Value of Prostate-Specific Antigen Kinetics in Patients with Low-Risk Prostate Cancer under Active Surveillance.

INTRODUCTION: This study analyzes the value of PSA kinetics, PSA speed (vPSA), and PSA doubling time (PSAdt), in patients with low-risk prostate cancer who are in an active surveillance (AS) program. METHODS: An observational, retrospective, and longitudinal study of a sample of 86 patients included in AS program between January 2014 and October 2021 was conducted. A review of their medical records was performed, and PSA kinetics were calculated, analyzing the causes of discontinuation of the AS program and its relationship with PSA kinetics. RESULTS: The mean age was 63.39 years, and the median follow-up was 62.55 months. The mean PSA at diagnosis was 8.27 ng/mL. A median of PSAdt of 62.55 months and 1.3 ng/mL/year for vPSA was obtained. 35 patients left the program, with a higher percentage of patients leaving with a PSAdt less than 36 months (73.7 vs. 31.1%) and a vPSA greater than 2 ng/mL/year (68.2 vs. 31.3%). The probability of permanence and the time of permanence in AS were statistically significantly higher for those patients with favorable kinetic parameters. CONCLUSION: PSA kinetics is a parameter to take into account when making decisions to keep patients in an AS program.

Cost-Effectiveness of a Sublingual Bacterial Vaccine for the Prophylaxis of Recurrent Urinary Tract Infections.

INTRODUCTION: Recurrent urinary tract infections (rUTIs) affect 5-10% of women, resulting in an enormous healthcare and society burden. Uromune® is a polybacterial sublingual vaccine with an excellent clinical benefit in rUTI prophylaxis. This study assesses the impact of sublingual vaccination on healthcare resource use and expenditures associated with this pathology. METHODS: A quasi-experimental, pretest-posttest, single center study including women with rUTI and vaccinated with Uromune® in real-life clinical practice was performed. Variables were the need of healthcare resources, collected prospectively during two follow-up years, and the rUTI-associated expenditure, calculated using the micro-costing methodology; these were compared before and after vaccination. RESULTS: A total of 166 women {mean (standard deviation [SD]) urinary tract infection episodes/year 6.19 (2.15)} were included. After vaccination, annual consultations with a primary care physician (PCP) (43.9%), emergency room visits (71.8%), urinary analysis (90.0%), and ultrasound exams (35.6%) decreased compared to pre-vaccination (all p < 0.001). Per patient consumption in antibiotics, PCP consultations, emergency room visits, and complementary exams significantly decreased (all p < 0.02), resulting in a reduction in healthcare expenditure per patient/year from mean (SD) 1,001.1 (655.0) to 497.1 (444.4) EUR. CONCLUSION: Sublingual bacterial vaccination with Uromune® decreased healthcare resource use and associated expenditure in women with rUTI, representing an optimal strategy to reduce rUTI-associated healthcare and economic burden.

Analysis of the Efficacy of a Sublingual Bacterial Vaccine in the Prophylaxis of Recurrent Urinary Tract Infection.

OBJECTIVES: Recurrent urinary tract infections (R-UTIs) are very common amongst women, and alternatives to antibacterial prophylaxis are necessary. This study evaluates the effectiveness of a sublingual bacterial vaccine for the prophylaxis of R-UTIs. METHODS: We conducted a quasi-experimental pretest-posttest study of 166 women diagnosed with R-UTIs. Both before and after the start of treatment with the vaccine, we analysed the total number of R-UTI episodes, the urine culture results, and the type and number of antibiotic packages consumed. Symptoms and urine cultures were evaluated 3, 6, 9, 12, 18, and 24 months after initiating treatment with the vaccine. RESULTS: The mean time of follow-up after vaccination was 1.7 years. After vaccination, there was a 54.6% reduction in episodes of UTI, and a 56.2% reduction in positive urine cultures. At 3 months, 74.4% of the patients had no R-UTI, the rate falling to 68.1% at 6 months, 52.4% at 12 months, and 44.5% at 24 months. The cumulative probability of maintaining negative urine cultures was 76% at 3 months, 37% at 12 months, and 18% at 2 years. CONCLUSIONS: The use of a sublingual bacterial vaccine for the prophylaxis of R-UTIs in women is an effective treatment that contributes to a reduction in the number of UTI episodes.

Tubulocystic renal carcinoma (low grade collecting duct carcinoma).

