Effect of repeated prostate biopsies on erectile function in men on active surveillance for prostate cancer.

PURPOSE: Active surveillance is becoming an increasingly common management strategy for low grade prostate cancer and involves repeat prostate biopsies over time. It has been hypothesized that serial biopsies can lead to reduced erectile function in patients on active surveillance and we explored this hypothesis in a longitudinally followed cohort. MATERIALS AND METHODS: We identified 342 men on active surveillance whose first biopsy occurred between 2000 and 2009. We investigated erectile function using patient reported outcomes, namely the 6 erectile function questions from the IIEF-6 (International Index of Erectile Function). We estimated the change in erectile function with time using locally weighted scatterplot smoothing. RESULTS: The median (IQR) patient age in this cohort was 64 years (58-68). Median followup on active surveillance was 3.5 years (2.3-5.0) and the median number of biopsies was 5 (3-6). During the first 4 years on active surveillance erectile function decreased 1.0 point per year (95% CI 0.2, 1.7) on the IIEF-6 (scale 1 to 30). When stratified by comorbidities or number of biopsies we see an almost identical decrease in erectile function with time. The use of phosphodiesterase-5 inhibitors increased from 5% to 27% from baseline to year 5 on active surveillance. CONCLUSIONS: In this longitudinally followed active surveillance cohort we observed a small decrease in erectile function and an increase in the use of phosphodiesterase-5 inhibitors with time. While we cannot separate out the effect of multiple biopsies from that of the natural aging process on erectile function in this observational study, our data suggest that active surveillance related biopsies do not have a large impact on erectile function.

Budget impact analysis of transurethral water vapor therapy for treatment of lower urinary tract symptoms associated with benign prostatic hyperplasia in the Spanish national healthcare system.

BACKGROUND: Several surgical treatments are available for managing lower urinary tract symptoms secondary to benign prostatic hyperplasia (LUTS/BPH). Water vapor thermal therapy (WVTT) is a new minimally invasive therapy. This study estimates the budget impact of introducing WVTT for LUTS/BPH into the Spanish health care system. METHODS: A model simulated the evolution of men over 45 years of age with moderate-severe LUTS/BPH after surgical treatment, over a 4-year time horizon, from the Spanish public health care service´s perspective. The technologies in scope included those most used in Spain: WVTT, transurethral resection (TURP), photoselective laser vapourization (PVP) and holmium laser enucleation (HoLEP). Transition probabilities, adverse events and costs were identified from the scientific literature and validated by a panel of experts. Sensitivity analyses were performed by varying the most uncertain parameters. RESULTS: Per intervention, WVTT resulted in savings of €3,317, €1,933 and €2,661 compared to TURP, PVP and HoLEP. Over a 4-year time horizon, when performed in 10% of the cohort of 109,603 Spanish males with LUTS/BPH, WVTT saved €28,770,125 against the scenario without WVTT availability. CONCLUSIONS: WVTT could reduce the cost of managing LUTS/BPH, increase the quality of health care and reduce the length of procedure and hospital stay.

Gold Glyconanoparticles Combined with 91-99 Peptide of the Bacterial Toxin, Listeriolysin O, Are Efficient Immunotherapies in Experimental Bladder Tumors.

This study presents proof of concept assays to validate gold nanoparticles loaded with the bacterial peptide 91-99 of the listeriolysin O toxin (GNP-LLO91-99 nanovaccines) as immunotherapy for bladder tumors. GNP-LLO91-99 nanovaccines showed adjuvant abilities as they induce maturation and activation of monocyte-derived dendritic cells (MoDCs) to functional antigen-presenting cells in healthy donors and patients with melanoma or bladder cancer (BC), promoting a Th1 cytokine pattern. GNP-LLO91-99 nanovaccines were also efficient dendritic cell inducers of immunogenic tumor death using different bladder and melanoma tumor cell lines. The establishment of a pre-clinical mice model of subcutaneous BC confirmed that a single dose of GNP-LLO91-99 nanovaccines reduced tumor burden 4.7-fold and stimulated systemic Th1-type immune responses. Proof of concept assays validated GNP-LLO91-99 nanovaccines as immunotherapy by comparison to anti-CTLA-4 or anti-PD-1 antibodies. In fact, GNP-LLO91-99 nanovaccines increased percentages of CD4+ and CD8+ T cells, B cells, and functional antigen-presenting DCs in tumor-infiltrated lymphocytes, while they reduced the levels of myeloid-derived suppressor cells (MDSC) and suppressor T cells (Treg). We conclude that GNP-LLO91-99 nanovaccines can work as monotherapies or combinatory immunotherapies with anti-CTLA-4 or anti-PD-1 antibodies for solid tumors with high T cell infiltration, such as bladder cancer or melanoma.

