[Interobserver agreement in the diagnosis of bladder outlet obstruction in women]

Background

The diagnosis of bladder outlet obstruction (BOO) in women is a challenge for functional urology. In Mexico there are few data that report the prevalence of OTSV in women, being up to 24% in a group of patients.

Objective

The aim of this study is to compare six different definitions of bladder outlet obstruction and evaluate the interobserver agreement in an educational setting.

Material and Methods

Urodynamic studies (UDS) of women with and without diagnosis of BOO were retrospectively assesed. Farrar, Chassagne, Lemack, Defreitas, Blavais and Groutz, Solomon-Greenwell definitions were evaluated. All UDS were independently reviewed by 5 observers. The easiest, the hardest and the fastest were chosen. Interobserver agreement to classify the patients as obstructed was assessed by kappa reliability statistical analysis. We classified the type of mistakes the participants made; error of interpretation and miscalculation.

Results

A total of 28 urodynamic studies were reviewed. All observers had a substantial agreement (0.64-0.78) to classify BOO using all but Lemack and Solomon-Greenwell definitions. A total 120 errors from 840 responses were found; 45.8% errors of interpretation of UDS and 54.1% miscalculation of the equation. Finally, all the participants chose the Solomon-Greenwell was the most difficult definition.

Conclusion

Chassagne, Defreitas and Farrar definitions proved substantial interobserver agreement. Solomon-Greenwell and Lemack´s definitions had the highest number of pitfalls and the lowest level of agreement.

[ROC curves: general characteristics and their usefulness in clinical practice]

The use of diagnostic tests to determine the presence or absence of a disease is essential in clinical practice. The results of a diagnostic test may correspond to numerical estimates that require quantitative reference parameters to be transferred to a dichotomous interpretation as normal or abnormal and thus implement actions for the care of a condition or disease. For example, in the diagnosis of anemia it is necessary to define a cut-off point for the hemoglobin variable and create two categories that distinguish the presence or absence of anemia. The method used for this process is the preparation of diagnostic performance curves, better known by their acronym in English as ROC (Receiver Operating Characteristic). The ROC curve is also useful as a prognostic marker, since it allows defining the cut-off point of a quantitative variable that is associated with greater mortality or risk of complications. They have been used in different prognostic markers in COVID-19, such as the neutrophil/lymphocyte ratio and D-dimer, in which cut-off points associated with mortality and/or risk of mechanical ventilation were identified. The ROC curve is used to evaluate the diagnostic performance of a test in isolation, but it can also be used to compare the performance of two or more diagnostic tests and define which one is more accurate. This article describes the basic concepts for the use and interpretation of the ROC curve, the interpretation of an area under the curve (AUC) and the comparison of two or more diagnostic tests.

[Clinician and researcher at the time. Is it possible?]

Research in clinical practice arises as a constant need for improvement to provide better care to patients, train better human resources and make a daily reflection on the amount of scientific information we receive every day. We want to reflect on how the Centro de Adiestramiento en Investigación Clínica (CAIC) from our healthcare activity changed our practice.

Diagnosis and treatment of urethral stricture in men with neurogenic lower urinary tract dysfunction: A systematic review

AIM

To summarize available data focused on diagnosis and management of urethral stricture in men with neurogenic lower urinary tract dysfunction by a systematic review of the literature.

MATERIALS AND METHODS

A systematic review of the literature was carried out through an extensive electronic database search performed in PubMed/MEDLINE and Scopus databases for full texts, and International Continence Society, American Urology Association, and European Association of Urology abstracts for citations related to urethral structure. This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis.

RESULTS

A total of 316 articles were identified, 48 of which were selected for this review. Different strategies are currently being used for the management of urethral strictures, such as clean intermittent catheterization (CIC) which reduces stricture by up to 68%; direct vision internal urethrotomy which shows lower rates of renarrowing; urethroplasty which shows a success rate up to 70%; urinary diversion is the treatment of choice when reconstruction is not possible.

CONCLUSIONS

Further studies are needed in this population because of the heterogeneity of the outcomes and the lack of a standardized definition and classification of this population.

Cross-cultural adaptation and validation of the neurogenic bladder symptom score for Spanish speakers

AIM

To perform a cross-cultural adaptation and validation of the Neurogenic Bladder Symptom Score (NBSS) to Spanish in patients with neurogenic lower urinary tract dysfunction.

MATERIALS AND METHODS

The questionnaire was culturally adapted according to international guidelines. It was applied, twice in a range of 14-28 days. Psychometric properties were tested such as content validity, construct validity, internal consistency, and test-retest reliability.

