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STHAPYLOCOCCUS AUREUS PROSTATIC ABSCESS AND SUBDURAL EMPYEMA: A CASE REPORT. Introduction and objectives: To report one case of prostatic abscess and subdural empyema by Staphylococcus aureus. Methods: We describe the case of a 51 year old male patient who was diagnosed of prostatic abscess and subdural empyema by Staphilococcus aureus. We use clinical presentation and physical exploration based on rectal digital examination, as diagnostic approach method. And computerized axial tomography and transrectal ultrasonography, which allows the guided needle drainage of the abscess, as diagnostic confir- mation methods. Results: The clinical picture resolved with the transrectal ultrasonography guided needle aspiration of the abscess and conservative treatment with antibiotics and urinary diversion. Conclusions: Prostatic abscess is an uncommon entity nowadays. Provided the great variety of symp- toms, a great degree of clinical suspicion is needed for the diagnosis, and once it is got it, immediate aggres- sive treatment must be initiated. Transrectal ultrasonography allows not only the diagnosis, but also the drainage of the abscess. The culture of the obtained material identifies the etiological agent and the most specific antibiotic therapy.

Resumen La brucelosis es una zoonosis poco frecuente, aunque es endemica en Espana. Suele manifestarse como una enfermedad sistemica con presentacion aguda o cronica, en ocasiones lo hace de manera localizada afectando a uno o varios aparatos La presentacion focal mas frecuente es la forma osteoarticular. Esta se puede complicar en ocasiones con abscesos para-perivertebrales, la afectacion del psoas unilateral es rara y en casos excepcionales existe extension a ambos musculos bilateralmente Las manifestaciones clinicas de los abscesos de psoas(AP) suelen ser insidiosas, es infrecuente la aparicion de la triada clasica de fiebre, dolor lumbar e impotencia funcional. Para el diagnostico son necesarias las pruebas serologicas y medios de cultivo. El uso extendido de la Ecografia (ECO) y la Tomografia Axial Computerizada (TAC) ha mejorado el diagnostico y tratamiento de las complicaciones. El tratamiento de eleccion es antibiotico y se basa en el uso de tetraciclinas y estreptomicina. En ocasiones se hace necesaria la puncion percutanea o drenaje abierto de los abscesos. Presentamos un caso de AP brucelosico bilateral y revisamos la bibliografia

Germ cell tumour is the most frequent malignant tumour type in young men with a 100% rise in the incidence every 20 years. Despite this, the high sensitivity of germ cell tumours to platinum-based chemotherapy, together with radiation and surgical measures, leads to the high cure rate of > or = 99% in early stages and 90%, 75-80% and 50% in advanced disease with 'good', 'intermediate' and 'poor' prognostic criteria (IGCCCG classification), respectively. The high cure rate in patients with limited metastatic disease allows the reduction of overall treatment load, and therefore less acute and long-term toxicity, e.g. organ sparing surgery for specific cases, reduced dose and treatment volume of irradiation or substitution of node dissection by surveillance or adjuvant chemotherapy according to the presence or absence of vascular invasion. Thus, different treatment options according to prognostic factors including histology, stage and patient factors and possibilities of the treating centre as well may be used to define the treatment strategy which is definitively chosen for an individual patient. However, this strategy of reduction of treatment load as well as the treatment itself require very high expertise of the treating physician with careful management and follow-up and thorough cooperation by the patient as well to maintain the high rate for cure. Treatment decisions must be based on the available evidence which has been the basis for this consensus guideline delivering a clear proposal for diagnostic and treatment measures in each stage of gonadal and extragonadal germ cell tumour and individual clinical situations. Since this guideline is based on the highest evidence level available today, a deviation from these proposals should be a rare and justified exception

Abdominal trauma is relatively frequent and around 5% of the cases correspond to renal trauma. At present, a large percentage of cases can be managed conservatively. Generalised use of CT and cumulative experience have defined the cases that can be treated with good prospects. The currently accepted indications for imaging techniques and the most frequent ratings used are described. Similarly, the indications for surgical renal examination are listed and the principles for renal reconstruction described in the most recent publications of the most experienced medical centres.

Leydig cell tumor is the most frequent non-germ cell tumors of testis, included in the group of specialized gonadal stromal neoplasms. It has a low incidence, accounting for 1-3% of testicular neoplasms. This tumor is characterized by its endocrine manifestations, due to the tumor's capacity to secrete hormones. We report eight cases, including the description of their clinical, diagnosis and therapeutic features, as well as their follow-up. We also make a review of the literature about this rare testicular tumor.

