Early kinetics of donor-derived cell-free DNA after transplantation predicts renal graft recovery and long-term function.

BACKGROUND: Ischemia-reperfusion injury (IRI) upon transplantation is one of the most impactful events that the kidney graft suffers during its life. Its clinical manifestation in the recipient, delayed graft function (DGF), has serious prognostic consequences. However, the different definitions of DGF are subject to physicians' choices and centers' policies, and a more objective tool to quantify IRI is needed. Here, we propose the use of donor-derived cell-free DNA (ddcfDNA) for this scope. METHODS: ddcfDNA was assessed in 61 kidney transplant recipients of either living or deceased donors at 24 h, and 7, 14 and 30 days after transplantation using the AlloSeq cfDNA Kit (CareDx, San Francisco, CA, USA). Patients were followed-up for 6 months and 7-year graft survival was estimated through the complete and functional iBox tool. RESULTS: Twenty-four-hour ddcfDNA was associated with functional DGF [7.20% (2.35%-15.50%) in patients with functional DGF versus 2.70% (1.55%-4.05%) in patients without it, P = .023] and 6-month estimated glomerular filtration rate (r = -0.311, P = .023). At Day 7 after transplantation, ddcfDNA was associated with dialysis duration in DGF patients (r = 0.612, P = .005) and worse 7-year iBox-estimated graft survival probability (ß -0.42, P = .001) at multivariable analysis. Patients with early normalization of ddcfDNA (<0.5% at 1 week) had improved functional iBox-estimated probability of graft survival (79.5 ± 16.8%) in comparison with patients with 7-day ddcfDNA ≥0.5% (67.7 ± 24.1%) (P = .047). CONCLUSIONS: ddcfDNA early kinetics after transplantation reflect recovery from IRI and are associated with short-, medium- and long-term graft outcome. This may provide a more objective estimate of IRI severity in comparison with the clinical-based definitions of DGF.

Impact of robotic-assisted kidney transplantation on post-transplant infections: a case-control study.

BACKGROUND: The aim of this study was to determine the differences in the incidence, epidemiology, clinical characteristics and risk factors of infections in living donor kidney transplant recipients using robotic-assisted kidney transplantation (RAKT) and open approach. METHODS: We conducted a retrospective observational study from January 2016 to December 2019. For the risk factor analysis, a matched case-control study (1:1 ratio) was performed (robotic vs open). Control subjects were matched for living donor and time of transplantation. The data included de novo immunosuppressive regimen, delayed graft function, urological complications, acute allograft rejection and incidence, clinical features, microbiological findings and outcomes of infections. RESULTS: Ninety-four RAKT and 84 controls were included. There were no differences between groups in terms of age, gender, BMI, median days of hospitalization, immunosuppressive regimen, need for surgical urologic procedures post-transplantation, presence of urinary leak or acute allograft rejection. Thirty-five percent of all recipients analyzed presented an infection, mostly asymptomatic bacteriuria (49%), symptomatic urinary tract infection (31%) and surgical site infection (10%). Pseudomonas aeruginosa was the most frequent isolated microorganism in 67%, followed by E. coli (20%), Enterococcus faecalis (17%) and Klebsiella pneumoniae (10%). Eight percent of the microorganisms were multidrug resistant. The open kidney transplantation group presented more infections compared to RAKT (43 vs 27%, p = 0.04). After multivariate analysis, need for surgical urologic procedure post-transplantation (OR 6.2, 95% CI 1.1-35), BMI ≥ 30 (OR 3.6, 95% CI 1.5-9) and acute allograft rejection (OR 3.2, 95% CI 1.2-8.5) were associated with infection, whereas RAKT (OR 0.5, 95% CI 0.2-0.9) and the use of JJ catheter (OR 0.36, 95% CI 0.17-0.72) were protective factors. CONCLUSIONS: Infection is a frequent event in patients receiving a living donor kidney transplant. Acute allograft rejection, need for surgical urologic procedure post-transplantation and BMI were associated with infection, whereas robotic surgery was a protective factor in living donor kidney transplantation.

Outcomes after 20 years of experience in minimally invasive living-donor nephrectomy.