RESULTS

A total of 82 patients between 18 and 78 years old (mean age of 43.9) participated in the study, and completed the first NBSS assessment; only 39 (32.19%) performed the test-retest study. The internal consistency was tested by Cronbach α with a result of 0.86 (95% CI, 0.81-0.90). The reliability was tested by interclass correlation coefficient with a result of 0.91 [0.87-0.95] (p < 0.0001). The construct validity was tested by Pearson correlation between NBSS and Qualiveen-SF, which showed a moderate correlation with a result of 0.57 (p < 0.0001). One-way analysis of variance with trend analysis demonstrated that patients who reported having a more severe problem with their bladder function had a higher NBSS total score (p < 0.001).

CONCLUSION

The results of this study demonstrated that the Spanish version of the NBSS has a good internal consistency and reliability, proving its applicability.

Factores de riesgo preoperatorios en pacientes con pielonefritis xantogranulomatosa sometidos a nefrectomía

OBJETIVO

Identificar factores de riesgo asociados a complicaciones mayores en pacientes con pielonefritis xantogranulomatosa sometidos a nefrectomía.

MÉTODO

Análisis retrospectivo de expedientes clínicos de pacientes con pielonefritis xantogranulomatosa sometidos a nefrectomía. Se analizaron el sexo, el índice de masa corporal, el índice de comorbilidad de Charlson, la clasificación del estado físico de la American Society of Anesthesiologists, la etapa de Malek, el conteo leucocitario y los valores de creatinina. Las complicaciones se estratificaron en menores y mayores según la clasificación de Clavien-Dindo. Se realizó análisis univariado y bivariado usando las pruebas exacta de Fisher y ji al cuadrado de Pearson, y se establecieron medidas de riesgo utilizando la odds ratio (OR).

RESULTADOS

Se analizaron 72 pacientes con una edad media de 50 años, el 83% mujeres, el 58.3% con urocultivo positivo y el 66% con litiasis renal. El 32% tuvieron alguna complicación mayor y el 15% requirieron admisión a la unidad de cuidados intensivos. Los valores elevados de creatinina (OR: 3.8; intervalo de confianza del 95% [IC95%]: 1.1-13; p = 0.02) y la etapa Malek II-III (OR: 4.5; IC95%: 1.2-17.5; p = 0.02) se asociaron con complicaciones mayores.

CONCLUSIÓN

El estadio de Malek y los valores elevados de creatinina incrementan el riesgo de desarrollar complicaciones mayores en los pacientes con pielonefritis xantogranulomatosa sometidos a nefrectomía.

OBJECTIVE

To identify preoperative risk factors associated with major complications in patients with xanthogranulomatous pyelonephritis undergoing total nephrectomy.

METHOD

Retrospective analysis of patient’s charts with xanthogranulomatous pyelonephritis who underwent nephrectomy. Risk factors included for analysis were gender, body mass index, Charlson comorbidity index, American Society of Anesthesiologists physical status classification, Malek’s stage, leukocyte count and creatinine levels. Postoperative complications were stratified in minor and major according to Clavien-Dindo’s classification. Univariate and bivariate analysis using Fisher’s exact test, Pearson’s chi-squared and odds ratio (OR) was performed.

RESULTS

72 patients were analyzed, 83% women, mean age of 50 years, 58.3% positive urine cultures and 66% kidney stones. Major complications were present in 32% of cases, and 15% were admitted to the intensive care unit. Elevated creatinine (OR: 3.8; 95% confidence interval [95%CI]: 1.1-13; p = 0.02) and Malek’s stage II to III (OR: 4.5; 95%CI: 1.2-17.5; p = 0.02) were associated with major complications.

CONCLUSION

The Malek Stage and elevated creatinine increases the risk of major complications in patients undergoing nephrectomy due to xanthogranulomatous pyelonephritis.

[The relevance and irrelevance of charts in clinical research]

Charts are a visual aid that is used in articles in order to highlight the results of an investigation. They allow illustrating the results with the purpose of making them clearer. Charts, just like statistical tests, are selected based on the objective of the study, the types of variable, and the statistical analyzes to be illustrated. Some of the most commonly used charts in clinical practice are frequency histograms, which illustrate qualitative variables or frequencies; also error charts, that are used for normally distributed quantitative variables; box plots or violin plots are used for distribution-free quantitative variables, and survival curves are for variables that include the person-time variable. The aforementioned charts can be used to illustrate the comparisons between maneuvers and outcome depending on the type of variable that is being analyzed. When two groups are compared and the dependent variable is dichotomous, forest plots are used; for multivariate models, the chart depends on the type of analysis. As for logistic regression and linear regression, tree diagrams are used; and scatter plots are used for linear regression. Survival plots are used for Cox proportional hazards. Although charts can be very useful, if they are misused, they can show differences where there are none, which leads to a misinterpretation of the studies. In this article, we will use examples to complement the topics that were previously addressed in the articles of this series.