Arterial Fistulas in Urinary Diverted Patients: A Report of 5 Cases.

OBJECTIVE: Arterio-urinary fistulae are a rare but potentially lethal complication that may arise after pelvic surgery, such as radical cystectomy. Historically, open surgery was the gold standard treatment, but currently endovascular treatment has gained prominence. METHODS: We report our centre experience in endovascular treatment of cystectomy-related arterial fistulae and review the reported literature on the topic. During the postoperative period of radical cystoprostatectomy five patients presented different ranges of haematuria, and one presented rectal bleeding, four of them with haemodynamic instability. An urgent three-phase computed tomography was performed, showing active bleeding in 2 patients, while the rest of the patients presented indirect signs of fistulae. An angiography was performed, showing contrast extravasation in 60% of the cases and vessel wall irregularity in 40%. Five arteriourinary fistulae and one arterioenteric fistula were urgently treated with a covered stent placement, sealing the site of the fistula in the artery. RESULTS: Immediate results were satisfactory in all cases; however, one patient died secondary to fistula-related causes 15 days post-treatment. No stent thrombosis or rebleeding have been registered during follow-up. In this review, reported results and complications after covered stent placement are shown, and controversial topics such as antibiotic coverage and antithrombotic treatment after endovascular treatment are also reviewed.

Can partial nephrectomy preserve renal function and modify survival in comparison with radical nephrectomy?

OBJECTIVE: To investigate whether radical nephrectomy (RN) and nephron-sparing surgery (NSS) for T1 renal cell carcinoma influence renal function, oncological outcome or survival rate. MATERIAL AND METHODS: A retrospective study was performed, including 290 nephrectomies for tumours of a diameter of less than 7 cm; 174 radical nephrectomies were compared to 116 nephron-sparing surgeries. Preoperative and pathological data were compared between the two groups. The glomerular filtration rate was estimated using the abbreviated Modification of Diet and Renal Disease (MDRD4) study equation. The evolution of renal function was analysed from 6 months to 4 years after surgery, and the oncological outcomes were evaluated by means of cancer and non-cancer survival curves. RESULTS: The results showed a major impairment in renal function in the RN group compared to those who underwent NSS (25 vs 7 ml/min/1.73 m², 6 months after surgery), a difference that was maintained over time. Moreover, patients undergoing RN had a greater chance of developing renal failure. Overall, the survival curves showed a higher mortality rate for the RN group (p = 0.034), although the cancer-specific mortality rate did not show any statistically significant differences (p = 0.079). CONCLUSIONS: For stage T1 renal cortical tumours, NSS should, whenever possible, be regarded as the primary therapeutic option, given that it obtains similar oncological outcomes to RN and preserves renal function, which seems to translate into a lower overall mortality rate.

Testicular tumors: residual retroperitoneal mass surgery after chemotherapy;Is it possible to predict their histology?

