Volume 73, may - june 2013, Number 3 ISSN-0185
Transcripción
Volume 73, may - june 2013, Number 3 ISSN-0185
Volume 73, may - june 2013, Number 3 ISSN-0185-4542 ÓRGANO OFICIAL DE DIFUSIÓN DE LA SOCIEDAD MEXICANA DE UROLOGÍA Editor Dr. José Guzmán Esquivel Co-editor Miguel Maldonado Ávila ISSN-0185-4542 * ARTEMISA * SSALUD * LILACS * IMLA * PERIODICA-UNAM * IMBIOMED * LATINDEX Vesicourethral anastomosis after radical prostatectomy using the Capio suturing system Complications secondary to transrectal ultrasoundguided prostate biopsy Correlation between PSA and IPSS values, type of work, and educational level in a Spanish occupational population Transrectal ultrasound. A posterior paravesical lesion is identified at the seminal vesicle site. pp. 146-149 A review of our experience in treating male urinary incontinence through the AMS800™ artificial urinary sphincter Crystallographic analysis of 475 urinary tract calculi at the Hospital San José Tec Salud in Monterrey, N. L. Urinary diversion postoperative complication management Simple computed tomography scan. The image clearly shows a lesion at the left lateral base of the bladder. pp. 146-149 Contrast-enhanced computed tomography scan that newly identifies the left seminal vesicle lesion. pp. 146-149 www.elsevier.es Primary diffuse large B-cell lymphoma of the prostate: a case report •CONTENIDO •CONTENTS editorial editorial Estratificar el riesgo genético del cáncer de próstata para predecir la progresión de la enfermedad después de la prostatectomía radical 107 Stratifying genetic risk for prostate cancer to predict disease progression after radical prostatectomy J. Guzmán-Esquivel J. Guzmán-Esquivel ArtículoS originalES ORIGINAL ARTICLES Anastomosis vesico-uretral tras prostatectomía radical utilizando el sistema de sutura Capio 109 D. Hernández-Alcaraz, et al. 114 P. Cruz García-Villa, et al. Complications secondary to transrectal ultrasound-guided prostate biopsy 114 P. Cruz García-Villa, et al. Correlación entre los valores de APE, IPSS, tipo de trabajo y nivel educacional en población laboral española 119 M. T. Vicente-Herrero, et al. Correlation between PSA and IPSS values, type of work, and educational level in a Spanish occupational population 119 M. T. Vicente-Herrero, et al. Revisión de nuestra experiencia en el tratamiento de la incontinencia urinaria en el varón mediante el esfínter urinario artificial AMS-800TM 125 F. X. Elizalde-Benito, et al. A review of our experience in treating male urinary incontinence through the AMS800™ artificial urinary sphincter 125 F. X. Elizalde-Benito, et al. Análisis cristalográfico de 475 cálculos de vías urinarias en el Hospital San José, Tec Salud, en Monterrey, N.L. A. R. Aragón-Tovar, et al. Director General: 109 D. Hernández-Alcaraz, et al. Complicaciones secundarias a biopsia transrectal de próstata guíada por ultrasonido Editada por: Vesicourethral anastomosis after radical prostatectomy using the Capio suturing system 107 130 Crystallographic analysis of 475 urinary tract calculi at the Hospital San José Tec Salud in Monterrey, N. L. A. R. Aragón-Tovar, et al. MASSON DOYMA MÉXICO, SA. Av. Insurgentes Sur 1388, Piso 8, Col. Actipan Del. Benito Juárez, CP 03230, México, D.F. Tels.: 5524-1069, 5524-4920, Fax: 5524-0468. Pedro Turbay Garrido 130 CasoS clínicoS Manejo de las complicaciones postoperatorias en las derivaciones urinarias CLINICAL CASES 136 E. Mayorga-Gómez, et al. Linfoma primario prostático difuso de células B grandes. Reporte de un caso 140 Primary diffuse large B-cell lymphoma of the prostate: a case report 143 Scrotal angiomyolipoma: a clinical case 146 Leiomyoma of the seminal vesicle: a case report and literature review A. J. Camacho-Castro, et al. Comunicación breve Brief report A. J. Manrique, et al. 143 F. J. Flores-Murcio, et al. A. J. Camacho-Castro, et al. Aislamiento de ADN a partir de muestras de orina para la amplificación STR con un nuevo método rápido y seguro 140 D. Ríos-Cruz, et al. F. J. Flores-Murcio, et al. Leiomioma de vesícula seminal reporte de un caso y revisión de la literatura 136 E. Mayorga-Gómez, et al. D. Ríos-Cruz, et al. Angiomiolipoma escrotal, presentación de caso clínico Urinary diversion postoperative complication management 150 DNA isolation from urine samples for STR amplification with a rapid and safe new method A. J. Manrique, et al. 146 150 Rev Mex Urol 2013;73(3):107-108 ÓRGANO OFICIAL DE DIFUSIÓN DE LA SOCIEDAD MEXICANA DE UROLOGÍA www.elsevier.es/uromx Editorial Stratifying genetic risk for prostate cancer to predict disease progression after radical prostatectomy Estratificar el riesgo genético del cáncer de próstata para predecir la progresión de la enfermedad después de la prostatectomía radical T his year, in the month of April, practically one month before the congress of the American Urological Association (AUA), the validation of a genetic test for stratifying risk groups for prostate cancer (CaP) progression1 was published in the Journal of Clinical Oncology. The principal author of this study, Dr. Matthew R. Cooperberg, has commented that with this genetic test, the decision can be made as to when and how to aggressively treat CaP. These types of tests or biomarkers can provide us with data that guide us in our decision-making. CaP is the first cause of malignant tumors in adult men and the second cause of death from malignant diseases. However, many cases of CaP will never be clinically expressed even if they are left untreated. Randomized studies that have compared radical treatment such as surgery with active surveillance, have shown the benefits of this first modality in moderate and high risk CaP patients, but not in patients with low risk for CaP. The Prostate Intervention Versus Observation Trial (PIVOT) study is the most recent of these studies.2 For a long time, stratifying the risk for progression of this disease has been based on certain easily accessible variables, but ones that left a very important gap in relation to low risk patients, who would very probable be over-treated. All of us are aware of the morbidity and mortality resulting from these treatments, even with minimally invasive therapeutic alternatives, and we cannot deny the high percentages of complications in patients that could even die from a cause unrelated to the disease. The test The biomarker known as cell-cycle progression (CCP) identifies the expression of 31 genes related to CaP and 15 constitutive or normalization genes; their expression is quantified with a reference to the value of 1, thus having values of minus 1 or plus 1. After excluding patients that did not enter into the data analysis, 413 remained. These tests were performed on them to determine the gene expression. The CCP score was positive or negative if there was overexpression or underexpression of the genes, respectively. To further strengthen this test, it was compared with and added to a previously validated analysis known as the Cancer of the Prostate Risk Assessment (CAPRA-S), a validated instrument that predicts cancer-specific recurrence and mortality. Finally, the combination of these 2 predictive tests of risk, the CCP and CAPRA-S, was validated. What does this validated instrument give us? It is definitely a useful tool, especially in relation to the uncertainty of how to treat patients after radical prostatectomy. Without a doubt, CCP is an advance in the knowledge of the behavior of neoplastic cells. Even though the test in now available, we still do not know how much it will cost to carry it out, nor do we have * Corresponding author: Zaragoza 377 centro, Colima, Col., México. Telephone: 31231 22121. Email: [email protected] (J. GuzmánEsquivel). 0185-4542 - see front matter © 2013. Revista Mexicana de Urología. Publicado por Elsevier México. Todos los derechos reservados. 108 knowledge about its reproducibility or its access in Mexico. Objectively, we can see that not all the Mexican States are equipped with molecular biology laboratories that can perform these tests and for those that are, the costs of carrying them out would be a determining factor. Taking into consideration that the current expense for determining the expression of one gene is $1,500.00 MXN, the identification of 31 genes and their expression would be significantly higher. We also know that there are microarrangements that could simplify these processes, but it is not known how feasible they would be in the short-term practice. The information is now available, the tests are being performed, and the CCP system is validated. Now we must wait and see how viable it will be in our environment. Every day more knowledge is generated, some of which transcends, benefitting the patients. J. Guzmán-Esquivel References 1. Cooperberg MR, Simko JP, Cowan JE, et al. Validation of a CellCycle Progression Gene Panel to Improve Risk Stratification in a Contemporary Prostatectomy Cohort. J Clin Oncol 2013;31:1428-1434. 2. Wilt TJ, Brawer MK, Jones KM, et al. Radical prostatectomy versus observation for localized prostate cancer. N Engl J Med 2012;367:203-213. Dr. José Guzmán-Esquivel Editor, Revista Mexicana de Urología Rev Mex Urol 2013;73(3):109-113 ÓRGANO OFICIAL DE DIFUSIÓN DE LA SOCIEDAD MEXICANA DE UROLOGÍA www.elsevier.es/uromx Original article Vesicourethral anastomosis after radical prostatectomy using the Capio suturing system D. Hernández-Alcaraz*, P. Moreno-Arcas, E. Carmona-Campos and A. Castro-León Urology Service, Hospital Comarcal de Antequera, Málaga, Spain KEYWORDS Radical prostatectomy; Urinary continence; Vesicourethral reconstruction; Spain Abstract Background: Proper vesicourethral anastomosis after radical prostatectomy is fundamental for preventing urinary extravasations and subsequent strictures, as well as for achieving satisfactory continence. A simpler and more watertight suture was attempted through the Capio suturing system. Methods: The 80 radical prostatectomies carried out at our service using the Capio suturing system for vesicourethral reconstruction are presented. In all patients the neurovascular bundle and bladder neck were spared. Six 2-0 sutures were used for the reconstruction and bladder catheter was maintained for 10 days. Results: The mean surgery duration was 163 minutes from the time of skin incision to the placement of the final staple. The mean suturing time was 20 minutes and the mean urinary drainage volume was 100 cc the first day and 40 cc the second day; the fluid had serohematic characteristics. The drain was removed on the third day, if there were no complications. Mean hospital stay was 4 days. Continence rates in our case series were: 35% after bladder catheter removal; 61% at 3 months; and 91.7% at one year. The results regarding continence were similar to those described in the medical literature for this type of technique. The mean suturing time and hospital stay were lower, in relation to conventional suturing. Conclusions: The Capio suturing system allows for simple and rapid vesicourethral sutures, obtaining good urethral realignment and reducing urinary leakage. * Corresponding author at: Servicio de Urología, Hospital Comarcal de Antequera. Av. Poeta Muñoz Rojas, C.P. 29200, Málaga, España. Telephone: 69605 8697. Email: [email protected] (D. Hernández-Alcaraz). 0185-4542 - see front matter © 2013. Revista Mexicana de Urología. Publicado por Elsevier México. Todos los derechos reservados. 110 Palabras clave Prostatectomía radical; Continencia urinaria; Reconstrucción vesico-uretral; España. D. Hernández-Alcaraz et al Anastomosis vesico-uretral tras prostatectomía radical utilizando el sistema de sutura Capio Resumen Introducción: Una buena anastomosis vesico-uretral después de una prostatectomía radical es fundamental para evitar extravasaciones urinarias y estenosis posteriores, así como para conseguir una buena continencia. Con el sistema Capio, intentamos realizar una sutura vesico-uretral más sencilla y estanca. Material y métodos: Presentamos 80 prostatectomías radicales realizadas en nuestro Servicio, en las cuales hemos utilizado el sistema de sutura Capio para la reconstrucción vesico-uretral. En todos los pacientes, se realiza preservación de bandeletas (cuando está indicado) y de cuello vesical. Se utilizan 6 puntos de 2-0 para la reconstrucción. La sonda vesical se mantiene 10 días. Resultados: La media de tiempo quirúrgico es de 163 minutos, desde la incisión en la piel hasta la colocación del último agrafe. El tiempo de sutura medio es de 20 minutos. La media de drenaje urinario es de 100 cc el primer día y 40 cc el segundo día, de características serohemáticas. El drenaje es retirado al tercer día, salvo complicaciones. La estancia media es de 4 días. Las tasas de continencia tras retirada de la sonda vesical son en nuestra serie de: 35%, tras retirada de ésta; 61% a los 3 meses y 91.7% al año. Los resultados en cuanto a continencia son similares a los observados en la literatura médica, comparados con los descritos con este tipo de técnica. El tiempo de sutura y la estancia media se reducen con respecto a la sutura convencional. Conclusiones: El sistema de sutura Capio, permite realizar la sutura uretro-vesical de forma sencilla y rápida; consiguiendo un buen realineamiento uretral y disminuyendo las fugas urinarias. Introduction The principal aim of radical prostatectomy is to eliminate the prostate tumor. Secondary aims paid attention to, in order of importance, are urinary continence and erectile dysfunction. Vesicourethral anastomosis after radical prostatectomy is a simple procedure that can be difficult to perform in deep pelvises or when there is not much of a urethral stump. A well-performed suture is essential for preventing urinary extravasations and later strictures, as well as for obtaining good continence. Urinary continence will depend on various factors such as neurovascular bundle and the bladder neck preservation, the size of the prostate, the experience of the surgeon, and the urinary extravasations. Through our suturing system, we attempt to reduce the anastomosis operative time and urinary leaks; we have also compared our functional results with those found in the existing medical literature. Methods We present 80 radical prostatectomies performed at our Service using the Capio suturing system for vesicourethral reconstruction. In all patients nerve bundles (when indicated) were spared, as was the bladder neck, with eversion of the mucosa at the level of the bladder neck. We used the Capio suturing system for vesicourethral junction reconstruction. This instrument is a needle-driving device that is introduced into the urethra with the help of a bladder catheter. Once inside the urethra, by pressing the device’s upper button, the needle driver places a suture in the urethra from the inside outwards (fig.1). The needle uses re-absorbable 2-0 suture and has a harpoon at the end that is introduced into the urethra; at the opposite end it has a cylindrical Tapercut® needle that is used to suture the bladder neck (figs. 2 and 3). After placing 6 sutures at the level of the urethra, we could place the suture at the bladder neck from the inside towards the outside, by means of a conventional holder. We used a 20 Ch 2-way silicon catheter with a perforated tip (fig.4). The bladder catheter was removed 10 days after the procedure, without imaging studies to confirm suture watertightness. Results The mean age of our patients that underwent radical prostatectomy was 59 years and the mean prostate-specific antigen (PSA) at the time of diagnosis was 7.39 ng/dL. The characteristics of our case series are described in table 1 and the clinical and pathologic stages are described in tables 2 and 3. The mean surgery duration was 163 minutes, from the time of skin incision to the placement of the last staple. The mean suturing time was 20 minutes (defined as the first suture at the level of the urethra to the confirmation of watertightness). The mean urinary drainage was 100 cc the first day and 40 cc the second day; this drainage had serohematic characteristics. The drain was removed on the third day, if there were no complications or suspicion of urinary leakage. Vesicourethral anastomosis after radical prostatectomy using the Capio suturing system 111 Figure 1 The suturing instrument is shown, as well as the loading of the suture thread. Figure 3 Placing one of the 6 sutures. Figure 4 Finalized urethrovesical suture. Figure 2 Bladder neck preservation. The mean hospital stay of our patients was 4 days. Six cases of urinary leakage were detected within the first 48 hours (due to high drain output, with an increase in creatinine values); and one case of delayed urinary leakage at 7 days after hospital release, associated with bladder catheter manipulation and its obstruction due to coagulates. All cases were conservatively resolved. The continence rates after bladder catheter removal in our case series were: 35%, after removal; 61% at 3 months, and 91.7% at one year (table 4). Continence was defined when the patient referred to having no urinary leaks or no drops of urine requiring a compress for protection. 112 D. Hernández-Alcaraz et al Table 1 Descriptive variables of the case series presented Minimum Age (years) Maximum Mean Typical deviation 49 71 59.09 4.95 Prostate volume(cm3) 16.7 80.00 39.40 16.40 Hospital stay (days) 4.00 10.00 6.03 1.40 90 240 163.33 45.55 Sum 6(3+3) 7(3+4) 7(4+3) 8(4+4) 8(5+3) Percentage 66.7 15.2 6.1 6.1 3.0 Operative time (min) Gleason Score 100 Table 3 Postoperative pathologic stage Table 2 Clinical stage and percentage of cases Percentage Valid percentage Accumulated percentage T1c 78.8 78.8 78.0 T2a 12.1 12.1 90.9 T2b 9.1 9.1 100 Clinical stage Total 100 100 Two percent of the patients presented with urethrovesical junction stricture that was resolved through endoscopic procedures. Discussion The main objective of radical prostatectomy is to eliminate the prostate tumor. Secondary objectives given attention, in order of importance, are urinary continence and erectile dysfunction. Urinary continence after radical prostatectomy is generally good and varies depending on the experience and skill of the specialist. Surgeons that perform large numbers of radical prostatectomies obtain complete continence for more than 90% of the patients. The return to continence is associated with the patient’s age; if the patients are under the age of 50 years the continence rate is 95%, and if they are above the age of 70 years, it is 85%. The small number of patients that do not have a return to continence require the placement of a suburethral sling or an artificial urinary sphincter.1 Regarding robotic surgery, the Vatikuti Urology Institute has published continence rates of 95.2% at 12 months, with 26% of the patients continent after bladder catheter removal, and 55% at 4 weeks after the procedure.2 Other authors have achieved continence rates after bladder catheter removal of 25% after removal, 32% at one month, and 76% at 9 months.3 Pathologic stage Percentage Valid percentage Accumulated percentage T2a 21.2 21-9 21.9 T2b 3.0 3.1 25.0 T2c 63.6 65.6 90.6 T3a 3.0 3.1 93.8 T3b 6.1 6.3 100 Total 100 Table 4 Urinary continence rate Urinary continence 1.5 months 3 months 6 months 12 months 35.0% 61.1% 80.0% 91.7% The surgical technique employed is fundamental for attaining correct continence and sparing the bladder neck improves this function. 