Complications and adverse events in lymphadenectomy of the inguinal area: worldwide expert consensus.

BACKGROUND: Inguinal lymph node dissection plays an important role in the management of melanoma, penile and vulval cancer. Inguinal lymph node dissection is associated with various intraoperative and postoperative complications with significant heterogeneity in classification and reporting. This lack of standardization challenges efforts to study and report inguinal lymph node dissection outcomes. The aim of this study was to devise a system to standardize the classification and reporting of inguinal lymph node dissection perioperative complications by creating a worldwide collaborative, the complications and adverse events in lymphadenectomy of the inguinal area (CALI) group. METHODS: A modified 3-round Delphi consensus approach surveyed a worldwide group of experts in inguinal lymph node dissection for melanoma, penile and vulval cancer. The group of experts included general surgeons, urologists and oncologists (gynaecological and surgical). The survey assessed expert agreement on inguinal lymph node dissection perioperative complications. Panel interrater agreement and consistency were assessed as the overall percentage agreement and Cronbach's α. RESULTS: Forty-seven experienced consultants were enrolled: 26 (55.3%) urologists, 11 (23.4%) surgical oncologists, 6 (12.8%) general surgeons and 4 (8.5%) gynaecology oncologists. Based on their expertise, 31 (66%), 10 (21.3%) and 22 (46.8%) of the participants treat penile cancer, vulval cancer and melanoma using inguinal lymph node dissection respectively; 89.4% (42 of 47) agreed with the definitions and inclusion as part of the inguinal lymph node dissection intraoperative complication group, while 93.6% (44 of 47) agreed that postoperative complications should be subclassified into five macrocategories. Unanimous agreement (100%, 37 of 37) was achieved with the final standardized classification system for reporting inguinal lymph node dissection complications in melanoma, vulval cancer and penile cancer. CONCLUSION: The complications and adverse events in lymphadenectomy of the inguinal area classification system has been developed as a tool to standardize the assessment and reporting of complications during inguinal lymph node dissection for the treatment of melanoma, vulval and penile cancer.

A new surgical technique for sutureless partial nephrectomy: renal sutureless device.

BACKGROUND: Several factors impact the preservation of renal function after partial nephrectomy. Warm ischemia time is the main modifiable surgical factor. Renorrhaphy represents the key of hemostasia, but it is associated with increase of warm ischemia time and complications. The aim of this study was to describe our initial surgical experience with a new surgical technique for sutureless partial nephrectomy, based on the application of our own developed renal-sutureless-device-RSD. METHODS: Between 2020-2021, 10 patients diagnosed with renal cell carcinoma stage cT1a-b cN0M0 with an exophytic component were operated using renal-sutureless-device-RSD. Surgical technique of sutureless partial nephrectomy with renal-sutureless-device-RSD is described in a step-by-step fashion. Clinical data was collected in a dedicated database. Presurgical, intraoperative, postoperative variables, pathology and functional results were evaluated. Medians and ranges of values for selected variables were reported as descriptive statistics. RESULTS: Partial nephrectomy was carried out with the use of renal-sutureless-device-RSD without renorrhaphy in all cases (70%cT1a-30%cT1b). Median tumor size was 3.15 cm (IQR: 2.5-4.5). R.E.N.A.L Score had a range between 4a-10. Median surgical time was 97.5 minutes (IQR 75-105). Renal artery clamping was only required in 4 cases, with a median warm ischemia time of 12.5 minutes (IQR 10-15). No blood transfusion, intraoperative and postoperative complications were noted. Free-of-disease margin rate achieved was 90%. Median length of stay was 2 days (IQR 2-2). Laboratory data on hemoglobin and hematocrit levels, as well as renal function tests, remained stable after partial nephrectomy. CONCLUSIONS: Our initial experience suggests that a sutureless PN using the RSD device is feasible and safe. Further investigation is needed to determine the clinical benefit of this technique.

Minimally Invasive Laparoscopic Technique for Lymph Node Dissection in Penile Cancer: The Pelvic and Inguinal Single-Site Approach: PISA Technique.

