[Evolution of open versus laparoscopic/robotic surgery: 10 years of changes in urology]. / Evolución de la cirugía abierta versus laparoscópica/robótica: 10 años de cambios en Urología.

INTRODUCTION: Laparoscopic surgery has been increasingly used in urology in recent years. Laparoscopy has been performed at our center since 2001. Changes over time in the indication of open versus laparoscopic/robotic surgery, hospital stay, and learning curve are reviewed. MATERIALS AND METHODS: A retrospective review of our database from 1997 to the end of 2007. A total of 3622 procedures were performed during this time (endoscopic procedures were excluded): 67.75% open, 26.17% laparoscopic, 2.29% perineal, and 3.78% robotic surgeries. Of these, 83.79% were performed in males and 16.20% in females. Mean patient age was 58.8 years. Data from the study period, including mean hospital stay and changes over time in operating time as a function of the learning curve, were analyzed and compared to data for the last 12 months of the study period. RESULTS: The percentages of all surgical procedures performed using a laparoscopic approach in the 1997-2006 versus the last 12 study months were as follows: nephrectomy, 31.8% versus 74.7%; living donor nephrectomy, 93% versus 100%; nephroureterectomy, 28.1% vs. 93.4%; partial nephrectomy, 31.3% vs 87%; and radical prostatectomy, 17.6% versus 73.5% including laparoscopic and robotic approaches. Shorter mean hospital stays and operating times were also seen. CONCLUSIONS: Use of the laparoscopic approach has greatly increased in the 10-year period studied. In renal surgery, few indications remain for open surgery. In prostate surgery, introduction of robotic surgery in 2005 and learning of laparoscopy by several of our urologists have dramatically changed the therapeutic approach. Gradual incorporation of laparoscopic surgery has led to a decreased hospital stay and to a shortening of the learning curve.

[Transurethral treatment of massive hematuria post retropubic adenomectomy]. / Tratamiento por vía transuretral de la hematuria masiva postadenomectomía retropúbica.

INTRODUCTION AND OBJECTIVES: to evaluate the frequency of reoperation caused by massive hematuria in the postoperation of open prostatectomy in benign prostatic hyperplasia (BHP) at our hospital. At the same time, we also want to evaluate the effectiveness and possible secondary effects of using transurethral approach to solve this surgical complications. MATERIAL AND METHODS: we analyzed retrospectively 540 open surgeries in benign prostatic hyperplasia, carried out from 1998 to 2005. We evaluated effectiveness, average surgery time and complications in case of endoscopic review. RESULTS: a reoperation was necessary in 2.5% of all 540 cases. In all the cases reoperated, hemorrhage was controlled using transurethral approach. Average surgery time was 37 minutes and secondary effects observed were not important. CONCLUSIONS: transurethral approach is a simple and effective technique in the treatment of massive hematuria after open prostatectomy in BPH. Surgery time spent is acceptable, and early and delayed complications observed have been few and cannot, in our opinion, be imputed only to this tech-

[History of robotics: from archytas of tarentum until Da Vinci robot. (Part II)]. / Historia de la rob6tica: de arquitas de tarento al robot da Vinci. (Parte II).

Robotic surgery is a reality. In order to to understand how new robots work is interesting to know the history of ancient (see part i) and modern robotics. The desire to design automatic machines imitating humans continued for more than 4000 years. Archytas of Tarentum (at around 400 a.C.), Heron of Alexandria, Hsieh-Fec, Al-Jazari, Bacon, Turriano, Leonardo da Vinci, Vaucanson o von Kempelen were robot inventors. At 1942 Asimov published the three robotics laws. Mechanics, electronics and informatics advances at XXth century developed robots to be able to do very complex self governing works. At 1985 the robot PUMA 560 was employed to introduce a needle inside the brain. Later on, they were designed surgical robots like World First, Robodoc, Gaspar o Acrobot, Zeus, AESOP, Probot o PAKI-RCP. At 2000 the FDA approved the da Vinci Surgical System (Intuitive Surgical Inc, Sunnyvale, CA, USA), a very sophisticated robot to assist surgeons. Currently urological procedures like prostatectomy, cystectomy and nephrectomy are performed with the da Vinci, so urology has become a very suitable speciality to robotic surgery.

[History of robotics: from Archytas of Tarentum until da Vinci robot. (Part I)]. / Historia de la robótica: de Arquitas de Tarento al robot da Vinci (Parte I).

