarged and firm, without nodules. The PSA level was 0.8 ng/mL and the catecholamines in the urine were elevated. On ultrasound a retrovesical 9 cm mass of undetermined origin measuring was present. A PET-CT scan showed a pelvic lesion measuring 9 cm with moderate increase in glucidic metabolism localized in the area of the prostate. A biopsy of the prostate revealed a neuroendocrine tumor, possibly a prostatic paraganglioma. A body scintigraphy with MIBG I-123 ruled out the presence of metastases or multifocal tumor. A radical prostatectomy with excision of the pelvic mass was performed under adrenergic blockade. One year after surgery the patient is asymptomatic and disease free. Discussion/Conclusions Prostatic paraganglioma is a rare, usually benign tumor, which should be considered in the differential diagnosis of prostate tumors in young males. Its diagnosis is based on the determination of catecholamine in blood and 24-hour urine and in imaging studies principally scintigraphy with MIBG I-123. Diagnostic confirmation is by histopathological study. The treatment consists of radical resection under adrenergic blockade and volume expansion. Given the limited number of cases reported, it is difficult to establish prognostic factors. Malignancy is defined by clinical criteria, and requires life long follow-up.

Influence of secondary diagnoses in the development of urinary incontinence after radical prostatectomy

OBJECTIVE To study whether there are factors related to secondary diagnoses (SDg) present in patients with prostate cancer that influence the development of urinary incontinence after radical prostatectomy (RP). MATERIALS AND METHODS A retrospective multicenter observational study was performed reviewing the medical records of 430 men who underwent RP due to organ-confined prostate cancer in 9 different hospitals. Two study groups were distinguished: Group A (GA): Patients without urinary incontinence after RP; Group B (GB): patients with any degree of post-surgical urinary incontinence. RESULTS Average age at surgery was 63.42 years (range 45-73). 258 patients were continent after surgery and 172 patients complaint of any degree of incontinence after RP. A higher percentage of healthy patients was found in group A (continent after surgery) than in group B (p = 0.001). The most common SDg prior to surgery were hypertension, lower urinary tract symptoms, dyslipidemia, diabetes mellitus and erectile dysfunction, but none did show a greater trend towards post-surgical incontinence. CONCLUSIONS A better health status prior to surgery is associated to a lower incidence of new-onset urinary incontinence after radical prostatectomy. However, no correlation was found between the most common medical disorders and the development of post-surgical urinary incontinence.

Comparative study of bacterial translocation control with nitric oxide donors and COX2 inhibitor

OBJECTIVE AND DESIGN To evaluate the beneficial effects of exogenous NO and an inhibitor of the COX2, and their action levels in a model of SIRS/bacterial translocation (BT) induced by Zymosan A(®). MATERIAL AND METHODS Ninety Wistar rats were submitted to different treatments, and after 12h and 24h they were anaesthetized in order to collect blood, mesenteric lymph nodes, and kidney for subsequent biochemical analyses and microbiological examinations. TREATMENTS A nitric oxide donor, Molsidomine(®), was compared with a COX2 inhibitor, Celecoxib(®). METHODS Zymosan A(®) was administered to Wistar rats. The animals were divided into 6 groups: one group for survival study, Group (1) No manipulation (BASAL); Group (2) vehicle of Zymosan A(®) given intraperitoneally (SHAM); Group I (control), with Zymosan A(®) (0.6g/kg) intraperitoneally; Group II (Molsidomine), with Molsidomine(®) (4mg/kg) through the penis dorsal vein, 30min prior to administration of the Zy(®) (0.6g/kg); Group III (Celecoxib), with Celecoxib(®) (400mg/kg) orally through a stomach tube, 6h prior to administration of the Zy (0.6g/kg). DETERMINATIONS The parameters survival, bacterial translocation, renal function, neutrophil accumulation, oxygen free radicals (OFR), detoxifying enzymes, and cytokines were measured at different times after Zymosan administration. RESULTS The model established induced a mortality rate of 100% and generated BT and systemic inflammatory response syndrome (SIRS) in all samples. It also significantly increased all variables, with p<.001 for MPO and all pro-inflammatory cytokines, and p<.01 for all OFR. Treatment with Molsidomine reduced mortality to 0%, decreased BT, MPO, pro-inflammatory cytokines and OFR (p<.001) significantly and increased IL-10 and IL-6 production. Moreover, the Celecoxib(®) showed a lower capacity for SIRS regulation. CONCLUSIONS The exogenous administration of NO prevented BT and controlled SIRS. Therefore these results suggest that Molsidomine could be used as a therapeutic strategy to protect against BT.