Resumen Introduccion Y Objetivo La expresion del oncogen bcl-2 se relaciona con una resistencia aumentada de las celulas tumorales a la apoptosis, lo que prolonga su supervivencia y contribuye a su transformacion neoplasica. En el adenocarcinoma renal todavia no se ha podido establecer su importancia en cuanto a la evolucion de estas neoplasias. Nuestra intencion es determinar la expresion de la proteina bcl-2 y su relacion con diferentes variables clinicas y anatomopatologicas, estableciendo su valor pronostico Metodo 58 adenocarcinomas renales, estadios pT 1-T 3a N 0 M 0 (TNM 1997), tratados mediante nefrectomia radical o parcial con intencion curativa. Analizamos diferentes variables clinicas y anatomopatologicas, asi como la expresion de bcl-2 en tejido parafinado, mediante tecnicas de inmunohistoquimica, obteniendo una tincion citoplasmatica que se valoro de forma cualitativa Resultados La tincion para bcl-2 fue positiva en 44 de los 58 tumores analizados (62,1%), en distintos grados de intensidad. En cuanto a la relacion de la expresion de bcl-2 con otras variables histopatologicas, no encontramos asociacion estadisticamente significativa con el grado nuclear, tamano, estadio o posibilidad de recidiva tumoral. Agrupando los tumores segun la intensidad de la tincion en dos grupos, tincion negativa y debil positiva, frente a tincion de intensidad moderada e intensa, tampoco obtuvimos relacion entre bcl-2 y la supervivencia Conclusiones La expresion de bcl-2 no se relaciono con ninguna de las variables histopatologicas analizadas; tamano, grado y estadio, ni con la supervivencia, por lo que esta proteina no parece relacionarse con la evolucion del adenocarcinoma renal

Resumen Objetivo La proteina p21ras es codificada por los tres genes de la familia ras (H-, K- y N-ras), participando en la regulacion del crecimiento y la diferenciacion celular. El objetivo de este estudio es determinar la expresion de esta proteina en el adenocarcinoma renal localmente confinado, asi como sus relaciones con diferentes variables histopatologicas y sus implicaciones pronosticas. Metodo 58 adenocarcinomas renales, estadios pT1-T3a N0 M0 (TNM 1997), tratados mediante nefrectomia radical o parcial con intencion curativa. Analizamos diferentes variables clinicas y anatomopatologicas, asi como la expresion de p21ras en tejido parafinado, mediante tecnicas de inmunohistoquimica. Resultados El porcentaje medio de nucleos tenidos fue de 6,1%, con un rango comprendido entre 0 y 45%. No obtuvimos asociacion estadisticamente significativa de la expresion de p21ras y el tamano tumoral (p=0,698), el grado nuclear (p=0,676) o el estadio histopatologico (p=0,095). El analisis de supervivencia tampoco demostro diferencias significativas cuando estratificamos a los pacientes utilizando como punto de referencia el valor medio de la muestra (p=0,134). Conclusiones La expresion de p21ras no ha demostrado relacionarse con ninguna de las variables histopatologicas analizadas; tamano, grado y estadio, ni con la supervivencia, por lo que esta proteina no parece relacionarse con la evolucion del adenocarcinoma renal.

Resumen Presentamos un caso de linfoma testicular primario en un paciente de 62 anos que debuto como masa testicular indolora. Se realizo orquiectomia izquierda, diagnosticandose de linfoma B no Hodgkin linfocitico difuso. Recibio tratamiento con quimioterapia tipo CHOP, presentando mala evolucion, con metastasis cerebrales, falleciendo 25 meses despues del diagnostico.

The spontaneous extraperitoneal bladder rupture is an uncommon event and the diagnosis is very difficult. It is defined like the rupture of bladder wall in absence of traumatism or iatrogenic techniques. The extravasation usually is produced into the peritoneal cavity, because of the greater weakness of the vesical dome. The diagnosis is based on the retrograde cystography, being necessary the surgical treatment in the intraperitoneal rupture, while the extraperitoneal one, could be treated in a conservative way with a vesical catheter. Here we present a case of sponteneus extraperitoneal bladder rupture, with oliguria, abdominal pain and a righ hypochondrius mass as clinic presentation. Due to this, the diagnosis was made by the TAC, in which it was appreciated a continuity solution in the anterior bladder wall, with a contrast extravasation through the anterior abdominal wall. The retrograde cystography confirmed the definitive diagnosis. The treatment followed was based on the keeping of the vesical catheter and antibiotherapy

Resumen El absceso retroperitoneal es una entidad clinica poco frecuente, cuyo tratamiento se basa en el drenaje. La introduccion progresiva de las tecnicas percutaneas de drenaje, bien mediante control ecografico o bien utilizando la tomografia axial computerizada (TAC), ha modificado su abordaje terapeutico, siendo alternativas validas al tratamiento quirurgico tradicional. Presentamos una serie de 16 pacientes diagnosticados de absceso retroperitoneal entre 1986 y 1998, que fueron tratados mediante puncion percutanea (en 14 casos dirigida por TAC y en 2 mediante control ecografico). Se consiguio la resolucion del absceso en 13 casos, recurriendo en 2 (ambos fueron tratados mediante nueva puncion) y falleciendo 1 paciente que presentaba una sepsis grave. En 12 de los pacientes fue el unico tratamiento aplicado, practicandose en los 4 restantes nefrectomia tras la mejoria del estado de los pacientes. Conclusiones El tratamiento percutaneo de los abscesos retroperitoneales supone una alternativa valida al tratamiento quirurgico tradicional, bien como tratamiento definitivo, bien como tratamiento paliativo que nos permite mejorar el estado clinico del paciente de forma previa a la cirugia.