OBJECTIVES: We present our series of residual retroperitoneal mass surgery after chemotherapy. We evaluate possible preoperative parameters that can predict the retroperitoneal mass histology. Survival and relapse rates were also evaluated. METHODS: We reviewed sixty resections of residual retroperitoneal masses of testicular tumours after chemotherapy performed at our department between 1995 and 2007. We evaluate the relationship between histology of the retroperitoneal mass and possible risk factors, such as outcomes after chemotherapy, which was evaluated as changes in the size of the retroperitoneal mass, and negativization of serum tumor markers. We also evaluate histology and size of the primary testicular cancer. RESULTS: The histology of retroperitoneal mass was necrosis or fibrosis in 25 (42%) cases, teratoma in 29 (48%) and viable tumor in 6 (10%). The size of the retroperitoneal mass decreased after the chemotherapy in 62% cases; moreover negative serum tumor markers were found in 87%. Elevated values of human chorionic gonadotropin were associated with viable cells in the retroperitoneal mass (p=0.014) and, the presence of teratoma in the primary tumor may be associated with teratoma in the retroperitoneal mass histology (p=0.002). However, no other preoperative factors that predict the residual mass histology were found. Repeated resections of retroperitoneal masses were required in four patients and 9 patients died during follow-up. CONCLUSIONS: We cannot determine preoperative parameters that accurately predict the histology of retroperitoneal masses. Therefore, resection of residual retroperitoneal masses after chemotherapy in non-seminomatous germ cell tumours must be performed.

[Benign prostatic hyperplasia management during COVID-19 pandemia.] / Manejo de la hiperplasia benigna de próstata durante la pandemia COVID-19.

OBJECTIVES: The pandemic caused by the new SARS / Cov-2 Coronavirus represents an unprecedented scenario in modern medicine that affects many aspects of daily healthcare. Lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH) has a high prevalence and is related to high consumption of health resources. For this reason, we performed a revision of the management of LUTS and HBP during and after COVID-19 pandemic. MATERIAL AND METHODS: A group of experts in benign prostatic hyperplasia from different regions of Spain were selected to design a strategy to reorganize the management of benign prostatic hyperplasia and lower urinary tract symptoms during the pandemic. A comprehensive review of the literature was undertaken and a set of recommendations are generated. RESULTS: Recommendations for the management of LUTS-BPH during and after the SARS/CoV2 coronavirus pandemic outbreak consist of promoting telemedicine and developing joint protocols with Primary Care Attention .Clear diagnostic and treatment criteria and referral criteria must be established. Referral of patients for risk complications such as kidney failure, recurrent hematuria and obstructive uropathy are a priority. Surgeries due to BPH are generally potentially delayed until phases I and II of the pandemic, in which the percentage of hospitalized patients with COVID-19 does not exceed 25%, and it is necessary to determine COVID19 negativity. The surgical technique that associates the least complications and the shortest stay should be selected. CONCLUSIONS: The diagnosis and prescription of treatment for BPH during the COVID-19 pandemic should be based on telemedicine and joint protocols for primary care attention and urology. Elective surgical treatment can be delayed until we are in phases I or II, individualizing the surgical and anaesthetic technique of choice to minimize risks.

OBJETIVOS: La pandemia causada por el nuevo Coronavirus SARS/Cov-2 supone un escenario sin precedentes en la medicina moderna que afecta de manera indirecta en numerosos aspectos de nuestra actividad diaria como sanitarios. La hiperplasia benigna de próstata (HBP) es una patología con una elevada prevalencia y consumo de recursos sanitarios. Por ello, es necesaria una revisión en el manejo de la misma con el fin de adecuarlo a las necesidades impuestas por los acontecimientos recientes.MATERIAL Y MÉTODOS: Un grupo de expertos en hiperplasia benigna de próstata de distintas comunidades autónomas de España fueron contactados para diseñar una estrategia para reorganizar el manejo de la hiperplasia benigna de próstata y los síntomas del tracto urinario inferior durante la pandemia. Se realiza una revisión narrativa de la literatura publicada y se generan una serie de recomendaciones de manejo. RESULTADOS: Entre las recomendaciones para el manejo de HBP en tiempos de pandemia por coronavirus SARS/CoV2 se incluyen la promoción de teleconsulta y la realización de protocolos conjuntos con Atención Primaria estableciendo criterios de diagnóstico, tratamiento y derivación claros y homogéneos. Deben priorizarse las derivaciones pacientes complicaciones de riesgo tales como insuficiencia renal, hematuria recidivante y uropatía obstructiva. Desde el punto de vista quirúrgico, se trata generalmente de cirugías potencialmente demorables hasta fases I y II de la pandemia, donde el porcentaje de pacientes hospitalizados con Covid-19 no supera el 25%, siendo preciso determinar negatividad de COVID19. Debe seleccionarse la técnica quirúrgica que asocie una menor tasa de complicaciones así como una estancia más baja. CONCLUSIONES: El diagnóstico y el inicio del tratamiento médico de la HBP durante la pandemia debe basarse en la instauración de la telemedicina y protocolos conjuntos con atención primaria y urología. El tratamiento quirúrgico electivo se puede demorar hasta encontrarnos en fases I o II, individualizando la técnica quirúrgica y anestésica de elección para minimizar riesgos.

