Purpose: This prospective case-control study explored the association between urinary magnesium levels and acute urinary retention (AUR) in individuals presenting to the emergency department. Materials and Methods: Forty-six participants, comprising 23 cases and 23 age- and sex-matched controls, underwent urine analysis for magnesium, calcium, and creatinine concentrations. The exclusion criteria mitigated potential confounding factors. Results: AUR cases exhibited significantly lower magnesium (5.97 vs.3.87, p = 0.031), calcium (11.04 vs. 5.3, p = 0.022), and creatinine (149.9 vs. 66.0, p = 0.005) levels (mg/dL) compared to controls. After adjusting for creatinine levels, no intergroup differences were observed. An inverse linear correlation was noted between the International Prostate Symptom Score and magnesium level (R2 = 0.15, p = 0.009). A magnesium cut-off of 3.57 mg/dL demonstrated 82.6% sensitivity, 56.5% specificity, and an AUC of 0.70. Patients with magnesium levels below 3.57 mg/dL had an 80% higher risk of AUR (OR: 1.80, 95% CI: 1.08-3.01, p = 0.016). Conclusions: This study highlights urinary magnesium as a potential marker for risk of AUR, paving the way for larger prospective studies in this intriguing domain. Future interventions that manipulate magnesium levels may offer innovative avenues for managing lower urinary tract disorders.

Background and Objectives: Robot-assisted radical prostatectomy (RARP) is a complex surgery with a steep learning curve (LC). No clear evidence exists for how previous laparoscopic experience affects the RARP LC. We report the LC of three surgeons with vast experience in laparoscopy (more than 400 procedures), analyzing the results of functional and oncological outcomes under the “Trifecta” concept (defined as the achievement of continence, potency, and oncological control free of biochemical recurrence). Materials and Methods: The surgical experience of the three surgeons from September 2021 to December 2022, involving 146 RARP consecutive patients in a single institution center, was evaluated prospectively. Erectile disfunction patients were excluded. ANOVA and chi-square test were used to compare the distribution of variables between the three surgeons. LC analysis was performed using the cumulative sum control chart (CUSUM) technique to achieve trifecta. Results: The median age was 65.42 (±7.34); the clinical stage were T1c (68%) and T2a (32%); the biopsy grades were ISUP 1 (15.9%), ISUP 2 (47.98), and ≥ISUP 3 (35%). The median surgical time was 132.8 (±32.8), and the mean intraoperative bleeding was 186 cc (±115). Complications included the following: Clavien–Dindo I 8/146 (5.47%); II 9/146 (6.16%); and III 3/146 (2.05%). Positive margins were reported in 44/146 (30.13%). The PSA of 145/146 patients (99%) at 6 months was below 0.08. Early continence was achieved in 101/146 (69.17%), 6-month continence 126/146 (86%), early potency 51/146 (34.9%), and 6-month potency 65/146 (44%). Surgeons “a”, “b”, and “c” performed 50, 47, and 49 cases, respectively. After CUSUM analysis, the “Trifecta” LC peak was achieved at case 19 in surgeon “a”, 21 in surgeon “b”, and 20 in surgeon “c”. Conclusions: RARP LC to accomplish “Trifecta” can be significantly reduced in surgeons with previous experience in laparoscopy and be achieved at around 20 cases.

Objetivo: El objetivo de nuestro estudio es conocer los datos de aparición de litiasis renal y sus características en los pacientes trasplantados renales con injertos funcionantes en nuestro centro. Diseño: Se llevó a cabo un estudio retrospectivo de los trasplantes realizados en nuestro centro desde enero de 1981 hasta diciembre de 2019. Se seleccionaron aquellos con injertos funcionantes y en los que se haya diagnosticado patología litiásica. Se recogen las características de esta (localización, composición, forma de presentación y tratamiento realizado). Resultados: Se encontraron 2658 pacientes con injerto funcionante en nuestro centro. Se reporta una incidencia de patología litiásica del 1.8%. De entre ellos, el 44% se localizaban en el cáliz inferior. En cuanto a la composición, en el 45.4% fue observada la cálcica. Limitaciones: Es importante destacar que nuestro estudio es observacional y retrospectivo con todas las limitaciones de validez que eso entraña. Originalidad: Nuestra serie es la más numerosa reportada hasta la fecha en el estudio de la patología litiásica en el trasplante renal. Es también importante resaltar que los datos se extrajeron teniendo sólo en cuenta injertos funcionantes. Conclusiones: La incidencia de aparición de litiasis es pequeña, pero es una patología a tener en cuenta por las complicaciones que puede conllevar. La localización más frecuentemente observada en nuestra serie fue el cáliz inferior. Aunque estos resultados están respaldados por un gran número de casos, son necesarios estudios de mayor solidez que los refrenden.