Considering the scarcity of organs for transplantation, one possible solution is the use of grafts from aged donors (over 50 years). We have reviewed our experience in the case of kidney transplantation considering the period from 1989-1994 in order to attain a minimum follow-up of 36 months. We compare three groups: donors aged between 50-60 years (n = 32), donors aged over 60 years (n = 25) and a control group formed by donors of "ideal" ages. The results show that kidneys from donors over 60 years evidence, as compared to the control group, a higher incidence of acute tubular necrosis (p = 0.032), significantly higher blood creatinine levels in all the intervals considered, and a graft survival which is 14% less at 12 months and 40% less at 36 months (p = 0.0009). These differences are most probably to be attributed to the changes caused in these organs by advancing age and by previous pathological situations, as we have not detected a higher incidence of immunologic or surgical complications.

Although deceased donors older than 60 years of age (D60) are increasing in number, little information exists on the rate of discarded kidneys from these aged individuals. This study sought to analyze causes of discard of kidneys from D60. Since 1997, we have transplanted kidneys from D60 into elderly recipients after assessing their functional and anatomical viability. Among 3444 renal offers for transplantation between 1997 and 2005, 1967 (57%) came from D60. Of these, 1145 offers were discarded, because the kidney donor was not adequate (n = 470) or because there was no elderly recipient on our waiting list (n = 675). We also examined 1745 kidneys, 822 (47%) of which came from D60. The percentage of discarded kidneys due to macroscopic or microscopic alterations was 46% in the D60 group compared with 14.7% in the donor group younger than 60 years of age (D60; P.01). We transplanted 443 kidneys from D60 (85 dual, 273 single) to 358 recipients of matching age and 900 kidneys from D60. Three-year death-censored actuarial graft survival rate was 83% for D60 compared with 89% for D60 transplant (P = not significant). In conclusion, kidneys from D60 were discarded for transplantation mainly because there was no elderly recipient on the waiting list and due to macroscopic or microscopic alterations. Given the increasing offer of kidneys from D60 and the good results of transplantation with these aged kidneys in elderly recipients, the indications for kidney transplantation should be expanded to include more of the elderly population on dialysis to the waiting list.

Resumen En el momento actual se conocen algunos factores predictivos de la evolucion del segundo trasplante renal de cadaver, especialmente la influencia de la respuesta del receptor frente al primer injerto. No obstante, no sabemos si el mantenimiento o la extirpacion de un organo no funcionante ejercen alguna repercusion sobre siguientes trasplantes. Este es el objetivo del presente trabajo. Material y metodos Se analizan retrospectivamente los registros clinicos de 80 receptores de un segundo trasplante renal de cadaver en la era CyA, entre 1985 y 1995 en el Hospital 12 de Octubre de Madrid. Se recogieron las caracteristicas y evolucion de primer y segundo trasplantes, variables que fueron empleadas en la construccion de un modelo de analisis multivariante de la supervivencia del segundo injerto. La trasplantectomia del primer injerto no funcionante solo se llevo a cabo en caso de ser estrictamente necesaria, circunstancia que ocurrio en el 72% de nuestros pacientes (n = 58). Resultados El analisis multivariante demostro que la nefrectomia del injerto no funcionante no modificaba el riesgo de sensibilizacion del receptor o la probabilidad de desarrollar rechazo agudo o cronico en el segundo injerto; sin embargo, redujo significativamente el riesgo de perdida del mismo a medio y largo plazo (p = 0,009). CONCLUSIONES: Estos datos constituyen el primer argumento solido a favor de la trasplantectomia electiva en los pacientes candidatos a un segundo trasplante renal de cadaver. Sin embargo, es preciso una investigacion profunda de los mecanismos involucrados en esta observacion antes de recomendar la generalizacion del procedimiento.

Report on one case of prostate leiomyosarcoma, an infrequent and usually highly aggressive urologic neoplasia. Emphasis on the imaging and pathoanatomical diagnosis, highlighting the high value of the later as immunohistochemistry is usually essential to establish its nature. Choice treatment is oncologically radical surgery. Quite often this is impossible to carry out and so chemo- and radiotherapy schedules are commonly associated as neoadjuvant, adjuvant or palliative therapies. The reported case showed aggressive evolution unresponsive to management. Also, during the condition development a rare complication such as occurrence of an exophytic tumoral mass in the perineum appeared.