Is there a role for sacral neuromodulation in patients with neurogenic lower urinary tract dysfunction?

PURPOSE

To review current literature regarding sacral neuromodulation (SNM) for neurogenic lower urinary tract dysfunction (NLUTD) focused on indications, barriers and latest technological developments.

MATERIAL AND METHODS

A PubMed database search was performed in April 2020, focusing on SNM and various neuro-urological conditions.

RESULTS

SNM has been increasingly indicated for lower urinary tract dysfunction (LUTD) in neuro-urological patients. Most studies are cases series with several methodological limitations and limited follow-up, lacking standardized definition for SNM clinical success. Most series focused on neurogenic overactive bladder in spinal cord injured (incomplete lesions) and multiple sclerosis patients. Barriers for applying this therapy in neurogenic LUTD were mainly related to magnetic resonance imaging incompatibility, size of the implantable pulse generator (IPG), and battery depletion. Newer technological advances have been made to address these limitations and will be widely available in the near future.

CONCLUSIONS

SNM seems a promising therapy for neurogenic LUTD in carefully selected patients with incomplete lesions. Further studies are still needed to define which subgroups of neurological patients benefit the most from this minimally invasive technique.

[Lower urinary tract symptoms in medical residents as reflection of a stressful work environment.]

OBJECTIVE

To determine if the presence of moderate to severe lower urinary tract symptoms in medical resident are associated with workplace bullying.

MATERIAL AND METHODS

Cross-sectional study conducted in medical residents. Moderate to severe lower urinary tract symptoms were defined as greater than 8 points on the International Prostate Symptom Score. Residents were classified as bullied if their total score on the Negative Acts Questoinnarie-Revised, was above 41 points. Perceived bullying was considered as present when any positive answer was documented in a specific question to measure this variable. Bivariate analysis to determine statistical differences between presence of lower urinary tract symptoms and exposure to both types of bullying was performed using χ² . The magnitude and directions of all associations were determined by calculating the Odds Ratio with 95% level of confidence.

RESULTS

209 residents were included, 63% men; 68% reported at least one lower urinary tract symptom, of which, 56% were mild, 10% moderate and 2% severe. The prevalence of bullying was 42% while perceived bullying was present in 39%. Residents with ≥8 points on the International Prostate Symptom Score had higher risk of being exposed to bullying (OR: 2.8, 95% CI: 1.1-6.7, p=0.01) and/or perceived bullying (OR: 3.1 95% CI: 1.3-7.5, p=0.00). Female gender had greater risk than man for presenting lower urinary tract symptoms at basal state (OR: 2.8, 95% CI: 1.1-6.6, p=0.01).

CONCLUSIONS

Medical residents with moderate or severe urinary tract symptoms may be related to bullying. Being a woman is associated with an increased risk of developing LUTS.

Factores predictores del estado libre de cálculos en la primera ureteroscopia flexible con litotricia láser

Introduction

Flexible ureteroscopy and laser fragmentation (FURSL) is a minimally invasive modality for surgical treatment of renal stones. Inadequate selection of patients for this treatment generates a cost-effectiveness unbalance.

Objective

To know the stone-free rate predictors in a single surgical time in patients undergoing FURSL.

Method

Retrospective cohort of patients undergoing FURSL. Global and gender-categorized univariate and multivariate (logistic regression) analyses were performed to identify stone-free predictors at first FURSL.

Results

Stone-free rate at first FURSL was 73.62%. Predictors in males were patient age and stone size, density and multiplicity; in females, body mass index and multiplicity of stones.

Conclusions

Stone-free rate predictors at first FURSL are different in males and females. Women with overweight and obesity probably have easy-to-fragment and easy-to-extract stones associated with uric acid.

[Tasa libre de litos sin complicación mayor como definición de éxito en nefrolitotomía percutánea]

Introduction

Success in percutaneous nephrolithotomy (PCNL) is defined as a stone-free status; however, major complications are highly common and have been reported as a secondary outcome.

Objective

To propose a new definition of PCNL success that comprises a stone free rate without major complications and a risk scale to predict this outcome.