4 It was first described by Gaker et al. in 1996, and in 2004 they presented the results of a retrospective study on 275 patients. There was immediate total continence (without compress) after catheter removal in 36% of the patients, in 69% at 14 days, and in 78% at 7 weeks, compared with 1%, 6%, and 41% of the 80 patients that underwent the standard technique. In addition, they described a reduction in bladder neck strictures. Many articles have been published on this subject, with a wide variety of results and with different approaches.5 Vesicourethral anastomosis after radical prostatectomy is a simple procedure that can nevertheless become difficult in deep pelvic cavities or when there is not much of a Vesicourethral anastomosis after radical prostatectomy using the Capio suturing system urethral stump. A well-performed suture with mucosa-tomucosa coaptation and a lack of tension in the urethrovesical suture are essential for preventing urinary extravasations and for attaining good continence. There are numerous studies in the medical literature in which improvements in the suturing technique have been attempted, as well as those reporting on techniques that endeavor to optimize the urinary continence rate. The continence rates described in the literature with this suture system are 86.6% after catheter removal, 90% at 1.5 months, and 98% at one year.6,7 The continence rates of our case series were somewhat lower after immediate catheter removal, and similar in relation to the other times. It should be kept in mind that the differences can be due to the multiple surgical techniques among centers, the diverse skills of the surgeons, and even on the definition given to continence. The literature describes 4.6% cases of vesicourethral stricture at 8 weeks after bladder catheter removal that have been satisfactorily resolved through a single endoscopic procedure.6,7 In our case series 2% of the cases presented with stricture at 3 months after bladder catheter removal. The literature also shows that the rates of urine leakage at the suture associated with a higher rate of incontinence and fibrosis of the anastomosis9 have gone down. The urethrovesical suture time and the mean hospital stay were reduced with respect to conventional suture.9,10 Conclusions The Capio suturing system enables simple and rapid urethrovesical suture, obtaining good urethral alignment with a reduced number of urine leaks. Financial disclosure No financial support was received in relation to this article. 113 Conflict of interest The authors declare that there was no conflict of interest. References 1. Catalona WJ, Han M. Definitive Therapy for Localized Prostate Cancer-An Overview. En: Campbell-Walsh. Urology. 9Th edition. Philadelphia: Saunders; 2007. 2. Menon M, Shrivastava A, Kaul S, et al. Vattikuti Institute prostatectomy: contemporary technique and analysis of results. Eur Urol 2007;51:648-658. 3. Rocco B, Gregori A, Stener A, et al. Posterior Reconstruction of the Rhabdosphincter Allows a Rapid Recovery of Continence after Transperitoneal Videolaparoscopic Radical Prostatectomy. European Urology 2007;51:996-1003. 4. Freire MP, Weinberg AC, Ley Y. Anatomic Bladder Neck Preservation During Robotic-Assisted Laparoscopic Radical Prostatectomy: Description of Technique and Outcomes. European Urology 2009;56:972-980. 5. Gaker D, Steel B. Radical prostatectomy with preservation of urinary Continence: pathology and long-term results. J Urol 2004;172:2549-2552. 6. Consultado el 28 de mayo de 2013. http://www.ics.org/Abstracts/Publish/47/000016.pdf se 7. Consultado el 28 de mayo de 2013. http://www.ics.org/Abstracts/Publish/47/000546.pdf 8. Borboroglu PG, Sands JP, Roberts JL. Risk factors for vesicourethral anastomotic strictures after radical prostatectomy. Urology 2000;56:96-100. 9. Walsh PC, Partin AW. Anatomic Radical Retropubic Prostatectomy. In: Campbell-Walsh. Urology. 9Th edition. Philadelphia: Saunders; 2007. 10.Barré C, Pocholle P, Chauveau P. Improving bladder neck division in radical retropubic prostatectomy by prior dissection of the seminal vesicles and vasa deferentia. Eur Urol 1999;36(2):107-110. Rev Mex Urol 2013;73(3):114-118 ÓRGANO OFICIAL DE DIFUSIÓN DE LA SOCIEDAD MEXICANA DE UROLOGÍA www.elsevier.es/uromx Original Article Complications secondary to transrectal ultrasound-guided prostate biopsy P. Cruz García-Villaa,*, D. López-Alvaradoa, H. Castellanos-Hernándezb, M. Estrada-Loyoa, E. Monroy-Bolañosa and M. Schroeder-Ugaldea a Urology Speciality Residency, Urology Service, Hospital Regional “Lic. Adolfo López Mateos”, ISSSTE, Mexico City, Mexico b Uro-oncology Speciality, Hospital Regional “Lic. Adolfo López Mateos”, ISSSTE, Mexico City, Mexico KEYWORDS Biopsy; Prostate; Complications; Mexico. Abstract Background: Transrectal ultrasound (TRUS)-guided prostate biopsy is a definitive procedure for diagnosing prostate cancer (CaP) and it can have complications. Aims: To report the frequency of complications following TRUS-guided prostate biopsy. Methods: An analytic, descriptive, retrolective, cross-sectional study of 245 patients having undergone TRUS-guided prostate biopsy was conducted. Results: The mean age was 68 years and patients had a mean prostate-specific antigen (PSA) value of 20.2 ng/ml. They presented with hematuria for a mean 1.7 days and hematochezia for a mean 0.5 days. Mean prostate volume was 62.4 cc. A total of 35.6% of the patients had a positive malignancy result. Fever presented in 5.7% of the patients and hematospermia in 9.8%. A total of 69% of the patients presented with hematuria and 2.4% with acute urine retention. Discussion: The use of antibiotics, dietary measures, and intestinal preparation ensures a low frequency of infectious complications with this method. Our results coincide with those reported on in the medical literature. The low frequency of complications makes it the method of choice for the definitive diagnosis of CaP. Conclusions: TRUS-guided prostate biopsy is not innocuous. The use of prophylactic antibiotics has resulted in a low complication frequency rate for the procedure, making it the definitive diagnostic method for CaP. * Corresponding author at: Av. Universidad N° 1321, Colonia Florida, Delegación Álvaro Obregón, C.P. 01030, México D.F., México. Telephone: 5322 2300. Email: [email protected] (P. Cruz García-Villa). 0185-4542 - see front matter © 2013. Revista Mexicana de Urología. Publicado por Elsevier México. Todos los derechos reservados. Complications secondary to prostate biopsy Palabras clave Biopsia; Próstata; Complicaciones; México. 115 Complicaciones secundarias a biopsia transrectal de próstata guíada por ultrasonido Resumen Introducción: La biopsia transrectal de próstata (BTRP) es el procedimiento definitivo para el diagnóstico de cáncer de próstata (CaP). La BTRP tiene posibles complicaciones. Objetivo: Reportar la frecuencia de complicaciones posterior a la BTRP. Material y método: Estudio transversal, analítico, descriptivo, retrolectivo de 245 pacientes con BTRP. Resultados: Edad promedio de 68 años. Los pacientes tenían un antígeno prostático específico (APE) de 20.2 ng/mL. Presentaron hematuria 1.7 días y hematoquezia 0.5 día. El volumen prostático medio fue de 62.4 cc. El 35.6% tuvieron un resultado positivo para malignidad. Se presentó fiebre en el 5.7%, hemospermia en el 9.8%. El 69% presentó hematuria y el 2.4% retención aguda de orina. Discusión: El uso de antibióticos, médidas dietéticas y preparación intestinal hacen que éste sea un método con baja frecuencia de complicaciones infecciosas. Nuestros resultados coinciden con lo reportado en la literatura médica. La baja frecuencia de complicaciones la hacen el método de elección, para el diagnóstico definitivo de CaP. Conclusiones: La BTRP guíada por ultrasonido (USG) no es inocua. El uso de antibióticos profilácticos ha logrado una frecuencia de complicaciones baja. La BTRP es el método diagnóstico definitivo para el CaP. Introduction Methods Early detection of prostate cancer (CaP) has greatly benefitted from efforts of systematic detection, with the introduction of prostate-specific antigen (PSA) and the refinement of transrectal ultrasound (TRUS)-guided prostate biopsy techniques.1 Taking into account the figures from the National Health Data System (SINAIS for its initials in Spanish), CaP in Mexico is the eighth cause of death in men above the age of 65 years, with 4,435 deaths from this pathology reported in 2007. In 2008, it was reported as the twelfth cause of death in men of all ages, representing 1.7% of the deaths in the male population. Of the total of deaths by cancer in the country, Mexico City holds first place with 478 deaths (15.7/100,000 inhabitants), followed by Jalisco with 473 (21/100,000 inhabitants), and the State of Mexico with 411 (12.2/100,000 deaths).2 TRUS-guided prostate biopsy is currently regarded as the criterion standard for CaP diagnosis in patients presenting with elevated PSA or abnormal digital rectal examination (DRE). As with any procedure, TRUS-guided prostate biopsy is not free from complications. An average of 250 TRUS-guided prostate biopsies are annually performed in our hospital, making it one of the most frequently carried out procedures in our daily clinical practice; therefore it is important to analyze its main complications in an effort to improve study and prevention protocols. The aim of this study was to report the frequency of complications following TRUS-guided prostate biopsy performed at the Hospital Regional “Lic. Adolfo López Mateos” del ISSSTE. From a total of 420 biopsied patients at our hospital, a cross-sectional, analytic, descriptive, and retrolective study was conducted on 245 patients that, after undergoing biopsy, answered a telephone questionnaire applied to investigate if there were any complications. All the patients underwent TRUS-guided prostate biopsy with the same technique. Twenty-four hours prior to the procedure patients were given a liquid diet, and 12 and 6 hours before biopsy they were given an enema. They also received antibiotic prophylaxis of 500 mg oral ciprofloxacin every 12 hours 2 days prior to the procedure. All patients gave their signed informed consent before undergoing TRUSguided prostate biopsy. All biopsies were performed with ESAOTE My LabTM Desk ultrasound equipment using a 12 Hz intracavitary transducer. Anesthetic infiltration of the periprostatic segments was done with simple 2% xylocaine under ultrasound control with an 18G shiba needle. The biopsies were performed with a 22G needle. A total of 12 cores were taken, using the sextant regimen for each lobe. In patients having had a previous negative biopsy, a total of 18 cores were taken. After the procedure, the patients were given a bland diet, 500 mg oral ciprofloxacin every 12 hours for 3 more days, and 500 mg oral paracetamol every 8 hours for 3 days. They were informed as to alarm signs and symptoms and had open emergency room appointments. The frequencies, means, standard deviations, and percentages of the results were analyzed using the IBM SPSS v. 19 program. 116 P. Cruz García-Villa et al Table 1 Result comparison with a previous study 2011 (N=117) 3 2012 (N=45) Age 69 ± 8 68.4 ± 8.8 High blood pressure 25.6% 24.9% Type 2 DM 12.8% 10.6% 20.4 (4.53 – 273) 20.2 (3.3 – 273) 57.1 ± 25 (15.6 – 130) 62.4 ± 31.7 (15.6 – 189) Normal 78.6% 77.4% Suspicious 21.4% 22.6% PSA (ng/mL) Prostate volume (mL) Digital rectal exam Result Positive for malignancy 33.3% 35.6% Negative for malignancy 66.7% 64.4% Acute urine retention 5.1% 2.4% 6% 5.7% Fever Hematospermia 10.3% 9.8% Days with hematuria 2.14 1.78 Days with hematochezia 1.5 0.5 DM: diabetes mellitus; PSA: prostate-specific antigen. Results Of the 245 patients that answered the questionnaire, the mean age was 68.4 ± 8.8 years with a 42 to 89-year interval. A total of 24.9% of the patients had a past medical history of high blood pressure and 10.6% presented with type 2 diabetes mellitus. A total of 14.3% of the patients had more than one comorbidity. The mean PSA was 20 ng/mL, with an interval of 3.3 to 273 ng/mL. The mean prostate volume measured by TRUS at the time of biopsy was 62.4 ± 31.7 mL. Unremarkable DRE was found in 77.4% of the patients at the time of biopsy, whereas some abnormality was suspected in 22.6% of the patients. The procedure was the first biopsy for 77.1% of the patients (189 cases), the second for 15.1% (37 cases), and the third for 6.9% (17 cases). Of the patient total (245 cases), 35.6% presented with positive malignancy in the biopsy (table 1). In relation to the corresponding complication data, hematuria presented in 68.6% of the patients. The mean hematuria duration was 1.78 days with an interval of 0 to 20 days. Hematospermia presented in 9.8% (24 cases) and was second in frequency. Some type of symptomatology suggestive of a vasovagal reaction during biopsy presented in 8.6% of the patients. A total of 6.9% (17 cases) referred to hematochezia after biopsy that lasted a mean of 0.5 days. A total of 8.6% (21 cases) of the patients referred to difficulty in initiating micturition after TRUS-guided prostate biopsy and 2.4% (6 cases) presented with acute urine retention that required a bladder catheter. A total of 42% (103 cases) complained of dysuria after TRUS-guided prostate biopsy. The mean duration of dysuria was 1.5 days. According to the visual analog scale for pain, the mean score was 4.5 ± 2.6 points. A total of 2% (5 cases) of the patients said they selfmedicated after the procedure (fig. 1). Only 5.7% (14 cases) of the patients presented with fever, and only 2.9% (7 cases) required hospitalization for some reason. There were no cases of severe sepsis and no deaths related to the biopsy. Discussion In 2011, our group first published the results related to the frequency of complications due to prostate biopsy at our hospital.3 In the present study, we reported the results from a larger sample for the purpose of determining whether our figures remained the same or were modified (table 1). TRUS-guided prostate biopsy is the procedure of choice for CaP diagnosis. Indications for performing prostate biopsy are the presence of elevated PSA or an increase in prostatic consistency or nodule upon DRE. The utilization of TRUS of the prostate, first described by Watanabe in 1968, expanded to include its systematic clinical use with the advances in ultrasound technology and the introduction of sextant biopsy protocols, guided by the Hodge protocols in 1989.1,4 TRUS-guided prostate biopsy has been very widely used in the diagnosis of CaP. The procedure can be associated with significant morbidity in a small proportion of patients. Hemorrhagic complications are the most frequent, followed by infection presenting as simple urinary tract infection (1.2% to 11.3%) or complicated with fever (1.4% to 4.5%).1,5 The mortality rate following a TRUS-guided prostate biopsy is estimated at 0.09%.6 Other much less frequent complications are acute urine retention and prolonged rectorrhagia.7 Complications secondary to prostate biopsy 117 2% Hematuria 42% Hematospermia Vasovagal reaction Hematochezia Urinary stress 2.40% Urinary retention 68.60% 8.60% Dysuria Self-medication 6.90% 8.60% 9.80% Figure 1 Complication percentage after TRUS-guided prostate biopsy. In our study, hematuria was the most frequent complication, with a percentage of 68.6%, followed by hematospermia at 9.8%. In accordance with other studies, hematuria can present from 12% up to 60%, whereas hematospermia on average appears in 10%.3 Fever presented in 5.7% of the patients. The fact that we did not carry out control urine culture after the biopsy is a limitation of our study. Because of this, we cannot determine the precise number of urinary infections directly related to biopsy. Following the recommendation of the American Academy of Urology regarding prophylaxis with fluoroquinolones prior to TRUS-guided prostate biopsy, we administered 500 mg of oral ciprofloxacin every 12 hours to all patients 2 days prior to the biopsy and 3 days after.8,9 Upon comparing our present results of fever after TRUS-guided prostate biopsy (5.7%) with the figures from our previous study (6%), we found that there was no increase in the clinical cases of infection, nor data that suggested resistance to ciprofloxacin use.10 We consider prior intestinal preparation to be useful in reducing infection. The mechanical sweeping of bacteria found in the rectum through the use of laxatives, promotes a reduction in the risk for infections from gram-negative bacteria. A slight increase in the positive biopsy rate of 35.6% was striking in the present study. This result could be due to a certain bias, given that this study only included patients that answered the questionnaire, whereas in another study conducted by our group on 420 patients, the percentage of positivity was 33.8%, the same as in the study published in 2011. TRUS-guided prostate biopsy is an adequate detection method because it is safe, accessible, ambulatory, and tolerable. The use of antibiotic prophylaxis and previous anesthesia makes it well tolerated by patients. Despite taking all the precautionary measures for reducing the risks for infection and hemorrhage, they can still persist. Therefore, we believe that TRUS-guided prostate biopsy should only be performed when there is an indication justifying it. Likewise, the opportune suspension of anticoagulants or anti-platelet drugs, the absence of urinary infection, the initiation of antibiotic prophylaxis, and intestinal preparation are all factors that we feel are necessary for carrying out biopsy. It is also our opinion that those patients needing anticoagulant maintenance that have an increased risk for bleeding should be hospitalized to undergo biopsy. This way, there can be strict surveillance before and after the procedure. Today there are recommendations and guidelines supported by different associations with respect to TRUS-guided prostate biopsy. However, we believe that the experience at each hospital and in each country can have variations and therefore it is important to carry out pertinent modifications to the protocol being used in order to offer the patient a procedure that has a minimum of risks and a maximum detection rate. Conclusions TRUS-guided prostate biopsy continues to be the definitive diagnostic procedure for CaP. Even though there is a risk for complications, their low percentage makes it a suitable and relatively safe method. When certain preventive measures are carried out, such as antibiotic prophylaxis, intestinal preparation, and the suspension of anticoagulants, the risk for complications is reduced. Conflict of interest The authors declare that there is no conflict of interest. Financial disclosure No financial support was received in relation to this article. References 1. Djavan B, Waldert M, Zlotta A, et al. Safety and morbidity of first and repeat transrectal ultrasound-guided prostate needle biopsies. Results of a prospective European prostate cancer detection study. J Urol 2001;166(3):856-860. 