Comparison of surgical approaches to radical prostatectomy in our series beyond oncological and functional outcomes.

OBJECTIVES: To evaluate the outcomes of robot-assisted radical prostatectomy (RARP) compared to those of open (ORP) and laparoscopic (LRP) surgery. The interest lies fundamentally in the quality-of-life (QoL) evaluation, postoperative recovery, and personal satisfaction of patients with the intervention (PS) beyond oncological and functional outcomes. METHODS: Six hundred eighty-five RPs were performed in our center between 2011-2018 (17,8% ORP, 22,2% LRP and 60% RARP). Patients were prospectively assessed through follow-up until April 2020 and a multiple questionnaire at 12-months post-RP that included ICIQ-SF, SHIM, IPSS, IQL and questions about pain, postoperative recovery and PS. Also baseline and postoperative patient- and treatment-related data were collected, and binomial logistic regressions were performed for the 1 vs.1 comparisons (ORP vs. RARP and LRP vs. RARP). RESULTS: RARP patients have overall fewer comorbidities, less tumor aggressiveness, more operative time requirements and more positive surgical margins than ORP and LRP patients. Nevertheless, RARP outperforms ORP in: hospital stay (days) (OR 0,86; 95% CI: 0,80-0,94), hemoglobin loss (OR 0,38; 95% CI: 0,30-0,47), transfusion rate (OR 0,18; 95% CI: 0,09-0,34), early complications (p = 0,001), IQL (OR 0,82; 95% CI: 0,69-0,98), erectile function (OR 0,41; 95% CI: 0,21-0,79), pain control (OR 0,82; 95% CI: 0,75-0,89), postoperative recovery (p < 0,001) and choice of a different approach (OR 5,55; 95% CI: 3,14-9,80). RARP is superior to LRP in: urinary continence (OR 0,55; 95% CI: 0,37-0,82), IPSS (OR 0,96; 95% CI: 0,93-0,98), IQL (OR 0,76; 95% CI: 0,66-0,88), erectile function (OR 0,52; 95% CI: 0,29-0,93), postoperative recovery (p = 0,02 and 0,004), PS (p = 0,005; 0,002; and 0,03) and choice of a different approach (OR 7,79; 95% CI: 4,63-13,13). CONCLUSIONS: The findings of our study globally endorse a positive effectiveness of RARP over ORP and/or LRP, both on functional issues, postoperative recovery, QoL and PS. Oncologic results should still be improved.

Surgical thromboprophylaxis in daily urologic surgery: Beyond bridge therapy. / La tromboprofilaxis quirúrgica en el día a día de la cirugía urológica: más allá de la terapia puente.

INTRODUCTION: With the advanced laparoscopic and robotic surgery, thromboembolic prophylaxis in urologic procedures has traditionally been based on the experience of other surgical specialties. This paper aims to analyze the current recommendations, through a detailed study of the European clinical guidelines and bibliography, applying the recommendations of thromboprophylaxis to the daily urological practice. OBJECTIVES: To elaborate general recommendations to surgical patients in Urology, avoiding the risk of perioperative thromboembolic events. Optimize medication in chronic patients and accurately classify who are eligible for bridge therapy. MATERIAL AND METHODS: A review of the available literature and the European clinical guidelines was carried out. We analyzed the most recent consensus articles by studying the available bibliography, trials and reviews on which the European guidelines for thromboprophylaxis in urology are based. RESULTS: Thromboembolic prophylaxis should be targeted towards surgeries that require abdominal approaches, prolonged bed rest or oncological pathologies. Bridge therapies with low molecular weight heparins should be limited. Patients undergoing treatment for chronic conditions can benefit from bridge therapies in specific cases. CONCLUSIONS: According to the current guidelines, there might be an overuse of heparins in the daily clinical practice. The development of -direct oral- anticoagulants have shown to reduce the time to reintroduction of medication for chronic conditions as well as a more effective bleeding management.

Xenograft iterposition in female urethral diverticulum surgery.

OBJECTIVE: To describe the use collagen xenograft as adjuvant therapy in the surgical treatment of female urethral diverticulum (FUD) and to perform a bibliographic review. METHODS: We performed a surgical approach to remove the diverticulum and repair the remaining dead space with a porcine collagen mesh to avoid fistulas. Monitoring is done by MRI. RESULTS: After two years of follow up the patient improved considerably, disappearing the previous symptoms. Follow-up MRI showed no abnormality: There was no inflammatory reaction or encapsulation of any kind. CONCLUSIONS: We recognize that the flap or the use of a xenograft are not always necessary, but due to its technical simplicity and effectiveness, it is an important tool for diverticulum surgery. However, more experience is needed to assess the appropriateness of this method.

[Laparoscopic partial nephrectomy. Analysis of first 30 cases of our series and review of the literature]. / Nefrectomía parcial laparoscópica. Análisis de los primeros 30 casos de nuestra serie y revisión de la literatura.