BACKGROUND: Lymph node dissection(LND) remains the gold standard in the staging and treatment of locally advanced penile cancer(PC)1. OBJECTIVE: To describe our initial experience with a new minimally invasive inguinal and pelvic single-access laparoscopic approach2,for performing LND in PC, first described in Urology by our group in 20153: the Pelvic and Inguinal Single Access(PISA) technique (Fig. 1). MATERIAL: Between 2015 and 2018, 10 consecutive patients with different PC stages and indication of inguinal LND (cN0 and ≥pT1G3 or cN1/cN2)1 were operated by means of the PISA technique (Table 1). Intraoperative frozen section(FS)4 analysis was carried out routinely and if ≥2 inguinal nodes(pN2) or extracapsular nodal extension(pN3) are detected1,5, ipsilateral pelvic LND was performed sequentially as a single-stage procedure and using the same surgical incisions. If this condition occurs bilaterally in the inguinal LND, the pelvic LND will be bilateral. The video shows the PISA technique in a step-by-step. Instrumental requirements: 30°laparoscopy optic, monopolar scissors,Ligasure (Covidien Surgical,Minneapolis,MN,USA) vascular sealant, extraction-bag, bipolar forceps and 5-mm endo-clip(Hem-o-lok)are required. RESULTS: Intraoperative and postsurgical variables are shown in Table 2. Inguinal LND was bilateral in all cases. Pelvic LND was required in 40% of patients. Total operative time was 120-170 minutes. Median estimated blood loss(EBL) was 66(30-100)cc, but no blood transfusion was required. No intraoperative complications were noted. 40% of patients had postoperative complications (10% major complication- symptomatic inguinal lymphocele). Median lenght of hospital stay(LOS)was 5.8(3-10) days. Median inguinal drain removal was 4.7 days. The pathological analysis outcomes are shown in Table 3. Mean number of lymph nodes removed by inguinal LND was 10.25(8-14). CONCLUSION: PISA technique allow a minimally invasive inguinal and pelvic LND using the same set of incisions and carry it out in the same surgical procedure. PISA technique in PC LND seems to be safe, with a low rate of major complications and preserving oncological efficacy.

[Penile metastasis from urothelial carcinoma: Review of literature.] / Metástasis peneana de carcinoma urotelial: revisión de la literatura a raíz de un caso.

OBJECTIVE: Penile metastasis is a very rare clinical entity. The primary origin is usually genitourinar y followed by the gastrointestinal. MATERIAL AND METHODS: Review of the available literature on a case of penile metastasis of urothelial bladder carcinoma. RESULTS: Penile metastasis is an exceptional entity despite the rich vascularization of this organ. Less than 500 cases have been described. Most cases manifestas exophytic or nodular lesions. Its association with disseminated disease conditions its palliative management in a large part of the cases, as well as an unfavorable prognosis. In selected cases, surgical treatment can be chosen. CONCLUSIONS: Since its clinical presentation is variable, clinical suspicion is important in the presence of a skin lesion of torpid evolution taking into account the patient's oncological history.

OBJETIVO: La metástasis peneana es una entidad clínica muy poco frecuente. El origen primario suele ser genitourinario seguido del gastrointestinal. MATERIAL Y MÉTODOS: Revisión de la literatura disponible a propósito de un caso de metástasis peneana de carcinoma urotelial de vejiga. RESULTADOS: La metástasis peneana es una entidad excepcional a pesar de la rica vascularización de este órgano. Se han descrito menos de 500 casos hasta  la fecha. La mayor parte de los casos se manifiestan como lesiones exofíticas o nodulares. Su asociación a enfermedad diseminada, condiciona su manejo paliativo en gran parte de los casos, así como un pronóstico desfavorable. En casos seleccionados puede optarse por tratamiento quirúrgico. CONCLUSIONES: Dado que su presentación clínica es variable, es importante la sospecha clínica ante la presencia de una lesión cutánea de evolución tórpida teniendo en cuenta los antecedentes oncológicos del paciente.

[Effect of surgical approach on radical nephrectomy outcomes: Comparative study between open and laparoscopic nephrectomy.] / Influencia de la vía de acceso para la nefrectomía radical en el tratamiento del cáncer renal: estudio comparativo entre cirugía abierta y cirugía laparoscópica.

