Biomedical subjects
Publications and source records attributed to J M Liédana Torres.
We want to make in this article, a deep review of our experience in kidney transplantation since the moment we started the technique in 1986 to the end of the year 2000. We also want to make a compilation of the most important points of the surgical technique, patients selection criteria, and the most common and uncommon complications that can appear in kidney transplantation, analizing our results all along this time.
PURPOSE: To review our series of 416 renal transplants, with special reference to the surgical complications and their management. METHODS: From June, 1986 to October 1997, we are performed 416 heterotopic renal transplants, harvested from cadavers. Reconstruction of the urinary tract reconstruction was by ureteroneocystostomy in practically all the cases. RESULTS: There were some urological complications in 80 patients (19.2%). The most common urological complication was obstruction of the urinary tract arising from stenosis (3.3%), lymphocele (4.3%) and clotting (1.2%). 78.1% of these urological complications were resolved by endourological techniques. Urinary fistula was observed in 12 cases (2.8%). Vascular complications in 22 (6.9%), lithiasis in 5 (1.2%), and eventrations in 11 (2.6%). The treatment of these complications is described. The actuarial survival rates were 87.8% and 77.3% at one and five years respectively for the graft, and 92.4% and 83.5% for the patients. CONCLUSIONS: Our surgical complication rate in patients undergoing renal transplantation was 19.2%. The most common complication was urinary tract obstruction from stenosis (3.3%), lymphocele (4.3%) and clotting (1.6%); 78.1% of these obstructive complications were resolved by endourologic techniques. Percutaneous drainage and esclerotherapy of the lymphoceles resolved 66.6% of them. Renal biopsy performed with a 14G needle caused 5 severe hemorrhagic complications. There were no complications when an 18G needle was utilized.
OBJECTIVES: To review our series of 300 renal transplants, with special reference to the surgical complications and their management. METHODS: From June, 1986 to August, 1995, we performed 300 heterotopic renal transplants harvested from cadavers. Reconstruction of the urinary tract was by ureteroneocystostomy in practically all of the cases. RESULTS: The overall surgical complication rate was 20.3%. The graft was lost in 2 cases (0.66%). The most common urological complication was obstruction of the urinary tract arising from stenosis (3.6%), lymphocele (5.3%) and clotting (1.6%); 78.1% of these obstructive complications were resolved by endourological techniques. Urinary fistula was observed in 9 cases (3%) and lymphocele in 16 (5.3%), which were resolved by percutaneous drainage and sclerotherapy in 81.2% of the cases. Vascular complications were observed in 14 cases (4.6%), lithiasis in 5 (1.66%) and eventration in 6 (2%). The treatment of these complications are described. The actuarial graft and patient survival rates were 90.9% and 84.7% at one and five years, respectively, for the graft and 93.5% and 89% for the patients. CONCLUSIONS: Our surgical complication rate in patients undergoing renal transplantation was 20.3%. The most common complication was urinary tract obstruction from stenosis (3.6%), lymphocele (5.3%) and clotting (1.6%); 78.1% of these obstructive complications were resolved by endourological techniques. Percutaneous drainage of the lymphocele combined with sclerotherapy achieved resolution in 81.2%. Renal biopsy performed with a 14 G needle caused 5 severe hemorrhagic complications. There were no complications when an 18 G needle was utilized.
Since the late 1980s, different reservoirs and bladder substitution techniques have been added to the urological surgical armamentarium. The necessary use of an intestinal segment--generally detubularized--make these surgical procedures complicated and time-consuming. Furthermore, problems are encountered postoperatively due to the important morbidity arising from these procedures. The present article describes our experience with mechanical sutures and resorbable material. Although the results have not been analyzed, our initial experience at the Miguel Servet Hospital has shown that these devices significantly facilitate the operative procedure, thereby reducing the incidence of urinary and intestinal fistulas. Although there is an evident risk of calculi formation, complicated solutions are not required and the biological tolerance to the metal sutures is excellent.