BACKGROUND:Living donor kidney transplantation (LDKT) is one of the best options for patients with chronic renal failure, but approximately one-third of cases are limited by incompatibility ABO and/or HLA between recipient and donor. This study aims to analyze the surgical complications and bleeding events presented in ABO-incompatible (ABOi) and HLA-incompatible (HLAi) patients within a pre-transplant desensitization program compared with ABO-compatible (ABOc) recipients. MATERIAL AND METHODS:We performed a retrospective analysis of ABOi and HLAi recipients undergoing LKDT between 2009 and 2019, resulting in a total of 62 patients that we compared with the same number of ABOc performed consecutively before 2019. The following variables were analyzed: surgical complications, presence, size and rate of reintervention of peri-graft hematomas, and number of transfusions received in the postoperative period. RESULTS:No statistical differences were shown in donor and recipient age, BMI, or sex; in the case of pre-surgical hematocrit, the ABOi group presented slightly lower figures. In the incompatible group (ABOi + HLAi), we found a greater number of postoperative surgical complications when analyzing the number of hematomas, size, need for surgical reintervention, and the number of blood units transfused; incompatible patients showed higher rates of hematomas, need for surgical reinterventions, and transfused units (P < .05). CONCLUSION:Desensitized patients need more transfusions, have a greater number and size of hematomas, and have higher reintervention rates. Although these are present in greater numbers, we did not observe statistically significant differences in the number of surgical complications.

Lower urinary tract symptoms (LUTS) are highly prevalent, and their treatment is mainly focused on the control of symptoms. Histamine intolerance (HIT) has been related to a variety of systemic symptoms. DAO deficiency has been identified as a significant factor contributing to histamine intolerance (HIT). Preclinical evidence indicates the involvement of histamine in the lower urinary tract. This study aimed to assess the prevalence of diamine oxidase deficiency (DAO) in a prospective cohort of 100 patients with at least moderate LUTS. A genetic study of four single nucleotide polymorphisms (SNPs) (c.-691G>T, c.47C>T, c.995C>T, and c.1990C>G) was performed. HIT was found in 85.9% of patients. The prevalence of at least one minor allele in the SNPs analyzed was 88%, without gender differences. Storage symptoms were more intense in the presence of HIT as well as asthenia and neurological and musculoskeletal symptoms. The presence of minor alleles of the AOC1 gene was associated with a higher intensity of symptoms. Minor alleles from c.-691G>T and c.47C>T SNPs were also associated with a greater severity of obstructive symptoms. Thirty-one percent of patients presented the four SNPS with at least one associated minor allele. The relationship between HIT and LUTS in a mixed population of men and women found in this study supports further investigations to define the pathophysiology of histamine in LUTS.

Objetivo: El advenimiento de la pandemia de síndrome respiratorio agudo por coronavirus 2 (SARS-CoV-2) ha tenido un impacto en el manejo del resto de las patologías por la elevada presión asistencial generada. Por su historia natural, el cáncer vesical susceptible de cistectomía radical (CR) requiere especial atención. Nuestro objetivo es comparar los resultados perioperatorios y oncológicos de estos pacientes durante el estado de alarma respecto a la era pre-COVID en un centro de tercer nivel. Material y métodos: Estudio retrospectivo observacional descriptivo y analítico. Pacientes intervenidos de cistectomía radical por neoplasia entre abril de 2019 y marzo de 2021 divididos en dos grupos, abril 2019-marzo 2020 (n = 42) y abril 2020-marzo 2021 (n = 43). Resultados: Ambos grupos resultaron ser homogéneos. La mediana de espera desde la resección transuretral de vejiga hasta la realización de la CR no aumentó (82,5 vs. 83 días, p = = 0,860). No se observan tampoco diferencias en la estadificación TNM de las piezas quirúrgicas. Los tumores localmente avanzados no aumentaron significativamente (18 vs. 21, p = 0,580). La presencia de afectación ganglionar tampoco presentó diferencias significativas (10 vs. 13, p = 0,675). La estancia media disminuyó en un valor cercano a significación (mediana en días: 11 vs. 8, p = 0,056) sin que ello asociase un mayor número de complicaciones o de reingresos a los 30 días. Conclusión: En nuestra serie no hemos constatado diferencias significativas en los resultados perioperatorios y oncológicos de pacientes tratados mediante CR durante la pandemia de COVID-19.