118 2. Consultado el 29 de mayo de 2013. Sinais.salud.gob.mx. 3. Castellanos-Hernández H, Cruz García-Villa P, Navarro-Vargas JC, et al. Frecuencia de complicaciones de la biopsia transrectal de próstata ecodirigida. Rev Mex Urol 2011;71(2):81-86. 4. Hodge KK, McNeal JE, Terris S, et al. Random systematic versus directed ultrasound-guided transrectal core biopsies of the prostate. J Urol 1989;142(1):71-74. 5. Aus G, Ahlgren G, Bergdahl S, et al. Infection after transrectal core biopsies of the prostate-risk factors and antibiotic prophylaxis. Br J Urol 1996;77(6):851-855. 6. Ismail M, Saini A, Nigam R. Ciprofloxacin-resistant infection after transrectal ultrasonography-guided prostate biopsy: should we reassess our practice? BJU Int 2011;108(3):305-306. P. Cruz García-Villa et al 7. Dodds Pr, Voucher JD, Shield DE. Are complications of transrectal ultrasound-guided biopsies of the prostate gland increasing? Conn Med 2011;75(8):453-457. 8. Wolf JS Jr, Bennett CJ, Dmochowski RR et al. Best practice policy statement on urologic surgery antimicrobial prophylaxis. J Urol 2008;179(4):1379-1390. 9. Kapoor DA, Klimberg IW, Malek GH, et al. Single dose oral ciprofloxacin versus placebo for prophylaxis during transrectal prostate biopsy. Urology 1998;52(4):552-558. 10. Loeb S, Ballentine C, Berndt SI, et al. Complications after prostate biopsy: Data From SEER-Medicare. J Urol 2011;186(5):18301834. Rev Mex Urol 2013;73(3):119-124 ÓRGANO OFICIAL DE DIFUSIÓN DE LA SOCIEDAD MEXICANA DE UROLOGÍA www.elsevier.es/uromx Original article Correlation between PSA and IPSS values, type of work, and educational level in a Spanish occupational population M. T. Vicente-Herreroa,*, Á. A. López-Gonzálezb, M. V. Ramírez-Iñiguez de la Torrec, L. M. Capdevila-Garcíad and M. J. Terradillos-Garcíae a Occupational Medicine Speciality, Grupo Correos-Valencia, Grupo de Investigación en Medicina del Trabajo (GIMT), Spain Occupational Medicine Speciality, Grupo de Investigación del IUNICS, Grupo de Investigación en Medicina del Trabajo (GIMT), Spain b c Occupational Medicine Speciality, Grupo Correos-Albacete, Grupo de Investigación en Medicina del Trabajo (GIMT), Spain Occupational Medicine and Family Medicine Speciality, Servicio de Prevención Mancomunado MAPFRE, Grupo de Investigación en Medicina del Trabajo (GIMT), Valencia, Spain d e Occupational Medicine Speciality, INSS-Madrid, Spain KEYWORDS Benign prostatic hyperplasia; Prostate cancer; Prostate disease; Occupational health; Occupational medicine; Urology; Spain. Abstract Background: By way of the Occupational Health Department and the occupational physician, the International Prostate Symptom Score (IPSS) questionnaire was used to screen for benign prostatic hyperplasia (BPH), and prostate-specific antigen (PSA) was used as a biomarker for the diagnosis, staging, and monitoring of prostate cancer (CaP). Aims: The aim of our study was to evaluate the influence of the workplace and the educational level of white-collar and blue-collar workers on IPSS and PSA values. Methods: PSA, IPSS, type of work, and educational level of 620 workers from the service sector above the age of 40 years were included. Data were collected during the periodic company health monitoring check-ups. The chi-square test was used for proportion differences and the Student’s t test for the differences in the mean values of age, IPSS, and PSA, according to the type of work and the level of education. Results: There were statistically significant differences in the mean IPSS and PSA values according to the type of work and educational level of the workers, and in the proportions, according to IPSS cataloguing related to the type of work performed. There were no statistically significant differences * Corresponding author at: Telephone: 963 102 752. Spain. Emails: [email protected], [email protected] (M. T. Vicente-Herrero). 0185-4542 - see front matter © 2013. Revista Mexicana de Urología. Publicado por Elsevier México. Todos los derechos reservados. 120 M. T. Vicente-Herrero et al regarding level of education. Conclusions: The PSA and IPSS values were higher in the white-collar workers and the PSA values were also higher in workers with a low educational level. Palabras clave Hipertrofia benigna de próstata; Cáncer de próstata; Enfermedad prostática; Salud laboral; Medicina del trabajo; Urología; España. Correlación entre los valores de APE, IPSS, tipo de trabajo y nivel educacional en población laboral española Resumen Introducción: En Salud Laboral y por el médico del trabajo, se recurre al IPSS como screening de hiperplasia benigna de próstata (HBP) y al antígeno prostático específico (APE), como biomarcador para diagnóstico, estadificación y seguimiento del cáncer de próstata (CaP). Objetivo: El objetivo de nuestro estudio es valorar la influencia que sobre los valores del Índice Internacional de la Sintomatología Prostática (IPSS, International Prostate Symptom Score, por sus siglas en inglés) y APE, tiene el puesto de trabajo desempeñado (white collar-blue collar) y el nivel educacional de los trabajadores. Material y métodos: Se incluyen 620 trabajadores del sector servicios, de más de 40 años valorando APE, IPSS, tipo de trabajo y nivel de estudios, con captación realizada durante los reconocimientos periódicos de vigilancia de la salud. Se aplica el test de ji cuadrada para la diferencia de proporciones y el test de la t-Student para las diferencias en los valores medios de edad, IPSS y APE según tipo de trabajo y nivel de estudios. Resultados: Se observan diferencias estadísticamente significativas en los valores medios del IPSS y APE, según tipo de trabajo y nivel de estudios de los trabajadores, y en las proporciones, según catalogación del IPSS de acuerdo al trabajo realizado. No se observan diferencias significativas según el nivel académico. Conclusiones: Los valores de IPSS y APE son más altos en los trabajadores no manuales (white collar). Los valores de APE son más altos en trabajadores con bajo nivel de estudios. Introduction Benign prostatic hyperplasia (BPH) is a disease with a high prevalence among men over 50 years of age, both in Spain, as well as in countries of a similar sociocultural environment. Approximately 16.5% of the patients with lower urinary tract symptomatology have scores regarded as moderate or severe on the International Prostate Symptom Score (IPSS) that affect quality of life (IPSS ≥ 8).1 Diagnosis can be made through adequate anamnesis, lower urinary tract symptom evaluation through the IPSS, physical examination with a digital rectal exam (DRE), and prostate-specific antigen (PSA) values. All these tests are recommended by the different guidelines for the initial evaluation and they are within reach of all physicians.2,3 Prostate cancer (CaP) is the most frequent tumor in men and is the second cause of death by cancer in men, behind lung cancer. Its early detection and treatment continue to be a pressing and controversial problem.4 The traditional PSA value for indicating prostate biopsy is 4 ng/mL. However, there is an important number of tumors below this value that are not detected unless they are palpable or visible, resulting in the research that has been carried out in recent years on more sensitive and specific next-generation CaP biomarkers.5 The patient’s medical history, IPSS, DRE, and PSA are accessible tools in the Occupational Medicine environment that enable the adequate diagnosis of prostate pathology. The consensus criteria established by the primary attention scientific societies (Sociedad Española de Médicos de Atención Primaria, SEMERGEN; Sociedad Española de Medicina General, SEMG; Sociedad Española de Medicina de Familia y Comunitaria, semFYC) and the Asociación Española de Urología (AEU), are also applicable in the workplace, so there can be coordinated action on the part of the specialities involved.6 The IPSS (Level 3 Evidence, Grade B Recommendation) is a standardized, validated, and self-applicable scale that should not replace the medical interview, but that aids in evaluating the need for treatment and in monitoring the progression of symptom severity during follow-up. There is a validated Spanish version that includes a question on the impact of symptoms on the patient’s quality of life.6 PSA is a prostate tissue marker that is not CaP specific. Various diseases in addition to cancer can cause elevated antigen levels: urinary tract infections (UTIs), BPH, and prostatitis. PSA use is not recommended without a previous DRE. The combination of the two is the most effective method for early CaP detection. Normal values vary with age, but in general a PSA < 4 is regarded as normal; however, 25% of men with CaP have PSA values < 4. Likewise, a high PSA value does not confirm the presence of cancer and a PSA > 10 demands ultrasound-guided biopsy. Correlation between PSA and IPSS values, type of work, and educational level in a Spanish occupational population Table 1 Mean sample values: age, IPSS, PSA Mean TD 95%CI Median Range Age 52.6 4.4 52.3-52.9 52 42-67 IPSS 5.1 4.7 4.7-5.5 3.5 0-29 PSA 1.2 1.1 1.1-1.3 0.95 0.1-6.4 TD: typical deviation; CI: confidence interval. 121 Table 2 Sample characteristics: type of work and educational level n % White-collar* 337 54.4 Blue-collar** 283 45.6 With no studies/ primary school 149 24 Junior high and High school 310 50 University 161 26 *Manual laborers. ** Non-manual laborers. IF PSA is between 4 and 10, the free/total PSA coefficient and PSA velocity must be evaluated. A free/total PSA coefficient > 0.2 (> 20%) suggests BPH, but a free/total PSA coefficient < 0.2 (< 20%) suggests CaP and makes a biopsy necessary. An increase in PSA > 0.75 ng/mL/year also suggests CaP. PSA (Level 3 Evidence, Grade B Recommendation) should be ordered in all patients being seen for prostatism that are over 50 years of age (or before 40-45 years of age if there is a family history of CaP). The high level of this antigen is linked to an increased possibility of developing CaP.2 Given the abovementioned, prostate pathology requires healthcare continuity among the different existing levels in Spain, especially those of primary attention and specialized attention. This is where Occupational Medicine acquires special preventive and diagnostic relevance in the population it has access to. According to the National Statistics Institute (NSI) 2011 data, this population reached 18,104,500 employed workers of all ages, more than 3,346,000 of which are men over the age of 50 years that can be incorporated into prostate pathology prevention campaigns.6 Even though there are multiple studies relating, among other things, the correspondence of results between IPSS and PSA in prostate pathology, few studies have related these values with the educational level or with the type of work performed; there have been studies relating the rejection by patients of DRE to their cultural or educational level, with family income, or with socioeconomic status.7-9 For this reason, we felt it was interesting to introduce the lessstudied parameters of type of work performed and educational level of the worker, together with a much more standardized PSA and IPSS evaluation, in an attempt to find earlier and more effective preventive support strategies of special interest in the workplace. The aim of this study was to establish a possible correspondence between the IPSS and PSA value results obtained in the Spanish blue-collar and white-collar working population with the type of work performed and the cultural and educational level of the participants.10,11 The blue-collar and white-collar concepts have been used in health promotion to evaluate highly prevalent pathologies such as the cardiovascular diseases and the risk for developing them12, or in addictions to alcohol13 or tobacco.14 Methods A total of 620 Spanish workers above the age of 40 years participated in the study. They belonged to the service sector and were randomly selected during the periodic health monitoring check-ups carried out by their companies. Randomization was done by choosing the first and last worker per day that fit the selection criteria. The sample size that provided a 95% confidence interval and 3% accuracy was made up of 615 persons. During the study period from January 2010 to December 2011, 658 men over the age of 40 years had a medical check-up; from that total, 29 had a past medical history of prostate problems and 9 refused to participate in the study, leaving a final sample size of 620 persons. The selection criteria were: men over 40 years of age, not being treated for any neoplastic or hyperplastic prostate pathology, and willingly participating in the study. Informed consent was obtained for epidemiologic use of the data and the study was approved by the Safety and Health Committees of the corresponding companies. PSA values were determined, lower urinary tract symptomatology was evaluated through the validated IPSS, the type of work was established (blue collar/manual laborers, white collar/non-manual laborers), as well as the level of education (no studies/primary school, junior high and high school, university). Concerning the statistical analysis of the results, the chisquare test was applied for the difference in proportions and the Student’s t test for the difference in the mean values of age, IPSS, and PSA according to the type of work and level of education. Results Sample characteristics The sample consisted of 620 workers with a mean age of 52.6 years, a mean IPSS score of 5.1, and a mean PSA value of 1.2 (table 1). Of the workers, 337 were white collar and 283 were blue collar. In regard to the educational level, 149 had no studies or only primary school, 310 attended junior high or high school, and 161 had attended university (table 2). 122 M. T. Vicente-Herrero et al Table 3 Sample distribution according to IPSS and PSA values IPSS* % Mild 484 78.1 Mean TD 95% CI p* Moderate 131 21.1 Age Blue-collar 52.3 4.3 51.8-52.8 > 0.05 5 0.8 White-collar 52.9 4.5 52.4-53.4 Primary school 53.2 4.5 52.5-53.9 Junior high and High school 52 3.9 51.6-52.4 Severe PSA** Table 4 Correlations between age, IPSS, PSA, and the type of work and educational level n Normal 596 96.1 Elevated 24 3.9 * IPSS: 0-7 mild, 8-19 moderate, ≥ 20 severe. ** PSA: elevated starting from 4. IPSS A total of 484 workers had mild UTI symptoms (IPSS 0-7), 131 had moderate symptoms (IPSS 8-19), and 5 presented with severe symptoms (IPSS ≥ 20). PSA values regarded as normal (< 4) were found in 596 workers and 24 presented with elevated figures (≥4) (table 3). Correlation study No difference was observed in relation to age, the type of work, and the educational level (p > 0.05). There was statistical difference in regard to IPSS values and the type of work (p < 0.05), but it was not related to the educational level; statistically significant differences were observed in the PSA values and the type of work and also in the educational level (p < 0.05) (table 4). The cataloging of IPSS severity values according to the type of work and educational level was statistically significant. The chi-square test was applied in order to see the difference in proportions (table 5). The cataloging of PSA values that were regarded as pathologic (≥ 4) was statistically significant in relation to the level of education (p < 0.05), but not for the type of work (table 6). Discussion Occupational medicine as a preventive speciality is legally based on the 1995 Ley de Prevención de Riesgos Laborales15 and the 1997 Reglamento de los Servicios de Prevención16. The functions of the preventive service occupational physician are part of the Occupational Medicine speciality program (approved in 2005) and also include other international recommendations sustained by the ILO (recommendations 161, 171) and the WHO, the majority of which appear in the Framework Directive 89/391/EEC17. A company’s Preventive Service, which incorporates Occupational Medicine, «is a set of necessary human and material resources for carrying out the preventive activities for guaranteeing adequate worker safety and health protection by advising and aiding the businessperson, workers, and their representatives and the organs of specialized representation». Article 37 of the RD 39/97 lists the higher level functions, which include occupational medicine, and section 3 states the specific actions with respect to health surveillance. This is the principal, and most well known, sphere PSA University 53.2 5.1 52.4-54 Blue-collar 4.1 4.7 3.6-4.6 White-collar 5.9 4.6 5.4-6.4 Primary school 5.4 4.9 4.6-6.1 Junior high and High school 4.8 4.4 4.3-5.3 University 5.4 5.1 4.7-6.2 Blue-collar 1.1 0.9 1-1.2 White-collar 1.3 1.3 1.2-1.4 Primary school 1.9 1.8 1.6-2.2 Junior high and High school 1 0.8 1-1.1 University 0.8 0.6 0.7-0.9 > 0.05 < 0.05 > 0.05 < 0.05 < 0.05 *p < 0.05: statistically significant; TD: typical deviation; CI: confidence interval. of action, perhaps due to traditionally being carried out before it was signed into Law. Health promotion is also included and in the area of healthcare, diagnosis, treatment, and follow-up of common diseases, redirecting the process to the corresponding healthcare level; thus prostate pathology is a priority, taking into account that the current occupational age is up to 65 years and this pathology has a high prevalence in this group of workers. Diseases of the prostate can be initially diagnosed by the preventive service occupational physician if the material means for doing so are available. This is especially true in relation to BPH as a highly prevalent disease and to early CaP diagnosis, always being managed as a coordinated action with the specialized medical attention; this justifies the necessity of having systematized criteria as to when a patient with prostate pathology should be referred to the urologist. This coordinated action is now established and protocoled with family medicine and primary healthcare specialists. In contrast, it is an area that is deficient in the speciality of Occupational Medicine. Of all the risk