Resumen La fractura de pene es una entidad clinica poco frecuente que se produce por la rotura traumatica de la albuginea de los cuerpos cavernosos. Presentamos nuestra experiencia en 9 casos atendidos en nuestro Servicio entre 1989 y 1998. La mayoria de los casos se produjeron por traumatismos sobre el pene durante el coito, siendo suficiente la presentacion clinica y la exploracion fisica para su diagnostico. El tratamiento llevado a cabo fue quirurgico en todos ellos, procediendose a la evacuacion del hematoma y posterior reparacion de la rotura con suturas reabsorbibles. El resultado estetico y funcional fue excelente en todos los casos. No hemos encontrado en el seguimiento ningun caso de incurvacion peneana, refiriendo todos los pacientes una recuperacion total de la funcion erectil. Conclusiones En nuestra experiencia, el tratamiento quirurgico de la fractura de pene ofrece unos buenos resultados, con recuperacion de la funcion erectil de forma completa, sin aparicion de incurvaciones peneanas.

Se presenta una variante técnica de la desinserción endoscópica ureteral, con la que se intenta evitar el contacto de la orina con el lecho quirúrgico, condición preceptiva para evitar la posible diseminación tumoral local, al realizar la nefroureterectomía radical en tumores de urotelio superior.

Objectives To estimate and compare recurrence rates, index of recurrence and disease-free interval in patients with superficial recurrent bladder cancer receiving bacille Calmette-Guerin (BCG) or interferon (IFN) for immunoprophylaxis. Methods One hundred twenty-two patients with recurrent superficial Stage pT1, grade 1 to 3 tumors were enrolled in a randomized, prospective, multicenter trial with two treatment arms of endovesical immunoprophylaxis: 150 mg of BCG versus 54 MU of recombinant IFN-alpha-2a. Administration was weekly during the first month, biweekly for 2 months and monthly for 9 months. Both groups were similar with regard to tumor stage, grade, size and number. Results Sixty-one patients were evaluable in the BCG group and 49 in the IFN group. Tumors recurred in 34 (69.4%) of 49 patients in the IFN group (890 months of follow-up) and in 24 (39.3%) of 61 in the BCG group (1272 months of follow-up). The total number of recurrences (28 for BCG, 47 for IFN), disease-free interval (mean 19.3 months for BCG, 15.3 months for IFN) and index of recurrence (2.2 for BCG, 5.5 for IFN) were statistically significant (P = 0.001) in favor of BCG. Progression to invasive carcinoma was similar in both study arms. Neither systemic nor local side effects were seen in the IFN group. However, the previously reported toxicity of BCG was confirmed. Conclusions According to our trial, BCG remains the most efficacious agent for immunoprophylaxis of recurrent superficial bladder tumors.

Introduction of a new approach for uretero-ileal implantation when only one kidney is available. The technique follows the same approach as the Wallace-type re-implantation but in this case the uretero- ileal anastomosis plate is formed with the far en 2-3 cm of ureter. all cases performed with this technique have been highly sucessful as reported in this clinical account.

Objective We studied the long-term renal graft functions, survivals, and complications among patients with augmented bladders. Patients and Methods Between 1976 and 2008, we performed 6/2600 renal transplantations in patients with augmented bladders. The mean patient age was 52 years. The cause of end-stage renal disease was chronic interstitial kidney disease in all patients, being secondary to lower urinary tract dysfunction. The etiology of bladder dysfunction was tuberculosis in 4 cases, bladder exstrophy in 1, and myelomeningocele in 1. Enterocystoplasty had been performed at a mean of 19 years prior to transplantation. The ureter was implanted into the native ureter in 5 cases and the bowel segment in 1 case. Results With a mean follow-up of 56 months (range, 20–100 months), the overall graft survival was 50%. Three grafts were lost due to venous thrombosis (n = 1), and chronic allograft nephropathy (n = 2) at 37 and 100 months posttransplantation. No patient died during follow-up. Mean serum creatinine was 1.44 mg/dL with Modification of Diet in Renal Disease (MDRD) clearance of 76 mL/min/1.73 m2. One fistula that caused obstructive uropathy and 2 cases of migration of a double J catheter were among the surgical complications. These patients showed a mean of 7 episodes of uncomplicated urinary infections. Only 1 patient was rehospitalized due to a complicated urinary tract infection. Conclusions Patients with enterocystoplasty and renal transplantation show a greater risk of urinary tract infections, albeit mostly uncomplicated. Despite this, the long-term results are acceptable.

The aim of this study was to analyze the 30 third transplantations performed at our center since 1976. They were all from cadaveric donors. Recipient mean age was 40 years (range, 21-57 years). Twenty-one patients (70%) had hepatitis C virus infection and 16 (53%) were hypersensitized (panel-reactive antibodies [PRA] >50%), with a mean time on dialysis since second graft loss of 65 months (range, 1-250 months). The imaging tests showed iliac calcifications in 14 patients (47%). The graft was preferably placed in the iliac fossa (27/30). Twenty-five patients (83%) had prior graft nephrectomy and transplantectomy was performed at the same surgery in 2 cases. Immunosuppressive protocol was quadruple therapy in 23 patients (77%). At a mean follow-up of 43 months, 24 grafts were functioning. Mean serum creatinine was 1.5 mg/dL and Modification of Diet in Renal Disease (MDRD) clearance was 64.5 mL/min. Six grafts were lost: 3 due to acute rejection, 2 due to chronic allograft nephropathy, and 1 due to venous thrombosis. Four patients died: 2 due to infectious complications, 1 due to hepatic encephalopathy, and 1 to an accident with a functioning graft. The acute rejection rate was 30% and 4 patients had an acute humoral rejection episode. The main surgical complication was lymphocele in 7 cases (23%). Estimated survival at 5 years was 76% for grafts and 86% for patients. Graft survival worsened among patients with PRA > 80% and among those who had lost the previous grafts in the first month posttransplantation (P < .05). In conclusion, the outcomes of the third kidney transplantations encourage us to continue with this procedure. However, worse graft survival should be expected among hyperimmunized patients and among those who had lost previous grafts early in their course.