Methods

Historical cohort of patients undergoing PCNL. The included variables were age, gender, urine culture, Charlson's comorbidity index (CCI) and complex stones. Success was defined as a stone free status with or without Clavien grade ≤ 2 complication; intermediate success: with stones, with or without Clavien grade ≤ 2 complication; and failure: with or without stones with Clavien grade ≤ 2 complication. Bivariate analysis was performed to identify which factors are associated with the outcome. The independent weight of each factor was calculated by multiple logistic regression analysis.

Results

568 procedures were included, 59% of which were in females. Median age was 49 years; 65%, 22% and 13% of cases were classified as success, intermediate success and failure, respectively. Female sex, positive urine culture, complex stones and severe CCI were associated with failure.

Conclusions

The likelihood of success was directly proportional to the number of risk factors.

Rearrangement of the Guy's stone score improves prediction of stone-free rate after percutaneous nephrolithotomy

Objective

We propose a modification of the original Guy's Stone Score (GSS) to hold on 20 % of prognostic discrimination among groups which makes this score a more reliable resource for risk assessment in patients undergoing percutaneous nephrolithotomy (PCNL).

Material and methods

Historical cohort of 126 patients undergoing PCNL from December 2010 to November 2014 was included in the survey. Every patient was classified according to the original GSS. For the new classification of Guy Stone Score (GSS-M) all of the subgroups included in the scale were analyzed individually and then ranked from better to worst according to the postoperative stone- free rates (SFRs). This ranking led us to reclassify all the original subgroups, clustering them in three new categories according to their SFRs as subgroups of good, intermediate and poor prognosis, trying to achieve at least 20% of prognostic discrimination among the groups.

Results

Hundred and twenty-six PCNL procedures were evaluated, but only 124 were included for statistical analysis and classified based on SFR according to the GSS as follows: 76% for grade 1, 71% for grade 2, 55% for grade 3 and 20% for grade 4. The SFRs were also assessed for the GSS-M obtaining the following predictive values as 93%, 67% and 44% for the good, intermediate and poor prognostic groups, respectively. The prognostic difference among the GSS-M groups was always >20% (p<0.05).

Conclusion

The original GSS has limitations to predict SFR because of its poor discrimination power among prognostic groups. This rearrangement improves prediction of SFR and better discriminates risk groups in PCNL.

[Tamsulosin, oxybutynin or their combination in the treatment of ureteral stent-related symptoms]

BACKGROUND

The aim of this paper is to compare the efficacy of tamsulosin, oxybutynin or their combination for the treatment of symptoms related to double J stent (DJS).

METHODS

Randomized clinical non-blinded trial with three arms (tamsulosin, oxybutynin or combination) to assess the improvement of ureteral related symptoms with DJS with the questionnaire of Ureteral Stent Symptom Questionnaire (USSQ) and the adverse effects of treatment. Evaluations were made at 7 and 21 days after the placement of DJS. The maneuvers were compared using Chi squared test, Kruskall-Wallis, ANOVA and Wilcoxon considering a statistically significant p ≤ 0.05.

RESULTS

170 patients with CJJ were evaluated. A perprotocol analysis was performed in 142 patients, 53 received tamsulosin (37.4%), 42 oxybutynin (29.6%) and 47 the combination of both (33%). At 7 and 21 days the improvement was similar in all three arms. Men with tamsulosin and women with oxybutynin had less general symptoms.

CONCLUSIONS

Tamsulosin, oxybutynin or its combination similarly improve ureteral stent related symptoms and this improvement becomes more noticeable over time. Men are less symptomatic with tamsulosin and women with oxybutynin.

[Stone free rate assesment after percutaneous nephrolithotomy using nephrolitometric nomogram]

BACKGROUND

Percutaneous nephrolithotomy remains the standard of care for kidney stones larger than 2cm. Therefore, setting a prognosis for complete stone resolution through this method is essential. The prognostic tools available have limited prediction.

OBJECTIVES

To evaluate the stone-free rate in patients undergoing percutaneous nephrolithotomy with the Clinical Research Office of the Endourological Society nomogram and suggest modifications to improve the classification.

MATERIAL AND METHODS

We analyzed a retrospective cohort of patients undergoing percutaneous nephrolithotomy applying the nephrolithometric nomogram specified. We modified the scale dividing the patients into 3groups: i from 80 to 110 points, II from 111 to 170 points, and III more than 170 points, respectively assessing the stone-free rate (Kruskall-Wallis test was performed, p<0.05).