factors for CaP, those that have shown the greatest evidence (strength of evidence B) are: causal Correlation between PSA and IPSS values, type of work, and educational level in a Spanish occupational population 123 Table 5 IPSS severity value cataloguing according to the type of work and educational level Mild Moderate Severe Χ²* p** N % N % N % Blue collar 234 82.7 44 15.5 5 1.8 15.1 0.0005 White collar 250 74.2 87 25.8 0 0 Primary school 100 67.1 47 31.6 2 1.3 16.1 0.0029 Junior high and High school 258 83.2 50 16.1 2 0.7 University 126 78.3 34 21.1 1 0.6 * χ²: chi-square. ** p < 0.05: statistically significant. Table 6 PSA severity value cataloging according to the type of work and educational level Normal Elevated Χ²* p** N % N % Blue collar 276 97.5 7 2.5 2.7 0.09 White collar 320 95 17 5 Primary school 129 86.6 20 13.4 48.6 < 0.0001 Junior high and High school 306 98.7 4 1.3 University 161 100 0 0 * χ²: chi-square. ** p < 0.05: statistically significant. association with antioxidants (vitamin E, lycopene, and selenium), fertilizers used in the rural environment, overweight, low intake of fruit, high intake of calcium, fats, and meats. Likewise, in the labor environment, a relation to exposure to cadmium18,19, herbicides, and pesticides used in agriculture, ionizing radiations, exposure to agent orange, ultraviolet radiation, and mineral substances used in the manufacture of tires and batteries has been observed.20 Of all the screening techniques, PSA determination in blood has been shown to have the greatest use, with 84.5% sensitivity and 98% specificity; DRE has a sensitivity of 69% and a specificity of 92%. Even though it varies with age, PSA serves as a tumor extension indicator. Different international and prestigious associations such as the American Cancer Society (ACS), the American Urological Association (AUA), and the Preventive Services Task Force (USPSTF, U.S.) recommend screening for CaP (PSA determination) for men starting at 50 years of age. Given this background, PSA determination, as one aspect of the periodic medical check-up (health surveillance) in men over the age of 45, has been included in an important part of company preventive and occupational health services. A large number of clinical trials from the perspectives of primary care and urology have been conducted to determine the usefulness of IPSS and PSA values in the detection, control, and follow-up of prostate pathologies, as well as the concordance between their values and validity for establishing standardized protocols.21 These are patterns that are also applicable to Occupational Medicine, even though no formal coordination has been organized between this speciality and others, despite the high number of workers receiving this regular follow-up. This represents a deficiency in the health chain that includes occupational health as part of Public Health. In carrying out his or her preventive or healthcare activities, the occupational physician has access to specific information related to workplace exposures and, as in the present study, to aspects related to the jobs of workers with specific positions or to their educational levels. Even though these aspects have been less frequently addressed, they have been evaluated in regard to cardiovascular risks and addictions to tobacco or alcohol in white-collar and bluecollar workers, analyzing the type of work and its influence on certain pathologies. The agreement among results obtained here indicates that there is a tendency for these concrete aspects to have an influence on prostate pathology. However, the results must be confirmed through studies that have larger worker samples and that provide more specific aspects related to the type of work. The same was also true for the educational or socioeconomic level; the data appear to indicate a tendency to have repercussions on these pathologies. There 124 are published studies on the influence of socioeconomic and racial aspects in relation to lower urinary tract pathologies,22,23 but not with the occupational aspects considered in the present study. We recommend continuing this line of study on greater numbers of workers and coordinating specific aspects that could corroborate the tendency observed herein. At any rate, Occupational Medicine can and must collaborate on preventive campaigns that are begun at the different healthcare levels, especially that of Public Health. It should also be included in the coordinated protocols that are already being established with great efficacy, together with other first level specialities. Occupational health can incorporate important information that is not accessible from other healthcare levels, providing mutual benefit and optimizing the available resources. Financial disclosure No financial support was received in relation to this article. Conflict of interest The authors declare that there is no conflict of interest. References 1. Chong C, Fong L, Lai R, et al. The prevalence of lower urinary tract symptoms and treatment-seeking behaviour in males over 40 years in Singapore: a community-based study. Prostate Cancer Prostatic Dis 2012;15(3):273-277. 2. Castiñeiras J, Cozar JM, Fernández-Pro A, et al. Referral criteria for benign prostatic hyperplasia in primary care. Actas Urol Esp 2010;34(1):24-34. 3. Molero JM, Pérez-Morales D, Brenes F, et al. Benign prostatic hyperplasia referral criteria for primary care, 2011 version. Aten Primaria 2012;44(6):371-373. 4. Granado de la Orden S, Saá Requejo C, Quintás Viqueira A. Epidemiological situation of prostate cancer in Spain. Actas Urol Esp 2006;30(6):574-582. 5. Prensner JR, Rubin MA, Wei JT, et al. Beyond PSA: the next generation of prostate cancer biomarkers. Sci Transl Med 2012;4(127):127rv3. 6. Consultado el 15 de diciembre de 2012. http://www.ine.es/jaxiBD/menu.do?divi=EPA&his=1&type=db&L=0 7. Romero FR, Romero KR, Brenny FT, et al. Reasons why patients reject digital rectal examination when screening for prostate cancer. Arch Esp Urol 2008;61(6):759-765. M. T. Vicente-Herrero et al 8. Woods VD, Montgomery SB, Herring RP, et al. Social ecological predictors of prostate-specific antigen blood test and digital rectal examination in black American men. J Natl Med Assoc 2006;98(4):492-504. 9. Lim LS, Sherin K. ACPM Prevention Practice Committee. Screening for prostate cancer in U.S. men ACPM position statement on preventive practice. Am J Prev Med 2008;34(2):164-170. 10. Rundle A, Neckerman KM, Sheehan D, et al. A prospective study of socioeconomic status, prostate cancer screening and incidence among men at high risk for prostate cancer. Cancer Causes Control 2013;24(2):297-303. 11. DeVault IA. White collar/blue collar [Electronic version]. Sons and daughters of labor: Class and clerical work in turn-of-thecentury Pittsburgh. Ithaca, NY: Cornell University Press; 1990. p. 1-8. 12. Alexy B. Workplace health promotion and the blue collar worker. AAOHN J 1990;38(1):12-16. 13. Sánchez-Chaparro MA, Calvo E, González-Quintela A, et al. High cardiovascular risk in Spanish workers. Nutrition,Metabolism & Cardiovascular Diseases. 2011;21:231236. 14. Holmila M, Mustonen H, Rannik E. Alcohol use and its control in Finnish and Soviet marriages. Br J Addict 1990;85(4):509-520. 15. White V, Hill D, Siahpush M, et al. How has the prevalence of cigarette smoking changed among Australian adults? Trends in smoking prevalence between 1980 and 2001. Tob Control 2003;12(Suppl 2):ii67-74. 16. España. Ley 31/1995, de 8 de noviembre, de Prevención de Riesgos Laborales. 17. España. Real Decreto 39/1997, de 17 de enero, por el que se aprueba el Reglamento de los Servicios de Prevención. BOE nº 27 31-01-1997. 18. Consultado el 15 de diciembre de 2012. http://www.upf.edu/ udmt/_pdf/programaesp.pdf (consultado 15/12/2012) 19. Directiva 89/391/CEE del Consejo, de 12 de junio de 1989, relativa a la aplicación de medidas para promover la mejora de la seguridad y de la salud de los trabajadores en el trabajo. Doce 183/L, de 29-06-89 20. Granado de la Orden S, Saá Requejo C, Quintás Viqueira A. Epidemiological situation of prostate cancer in Spain. Actas Urol Esp 2006;30(6):574-582. 21. Mullins JK, Loeb S. Environmental exposures and prostate cancer. Urol Oncol 2012;30(2):216-219. 22. Cozar JM, Solsona E, Brenes F, et al. Clinical management of patient with benign prostatic hyperplasia in Spain. Actas Urológicas Españolas 2011;35(10):580-588. 23. Fowke JH, Munro H, Signorello LB, et al. Urologic Diseases of America Project. Association between socioeconomic status (SES) and lower urinary tract symptom (LUTS) severity among black and white men. J Gen Intern Med 2011;26(11):1305-1310. Rev Mex Urol 2013;73(3):125-129 ÓRGANO OFICIAL DE DIFUSIÓN DE LA SOCIEDAD MEXICANA DE UROLOGÍA www.elsevier.es/uromx Original article A review of our experience in treating male urinary incontinence through the AMS-800™ artificial urinary sphincter F. X. Elizalde-Benito*, Á. G. Elizalde-Benito, M. Urra-Palos and Á. G. Elizalde-Amatria Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain KEYWORDS Artificial sphincter; Urinary incontinence; Post-prostatectomy incontinence; Spain. Abstract Background: Since 1983, the AMS-800™ artificial urinary sphincter has been a therapeutic procedure in the management of urinary incontinence due to incompetent sphincter. We present herein treatment results and effectiveness according to our experience. Methods: Within the time frame of 1997 to 2012, this prosthesis has been implanted in 50 patients presenting with incontinence due to sphincterial incompetence that was secondary to prostate surgery in 90% of the cases. It was placed in the bulbar urethra in men and in the bladder neck in women, implanting a single cuff, between 4 and 5.5 cm, with reservoir pressures of 60 to 70 cm of water. Results: The answers “very much better” and “much better” on the Patient Global Impression of Improvement (PGI-I) questionnaire and the need to use fewer than 2 compresses/day were regarded as the treatment outcome criteria. There was cure or improvement in 42 of the patients (84%). Eight patients (16%) presented with complications and a total of 8 patients (16%) were re-operated on for artificial sphincter removal and reimplantation, with good results in 3 patients. Conclusions: Treatment with the AMS-800™ prosthesis for severe urinary incontinence in men due to sphincterial incompetence is an effective therapeutic alternative. Nevertheless, the procedure is not without complications and other techniques with similar results are preferred for women. *Corresponding author at: Paseo Ruiseñores 22-24, puerta 12, C.P. 50006, Zaragoza, España. Telephone: (0034) 6467 35167. Fax: (0034) 97627 8904. Email: [email protected] (F. X. Elizalde-Benito). 0185-4542 - see front matter © 2013. Revista Mexicana de Urología. Publicado por Elsevier México. Todos los derechos reservados. 126 Palabras clave Esfínter artificial; Incontinencia urinaria; Incontinencia posprostatectomía; España. F. X. Elizalde-Benito et al Revisión de nuestra experiencia en el tratamiento de la incontinencia urinaria en el varón mediante el esfínter urinario artificial AMS-800TM Resumen Introducción: El esfínter urinario artificial AMS-800TM es un procedimiento terapéutico, en el manejo de la incontinencia urinaria por incompetencia esfinteriana desde 1983. Presentamos los resultados y eficacia del tratamiento según nuestra experiencia. Material y métodos: Se ha implantado esta prótesis a 50 pacientes, desde 1997 hasta 2012, con incontinencia debida a incompetencia esfinteriana secundaria a cirugía prostática en el 90% de los casos. En hombres se han colocado en uretra bulbar, y en mujeres en cuello vesical, implantado un solo manguito entre 4 y 5.5 cm, con presiones del reservorio de 60 a 70 cm de agua. Resultados: Se evaluó como criterio de curación las respuestas “muchísimo mejor” o “mucho mejor” del cuestionario Patient Global Impression of Improvement (PGI-I) y la necesidad de menos de 2 compresas/día, siendo de curación o mejoría en 42 (84%) pacientes. Se observaron complicaciones en 8 pacientes (16%) y se reintervino a un total de 8 pacientes (16%) para la retirada del esfínter artificial, usándose el reimplante con buenos resultados en 3 pacientes. Conclusiones: El tratamiento de la incontinencia urinaria severa en el varón por incompetencia esfinteriana mediante el uso de la prótesis AMS-800TM, es una alternativa terapéutica eficaz, sin olvidar sus posibles complicaciones, prefiriéndose en mujeres la utilización de otras técnicas de similares resultados. Introduction Urinary incontinence has an important psychological and social impact and affects the patient’s quality of life. There are many therapeutic alternatives for the treatment of stress incontinence. Since 1983, AMS-800TM artificial urinary sphincter implantation1,2 (fig. 1) has been a good alternative in treating severe urinary incontinence in men due to sphincterial incompetence, with much experience in its use.3-5 We present herein our experience using the AMS800TM artificial urinary sphincter, evaluating both the effectiveness and complications in the treatment of severe urinary incontinence with the AMS-800TM artificial urinary sphincter, by means of a retrospective analysis of the etiology of incontinence, the functional results, and the surgical and postoperative complications. Methods We conducted a descriptive and retrospective study within the time frame of 1997 to 2012 during which this prosthesis was implanted in a total of 50 patients, 47 men and 3 women. Before implantation, all the patients underwent urethrocystoscopy to rule out stricture and foreign bodies and they also had a complete urodynamics study (cystometry and pressure-flow study). The cause of incontinence has always been sphincterial incompetence secondary to: ✓ Prostate surgery: • Radical prostatectomy: 36 cases. • TURP: 6 cases. • Adenomectomy: 3 cases. ✓Neurologic origin: • Moyamoya disease: one case. • Intrinsic sphincterial incompetence: one case. • Ependymoma of the filum terminale: one case. ✓ Radical cystoprostatectomy and neobladder: one case. ✓ Failure of previous incontinence surgery: one case. The procedure was performed with the technique habitually used with the AMS-800TM artificial urinary sphincter (fig. 2). A single cuff has always been implanted, varying between 4 and 5.5 cm, with reservoir water pressures of 60 to 70 cm; it was placed in the bulbar urethra in men and the bladder neck in women. Mean postoperative hospital stay was 1.13 days, with a postoperative check-up at one month and activation of the artificial sphincter device. Patients answered the Patient Global Impression of Improvement (PGI-I) questionnaire6, which collects data on the current status of urinary symptoms in comparison with the situation prior to surgery. El PGI-I consists of a single question that asks the patient to classify the relief obtained from the treatment on a 7-point Likert scale as: “very much better”; “much better”; “a little better”; “no change”; “a little worse”; “much worse”; or “very much worse”. The established cure criteria were the answers “very much better” or “much better” (all the other answers were defined as treatment failure), together with the need for fewer than 2 compresses/day. Although the PGI-I has only been applied to women with stress urinary incontinence and urogenital prolapse, its use has not been established in men and women with other urinary tract symptoms or conditions. However, the PGI-I is an overall index that can be used to evaluate the response of a condition to a therapy (transition scale). It is a simple, direct, easy-to-use scale that is intuitively comprehensible for clinicians, which is why it was chosen for this study. A review of our experience in treating male urinary incontinence through the AMS-800™ artificial urinary sphincter Figure 1 AMS-800TM prosthesis: cuff in the bulbar urethra, pump, reservoir, and connecting tubes. Results The functional results showed that 24 patients (48%) achieved complete continence and 18 patients (36%) had minimum incontinence (defined as the use of 1-2 compresses/ day). There was procedure failure in 8 cases (16%). These results were correlated with the PGI-I questionnaire in which 42 patients (84%) referred to being “very much better”/“much better” and the remaining 8 patients (16%) did not. A total of 8 patients (16%) were reoperated on, removing the artificial urinary sphincter and replacing it with a new implant. There were good results in 3 of those patients; 2 were reoperated on due to mechanical failure of the artificial urinary sphincter and the other because of infection of the prosthetic material. In these cases the AMS-800TM artificial urinary sphincter (inhibizone) covered with rifampicin and minocycline was implanted. Of the women operated on, 2 had to have the sphincter removed due to vaginal and internal urethral erosion, with no new reimplantation. The other female patient had no clinical improvement and the sphincter was maintained, but inactive. There were complications in 8 patients (16%) and the most frequent was internal urethral erosion (fig. 3) in 3 cases, as shown in table 1, resulting in the necessity for removal of the prosthesis. Only one patient presented with infection of the artificial urinary sphincter, ending in its consequent removal (fig. 4). Discussion There are currently many options for urinary incontinence treatment due to sphincterial incompetence in men, such as pelvic floor rehabilitation exercises, drug treatments, transurethral injections of space-occupying substances like collagen and other polymers, or male slings, all with different results and complications. Since 1947 when Foley designed the first artificial catheter -a cuff that was inflated and 127 Figure 2 Cuff implantation in the bulbar urethra during the procedure. Table 1 Complications Complications* N° of patients % Internal urethral erosion 3 6% Vaginal erosion 1 2% Control pump failure 1 2% Reservoir shift 1 2% Scrotal hematoma 1 2% 1 2% Infection * Complications after AMS-800 implantation. TM artificial urinary sphincter deflated around the penis-7 many sphincters have been developed. The AMS-800TM artificial urinary sphincter (American Medical Systems) was first implanted in 1983,1,2 and has been progressively improved,8 with an average success rate of 82%.9,10 The AMS-800TM artificial urinary sphincter is a device with a hydraulic mechanism that has 3 fundamental components connecting to one another: the occlusive cuff, reservoir, and control pump. The cuff is made up of a silicon band with an inflatable balloon in its inner side that measure from 4 to 11 cm in length and 2 cm in width that can be placed around the bladder neck or the bulbar urethra.5,10,11 The reservoir is preferably placed intraperitoneally, because at the paravesical level it can cause fibrosis at the level of the reservoir, altering its function and not letting it reach the adequate pressure. It is the component that regulates the occlusive cuff pressure with a capacity of 22 cc. Continence should be produced with a minimum of pressure to avoid obstruction, atrophy, and erosion that can be caused by high pressure. 