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Primary vesicoureteral reflux is defined as the dysfunction of the vesicoureteral junction in the absence of any other bladder pathology. Most works in the literature focus on pediatric vesicoureteral reflux, paying little attention to reflux in adults. There is not much knowledge about the real incidence of this pathology in adults and there are few published papers about what are the situations in which we should suspect, perform a diagnostic work up and treat reflux in adult patients. It is article we perform a bibliographic review on topics as important as epidemiology, diagnosis and treatment of reflux in adults. The objective of this article is to transmit what are the clinical manifestations in front of which we should look for adult reflux and when to treat when it is diagnosed.

Objective: To present a series of 63 patients with urinary incontinence due to sphincteric incompetence who underwent the implantation of an AMS-800 artificial sphincter., Methods: From 1984 to December 2002 a total of 69 patients received this prosthesis, 63 of which were available for review. The cause of incontinence was sphincter incompetence in all cases, said secondary to prostate surgery, neurogenic bladder, post-traumatic urethral lesion, and epispadias. 52 of them were placed in the bulbar urethra, and 11 in the bladder neck. The cuff diameters varied from 4 to 10 cm and reservoir pressures from 51-60 to 71-18 H2O cm., Results: The complications that appeared, ordered by frequency, were: malfunction, infection and rejection or exteriorization, fistula, and unappropriate size. The total number of reoperations was 39 in 28 patients. Functional results were successful in 48 cases and failure in 15., Conclusions: The use of an AMS-800 prosthesis for the treatment of urinary incontinence due to sphincteric incompetence is effective but not without complications. The most frequent indication was following prostate surgery, being this group the one that obtains the best results. Patients with incontinence of neurogenic origin have the highest complication rate, and the worst results in relation to vascularization and tissue trophism abnormalities. In female patients we prefer other techniques that have similar results, are technically easier and more economic.

Objective: To present the results achieved by rigid transurethral ureteroscopy for the management of ureteral calculi over a period of 10 years., Methods: From January 1991 to November 2000, 735 rigid transurethral ureteroscopy procedures for ureteral calculi were performed in our Lithotripsy Unit. The rigid ureteroscopes utilized ranged from 9.5-11.5 F. There was a higher prevalence of male patients (63%). The mean age was 49.9 years. Calculi were more frequently localized in the pelvic ureter (74.2%). The mean maximum diameter of the calculi was 9.6 mm and caused moderate to severe uropathy in 78.6% of the cases and functional impairment in 3.7% of the cases. After performing ureteroscopy, a double-J catheter was left indwelling in 65.8% of the patients. The patients were discharged from hospital usually 12-18 h after the endoscopic procedure., Results: Of the 735 ureteroscopies performed, satisfactory results were achieved in 676 cases (92%); stone resolution was not achieved in 59 cases. For complete resolution of the calculi, mechanical or electrokinetic fragmentation was used in a high proportion of patients (56.3%). Removal of the stone or stone fragments was mainly by forceps (79.7%); the Dormia basket was used in 18.2% of the cases. The complications occurred during or immediately after the procedure and were minor (10.7%), although there were 3 patients with major complications (2 ureteral eversion and one case of ureteral avulsion)., Conclusions: In our view, rigid transurethral ureteroscopy is a useful, safe and efficient technique in the treatment of calculi in the pelvic ureter, and in selected cases of calculi in the sacral or lumbar level, after failed ESWL. Rigid transurethral ureteroscopy achieves excellent resolution and the complications are scanty.

Objective: To analyze the therapeutic approach in epidermoid or squamous cell carcinoma of the scrotum, a rare tumor that is of interest for clinical and historical reasons., Methods/results: A case of epidermoid carcinoma of the scrotum is described. The patient had undergone urethroplasty in 1972, using preputial free graft, according to the technique of Ben Johnson. Right scrotectomy and orchidectomy were performed and partial urethrectomy with inguinal lymphadenectomy 6 weeks later. At 24 months' follow-up, the patient has no tumor recurrence., Conclusion: Malignant tumors of the scrotum are rare. Squamous cell carcinoma is the most frequent tumor type. Radical surgery with inguinal lymphadenectomy is the treatment of choice. It must be distinguished from verrucous carcinoma, a tumor that requires a different therapeutic approach and for which radical surgery is not indicated.