Objective We evaluated the incidence of urological complications after simultaneous renal and pancreatic transplantation. Patients and Methods We retrospectively reviewed urological complications following 107 simultaneous kidney-pancreas transplantations performed at our institution between March 1995 and June 2008. The 46 women and 61 men were of mean age 37.8 years (range, 25–66). The mean duration of diabetes mellitus was 23.0 years (range, 9–48) and the mean duration of dialysis was 19.9 months (range, 0–70). The exocrine pancreatic secretions were drained to bladder in 58 cases, or enterically in 49 patients. The mean length of follow-up was 51.7 months. Results The most frequent urological complication was urinary tract infection, reported in 63.8% of patients: 42 bladder-drained and 25 enteric-drained ( P = .011). Hematuria occurred in 13 patients (12.5%): 12 bladder-drained and 1 enteric-drained ( P = .002). Five bladder-drained patients developed bladder calculi. Among 58 bladder-drained patients, reflux pancreatitis occurred in 28 patients and urine leaks related to the pancreatic graft occurred in 7 patients. Conversion of exocrine secretions from bladder to enteric diversion was required in 6 patients. One- and 3-year patient survival rates were 92.7% and 89.1%, respectively. Moreover, 1 and 3-year kidney graft survival rates were 90.6% and 84.4%, and pancreas graft survival rates were 78.1 and 70.3%, respectively. Conclusion Simultaneous kidney-pancreas transplantation with bladder drainage is associated with a high frequency of urological complications. Appropriate treatment can resolve most complications. In our opinion, both enteric and bladder drainage seemed to be safe and effective alternatives to manage pancreatic exocrine secretions.

This study evaluates the risk factors and prognostic variables that affect survival of patients with gangrene of Fournier.The study retrospectively analyzed 90 consecutive patients with gangrene of Fournier treated in our institution between 1975 and 2008. We evaluated the average age, associated systemic diseases, and the source, time of evolution and extent of necrotizing fasciitis. The outcomes were assessed according to whether the patient survived or died. All patients had aggressive surgical debridement, and received parenteral antibiotic therapy.The mortality rate was 34.4%. The mean age was 63.0 years (range 33-95), a statistically significant difference was found between the age of the survivors (median age, 59.84 years) and those who died (median age, 70.20 years) (p = 0.001). Medical comorbidities were identified in 51 patients; the death rate was higher in patients who had any medical disease, especially those who suffered from cancer. Although diabetes mellitus was the most common associated pathology, it was not related to a statistically significant worst prognosis. The source of the infection was identified in 62 patients, who showed a higher mortality (p = 0.015), the mortality rate when a urological source is identified was 50%. Moreover, patients suffering from a more extensive necrotizing infection showed a worst prognosis.The gangrene of Fournier has a high mortality rate. Large series are required to study prognostic variables of this disease. The patient age, the presence of systemic risk factors, especially cancer, a urological source of infection and the extent of the disease have impact on the prognosis of Fournier's gangrene.

Resumen Introduccion Este estudio evalua los factores de riesgo y aquellas variables pronosticas que influyen en la supervivencia de los pacientes con gangrena de Fournier. Material y metodos El estudio analiza retrospectivamente 90 pacientes con gangrena de Fournier tratados en nuestra institucion entre 1975 y 2008. Evaluamos la edad media, enfermedades medicas asociadas, el origen de la fascitis necrotizante, el tiempo de evolucion y la extension de la fascitis necrotizante. Los resultados fueron valorados de acuerdo si el paciente sobrevivia o fallecia. En todos los pacientes se realizo desbridamiento quirurgico extenso y recibieron terapia antibiotica parenteralmente. Resultados La tasa de mortalidad fue del 34,4%. La edad media 63,0 anos (rango 33-95), encontramos diferencias estadisticamente significativas entre la edad media de los supervivientes (edad media 59,84 anos) y los fallecidos (edad media 70,20 anos) (p=0,001). Presentaban alguna comorbilidad medica asociada 51 pacientes, la tasa de mortalidad fue mayor en estos pacientes, especialmente en aquellos que sufrian cancer. Aunque la diabetes mellitus fue la patologia mas frecuentemente asociada, no se relaciono con un peor pronostico de modo estadisticamente significativo. El origen de la infeccion se identifico en 62 pacientes, que presentaron una mayor mortalidad (p=0,015), la mortalidad cuando existia un origen urologico fue del 50%. Ademas, los pacientes que padecian una infeccion mas extensa tambien mostraron un peor pronostico. Conclusiones La gangrena de Fournier tiene una alta tasa de mortalidad. Para evaluar las posibles variables pronosticas de esta en enfermedad son necesarios estudios con un elevado numero de casos. La edad del paciente, la presencia de factores de riesgo, especialmente cancer, un origen urologico de la infeccion y la extension de la enfermedad tienen influencia en el pronostico de la gangrena de Fournier.