5,10 There are 5 different pressure 128 F. X. Elizalde-Benito et al Figure 3 Urethrocystoscopy showing the internal urethral erosion at the level of the bulbar urethra. Figure 4 Artificial urinary sphincter after removal due to infection. ranges, but the most widely used are 51-60, 61-70, and 7180 cm of water. The recommended pressure values are: in men 71-80 in the bladder neck and 61-70 in the urethra; in women 61-70 in the bladder neck; and in children 61-70 in the bladder neck and 51-60 in the urethra.5,10 The control pump is placed in the scrotum or labia majora. A system of valves in its interior directs the passage of the filling liquid in one direction or another, letting the cuff inflate or deflate, allowing for micturition during 3 to 5 minutes. Continence is re-established subsequent to sufficient time for micturition. The pump has a button that deactivates the prosthesis, emptying the occlusive cuff.5,11 The artificial urinary sphincter is indicated in all patients with genuine stress incontinence, men or women, and of any age, that have the ability to manipulate the control pump.10 There are a series of previous conditions such as bladder capacity > 200 mL, stable bladder, sterile urine, and absence of obstruction prior to implantation; therefore it is elective in the patient with irreversible sphincterial insufficiency and normal bladder function.5,11 Indications for the prosthesis, in order of frequency, are incontinence after radical prostatectomy or transurethral resection of the prostate, congenital malformation, spinal trauma, neurogenic bladder, and stress incontinence in women when other surgical techniques have failed.4,10 The group of patients with sphincterial deficiency after radical prostatectomy is the most important group that recurs most often to incontinence management with an artificial sphincter. In approximately 70% or more of the patients with implants, the cause of their incontinence is an aftereffect of radical prostate surgery.3 In our case series, this was also the main cause of incontinence in the patients with implantation, with a total of 36 patients (72%). There are substantial variations in the literature in both the complication as well as the success rates. This can largely be explained by the heterogeneity of the studies and in the different definitions used to classify the results.9 In relation to incontinence improvement, our case series reported improvement of 84%, compared with other series that vary from 61.4% to 90.4%.3-5,12-16 There are different types of complications and they vary from 2.7% to 49.5%, depending on the series. In our case series the complication rate was 16%, and 16% of the patients were re-operated on; this is comparable to other series described in the literature (1.3% to 44%).3-5,12-16 When these devices were introduced, the mechanical failures of the equipment were an important cause of complications; there is a 7% to 53% incidence with an average of 13.8% reported on in the literature.3,4,17 Over time, this type of complication has been reduced, thanks to improvements in the devices themselves, and today’s prostheses are longlasting and reliable systems.8 In general the problems arise from damage to the control pump or perforations resulting in the exit of the system’s liquid. The average prosthesis is calculated to have a useful life of approximately 10 years.10 The most devastating complication in the entire prosthetic procedure is infection; it is estimated that infection of the prosthesis makes up approximately 12.9% of the possible complications,4 and the seriousness of this is, that in order to resolve the infection, the artificial urinary sphincter almost always must be removed.10 Fundamental preventive measures are required to prevent this from happening; there must be scrupulous surgical asepsis and a meticulous surgical procedure. Additionally, in our case, we administered preoperative antibiotic prophylaxis to all our patients, with aminoglycosides and beta-lactam antibiotics in combination with the recommended antimicrobials as established by the chemoprophylaxis protocol of surgical procedures, with strength of evidence B, level III.18 We also carried out constant irrigations of the surgical site and all the components of the prosthesis with an antibiotic solution containing gentamycin. In relation to prosthetic material erosion, the incidence in different case series varies from 12% to 14%.9 It can present as an internal erosion, when the protrusion of the components (generally the cuff) is toward the bladder neck or the urethra; or external erosion, when the component (the control pump, reservoir and/or connecting tubes) protrude through the skin. The form most frequently reported in A review of our experience in treating male urinary incontinence through the AMS-800™ artificial urinary sphincter the literature is the internal erosion of the cuff toward the bulbar urethra, which can be caused by an excess of pressure in the system, infection, or progressive ischemia.10 Conclusions The treatment of urinary incontinence due to sphincterial incompetence through the use of the AMS-800TM prosthesis is an effective therapeutic alternative, keeping in mind its possible complications. In women, the use of other techniques is preferred. The most frequent indication is after prostate surgery and the most favorable results are obtained in these cases. In our experience, placement of the AMS-800TM prosthesis at the level of the bulbar urethra is the location of choice. Conflict of interest The authors declare that there is no conflict of interest. Financial disclosure No financial support was received in relation to this article. References 1. Englemann UH, Felderman TP, Scott FB. The use of the AMS-AS 800 artificial sphincter for continent urinary diversion. Investigations including pressure-flow studies, using rabbit intestinal loops. J Urol 1095;134:183. 2. Englemann UH, Felderman TP, Scott FB. Evaluation of the AMSAS 800 artificial sphincter for continent urinary diversion using intestinal loops. Urology 1985;25:620. 3. Elliot DS, Barrett DM. Mayo Clinic longterm analysis of the functional durability of the AMS-800 artificial urinary sphincter: A review of 323 cases. J Urol 1998;159:1206. 4. Hajivassiliou CA. A review of the complications and results of implantation of the AMS artificial urinary sphincter. Eur Urol 1999;35:36. 5. Sanz Mayayo E, Gómez García I, Fernández Fernández E, et al. Esfínter artificial AMS-800. Nuestra experiencia en los últimos 20 años. Arch Esp Urol 2003;56(9):989-997. 129 6. Yalcin I, Bump RC. Validation of two global impression questionnaires for incontinence. Am J Obstet Gynecol 2003;189(1):98101. 7. Foley FEB. An artificial sphincter: a new device and operation for control of enuresis and urinary incontinence. General considerations, indications and results. J Urol 1947;58:250. 8. Hajivassiliou CA. The development and evolution of artificial urethral sphincters. J Med Eng Technol 1998;22:154-159. 9. Silva LA, Andriolo RB, Atallah AN, et al. Surgery for stress urinary incontinence due to presumed sphincter deficiency after prostate surgery. Cochrane Database of Systematic Reviews 2011, Issue 4. Art. No.: CD008306. DOI:10.1002/14651858. CD008306.pub2. 10. García Montes F, Gómez Sancha F, Mundy A. El esfínter urinario artificial. Arch Esp Urol 2000;53:201. 11. Briones Mardones G, Jiménez Cidre M, Fernández Fernández E, et al. Tratamiento de la incontinencia urinaria de esfuerzo femenina con el sistema TVT (Tension free vaginal tape): nuestra experiencia. Actas Urol Esp 2001;25(6):423-429. 12. Batista JE, Arañó Bertrán P, Errando Smet C. Esfínter artificial en incontinencia urinaria severa: nueve años de experiencia. Arch Esp Urol 2000;53:409-416. 13. Kip A, İmamoğlu MA, Tuygun C, et al. Long-term results of artificial urinary sphincter implantation for the treatment of urinary incontinence. Journal of Ankara Medical School 2003;25(4):185-190. 14. Bosch JL, Klijn AJ, Schroder FH, et al. The artificial urinary sphincter in 86 patients with intrinsic sphincter deficiency: satisfactory actuarial adequate function rates. Eur Urol 2000;38:156-160. 15. Mottet N, Boyer C, Chartier-Kastler E, et al. Artificial Urinary Sphincter AMS 800 for Urinary Incontinence after Radical Prostatectomy: The French Experience. Urol Int 1998;60:25-29. 16. Kuznetsov DD, Kim HL, Patel RV, et al. Comparison of artificial urinary sphincter and collagen for the treatment of postprostatectomy incontinence. Urology 2000;56:600. 17. Light JK. Controversies and Innovations in Urological surgery. London: Springer- Verlag; 1989. p. 235-252. 18. Dellinger EP, Gross PA, Barret TL, et al. Quality standard for antimicrobial prophylaxis in surgical procedures. Clin Infect Dis 1994;18:422-427. Rev Mex Urol 2013;73(3):130-135 ÓRGANO OFICIAL DE DIFUSIÓN DE LA SOCIEDAD MEXICANA DE UROLOGÍA www.elsevier.es/uromx Original article Crystallographic analysis of 475 urinary tract calculi at the Hospital San José Tec Salud in Monterrey, N. L. A. R. Aragón-Tovara,* and M. Á. Hernández-Faríasb a Head of Urology Service , Unidad Médica de Alta Especialidad N° 25, IMSS, Monterrey, N. L., Mexico b Bachelor of Medicine, Escuela de Medicina de Ignacio Santos, Tecnológico de Monterrey, Monterrey, N. L., México KEYWORDS Lithiasis; Urinary calculus; Epidemiology; Crystallography; Mexico. Abstract Background: Calculi are the third most common disease of the urinary tract, surpassed only by urinary tract infections and pathologic conditions of the prostate. At present there are no epidemiologic studies on patients seeking medical attention at the Hospital San José Tec Salud, or any other hospital in Mexico, for problems related to kidney stones. Aims: The principle aim of our study was to statistically determine the chemical composition of urinary tract calculi in patients admitted to the Hospital San José Tec Salud and to extrapolate the data to Monterrey and its metropolitan area. Results: The cases were obtained retrospectively from the database of the laboratory of the Hospital San José Tec Salud and from patient medical records within the time frame of July 2009 to October 2012. In the data analysis, 313 (66%) cases were men and 162 (34%) were women, resulting in a 2:1 ratio. The age of greatest prevalence was between 30 and 50 years. Discussion: The analysis of the crystallography results, together with the medical record review, provides information on how many of these patients will be attended to and on the crystallographic type of calculi they will present with in the near future at the Hospital San José Tec Salud. This data can then be extrapolated to Monterrey and its metropolitan area. * Corresponding author at: Dr. F. Guajardo N° 160-307, Colonia Doctores, C.P. 64710, Monterrey, N. L., México. Telephone/Fax: (818) 3489169. Cell phone: (818) 0206633. Email: [email protected] (A. R. Aragón-Tovar). 0185-4542 - see front matter © 2013. Revista Mexicana de Urología. Publicado por Elsevier México. Todos los derechos reservados. Crystallographic analysis of 475 urinary tract calculi at the Hospital San José Tec Salud in Monterrey, N. L. Palabras clave Litiasis; Cálculo urinario; Epidemiología; Cristalografía; México. 131 Análisis cristalográfico de 475 cálculos de vías urinarias en el Hospital San José, Tec Salud, en Monterrey, N.L. Resumen Introducción: Los cálculos son la tercera afección más común del tracto urinario, excedida únicamente por las infecciones del mismo y las condiciones patológicas de la próstata. A la fecha no hay estudios epidemiológicos de los pacientes que acuden al Hospital San José, Tec Salud, así como ningún otro hospital de México con problemas de litiasis renal. Objetivo: El objetivo principal es determinar estadísticamente la composición química de cálculos de vías urinarias, en los pacientes ingresados al Hospital San José, Tec Salud, y extrapolarlo a Monterrey y su área metropolitana. Resultado: Los casos se obtienen retrospectivamente mediante la base de datos del laboratorio del Hospital San José, Tec Salud, y expediente clínico, del periodo comprendido entre julio de 2009 a octubre de 2012. En el análisis de los datos 313 (66%) casos fueron masculinos y 162 (34%) casos femeninos, obteniendo una relación 2:1. La edad de mayor prevalencia fue entre los 30 y 50 años. Discusión: El análisis del resultado de cristalografía en conjunto con la revisión de su expediente clínico, aporta información de cuántos casos serán atendidos y el tipo cristalográfico de cálculos en los pacientes que se atenderán en un fututo cercano en el Hospital San José, Tec Salud, y extrapolarlo a Monterrey y su área metropolitana. Introduction Calculi are the third most common disease of the urinary tract, surpassed only by urinary tract infections and pathologic conditions of the prostate.1 The worldwide prevalence of renal lithiasis is estimated to be between 1% and 15%,1-4 and the probability varies according to age, sex, race, climate, occupation, social class, nutritional factors, genetic particularities, and geographic location.2,3,5-7 Methods A retrospective, cross-sectional study using descriptive statistics was conducted that included 475 cases of urinary tract lithiasis within the time frame of July 2009 and October 2012. The information was obtained from the laboratory registers and the clinical case records of the Hospital San José, Tec Salud that contained 100% of the data. The sample was determined with a prevalence of 10%, a 95% confidence interval, and a 5% margin of error. There was a minimum result of 384 cases required, but the sample size was increased for more reliability. Measures of central tendency and dispersion were carried out, showing a homogeneously distributed population. Results Of the 475 cases, 66% were men (313 cases) and 34% were women (162 cases), with a frequency ratio of 2:1. In men, the mean age of appearance of lithiasis was 42 years ± 14.41 and in women it was 41 years ± 15.27. The peak appearance in both sexes was between 30 and 49 years; 49% of the sample fit in this age range (92% was between 20 and 69 years of age). Nineteen (4%) cases were under 20 years of age and 15 (3%) were over the age of 70 years. In relation to women, their age distribution was the same as that of the men; this was not the expected result, given the reported increase of lithiasis after menopause8,9 (tables 1 and 2). Lithiasis frequency rose to 40% (19 cases per month) during the warm months (May, June, July, August), in correlation with the mean (12 cases). With respect to the crystallographic composition, 20% (97 cases) of the calculi were pure, and 80% (378 cases) were mixed. Calcium oxalate was the most common of the pure calculi for both sexes, with 13% (41 cases) in men and 12% (20 cases) in women. It was followed by uric acid calculi in men with 6% (19 cases) and by carbonate apatite in women with 5% (8 cases). In regard to the mixed calculi, the most common composition was calcium oxalate plus calcium phosphate, representing 52% (247 cases) of the total sample, 52% (164 cases) of the total of calculi in men, and 51% (83 cases) in women. It was the most common in both sexes, as well as in all ages. The second in frequency in men was the calcium oxalate calculus plus carbonate apatite with 17% (53 cases) and in women it was the calcium oxalate calculus plus calcium phosphate plus calcium hydrogen phosphate, with 17% (27 cases). There was an increase in the frequency of uric acid calculi (pure and mixed) after the age of 50 years, with more than 70% of the uric acid calculi in patients above that age. The mean weight of the stones was 55.21 mg (fig. 1). A total of 97% of the patients were from the State of Nuevo León, and of that percentage, 95% resided in Monterrey and its metropolitan area. The sample’s most common place of origin was Monterrey with 189 cases (40%), followed by San Pedro Garza García with 99 (21%), Ciudad Guadalupe 44 (9%), San Nicolás de los Garza 42 (9%), Santa Catarina 23 (5%), Apodaca 19 (4%), and Escobedo with 13 (3%) (fig. 2). 132 A. R. Aragón-Tovar et al Table 1 Number of cases according to composition, age, and sex Composition/age 0/9 19/19 29/29 30/39 40/49 50/59 60/69 70/79 80/89 Total CO 1 1 4 6 5 3 - - - 20 UA - - - 1 - 3 1 - - 5 CA - 1 1 4 1 - 1 - - 8 PA - - - - - - 1 - - 1 1 2 5 11 6 6 3 0 0 34 50/59 60/69 70/79 80/89 Total Women Composition/age 0/9 19/19 29/29 30/39 40/49 CO - 1 7 9 13 6 4 1 - 41 UA - - 2 3 5 3 3 2 1 19 CA 1 - - 2 - - - - - 3 PA - - - - - - - - - 0 1 1 9 14 18 9 7 3 1 63 Men CO: calcium oxalate; UA: uric acid; CA carbonate apatite; PA: protein (albumin). 80 Women 70 Men 60 Both 50 40 30 20 10 0 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 Figure 1 Number of cases according to age and sex. Discussion Nephrolithiasis is one of the most common pathologies of modern society and in recent years has increased up to 50% in the industrialized countries.5,6,8 Due to the frequency of stone recurrence, the development of a prophylactic program to reduce this persistence is imperative. 