OBJECTIVE: The aim of this study is to evaluate the influence of laparoscopy in patients with renal cancer treated with radical nephrectomy in terms of surgical time, hospital stay, postoperative complications and survival.MATERIAL AND METHODS: Retrospective study of 570 patients with renal cancer treated with radical nephrectomyin stage ≤pT3a. Differences between groups were analysed using ANOVA test for quantitative variables and Chi squared test for qualitative. In order to evaluate possible risk factors for longer hospital stay and surgical time, multivariate analysis was performed (lineal regression). For complications we performed binary logistic regression. Overall survival (OS), recurrence free survival (RFS) and cancer specific survival (CSS) were estimated using Kaplan Meier and compared using Log Rank test. Univariate and multivariate analysis was performed using Cox regression in order to identify independent risk factors for overall, cancer specific and recurrence mortality. RESULTS: Two cohorts: 361 (63.3%) open radical nephrectomies (ORN) and 209 (36.7%) laparoscopic (LRN). Surgical time was longer in LRN (p=0.001) globally. After the period when the learning curve was over these differences were no longer significant. Hospital stay was shorter in LRN (p=0.0001). cT stage (p=0.005) and surgical access (p=0.001) acted as independent risk factors for longer surgical time. 33,5% (121 patients) of the ORN had some sort of postoperative complication vs. 11% (23 patients) in the LRN group (p=0.0001). These differences were observed in the Clavien-Dindo's grade II group. Independent risk factors for postoperative complications observed were: ASA≥III (OR=1.82, p=0.004) and stage pT3a (OR=2.29,p=0.0001). Laparoscopy acted as a protective factor for complications (OR=0,26, p=0.0001). Surgical access did not influence RFS (HR=0.87, p=0.50), CSS(HR=0.69, p=0.12). CONCLUSIONS: Laparoscopic access to RN in patients with renal cancer in ≤pT3a stage increased surgical time only in the first years, reduced hospital stayand postoperative complications and did not influence RFS, OS or CSS.

OBJETIVO: El objetivo del estudio es evaluarla influencia de la laparoscopia en pacientes concáncer renal tratados con nefrectomía radical (NR) en términos de tiempo quirúrgico, estancia media, complicaciones postoperatorias y supervivencia.MATERIAL Y MÉTODO: Análisis retrospectivo de 570 pacientes con cáncer renal tratados con NR en estadio ≤pT3a comparando cohorte de acceso abierto (NRA) y laparoscópico (NRL). Contraste de variables cualitativas con el test de Chi cuadrado y cuantitativas con ANOVA. Para identificar factores de riesgo (FR) de tiempo quirúrgico y estancia media se utilizó regresión lineal multivariante y para complicaciones la regresión logística binaria. Estimación de la supervivencia libre de recidiva (SLR), global (SG) y cáncer específica (SCE) mediante Kaplan-Meier y test de log-rank para analizar las diferencias. Análisis multivariante mediante regresión de Cox para identificar variables predictoras independientes (VPI) de SLR y SCE. Todos los cálculos se han realizado con el paquete estadístico IBM® SPSS® statisticsv-21. RESULTADOS: Dos cohortes: 361 (63,3%) NRA y 209(36,7%) NRL. El tiempo de cirugía fue mayor en NRL (p=0,001) de forma global siendo las diferencias entre ambas en el periodo tras la curva de aprendizaje no significativas. La estancia media fue menor en NRL(p=0,0001). El estadio cT (p=0,005) y la vía de acceso (p=0,001) se comportaron como VPI de prolongación del tiempo quirúrgico. El 33,5% (121 casos) de las NRA presentaron algún tipo de complicación en el postoperatorio, frente al 11% (23 casos) de las NRL (p=0,0001). Esta diferencia se observó en complicaciones tipo II de Clavien. VPI de complicaciones postoperatorias: ASA≥III (OR=1,82, p=0,004) y el estadio pT3a (OR=2,29, p=0,0001). La laparoscopia se comportó como factor protector de complicaciones (OR=0,26, p=0,0001). La vía de acceso no influyó en la SLR (HR=0,87, p=0,50) ni en la SCE (HR=0,69,p=0,12). CONCLUSIONES: El acceso laparoscópico a la nefrectomía radical en pacientes con cáncer renal en estadio ≤pT3a aumentó el tiempo quirúrgico pero solo en los primeros años, presentó menor estancia y complicacionespostoperatorias y no influyó en la SG,SLR y SCE.