Objective: To determine the telomerase activity in urine samples of patients with superficial bladder cancer, its sensitivity and specificity as a tumor marker, and possible implications for prognosis, diagnosis and therapeutic efficacy., Methods: Urine samples of 50 patients with superficial bladder cancer were analyzed. Telomerase activity was determined by TRAP (telomeric repeat amplification protocol). Standard urinary cytology, urine culture and urinary sediment analysis were performed, as well as a pathological analysis of the surgical specimen., Results: 84% of the patients were positive for telomerase activity and only 52% had a positive cytology. Telomerase activity showed a sensitivity and specificity of 73.6% and 92.7%, respectively, versus 53.2% and 81.8% for urinary cytology. The degree of cell differentiation and, to a lesser extent, bladder wall infiltration showed differences in comparison with conventional urinary cytology., Conclusions: Telomerase activity can be determined in voided urine samples of patients with superficial bladder cancer. It has a higher sensitivity and specificity than conventional urinary cytology and is a good marker for diagnosis and follow-up of these patients.

Objective: The artificial sphincter has been utilized for urinary incontinence due to intrinsic sphincteric insufficiency, with good fixation of the urethra and a maximum urethral closing pressure of 20-30 cms H2O, or after failed attempts at correction using other techniques. This procedure is difficult to perform since the patients have generally undergone several operations and it is necessity to prepare the cleavage between the urethra and vagina. We propose a modified combined vaginal and suprapubic approach of the technique described by Appell and Abbassian in 1988 for enhanced exposure of the urethra and bladder neck and easy access., Methods: The modified combined abdominovaginal approach has been utilized in 18 females aged 16-62 years since 1995., Results: 16 patients were continent (88%). One patient (5.5%) required removal of the artificial sphincter due to infection. Another patient (5.5%) has mild incontinence and requires 2 pads a day. Four patients (22%) with detrusor instability are receiving anticholinergics. Three patients (16%) with an underlying neurogenic incontinence require intermittent catheterization. Fourteen patients (77.7%) have type III stress urinary incontinence. We performed the Kelly procedure in 10 patients (55.5%), the Marshall-Marcetti-Kranz in 7 (38.8%), Gittes in 3 (16.6%), and 2 patients (11.1%) had a sling procedure. Two techniques were simultaneously performed in some patients., Conclusions: Although the number of patients in this series is small, the fact that only one case required removal of the artificial spincter due to infection indicates that this is a useful alternative approach that significantly facilitates implantation of the artificial sphincter in these patients.

Objective: A case of extravesical leiomyoma that had been incidentally discovered in a patient presenting with unspecific pelvic pain is described., Methods/results: A 51-year-old male patient consulted for unspecific pelvic pain. Patient evaluation disclosed a well-defined mass. A partial cystectomy was performed. Pathological analysis confirmed the diagnosis of leiomyoma of the bladder., Conclusions: Mesenchymal tumors of the urinary bladder are rare and account for 1%-5% of all bladder tumors. Leiomyoma is the most common benign non-epithelial tumor. The symptoms caused by this tumor type is varied, unspecific and in most of the cases depends on its location (intravesical, intramural or extramural). Treatment is by surgery, which achieves excellent results.