1,4,7-10 . Without medical intervention, recurrence can be as high as 50% at 5 years; it can be even more frequent in uric acid calculi.7,8,11 The metabolic and crystallographic study aids in establishing and understanding the etiology and pathogenesis of the patient’s calculi.8,10,11 In this manner, with medical fol- low-up, recurrences are reduced, and consequently, there are fewer surgical procedures and patient comorbidities.8,10 The presentation of lithiasis before the age of 20 years and after the age of 70 years is rare and the prevalence peaks are between the fourth and sixth decades of life;8,9 these are international data that coincide with our study sample. According to international reports, women show a bimodal distribution in the formation of calculi, demonstrating in these studies a second incidence peak in the sixth decade of life that corresponds to the post-menopause period. This finding, together with that of a lower lithiasis incidence in the pre-menopause period, compared with men, suggests a protective effect of estrogen for the formation of calculi.8,9 Such an effect was not seen in Crystallographic analysis of 475 urinary tract calculi at the Hospital San José Tec Salud in Monterrey, N. L. 133 Table 2 Number of cases according to age and sex Men Composition/age 0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 Total CO+CP 1 6 27 49 47 21 9 3 1 164 CA+CO - 2 10 14 11 15 1 - - 53 CO+UA - - 1 2 1 3 2 3 - 12 CO+CHP - - - - - - - - - 0 CP+MAP - - - - - - - - - 0 CP+CHP - - - 1 - - - - - 1 CO+UA+CP - - - - 2 1 7 - - 10 CO+CP+CHP - - - 2 1 - - - 3 CO+CA+UA - 1 - - - - - - - 1 CO+CP+MAP - - - 1 - 1 - - - 2 CO+CA+MAP - - - - - - - - - 0 CO+UA+CP+MAP - - - - - 1 - - - 1 CO+UA+CP+AAU - - - - - 2 - - - 2 UA+MAP+AAU+UA - - - - - - - - - 0 UA+MAP+AAU+UA - - - 1 - - - - - 1 1 9 38 70 62 44 19 6 1 250 Women 0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 Total CO+CP Composition/age - 4 19 19 17 11 11 2 - 83 CA+CO - - - 1 1 - - - - 2 CO+UA - - - 1 1 2 2 - - 6 CO+CHP - - - - - 1 - - - 1 CP+MAP - - - - - 1 1 - - 2 CP+CHP - - - - - - - - - 0 CO+UA+CP - - - - - 2 1 - - 3 CO+CP+CHP - 1 4 9 6 3 3 1 - 27 CO+CA+UA - - - - - - - - - 0 CO+CP+MAP - - - - - - - - - 0 CO+CA+MAP - - - - - - 1 - - 1 CO+UA+CP+MAP - - - - - 1 - - - 1 CO+UA+CP+AAU - - - - - - - - - 0 UA+MAP+AAU+UA 1 - - - - - - - - 1 UA+MAP+AAU+UA - - - - - - 1 - - 1 1 5 23 30 25 21 20 3 0 128 CO: calcium oxalate; CP: calcium phosphate; UA: uric acid; CA: carbonate apatite; PA: protein (albumin); CHP: calcium hydrogen phosphate; MAP: magnesium ammonium phosphate (struvite); AAU: ammonium acid urate; T: triamterene.Bibliografía 134 A. R. Aragón-Tovar et al Sex A Composition B 34% 20% Women Men 66% Pure calculi Mixed calculi 80% Place of origin C 3% 5% Monterrey 4% San Pedro Garza García 5% Guadalupe 4% San Nicolás de los Garza 40% 9% Apodaca Santa Catarina Escobedo 9% 21% Other cities of NL Other States Figure 2 A) Percentage of stones by sex. B) Percentage of stones by composition. C) Place of origin of the patients in the sample. the Hospital San José, Tec Salud population; in contrast, a homogeneous distribution was observed in the frequency of lithiasis in pre and post-menopausal women, differing, as mentioned above, from the results published in the international literature. The city of Monterrey and its metropolitan area experience high temperatures in the summer, and together with heat exposure and dehydration, these are risk factors that explain the higher lithiasis frequency in hot, arid, and dry climates (mountains, deserts, or the tropics).8,9,11 In addition, an increase has been observed in the prevalence of lithiasis related to seasonal temperature, due to the fact that a higher temperature augments the imperceptible losses of liquids and increased exposure to the sun causes an increment in vitamin D and calcium absorption.2,3,6,9,12 The risk for lithiasis is greater when there is low water intake, high protein intake, and a sedentary lifestyle.2,3 Moreover, genetic and dietary influences may be more important than geographic factors.8 One of the factors that may also play a role is the hardness of the drinking water (as is the case in Monterrey13), which can also increase the presentation of stones, although some studies have found no difference.2 It should be noted that the population of Monterrey includes many heavy consumers of animal meat and beer. Even though a protein-rich diet is regarded as a factor in the formation of uric acid calculi, no increase in the number of cases in Monterrey in relation to other studies was observed.2,9 Crystallographic analysis of 475 urinary tract calculi at the Hospital San José Tec Salud in Monterrey, N. L. Beer also predisposes to the forming of stones by causing elevated diuresis, followed by dehydration and urinary stasis, promoting the formation of calcium oxalate and uric acid calculi. Moreover, beer contains purines, the precursors of uric acid, and together with purine-rich foods, increases the excretion of uric acid in urine.14 Nevertheless, age was determined as the main risk factor for uric acid stones, given that prevalence rises especially after 60 years of age.9 In the study population that presented with calculi composed of uric acid (pure and mixed), 70% were patients above the age of 50 years, with a prevalence in men, resulting in a 4.6:1 ratio. The increased prevalence with age is attributed to the progressive defect in ammoniagenesis in urine, which is the principal factor in low pH.9,11 Hyperuricemia, low urinary pH, ammoniagenesis reduction, and insulin-resistance are characteristics of metabolic syndrome, catalogued as stone recurrence factors in uric acid calculi.9,11 Metabolic syndrome is also more frequent with age. It has been suggested that an elevated body mass index (BMI) increases the excretion of supersaturated urine, increasing the risk for lithiasis.1,6 Supersaturated urine depends on the urinary pH, ionic charge, and concentration of solutes. 1,6 For this reason, drinking abundant quantities of water prevents the formation of stones.9 The stone composition most frequently observed in the study and the reviewed bibliography, is that of calcium oxalate. The majority of patients with this kind of stone have no systemic disease and so its origin is thought to be idiopathic.2,3,6,7,9,15,16 Secondary causes can be hyperparathyroidism, calcium metabolism disorders, gut-related hyperoxaluria, and genetic disorders of oxalate metabolism. In conclusion, crystallographic analysis and metabolic study is essential for the medical management of patients with nephrolithiasis; it enables us to identify the pathologies that are the precursors of urinary lithiasis, to correct them, and to prevent stone recurrence and complications characteristic of the pathology and of the surgical treatments. Financial disclosure No financial support was received in relation to this article. Conflict of interest The authors declare that there is no conflict of interest. Acknowledgments The authors wish to thank Dr. Carlos Díaz Olachea, Head of the Laboratory of the Hospital San José, Tec Salud and QFB Cruz Palacios for their contribution in accessing information, 135 and to also thank Dr. Homero Decanini Livas, Head of the Department of Urology and the medical staff of the Hospital San José, Tec Salud. References 1. Stoller ML. Urinary Stone Disease. In: Tanagho EA, McAninch JW (editors). Smith´s General Urology, 17ª Ed. Estados Unidos de América: Editorial McGraw-Hill; 2008. 2. Batista LA, Pelegrini L, Bertinato L, et al. Investigation of nephrolithiasis in the West of Paraná. J Bras Nefrol 2011;33(2):160165. 3. Trinchieri A. Epidemiology of urolithiasis: an update. Clin Cases Miner Bone Metab 2008;5(2):101-106. 4. Raif O, Ipek B, Orturk U, et al. Metabolic Evaluation in Stone Disease Metabolic Differences Between the Pediatric and Adult Patients With Stone Disease. Urology 2010;76(1):238241. 5. Romero V, Akpinar H, Dean G. Kidney Stones: a global picture of prevalence, incidence, and associated risk factors. Rev Urol 2010;12(2-3);86-96. 6. Fredic LC, Andrew E, Elaine W. Kidney Stone Disease. J Clin Invest 2005;115(10):2598-2608. 7. Ribeiro da Silva, Cordeiro de Matos, Leite da Silva, et al. Chemical and morphological analysis of kidney stones. A double blind comparative study. Acta Cirúrgica Brasileira 2010;25(5):444448. 8. Pearle MS, Lotan Y. Urinary Lithiasis: Etiology, Epidemiology, and Pathogenesis. In: Wein AJ, Kavoussi LR, Partin AW (editors). Wein: Campbell-Walsh Urology. 10ª Orlando, FL: Editorial Elsevier; 2011. 9. Daudon M, Doré JC, Jungers P, et al. Changes in stone composition according to age and gender of patients: a multivariate epidemiological approach. Urol Res 2004;32:241-247. 10. Pak C, Poindexter JR, Adams-Huet B, et al. Predictive Value of Kidney Stone Composition in the Detection of Metabolic Abnormalities. Am J Med 2003;115:26-32. 11. Ansari M, Narmada G, Ashok H, et al. Spectrum of stone composition: structural analysis of 1050 upper urinary tract calculi from northern India. International Journal Urology 2005;12:1216. 12. Costa-Bauzá A, Ramis M, Montesinos V, et al. Type of renal calculi: variation with age and sex. World J Urol 2007;25:415-421. 13. Consultado el 01 de marzo de 2013. http://www.google.com/ url?sa=t&rct=j&q=&esrc=s&source=web&cd=6&ved=0CEsQFjAF &url=http%3A%2F%2Fwww.inegi.gob.mx%2Fprod_serv%2Fconte nidos%2Fespanol%2Fbvinegi%2Fproductos%2Fintegracion%2Fsoc iodemografico%2Fmedioambmty%2F2001%2Femazmm01-2. pdf&ei=U0oxUba_J_KA2QW sYDQAQ&usg=AFQjCNEkkr-D5hHcTaBJwX-gmkV24e64bQ&bvm=bv.43148975,d.b2I 14. Rayhan Z, Yoshihide O, Sanehiro H, et al. Urolithiasis in Okinawa, Japan: A relatively high prevalence of uric acid stones. International Journal Urology 2003;10:411-415. 15. Curhan GC. Epidemiology of Stone Disease. Urol Clin N Am 2007;34:287-293. 16. Ross AE, Handa S, Lingeman JE, et al. Kidney stones during pregnancy: an investigation into stone composition. Urol Res 2008;36:99-102. Rev Mex Urol 2013;73(3):136-139 ÓRGANO OFICIAL DE DIFUSIÓN DE LA SOCIEDAD MEXICANA DE UROLOGÍA www.elsevier.es/uromx Clinical case Urinary diversion postoperative complication management E. Mayorga-Gómez*, V. Cornejo-Dávila, A. Palmeros-Rodríguez, I. Uberetagoyena-Tello de Meneses, G. Garza-Sainz, V. Osornio-Sánchez, A. Camacho-Castro, F. García-Salcido, E. Muñoz-Ibarra, S. Ahumada-Tamayo, G. Fernández-Noyola, A. Martínez, M. CantellanoOrozco, C. Martínez-Arroyo, G. Morales-Montor and C. Pacheco-Gahbler Urology Division, Hospital General “Dr. Manuel Gea González”, Mexico City, Mexico KEYWORDS Cancer; Bladder; Complications; Treatment; Mexico. Palabras clave Cáncer; Vejiga; Complicaciones; Tratamiento; México. Abstract Bladder cancer is the fourth most common malignant tumor in the developed countries. The treatment of choice for high grade muscle-invading and non-muscle-invading tumors that do not respond to intravesical BCG application continues to be radical cystoprostatectomy in men and anterior pelvic exenteration in women, both associated with extended pelvic lymphadenectomy. Before 1990, case series reported a mortality rate close to 15%; however, in the last 10 years that rate has been reduced to 0%-3%. We present herein a special case of radical cystectomy (RC) due to bladder cancer with multiple complications, describing some of their management alternatives. Manejo de las complicaciones postoperatorias en las derivaciones urinarias Resumen El cáncer de vejiga es el cuarto tumor maligno más común a nivel mundial, en países desarrollados. El tratamiento de elección para los tumores músculo invasores y no músculo invasores de alto grado que no responden al manejo con aplicación intravesical de BCG, continúa siendo la cistoprostatectomía radical en los hombres y la exenteración pélvica anterior en las mujeres, ambas asociadas a linfadenectomía pélvica extendida. Antes de 1990, las series reportaban una mortalidad cercana al 15%, sin embargo en los últimos 10 años se ha logrado reducir la mortalidad al 0%-3%. Se presenta un caso especial de cistectomía radical (CR) por cáncer de vejiga con múltiples complicaciones; se pretende dar a conocer las alternativas de manejo de las mismas. * Corresponding author at: Hospital General “Dr. Manuel Gea González”, División de Urología. Av. Calzada de Tlalpan N° 4800, Colonia Sección XVI, Delegación Tlalpan, C.P. 01480, México D.F., México. Email: edgar_mg18@hotmail. (E. Mayorga-Gómez) 0185-4542 - see front matter © 2013. Revista Mexicana de Urología. Publicado por Elsevier México. Todos los derechos reservados. Urinary diversion postoperative complication management Introduction 137 A 56-year-old man from Mendoza, Argentina, residing in Mexico City, has a past medical history of intense smoking from the age of 20 years to the present, smoking 15 cigarettes a day with a smoking index of 15. He also has a 10-year progression of high blood pressure that is treated with losartan. His present illness began in December 2011 with total gross hematuria, the presence of amorphous coagulates, but with no other added symptomatology. The hematuria lasted 15 days and then remitted spontaneously. Physical examination revealed a normal head and neck, well-ventilated pulmonary fields with no abnormal sounds, rhythmic heart sounds of adequate intensity and frequency, a distended abdomen due to the adipose panniculus that was soft, depressible, non-painful, and with no peritoneal irritation data. There were no palpable tumors or enlarged organs. His superior and inferior extremities had no alterations in their form, strength, function, or neurovascular status. Upon digital rectal examination, palpation of the anal sphincter showed a normal tone and a non-suspicious grade 1 adenomatous prostate. Hematuria protocol was begun (table 1) ordering laboratory tests. A urotomography (UroCAT) scan identified a bladder tumor that was dependent on the left lateral wall. Cystoscopy with transurethral resection of the bladder (TURB) was performed, finding a 3 cm bladder tumor on the left lateral wall; it had a papillary aspect and was completely resected (16/01/2012) (fig. 1). The histopathologic report stated high grade urothelial papillary carcinoma with detrusor muscle invasion. Biopsies of the bladder neck and prostate were carried out later and were negative for malignancy (24/02/12). The patient was programmed for radical cystoprostatectomy with urinary diversion through a Studer orthotopic neobladder (12/03/12) and it was performed with no perioperative complications (fig. 2). On the third postoperative day, serohematic matter began to come out through the surgical wound; it was managed as a seroma, with drainage and wound dressings. The patient began to eat food on the sixth postoperative day and tolerated it well: he presented with fever of 38.5°C without leukocytosis. On 22/03/12 there was evidence of dehiscence of the aponeurosis, and exploratory laparotomy (ex-lap) revealed the dehiscence and purulent matter in the abdominal cavity that was managed with an open abdomen and Bogotá bag (fig. 3). Once again, on 27/03/12, serohematic matter came out of the Bogotá bag. An x-ray study showed a contrast medium leak through the urethrointestinal anastomosis and so the patient underwent surgery performing a surgical Figure 1 Urotomography scan. Figure 2 Studer-type neobladder. Bladder cancer is the fourth most common malignant tumor in the developed countries and the ninth on a worldwide level. In Mexico, it is in fourth place among the urogenital tumors, with 1,136 cases reported from 2007 to 2009, according to the latest regional statistics update.1-3 The treatment of choice for muscle-invading and nonmuscle-invading high grade tumors that do not respond to management with intravesical BCG application continues to be radical cystoprostatectomy in men and anterior pelvic exenteration in women, both associated with extended pelvic lymphadenectomy. Radical cystectomy (RC) provides the best cancer-specific survival rate for muscle-invading urothelial cancer4, with recurrence-free survival rates at 10 years of up to 60% and a total survival rate of 45%.5,6 RC with urinary diversion is a procedure that attempts to reduce morbidity, provide rapid postoperative rehabilitation, reduce hospital stay, and finally, reduce costs. These are the goals towards which modern surgery aims, but they have been very difficult to achieve. Before 1990, case series reported a mortality rate close to 15%, but in the last 10 years it has been reduced to 0%-3%;7,8 nevertheless, morbidity continues to be elevated, reaching up to 68% in the large case series.9 Late complications are from 19% to 58%. The important reduction in perioperative morbidity reflects both the current effort of multidisciplinary teams in managing the surgeries and the recognition and adequate treatment of early complications. Case presentation 138 E. Mayorga-Gómez et al Table 1 Pre-TURB Date 16/01/12 Parameter Result Reference Hemoglobin 14.8 13.5-17 g/dL Hematocrit 43.3 47-55% Platelets 135 150-450x103 Leukocytes 7.6 4.5-11x103 Neutrophils 84.4 40-85% Glucose 117 70-115 mg/dL BUN 17.7 8-20 mg/dL Creatinine 0.99 0.70-1.2 mg/dL Na+ 134 136-144 mEq/L K 3.3 3.6-5.1 mEq/L Cl- 106 101-111 mEq/L PT 11.2 12.5-15.9 sec PTT 38.4 23-40 sec 0.80 0.8-1.2 + INR Na : sodium; K : potassium; Cl : chloride; PT: prothrombin time; PTT: partial thromboplastin time; INR: International Normalized Ratio.Bibliografía + + - lavage, abdominal wall closure, transurethral catheter relocation, and neocystostomy. A frozen abdomen and minimal dehiscence of the anastomosis was found. On 28/03/12 there was output of serohematic matter from the surgical wound; A Bogotá bag was placed once again and surgical lavage was done. Due to the presence of Zulkhe IV intra-abdominal adherences, the patient was managed with a change of the Bogotá bag every 2 days and surgical lavages, getting the neocystourethral anastomosis wound to behave like a controlled neocystocutaneous fistula. On 24/04/12 bilateral percutaneous nephrostomies were placed without complications, resulting in a reduction of the output through the surgical wound. On 25/04/12 a vacuum-assisted closure (VAC) system was placed in an attempt to close the anastomosis and the surgical wound (fig. 4). Replacement of the VAC system every 2 days was begun. On 12/05/12 the patient was released from the Service and continued the VAC therapy as an outpatient, with re-admittance once a week for system replacement. This management resulted in 80% closure of the surgical wound, however the exit of urine persisted through the inferior third of the wound because the urethrointestinal anastomosis dehiscence persisted. On 27/06/12 ex-lap was performed and the Studer neobladder was dismantled, the urinary diversion was reconstructed with an ileal conduit using the Bricker technique, and the abdominal wall was closed. The patient had good postoperative progression with no complications and adequate functioning of the ileal conduit with no intestinal or urinary complications. He was released on the fifth postoperative day. In the outpatient follow-up he remained free of complications derived from the urinary diversion. Figure 3 Cystogram with anastomosis dehiscence. Figure 4 VAC system. Discussion In the whole of the case series reviewed, 64% of all cystectomies have some kind of complication and 13% of the patients present with a high-grade complication. The mean Urinary diversion postoperative complication management hospital stay is 9 days for radical cystoprostatectomy, with grade 2-3 complications. Twenty-six percent of patients require re-admittance and 34% have emergency consultations once they have been released. Five percent of the patients require admittance to the Intensive Care Unit, 2% require a second surgery during their first hospitalization, and only 1% require re-intervention within the first 90 after being released.10 Hospital mortality is 0.7% and rises to 2.7% within the first 90 days; cardiopulmonary events are the principal cause of death. Among the complications, the most common were gastrointestinal (40%), infectious (39%) and bleeding (16%).11 Opportune detection of a complication in the postoperative period and its early intervention determine the patient outcome. Adequate diversion of the urinary tract, fistula management, and control with the VAC system are an alternative for the management of an open abdomen in patients with abdominal complications resulting from RC. To reduce the number of complications derived from highly complex procedures such as RC, it is necessary to establish multidisciplinary teams that perform a high number of surgeries. Conflict of interest The authors declare there is no conflict of interest. Financial disclosure No financial support was received in relation to this article. References 1. Ploeg M, Aben KK, Kiemeney LA. The present and future burden of urinary bladder cancer in the world. World J Urol 2009;27(3):289-293. 