[Prognostic factors of mortality in patients with urothelial bladder tumor treated with radical cistectomy.] / Factores pronósticos de mortalidad en pacientes con tumor urotelial de vejiga tratados con cistectomía radical.

INTRODUCTION: Radical cystectomy (RC) with pelvic lymphadenectomy is the treatment of choice in patients with muscle invasive bladder cancer (MIBC). OBJECTIVE: To identify clinical and pathological variables that influence global mortality (GM) and cancer specific mortality (CSM) in patients with urothelial bladder tumor (UBT) treated with RC. METHODS: Retrospective analysis of 517 patients diagnosed with UBT and treated with RC between 1986 and 2009. Demographic, clinical, surgical and pathological variables, as well as complications and evolution after RC were collected. A comparative analysis was carried out with Chi square and ANOVA test. Survival analysis was performed with the Kaplan-Meier method and the long-rank test. Univariate and multivariate analysis were performed using Cox regression to identify independent predictors of GM and CSM. RESULTS: 91% of the patients were males with a median age of 66 years. The most frequent local pathological stage was pT3 (32.6%), with lymph node involvement in 23.8% of the patients. After a median follow-up of 34 months, 170 patients were alive and 311 had died from any cause (63.5%), being UBT the cause of death in 225 patients (45%). Rates of global survival and cancer specific survival at 5 and 10 years were 45%/34.3% and 52.5%/46.6% respectively. On the multivariate analysis age ( p = 0.004), ASA ( p = 0.000), the existence of hydronephrosis ( p = 0.01), pT ( p = 0.000) and pN ( p = 0.003) were identified as independent predictors of GM, as well as pT ( p = 0.000) and pN ( p = 0.002) for CSM. CONCLUSIONS: Age, anesthetic risk, presence of hydronephrosis, pT and pN stage were identified as independent predictors of GM, as well as pT and pN stage for CSM.

INTRODUCCIÓN: La cistectomía radical (CR) con linfadenectomía pélvica es el tratamiento de elección en los pacientes con tumor vesical músculoinfiltrante (TVMI). OBJETIVO: Identificar variables clínicas y patológicas que influyen en la mortalidad global (MG) y cáncer-específica (MCE) en pacientes con tumor urotelial vesical (TUV) tratados con CR. MATERIAL Y MÉTODOS: Análisis retrospectivo de 517 pacientes diagnosticados de TUV y tratados con CR entre 1986 y 2009. Se recogieron variables demográficas, clínicas, quirúrgicas y patológicas, así como complicaciones acontecidas y evolución tras CR. Análisis comparativo con test de Chi Cuadrado y ANOVA. Cálculo de supervivencia con el método de Kaplan-Meier y test de long-rank. Análisis univariante y multivariante mediante regresión de Cox para identificar variables predictoras independientes de MG y MCE. RESULTADOS: El 91% de los pacientes fueron varones con mediana de edad de 66 años. El estadio patológico local más frecuente fue el pT3 (32,6%), con afectación ganglionar en el 23,8% de los pacientes. Tras mediana de seguimiento de 34 meses, 170 pacientes estaban vivos y 311 habían fallecido por cualquier causa (63,5%), siendo el TUV la causa de muerte en 225 pacientes (45%). Se objetivaron tasas de supervivencia global y cáncer específica a 5 y 10 años del 45/34,3% y del 52,5/46,6% respectivamente. En el análisis multivariante se identificaron la edad ( p = 0,004), el ASA ( p = 0,000), la existencia de hidronefrosis ( p = 0,01), el pT ( p = 0,000) y el pN ( p = 0,003) como variables predictoras independientes de MG, así como el pT ( p = 0,000) y pN ( p = 0,002) para MCE. CONCLUSIONES: La edad, el riesgo anestésico, la presencia de hidronefrosis, el estadio pT y pN se identificaron como variables predictoras independientes de MG, así como el estadio pT y pN para MCE.

[Laparoscopic treatment of retroperitoneal fibrosis.] / Tratamiento laparoscopico de la fibrosis retroperitoneal.