Robotic surgery is the newst technologic option in urology. To understand how new robots work is interesting to know their history. The desire to design machines imitating humans continued for more than 4000 years. There are references to King-su Tse (clasic China) making up automaton at 500 a. C. Archytas of Tarentum (at around 400 a.C.) is considered the father of mechanical engineering, and one of the occidental robotics classic referents. Heron of Alexandria, Hsieh-Fec, Al-Jazari, Roger Bacon, Juanelo Turriano, Leonardo da Vinci, Vaucanson o von Kempelen were robot inventors in the middle age, renaissance and classicism. At the XIXth century, automaton production underwent a peak and all engineering branches suffered a great development. At 1942 Asimov published the three robotics laws, based on mechanics, electronics and informatics advances. At XXth century robots able to do very complex self governing works were developed, like da Vinci Surgical System (Intuitive Surgical Inc, Sunnyvale, CA, USA), a very sophisticated robot to assist surgeons.

[Transperitoneal laparoscopic partial nephrectomy in the renal tumor treatment]. / Nefrectomía parcial laparoscópica transperitoneal en el tratamiento del tumor renal.

Laparoscopic surgery is a surgical technique the urologist should add to his surgical armamentarium. Its performance tries to mimic the surgical phases of open surgery, and also its indications. Laparoscopic partial nephrectomy is a sophisticated technique that requires wide experience in the performance of endoscopic strategies. We are submitting our experience with 35 laparoscopic partial transperitoneal nephrectomies with a mean follow-up of 25 months. The mean surgical time was 200 minutes, the mean bleeding 190 cc, and the mean hospitalisation five days. Two postoperative bleedings were identified, there were no conversions, and positive margins were notified in two cases, where upon a conservative attitude was adopted.

Bladder neoplasms after nephroureterectomy: does the surgery of the lower ureter, transurethral resection or open surgery, influence the evolution?

OBJECTIVE: Nephroureterectomy is the treatment of choice for tumors of the upper urinary tract (UUTT). In 1952, a modified version of this technique was described, involving endoscopic detachment of the ureter followed by nephroureterectomy with a single lumbar incision. We reviewed a retrospective survey to assess whether UUTT patients treated with nephroureterectomy with no prior history of bladder tumor had different rates of incidence or different sites of bladder recurrence according to the specific technique employed. METHODS: Patients were divided into group A, 87 patients who underwent a double incision nephroureterectomy and group B with 58 patients with prior detachment of the ureter. In both groups, incidence was calculated for two variables (bladder tumor recurrences and homolaterality of such recurrences) and chi-square tested. RESULTS: Bladder tumor was diagnosed at follow-up in 39% of patients in group A and 34.5% in group B, with no statistically significant difference (N.S.). Bladder tumor recurrences were homolateral to UUTT in 50% of group A cases and 55% of group B cases (N.S.). CONCLUSIONS: Although this is a retrospective survey of two asynchronous groups, given the similar nature of the UUTT cases in both groups and the fact that no statistically significant differences have been found, it is reasonable to conclude that nephroureterectomy with prior endoscopic detachment of the ureter is a safe and radical procedure.

Upper tract transitional cell carcinoma following cystectomy for bladder cancer.

PURPOSE: We assessed the incidence of upper urinary tract tumors (UUTTs) after cystectomy for invasive or superficial transitional cell carcinoma (TCC) of the bladder. The risk factors, patients' characteristics and evolution of those who developed UUTTs are analyzed. MATERIALS AND METHODS: From August 1980 to February 1994, 568 radical cystectomies were performed for TCC of the bladder: in 469 instances (82.5%) due to invasive tumor (T2-T4), and in 99 cases (17.5%) for superficial tumor (Ta, T1, Tis). All patients were followed for at least 5 years or until death. A retrospective study of patients who developed UUTTs has been performed. A revision of bladder tumor and UUTT characteristics, and the intervals between both is also evaluated. RESULTS: 26 patients (4.5%) developed UUTTs: 11 of the 99 patients cystectomized for superficial TCCs (11.1%); 6 of the 392 patients with primary invasive TCC (1.5%), and 9 of the 77 (11.6%) patients with invasive tumors and a prior history of superficial TCC. The interval to the development of UUTT was higher after cystectomy for superficial tumor. TCCs of the bladder that subsequently developed UUTTs were high grade in 84%, multifocal in 80%, or had carcinoma in situ in 65%, tumor in the prostatic urethra in 52%, and involvement of the distal ureter in 57%. Twenty-two UUTTs (84%) were located in the calyces or the renal pelvis, 3 were bilateral (11.5%), 14 multiple (58%) and 4 superficial (16%). With a median follow-up time of 18 (range 3-103) months, 14 patients (53.8%) died of tumor, 2 were alive with disease, 2 were lost for follow-up, and 8 (30%) were alive and free of disease. CONCLUSIONS: We found that patients cystectomized for superficial or invasive TCC with a prior history of superficial TCC have a higher incidence of UUTTs. These cases require follow-up with annual urography or loopography.