INTRODUCTION: The transperitoneal laparoscopic approach is considered the gold standard technique for living kidney donation. Other accepted laparoscopic techniques include the retroperitoneal approach, natural orifice transluminal endoscopic surgery (NOTES)-assisted, laparo-endoscopic single-site surgery (LESS), with excellent results in the donor and graft. Many studies have compared these techniques with open ones. Our objective is to describe our experience and results in minimally invasive living-donor nephrectomies (MILDN): laparoscopic, NOTES-assisted, and LESS since their introduction in March 2002. MATERIALS AND METHODS: We conducted a retrospective observational study of donors undergoing MILDN between March 2002 and March 2020. RESULTS: A total of 714 MILDNs were performed at our centre. All were completed, except for one, because of recipient death. The conventional laparoscopic approach was used in 541 cases (75.88%), NOTES in 116 (16.9%), LESS in 55 (7.7%), and one mini open (0.14%). Two-thirds of the donors were females (478 cases). The mean donor age was 52.87 years (SD 10.93). Six donors (0.8%) were diagnosed beforehand with a small renal mass, which was removed before transplantation in bench surgery. The right kidney was removed in 17.8% of cases. Warm ischaemia time was higher in the NOTES and LESS groups. We had eight conversions. The global intraoperative and postoperative complication rates were 6.8% and 4.9%, respectively. None of the donors developed renal disease during follow-up (mean 3.68 years). Five-year recipient and graft survival rates were 98.8% and 96.8%, respectively. CONCLUSIONS: MILDN techniques are safe for donors and grafts, with low complication.

Robot-assisted kidney transplantation: update from the European Robotic Urology Section (ERUS) series.

OBJECTIVE: To report the results of the robot-assisted kidney transplantation (RAKT) experience performed in 10 European centres by members of the European Robotic Urology Section (ERUS)-RAKT group. PATIENTS AND METHODS: This is a multicentre prospective observational study of RAKT. Descriptive analysis of recipients and donor characteristics, surgical data, intraoperative outcomes, complications rate and functional results were collected and analysed. RESULTS: Between July 2015 and September 2019, 291 living-donor RAKTs were performed. Recipients were mostly male (189 [65%]), the mean Standard deviation (sd) age was 45.2 (13.35) years, the mean (sd) body mass index was 27.13 (19.28) kg/m2 , and RAKT was pre-emptive in 155 (53.8%) cases. Right and multiple arteries kidneys were used in 15.4%. The mean (sd) total surgical and re-warming time was 244 (70.5) min and 53.16 (15.27) min, respectively. In all, 17 patients presented with postoperative bleeding (5.7%). Five kidneys had delayed graft function; five (2%) were lost due to thrombosis and one due to acute rejection. Two patients had arterial stenosis, three had incisional hernias, six had ureteric stenosis, and nine had lymphoceles. Neither surgical nor re-warming times were correlated with postoperative serum creatinine levels (P > 0.05). Comparison of surgical data between the first 120 cases and the following 171 cases showed a significantly shorter total surgical time in the second group (265 vs 230 min, P = 0.005). CONCLUSIONS: This is the largest European multicentre study of RAKT with good surgical and functional results competitive with open kidney transplant series, with a relatively short learning curve when performed in centres with a wide experience in open kidney transplantation and robotic surgery.

Increasing kidney grafts for transplantation.

INTRODUCTION: The current pool of organs available for transplantation does not cover requirements, for this reason non-standard risk donors need to be incorporated into the pool. In this way, donors with small renal tumour are considered for transplantation after bench tumour excision. The aim of our study was to analyse our experience in using these grafts for transplantation. MATERIALS AND METHODS: Retrospective analysis from our prospective accrued database of donors with incidental renal mass used for kidney transplantation between January 2007 and August 2018. RESULTS: Twenty kidney transplantations were performed, thirteen cases received the affected kidney (after tumour removal) and seven the contralateral kidney; from six living and eleven deceased donors. Donor and recipient median age was 58 years (range 22-82) and 56.5 years (range 38-74), respectively. Mean tumour diameter was 12.7 mm (SD 9.5). Tumours resulted in two benign lesions and fifteen renal cell carcinoma. Surgical margins were negative. Two cases presented with bleeding after reperfusion was solved without repercussion. One case presented with immediate vein thrombosis. None of them present delayed graft function. After a 69 month follow-up none of the donors or the recipients presented tumour recurrence. CONCLUSIONS: Kidneys with small incidental tumours seem to be a good option for kidney transplantation in selected patients after bench surgery excision with good functional and oncologic results. More studies and longer follow-up are needed to confirm these results.