OBJECTIVES: Retroperitoneal fibrosis is a disease that may condition a severe involvement of various organs, mainly upper urinary tract, even causing renal insufficiency. It was first described by Albarran in 1905 and it is also known as Ormonds disease. The correct diagnosis includes, in many cases, the performance of one or more tests: CT scan, MRI, renal scan, etc. It is often necessary the insertion of double J catheters on percutaneous nephrostomy tubes with the aim to preserve renal function. Initial treatment is medical, based on corticoids, and , less frequent, immunosuppressive or chemotherapy drugs. Surgery is the treatment of choice when ureteral entrapment by the fibrous plaque is not solved with medical treatment. Such operation may be performed with a conventional open approach (laparotomy) or by pure, hand assisted laparoscopic surgery, or robotic surgery. In all cases, the technique involves freeing the ureters from the fibrous plaque that entraps them, leaving them intraperitoneal, and it is recommendable to wrap them with an omental flap. The implantation of minimally invasive techniques has made that, in groups with experience in laparoscopy, open surgery is being abandoned and the laparoscopic approach indication is increasing. Our group has performed 10 laparoscopic ureterolysis from 2005. In two patients, it was bilateral. Despite surgical repair, two renal units were lost, keeping the rest with different levels of renal function depending on the preoperative level of disease. We did not have major complications and the mean hospital stay was 5.5 days. Although, there is not important published scientific evidence about this technique and it is unlikely we will have it in an immediate future, due to the rarity of this disease, and the different degree of involvement that conditions. It is not unreasonable to propose that, based on the literature reviewed and our own experience, laparoscopic approaches, despite being complex, may solve the ureteral entrapment with similar results to open surgery but less morbidity and shorter hospital stay.

Prognostic factors in patients with stage pT0/pT1/pTa in the radical cystectomy specimen.

OBJECTIVES: To identify risk factors for progression in patients with invasive bladder carcinoma who were pT0/pT1/pTa after cystectomy. METHODS: We analyzed the clinical records of 97 post-cystectomy pT0/pT1/pTa patients for the following variables: hydronephrosis, carcinoma in situ (CIS), lymphovascular invasion, history of non-muscular invasive disease, residual tumor in the specimen and lymphatic invasion (pN). pN+patients were excluded from definitive analysis. The quantitative and qualitative variables were analyzed using standard statistics. The chi-square test was used to analyze associations between categorical variables. Univariate Cox proportional hazard regression analysis (enter method) was performed. The Kaplan-Meier method was used to evaluate survival and the log-rank test to assess differences between groups. Statistical significance was set at p<0.05. The analysis was performed using SPSS version 15.0. RESULTS: The study sample included 97 cases. The specimen was staged at T2 in 97% of patients after transurethral resection (TUR); After cystectomy, the specimen was staged as pT0 (R0) in 44.3% and pT1/Ta (R1) in 55.7%. Median follow-up was 47 months. Lymph node metastasis were detected in 5.2% of patients (pN+rpar; and had a negative impact on survival (p=0.02). Overall survival was 59.8% and cancer-specific survival 76.6%. Univariate analysis showed a relationship between tumor progression and the presence of CIS (p < 0.001), lymphovascular invasion (p=0.049), and hydronephrosis(p < 0.001). In the multivariate analysis, only the presence of CIS in the transurethral resection was associated with reduced cancer-specific survival (HR 100.5; 95% CI, 10.8 to 933.1; pp<0.001). CONCLUSIONS: Although the prognosis of stage pT0/pT1/pTa carcinoma in the cystectomy specimen is excellent, some patients experience progression. The presence of CIS in the transurethral resection was an independent predictor of recurrence in these cases.

First percutaneous computed tomography-guided radiofrequency ablation of renal tumor in horseshoe kidney.

OBJECTIVE: To report the first case of percutaneous radiofrequency ablation of a tumor in a horseshoe kidney. MATERIALS AND METHODS: A 75-year-old man presented with a 3-cm solid mass on the isthmus of a horseshoe kidney. The tumor was discovered incidentally on a routine computed tomography scan performed during follow-up of a colon carcinoma treated with open hemicolectomy. The patient presented a high anesthetic risk (American Society of Anesthesiologists score of 3) because of a comorbid cardiovascular condition. Biopsy of the mass revealed type I papillary carcinoma. We performed percutaneous radiofrequency ablation using a posterior approach. RESULTS: No complications occurred, and postoperative computed tomography 3 months after the procedure showed no significant contrast enhancement in the treated area. CONCLUSIONS: To our knowledge, this is the first case of a tumor in a horseshoe kidney satisfactorily treated with percutaneous radiofrequency ablation. The technique could represent an alternative to traditional surgery in selected cases.