Objective: The UroLume stent has been utilized in the management of symptomatic benign prostatic hyperplasia (BPH), particularly in patients at high surgical risk. Our results are analyzed and the literature reviewed., Methods: From June, 1994 to November, 1996, 19 patients at high surgical risk (ASA III/IV) with symptomatic BPH were treated at our center; 17 (89.4%) had an indwelling catheter. The UroLume stent was inserted under local anesthesia and intravenous sedation., Results: Stent placement as monotherapy was found to be clinically effective in 15 patients (78.9%) with a mean follow-up of 8.2 +/- 5.7 months (range 1-18). The mean symptom score (Madsen-Iversen) was 6.1 +/- 1.2. Patients with no further manipulations had a mean maximum flow rate of 8.8 +/- 3.8 ml/s. Two patients (10.5%) required stent removal due to retrograde displacement in one case and perineal discomfort and irritative voiding symptoms in the other. In two other patients (10.5%), remnant tissue had to be resected in order to void spontaneously. Seventeen patients (89.4%) were satisfied with the results. No case of urosepsis or incrustations were documented. A microbiological analysis disclosed urinary tract infection in one patient., Conclusions: The UroLume stent is clinically effective in the treatment of symptomatic BPH in patients unfit for prostatic surgery. It carries a low incidence of major complications and procedure-related morbidity.

Objectives: The widely accepted and, until recently, the only alternative in muscle-infiltrating transitional cell carcinoma of the bladder, whatever the extent of muscle infiltration, has been radical cystectomy, although the advantages of partial cystectomy has not been questioned., Methods: We reviewed the records of 34 patients with infiltrating carcinoma of the bladder stage T2 or higher and a follow-up ranging from 3 to 194 months, who underwent partial cystectomy. The patient received no radiotherapy and only one patient was treated with preoperative chemotherapy., Results: The surgical specimen was tumor free (pTO) in 7 patients, pT1 in 7 pts, pT2 in 4 pts, pT3 in 4, pT3b in 8 and Px in 4. Six patients showed lymph node involvement. Eleven patients had bladder recurrence; 3 had bladder recurrence and metastasis; 1 had bladder recurrence, a pelvic mass and metastasis and 2 had metastasis alone. We performed radical cystectomy in 2 cases; one for a prostatic cancer and the other for an upper urothelial tumor in a solitary kidney. Both bladders were tumor free. The extravesical disease free interval and survival were better that those of patients submitted to radical cystectomy, although this was a highly selected group., Conclusions: With the same possibilities relative to the extravesical disease free interval and survival, this approach requires a shorter operating time, carries less risk, low postoperative morbidity and mortality, requires less hospitalizations, and has less late sequelae. It affords a better quality of life, with no cutaneous stoma, incontinence or impotence. The risk of bladder recurrence persists, although the procedures required to resolve the complications of bladder diversion or substitution are more aggressive than TUR, which is sufficient for most of the recurrences, and if the recurrence is an infiltrating tumor, one can always recur to radical cystectomy. This is the current situation, even in the era of the so-called "minimally invasive techniques". We believe that in this group of patients combination preoperative radio- and chemotherapy would have contributed little to the partial cystectomy. In our series, it is evident that the pT0 is the result of complete resection by TUR. The differences in tumor definition make it very difficult to evaluate the benefits of the neoadjuvant measures. Patients with no bladder tumor (pT0) or pT1-pT2, and even pT3a tumors, should not be included in protocols for evaluating the efficacy of combination cystostatic therapy; many of them can be overtreated. Preoperative radiotherapy adds nothing with respect to local recurrence of this tumor type and it evidently has no effect on metastasis. We should not forget that the cytostatic agents currently utilized in combination therapy have severe side effects and are therefore only indicated in patients at higher risk of distant dissemination at diagnosis. Some studies, however, have indicated that the cytostatics may have some negative tumoral effect.