Accuracy of Transvaginal Ultrasound Compared to Cystoscopy in the Diagnosis of Bladder Endometriosis Nodules.

OBJECTIVES: To evaluate the accuracy of transvaginal ultrasound (TVUS) in predicting detrusor infiltration and ureteral meatus involvement in patients with bladder endometriosis (BE) to select which cystoscopic procedures could be avoided and, secondarily, to assess the relationship between symptoms and the characteristics of nodules and the association of BE with other forms of endometriosis. METHODS: Patients with BE diagnosed by TVUS were classified according to detrusor infiltration: BE with partial involvement of the muscular layer (group 1) and total muscular layer involvement with bladder protrusion (group 2). We analyzed the accuracy of TVUS compared with subsequently performed cystoscopy, the correlation with symptoms, and the association with other forms of endometriosis. RESULTS: Among the 22 patients included, TVUS showed 9 patients with BE nodules partially affecting the detrusor (group 1) with normal cystoscopic findings (TVUS negative predictive value, 100%). Transvaginal ultrasound detected 13 nodules with total involvement, all visible by cystoscopy (TVUS positive predictive value, 100%). Transvaginal ultrasound also identified ureteral orifices that were free of involvement at greater than 10 mm from the BE nodule in 21 of 22 women (TVUS sensitivity, 95%). Ultrasound criteria for adenomyosis and endometriosis in other locations were present in 20 of 22 patients. CONCLUSIONS: Transvaginal ultrasound can identify the infiltration of BE nodules in the bladder wall and predict cystoscopic findings with great accuracy. Nodules that partially affect the muscular layer have normal cystoscopic findings, thereby obviating the need for this procedure. Bladder endometriosis nodules are commonly associated with other forms of endometriosis and do not usually affect the ureteral meatus.

Orthotopic Renal Transplantation: Indication, Technique and Outcomes.

PURPOSE OF REVIEW: Nowadays many ESRD patients awaiting kidney transplantation have known unsuitable iliac vessels for vascular anastomosis, due to severe atheromatosis, occupied iliac fossa, or other uncommon vascular abnormalities. In these cases, orthotopic kidney transplantation (OKT) could be the solution. RECENT FINDINGS: Since the update on OKT published in 2010, no more large series have been reported. Some small series or case reports being described in the literature. The orthotopic position has shown good recipient and graft results with acceptable complication rate in selected patients. This technique permits the possibility of kidney transplantation, in patients unfit for heterotopic kidney transplantation (HKT), and consequently the avoidance of the dialysis treatment. In this paper, we review what is new in the literature, analyzing indications, technique, and results of this surgical approach.

An mTOR-inhibitor-based protocol and calcineurin inhibitor (CNI)-free treatment in kidney transplant recipients from donors after cardiac death: good renal function, but high incidence of conversion to CNI.

Donor after cardiac death (DCD) grafts have excellent survival despite the high incidence of delayed graft function (DGF). We assessed the feasibility of a mammalian target of rapamycin inhibitor (mTOR-I) protocol in uncontrolled DCD kidney transplantation and compared it with brain-dead donor (DBD) transplantation under calcineurin inhibitor (CNI) treatment. This retrospective study (2002-2011) included 109 Maastricht category II DCD patients and 218 standard-criteria DBD as controls. Immunosuppression consisted of polyclonal antibody induction, mycophenolate mofetil, prednisone, and mTOR-I (starting on day 6) in the DCD group and tacrolimus in the DBD group. DGF occurred in 72.5% of the DCD group vs. 26.1% of the DBD group (P = 0.001). Patient survival at 1 year was 99.1% vs. 95.9% (P = 0.112), and graft survival was 89% vs. 92.2% (P = 0.253). Patient survival at 5 years was 85.3% vs. 90.1% (P = 0.340) and graft survival was 85.5% vs. 78.8% (P = 0.166). During the first year, 46.8% (n = 51) of DCD patients were converted to CNI therapy. Serum creatinine at 1 year was 1.5(1.26-2) mg/dl vs. 1.4(1.16-1.8) mg/dl (P = 0.078). At 1 year, the acute rejection rate was 7.3% vs. 12.5% (P = 0.766). mTOR-I-based therapy was not associated with inferior graft function or higher rejection rates than standard CNI therapy. DCD kidney transplantation with an mTOR-I-based protocol is feasible but is associated with a high conversion rate to CNI-based therapy.

