Nadir prostate-specific antigen after salvage cryotherapy as a potential prognostic factor for oncologic outcomes.

PURPOSE: To report oncologic outcomes of patients undergoing salvage cryotherapy (SCT) for local recurrence of prostate cancer (PCa) and to establish a nadir PSA (nPSA) value that best defines long-term oncologic success. METHODS: Retrospective study of men who underwent SCT for local recurrence of PCa between 2008 and 2020. SCT was performed in men with biochemical recurrence (BCR), after primary treatment and with biopsy-proven PCa local recurrence. Survival analysis with Kaplan-Meier and Cox models was performed. We determined the optimal cutoff nPSA value after SCT that best classifies patients depending on prognosis. RESULTS: Seventy-seven men who underwent SCT were included. Survival analysis showed a 5-year biochemical recurrence-free survival (BRFS), androgen deprivation therapy-free survival (AFS), and metastasis-free survival (MFS) after SCT of 48.4%, 62% and 81.3% respectively. On multivariable analysis for perioperative variables associated with BCR, initial ISUP, pre-SCT PSA, pre-SCT prostate volume and post-SCT nPSA emerged as variables associated with BCR. The cutoff analysis revealed an nPSA < 0.5 ng/ml to be the optimal threshold that best defines success after SCT. 5-year BRFS for patients achieving an nPSA < 0.5 vs nPSA ≥ 0.5 was 64% and 9.5% respectively (p < 0.001). 5-year AFS for men with nPSA < 0.5 vs ≥ 0.5 was 81.2% and 12.2% (p < 0.001). Improved 5-year MFS for patients who achieved nPSA < 0.5 was also obtained (89.6% vs 60%, p = 0.003). CONCLUSION: SCT is a feasible rescue alternative for the local recurrence of PCa. Achieving an nPSA < 0.5 ng/ml after SCT is associated with higher long-term BRFS, AFS and MFS rates.

Prognostic significance of Fuhrman grade and age for cancer-specific and overall survival in patients with papillary renal cell carcinoma: results of an international multi-institutional study on 2189 patients.

PURPOSE: Because the prognostic impact of the clinical and pathological features on cancer-specific survival (CSS) and overall survival (OS) in patients with papillary renal cell carcinoma (papRCC) is still controversial, we want to assess the impact of clinicopathological features, including Fuhrman grade and age, on survival in surgically treated papRCC patients in a large multi-institutional series. METHODS: We established a comprehensive multi-institutional database of surgically treated papRCC patients. Histopathological data collected from 2189 patients with papRCC after radical nephrectomy or nephron-sparing surgery were pooled from 18 centres in Europe and North America. OS and CSS probabilities were estimated using the Kaplan-Meier method. Multivariable competing risks analyses were used to assess the impact of Fuhrman grade (FG1-FG4) and age groups (<50 years, 50-75 years, >75 years) on cancer-specific mortality (CSM). RESULTS: CSS and OS rates for patients were 89 and 81% at 3 years, 86 and 75% at 5 years and 78 and 41% at 10 years after surgery, respectively. CSM differed significantly between FG 3 (hazard ratio [HR] 4.22, 95% confidence interval [CI] 2.17-8.22; p < 0.001) and FG 4 (HR 8.93, 95% CI 4.25-18.79; p < 0.001) in comparison to FG 1. CSM was significantly worse in patients aged >75 (HR 2.85, 95% CI 2.06-3.95; p < 0.001) compared to <50 years. CONCLUSIONS: FG is a strong prognostic factor for CSS in papRCC patients. In addition, patients older than 75 have worse CSM than patients younger than 50 years. These findings should be considered for clinical decision making.

[Kidney transplantation in children weighing 11 kg or less]. / Trasplante renal en el paciente con peso igual o menor a 11 kg.

AIMS OF THE STUDY: To evaluate the outcome of kidney transplantation in children with low weight. METHODS: Retrospective review of the medical records of patients weighing 11 kg or less that received kidney transplantation between 2001 and 2013 were retrospectively reviewed. RESULTS: Fifty-nine kidney transplantations were performed in pediatric patients in our center, 12 of them were performed in patients weighing 11 kg or less (20%). The mean age of the recipient at the time of transplantation was 2 years (1-3.5); the mean weight was 9.4 ± 1.1 kg (8.3-11). The etiology of kidney failure was malformative in 42% of patients, inherited in 33%, glomerular in 8% and oiler etiologies in 17% of the patients. Two patients did not receive replacement therapy before transplantation (16.7%), nine received peritoneal dialysis (75%) and one of them hemodialysis (8.3%). Eleven of the grafts were from cadaveric donor (91.7%) and one of them from a living donor (8.3%). The mean donor age was 10 years (0.5-29). There was one case of acute graft thrombosis (8.3%) and one case of eventration requiring reoperation; there were no other major complications. Mean follow-up was 59 months (4-130). Overall survival (OS) was 100% at 1 year and 91.7% at 5 years. There was one death in a patient with mitochondrial disease with a functioning graft. Graft survival (GS) was 92% at 1 year and 75% at 5 years. CONCLUSION: Kidney transplantation is the treatment of choice for end-stage kidney failure in the young child. It provides good results in terms of patient and graft survival.