Minimally invasive percutaneous treatment of urological diseases is daily increasing. Puncture, access to renal cavities and dilation the percutaneous tract is not a simple maneuver not free of complications. Percutaneous access of the kidney is sometimes mandatory such as drainage of distally obstructed kidneys in several situations like advanced tumors, stone-related situations and so others. Although the number of surgeries and the grade of specialization are rising, several complications like injuries to in-neighborhood organs, secondary sepsis or kidney bleeding may happen. The kidney is an extremely vascularized organ and this can facilitate vascular damage if some considerations are no taken into account previously. Major vessels (aorta artery and vena cava) damage is exceptional and generally require urgent surgery as in most penetrating injuries. A full endovascular treatment and repair in these situations is uncommon but possible. Initial misplacement of percutaneous nephrostomy tube (PNT) is not a frequent situation and when involving vessels, the small number of publications in literature mainly report catheter misplacement into the renal vessels or inferior vena cava, none affecting the aorta. This article presents two cases of misposition of PNT involving major vessels affecting vena cava and aorta artery. Both of them were successfully managed exclusively with endovascular treatment via femoral access.

OBJECTIVE:Kidney transplantation process involves a series of challenges such as the shortage of organs worldwide for a population waiting for a first and subsequent kidney transplants and the search forthe most appropriate graft for each recipient, optimizing the ischemia time as much as possible, minimizing the impact of surgery and subsequent immunosuppressive therapy.METHODS:We carry out a review of the different advances and lines of research in the different areas involved in the kidney transplantation process from strategies focused on increasing the donor pool, enabling the expansion of living donor programs as well as orga preservation strategies previous to transplantation surgery.The arrival of robotic surgery in the field of kidney transplantation has been an important milestone in the last decade, showing improvements compared to traditional open surgery, maintaining satisfactory functional results, although its implementation is currently reduced with technical limitations in the extension to any type of recipient. New immunosuppressive agents that minimize potential side effects or reduce anticalcineurinic drugsdoses are also important lines of research.CONCLUSIONS:The future of kidney transplantation involves the search for increasingly global strategies to improve the supply of organs, improvements in the conditioning and preservation of grafts or the global development of minimally invasive surgery in the different areas of kidney transplantation. The weight of biotechnology and gene therapies represent promising tools in the field of tissue generation or targeted immunosuppressive therapies.

4505 Background: Bladder-preserving combined-modality therapies constitute an alternative to radical cystectomy for selected pts with MIBC. In preclinical studies, combination of radiation and dual checkpoint blockade appears to activate non-redundant immune mechanisms, potentiating antitumor activity. The purpose of the present study is to explore feasibility, toxicity and activity of this approach in MIBC. Methods: Pts with localized MIBC in clinical stages T2-4a N0 M0, ECOG 0-1, without contraindications to immunotherapy, who either wished for bladder preservation or were ineligible for cystectomy, were included in this phase II study. Treatment consisted of initial transurethral resection (TUR) of the tumor, followed by durvalumab 1,500 mg i.v. plus tremelimumab 75 mg i.v., every 4 weeks for 3 doses. Normofractionated external-beam RT was started 2 weeks later, at doses of 46 Gy to minor pelvis and 64-66 Gy to bladder. Pts with either residual or relapsed MIBC were offered salvage cystectomy. The primary endpoint was complete response (CR) defined as absence of MIBC at post-treatment tumor site biopsy. A 2-stage sequential design was used (CR rate P0=5, P1=0.7, α=0.10, β=0.20) requiring at least 6 CR in the first 12 pts to expand to a second cohort of 20 pts. Results: From 1/2019 to 8/2020, 32 pts were enrolled at 6 centers. Median age was 71 years (49-91). PS was 0 in 24 pts,1 in 8. 25 were males. Clinical stage was T2 in 28 pts, T3 in 3 and T4a in 1. All pts received at least two immunotherapy cycles. The median dose of RT administered was 64 Gy (60-65). CR at post-treatment biopsy was documented in 26 (81%) pts, 2 pts had residual MIBC and 4 pts were not evaluated due to rejection (1), clinical impairment (1), death from COVID 19 (1) and a suspected treatment-related death from peritonitis (1). After a median follow up of 6.1 months (2.5 - 20.1), 2 pts underwent salvage cystectomy because of MIBC and T1 relapses, respectively. The estimated 6-months rates for disease-free survival (DFS) with bladder intact, DFS and overall survival were 76% (95%CI, 61%-95%), 80% (95%CI, 66%-98%) and 93% (95%CI, 85%-100%), respectively. A total of 31 (97%) pts experienced adverse events related to RT and/or immunotherapy, with diarrhea (41%) and urinary disorders (37.5%) as the most frequent. Grade 3 or 4 adverse events related to therapy were reported in 31% pts, being the most frequent gastrointestinal toxicity (12.5%), acute kidney failure (6%) and hepatitis (6%). Conclusions: A combined-modality approach including durvalumab + tremelimumab with concurrent RT is feasible and safe, showing high efficacy in terms of response and eliciting bladder preservation in a large number of pts. Further research on this approach as an alternative to cystectomy is warranted. Clinical trial information: NCT03702179.