Prior Lubrication of the Urethra Does Not Reduce Pain Perception in Men Undergoing Flexible Cystoscopy.

OBJECTIVE: The study aimed to test the hypothesis that the instillation of lidocaine gel does not reduce the pain related to flexible cystoscopy. MATERIAL AND METHODS: A prospective randomized study was designed to compare the pain perception between intraurethral instillation of lidocaine gel and saline solution in flexible cystoscopy. One hundred consecutive male patients attending for flexible cystoscopy were randomized to receive 10 ml of lidocaine gel or 10 ml of saline solution. Saline solution was also used for the irrigation pressure. Patients recorded their pain on a 10 cm Visual Analog Scale before and after the procedure. Patients also assessed whether the cystoscopy was more painful than the previous one. Statistical comparison was made using the t test for parametrical data and the Mann-Whitney U test for non-parametrical data. RESULTS: Mean pain score in the lidocaine group was 0.67 ± 1.11 cm (range 0-5) compared to 0.55 ± 1.10 cm (range 0-5) in the saline solution group. Pain perception did not differ significantly between the 2 groups (mean difference 0.12 cm, 95% CI -0.32 to 0.55, p = 0.40). CONCLUSIONS: Prior lubrication of the urethra does not reduce the pain produced during flexible cystoscopy. The introduction of flexible cystoscopes under direct vision and with an irrigation pressure might guarantee sufficient comfort and the lubricant gel instillation could be avoided.

The role of cystectomy in elderly patients - a multicentre analysis.

INTRODUCTION: Life expectancy in developed countries is continuously increasing. Hence elderly patients are becoming more common in our clinical practice. Currently, one of the greatest challenges of medicine is balancing the life expectancy of elderly patients against aggressive treatments that carry significant risks. OBJECTIVE: To outline the complications and survival in surgical patients 80 years and over undergoing radical cystectomy for bladder cancer. PATIENTS AND METHODS: A review of a radical cystectomy in elderly recorded in four different institutional prospective databases during the period between 1991 and 2014. Clinical and pathologic features, complications and survival were evaluated. RESULTS: A total of 111 patients were available. Median (range) age 82.2 (80-89) years. Seventeen women and 94 men. Regarding the ASA score, 6 patients were ASA I, 47 patients were ASA II, 49 patients ASA III and 9 ASA IV. Prior to surgery, 48 patients had hydronephrosis. The median (range) creatinine series was 1.1 (0.71-11.1) ng/dL. In 88 cases an ileal conduit was performed, 17 a cutaneous ureterostomy diversion, 5 neobladders and 1 ureterosigmoidostomy case. The median (range) operative time was 230 (120-420) min and a total of 97 patients required blood transfusion. The median (range) hospital stay was 14 (7-126) days. The early and late complication rates were 50.4% and 32%, respectively. A total of 14 patients (12.6%) required surgical reintervention. Eight patients (7.2%) died in the immediate postoperative period. The readmission rate of the series was 27.2%. The mean follow-up of the series was 18 (0.27-134.73) months. During this period 66 patients died, 52 of them due to the tumor. Twelve month tumour progression free survival was 83.9% for ≤pT1, 70.2% for pT2 and 36% for ≥pT3, respectively. Twelve month cancer specific survival was 85.6% for ≤pT1, 75.1% for pT2 and 42.5% for ≥pT3, respectively. CONCLUSION: Radical cystectomy in elderly population is an aggressive surgical treatment with a significant complication rate, hospital readmission and perioperative mortality rate. Careful selection of patients is essential in order to minimize the complications of this surgery and balance benefits against risks in the elderly population. Tumour progression and cancer specific survival are poor for patients with ≥pT3 disease. Alternatives such as tri-modality therapy need to be considered within a multi-disciplinary approach. More data is required to determine which sub-groups of elderly patients would benefit from a complication, survival and quality of life perspective.