139 2. Consultado el 28 de mayo de 2013. http://globocan.iarc.fr/ factsheets/populations/factsheet.asp?uno=962 3. Jiménez Ríos MA. Panorama epidemiológico del cáncer genitourinario en la Zona Centro de México. Rev Mex Urol 2011;71(Supp 3):3-6. 4. Meyer JP, Blick C, Arumainayagam N, et al. A three-centre experience of orthotopic neobladder reconstruction after radical cystectomy: revisiting the initial experience, and results in 104 patients. BJU Int 2009;103(5):680-683. 5. Cookson MS, Chang SS, Wells N, et al. Complications of radical cystectomy for nonmuscle invasive disease: comparison with muscle invasive disease. J Urol 2003;169(1):101-104. 6. Colombo R. Editorial comment on: defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology. Eur Urol 2009;55(1):175176. 7. Maffezzini M, Campodonico F, Canepa G, et al. Current perioperative management of radical cystectomy with intestinal urinary reconstruction for muscle-invasive bladder cancer and reduction of the incidence of postoperative ileus. Surg Oncol 2008;17(1):41-48. 8. Charbit L, Beurton D, Cukier J. Mortality and morbidity after total cystectomy for cancer [in French]. J Urol (Paris) 1984;90(1):39-46. 9. Skinner DG, Crawford ED, Kaufman JJ. Complications of radical cystectomy for carcinoma of the bladder. J Urol 1980;123(5):640-643. 10. Shabsigh A, Korets R, Vora KC, et al. Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology. Eur Urol 2009;55(1):164174. 11. Lawrentshuck N, Colombo R, Hakenbergc OW, et al. Prevention and management of complications following radical cystectomy for bladder cancer. Eur Urol 2010;57(6):983-1001. Rev Mex Urol 2013;73(3):140-142 ÓRGANO OFICIAL DE DIFUSIÓN DE LA SOCIEDAD MEXICANA DE UROLOGÍA www.elsevier.es/uromx Clinical case Primary diffuse large B-cell lymphoma of the prostate: a case report D. Ríos-Cruza,*, J. Valerio-Ureñab and J. Hernández-Ascencioa a General Surgery Speciality Residency, Hospital Regional de Alta Especialidad de Veracruz, Veracruz, Ver., Mexico b Surgery Division Administration, Hospital Regional de Alta Especialidad de Veracruz, Veracruz, Ver., Mexico KEYWORDS Prostate cancer; Lymphoma of the prostate; Mexico. Palabras clave Cáncer de próstata; Linfoma prostático; México. Abstract Lymphoma of the prostate is an extremely rare entity with very few cases reported on in the medical literature. It can present as primary disease in the gland or be secondary to extraglandular invasion. Great diagnostic suspicion is required given that it manifests with a similar symptomatology to benign diseases. We present herein the case of a patient with lymphoma of the prostate, along with a literature review in relation to diagnosis and management. Linfoma primario prostático difuso de células B grandes. Reporte de un caso Resumen El linfoma de próstata es una entidad sumamente rara, con pocos casos reportados en la literatura médica. Puede presentarse de manera primaria en la glándula o, secundariamente debido a invasión extraglandular. Se requiere de una gran sospecha diagnóstica, ya que cursa con una sintomatología similar a la de los padecimientos benignos. Presentamos el caso de un paciente con linfoma prostático, y hacemos una revisión de la literatura en cuanto a diagnóstico y manejo. * Corresponding author at: Callejón JF Oca N° 43, Interior 4, entre Hernández y Hernández y Amado Nervo, Fraccionamiento Flores Magón, C.P. 91900, Veracruz, Ver., México. Telephone: 229780 6611. Email: [email protected] (D. Ríos-Cruz). 0185-4542 - see front matter © 2013. Revista Mexicana de Urología. Publicado por Elsevier México. Todos los derechos reservados. Primary diffuse large B-cell lymphoma of the prostate: a case report Introduction Prostate cancer is a health problem with an elevated mortality rate. A total of 90% of cases correspond to adenocarcinomas and hematologic tumors represent 0.2% of cases.1 Lymphomas of the prostate can be primary or secondary. They are extremely aggressive and have a poor short-term outcome. We present herein the clinical case of a primary lymphoma of the prostate that was diagnosed as a consequence of prostate symptoms. Case presentation A 54-year-old man presented with a 6-month illness characterized by weight loss of 10 Kg, night sweats, fever, and constipation requiring laxatives; he had reduced urine stream caliber, bladder strain, post-micturition dripping, dysuria, and acute urine retention that conditioned transurethral catheter placement. He was evaluated by the Urology Service and was found to have tegumentary paleness and a distended abdomen due to the adipose panniculus. Upon digital rectal examination the prostate was enlarged, hard, had a fibro-adenomatous consistency, weighed approximately 70 g, and had irregular edges. The laboratory work-up reported elevated creatinine of 6.3 mg/dL and urea of 146 mg/dL, BUN was 68 mg/dL, creatinine depuration was 10.06 mL/min/24 hours, hemoglobin 10.8 g/dL, hematocrit 29.5%, and leukocytes, platelets, prostate-specific antigen (PSA), and alkaline phosphatase were all normal. The patient underwent transurethral resection of the prostate with no complications. The histopathologic study revealed images consistent with anaplastic, large B-cell lymphoma with an extranodal diffuse pattern as a primary disease of the prostate. Immunohistochemistry showed CD45 and CD20 expression, with Bcl-2, Bcl-6, CD3, Ki67 and MIB-1 co-expression, and a proliferation rate of 80% (fig. 1). ß2microglobulin was measured, reporting 6,273 ng/mL and LDH of 614 U/L. A scintigram image revealed an increase in the ionic bone turnover in the bilateral scapulohumeral joint, the coxofemoral joint, the pubis, the sacroiliac joints, the sacrum, and the anterior-superior and inferior iliac spines, as well as ectasia of the left renal pelvis (fig. 2). The disease was cataloged as stage IV extranodal prostate lymphoma. The proposed treatment was based on 15 sessions of 30Gy of radiotherapy plus chemotherapy based on 4 cycles of cyclophosphamide, doxorubicin, vincristine, and prednisone. However, the patient died before completing the treatment. 141 other more frequent pathologic processes of the prostate that present as lower obstructive symptoms.3 Our patient manifested the classic symptoms of a benign prostate pathology, with the exception of fever, sweats, and weight loss, which led to the suspicion of a lymphoproliferative problem. However, due to its remote frequency it was not taken as the first diagnostic option. Primary lymphomas are less frequent than secondary ones. Initially, the possibility that the prostate could present with this type of tumor was questioned, due to the scarcity of its lymphatic tissue. Nevertheless, Furkase described the existence of intraprostatic lymphatic nodules. This, together with the recognition of extranodal lymphomas and the histologic confirmation of lymphomas limited to the prostate, has resulted in the acceptance and confirmation of the existence of lymphomas of prostatic origin.1 It has been proposed that the classification of lymphomas of the prostate follow the Working Formulation according to the Ann Arbor classification5: Stage I. Involvement of a single nodal or extranodal group. Stage II. Separate nodal areas on the same side of the diaphragm. Stage III. Two nodal groups on both sides of the diaphragm. Discussion Lymphomas are a group of malignant diseases of the lymphoreticular system, in potential. They can present in the urinary tract in the following 3 forms: primary extranodal disease, primary nodal disease, or advanced-sate disseminated lymphoma.2 Lymphomatous infiltration of the kidney, ureter, bladder, prostate, penis, and testes has been described.3 Lymphoma of the prostate has an incidence of 0.09% to 0.1% of all prostate tumors,4 with fewer than 200 reported cases in the medical literature.1 Its clinical diagnosis requires a high degree of suspicion because it can simulate Figure 1 Microscopic view showing the positive immunohistochemistry markers for Ki67 and Bcl-6. 142 D. Ríos-Cruz et al unfortunately not with the same results as those just described. We could argue that his fatal outcome was due to the advanced stage of the disease, with involvement of neighboring structures, as well as distant metastasis. In general, prognosis is bad, regardless of the patient’s age, the histologic type and stage of the disease, and the treatment.10 Conclusion Lymphoma of the prostate is an extremely rare tumor, with obstructive manifestations of the lower urinary tract. Diagnosis requires a high degree of suspicion and is made through immunohistochemistry. Treatment is directed at alleviating the obstructive symptoms, centering on radiotherapy and/or chemotherapy, but despite this, the short-term outcome is very poor. Conflict of interest The authors declare that there is no conflict of interest. Figure 2 Scintigram revealing the bone metastases sites. Financial disclosure No financial support was received in relation to this article. Stage IV. One nodal area and one non-nodal area that are not adjacent. Our patient presented with stage IV disease. Presentation age is the seventh decade of life and cases rarely present in patients under 30 years of age.6 Our patient was 54 years old. Generally, PSA parameters are normal, as was the case with our patient.7,8 Radiologically, the disease behaves like an advanced prostate tumor with infiltration into the bladder floor and compression of both ureters.9 Definitive diagnosis is made through immunohistochemistry. In the majority of cases initial treatment is surgery, for resolving the obstructive problem, along with systemic chemotherapy. We found different proposed regimens in the medical literature with varying results, such as the one described by Rodríguez-Ledesma et al. They employed a CHOP (cyclophosphamide, adriamycin, vincristine, and prednisone) regimen in a patient with non-Hodgkin’s B-cell lymphoma, who after 28 months of follow-up was in complete remission.8 Ochoa-Undargarain et al. used radiotherapy, in addition to surgery, with good results.3 The association of radiotherapy with chemotherapy after the surgical event has been described in the medical literature with favorable results. Fernandez-Marichal used a combination of VP 16, doxorubicin, cyclophosphamide, and prednisolone, together with radiotherapy, in a patient with non-Hodgkin’s lymphoma, achieving improvement, and after a 3-year follow-up he had a normal-sized prostate.7 In our patient, in addition to surgery, we used chemotherapy and radiotherapy, but References 1. Rioja Zuazu J, Iglesias R, Rosell Costa D, et al. Linfoma Prostático y revisión de la literatura. Actas Urol Esp 2009;33(6):686690. 2. Amat CM, Romero Pérez P, Ignacio Sevilla F. Linfomas del tracto genitourinario. Revisión de conjunto y aportación de dos casos de localización testicular. Arch Esp de Urol 1994;47:992. 3. Ochoa Undargarain O, Hermida Perez J, Ochoa Montes de Oca J, et al. Linfoma Linfocítico, Bien diferenciado de la próstata, Presentación de un caso y breve revisión de la literatura. Arch Esp Urol 2006;59(5):538-541. 4. Martin Plata C, Rojo Todo F, Tremps Velásquez D, et al. Linfoma Primario de Próstata: Presentación de un caso clínico-patológico y revisión de la literatura. Actas Urol Esp 2000;24(5):437-441. 5. Sarris A, Dimopoulos M, Pugh W, et al. Primary lymphoma of the prostate: good outcome with doxorrubicin-based combination chemotherapy. J Urol 1995;153:1852-1854. 6. National Cancer Institute Sponsored study of classification of non-Hodgkin´s lymphomas: summary and description of a working formulation for clinical usage. The non-Hodgkin´s lymphoma Pathologic Classification Project. Summary and description of a working formulation for clinical usage: Lymphoma Pathologic Classification Project. Cancer 1982;49(10):2112-2135. 7. Fernandez Marichal F, Pila Pérez R, Chavez Olivera R. Linfoma no Hodgkin de próstata: Informe de un nuevo caso. Arch Esp Urol 1996;49:521. 8. Rodriguez Ledesma J, López Tello J, Picaso L. Linfomas de tracto urinario. Arch Esp Urol 1996;49:587. 9. Peyri E. Linfoma Primario de Próstata. Act Urol Esp 1991;405. 10. Bostwick DG, Iczkowski KA, Amin MB, et al. Malignant lymphoma involving the prostate. Report of 62 cases. Cancer 1998;83(4):732-738. Rev Mex Urol 2013;73(3):143-145 ÓRGANO OFICIAL DE DIFUSIÓN DE LA SOCIEDAD MEXICANA DE UROLOGÍA www.elsevier.es/uromx Clinical case Scrotal angiomyolipoma: a clinical case F. J. Flores-Murcioa,*, M. P. Ávila-Bozab and D. E. Aguirre-Quezadac a Urology Service, Hospital Regional de Tlalnepantla ISSEMyM, Tlalnepantla, Mex., Mexico b General Surgery Speciality Residency, Hospital Regional de Tlalnepantla ISSEMyM, Tlalnepantla, Mex., Mexico c Pathology Service, Centro Oncológico Estatal ISSEMyM, Toluca, Mex., Mexico KEYWORDS Angiomyolipoma, Scrotal tumor; PEComa; Mexico. Palabras clave Angiomiolipoma; Tumor escrotal; PEComa; México. Abstract A case of scrotal angiomyolipoma is presented herein. A 22-year-old man was evaluated due to left orchialgia. Physical examination showed an increase in scrotal volume dependent on the left side with apparent hydrocele and grade III varicocele, and the so-called “bag of worms” in the scrotum. During surgery a highly vascularized paratesticular mass was found that extended from the inguinal region along the entire tract of the spermatic cord to the perineal region. The mass was excised and the histopathologic study reported a tumor composed of adipose tissue, smooth muscle, and blood vessels, corresponding to scrotal angiomyolipoma. This benign tumor is rare and there are very few cases reported on at the scrotal level. Angiomiolipoma escrotal, presentación de caso clínico Resumen Se presenta el caso de un angiomiolipoma escrotal. Paciente masculino de 22 años de edad, con valoración por orquialgia izquierda; se realiza exploración física mostrando aumento de volumen escrotal dependiente de lado izquierdo, con aparente hidrocele y varicocele grado III, con escroto en bolsa de gusanos. En el transoperatorio se encontró masa paratesticular con gran vascularidad, que se extendía desde región inguinal en todo el trayecto del cordón espermático hasta región perineal, se realiza excisión de la misma, el reporte histopatológico mostró tumor compuesto por tejido adiposo, músculo liso y vasos sanguíneos, correspondiente con angiomiolipoma escrotal. Este tumor benigno es raro, con pocos casos reportados a nivel escrotal. * Corresponding author at: Hospital Regional Tlalnepantla. Paseo del F.C. s/n, Unidad Habitacional Los Reyes Ixtacala 1ra Sección, C.P. 54090, Tlalnepantla, Méx., México. Telephone: (55) 2626 9200. Email: [email protected] (M. P. Ávila-Boza). 0185-4542 - see front matter © 2013. Revista Mexicana de Urología. Publicado por Elsevier México. Todos los derechos reservados. 144 Introduction Angiomyolipoma is a rare tumor (0.13% to 0.3% in the general population) that mainly involves the kidneys, presents in women over 50 years of age, 1 and is particularly associated with tuberous sclerosis. Originally described by Fischer in 1911, Morgan gave it its present name in 1951. Angiomyolipoma is a benign tumor consisting of thick-walled, aneurysmal blood vessels, smooth muscle, and adipose tissue. It was initially regarded as a form of hamartoma or choristoma, but today is considered to be a tumor derived from perivascular epithelioid cells (PEC), or PEComas. They include the angiomyolipoma, clear cell “sugar” tumor (CCST), and lymphangioleiomyomatosis (LAM), in addition to the clear cell myomelanocytic tumor (CCMMT). PEComas can affect the visceral organs including the kidney, lung,2 liver3, nasal cavity4, small and large intestine,5 prostate, and uterus, as well as the retroperitoneum,6,7, pelvis8, pancreas9, skin10,11, testis,12 and scrotum.13 Case presentation A 22-year-old man was evaluated for left orchialgia and increased left scrotal volume of 2-year progression, and scrotal varicose veins. His past medical history was unremarkable. Physical examination revealed an increase in scrotal volume that was dependent on the left side, with apparent hydrocele and grade III varicocele. The scrotum had the so-called “bag of worms” aspect. An ultrasound (US) study showed data of orchiepididymitis, grade III left varicocele and associated hydrocele, and the right testis had no alterations. He was programmed for hydrocelectomy plus varicocelectomy, but in the intraoperative period the increase in volume was observed to be dependent on a paratesticular mass with great vascularity that extended from the inguinal region, all along the spermatic cord, to the Figure 1 Microscopic appreciation of a benign tumor composed of adipose tissue and mature smooth muscle, as well as abundant blood vessels (hematoxylin & eosin X10). F. J. Flores-Murcio et al perineal region. The mass was completely excised, obtaining adipose-type tissue with abundant adhered vessels; the tumor diameter was approximately 13 cm. The histopathologic study reported a 12 x 8 x 7 cm scrotal lesion that weighed 224 g. Diagnosis was angiomyolipoma with chronic inflammation and organized vascular thrombosis (figs. 1-3). Only a few cases of scrotal localization of this benign tumor derived from blood vessels, adipose tissue, and smooth muscle are referred to in the medical literature. Discussion The anatomic origin of scrotal tumors is extratesticular in the majority of cases. They arise from the spermatic cord and the epididymis and include different mesenchymal tumors.13 Many of the tumors within the scrotal sac are derived from paratesticular tissue. The paratesticular region is a complex anatomic area that includes the spermatic cord, the testicular tunica, epididymis, and vestigial remnants such as the appendix epididymis and the appendix testis: histogenetically, this area is composed of a variety of epithelial, mesothelial, and mesenchymal elements. Therefore, the neoplasms originating from this region form a heterogeneous group of tumors with distinct behavior patterns; on rare occasions they can have distant metastases.14 The proximity, and in some cases, the communication between the testicular and paratesticular structures results in a diversity of masses and lesions that resemble tumors and as a whole are a formidable diagnostic challenge due to their rareness and morphologic overlapping. Their main approach continues to be the classic histopathologic analysis with the prudent incorporation of contemporary immunohistochemical markers.15,16 Solid tumors of paratesticular tissue are rare, although they have a reported prevalence that varies from 3% to 16% of all the patients for whom scrotal US Figure 2 Blood vessels, adipose tissue, and mature smooth muscle at a higher magnification (hematoxylin & eosin X40). Scrotal angiomyolipoma: a clinical case 145 Financial disclosure No financial support was received in relation to this article. References Figure 3 Photomicrography showing disorganized mature smooth muscle segments without atypia (hematoxylin & eosin X40). studies are ordered. Even though scrotal US is the modality of choice for initial evaluation of pathologic scrotal alterations, given its wide availability, low cost, and high sensitivity for paratesticular disease detection, US findings are often not conclusive;17 in such cases MR can provide additional information necessary for modifying their management.18 In contrast to testicular tumors, these neoplasms affect patients of all ages, and they have an asymptomatic presentation as a non-fluctuating or firm mass of varying growth; it is not unusual for the patient to complain of a firm mass of rapid growth. Conclusion Angiomyolipoma is an uncommon, benign tumor that is rarely located in the scrotum. Its management should take into account the size of the tumor, the presence of symptoms and factors characteristic of the patient, particularly the risk for hemorrhage; the majority of symptomatic angiomyolipomas measure around 4 cm. Even though US is usually an adequate study for evaluating the scrotal region and the testes, its findings can be inconclusive in the case of angiomyolipomas. Histopathologic study regularly provides the definitive diagnosis and there should always be diagnostic suspicion when dealing with uncommon tumors such as angiomyolipoma, since tumor treatment and approach must be modified according to each case. Conflict of interest The authors declare that there is no conflict of interest. 