[Mini-laparoscopic pyeloplasty.] / Pieloplastia por Minilap..

Continued progresses in the field of laparoscopy have been introduced in urological surgery. With the development of smaller instrumental minilaparoscopy was born seeking to reduce abdominal trauma and improve cosmetic scars, obtaining similar or better results than conventional laparoscopy. OBJECTIVE: The objective of this paper is to evaluate the results and reproducibility of mini-laparoscopic pyeloplasty. METHODS: A literature review and a bibliographic search in PubMed were performed. We describe the technique used in the "Hospital Marqués de Valdecilla" (HUMV), Santander (Spain). RESULTS: 60 articles about mini-laparoscopy were found. Although there are few reported minilap pyeloplasty series, they offer excellent cosmetic and functional results. We analyze operative time, complications, postoperative hospital stay, conversion rate, functional and cosmetic results, and we compare them with conventional laparoscopic pyeloplasty. CONCLUSIONS: More reported series are necessary but it has been proved that minilap pyeloplasty is a reproducible and safe technique with excellent results.

Pieloplastia robótica y laparoscópica / Robot-assisted and laparoscopic pyeloplasty

Los continuos avances en el campo de la laparoscopia han ido siendo introducidos progresivamente en la cirugía urológica. Con el desarrollo de instrumental de menor tamaño nace la minilaparoscopia, buscando reducir el trauma abdominal y mejorar la cosmética de las cicatrices, obteniendo unos resultados similares o mejores a los logrados en la laparoscopia convencional. Objetivo: El objetivo es evaluar los resultados y la reproducibilidad de la pieloplastia por minilap. Método: Para ello se ha realizado una revisión de la literatura y una búsqueda bibliográfica en PubMed. Describimos la técnica quirúrgica realizada en el Hospital Universitario Marqués de Valdecilla, Santander (HUMV). Resultados: se encontraron más de 60 artículos que hacían referencia a la minilaparoscopia. Aunque a día de hoy son escasas las series reportadas de pieloplastia por minilap, estas ofrecen unos resultados excelentes. Analizamos los datos de tiempo quirúrgico, complicaciones, estancia hospitalaria, tasa de conversión, resultado funcional y cosmético, comparándolos con la pieloplastia laparoscópica convencional. Conclusiones: Aunque es necesario que se reporten más series, se ha demostrado que la pieloplastia por minilap es una técnica reproducible y segura, que otorga así mismo unos resultados excelentes

Continued progresses in the field of laparoscopy have been introduced in urological surgery. With the development of smaller instrumental minilaparoscopy was born seeking to reduce abdominal trauma and improve cosmetic scars, obtaining similar or better results than conventional laparoscopy. Objective: The objective of this paper is to evaluate the results and reproducibility of mini-laparoscopic pyeloplasty. Methods: A literature review and a bibliographic search in PubMed were performed. We describe the technique used in the Hospital Marqués de Valdecilla (HUMV), Santander (Spain). Results: 60 articles about mini-laparoscopy were found. Although there are few reported minilap pyeloplasty series, they offer excellent cosmetic and functional results We analyze operative time, complications, post-operative hospital stay, conversion rate, functional and cosmetic results, and we compare them with conventional laparoscopic pyeloplasty. Conclusions: More reported series are necessary but it has been proved that minilap pyeloplasty is a reproducible and safe technique with excellent results