RESULTS

A total of 126 patients were included. According to the nehrolithometric nomogram the stone-free rate was 12.5% for patients with fewer than 111 points and 70.9% for those with 111 points or more. In the modification proposed for groups I, IIand III the stone-free rate was 12.5%, 50% and 80% respectively (p=0.000).

CONCLUSIONS

Evaluation using the nephrolithometric nomogram demonstrated accurate stone-free rate prediction for complex and simple stones, with a lack of discrimination for patients with intermediate scores. Our modification enabled better differentiation of the intermediate groups from the high and low stone-free rate groups.

[Prevalence of urinary tract symptoms in women with diabetes mellitus]

BACKGROUND

The objective was to evaluate the prevalence of urinary tract symptoms and the impact in the quality of life in women with diabetes, the association with DM and neuropathy evolution time and glycemic control.

METHODS

A cohort of women from the DiabetIMSS program was evaluated from January 2011 to 2013. The personal history, time of DM diagnosis, neuropathy, urinary symptoms, glycemic control and quality of life impact were noted.

RESULTS

A total of 169 women were evaluated. The median age was 58 years (29-85) and DM main evolution time was 9 years (0.5-31). Urinary tract symptoms were present in 128 (75.7 %) patients. Stress and urge incontinence were predominantly present (45.3 and 40.6 % respectively), followed by obstructive and irritative symptoms (25 and 10.1 % respectively). The impact in the quality of life was mild-moderate in 91.1 % of the patients. At least one criteria for neuropathy was noted in 154 (91.1 %) patients. Neuropathy evolution time was longer in the symptomatic group (12 vs 4.8 months). Symptoms were mainly present in patients with more than one year of neuropathy; p < 0.05.

CONCLUSION

There is a high prevalence of urinary tract symptoms in diabetic women. The only associated risk factor was neuropathy. No significative association was found between the rest of the factors.

[Prognostic factors of morbimortality in patients with emphysematous pyelonephritis]

BACKGROUND

Emphysematous pyelonephritis (EPN) is a severe infection of the urinary tract, caused by gas accumulation within the collecting system, the renal parenchyma, and/or the perirenal tissue. The cause of this infection is not known at all; however, it has been suggested that it is produced by the glucose fermentation provoked by enterobacteriaceae or anaerobic organisms. Our objective was to evaluate the predictors of morbidity and mortality in patients diagnosed with EPN.

METHODS

It was carried out a historical cohort study of patients diagnosed with EPN in our hospital from March 2005 to December 2014. Patients with adverse outcome were identified. We defined adverse outcome as patients requiring stay in intensive care unit, who presented nephrectomy and/or who died. A multiple regression analysis was conducted to establish the relation of each clinical factor with the adverse outcome.

RESULTS

73 records were included for analysis, 48 were women (65.8 %) and 25 men. Diabetes, urolithiasis, E. coli infection and septic shock occurred in 68.5, 68.5, 63, and 15.1 %, respectively. We found that leukocytosis ≥12 000 µl (OR 43.65, 95 % CI 2.36-805, p <0.001), thrombocytopenia ≤120 000 µl (OR 363, 95 % 9.2-14208, p <0.0001), and Huang's radiological class 3 (OR 62, 95 % CI 4-964, p < 0.001) were factors significantly associated with adverse outcome.

CONCLUSION

Thrombocytopenia, leukocytosis and Huang's radiological class 3 are associated with adverse outcome in patients with EPN.

[Intrarectal povidone-iodine to reduce the risk of genitourinary infections after transrectal prostate biopsy]

BACKGROUND

The aim of this study is to compare two different preparations in patients undergoing transrectal prostate biopsies samples (TPBS) and assess the prevalence of genitourinary infections (GUI).

METHODS

A historical cohort of patients undergoing TBPS for suspected prostate cancer. Two groups were compared: one with endorectal lubricant jelly and another with the addition of a povidone-iodine lubricating jelly. Complications were evaluated at three weeks. A bivariate analysis was performed by calculating the OR (95 % CI) to determine if the additional endorectal povidone-iodine pre-TBPS reduced GUI and other complications.

RESULTS

185 patients (Group I n = 86, Group II n = 96) were evaluated. 45 and 25 % had genitourinary tract infection (OR: 0.4, CI: 0.2-0.9, p = 0.004); fever was presented in 21 and 10 % respectively (OR: 0.42, CI: 0.1-0.9, p = 0.04).

CONCLUSIONS

A reduction was observed in the presence of genitourinary infections in patients who had intrarectal povidone-iodine preparation applied.

[The use of S.T.O.N.E. scale in patients undergoing percutaneous nephrolithotomy]

OBJECTIVES

The aim of this study was to apply the S.T.O.N.E. scale on our patients undergoing PCNL to predict stone free rate and complications using the modified Clavien scale.