1. Yang L, Feng XL, Shen S, et al. Clinicopathological analysis of 156 patients with angiomyolipoma originating from different organs. Oncol Lett 2012;3(3):586-590. 2. Marcheix B, Brouchet L, Lamarche Y, et al. Pulmonary angiomyolipoma. Ann Thorac Surg 2006;82(4):1504-1506. 3. Tryggvason G, Blöndal S, Goldin RD, et al. Epithelioid angiomyolipoma of the liver: case report and review of the literature. APMIS 2004;112(9):612-616. 4. Stodulski D, Stankiewicz C, Rzepko R, et al. Angiomyolipoma of the larynx: case report. Eur Arch Otorhinolaryngol 2007;264(1):89-92. 5. Lin CY, Chen HY, Jwo SC, et al. Ileal angiomyolipoma as an unusual cause of small-intestinal intussusception. J Gastroenterol 2005;40(2):200-203. 6. Tseng CA, Pan YS, Su YC, et al. Extrarenal retroperitoneal angiomyolipoma: case report and review of the literature. Abdom Imaging 2004;29(6):721-723. 7. Yener O, Ozçelik A. Angiomyolipoma of the right adrenal gland. ISRN Surg 2011;2011:10274. 8. Gronchi A, Diment J, Colecchia M, et al. Atypical pleomorphic epithelioid angiomyolipoma localized to the pelvis: a case report and review of the literature. Histopathology 2004;44(3):292-295. 9. Gleeson FC, de la Mora Levy JG, Zhang L, et al. The differential broadens. EUS FNA appearance and cytological findings of pancreatic angiomyolipoma. JOP 2008;9(1):67-70. 10. Mikoshiba Y, Murata H, Ashida A, et al. Case of a cutaneous angiomyolipoma in the ear. J Dermatol 2012;39(9):808-809. 11. Singh K, Pai RR, Kini H, et al. Cutaneous angiomyolipoma. Indian J Pathol Microbiol 2009;52(2):242-243. 12. Saito M, Yuasa T, Nanjo H, et al. A case of testicular angiomyolipoma. Int J Urol 2008;15(2):185-187. 13. Hosseini MM, Geramizadeh B, Shakeri S, et al. Intrascrotal solitary neurofibroma: A case report and review of the literature. Urol Ann 2012;4(2):119-121. 14. Khoubehi B, Mishra V, Ali M, et al. Adult paratesticular tumours. BJU Int 2002;90(7):707-715. 15. Amin MB. Selected other problematic testicular and paratesticular lesions: rete testis neoplasms and pseudotumors, mesothelial lesions and secondary tumors. Mod Pathol 2005;18(Suppl 2):S131-145. 16. Womack C, Turner AG, Fisher C. Paratesticular liposarcoma with smooth muscle differentiation mimicking angiomyolipoma. Histopathology 2000;36(3):221-223. 17. Syed Ali A, Tawfeeq Amjadali S, Syed Zafar HJ, et al. Multimodality Imaging of Paratesticular Neoplasms and Their Rare Mimics. RadioGraphics 2003;23:1461-1476. 18. Cassidy FH, Ishioka KM, McMahon CJ, et al. MR imaging of scrotal tumors and pseudotumors. Radiographics 2010;30(3):665683. Rev Mex Urol 2013;73(3):146-149 ÓRGANO OFICIAL DE DIFUSIÓN DE LA SOCIEDAD MEXICANA DE UROLOGÍA www.elsevier.es/uromx Clinical case Leiomyoma of the seminal vesicle: a case report and literature review A. J. Camacho-Castro*, V. Osornio-Sánchez, J. A. Martínez, G. Fernández-Noyola, G. Recinos-Carrera, S. Ahumada-Tamayo, F. García-Salcido, E. Muñoz-Ibarra, E. MayorgaGómez, G. Garza-Sainz, I. Uberetagoyena-Tello de Meneses, A. Palmeros-Rodríguez, V. Cornejo-Dávila, C. Martínez-Arroyo, M. Cantellano-Orozco, J. G. Morales-Montor and C. Pacheco-Gahbler Urology Division, Hospital General “Dr. Manuel Gea González”, Mexico City, Mexico KEYWORDS Seminal vesicle; Leiomyoma; Mexico. Abstract Seminal vesicle anomalies can be classified as abnormalities of number (agenesis, fusion), canalization (cysts), and maturation (hypoplasia). Their importance lies in the frequency with which they are related to developmental abnormalities of other mesonephric derivatives. Primary tumors of the seminal vesicles are extremely rare and mesenchymal tumors are less frequent than those of epithelial origin. The aim of this article was to describe a case of leiomyoma of the seminal vesical and its management at the Hospital General “Dr. Manuel Gea González”. A 37-year-old man with a past medical history of insulin-treated type 2 diabetes mellitus had symptom onset 7 days prior to seeking medical attention for moderate, continuous, colicky lumbar pain irradiating to the left flank and iliac fossa. Digital rectal examination found a nonsuspicious, grade 1 adenomatous prostate. A kidney and suprapubic ultrasound revealed an image suggestive of a 2 x 2 cm, left paravesical lesion that was hyperechoic, homogeneous, and had well-defined edges. A urotomography (UroCAT) scan identified a dense, solid, 3 x 2 cm lesion between the base of the bladder and the left seminal vesicle. A transrectal ultrasound showed a lesion that was dependent on the left seminal vesicle. Diagnostic cystoscopy found a left parameatal extrinsic compression. A 3 x 2 cm tumor of the left seminal vesicle was then laparoscopically resected and the histopathologic study reported leiomyoma of the seminal vesicle. Ideal management data for seminal vesicle tumors are limited due to the lack of reported cases. Nevertheless, resection is the preferred option for these lesions. There are 75 accepted cases of primary tumors of the seminal vesicle and 8 of them are benign: one schwannoma and 7 leiomyomas. *Corresponding author at: Calzada de Tlalpan N° 4800, Colonia Sección XVI, Delegación Tlalpan, C.P. 14080, México D.F., México. Telephone: 4000 3000, ext. 3298. Email: [email protected] (A. J. Camacho-Castro). 0185-4542 - see front matter © 2013. Revista Mexicana de Urología. Publicado por Elsevier México. Todos los derechos reservados. Leiomyoma of the seminal vesicle: a case report and literature review Palabras clave Vesícula seminal; Leiomioma; México. 147 Leiomioma de vesícula seminal reporte de un caso y revisión de la literatura Resumen Las anormalidades de las vesículas seminales pueden ser categorizadas en anormalidades de número (agenesia, fusión), canalización (quistes) y maduración (hipoplasia); la importancia de éstas reside en la frecuencia con que se relacionan con anormalidades del desarrollo de otros derivados mesonéfricos. Los tumores primarios de las vesículas seminales son extremadamente raros, y los tumores mesenquimales son encontrados con menor frecuencia que los de origen epitelial. El objetivo del presente artículo es describir el caso y manejo de un leiomioma de vesícula seminal, en el Hospital General “Dr. Manuel Gea González”. Se presenta hombre de 37 años de edad, con antecedente de diabetes mellitus tipo 2 tratado con insulina. Inició 7 días previos a acudir a valoración, con dolor lumbar irradiado a flanco y fosa ilíaca izquierda, tipo cólico, de moderada intensidad, continúo. Al tacto rectal con próstata adenomatosa grado 1, no sospechosa, se realizó ultrasonido (USG) renal y suprapúbico, donde se encontró imagen sugestiva de lesión paravesical izquierda, hiperecoica, homogénea, de bordes bien definidos, de 2 x 2 cm. La urotomografía (UroTAC) reporta lesión de densidad sólida, entre base de vejiga y vesícula seminal izquierda, de 3 x 2 cm. Ultrasonido transrectal con lesión dependiente de vesícula seminal izquierda. En la cistoscopía diagnóstica se encontró compresión extrínseca parameatal izquierda. Posteriormente, se realizó resección de neoplasia de vesícula seminal izquierda por vía laparoscópica de 3 x 2 cm, con resultado de histopatología de leiomioma de vesícula seminal. Los datos en el manejo óptimo de las neoplasias de vesícula seminal se encuentran limitados debido a la falta de casos reportados, sin embargo la resección de dichas lesiones es la opción preferida. Existen 75 casos aceptados de tumores primarios de la vesícula seminal, de los cuales 8 son benignos: un schwannoma y 7 leiomiomas. Introduction Seminal vesicle anomalies can be categorized into abnormalities of number (agenesis, fusion), canalization (cysts), and maturity (hypoplasia); their importance lies in the frequency with which they are related to developmental abnormalities of other mesonephric derivatives. Primary tumors of the seminal vesicles are extremely rare and mesenchymal tumors are found less frequently than those of epithelial origin. In 1910, Emmerich reported the first case of cystomyoma of the seminal vesicle, and since then isolated cases of benign tumors have been reported. Ideal management data of seminal vesicle tumors are limited, due to the lack of reported cases. However, resection of these lesions is the preferred option. Open exploration can be performed through a variety of approaches, which can be retropubic, transvesical, perineal, transrectal, and trans-sacral. The approach can also be combined with removal of the complete seminal vesicle; likewise there are reports of laparoscopic lesion excision.1,2 Benign tumors are usually asymptomatic and can be discovered incidentally during surgery or autopsy. The seminal vesicles are paired, sacculated structures located between the bladder and the rectum. The upper pole ends in a blind point, whereas the lower pole forms a straight duct that joins with the contralateral duct, becoming the ejaculatory duct. Asymmetry in shape and form of the seminal vesicles is normal and the right gland is generally slightly larger in one third of men.3-5 The seminal vesicles develop in puberty and are androgen-dependent organs. During ejaculation, the secretions of the male reproductive tract are sequentially released and the final portion consists mainly of seminal vesicle fluid. The exact physiological role of the seminal vesicles is unknown, but its secretions can optimize the conditions for spermatic motility, transport, and survival.6-8 The aim of the present article is to describe the case and management of a leiomyoma of the seminal vesicle at the Hospital General “Dr. Manuel Gea González”. Case presentation A 37-year-old man with a past medical history of type 2 diabetes mellitus treated with insulin (20 U intermediate and 15 U rapid) had symptom onset of his present illness 7 days prior to seeking medical attention. His symptoms were moderate, colicky, and continuous lumbar pain irradiating to the left flank and iliac fossa. At the physical examination, digital rectal exam identified a non-suspicious, grade 1, adenomatous prostate. A suprapubic renal ultrasound (US) study revealed an image suggestive of a left, hyperechoic, homogeneous 2 x 2 cm paravesical lesion with well-defined edges (fig. 1). A urotomography (UroCAT) scan corroborated the image of the lesion, with a solid density between the base of the bladder and the left seminal vesicle that measured 3 x 2 cm (figs. 2 and 3). A transrectal US showed a lesion dependent on the left seminal vesicle (fig. 1). Diagnostic cystoscopy found a left parameatal extrinsic compression. A laparoscopic resection of the 3 x 2 cm left seminal vesicle tumor was performed (fig. 4) and the histopathologic study reported leiomyoma of the seminal 148 A. J. Camacho-Castro et al Figure 1 Transrectal ultrasound. A posterior paravesical lesion is identified at the seminal vesicle site. Figure 2 Simple computed tomography scan. The image clearly shows a lesion at the left lateral base of the bladder. Figure 3 Contrast-enhanced computed tomography scan that newly identifies the left seminal vesicle lesion. Figure 4 Surgical specimen. vesicle. The patient is presently in the follow-up period and his progression is good. other anatomic abnormalities of the bladder.3 Imaging studies such as US, computed tomography, and magnetic resonance have improved diagnostic ability.6 Discussion Transrectal and abdominopelvic US in the most useful initial diagnostic tool for patients with prolonged pelvic pain and other suspicious findings in the medical interview or physical examination; a subsequent computed abdominopelvic tomography scan can be ordered to evaluate renal abnormalities and define the presence of some other pathologic process of the pelvis. Other imaging studies such as excretory urography, magnetic resonance, and seminovesiculography can also be done when there is doubt about the etiology of the disease. Cystoscopy can identify an absent ipsilateral hemitrigone, an intravesical protrusion, and Conclusions There are 75 accepted cases of seminal vesicle primary tumors, 49 of which are adenocarcinomas, 5 are sarcomas, and one is squamous cell carcinoma, contrasting with the benign tumors that are extremely rare with only 8 reported cases: one schwannoma and 7 leiomyomas. Conflict of interest The authors declare that there is no conflict of interest. Leiomyoma of the seminal vesicle: a case report and literature review Financial disclosure No financial support was received in relation to this article. References 1. Moudouni SM, Tligui M, Doublet JD, et al. Laparoscopic excision of seminal vesicle cyst revealed by obstruction urinary symptoms. Int J Urol 2006;13(3):311-314. 2. Buck AC, Shaw RE. Primary Tumours of the retro-vesical region with special reference to mesenchymal tumours of the seminal vesicles. Br J Urol 1972;44(1):47-50. 149 3. Lee CB, Choi HJ, Cho DH, et al. Cystadenoma of the seminal vesicle. Int J Urol 2006;13(8):1138-1140. 4. Yasunaga Y, Ueda T, Kodama Y, et al. Poorly differentiated neuroendocrine carcinoma of the seminal vesicle. Int J Urol 2012;19(4):370-372. 5. Agrawal V, Kumar S, Sharma D, et al. Primary leiomyosarcoma of the seminal vesicle. Int J Urol 2004;11(4):253-255. 6. Patel B, Gujral S, Jefferson K, et al. Seminal vesicle cysts and associated anomalies. BJU Int 2002;90(3):265-271. 7. Hoshi A, Nakamura E, Higashi S, et al. Epithelial stromal tumor of the seminal vesicle. Int J Urol 2006;13(5):640-642. 8. Abe H, Nishimura T, Miura T, et al. Cystosarcoma phyllodes of the seminal vesicle. Int J Urol 2002;9(10):599-601. Rev Mex Urol 2013;73(3):150-151 ÓRGANO OFICIAL DE DIFUSIÓN DE LA SOCIEDAD MEXICANA DE UROLOGÍA www.elsevier.es/uromx Brief report DNA isolation from urine samples for STR amplification with a rapid and safe new method Aislamiento de ADN a partir de muestras de orina para la amplificación STR con un nuevo método rápido y seguro A. J. Manriquea,b, I. C. Ortiz-Trujilloc,*, L. M. Martínez-Sánchezc, C. A. Agudeloc,d, D. A. Vásquez-Hincapiéc, A. E. Toro-Montoyac, I. C. Barguil-Díazc, D. P. Cuesta-Castroc, M. L. Bravob, D. P. Aguirreb y J. J. Builes-Gómeza,b a The Biology Institute, Universidad de Antioquia, Medellín, Antioquia, Colombia b Laboratorio Genes Ltda., Medellín, Antioquia, Colombia c The Faculty of Medicine, The School of Health Sciences, Universidad Pontificia Bolivariana, Medellín, Antioquia, Colombia d Clínica Universitaria Bolivariana, Medellín, Antioquia, Colombia Urine can be very useful for isolating DNA because it is non-invasive, the sample volume is not restricted, and it is easily obtained.1 Forty-six urine samples from healthy volunteers (24 men and 22 women) were obtained. They were immediately centrifuged at 13,000 rpm for 20 minutes and maintained at a temperature of 4°C overnight. All the study participants provided their informed consent. DNA isolation was carried out with a modified salting out protocol.2 The median values were 29.25 ng for the men and 29.20 ng for the women. PCR with 5 STR markers was used to analyze DNA quality: D16S539, D7S820, D13S317, D5S818, and Penta D. The PCR products were separated by means of electrophoresis in silver-stained denaturing polyacrylamide gels. All the markers were successfully typed with an 85% yield and the rate was reduced in relation to the length of the amplicon. The amplification percentage showed a tendency to decrease with respect to the length of the amplicon, as occurred in other studies.3 These results indicate that urine is a suitable sample for DNA amplification and the modified procedure has a very low cost compared with the high cost of commercial kits. Financial disclosure No financial support was received in relation to this article. Conflict of interest The authors declare that there is no conflict of interest. * Corresponding author at: Carrera 72a N° 78b-50, Medellín, Antioquia, Colombia. Telephone: (57) 493 6300, ext. 854. Cell phone: (300) 6036234. Email: linam.martinez @upb.edu.com (I. C. Ortiz-T). 0185-4542 - see front matter © 2013. Revista Mexicana de Urología. Publicado por Elsevier México. Todos los derechos reservados. DNA isolation from urine samples for STR amplification with a rapid and safe new method References 1. Botezatu I, Serdyuk O, Potapova G, et al. Genetic analysis of DNA excreted in urine: a new approach for detecting specific genomic DNA sequences from cells dying in an organism. Clin Chem 2000;46(8):1078-1084. 151 2. Miller SA, Dykes DD, Polesky HF. A simple salting out procedure for extracting DNA from human nucleated cells. Nucleic Acids Res 1988;16(3):1215. 3. Cheong-Sik K, Jin Hee-K, Daehee K, et al. Gene Amplification using DNA from Human Spot Urine Samples. Asian Pacific J Cancer Prev 2006;7(2):318-320.