Objectives: To analyze the indications, diagnostic cost-effectiveness and therapeutic implications of urodynamic assessment of the lower urinary tract in two groups of patients: 1) those awaiting renal transplantation and those with a functioning renal graft and voiding disturbances., Methods: The first group comprised 22 patients who were evaluated before renal transplantation for a total of 32 urodynamic studies. The second group comprised 10 patients with a functioning renal graft for a total of 14 post-transplant urodynamic studies. The etiology of the chronic renal failure, indications for urodynamic assessment and videourodynamic findings in both groups were compared., Results: Interstitial nephropathy associated with vesicoureteral reflux was the most common cause of chronic renal failure in the pre-transplant group, whereas glomerular nephropathy was the most common cause of chronic renal failure in the posttransplant group. Vesicoureteral reflux was the most frequent videourodynamic finding and was associated with other urodynamic disturbances in 75% of the cases. Lower urinary tract obstruction was the most common finding in the posttransplant group., Conclusions: The indications for urodynamic study in patients awaiting renal transplantation are: 1) interstitial nephropathy associated with vesicoureteral reflux, neurogenic bladder and congenital malformations; 2) patients aged 45 or older with a flowmetry suggesting obstruction; 3) those with urinary diversion, and 4) systemic diseases potentially associated with neurological damage.

Objectives: Urological complications in renal transplantation occasionally denote the failure of a technique intended to provide the patient on hemodialysis a significant improvement of quality of life. Our experience in the management of these complicated cases which could not be resolved by conventional measures is described., Methods: Since the transplantation program began, our department has performed 530 renal transplants. There have been 40 fistulae (7.5%) and 23 stenoses (4.3%) of graft urinary tract. All the foregoing complications had been treated by endourological procedures (nephrostomy or ureteral stent) and/or simple ureteral reinsertion. There were 5 unresolved or recurrent fistulae (0.9%) and 2 stenoses (0.4%) that were repaired using the recipient's ipsilateral urinary tract (6 pyeloureterostomies and 1 pyelopyelostomy)., Results: Good results were achieved in all of the cases with adequate urinary tract function., Conclusions: Urological complications following renal transplantation can be successfully treated by surgical correction (pyeloureterostomy or pyelopyelostomy).

Objectives: We reviewed our series of upper urinary tract tumors submitted to endoscopic management as definitive treatment., Methods: The series comprised 18 patients with transitional cell carcinoma of the upper urinary tract; 14 were treated by the percutaneous approach and 4 by ureteroscopy. All of them were single, papillary and low grade tumors. In 17 patients we analyzed the nephrostomy track for local tumoral seeding., Results: The mean follow up was 29 months. Fourteen patients remain free of recurrent disease (5-84 months); 2 patients recurred and 2 others were diagnostic errors. No evidence of tumoral seeding was observed., Conclusions: Percutaneous or ureteroscopic surgery can achieve cure in selected cases. Local recurrence outside the urinary tract ascribable to percutaneous surgery appears to be unlikely.

Objectives: Ureterointestinal stricture represents a serious problem whose management has traditionally been by open surgery. Endourological treatment is an alternative that is generally free from the complications of open surgery, but with a lower success rate. The efficacy of endourological treatment is analyzed in 14 cases of ureteroileal stricture (12 patients) and the different treatment options are discussed., Methods: Ureteroileal stricture was managed endourologically in 9 of 13 cases (69%) by dilatation (6 cases), incision+dilatation (2 cases) and stenting (1 case)., Results: Of the 6 cases submitted to dilatation, 3 recurred at 6 months, 2 remained patent at 18 and 24 months, respectively, and 1 was lost to follow up because the patient underwent reimplantation (40% success rate). The two cases submitted to incision are patent at 18 and 19 months, respectively., Conclusions: The overall success rate for endourological treatment of ureteroileal stricture is 28% (4/14 cases) at 19 months mean follow up.