Perioperative outcome and female sexual function after laparoscopic transvaginal NOTES-assisted nephrectomy.

PURPOSE: There is a concern about the impact that this surgery could have on a patient's sexuality, although this has not been well documented. The objective of our study is to describe the surgical results and assess sexual function and patient satisfaction after transvaginal NOTES-assisted laparoscopic radical and living donor nephrectomy. METHODS: Between March 2008 and October 2014, 100 women underwent transvaginal NOTES-assisted nephrectomy (78 living donor and 22 radical nephrectomy) in our centre. The procedure was performed using two different techniques depending on the indication as described previously, but using the same vaginal approach. Variables evaluated were operative time, blood loss, intra-operative complications, hospital stay, satisfaction, first-month creatinine and warm ischaemia time in donors. Sexual function was assessed with the Female Sexual Function Index questionnaire before and after surgery. All variables were accrued in a prospective database. RESULTS: The procedure was completed in all cases. Mean age and body mass index was higher in the radical nephrectomy group. Mean operative time and hospital stay were similar for both techniques. All sexually active women reported unaltered sexual function after surgery and satisfaction with the results. The pre- and post-FSFI scores for living donor (n = 54) and radical nephrectomy (n = 4) were 27.47 ± 1.02/27.27 ± 1.10 (p > 0.05) and 31.17 ± 0.81/31.87 ± 0.97 (p > 0.05). CONCLUSIONS: Transvaginal NOTES-assisted or hybrid NOTES nephrectomy offers a safe technique with excellent cosmetic results and no sexual effect. Despite promising results, randomized controlled studies with longer follow-up are warranted to further elucidate the potential of this novel technique.

Air cystoscopy is superior to water cystoscopy for the diagnosis of active hematuria.

PURPOSE: We evaluated the clinical use of air cystoscopy, including its possible advantages and disadvantages over water cystoscopy. MATERIALS AND METHODS: Two independent observers prospectively studied consecutive patients who underwent water cystoscopy first and then air cystoscopy at our center from May to September 2012. The indication for rigid cystoscopy in the operating room was noted independently by either observer. Findings after rigid cystoscopy were correlated with the results of flexible water and air cystoscopy using the Pearson correlation and Student t-test. RESULTS: Included in the study were 57 patients with active hematuria, of whom 36 had bladder cancer, and 257 with a history of bladder tumor. The cause of bleeding was clearly identified on water cystoscopy in 22 patients (38%), including tumors in 17 and prostate bleeding in 5, and by air cystoscopy in 49 (86%), including tumors in 32 and prostate bleeding in 17. For diagnosing bladder tumors air cystoscopy had higher sensitivity than water cystoscopy (88% vs 47%, p=0.003) and similar specificity (97% vs 100%, p=0.93). In the 295 patients without hematuria there was no difference in the indication compared to that identified on rigid cystoscopy (43 vs 43, p=1.0). Water cystoscopy revealed more small papillary tumors than air cystoscopy but the number was not significantly different (76 vs 67, p=0.26). All such implants identified on water cystoscopy alone were less than 2 mm. No complication specifically related to air cystoscopy was noted. CONCLUSIONS: We found no statistical difference between water and air cystoscopy in patients without hematuria. Air cystoscopy had higher sensitivity and specificity for diagnosing active hematuria while adding almost no specific complications to the procedure.

Recent advances of natural orifice transluminal endoscopic surgery in urological surgery.

Natural orifice transluminal endoscopic surgery designates a surgical procedure that utilizes one or more patent natural orifices of the body with the intention to puncture a hollow viscera in order to enter the abdominal cavity. First carried out at the beginning of the 2000s in experimental models, it can be considered the natural evolution of laparoscopy towards the ideal of scarless surgery, as the avoidance of a large abdominal scar is associated with better cosmetic results and better recovery. However, the technology currently available does not allow the performance of complete pure natural orifice transluminal endoscopic surgery procedures. The surgical tools used are not specially designed for this approach, so difficulties in retracting organs, bleeding control and clashing of instruments are the main obstacle surgeons face. For this reason, the current available technique is the so-called hybrid approach, where a natural orifice approach is combined with some abdominal trocars, using the natural orifice as the exit door for the specimen removal. As not many comparative studies have been published evaluating the advantages of natural orifice transluminal endoscopic surgery in front of traditional laparoscopic surgery, a review of the history of natural orifice transluminal endoscopic surgery, and an assessment of the available evidence of this technique regarding renal and urological pelvic surgery are performed in this article.