Gender trends at the annual Spanish Urologic Association (AEU) meeting: A review of AEU programmes over a 10-year period (2012-2022).

INTRODUCTION: Gender equity in urological meetings is pivotal for fostering diversity and inclusivity in the field. This study aims to evaluate the representation of Spanish urologist and regional disparities, and to assess its alignment with the demographic composition of the urological community. MATERIALS AND METHODS: All urology meetings organized by the AEU between January 2012 and December 2022 were reviewed, including meeting information and details of the faculty. Additionally, we analysed geographic distribution of speakers across 17 different regions. Gender demographics were obtained disaggregating data by sex and year from the Organización Médica Colegial de España (OMC) and from those urologists affiliated to the AEU. RESULTS: Analysing 52 AEU congresses held from 2012 to 2022, encompassing 3,407 speakers, the study found that 95.25% of speakers were from Spain and 89.6% were male speakers. Over the years, there was a positive trend in female speaker representation, increasing by 1.1% annually, slightly lagging the 1.8% annual rise in the number of female urologists in Spain. In specific subfields like functional, transplantation, and oncology sessions, the study revealed a higher representation of women, indicating focused efforts in these areas. Geographically, Madrid, Catalonia and Andalusia exhibited the highest representation. CONCLUSIONS: Although there was a positive trend towards an increased participation of female urologists in Spanish urological meetings, it fails to accurately reflect the proportional increase in the number of women entering the urology profession in recent years. This study underscores the importance of ongoing efforts to ensure diverse and balanced representation in urological forum.

Functional outcomes after prostatic cryosurgery. / Resultados funcionales después de crioterapia prostática.

OBJECTIVE: To assess the functional effects of prostatic cryosurgery on micturition. MATERIAL AND METHODS: Prospective study of men who underwent cryosurgery (CS) for prostate cancer between 2013 - 2015. Low urinary tract symptoms (LUTS) and quality of life (QoL) were assessed 1 month before surgery using IPSS questionnaire, a three-day voiding diary (3DVD) and uroflowmetry with ultrasound-measured postvoid residual volume. Need of medical treatment for LUTS was also recorded. The same assessment was performed at 3, 6 and 12 months after CS. Outcomes after surgery were compared to those prior to surgery. RESULTS: Forty-five patients underwent a CS during the study period, of whom 25 patients could be recruited in the study. Mean age was 73.5 years (range 66-84). Nineteen CS (76%) were performed as a primary procedure, while 6 CS (24%) as a salvage procedure. No statistical differences were found comparing results of IPSS, QoL, D3vd or uroflowmetry and PVR at 3, 6 or 12 months after CS compared to before surgery. Before CS, 8 (32%) patients were on medical treatment for LUTS, while at 6 and 12 months after surgery, 3 (13.6%) and 2 (9.5%) patients required some medication, respectively. CONCLUSION: According to the punctuation of IPSS, QoL questionnaire, and a 3-day voiding diary, LUTS does not worsen after CS. Prostatic cryosurgery does not seem to impact uroflowmetry results.

Nephron-sparing surgery for renal tumor: a choice of treatment in an allograft kidney.

The incidence of de novo malignancies is an accepted complication of organ transplantation. Renal cell carcinoma (RCC) was 4.6% of cancers occurring de novo in organ allograft recipients compared with 3% in the general population. Less than 10% of these renal cancers affected the renal allograft. Among patients developing a renal tumor in the kidney allograft, transplant nephrectomy reduced the quality of life. For these patients for whom preservation of renal function is a relevant clinical consideration, partial nephrectomy may be considered the choice for treatment. Fifteen cases have been reported regarding conservative surgery on kidney transplant tumors. Herein we have reported three cases of renal masses in well-functioning kidney transplants that were successfully treated with nephon-sparing surgery. Our experience demonstrated that in selected patients, nephron-sparing surgery on a renal allograft represents a feasible approach for tumor removal with preservation of graft function.

Changing patterns in the surgical management of renal masses.