OBJECTIVE: To report a case of tubulocystic renal carcinoma diagnosed in an adult, after a work up study for hematuria. METHODS/RESULTS: 59-year-old male, CT scan was performed during a study for self-limited hematuria showing a 4.2 cm solid mass with areas suspicious of pseudocystic malignancy. Due to its debut with hematuria and renal sinus involvement laparoscopic radical nephrectomy was performed, establishing the diagnosis of tubulocystic carcinoma (low grade collecting duct carcinoma). CONCLUSION: Tubulocystic carcinoma presents histological characteristics and a natural history that makes it different from the classic type of Bellini duct carcinoma, the latter being a rapidly growing tumor with poor prognosis which is usually diagnosed in advanced stages.

Adrenal ganglioneuroma.

OBJECTIVE: To present one case of adrenal ganglioneuroma incidentally diagnosed in an adult. METHODS/RESULTS: 44-year-old woman with a 2.3 cm incidentaloma in the left adrenal gland diagnosed by CT scan. At 6 months, MRI was performed and a left adrenal nodule 3.7 cm was shown. Due to the progressive growth of the mass, surgery was indicated and left laparoscopic adrenalectomy was carried out. The final pathologic diagnosis was adrenal ganglioneuroma. CONCLUSIONS: The ganglioneuroma is a tumor composed of Schwann cells and ganglion cells. Its location in the adrenal gland is unusual, most frequently affecting other regions. Being asymptomatic lesions, they are often detected incidentally when performing imaging tests. There are radiological features that differentiate them from other adrenal masses. The treatment of choice is surgery, with adrenalectomy.

Supernumerary testicle: case report and bibliographic review.

OBJECTIVE: We report a case of supernumerary testis, a rare anomaly with only around 100 cases reported in the literature. METHODS: We describe the case of a 26-year-old man who consulted for a left paratesticular tumor. Physical examination and ultrasound showed a 2-cm nodular lesion over the left epididymis. The lesion was confirmed as supernumerary testis by surgical examination and biopsy and was subsequently excised, given the malignancy potential. RESULTS: The supernumerary testis was evaluated using two standard classifications, one assessing function and embryological development, and the other assessing topography, anatomy, and reproductive potential. CONCLUSIONS: The differential diagnosis for an intrascrotal mass should include the possibility of a supernumerary testis; hence, surgical examination and biopsy are necessary. Supernumerary testes should be excised in the case of pain, dysplasia, or in situ carcinoma, or whenever the biopsy is inconclusive.

Prognostic Value of the Neutrophil/Lymphocyte Ratio in Squamous Cell Carcinoma of the Penis.

INTRODUCTION: To determine the predictive role of the neutrophil/lymphocyte ratio (NLR) in the prognosis and survival of patients with squamous cell carcinoma of the penis. MATERIALS AND METHODS: A retrospective cohort study of 96 patients with squamous cell carcinoma of the penis (SCCP). Clinical and histological data, bloodwork and disease evolution information were collected. We determined neutrophil/lymphocyte ratios and analyzed their relationship to prognosis and survival. RESULTS: The mean age of patients was 72,1 years. The average follow-up time for the sample was 3,8 years (CI 95%: 3,0-4,6). Compared to patients with NLR <3, those with NLR >3 presented a higher proportion of cancers in stages cN1 (29.7% vs 6.8%; p = 0,004), stages pT3 and pT4 (24,3% vs 9,5%; p = 0,05), and stages TNM III and IV (32,4% vs 10,2%; p = 0,01); additionally, there were more cases of perineural invasion in the NLR >3 patients (29,7% vs 10,2%; p = 0,03). The mean overall survival (OS) was 7,9 years (CI 95%: 6,2-9,6) and the cancer-specific survival (CSS), 1,3 years (CI 95%: 0,7-1,9). There were no differences in OS, CSS or in progression-free survival (PFS) in patients with NLR >3 compared to those with NLR <3 . However, in the Cox regression analysis, a higher NLR was independently associated (along with metastasis and need for adjuvant treatment) with lower PFS, with an HR: 1,27 (CI 95%: 1,02-1,57; p = 0,02). CONCLUSIONS: The utilization of NLR in clinical practice can be considered an additional tool to aid in the diagnosis and prognosis of patients with squamous cell carcinoma of the penis.

Vaginal metastasis of a clear renal cell carcinoma.

OBJECTIVE: Remember that kidney cancer is a disease whose incidence is increasing due to increased use of additional imaging tests, which is changing the way of diagnosis, making the classic clinical syndrome synonymous with advanced illness. METHODS: We report the case of a patient with a right renal tumor with renal vein involvement that in the natural course of the disease showed a vaginal metastasis of clear renal cell carcinoma, which was treated with surgical excision. RESULTS: This case is a clear example of how unpredictable is the clinical evolution of this disease and how little we know about the way of dissemination. CONCLUSIONS: Local excision, with or without radiotherapy, or radiotherapy alone are recommended in cases of unique metastasis after nephrectomy.