Intravenous sildenafil as a preconditioning drug against hemodynamic consequences of warm ischemia-reperfusion on the kidney.

PURPOSE: We designed an experimental model of renal ischemia-reperfusion to evaluate the preemptive effect of intravenous sildenafil according to the dose administered (0.7 vs 1.4 mg/kg) and the time of administration (30 minutes before ischemia or during ischemia). MATERIALS AND METHODS: A total of 20 minipigs were divided into groups of 4 each, including group 1-control, group 2-sildenafil 0.7 mg/kg intravenously 30 minutes before vascular clamping, group 3-sildenafil 0.7 mg/kg intravenously during warm ischemia, group 4-sildenafil 1.4 mg/kg intravenously 30 minutes before vascular clamping and group 5-sildenafil 1.4 mg/kg intravenously during warm ischemia. The ischemia-reperfusion model was applied using laparotomy and right kidney vascular clamping for 30 minutes, followed by unclamping and reperfusion for 45 minutes. Renal vascular flow and systemic mean arterial pressure were recorded for 45 minutes after unclamping. Mean values were compared using Student t test with significance considered at p <0.05. RESULTS: Sildenafil led to a decrease in arterial pressure compared to that in controls, especially at the dose of 1.4 vs 0.7 mg/kg, including 113.77, 109.76, 106.12, 97.41 and 82.85 mm Hg in groups 1 to 5, respectively. Renal vascular flow was significantly higher in groups 2 and 3 than in groups 1, 4 and 5 (112.82 and 111.33 vs 88.25, 87.91 and 84.37 ml per minute, respectively, p = 0.000). CONCLUSIONS: The effect of intravenous sildenafil as a preemptive drug against the hemodynamic effects of renal ischemia-reperfusion is dose dependent. The 0.7 mg/kg dose significantly increased reperfusion renal vascular flow with a small decrease in arterial pressure compared to the 1.4 mg/kg dose.

Cadaver donor kidney retransplantation in the pediatric patient: complications and long-term outcome.

PURPOSE: We compared the outcome of second and third kidney allografts with that of the first kidney allograft in pediatric recipients. MATERIALS AND METHODS: We classified 173 cadaveric kidney recipients into 2 groups. Group 1 comprised 120 first transplants and group 2 comprised 53 retransplants, including 43 second and 10 third transplants. We compared demographic characteristics and survival in groups 1 and 2. RESULTS: Group 1 consisted of 78 boys and 42 girls with a mean ± SD age of 11.5 ± 4.2 years. Group 2 consisted of 37 boys and 16 girls with a mean age of 10.4 ± 4.7 years. One, 5, 10 and 15-year graft survival rates were 78.7%, 64.3%, 54.5% and 50.7% for first transplants vs 82.8%, 57.8%, 57.8% and 41.3%, respectively, for retransplants (p = 0.757). Patient survival at 1, 5 and 15-year was 95.8%, 89.6%, 84.9% in the first transplant group vs 93.6%, 93.6% and 93.6%, respectively, in the retransplant group (p = 0.0.63). Graft survival was significantly higher in patients who did vs did not receive calcineurin inhibitors in the 2 groups (p = 0.02). CONCLUSIONS: Kidney retransplantation in the pediatric population can yield excellent long-term outcomes, especially in patients treated with calcineurin inhibitors.

Villous adenoma in augmentation colocystoplasty asociated to infiltrating urotelial cancer in bladder remanent.