We show a technical modification of the ureteral endoscopic resection with which we try to avoid comunication between urine and surgical bed in order to prevent tumor local spread of upper urotelial tumor.

To report one case of prostatic abscess and subdural empyema by Staphylococcus aureus.We describe the case of a 51 year old male patient who was diagnosed of prostatic abscess and subdural empyema by Staphilococcus aureus. We use clinical presentation and physical exploration based on rectal digital examination, as diagnostic approach method. And computerized axial tomography and transrectal ultrasonography, which allows the guided needle drainage of the abscess, as diagnostic confirmation methods.The clinical picture resolved with the transrectal ultrasonography guided needle aspiration of the abscess and conservative treatment with antibiotics and urinary diversion.Prostatic abscess is an uncommon entity nowadays. Provided the great variety of symptoms, a great degree of clinical suspicion is needed for the diagnosis, and once it is got it, immediate aggressive treatment must be initiated. Transrectal ultrasonography allows not only the diagnosis, but also the drainage of the abscess. The culture of the obtained material identifies the etiological agent and the most specific antibiotic therapy.

The Brucellosis is a zoonotic and unfrequent infection but it is endemic in Spain. It is a well documented cause of fever of unknown origin with varied and nonspecific symptoms. The onset of symptoms of brucellosis may be abrupt or insidious, developing over several days to weeks. Virtually any organ system can be involved with brucellosis and localization of the process may cause focal symptoms. The most frequent focal presentation is the osteoarthicular. Some times it can complicates with para-perivertebral abscess. The unilateral psoas abscess(PA) is uncommon and the bilateral afection is exceptional. The manifestations of PA usually are insidious, the classic tiad of: feber, lumbar pain and functional impotence is rare. For the diagnosis the serology c tests and cultures are necesary. The imaging techniques like: Ultrasonography and Tomography have improved the diagnosis and treatment of this pathologies' complications. The recommended therapy is the use of doxycicline and streptomicine. Some times the use of percutaneous drainage or open surgery is necessary.

The overall objective of this study was to carry out a prospective investigation of the usefulness of the IMMUNOCYT commercial kit in the follow-up of patients treated for bladder cancer and to evaluate its utility as a complement to urinary cytology and a possible tool for reducing the number of follow-up cystoscopies required.From September 2001 to December 2002, the ImmunoCyt test and urinary cytology were performed in urine simples from a total of 136 patients (115 with a history or suspicion of bladder cancer and 21 patients with other urological pathologies). Urine simples were fixed with an equal volume of 50% alcohol. Urinary cytology and the ImmunoCyt test were interpreted by a cytopathologist unacquainted with the result of the corresponding cytology and bladder biopsy report. Samples were staged and graded using the 1997 TNM classification of the UICC and the 1998 WHO/ISUP classification. Histopathological confirmation of lesions was available for 111 patients (81.6%).The gender distribution was 89% men and 11% women. Mean age was 71.68 years (range 27 to 98 years). Overall sensitivity and specificity were 77.9% and 92.3% for the ImmunoCyt test and 47.9% and 100% for urinary cytology, respectively. The positive (PPV) and negative predictive values (NPV) were 96.4% and 61.7%, respectively, for the ImmunoCyt test and 100% and 36.7% for cytology. In Ta and low-grade carcinomas, the sensitivity of the ImmunoCyt test was 70% (n=20) and 76.4% (n=34) respectively, whereas it was 25% (n=28) and 29.7% (n=37), respectively, for urinary cytology. The differences observed between the sensitivities of the ImmunoCyt test and cytology were statistically significant (X2 p0.05) overall and for Ta and low-grade carcinomas. The sensitivity and specificity of the combination of both tests were 86.8% and 96.2%, respectively. The sensitivity of the combination of both tests for Ta and low-grade carcinomas was 80% (n=20) and 82.3% (n=34), respectively. The ImmunoCyt test was diagnostic in 36.2% of tumors overall.In view of the results obtained, we decided to change our follow-up protocol to reduce the number of follow-up cystoscopies by 32.2% in the first 5 years of postoperative follow-up (in a cohort of 140 patients who undergo surgery annually). This benefits patients by reducing the number of urinary infections and iatrogenesis originated by follow-up cystoscopy. In addition, this 32.2% reduction in the number of cystoscopies in 5 years will yield a savings of approximately 35,560 EUR to the health care system in 5 years.

