Miguel Maldonado-Avila

Emphysematous Pyelonephritis: Multicenter Clinical and Therapeutic Experience in Mexico

OBJECTIVE To analyze the outcomes of emphysematous pyelonephritis (EPN), the impact of different treatment modalities, and to determine risk factors associated with mortality. METHODS We retrospectively reviewed cases of EPN from 3 tertiary care institutions in Mexico. The diagnosis was confirmed with computed tomographic scan. Treatment was classified as follows: medical management (MM), minimally invasive, and surgical. Demographic, clinical, biochemical, and radiological characteristics were assessed and compared between survivors and nonsurvivors. Comparison was assessed using 1-way analysis of variance and chi-square. Univariate and multivariate logistic regression analyses were performed to determine prognostic factors. Main end point was mortality. RESULTS A total of 62 patients were included (49 women and 13 men), with a mean age of 53.9 years. The most common comorbidities were diabetes (69.3%) and hypertension (40.3%). Escherichia coli was the most common isolated microorganism (62.7%). MM was provided to 24.2%, minimally invasive treatment to 51.6%, open drainage to 19.3%, and emergency nephrectomy to 4.8%. Overall mortality was 14.5% and was similar among different treatment modalities (P=.06). Survivors were younger (P=.004), had lower creatinine (P=.002), and better estimated glomerular filtration rate (P=.007). In univariate analysis, age (P=.009), creatinine (P=.009), and need for nephrectomy (P=.03) were associated with mortality. In multivariate logistic regression analysis, creatinine (odds ratio 1.56, 95% confidence interval 1.03-2.35, P=.03) and nephrectomy (odds ratio 9.7, 95% confidence interval 1.007-93.51, P=.049) remained significant predictors of mortality. CONCLUSION EPN needs an aggressive MM and stepwise approach; nephrectomy should be the last resort of treatment. Creatinine level and need for nephrectomy are the strongest predictors of mortality according our analysis.

Efficacy of Tamsulosin, Oxybutynin, and their combination in the control of double-j stent-related lower urinary tract symptoms

ABSTRACT Introduction and objective Indwelling double J ureteral stents are used routinely in the resolution of ureteral obstruction caused by different etiologies. Evaluation of urinary symptoms related to double-J stent, indicate that these affect 73-90% of patients. We conducted a prospective, randomized study, to evaluate the efficacy of tamsulosin, oxybutinin and combination therapy in improving the urinary symptoms. Methods Patients who underwent ureteral stent placement after ureterolithotripsy (total 51), were randomized into three groups: Group I: Tamsulosin 0.4 mg. once per day(17 patients), Group II: Oxybutinin 5 mg. once per day (17 patients), Group III: Tamsulosin+ oxybutynin once per day (17 patients). All the groups received the drugs for three weeks and completed a Spanish validated Ureteral Stent Symptom Questionnaire (USSQ) at day 7 and 21. Results Repeated measures ANOVA showed mean urinary symptom index score was 22.3 vs. 15.5 in group three (p<0.001) at day 7 and 21 respectively. The mean work performance index was 6.6 vs 8.1 (p=0.049) favoring tamsulosin group, the mean sexual score was 0.5 vs 1.5 (p=0.03). Among additional problems the mean was 7.2 vs 6.2 (p=0.03). No significant difference was noted among pain and general health index. No side effects were reported. Conclusions Combination therapy with tamsulosin and oxybutynin improved irritative symptoms and work performance as well as sexual matters. Combination therapy should be considered for patients who complained of stent related symptoms.

Enucleation of schwannoma of the penis with neurovascular bundle sparing using the VTI 20 MHz Microvascular Doppler System

A 48-year-old man had an unremarkable past medical history. His current illness began 8 years prior to medical consultation with a non-painful, progressive increase in volume at the base of the penis in the dorsal region. The patient had adequate erections but was unable to perform coitus due to the presence of a mass. He complained of no other symptomatology. Physical examination revealed an uncircumcised cylindrical penis and a central meatus. A non-painful, mobile, stony hard tumor measuring approximately 6 cm × 5 cm was located at the dorsal region of the base of the penis. It was not fixed to the deep planes and there were no color changes. MRI of the penis identified a round, solid, well-circumscribed tumor with a heterogeneous content and extremely vascularized aspect. It was not dependent on the corpora cavernosa but caused compression and displacement to the left. The penile tumor was completely extirpated using the VTI 20 MHz Microvascular Doppler System, sparing the neurovascular bundles. The histopathologic report and immunohistochemistry study confirmed the diagnosis of Schwannoma of the penis. At follow-up at more than two years, the patient has no signs of tumor activity and erections are adequate.

Estudio comparativo en el manejo laparoscópico transperitoneal y lumboscópico de quistes renales

Resumen Introduccion Los quistes renales sintomaticos requieren manejo quirurgico. Objetivo Comparar los resultados en el manejo de quistes renales mediante abordaje laparoscopico transperitoneal y lumboscopico. Material y metodo Estudio prospectivo, descriptivo, longitudinal, en pacientes con diagnostico de quiste renal Bosniak I sintomatico. Se dividen en 2 grupos: grupo 1, laparoscopia transperitoneal y grupo 2, lumboscopia. Variables: sangrado transoperatorio, dias de estancia hospitalaria y edad. Resultados Veintiocho pacientes, grupo 1: 19 pacientes, y grupo 2: 9 pacientes. Grupo 1, medias: edad 52 anos, tamano del quiste 6.6 cm, dias de estancia 1.26, sangrado transoperatorio 20.5 mL. Grupo 2, medias: edad 63 anos, tamano del quiste 7.3 cm, dias de estancia 1.11, sangrado transoperatorio 20 mL. Se encontro diferencia estadisticamente significativa en la edad (p=0.01), no asi en el tamano del quiste (p=0.3), dias de estancia (p=0.3) y sangrado transoperatorio (p=0.9). No hubo complicaciones. Discusion Se han publicado buenos resultados con el manejo laparoscopico de los quistes renales, sin embargo son series pequenas y con poco seguimiento. En la literatura se reportan promedios de sangrado transoperatorio de 70-150 cc, siendo menor en nuestro estudio (20 cc); asi como promedios de 3 dias de estancia, encontrandonos por debajo (1.2 dias). Conclusion Nuestro estudio nos aclara y aporta que no existen diferencias estadisticamente significativas entre ambos abordajes; este dependera de la localizacion del quiste, asi como la preferencia y experiencia del cirujano.