Objective: This paper describes the endoscopic incision of uretero-ileal anastomotic strictures by a combined approach (percutaneous antegrade and endoscopic retrograde) using the intraluminal invagination technique over a balloon dilatation catheter., Methods: The different steps of the surgical procedure of incision of the stenotic segment of different techniques of ureteroileal diversion (Bricker, Camey, ureterosigmoidostomy) are described in detail. Endoscopic images and those from the image intensifier are shown., Results: Of the 6 cases described herein, incision was achieved in 5 and in 1 case stenting of the stenotic segment could not be achieved., Conclusions: Intraluminal invagination of the stenotic segment considerably facilitates endoscopic incision.

We report a case of renal polar infarction in a 13-year old boy following surgical excision of contralateral congenital lobar emphysema. Patient history was unremarkable and yielded no data suggestive of any other underlying pathology or systemic disease. The diagnosis was made on the CT, arteriography and DMSA scan findings. The etiology could not be determined. The patient was treated conservatively with prophylactic antibiotic therapy and followed closely. There were no complications; the patient was asymptomatic one month after the episode. The control IVP showed residual segmental atrophy and ultrasound evaluation disclosed cortical atrophy. The most common cause of this condition, the diagnostic algorithm, treatments and their indications are discussed. Renal graft infarction, which may be associated with acute rejection or venous and/or arterial thrombosis, warrants special attention. The treatment and clinical course are significantly different, although the diagnosis is made using the same methods.

We report on a rare case of bilateral ureteral triplicity with a definitive urinary diversion (Brickner loop ureteroileostomy) who presented a staghorn stone in the upper calyx of the left kidney. The patient was submitted to percutaneous nephrolithotomy with direct access to the upper calyx of the anomalous kidney. We discuss the indication for this treatment, which resolved the lithiasis in a single session and with no complications. Furthermore, this treatment modality is compared with ESWL and open surgery, which we reserve for failures or those cases where the percutaneous approach is contraindicated. Percutaneous nephrolithotomy can be considered a therapeutic alternative for lithiasis in patients with congenital malformation and/or urinary diversion.

The present study reviewed the first 25 incontinence prostheses implanted at the Urology Services of the Ramón y Cajal Hospital. The literature is briefly reviewed and the indications for the AUS-800 incontinence prosthesis are discussed.

We reviewed the clinical records of 37 patients who had been treated with neoadjuvant chemotherapy + radical cystectomy and bilateral lymphadenectomy. The patients were followed until they died and the survivors have a follow-up of 43 to 68 months. There were 28 deaths: 20 patients died within 24 months following treatment and 6 died after two years. Five patients were not submitted to surgery due to rapid tumor progression while they were receiving cytostatic therapy. Bladder removal was ruled out in 5 patients with important loco-regional spread demonstrated on laparotomy. The bladder was preserved in 12 patients. Eight patients had cRC: 1 died from causes unrelated to the disease; 1 was lost to follow-up at 16 months, with no evidence of bladder cancer or metastasis; 3 developed distant metastasis, and 3 are alive and tumor-free. One pCR died with evidence of metastasis; 1 cRP required radical cystectomy and died from metastasis. Of the patients classified as sRC, 1 subsequently underwent radical cystectomy and is disease-free and the other died from metastasis. Fifteen patients underwent radical cystectomy: 3 are alive and tumor-free, 2 were lost to follow-up and 10 patients died (3 from causes unrelated to the disease and 7 died from the disease). Lymph node invasion was observed in 54%. Metastasis was observed in 57.3% and local recurrence in 17.3%. The preoperative chemotherapy schedule under study did not prolong the metastasis-free period in this group of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

This study was undertaken in 69 patients with transitional cell carcinoma of the upper urinary tract. In 31, bladder tumor was diagnosed prior to (35.5%), concomitant with (38.5%), and after treatment of the upper urothelial tumor. Localization in the bladder more commonly involved the ipsilateral left or right lateral aspect and less frequently involved the trigone. It is difficult to predict the nature of the bladder tumor from the upper urinary tract tumor. However, we have observed that excision of the upper tract tumor favourably affects the evolution of the bladder tumor diagnosed prior to or concomitant with treatment of the upper tract tumor.