METHODS

A historical cohort of patients undergoing PCNL was analyzed. All patients with computed tomography to assess stone-free rate with the S.T.O.N.E. scale and complications were evaluated by the modified Clavien scale.

RESULTS

In 102 patients 104 procedures were performed; the mean age was 48.4 years and 71% were women. The distribution of cases were classified as mild: 6.7%, moderate: 63.5% and severe: 29.8%. The stone free rate after the first procedure globally reached 58% and by grade was: mild 85.7%, moderate 71.2% and severe 25%. The RR for residual stones after the first procedure was 2.4 for moderate grade (CI 0.3 to 15, p=0.03) and 4.9 for severe grade (CI 0.7 - 30.9, p=0.08). The overall complication rate was 33%, separately Clavien 1: 14.4%, 2: 9.6%, 3a: 2.9%, 3b: 2.9% 4:1.9%, 5:1%.

CONCLUSIONS

The S.T.O.N.E. scale applied in our population can predict accurately and easily stone free rate in patients undergoing PCNL. We found no predictive association for this scale on complications.

Evaluation and comparison of urolithiasis scoring systems used in percutaneous kidney stone surgery

PURPOSE

Contemporary predictive tools for percutaneous nephrolithotomy outcomes include the Guy stone score, S.T.O.N.E. nephrolithometry and the CROES nephrolithometric nomogram. We compared each scoring system in the same cohort to determine which was most predictive of surgical outcomes.

METHODS

We retrospectively reviewed the records of patients who underwent percutaneous nephrolithotomy between 2009 and 2012 at a total of 3 academic institutions. We calculated the Guy stone score, the S.T.O.N.E. nephrolithometry score and the CROES nephrolithometric nomogram score based on preoperative computerized tomography images. A single observer at each institution reviewed all images and assigned scores. Univariate and multivariate analysis was done to determine the most predictive scoring system.

RESULTS

We enrolled 246 patients in study. In stone-free patients vs those with residual stones the mean Guy score was 2.2 vs 2.7, the mean S.T.O.N.E. score was 8.3 vs 9.5 and the mean CROES nomogram score was 222 vs 187 (each p <0.001). Logistic regression revealed that the Guy, S.T.O.N.E. nephrolithometry and CROES nomogram scores were significantly associated with stone-free status (p = 0.02, 0.004 and <0.001, respectively). The Guy and S.T.O.N.E. nephrolithometry scores were associated with estimated blood loss (p <0.0001 and 0.03) and length of stay (p = 0.03 and 0.009, respectively). The CROES nomogram did not predict estimated blood loss or length of stay.

CONCLUSIONS

All scoring systems and the stone burden equally predicted stone-free status. The Guy and S.T.O.N.E. nephrolithometry scores were associated with estimated blood loss and length of stay. A single scoring system should be adopted to unify reporting.

[VVF: laparoscopic versus open surgical abdominal]

BACKGROUND

Vesico vaginal fistula is the most common acquired fistula of the urinary tract that originates from an abnormal communication between the bladder and vagina, its main manifestation is transvaginal urine output and significantly affects the quality of life of women suffer.

OBJECTIVE

To compare the success and complications of open abdominal versus laparoscopic surgical treatment of patients with vesicovaginal fistula (VVF).

MATERIAL AND METHODS

A retrospective, observational, comparative study of patients with a diagnosis of VVF. We included patients with a diagnosis of VVF with full clinical documentation and at least one evaluation after 3 months of surgery. All patients underwent surgical closure type O'Conor and grouped into two groups: Group I: Open abdominal and group II: Laparoscopic. Age, body mass index (BMI), size, location of the fistula, surgical time, intraoperative bleeding, and length of hospital stay were compared.

RESULTS

Twenty seven patients with a diagnosis of VVF were evaluated. Eighteen patients had open abdominal surgery (group I) and 9 laparoscopic (group II). The average age was 42.8 vs 41.4 years, the average size of the VVF was 0.9 vs 1.3 cm, the success rate was 94.4 vs 77%, p> 0.05, for group I and II respectively. There were differences in favor of group II with respect to days of using transurethral catheter, days of hospitalization and postoperative bleeding, p<0.05.

CONCLUSIONS

In our experience we believe that the laparoscopic approach is an excellent alternative to traditional abdominal approach, although it requires experience in laparoscopic pelvic surgery.