[Is LESS/NOTES surgery the new gold standard of minimally invasive surgery?]. / ?Es la cirugía LESS o NOTES el nuevo "gold standard" de la cirugía mínimamente invasiva?

Over the last 20 years surgery has suffered a dramatic change. We saw how open surgery was almost replaced by laparoscopic surgery and this latter has evolved to minimally invasive surgical techniques such as LaparoEndoscopic Single-site Surgery (LESS) and NOTES ((Natural Orifice Transluminal Endoscopic Surgery). These minimally invasive operations try to maximally reduce the size and number of abdominal scars in order to minimize morbidity, reducing surgical aggression and therefore the need for analgesia during the postoperative period, and they offer excellent cosmetic results. LESS surgery implies the performance of intra-abdominal surgery through a single 3-4 cm incision, through which laparoscopic instruments are introduced. This may be considered the next step in the evolution of laparoscopic surgery advancing to the ideal of scarless surgery. This modality is having great acceptance, since it allows the insertion of an extra trocar at any time transforming it in conventional laparoscopic surgery. Furthermore, when performing the incision within the umbilical scar, it enables concealing the incision in it at the end of the operation, achieving very good cosmetic results. NOTES surgery would be another step forward. Pure NOTES techniques in the field of Urology are very complex to perform today with the available equipment. Hybrid NOTES and assisted NOTES are variations described which have demonstrated they are viable and offer very good cosmetic results and lower morbidity. Regarding this, the vaginal approach offers a good working channel that can also be used for specimen extraction. Recent published studies confirm the feasibility and reproducibility of both techniques in urologic surgery, specifically in the treatment of renal cancer, with comparable results to conventional laparoscopic surgery.

Risk factors for irreversible unilateral loss of renal function in patients with deep endometriosis.

Deep endometriosis (DE) can be more aggressive than other types of endometriosis, and may even lead to irreversible severe complications such as complete unilateral loss of renal function. We aimed to describe the clinical and radiologic characteristics of DE patients diagnosed with irreversible unilateral loss of renal function due to unilateral ureteral stenosis and evaluate risk factors for developing this loss. This retrospective cohort study included 436 patients who underwent laparoscopic DE surgery. We evaluated two groups of patients according to preserved (Non-Renal Loss Group; n = 421) or irreversible unilateral damaged renal function (Renal Loss Group; n = 15). Preoperative epidemiologic variables, clinical characteristics, radiologic findings and surgical treatments of all the patients were collected. The Renal Loss Group had a higher infertility rate and a higher proportion of asymptomatic patients. The following radiological variables showed statistically significant differences between the two groups: mean endometrioma diameter, the presence of intestinal DE and negative sliding sign. Multivariate analysis showed that infertility, being asymptomatic, having intestinal DE or torus uterinus/uterosacral ligament DE and a negative sliding sign significantly increased the risk of loss of renal function. Therefore, among patients with these clinical and/or radiological variables, severe urinary tract obstruction should be specifically ruled out.

Living donor-gifted allograft lithiasis: surgical experience after bench surgery stone removal and follow-up.

This study presents the surgical experience and long-term outcomes of living donor kidney transplantations involving asymptomatic kidney stones, using ex vivo flexible ureterorenoscopy (f-URS) during bench surgery for stone removal. Out of 1743 living kidney donors assessed between January 2012 and October 2022, 18 (1%) were diagnosed with urolithiasis. Among them, 12 donors were rejected, and 6 were accepted for kidney donation. Stone removal was successfully performed using f-URS during bench surgery, with no immediate complications or acute rejections observed. The study analyzed six living kidney transplants, of which 4 (67%) donors and three recipients were female, and 4 (67%) donors were blood-related to the recipient. The median age for donors and recipients was 57.5 and 51.5 years, respectively. The stones, primarily located in the lower calyx, had a median size of 6 mm. The median cold ischemia time during surgery was 41.6 min, and ex vivo f-URS ensured complete stone removal in all cases. After a median follow-up of 120 months, the remaining grafts were functioning well, and no urinary stone recurrence was observed in either the recipients or living donors. The findings suggest that bench f-URS is a safe approach for managing urinary stones in kidney grafts, providing good functional outcomes without stone recurrence in selected cases.