OBJECTIVE: Our goal is to analyze the surgical and clinicopathological results of our first 30 laparoscopic partial nephrectomies (LPN) performed consecutively and correlate the results with the literature. MATERIAL AND METHODS: This is a cases series, with 30 patients (20 men and 10 women) operated between 2006 and 2008. We assessed the clinicopathological factors and complications. The mean and median follow-up was 25 and 5 months. RESULTS: Resected tumors had an average size of 2.4 cm. 60% of the tumors were malignant. The pathological stage was pT1 in 100% of cases (47% grade I, 53% Fuhrman grade II).Surgical margins were positive in 3 cases, switching to open surgery. Intraoperative bleeding was 74.66 cc (35.7±SD) and 70 cc of mean and median. The mean operative time was 214.4min (±69) and ischemia time of 31.3min (±13.8). CONCLUSIONS: Our results are similar to those reported in the literature, except for positive margins and conversion attributable to the learning curve.

[Laparoscopic adrenalectomy for metachronous metastasis. Experience in 12 cases]. / Adrenalectomía laparoscópica por metástasis metácrona. Experiencia en 12 casos.

OBJECTIVE: To assess the peroperative and oncological results of laparoscopic adrenalectomy for an isolated metastasis. MATERIAL AND METHODS: A retrospective, descriptive study was conducted of 12 laparoscopic adrenalectomies performed for metastases out of a total of 40 adrenalectomies performed from May 1998 to April 2009. The primary tumor was pulmonary in 7 patients, renal in 3, and colonic in 2. Demographic data collected included median age, operating time, blood loss, complications, tumor size, and length of hospital stay. The Kaplan-Meier method was used to analyze survival. RESULTS: Operating time was 150 min (range, 90-206). Peroperative bleeding was 60 ml (range, 15-150). Peroperative complications occurred in 3% of patients. Tumor size was 4.5 cm (range, 1.3-8.5). No positive margins were seen in the resected specimens. Hospital stay was 3 days (range 3-5). Actuarial survival was 55.6% at 23 months (range, 2-38) with mean and median follow-up times of 20.9 and 23 months. CONCLUSIONS: In selected patients, laparoscopic adrenalectomy for metastasis is a safe procedure with oncological results superimposable to those of open surgery.

[Laparoscopic adrenalectomy. Reflections after 24 procedures]. / Adrenalectomía laparoscópica. Consideraciones a propósito de 24 procedimientos.

INTRODUCTION AND OBJECTIVES: Laparoscopic adrenalectomy has gained rapid recognition since publication of the first case in 1992. Currently it is the technique of choice for the surgical treatment of the adrenal gland. Our objective in this paper is to share our experience with this technique and offer some practical advice on how to approach it. MATERIALS AND METHODS: Between May 1998 and August 2006 we did a total of 24 laparoscopic adrenalectomies in 22 patients (15 men, 7 women). The right gland was removed in 13 cases and the left in 11. Surgery was bilateral in two cases (one was MEN II, the other bilateral cortical hyperplasia). Average age was 49.5 +/- 14.3 years (range 24 to 78). Clinical diagnosis was: Pheochromocytoma (n = 10), Cushing (n = 6), Conn (n = 4), metastases from lung carcinoma (n = 2) and non-functioning tumor (n = 2). For surgery, all patients were in total lateral decubitus with a pillow to increase the costal-iliac space. We used four trocars on the right side and three on the left. Abdominal access was by Hasson trocar after minilaparotomy. We kept pneumoperitoneal pressure below 12 mmHg; a Veress needle was not used for this procedure. RESULTS: Open surgery was required in one case. Time operation was between 59 and 400 minutes (mean 182 +/- 98 min.). In the first 12 cases average time was 261 +/- 77 minutes and in the final 12 cases was 103 +/- 21 minutes (p < 0.001). Tumour diameter was between 1.3 and 6 cm (mean 3.08 +/- 1.25 cm) and tumour weight was between 8 and 92g (mean 30.13 +/- 21 g). Except in one case with 600 ml blood loss, bleeding was less than 100 ml (n = 23, range: 10-100, mean 43.26 +/- 25ml). We only had intraoperative complications in two cases: perforation of the liver by the laparoscope retractor (at the beginning of the series) and injury to the spleen capsule. Both complications were resolved laparoscopically. Cases by histologic type were: nine cortical adenomas, nine pheochromocytomas, three nodular hyperplasias, two metastases from lung carcinoma, and one adrenal pseudocyst. Discharge from hospital was between three and five days (mean 3.62 +/- 0.82) with a statistical difference (p < 0.001) between twelve first cases and the last ones. CONCLUSIONS: The adrenal laparoscopic approach is currently the technique of choice for removing adrenal tumours although with malign tumours or over 7 cm in diameter there are some contraindications and disadvantages relative to open surgery. There is inevitably a learning curve but satisfactory results are quickly attainable.

[Laparoscopic radical prostatectomy. Only at centers of expertise]. / Prostatectomía radical laparoscópica. Sólo en centros de excelencia?