OBJECTIVE: To describe the temporal trends in surgical techniques for the management of renal masses at a single Spanish academic institution and identify factors associated with partial nephrectomy (PN) decision. MATERIALS AND METHODS: A total of 646 patients were treated by surgery for clinically localised renal masses from January 2004 to December 2012 at a tertiary referral center. Surgical techniques included open radical nephrectomy (RN), open PN, laparoscopic RN, and laparoscopic PN. Descriptive statistics were used to compare baseline characteristics and proportions of patients treated by different surgical techniques. Annual trends in the proportion of procedures performed were determined. Adjusted odds ratios (OR) and 95% confidence intervals were calculated to evaluate clinical variables predictive of PN. RESULTS: During the 9-year study period, the proportion of PN relative to RN increased from 21% to 55%. With regard to surgical approach, open procedures for both RN and PN decreased gradually in favor of minimally invasive approaches (83% in 2004 to 4% in 2011-2012). While median tumor size did not significantly change over the study period, laparoscopic PN became the most commonly performed kidney procedure in 2011-2012 (49% of all procedures). Clinical variables independently predictive of partial nephrectomy were ASA score, baseline renal function and tumor size (all P<.05). CONCLUSIONS: At our academic institution, temporal trends in the management of renal masses have established PN as the most common surgical option. Although PN was increasingly used over the study period, a parallel increase in minimally invasive approaches for RN and PN was seen.

Predictors, pathological characteristics and outcomes of bladder recurrences following nephroureterectomy.

OBJECTIVES: To analyze the predictors for bladder recurrence (BR) after nephroureterectomy (NU) for upper urinary tract tumors (UUTT), as well as its pathological characteristics, outcomes and impact on survival. MATERIAL AND METHODS: Retrospective study of 117 patients who underwent laparoscopic nephroureterectomy by UUTT between 2007-2012 at our center. The potential predictors for BR were analyzed using Cox regression; Kaplan-Meier curves were employed to study survival. RESULTS: The sample was composed of 85 men (73%) and 32 women (27%), with a mean age of 70 years. After a mean follow-up of 26 months, 23 patients presented BR (19.6%). In the multivariate analysis, sex (p=.003; HR [female], 3.8) and the location of the UUTT in the distal ureter (p=.002; HR, 4.8) were independent predictors for BR. The median time to BR was 8 months. Fifteen patients presented a nonmuscle-invasive BR (65.2%), and 8 presented a muscle-invasive BR (34.8%). All BRs, except for 2, appeared during the first 2 years. Five cases with nonmuscle-invasive BR presented a new BR. Six patients with muscle-invasive BR died before it could be determined whether cause of death was the BR or an UUTT relapse. The onset of BR showed no repercussion on the survival of patients with UUTT. CONCLUSIONS: Sex (female) and the location of the UUTT (distal ureter) are predictors for BR after NU. Patients with these characteristics might benefit from adjuvant intravesical treatment and closer monitoring. The onset for RV has no impact on the survival of patients with UUTT.

Transposition of iliac vessels in implantation of right living donor kidneys.

BACKGROUND: The rate of right laparoscopic living-donor nephrectomy (RLLDN) is low among kidney transplantations due to the short renal vein and presumed higher risk of thrombosis. Our objective was to describe a surgical technique to compensate for the shorter veins of these grafts. METHODS: Between January 2004 and July 2010, we prospectively collected data from all transplantations using RLLDN-harvested kidneys at our center. Recipient iliac vein transposition was performed in all patients. We reviewed the indications, surgical techniques, and postoperative courses. RESULTS: The 43 included cases showed a 2.1 +/- 0.6 cm, average length of the right renal vein as measured on abdominal computed tomography (CT). The mean extraction and implantation times were 109 +/- 33 and 124 +/- 31 minutes, respectively; the mean warm ischemia time was 151 +/- 29 seconds. Two recipients required postsurgical blood transfusions. In 97.6% of cases, there was immediate urine flow. Postoperative echo-Doppler revealed good arterial and venous flows in all patients. No venous thromboses were detected. The recipients' average hospital stay was 8 +/- 5 days. With a mean follow-up of 57 months, 86% of recipients maintain a glomerular filtration rate (GFR) >50 mL/min and creatinine levels <1.5 mg/dL. CONCLUSIONS: Transposition of the recipient iliac vein during implantation is a good technical solution to compensate for the short length of the right renal vein. The use of iliac vein transposition allowed us to perform safe implants of RLLDN-harvested kidneys with good short-term and long-term results.

[Pioneer experience in Spain with LSSS nephrectomy in living donor]. / Experiencia pionera en España con nefrectomía LESS de donante vivo.