Pieloplastia por Minilap / Mini-laparoscopic pyeloplasty

Los continuos avances en el campo de la laparoscopia han ido siendo introducidos progresivamente en la cirugía urológica. Con el desarrollo de instrumental de menor tamaño nace la minilaparoscopia, buscando reducir el trauma abdominal y mejorar la cosmética de las cicatrices, obteniendo unos resultados similares o mejores a los logrados en la laparoscopia convencional. Objetivo: El objetivo es evaluar los resultados y la reproducibilidad de la pieloplastia por minilap. Método: Para ello se ha realizado una revisión de la literatura y una búsqueda bibliográfica en PubMed. Describimos la técnica quirúrgica realizada en el Hospital Universitario Marqués de Valdecilla, Santander (HUMV). Resultados: se encontraron más de 60 artículos que hacían referencia a la minilaparoscopia. Aunque a día de hoy son escasas las series reportadas de pieloplastia por minilap, estas ofrecen unos resultados excelentes. Analizamos los datos de tiempo quirúrgico, complicaciones, estancia hospitalaria, tasa de conversión, resultado funcional y cosmético, comparándolos con la pieloplastia laparoscópica convencional. Conclusiones: Aunque es necesario que se reporten más series, se ha demostrado que la pieloplastia por minilap es una técnica reproducible y segura, que otorga así mismo unos resultados excelentes

Continued progresses in the field of laparoscopy have been introduced in urological surgery. With the development of smaller instrumental minilaparoscopy was born seeking to reduce abdominal trauma and improve cosmetic scars, obtaining similar or better results than conventional laparoscopy. Objective: The objective of this paper is to evaluate the results and reproducibility of mini-laparoscopic pyeloplasty. Methods: A literature review and a bibliographic search in PubMed were performed. We describe the technique used in the "Hospital Marqués de Valdecilla" (HUMV), Santander (Spain). Results: 60 articles about mini-laparoscopy were found. Although there are few reported minilap pyeloplasty series, they offer excellent cosmetic and functional results. We analyze operative time, complications, post-operative hospital stay, conversion rate, functional and cosmetic results, and we compare them with conventional laparoscopic pyeloplasty. Conclusions: More reported series are necessary but it has been proved that minilap pyeloplasty is a reproducible and safe technique with excellent results

Tratamiento hormonal en la recidiva bioquimica tras prostatectomía radical / Hormonal treatment in biochemical recurrence after radical prostatectomy

Hasta la fecha el papel de la HT en la recidiva bioquímica, su inicio, esquema y duración permanecen en controversia dada la ausencia de ensayos randomizados que analicen la supervivencia del paciente sometido a esta terapia tras fracaso bioquímico. La hormonoterapia mediante el empleo de análogos LH-RH resulta en este escenario la medida más frecuentemente empleada en la práctica clínica. Sin embargo el sustento científico de la misma es bastante endeble. Implica extrapolar los beneficios de la HT precoz vs diferida, vista en otros estadios de la enfermedad (generalmente avanzada), a un paciente asintomático con exclusivo aumento del PSA, que tendría en muchos casos una larga historia natural hasta el desarrollo de metástasis y con el impuesto añadido de los efectos secundarios bien conocidos actualmente. Probablemente los pacientes con Gleason >8 y TDPSA < 12 meses sí pudieran beneficiarse de un tratamiento hormonal precoz, sobre todo si son jóvenes (grado 2c). En muchos otros casos donde no se contemple un tratamiento local como RT, la decisión de HT precoz o tardía debe ser cuidadosamente valorada y comentada con el paciente. Las alternativas de tratamiento hormonal con preservación de función sexual, como el bloqueo intermitente, monoterapia con antiandrógenos o la suma de un 5- ARI con antiandrógeno, deben ser valoradas con cautela ante la escasez de información a largo plazo aunque éste parece un atractivo escenario para su empleo(AU)