Low testosterone levels are related to poor prognosis factors in men with prostate cancer prior to treatment.

UNLABELLED: What's known on the subject? and What does the study add? Prostate growth is ruled by testosterone. Nevertheless, the paradigm that high testosterone levels induce prostate cancer development or lead to a poor prognosis in prostate cancer is not supported by evidence. A growing number of studies suggest that, on the contrary, low testosterone levels are related to poor prognosis features in prostate cancer such as higher prostate-specific antigen or higher Gleason score. Our experience shows that testosterone levels are related to risk of progression of prostate cancer - those men with lower testosterone levels are at higher risk of progression of their prostate cancer after treatment delivery. OBJECTIVES: • Low testosterone levels have been related to a higher diagnosis of prostate cancer (PCa). Hormonal levels have been related to poor prognosis factors in men with PCa, mainly after radical prostatectomy. • Our aim was to determine the relationship between hormonal levels and PCa prognosis factors in men with PCa prior to the onset of treatment. PATIENTS AND METHODS: • We prospectively analysed 137 males diagnosed in our centre with PCa with 5+5 core prostate biopsies from February 2007 to December 2009. • As part of our clinical protocol, we performed hormonal determination (testosterone and sex hormone binding globulin) following International Society of Andrology, International Society for the Study of the Aging Male and European Association of Urology recommendations. • Free testosterone and bioavailable testosterone were calculated using Vermeulen's formula. • Age, prostate-specific antigen (PSA), free to total PSA, PSA density, number of previous biopsies, digital rectal examination staging, Gleason score, percentage of tumour in the biopsy sample, bilaterality of the tumour and risk of progression group were prospectively recorded. RESULTS: • Higher testosterone levels were related to lower digital rectal examination staging (P= 0.02) and lower PSA level (P= 0.05). Higher testosterone was not related to lower Gleason score (P= 0.08). • Testosterone was inversely related to PCa bilaterality (P < 0.01) and percentage of tumour in the biopsy (P < 0.01). • High testosterone levels were found in patients allocated to the low risk of progression group and inversely (P= 0.03). • In multivariate analysis, higher age and lower testosterone were related to higher D'Amico risk of progression. CONCLUSION: • Patients with PCa and lower testosterone levels have poor prognosis factors and higher tumour burden before treatment onset. These findings reinforce the idea that low testosterone levels pretreatment are related to a poor prognosis in PCa.

Low testosterone level predicts prostate cancer in re-biopsy in patients with high grade prostatic intraepithelial neoplasia.

UNLABELLED: What's known on the subject? and What does the study add? High grade prostatic intraepithelial neoplasia (HGPIN) is a risk factor for prostate cancer (PCa), but only multifocality is an indication for early rebiopsy. Other risk factors for PCa development from HGPIN remain unknown. PCa is related to testosterone. Testosterone has been proven to be linked to PCa detection and poor prognosis PCa. This study shows that low free and bioavailable testosterone levels are associated with an increased risk of PCa in a rebiopsy after HGPIN diagnosis. Men with low testosterone levels and HGPIN could therefore be considered a high-risk cohort for developing PCa. OBJECTIVE: To determine the relevance of the hormonal profile of patients with high grade prostatic intraepithelial neoplasia (HGPIN) and its relationship to prostate cancer (PCa) in rebiopsy. PATIENTS AND METHODS: We prospectively analysed 82 consecutive patients with a diagnosis of HGPIN without PCa in a prostate biopsy between September 2007 and December 2009. Of these 82 patients, 45 underwent rebiopsy and their hormonal profile was determined (testosterone and sex hormone-binding globulin [SHBG]) as part of our clinical protocol. Patient age, PSA level, prostate volume, PSA density, testosterone, free testosterone, bioavailable testosterone and SHBG were recorded prospectively. A comparative study between those patients with a positive rebiopsy and those with a negative rebiopsy was performed. RESULTS: We found that free testosterone (P = 0.04), bioavailable testosterone (P = 0.04) and SHBG (P = 0.02) were significantly associated with a positive rebiopsy. Other variables such as age (P = 0.745), PSA level (P = 0.630), prostate volume (P = 0.690), PSA density (P = 0.950), testosterone (P = 0.981) and prostatic intraepithelial neoplasia multifocality (P = 0.777) were not associated with the presence of adenocarcinoma in the rebiopsy. CONCLUSIONS: Patients with adenocarcinoma of the prostate after a diagnosis of HGPIN have higher SHBG levels and lower calculated free testosterone levels than patients with a negative rebiopsy. Testosterone levels might be a useful indication for rebiopsy after HGPIN diagnosis.