We present the case of a 27-year-old male patient who presented with fever and scrotal ulcer after pharyngotonsillar symptoms. The differential diagnosis with other entities that present with scrotal ulcer is proposed, including Fournier's gangrene and vascular ulcer secondary to infection by the SARS-CoV-2 virus.

espanolINTRODUCCION: La pandemia COVID-19 que ha afectado a Espana desde comienzos de 2020 obliga a definir unas recomendaciones para la practica de la Andrologia en la actualidad. MATERIAL Y METODOS: Se realiza una busqueda web en ingles y espanol y se define una propuesta conjunta por parte de expertos en Andrologia de distintas regiones de Espana. RESULTADOS: La mayor parte de los procedimientos diagnosticos y terapeuticos en Andrologia pueden ser demorados con seguridad durante la pandemia COVID-19. Se debe fomentar la consulta telematica y la cirugia ambulatoria. Las urgencias andrologicas y el manejo del cancer de pene deben considerarse una prioridad alta, diagnosticandose y tratandose con brevedadi ncluso en las fases mas severas de la pandemia. EnglishPURPOSE: The COVID-19 pandemic which has affected Spain since the beginning of 2020 compels us to determine recomendations for the practice of Andrology in present times. MATERIALS AND METHODS: A web search is carried out in English and Spanish and a joint proposal is defined by experts in Andrology from different regions of Spain. RESULTS: Most diagnostic and therapeutic procedures in Andrology can be safey postponed during the COVID-19 pandemic. Online consultations and outpatient surgeries must be encouraged. Andrologic emergencies and penile cancer management should be considered high priority, and should be diagnosed and treated promptly even in the most severe phases of the pandemic.

PURPOSE: The COVID-19 pandemic which has affected Spain since the beginning of 2020 compels us to determine recomendations for the practice of Andrology in present times. MATERIALS AND METHODS: A web search is carried out in English and Spanish and a joint proposal is defined by experts in Andrology from different regions of Spain. RESULTS: Most diagnostic and therapeutic procedures in Andrology can be safey postponed during the COVID-19 pandemic. Online consultations and outpatient surgeries must be encouraged. Andrologic emergencies and penile cancer management should be considered high priority, and should be diagnosed and treated promptly even in the most severe phases of the pandemic.

From the first radical prostatectomy (RP), this kind of surgeries have always led to the need of a vesicourethral anastomosis (VUA). We present a case of a 65 year-old patient with diagnosis of prostate cancer and candidate for laparoscopic RP. The approach was a conventional extraperitoneal access with complete urethral sparing that avoids the need of VUA. Bladder catheter was removed on the third postoperative day observing immediate urinary continence. The anatomopathological analysis revealed a pT2 adenocarcinoma with negative margins. We report for the first time, a minimally invasive technique that avoids the need of VUA with favorable functional results.