To date, the role of hormonal therapy (HT) after biochemical failure, when to initiate it, the therapeutic scheme and duration remains controversial due to the absence of well designed randomized trials analyzing the overall survival of patients. In clinical practice, the most widely spread treatment in this scenario is hormonal therapy with LH-RH analogues. However, the scientific support for this issue is very weak. We are extrapolating the benefits proven for early vs delayed HT in advanced prostate cancer, to asymptomatic patients presenting just an increase in PSA. These patients usually have a long time disease-history until development of metastasis. It should also be noticed the harmful secondary effects acquired with the time of employment of hormotherapy. Probably patients suffering a Gleason score >8 and PSA doubling time <12 months could obtain a benefit from an early castration treatment, even more if they are young (grade 2c). Except in selected cases of local treatment as radiotherapy, the decision for early or delayed hormonal therapy should be taken carefully with patient consensus. The alternatives for hormonal treatment to preserve sexual function, as intermittent treatment, antiandrogen monotherapy, or antiandrogen plus 5 alpha reductase inhibitors, are very attractive in this scenario. However due to the short time experience with these modalities of treatment should be evaluated with caution(AU)

Tumores testiculares: cirugía de masas retroperitoneales residuales tras tratamiento quimioterápico; ¿es posible predecir su histología? / Testicular tumors: residual retroperitoneal mass surgery after chemotherapy; ¿is it possible to predict their histology?

OBJETIVO: Presentamos nuestra serie de cirugías de masas retroperitoneales residuales postquimioterapia, evaluando aquellos parámetros que pudieran predecir su histología y mostramos la evolución tras la cirugía.MÉTODOS: Revisamos retrospectivamente 60 cirugías de masas retroperitoneales residuales tras quimioterapia, secundarias a tumores testiculares de células germinales realizadas en nuestro servicio entre 1995 y 2007. Estudiamos la relación entre la histología de la masa y sus posibles factores predictores, tales como: la respuesta a la quimioterapia valorada como reducción del tamaño de la masa retroperitoneal y evolución de los marcadores tumorales, la anatomía patológica y el tamaño del tumor primario.RESULTADOS: La histología de las masas residuales fue necrosis/fibrosis en 25 (42%) casos, teratoma en 29 (48%) y tumor viable en 6 (10%). La quimioterapia consiguió reducir el tamaño de la masa en el 62% de los casos, se logró negativización de los marcadores en el 87%. Aunque valores más altos de gonadotropina coriónica humana se asocian con masas que contienen células viables (p=0,014) y la presencia de teratoma en el tumor primario puede orientar hacia la histología de la masa retroperitoneal (p=0,002), no encontramos otros factores preoperatorios predictivos de la histología de la masa residual. En 4 pacientes fueron necesarias varias cirugías ante la existencia de recidiva y 9 pacientes fallecieron durante el seguimiento.CONCLUSIONES: No encontramos claros factores predictores de la histología de la masa retroperitoneal. Por tanto, en los tumores germinales no seminomatosos debe realizarse una completa resección quirúrgica de las masas retroperitoneales residuales tras el tratamiento quimioterápico(AU)

OBJECTIVES: We present our series of residual retroperitoneal mass surgery after chemotherapy. We evaluate possible preoperative parameters that can predict the retroperitoneal mass histology. Survival and relapse rates were also evaluated. METHODS: We reviewed sixty resections of residual retroperitoneal masses of testicular tumours after chemotherapy performed at our department between 1995 and 2007. We evaluate the relationship between histology of the retroperitoneal mass and possible risk factors, such as outcomes after chemotherapy, which was evaluated as changes in the size of the re-troperitoneal mass, and negativization of serum tumor markers. We also evaluate histology and size of the primary testicular cancer.RESULTS: The histology of retroperitoneal mass was necrosis or fibrosis in 25 (42%) cases, teratoma in 29 (48%) and viable tumor in 6 (10%). The size of the retroperitoneal mass decreased after the chemotherapy in 62% cases; moreover negative serum tumor markers were found in 87%. Elevated values of human chorionic gonadotropin were associated with viable cells in the retroperitoneal mass (p=0.014) and, the presence of teratoma in the primary tumor may be associated with teratoma in the retroperitoneal mass histology (p=0.002). However, no other preoperative factors that predict the residual mass histology were found. Repeated resections of retroperitoneal masses were required in four patients and 9 patients died during follow-up.CONCLUSIONS: We cannot determine preoperative parameters that accurately predict the histology of retroperitoneal masses. Therefore, resection of residual retroperitoneal masses after chemotherapy in non-seminomatous germ cell tumours must be performed(AU)