The ectopic ureter opening to the seminal vesicle is uncommon in the male and even less in a duplex kidney. It commonly presents as recurrent urinary infection with pelviperineal pain. Treatment is by heminephrectomy with total ureterectomy and removal of the seminal vesicle if it is cystic. Herein we describe a 70-year-old patient who had previously undergone a heminephrectomy and partial ureterectomy due to an ectopic ureter opening to the seminal vesicle of the ureter of the upper pelvis of the left kidney. The patient was submitted to a second ureterectomy procedure due to pyoureter in the ureteral stump. The main features of this pathological condition are described and the surgical approach is discussed.
A case of multilocular renal cyst in a 37-year-old patient is presented, which met all of the diagnostic criteria described by Powell (1951) and Boggs and Kimmelstiel (1956). The frequency of renal hydatid cyst observed in our setting warrants differential diagnosis from this disease entity. Conservative surgery is advocated as treatment.
Radical cystectomy continues to be the procedure of choice in the treatment of invasive bladder cancer and it is currently an exceptional procedure as monotherapy. The development of surgical techniques for urinary diversion, with less complications, has led to a significant improvement of the overall results achieved with this procedure. We performed a retrospective study of 143 cystectomy procedures that had been performed over a period of 15 years in patients with this tumor type. We evaluated the operative mortality, the morbidity resulting from the procedure, and patient nutritional status and its relation to the appearance of complications. Similarly, we analyzed the different therapeutic strategies we utilized throughout the course of our urological evolution, clearly differentiated into three periods during which we associated radical cystectomy with radiotherapy pre- and post-surgery, neoadjuvant or adjuvant chemotherapy (monotherapy with CDDP or multiple therapy with M-VAC). The operative mortality rate was 0.94% and the incidence of early complications varied according to the different periods, 62% and 32%. Late complications were observed to be 24%. The overall 5-year survival rate was 39% for cystectomy + radiotherapy, 59% when we utilized cisplatin as adjuvant therapy, and 70% (2 years) when we utilized M-VAC neoadjuvant chemotherapy. We believe that distant metastasis was the most common cause of late failures of total cystectomy for infiltrating bladder tumor. Similarly, we believe that the reduced incidence of early complications reported in recent years can be ascribed to the enhanced surgical techniques, better nutritional status of the patient undergoing this procedure, antibiotic therapy, perioperative care, and overall better management and understanding of this disease entity; i. e., the use of a combined therapeutic approach.
We reviewed our data on the diagnosis and treatment of testicular tumors during the period spanning January, 1975 to December, 1989 and compared them with the data reported in the literature. The records of 26 cases of germ cell tumors were analyzed. These had a follow-up ranging from 6 to 162 months (mean 36 months). We highlight the usefulness of CT and tumor markers in the diagnosis, staging and follow-up. We consider radical inguinal orchiectomy to be the initial treatment. The therapeutic approach thereafter depends on the histological findings and tumor stage. Currently, patients are followed very carefully after orchiectomy of stage I tumors. Multiple chemotherapy of tumors in the advanced stages has increased the incidence of survival and complete remission. Furthermore, this chemotherapeutic approach has occasionally converted surgery into and adjuvant treatment modality.
We report our early results in the treatment of nonmetastatic prostate cancer (stages A, B, C) by radical surgery. All but two patients classified as stage A1 received adjuvant treatment with hormone blockade using LH-RH analogues and an antiandrogen for a period of two to six months. A favorable local response was observed in almost all patients. Adjuvant therapy achieved reduction of prostate size and most of the cases could be staged down from the initial clinical staging to fall within the indication of radical surgery, including stage C2 tumors reclassified as local tumor stage C1 or lower. Staging lymphadenectomy prior to radical prostatectomy revealed multiple lymph node involvement in 3 patients who were consequently not submitted to radical surgery. In the remaining 14 cases, definitive postsurgical staging revealed minimum invasion of the capsule without seminal vesicle involvement (stage C1) in only two cases with A2 and B2 tumor in the initial staging. There were no operative deaths and morbidity was scant. Some modifications aimed at enhancing exposure of the surgical field and thereby reducing complications are described. Although a longer patient follow-up is warranted, to date all patients are alive and no local recurrence or distant metastases have been observed.