46,XX T testicular disorder of sex development. Case report.

OBJECTIVE: We present a case of X-Y translocation with male phenotype (46,XX testicular disorder of sex development) and review the literature. METHODS: Disorders of sex development with mismatch of genetic, gonadal and phenotypic sex are quite rare, and some are due to genetic or chromosomal abnormalities. The karyotype was investigated by a cytogenetic study of peripheral blood (phytohemagglutinin-timulated lymphocyte culture over 72 hours). G-banding analysis of 25 metaphases showed a 46,XX chromosome constitution (46 chromosomes with XX sexual composition). Fluorescence in situ hybridization (FISH) analysis with probes for X centromeres and the sex-determining region of the Y chromosome (SRY) (testis-determining factor gene) showed two X chromosomes. The analysis also showed the SRY signal in the telomeric region of the short arm of one of the chromosomes. RESULTS: In recent years, a number of other genes involved in disorders of sex development in animals and humans have also been identified. Genetic defects in the peptide hormone receptors, members of the steroid receptor superfamily, and other transcription factors, as well as any of a series of enzymes and cofactors involved in steroid biosynthesis can cause abnormal determination and differentiation. CONCLUSIONS: Although chromosomal abnormalities are rarely present in patients with apparently normal external genitalia, they should be considered in urology consultations by adolescents and adults, particularly in the investigation of gynecomastia or infertility.

Tumor inside an inguinoscrotal bladder hernia.

OBJECTIVE: To describe two cases of urothelial tumors in inguinoscrotal bladder hernias and comment on the low incidence of this condition. METHODS: Two patients were diagnosed and treated by partial cystectomy and hernia repair. RESULTS: The clinical outcome of both patients was good at two and three years, respectively, and neither patient experienced hernia or tumor recurrence. CONCLUSIONS: Inguinal bladder hernias are relatively common. However, few reports of tumor in the herniated bladder have been published. Treatment consists of tumor removal, hernia repair and treatment of any associated urethroprostatic condition.

Primary retroperitoneal tumors: review of our 10-year case series.

OBJECTIVES: To investigate our case series of patients with primary retroperitoneal tumors over the past 10 years, analyzing clinical symptoms, diagnostic tests, tumor pathology, surgical data, concomitant cancer treatments, recurrence and survival rates. METHODS: Retrospective analysis of 37 patients with primary retroperitoneal tumors diagnosed at our hospital over the past 10 years. RESULTS: Computed tomography (CT) was the imaging technique used most often and the most accurate. Tumors were malignant in 83% of patients and benign in 17%. Complete tumor resection was performed in 73% of cases; the most common approach was midline laparotomy. Neighboring organs were also removed in 51.8% of cases in which radical resection was performed. The recurrence rate was 45% in patients who underwent surgery. Median time to onset of recurrence following open surgery was 23 months. Repeat resection was performed in 66% of cases with recurrence. Five-year survival following total resection of malignant tumors was 44%. The mean patient survival after repeat resection was 9.8 months. CONCLUSIONS: Primary retroperitoneal tumors are rare and usually malignant. Surgery is the treatment of choice and complete tumor resection is the main factor that determines prognosis.

[Urology clinics referral Patterns after initiation of a Primary Care BPH-LUTS protocol.] / Evolución de las derivaciones desde atención primaria a la consulta de urología tras la aplicación de un protocolo de pacientes con síntomas del tracto urinario inferior por hiperplasia benigna de próstata.

OBJECTIVE: In the Spanish health system, General Practitioners (GPs) play a key role in regulating the flow of patients to hospital care. Most of patients with BPH can be managed through out the evolution of the disease exclusively by the GPs.  METHODS: A pre-experimental study was carried outin two periods, before (pre-test) and after (post-test) of the dissemination of a management protocol for patients with BPH. The protocol was trialled in the health area of Villarrobledo and included all referrals to the urology clinic for BPH from Primary Care. We analyzed the appropriate referrals according with the criteria set for thin the protocol and compared the complementary tests through statistical study (descriptive, a bivariate, multivariate analysis and rate calculation) using version 21of the SPSS. RESULTS: Referral rate decreased after the application of the protocol but did not increase the rate of appropriated referrals. Patients referred after setting forth protocol by GPs that assisted to the education program were younger. There were referred less patients with elevated PSA and more patients with clinical progression. These GPs used less test to achieve diagnosis. The GPs whodid not attend were significantly younger, mainly women, with no previous specific training in BPH and without a full time GP position. CONCLUSIONS: The implementation of a protocol has reduced the referral rate, but it has not improved the appropriate referrals. More research is required to understand the determinants of inequalities in referral from primary care.