Low testosterone bioavailability is related to prostate cancer diagnose in patients submitted to prostate biopsy.

INTRODUCTION: Relationship between prostate cancer (PCa) and testosterone (T) is controversial. Conflicting evidence has been published about T levels and development of PCa. AIM: (1) To determine the relationship between hormone levels and the diagnosis of PCa. (2) To specifically focus on the relationship between PCa and T in men classified as biochemically hypogonadal. MATERIALS AND METHODS: Prospective analysis of 1,000 transrectal ultrasound guided prostate biopsies (5 + 5 cores biopsies) between September 2007 and January 2010 in one center. Indication for prostate biopsy was suspicion of PCa on the basis of elevated prostate-specific antigen (PSA) and/or digital rectal examination (DRE). Serum testosterone and sex hormones binding globulin (SHBG) were determined in these patients. Of 557 men, the data were sufficient for further analysis. Age, body mass index (BMI), smoking/drinking habits, PSA, free PSA, PSA density, prostate volume, number of previous biopsies, DRE, and hormone levels were prospectively recorded. RESULTS: No relationship was found between T and PCa (449 ± 167 ng/dL in PCa versus 437 ± 169 ng/dL in non-PCa). SHBG was significantly higher in patients with PCa (51 ± 27 ng/dL in PCa vs. 44 ± 18 ng/dL in non-PCa). In hypogonadal men, T levels correlated with the PCa (235 ± 95 ng/dL in men with PCa versus 270 ± 58 ng/dL in men without PCa, P = 0.004). CONCLUSIONS: T levels were comparable in men with and without PCa, but SHBG levels were significantly higher in men with PCa. In men with low T, the men with PCa had a lower serum T levels and a lower prostate volume than the men without PCa.

Quality of life of multiple sclerosis patients: translation and validation of the Spanish version of Qualiveen.

PURPOSE: Up until now there were no specific questionnaire translated into Spanish for evaluating urinary disorder specific health-related quality of life (HRQoL) associated with multiple sclerosis (MS). Qualiveen is recommended by the European Association of Urology guidelines as a tool for evaluating neurogenic lower urinary tract dysfunction. The objective was to translate the Qualiveen into Spanish, adapt it cross-culturally and validate it against the currently available tools. MATERIALS AND METHODS: A bidirectional translation of Qualiveen was undertaken by professional translators. One hundred two Spanish MS patients were sent the Qualiveen and the ICIQ-SF questionnaires twice within a month. The questionnaires were sent and received by mail and reviewed when the patients came for the scheduled visit. RESULTS: Eighty-one patients participated. The validation study showed that the Spanish version of Qualiveen has good internal consistency with Cronbach's coefficient superior to 0.80 for all the questionnaire's subdomains and also for the entire Qualiveen demonstrating high discriminative power. Also the test-retest analysis proved internal stability of the Qualiveen (kappa coefficient between 0.81 and 0.89). Finally, all the Qualiveen scores correlated with the ICIQ-SF final score. CONCLUSIONS: The Spanish version of Qualiveen functions similarly to the English language version retaining its discriminating power. It has shown it could be a valid instrument for discriminating between patients in a cross-sectional survey, as well as for measuring within subject changes over time thus evaluating the extent to which MS patients' HRQoL is impaired by urinary-related problems.