Radical cystoprostatectomy is accepted as the standard treatment for muscle-invasive bladder cancer. During last years the indications for orthotopic neobladders have increased due to their advantages over other kind of diversions. Hautmann neobladder is one of the most commonly used. Several modifications have been later described. For example, after perform the W-shape pouch ureters can be anastomosed to a not-detubularized bowel segment (chimney modification). Here is described a modification of the Hautmann neobladder with two chimneys. Each ureter is spatulated in a golf club manner and anastomosed to the open end of each bowel loop. This kind of anastomosis provides several advantages. It is possible to use shorter ureteral segments by increasing the length of bowel used. It allows an anastomosis without tension, and less ischemia so the risk of stenosis and fistula is decreased. It is not necessary to perform additional enterothomies and in case of reintervention it is easier to access each anastomosis without damaging the other one.

Factors influencing the appearance and progression of renal damage in patients with unilateral renal agenesis and remnant kidney. Background Although some studies have shown that the risk to develop proteinuria and renal insufficiency is increased in patients with a remnant kidney (RK) or unilateral renal agenesis (URA), other patients maintain normal renal function and negative proteinuria, and the reasons to explain these different outcomes are not known. Methods We performed a retrospective study of 54 patients with a severe reduction in renal mass (33 patients with URA and 21 with RK). Follow-up was 100 ± 72 months. Results Twenty patients (group 1) showed normal renal function at presentation, whereas the 34 remaining (group 2) had proteinuria, and some of them renal insufficiency. Group 2 patients were older and had a higher blood pressure and BMI than group 1 patients. Eleven patients of group 1 remained normal throughout follow-up (group 1A), whereas the remaining 9 developed proteinuria/renal insufficiency (group 1B). BMI at presentation was significantly higher in group 1B: 27 ± 3.6 kg/m 2 versus 21.6 ± 2.6 kg/m 2 , and BMI was the only factor statistically associated with the risk to develop proteinuria/renal insufficiency in group 1. Among group 2 patients, renal function remained stable in 20 (group 2A), and deteriorated (>50% increase of baseline serum creatinine) in the remaining 14 patients (group 2B). BMI at presentation and treatment with ACEI during follow-up were the only factors statistically associated with the risk for renal failure progression among group 2 patients. Conclusion Overweight plays a fundamental role in the appearance of proteinuria and renal damage in patients with severe renal mass reduction.

Adenocarcinoma of the bladder is an uncommon neoplasm. Depending on its origin it is classified in: primary, secondary and urachal. Generally it grows to the density of the wall, so its clinical appearence is delayed, with the subsequent delayed diagnosis and although an agressive treatment is performed, it frequently has a very bad prognosis. Since there are very few publications of this kind of neoplasm in the literature the lines of actuation in this pathology are not well established. We report the eleven cases of adenocarcinoma neoplasm of the bladder treated in our centre and review the literature.

Objectivos: El objetivo global de este trabajo es el de determinar en un estudio prospectivo la utilidad del kit comercial IMMNUNOCYT‘ para el seguimiento de pacientes tratados de cáncer de vejiga y la evaluación de su utilidad como complemento de la citología urinaria y posible herramienta en la reducción del número de cistoscopias de revisión. Material y Métodos: Entre Septiembre/01 a Diciembre/02 se recogió la orina de un total de 136 pacientes (115 con antecedentes de neoplasia vesical o sospecha de la misma y 21 pacientes con otras patologías urológicas) para realizarles el test del InmunoCyt® (uCyt+) y la citología urinaria. La orina recogida era fijada con alcohol al 50% en un volumen igual. La citología urinaria y el InmunoCyt® fueron informados por un citopatólogo que desconocía tanto el resultado de su correspondiente citología como el informe de la biopsia vesical. Para el estadiaje y grado de las muestras se utilizaron la clasificación TNM de la UICC de 1997 y la de la WHO/ISUP de 1998. Se dispuso de confirmación histopatológica de las lesiones en 111 pacientes (81,6% de los pacientes). Resultados: La distribución por sexos fue del 89% para varones y del 11% mujeres. La edad media fue de 71,68 años [27-98]. La sensibilidad y especificidad globales fueron del 77,9% y 92,3% para el InmunoCyt® y del 47,9% y 100% para la citología urinaria respectivamente. Los valores predictivos positivos (VPP) y negativos (VPN) fueron del 96,4% y 61,7% respectivamente para el InmunoCyt® y del 100% y 36,7% para la citología. En los Ta y carcinomas de bajo grado la sensibilidad del InmunoCyt® fue del 70% (n=20) y 76,4% (n=34) respectivamente, mientras que para la citología urinaria fue del 25% (n=28) y 29,7% (n=37) respectivamente. Las diferencias observadas entre las sensibilidades del InmunoCyt® y de su citología fueron estadísticamente significativas (X² p

Resumen La cistoprostatectomia radical es el tratamiento de eleccion para el cancer vesical infiltrante. En los ultimos anos las indicaciones de sustitucion vesical se han ampliado debido a las ventajas que aportan sobre otros tipos de derivaciones siendo la neovejiga ileal descrita por Hautmann una de las mas utilizadas. Posteriormente se han descrito diversas modificaciones de la tecnica original como la utilizacion de un segmento de asa sin detubulizar a modo de chimenea a la cual se anastomosan los ureteres. Presentamos una variante tecnica de la neovejiga de Hautmann utilizando dos “chimeneas” anastomosando cada ureter a la luz previamente abierta de cada asa espatulando el ureter a modo de “palo de golf” para adaptar los calibres. Entre las ventajas de este tipo de anastomosis destacan la utilizacion de segmentos ureterales mas cortos adaptando la longitud del asa lo que posibilita una anastomosis sin tension y minimiza la isquemia disminuyendo por tanto la aparicion de fistulas y estenosis. No precisa la reali acion de enterotomias adicionales y se facilita el acceso a cada anastomosis por separado en caso de necesidad de reintervencion.