espanolEl eje de senalizacion de androgenos desempena un papel fundamental en la patogenesis del cancer de prostata. Desde el descubrimiento historico de Huggins y Hodges, la deplecion androgenica permanece como la piedra angular en el tratamiento de la enfermedad avanzada. Sin embargo, de forma invariable, la progresion a cancer de prostata resistente a la castracion se produce dentro de los 2-3 anos posteriores al inicio de la terapia de deprivacion androgenica (TDA). Multiples mecanismos de resistencia ayudan a la progresion a la enfermedad resistente a la castracion, y el receptor de androgenos (RA) sigue siendo un impulsor importante en esta progresion. Los mecanismos moleculares que subyacen a la reactivacion del RA en el cancer de prostata resistente a la castracion (CPRC) incluyen la amplificacion y sobreexpresion del RA, mutaciones del RA, expresion de variantes constitutivamente activas del RA, sintesis de androgenos intratumorales y suprarrenales y activacion promiscua del RA por otros factores. Tambien se discuten otros mecanismos de resistencia independientes del RA, que incluyen la activacion del receptor de glucocorticoides, la alteracion de las vias de reparacion del ADN, la resistencia mediada por mecanismos inmunes, la diferenciacion neuroendocrina y la expresion de microARN. El cancer de prostata resistente a la castracion es una enfermedad compleja, se caracteriza por multiples mecanismos de resistencia al tratamiento de deprivacion de androgenos, y sigue siendo una enfermedad incurable. La comprension de los mecanismos que subyacen a esta resistencia es necesaria para identificar objetivos terapeuticos futuros, asi como la identificacion y validacion de nuevos biomarcadores predictivos de resistencia, lo que puede conducir a una mejora terapeutica para pacientes con CPRC. EnglishThe androgen-signaling axis plays a pivotal role in the pathogenesis of prostate cancer. Since the landmark discovery by Huggins and Hodges, gonadal depletion of androgens has remained a mainstay of therapy for advanced disease. However, invariably progression to castration-resistant prostate cancer (CRPC) occurs within 2-3 years of initiation of ADT. Multiple mechanisms of resistance help contribute to the progression to castration resistant disease, and the androgen receptor (AR) remains an important driver in this progression. Molecular mechanisms behind AR reactivation in CRPC include AR gene amplification and overexpression, AR mutations, expression of constitutively active AR variants, intratumoral and adrenal androgen synthesis and promiscuous AR activation by other factors. Other AR-independent resistance mechanisms, including activation of glucocorticoid receptor, impairment of DNA repair pathways, immune-mediated resistance, neuroendocrine differentiation and microRNA expression, are also discussed. Castration-resistant prostate cancer is a complicated disease, characterized by multiple resistance mechanisms to androgen deprivation treatment, and it remains an incurable disease. An understanding of the mechanisms underlying this resistance is necessary to identify future therapeutic targets as well as the identification and validation of novel predictive biomarkers of resistance; they may lead to improved therapeutics for mCRPC patients.

Objectives: Estimate the frequency of erectile dysfunction in patients with essential hypertension and associated variables, degree of control, cardiovascular risk and the impact on quality of life. Material and methods: Type of study: Observational study of prevalence in men with essential hypertension. Measurements: Sociodemographic and comorbidity variables were collected from each patient (age, Charlson index, dyslipidaemia and prostatic hyperplasia), degree of control of essential hypertension and treatment, cardiovascular risk and metabolic syndrome. The erectile dysfunction was diagnosed by the International Index of Erectile Function (IIEF-15). Quality of life questionnaires were carried out in essential hypertension (MINICHAL), and the international scale of prostatic symptoms (IPSS). Results: The study included 262 hypertensive men with an average age of 65.84 years. Erectile dysfunction was presented in 46.1%, being severe in 54.9%. The bivariate analysis shows an independent association between erectile dysfunction and the variables: age, Charlon index, dyslipidaemia, benign prostatic hypertrophy, diastolic blood pressure, years of diagnosis of hypertension, number of treatments, Regicor and Framingham-Wilson, glycaemia, creatinine and GPT, glomerular filtration through the MDRD formula, irritative symptomatology (IPSS) and somatic manifestations (MINICHAL). The final multivariate model found association with age, presentation of dyslipidaemia, prostatic hyperplasia and metabolic syndrome. Conclusions: Erectile dysfunction is significantly associated with age, dyslipidaemia, benign prostatic hypertrophy and metabolic syndrome. (C) 2018 Elsevier Espana, S.L.U. All rights reserved.

The androgen-signaling axis plays a pivotal role in the pathogenesis of prostate cancer. Since the landmark discovery by Huggins and Hodges, gonadal depletion of androgens has remained a mainstay of therapy for advanced disease. However, invariably progression to castration-resistant prostate cancer (CRPC) occurs within 2-3 years of initiation of ADT. Multiple mechanisms of resistance help contribute to the progression to castration resistant disease, and the androgen receptor (AR) remains an important driver in this progression. Molecular mechanisms behind AR reactivation in CRPC include AR gene amplification and overexpression, AR mutations, expression of constitutively active AR variants, intratumoral and adrenal androgen synthesis and promiscuous AR activation by other factors. Other AR-independent resistance mechanisms, including activation of glucocorticoid receptor, impairment of DNA repair pathways, immune-mediated resistance, neuroendocrine differentiation and microRNA expression, are also discussed. Castration-resistant prostate cancer is a complicated disease, characterized by multiple resistance mechanisms to androgen deprivation treatment, and it remains an incurable disease. An understanding of the mechanisms underlying this resistance is necessary to identify future therapeutic targets as well as the identification and validation of novel predictive biomarkers of resistance; they may lead to improved therapeutics for mCRPC patients.