INTRODUCTION: LESS surgery (Laparoendoscopic single site surgery) is a surgical technique that aims to perform intraabdominal surgery using a single site entry, allowing for reduction in the number and size of the incisions, achieving better esthetic results with at least the same functional outcomes as with the conventional laparoscopic surgery. MATERIAL AND METHODS: We present the first experience of LESS living donor nephrectomy carried out by a totally European team. To perform it, a Quadport® device was placed through a 4 cm long paraumbilical incision. RESULTS: The nephrectomy was performed using the standards of conventional laparoscopic surgery, with the use of a precurved instrument in the left hand and straight instruments in the right. After bagging the kidney, the artery and vein were sectioned after clipping, allowing for rapid extraction of the organ through the same incision, with warm ischemia of 3.30" and 2.47," respectively. CONCLUSION: Living donor nephrectomy using the LESS technique is feasible and can be considered a good option for obtaining live donor kidney grafts in males. The application of said surgical in living kidney donor can increase the rate of donation, by reducing morbidity and improving the esthetic results with the same outcome for the donor as for the recipient.

[Delayed bleeding after partial nephrectomy. Management with selective embolization]. / Sangrado diferido después de nefrectomía parcial. Manejo mediante embolización selectiva.

INTRODUCTION: Bleeding after partial nephrectomy can be immediate or delayed and may have severe consequences. The incidence of this complication is low. The most frequent cause of delayed bleeding is arterial pseudoaneurysm. Superselective embolization is a feasible therapeutic option that has shown good results. OBJECTIVE: To evaluate treatment and outcomes of delayed bleeding in our series of patients with partial nephrectomy. MATERIAL AND METHODS: We performed a retrospective study of our database of partial nephrectomies. Patients who developed delayed bleeding (after discharge) were identified. Clinical histories were reviewed and data on presentation, diagnosis, treatment and outcomes were analyzed. RESULTS: Among our series of patients undergoing partial nephrectomy, three developed delayed bleeding (1.3%). Symptom onset occurred 17 to 25 days after surgery and consisted of hematuria or lumbar pain. Diagnosis was provided through ultrasound, abdominal computed tomography and renal angiography. In all three patients, a complicated pseudoaneurysm was diagnosed and all patients underwent renal artery catheterization with selective renal artery embolization. In all patients, immediate control of bleeding was achieved. Outcome after a follow-up of 61 to 92 months was favorable. CONCLUSIONS: Selective vascular embolization is the treatment of choice of renal pseudoaneurysm after partial nephrectomy in hemodynamically stable patients.

Third and fourth kidney transplant: still a reasonable option.

INTRODUCTION: At present, a second kidney transplant is considered an established therapeutic option for patients who have lost a previous graft. Second transplants show similar graft survival as first transplants. A debate exists about the benefit of submitting the patient to a third or fourth renal transplant, or to maintain dialysis. OBJECTIVE: We sought to analyze graft and patient survivals as well as associated variables and surgical complications of third and fourth transplantations. MATERIAL AND METHODS: From July 1985 to December 2008, we performed 74 third and 8 fourth transplantations among 2763 cases. We prospectively collected the variables of age, gender, graft origin, hyperimmunization, time on dialysis, location, bench surgery, acute rejection episodes, graft survival, and operative complications. RESULTS: Third and fourth trasplantations were performed in 49 men and 33 women, with an overall mean age of 40.26 years who were on dialysis for an average of 126.89 months before transplantation. Mean graft survivals of their first and second grafts were 35.6 and 50.1 months, respectively. Acute or chronic rejection was reason for renal failure in 71% and 75% of cases, respectively. Patient survivals at 1 and 5 years were 92.7% and 90.6%, for third and both 85.7% for the fourth transplantation. The third and fourth transplantations showed 1- and 5-year graft survivals of 88% and 76.4% and 71.4% and 42.9%, respectively. Sixty-eight cases underwent cadaveric donor and 14 living donor (mean age, 42.1 years) transplantations. Nine patients were hyperimmunized. In 60 cases, we used the left kidney. Orthotopic kidney transplantation was performed in 15 cases; heterotopic transplant to the right iliac fossa in 40 and in the left iliac fossa in 17 cases. Arterial bench surgery was necessary in 6 cases and venous in 3. We performed 3 hepatorenal and 1 cardiorenal transplantation. The complications included 29 cases (35.4%) of postoperative acute tubular necrosis, 14 of acute rejection episodes (17.1%); 12 of perirenal hematoma (14.6%); 1 urinary fistula (1.2%); 4 lymphocele (4.9%); 2 ureteral stenosis (2.4%); variables arterial kink requiring surgery (1.2%), and 1 venous thrombosis with graft loss (1.2%). The 4 patients who died in the perioperative period succumbed to intravascular disseminated coagulation (n = 1) cardiac failure (n = 2), and septic shock (n = 1). Induction antibody therapy, hyperimmunized status, or operative complications were not independent prognostic factors for patient or graft survival. CONCLUSIONS: Third or fourth renal transplantations constitute a valid therapeutic option with reasonable short- and long-term patient and graft survivals. Although orthotopic kidney transplantation was used in selected patients, we preferred an iliac fossa approach for most.