[Clinical research XVI. Differences between medians with the Mann-Whitney U test]

If you want to prove that there are differences between two groups with quantitative variables with non-normal distribution, the Mann-Whitney U test is used. This test is opposite of the Student t test that uses quantitative variables with a normal distribution. If you want to compare three or more nonrelated groups, the Kruskal-Wallis test is applied. When two related samples are compared, the Wilcoxon test is the best option (a before and after maneuver comparison); when three related samples are compared, the Friedman test is used. These tests correspond to the parametric opposing paired t test and ANOVA, respectively.

[Partial laparoscopic nephrectomy: treatment for hydrocalicosis due to infundibular stenosis]

BACKGROUND

This report describes a partial nephrectomy with a minimally invasive approach, carried out laparoscopically as a treatment for a hydrocalicosis caused by a congenital infundibular stenosis.

CLINICAL CASE

The patient presented a clinical background of one year of evolution, manifested as recurrent urinary tract infections caused by urine accumulation in the adjacent collecting tubules which were compressed by the superior hydrocalicosis. This procedure was made using a transperitoneal access, making a superior pole resection of the right kidney and respecting the adrenal gland.

CONCLUSIONS

In our opinion, to widen the usage of the laparoscopic surgery in urology can benefit patients to reduce post-surgery complications and hospitalization time, with a more comfortable recovery.

Percutaneous nephrolithotomy in crossed fused renal ectopia: superior calyceal access under fluoroscopic control

OBJECTIVE

To present a case report of crossed fused renal ectopia treated with percutaneous nephrolithotomy at our hospital and to perform a literature review.

METHODS/RESULTS

We present the case of a male with renal calculi in a crossed ectopic and fused kidney, treated satisfactorily with percutaneous nephrolithotomy in a one-stage surgery through an upper pole access

CONCLUSIONS

Percutaneous nephrolithotomy is a minimally invasive procedure with good results and low morbidity in this kind of patients. It is technically demanding and requires surgeon's ability and experience.

Outcomes and complications of sphincterotomy with bladder neck incision in neurologically healthy male patients with voiding dysfunction

OBJECTIVES

To evaluate the efficacy, complications and outcomes of sphincterotomy with bladder neck incision in patients with voiding dysfunction (VD).

METHODS

We evaluated our prospectively established urologic urodynamic database and identified the records of 30 male patients with VD that underwent sphincterotomy between Octuber 1993 and December 2008. The IPSS and urodynamics were analyzed before and after surgery, we recorded the outcomes and complications. Numerical data were analyzed with Student`s t and Wilcoxon tests (p < 0.05). ANOVA was used for the follow up.

RESULTS

Thirty patients underwent sphincterotomy with a mean age of 41 years (range 18-63 years). Statistical differences (p< 0.05) were found for: maximum flow rate (17.61 ± 7.7 vs 23.5 ± 12.19 ml/s), detrusor pressure (73.53 ± 21.51 vs 47.4 ± 16.24 cmH20), maximum cystometric capacity (462.74 ± 224.2 vs 382.2 ± 167.48 ml), functional urethral length (64.3 ± 22.6 vs 42.2 ± 18.4 mm), Maximum urethral pressure (120.1 ± 46.8 vs 59.23± 22.67 cmH20), total urethral closure area (3315 ± 1269.7 vs 1189 ± 49.23 cmH20*mm) and postvoid residual volume (161.3 ± 177.9 vs 57 ± 100.8 ml). The IPSS improved and was stable at 60 months (p < 0.02). No significant association was found to develop incontinence after the procedure.

CONCLUSION

Sphincterotomy for male patients with dysfunctional voiding improves voiding dynamics with a low rate of complications and minimum risk of incontinency.

Stauffer syndrome in transitional cell carcinoma of the bladder

OBJECTIVE

To present the case of a woman with the diagnosis of transitional cell carcinoma of the bladder and Stauffer's syndrome.

METHOD

The clinical and radiological files were analyzed, and a bibliographic review was performed.

RESULTS

We present an 82 year old female with a four month history of hematuria, presenting in the emergency room where abnormal hepatic profile was documented. The diagnosis of bladder tumor was established and she underwent transurethral bladder resection. The pathological report showed transitional cell bladder cancer, with complete resection. Metastasis and infectious hepatic dysfunction were discarded. The hepatic profile became normal days later, so Stauffer's syndrome diagnosis was performed.

CONCLUSION

This is the first report to our knowledge of this paraneoplastic syndrome in transitional cell carcinoma of the bladder.