Overall review that offers an integrated insight of the importance and repercussions of urinary by-pass and bladder replacement. Over the last decades there has been a growing interest in the possibility of reconstructing the urinary system and there are now an almost infinite number of surgical solutions. The history of the development of using the intestine for by-passes and the reconstruction of the urinary system is described. The secondary metabolic alterations, the possibility of secondary intestinal tumours and the rudiments of ureterointestinal anastomosis are dealt with. Bladder substitution techniques are highlighted, and the vast experience of the Urology Department of Hospital Miguel Servet explained, including criteria and conclusions that help to choose from the many urological surgery alternatives headed by urinary by-pass and bladder complications.
Conservative surgery is considered to be the treatment of choice in patients with bilateral renal tumors or tumor in the solitary kidney owing to the need to preserve renal function. A case of a 63-year-old patient with bilateral renal carcinoma is described. The presenting symptoms were pain and paraneoplastic signs. The patient did not present hematuria throughout the course of the disease. The urographic, ultrasound and tomodensitometric work up correctly determined tumor size, characteristics and anatomic relationship. Arteriography permitted mapping of the vascular structures of both kidneys. Fine needle aspiration biopsy permitted histologic classification preoperatively. The approach was via a Chevron incision. An extended nephrectomy was performed on the left kidney and surgical enucleation of the tumor in the right kidney in a one stage procedure. The diagnostic aspects are discussed and the therapeutic options are reviewed with special reference to the conservative procedures.
With the description of this new case of urachal adenocarcinoma in the vesical cupula we provide a review on the clinical, pathological and immunohistochemical aspects of this rare tumour, as well as a diagnostic and therapeutical approach. Its subepithelial infiltrant nature delays discovery and denotes both an insidious evolution and poor prognosis. Mucinoid production, nodes pattern and certain immunohistochemical substances as well as abnormalities in the cell's DNA content are attributes of this entity. Only surgery, either partial or exeresis, is effective since this is a radioresistant and dubiously chemosensitive tumour.
A case of Malignant Fibrous Histiocytoma in a 64 years old man, its rarity consisting in the location, the scrotal wall, is presented. An exposition on this pathological form of presentation, symptomatology, A.P., diagnostic, natural history, prognosis and treatment is made. Also, we review the literature on Malignant Fibrous Histiocytomas on the scrotal wall.
We present our experience in the performance of Camey II type substitution ileocystoplasty. The operation was performed between January 1988 and February 1989 on 11 patients who had been diagnosed as having vesical tumour by means of transurethral resection. All of them had received preoperative systemic chemotherapy. Technically, we single out the performance of ileo-obturating lymphadenectomy prior to the cystoprostatovesiculectomy in the same operation, creation of the neobladder with detubulized terminal ileum, uretero-ileal reimplantation according to Le Duc-Camey technique and use of mechanical sutures to reestablish intestinal continuity. Operative and postoperative mortality has been null. As complications, we may mention a urthro-ileal fistula as a result of the suture tension at this level, due to shortness of the mesointestine, and which yielded with conservative measures. Amongst tardive complications we may single out a urethro-ileal stenosis, which required performance of an internal urethrotomy. Daytime continence in all patients, except one. Night continence in six cases. Absence of ureteral reflux and upper urinary tract with correct function and morphology in all cases. The follow-up time ranges from 3 to 16 months. We conclude that this type of vesical substitution offers all patients a good quality of living and adequate mictional comfort.
As a novel item we present a case of the reconversion of a Bricker-Wallace type external urinary bypass into vesical replacement according to Camey technique type II. 5 years after radical cystectomy and external urinary bypassing due to a malignant infiltrating vesical carcinoma and considering the patient's malignant pathology controlled, we have converted this bypass into a bladder replacement with detubulized ileum. Renal function is preserved by means of a ileo-ileal intussusception mechanism, achieving mictional physiology and maintaining both daytime and nocturnal continence, thanks to the integrity of the external sphincter. The major advances in reconstructive urological surgery in recent years have enabled us to make a fresh study of these patients with bypasses, as in fact many of them are going to be able to be reconstructed.
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