OBJECTIVE: To report a new case of villous adenoma developed in augmentation colocystoplasty. METHODS: Characterization of a new case and review of the literature published to date. RESULTS: We report the case of a 66 year-old man with a villous adenoma and synchronic infiltrating transitional cell carcinoma of the bladder after augmentation colocystoplasty. The latency period until the development of villous adenoma after surgery is long. Treatment consisted of transurethral resection. CONCLUSIONS: Villous adenoma is a benign neoplasm that occurs in the colonic mucosa and shows a high ability to become a malignant colonic cancer. Only two cases of villous adenoma in augmentation colocystoplasty have been reported. We recommend follow up with periodic cystoscopy because of its high malignancy potency.

[Conservative treatment of renal cancer using HIFU. Procedure, indications, and results]. / Tratamiento conservador del cáncer renal mediante HIFU. Técnica, indicaciones y resultados.

This article reviews the mechanisms of action of high-intensity focused ultrasound (HIFU), as well as both experimental and clinical work related to renal tumor treatment. While most currently available experience in urological tumors with HIFU has been obtained with prostate cancer, an increasing number of studies support the efficacy and safety of this procedure for renal tumor destruction. HIFU completes, with cryotherapy and radiofrequency, the spectrum of minimally invasive surgery in renal cancer, intended to decrease surgical morbidity while achieving similar oncological control rates. It is still early to recommend this procedure for daily clinical practice because, while its safety and few side effects are known, many ongoing studies intended to confirm its mid- and long-term oncological efficacy should be completed.

Sildenafil as a protecting drug for warm ischemic kidney transplants: experimental results.

PURPOSE: In an experimental model we studied the protective effects of the phosphodiesterase-5 inhibitor sildenafil on kidney grafts autotransplanted after 45 minutes of warm ischemia by vascular clamping, nephrectomy and 60 minutes of isolated hypothermic pump perfusion. MATERIALS AND METHODS: A total of 14 laboratory minipigs were divided into group 1-7 administered 100 mg sildenafil orally 1.5 hours preoperatively and group 2-7 in which no sildenafil was given. Right single nephrectomy was completed after 45 minutes of warm ischemia by complete vascular clamping. Before autotransplantation all kidneys underwent 60 minutes of hypothermic pulsatile perfusion. Renal flow, arterial pressure and renal vascular resistance were recorded in real time for 60 minutes after autotransplantation. Nitric oxide levels were determined in blood samples from the renal vein at predefined intervals. Optical and electronic microscopy was done in all organs at the end of the procedure. RESULTS: In group 1 vs 2 renal vascular flow was significantly higher (155.30 vs 29.04 ml per minute per 100 gm) and renal vascular resistance was significantly lower (0.59 vs 3.10 mm Hg/ml per minute, each p <0.01). No significant differences were observed in systemic arterial pressure between groups 1 and 2 (84.08 and 84.65 mm Hg, respectively, p >0.05). Nitric oxide levels were significantly higher for all periods in group 1 (49.94 vs 16.85 muM, p <0.01). No significant differences were observed in histological studies, although endothelial cell structure was better preserved in the sildenafil group. CONCLUSIONS: To our knowledge our study suggests for the first time in the literature a positive effect of sildenafil in the immediate posttransplantation outcome of warm ischemic kidneys without secondary systemic effects.

[Prostate and KTP laser]. / Próostata y láser KTP.

OBJECTIVES: To analyze safety and efficacy of KTP green laser photovaporization for the treatment of lower urinary tract obstruction caused by benign prostatic hyperplasia based on data from the medical literature. RESULTS: Most articles consulted emphasize its low complication rate, efficacy, and short learning curve. They have the limitation that most papers are not comparative, the number of patients included is low, and follow-up in many of them short. CONCLUSIONS: Prostatic vaporization with KTP laser is today an alternative to TUR, more in patients with comorbidities, due to its low complication rate. Nevertheless, we accept it is an expensive technology and more follow-up is required to confirm the results remain.

[Unusual complications after radical cystectomy]. / Complicaciones inusuales post-cistectomía radical.