Laparoscopic management of retrocaval ureter: case report and literature review

BACKGROUND

Retrocaval ureter is a rare congenital anomaly with an incidence of approx. 1/1000 live births. Recently, the laparoscopic approach has become the gold standard for treatment, relegating open surgery as a second option.

CLINICAL CASE

We present the case of a 27-year-old male with a 2-year history of colicky pain in the right flank radiating to the ipsilateral thigh and genital region. The patient was initially treated with a right double-pigtail catheter stent due to obstructive uropathy as evidenced by ultrasound. He underwent laparoscopic ureteral anteposition with a successful outcome and has remained asymptomatic during a 12-month follow-up.

CONCLUSIONS

Retrocaval ureter is a rare entity that requires a high grade of suspicion for initial diagnosis to provide adequate and opportune treatment that will have repercussions on kidney function and quality of life for the patient. Open surgery has traditionally been the treatment of choice; however, in recent decades laparoscopic surgery has been practiced more during this era of minimally invasive therapy, without yet displacing open surgery in our country.

Management of bladder cancer with Studer orthotopic neobladder: 13-year experience

BACKGROUND

We present the results of patients submitted to a Studer type urinary orthotopic derivation after radical cystectomy.

METHODS

The files of patients with bladder cancer submitted to a radical cystectomy plus the procedure of the ileal neobladder were reviewed in our hospital from January 1992 until December 2004. Patients were divided into two groups: group A--60 years old or younger and group B-->60 years old.

RESULTS

From 306 patients submitted to radical cystectomy with urinary derivation, there were 42 patients (13.7%) included with Studer type neobladder. There were 34 (80.9 %) men and 8 (19.1%) women, with an average age of 60 years. Average surgical time was 7 h with an average blood loss of 1600 cc requiring transfer to intensive care unit (ICU) in 55% of the cases. The most frequent early complication was metabolic acidosis that was present in 28 (66%) patients. The most severe complication was ileal-ureter urinary leak, which was present in seven (16.6 %) patients. Among the most frequent late complications are the day- and night-time urinary incontinence often related to urinary infections and intestinal occlusion. Overall 5-year survival was 71%, cancer-specific mortality was 15% and surgical-related mortality was 7.3%.

CONCLUSIONS

The performance of procedures with orthotopic neobladders is actually feasible in experienced hospital centers and is a valuable alternative to urinary heterotopic derivation with ileal conduit. Postoperative patient management and regular follow-up is of major importance.

[Subtrigonal sling with abdominal fascia for treatment of complex stress urinary incontinence]

BACKGROUND

The aim of this study was to describe the technique of subtrigonal sling with abdominal fascia and demonstrate its usefulness in resolving complex stress urinary incontinence (SUI).

METHODS

We performed a cohort, longitudinal, observational study in adult females who attended the Urodynamics Department of the Hospital de Especialidades, Centro Medico Nacional Siglo XXI, Mexico City, with recurrent SUI or with risk factors for recurrence, whether or not associated with urge urinary incontinence (UUI).

RESULTS

Between 1995 and 2006, 40 patients were included. Mean follow-up was 41.95 months (9-106), and the average patient age was 55 years. In 35 patients (87.5%) SUI was resolved, in two patients (5%) it improved, and in three patients (7.5%) it persisted. Of the 40 study patients, 18 had UUI and in only 7/18 patients (39%) was it resolved postoperatively. UUI de novo was noted in 12/40 patients (30%). One patient presented crural hernia, two patients presented postincisional hernia and two patients required blood transfusion. No patient presented acute urinary retention or urinary voiding problems postoperatively.

CONCLUSIONS

Results obtained by this surgical technique are effective and long-lasting in patients with complex SUI. We did not observe bladder emptying dysfunction but there were formations of abdominal wall hernias. The minimally invasive approach consisting of the subtrigonal placement of synthetic tapes may maintain efficacy with minimal morbidity.

[Lumboscopic adrenalectomy for pheochromocytoma in a patient with multiple endocrine neoplasia type 2B]

Multiple endocrine neoplasia type 2B (MEN 2B) is an autosomal dominant syndrome characterized by medullary thyroid carcinoma, pheochromocytoma, a marfanoid habitus and mucosal ganglioneuromatosis. We present a case of a 35-year-old male with MEN 2B with right adrenal pheochromocytoma diagnosed biochemically and radiologically and treated by laparoscopic adrenalectomy. Diagnosis of pheochromocytoma includes detection of catecholamines in urine and plasma and radiological tests such as computed axial tomography, nuclear magnetic resonance imaging and metaiodobenzylguanidine scintigraphy. Laparoscopic techniques have become standard for treatment of tumors of the adrenal glands.