OBJECTIVES: To present and evaluate our experience and initial results in radical laparoscopic prostatectomy which we have been using for two and an half years in our General Hospital (covering a total population of 200.000 inhabitants). MATERIAL AND METHODS: Between December 2002 and August 2005, were selected 26 patients for radical laparoscopic prostatectomy (25 transperitoneal and 1 extraperitoneal). Mean age was 62.3 +/- 5.3 years (range 52-69). Mean PSA level was 9.16 +/- 4.20 ng/mL (range 5.26 to 24.3). Pre-operative classification was Tlc in 10 patients (38.4%), T2a in 8 (30.8%) and T2b in 8. Mean Gleason Score was 6 +/- 0.8 (range 4-7). Three patients had undergone preoperatively neo-adjuvant hormonal blockage (11.5%). Simultaneous bilateral inguinal lymphadenectomy was performed in two patients. In no case did we consider a nerve sparing approach. RESULTS: The procedure was accomplished in 20 patients. Mean follow-up was 12.4 +/- 8.6 months (range 3 - 34). There was no perioperative mortality. Conversion to open surgery was required six times in the ten first cases but not thereafter. Mean operating time for the whole series was 303 +/- 95 minutes (range 150-540) but with a distinct difference between the first fourteen and the last six cases: 332 +/- 92.58 versus 236.6 +/- 66.5 (p<0.02). Mean blood loss was 90.25 +/- 46.5 ml. There were early postoperative complications in 4 patients (15.38%). Final pathological staging was: T2a in three patients (15%), T2b (50%) in 10, T3a (15%) in three and T3b (20%) in four. Positive margins were found in three cases (11.5%): T2b, T3a and T3b. Mean hospitalisation time was 4.7 +/- 3.1 days. Provided there was no urinary leakage, the urinary catheter was removed at 12.7 +/- 2.7 days. Full continence at three months was achieved in 17 of the patients (85%) who had undergone the full laparoscopic procedure. CONCLUSIONS: Our previous experience in other major laparoscopic procedures has allowed us to perform radical laparoscopic prostatectomy with a fast learning curve even in a setting of a relatively low population. Initial long term results seem similar to those achieved with conventional surgery.

[Traumatic injuries to the central nervous system and their repair]. / Trauma en el sistema nervioso central y su reparación.

DEVELOPMENT: Brain and spinal cord lesions have an increasing social and economic importance. Accidental trauma of various kinds is the main cause of mortality of children and young adults in developed countries. Only cardiac disease and cancer surpass the number of death caused by accidents and, examining the number of potential work years lost, CNS lesions surpass all other problems. Most brain and spinal cord injuries cause chronic incapacity and frequently occur to individuals under 45 years of age. Edema and other acute events can be efficiently treated and CNS lesions may not be mortal, but are incurable. CONCLUSION: The final outcome of CNS injury depend on the area damaged and the extent of the lesion, but the best present therapies can offer is relief of the symptoms and rehabilitation. This review examines the present state of functional repair of experimental central nervous system trauma.

[Polycythemia as the first and only manifestation of renal adenocarcinoma]. / Policitemía como primera y única manifestación de adenocarcinoma renal.

We report on a 40-year-old patient with adenocarcinoma of the right kidney whose first and only manifestation was the erythrocytosis that had been detected on routine analytical work up. The diagnostic methods (US, IVP, CT, aspiration biopsy cytology and renal arteriography) and treatment (right nephrectomy via extended thoracophrenolaparotomy incision at the level of the ninth rib) are briefly described. The polycythemia remitted following nephrectomy. The etiopathogenesis and hypotheses that have been put forward relative to polycythemia in renal adenocarcinoma are briefly discussed. Renal tumor, particularly renal adenocarcinoma, should be suspected in the presence of polycythemia of unknown origin. Persistent or recurrent polycythemia should prompt us to suspect incomplete tumor excision or metastasis. Surgical risks (embolism, hemorrhage, etc.) may be reduced if hematocrit levels are brought down to within normal levels by bleeding.

[Primary ureteral adenocarcinoma. Ureteroscopic diagnosis]. / Adenocarcinoma ureteral primario. Diagnóstico ureteroscópico.

A case of primary adenocarcinoma of the ureter that had been diagnosed by ureteroscopy is described, highlighting the form of presentation and treatment. The anatomopathological features as well as the method employed for diagnosis make this an extremely uncommon case.

[Image diagnosis in primary retroperitoneal tumors]. / Diagnóstico por la imagen en los tumores retroperitoneales primitivos.

We present our experience in the diagnosis-through-image with 25 primitive retroperitoneal tumours over a period of 17 years. The histological type most frequently found was that derived from mesodermal tissue (64%). Abdominal pain and mass were the typical symptoms of the presentation. The paper analyzes the radiological studies used (except NMR) with regard to the diagnostic value they have in this sort of pathology. UIV continues to be the initial examination when a retroperitoneal tumour is suspected, obtaining a diagnostic orientation of 70%. The remaining diagnostic techniques (except arteriography and CAT) should be used as a diagnostic supplement or to assess the disease progression, unless the initial clinical symptoms make their use advisable, since the diagnostic orientation provided is usually below 50%. The use of CAT together with monitored aspiratory puncture provided a diagnostic reliability over 90%, so we conclude this should be the examination technique of choice when retroperitoneal tumour is suspected.