PRIMARY ADENOCARCINOMA OF THE URINARY BLADDER:OUR EXPERIENCE Adenocarcinoma of the bladder is an uncommon neoplasm. Depending on its origin it is classified in: primary, secondary and urachal. Generally it grows to the density of the wall, so its clinical aparience is delayed, with the subsequent delayed diagnosis and although an agressive treatment is performed, it frequently has a very bad prognosis. Since there are very few publications of this kind of neoplasm in the literature the lines of actuation in this pathology are not well established. We report the eleven cases of adenocarcinoma neoplasm of the bladder treated in our centre and review the literature.

Considering the scarcity of organs for transplantation, one possible solution is the use of grafts from aged donors (over 50 years). We have reviewed our experience in the case of kidney transplantation considering the period from 1989-1994 in order to attain a minimum follow-up of 36 months. We compare three groups: donors aged between 50-60 years (n = 32), donors aged over 60 years (n = 25) and a control group formed by donors of "ideal" ages. The results show that kidneys from donors over 60 years evidence, as compared to the control group, a higher incidence of acute tubular necrosis (p = 0.032), significantly higher blood creatinine levels in all the intervals considered, and a graft survival which is 14% less at 12 months and 40% less at 36 months (p = 0.0009). These differences are most probably to be attributed to the changes caused in these organs by advancing age and by previous pathological situations, as we have not detected a higher incidence of immunologic or surgical complications.

To describe the most relevant features of matrix lithiasis, an infrequent type of lithiasis seldom reported since the generalization of extracorporeal shock wave lithotripsy.We report a clinical case and analyze the most important bibliography found by MEDLINE search (1950-1999). We will focus on the physiopathology and etiology of these stones to understand its development and the clinical presentation showed by these patients.Matrix lithiasis is a very rare entity, described almost one century ago. It is mainly composed of lithiasis matrix, and the percentage of mineral content is really low in comparison with usual stones. Persistent urinary tract infection is another constant in these patients, which to some extent conditions the modification of the usual urinary components, creating a series of the disturbances within the urinary tract that favour the aggregation of the components of the lithiasis matrix up to the formation of a stone, without need of aggregation of mineralized crystals.A high degree of suspicion is necessary for the diagnosis of matrix lithiasis, because it does not show the usual clinical picture of a renal stone. Exhaustive lavage of caliceal cavities and elimination of bacteriuria are essential elements for treatment, in order to avoid recurrence of the disease.

INTRODUCCION Desde que hace unos 100 anos, la Urologia se individualizo de la Cirugia, se ha consolidado como especialidad por la relevancia de las patologias que aborda y por nuevas tecnicas especificas como la urografia, la endoscopia, los trasplantes renales o la litotricia, entre otros. En Espana, la Urologia ha experimentado importantes cambios a lo largo de los ultimos anos, y es de esperar que continue este proceso en el futuro previsible. La innovacion tecnologica, los avances cientificos, los cambios organizativos en el Sistema Nacional de la Salud, los cambios sociales, y los cambios demograficos, de alguna manera afectaran la organizacion de la asistencia urologica, la demanda asistencial, incluso la prevalencia de algunas enfermedades urologicas. La oferta de servicios asistenciales tambien puede ser cambiante en funcion de los urologos que se jubilan, residentes que se forman, servicios que se crean, y otros factores. La inadecuacion de la oferta a la demanda puede crear desajustes, tanto en el ambito nacional como regional. Los desajustes pueden dar lugar a tiempos de espera inaceptables, variabilidad en la carga de trabajo, variabilidad en la calidad, desigualdad en el acceso, o ineficiencia en la prestacion de la atencion urologica. Con estos antecedentes, la Asociacion Espanola de Urologia (AEU) se formulo diversas preguntas centradas en el numero de urologos que realmente hay en Espana, y en estimar los urologos que podrian ser necesarios en el futuro. Para responder a estas cuestiones, la AEU encargo un estudio a Tecnicas Avanzadas de Investigacion en Servicios de Salud (TAISS) en Julio de 2002. Abbott Laboratories S.A. (Abbott), patrono de la AEU, patrocino el estudio. En este articulo se presenta un resumen del estudio y sus hallazgos fundamentales. En un futuro proximo se publicara el estudio completo en distintos formatos, incluidas versiones accesibles en la pagina web de la AEU.