OBJECTIVES: To report complications that are very rare in patients undergoing radical cystectomy and Bricker's ileal conduit. In accordance to the literature and our own experience, to remark the importance of a proper preoperative preparation (nutritional, preanesthetic evaluation...), and adequate postoperative controls to avoid this kind of problems. METHODS: We report three cases which are demonstrative of these complications, their main characteristics, as well as their diagnosis, treatment, and outcomes. RESULTS: All three cases were complicated by fistulae, with different outcomes. The diagnostic measures undertook on each one are reviewed in detail. Although it is well shown in the literature that most of these fistulae appear in patients with intestinal inflammatory/infectious diseases, this was not our experience. CONCLUSIONS: After a bibliographic review and study of our cases, we insist on the importance of a good nutritional evaluation before surgery, and that radical cystectomy with Bricker's type urinary diversion, although consolidated as treatment for infiltrative bladder cancer, is not exempt of immediate postoperative complications or even deferred, as in our case.

[Relation of age and prostatic volume to cancer detection in prostatic biopsies from patients with non-suspect rectal palpation]. / Relación entre la edad y el volumen prostático con la detección de cáncer en la biopsia de próstata en los pacientes con tacto rectal no sospechoso.

OBJECTIVES: To evaluate which clinical variables are predictive for prostate cancer and possible relationships among them, in patients with elevated PSA and non suspicious digital rectal examination (DRE) undergoing first prostate biopsy. METHODS: 1618 patients with elevated PSA and non suspicious DRE who underwent sextant peripheral prostate biopsy were selected from our database. PSA, age, prostate volume, and detectable nodule by ultrasound were selected as variables related to cancer detection in first and second biopsies. RESULTS: Mean age was 67.5 +/- 7.4 (37-88) years, mean PSA was 16.9 +/- 116.5 (3.6-4500) ng\ml, mean prostate volume was 65.7 +/- 37.8 (8-352) cc. 23.3% patients presented a hypoechoic nodule within the peripheral zone of the gland. 18.8% presented prostate cancer on first biopsy. On multivariate analysis, age (p < 0.001), prostate volume (p < 0.001), and presence of a nodule on ultrasound (p = 0.003) were considered independent predictive variables for cancer detection on biopsy. Direct relationship with age, and inverse relationship with prostate volume were shown. Detection rates on second biopsy were greater in patients with prostates = 40 cc in comparison to those > 40 cc (p = 0.02). First two biopsies detected 95% of cancer cases, first three up to 98%. CONCLUSIONS: Age and prostate volume should be taken into consideration when individualizing the number of cores to obtain at the time of biopsy. The efficacy of peripheral sextant biopsy in prostates = for 40 cc should be re-evaluated. Third and fourth biopsies should be reserved for patients with very adverse risk factors.

[Laparoscopic technique in the treatment of stress urinary incontinence]. / La técnica laparoscópica en el tratamiento de la incontinencia urinaria de esfuerzo.

OBJECTIVES: To evaluate the usefulness of laparoscopy as a corrective technique for urinary stress incontinence in our experience. METHODS: We review 72 cases of urinary stress incontinence who were treated by laparoscopic bladder neck suspension between April 1996 and December 2001. RESULTS: Average operative time was less than 40 minutes and mean hospital stay was 1.6 days. The continence rate was 82% after a mean follow up of 32 months. From the 12 patients with incontinence recurrence, 7 had the urinary incontinence recurrence within 2 months from surgery. CONCLUSIONS: The results of laparoscopic correction in urinary stress incontinence seem to be satisfactory in the midterm, although it is necessary to have at least 5 years of follow up to be able to compare it with consolidated techniques considered the gold standard in the treatment of this disease.

[Female stress urinary incontinence. Surgical repair with pubovaginal sling techniques]. / Incontinencia urinaria de esfuerzo femenina. Corrección quirúrgica con técnicas de cabestrillo pubovaginal.

OBJECTIVES: To review the treatment of female stress urinary incontinence by new systems of tension-free urethral sling TVT type (Tension free vaginal tape) or IVS (intravaginal slingplasty), and the bone anchoring trasvaginal sling procedure Infast. METHODS: We describe the surgical techniques of the various procedures and perform a bibliographic review on the topic. RESULTS/CONCLUSIONS: The pubovaginal sling has become the gold standard in the treatment of female stress urinary incontinence, mainly if there is sphincter intrinsic dysfunction. The concept of tension free medium urethra support has been the most important contribution, that questions the classification of incontinence in types I, II and III, because the pubocervical tension free sling can correct all three. Tension free urethral sling techniques have demonstrated to be effective, minimally invasive with a low complication rate, easily reproducible, and with good continence results in the mid-term.