OBJETIVO: Los médicos de Atención Primaria (MAP) son fundamentales en la regulación del flujo de pacientes desde Atención Primaria (AP), por tanto,es esencial buscar métodos de adecuada gestión de la demanda asistencial y así optimizar recursos. En la hipertrofia benigna de próstata (HBP) se estima que 2/3 de los pacientes pueden ser manejados íntegramentedesd e AP a lo largo de todo el proceso de la HBP.MATERIAL Y MÉTODOS: Hemos realizado un estudio pre experimental en dos períodos, antes (pre-test) y después (post-test) de la creación de un protocolo de manejo y derivación de pacientes con HBP. Analizamos la adecuación a los criterios de derivación y el uso de los estudios complementarios para llevar a cabo el diagnóstico, realizando un análisis estadístico (descriptivo, bivariante, multivariante y cálculo de tasas) utilizando SPSS (versión 21). RESULTADOS: La tasa de derivación disminuyó tras la aplicación del protocolo, pero no logró mejorar la adecuación. Los pacientes derivados por los MAP que asistieron al programa educativo fueron más jóvenes. Se remitieron menos pacientes con PSA elevado y más pacientes con progresión clínica. Se utilizaron menos estudios complementarios. Los MAP que no acudieron a la formación eran más jóvenes, principalmente mujeres, sin formación especifica en HBP y con contrato temporal. CONCLUSIONES: A pesar de reducir la tasa de derivación no se consiguió mejorar la adecuación de la derivación de los pacientes. Consideramos necesario analizar la problemática de los MAP y valorar otras intervenciones que podrían mejorar la calidad en la transferencia de responsabilidades.

[Renal hematomas after extracorporeal shock-wave lithotripsy (ESWL)]. / Hematomas renales tras litotricia extracorpórea por ondas de choque (LEOCH).

INTRODUCTION: The use of fragmentation due to shock- waves as a treatment of urinary stone was one of the most important therapeutics findings in the history of urology. It's the first election treatment for most of the calculus at renal and urethral location due to the fact that it is a low invasive treatment and it has a few number of complications, but this method also has a few negative side effects, it can caused a more or less important traumatic lesion at the organs which crosses the shock-waves, including the kidney where it can caused a small contusion or renal hematoma with different resolution and treatment. MATERIAL AND METHOD: We reviewed 4815 extracorporeal shock-wave lithotripsy that we performed in our department in which we found six cases with subcapsular and perirenal hematoma which we followed up and treated. RESULTS: After the urological complications (pain, obstruction and infection) the renal and perirenal hematic collections are the most frequent adverse effects of shock-waves used in lithotripsy, these are related to the power of energy used and patient age. CONCLUSIONS: Between the years 1992-2007 we performed 4.815 extracorporeal shock-wave lithotripsy finding seven cases of severe hematoma, less then 1%. Treatment of these complications is usually not aggressive though sometimes it is necessary to perform surgical drainage and even nephrectomy.

Implications of mismatch repair genes hMLH1 and hMSH2 in patients with sporadic renal cell carcinoma.

OBJECTIVES: To analyse the implications of DNA mismatch repair genes hMLH1 and hMSH2 in sporadic renal cell carcinoma (RCC). MATERIALS AND METHODS: Specimens of tumour and healthy renal tissue were collected from 89 patients treated for sporadic RCC. Another 95 blood samples taken from individuals with no history of cancer were also analysed. After DNA extraction and PCR amplification, microsatellite instability (MSI) was determined using the Bethesda microsatellite panel, two exonic microsatellites of the TGFbRII and BAX genes, and the microsatellite D3S1611. The promoter methylation status of hMLH1 was investigated using the HpaII and MspI restriction enzymes. In addition, a sequencing analysis of complete coding region of hMLH1 and hMSH2 genes was performed. RESULTS: MSI and promoter hypermethylation of hMLH1 were not detected. Interestingly, loss of heterozygosity (LOH) was common among patients with RCC, particularly in microsatellite D3S1611 (34.9%). Mutations were identified in eight patients: K618A and V716M in gene hMLH1; and I145V, G322D, and the novel mutation P349A, in gene hMSH2. The mutations also appeared in healthy renal tissue and therefore, were considered as germline DNA sequence variations. There were G322D and K618A changes in >1% of the healthy control subjects, suggesting that they are DNA polymorphisms. CONCLUSIONS: Our data show that loss of function of both hMLH1 and hMSH2 is not involved in sporadic RCC, either by promoter methylation or mutation in their exons. However, LOH indicated that chromosomal instability affecting large fragments of DNA was the main genetic alteration we detected associated with RCC.