[Prostatic cysts of the midline: management and follow-up]. / Quistes prostáticos de la línea media: manejo y seguimiento.

OBJECTIVE: To analyze the presenting features, diagnosis and management of uncommon cystic lesions located at the midline of the prostate. METHODS: From 1990 to 1999, 8 patients with medial prostatic cyst were treated in our hospital. Vesicorenal ultrasound evaluation was the first procedure that was performed and was diagnostic in most of the cases. Only those patients that underwent surgery required admission to hospital. RESULTS: The most common presenting features were irritative and obstructive voiding syndromes. Treatment achieved cure or clinical improvement. CONCLUSIONS: Vesicorenal ultrasound assessment is the first procedure that should be considered in the diagnosis of this disease. Before ascribing the symptoms to a prostate cyst, other urological conditions with more prognostic relevance should be excluded. Treatment should be instituted only in the symptomatic patients and should be individualized according to the characteristics of each case.

[Cytoscopic follow-up of initial G3T1 bladder tumors treated with BCG]. / Seguimiento cistoscópico de los tumores vesicales G3T1 iniciales tratados con BCG.

OBJECTIVE: To evaluate the cystoscopic findings during initial follow-up, the anatomopathological correlation of tumor endoscopic features and the results of standard control multiple biopsy performed 6 months after TUR in patients with G3T1 transitional carcinoma treated with BCG. METHODS: 114 patients with G3T1 bladder tumor (52% associated with Cis) were treated with 81 mg Connaught BCG intravesical instillations weekly for 6 consecutive weeks. Follow-up was performed with cystoscopy and cytology at 3 months, and cystoscopy and standard multiple biopsy at 6 months. The endoscopic findings were described as normal bladder, macroscopically tumorous lesion or erythematous lesion. RESULTS: During the first 6 months of follow-up superficial recurrence was found in 16% and 5% showed progression to muscle invasion. Tumor recurrence or progression was found in 61% and 39% at 3 and 6 months, respectively. Most of the macroscopically tumorous lesions resulted in a tumor at 3 and 6 months in 56% and 64%, respectively, and the remaining lesions were mainly inflammatory granulomas produced by BCG therapy. Twenty biopsies of erythematous areas detected only one case of Cis (5%) and 98 standard multiple biopsies of endoscopically normal mucosa detected 10 cases of Cis (overall, 3 at 3 months and 7 at 6 months); all cases were preceded by initial Cis except in one case. CONCLUSIONS: Cystoscopy performed at 3 months is very useful since it detected 61% of the superficial recurrences and 66% of the cases with progression to muscle invasion during the first 6 months. Routine biopsy of erythematous areas detected during cystoscopy is of little value since a large number of these biopsies are unnecessary in view of its diagnostic yield (5%). Since 90% of the Cis detected during the first 6 months of follow-up were patients with Cis in the initial tumor, it would be appropriate to perform standard multiple biopsy for control only in this subgroup of patients if the sensitivity of cytology is low in high grade tumors or Cis.

Control group and maintenance treatment with bacillus Calmette-Guerin for carcinoma in situ and/or high grade bladder tumors.

PURPOSE: Intravesical instillations of bacillus Calmette-Guerin have demonstrated satisfactory results in the treatment of vesical carcinoma in situ and high grade superficial bladder tumors. We designed a protocol to evaluate the decrease in tumor recurrence with maintenance therapy. MATERIALS AND METHODS: Between June 1989 and May 1995 an initial course of 6 intravesical instillations of Connaught strain bacillus Calmette-Guerin was administered in patients with carcinoma in situ and/or high grade superficial bladder tumors. Six months later 131 disease-free patients were randomly assigned to a control group or a maintenance therapy group that received 6 instillations every 6 months (6 x 6) for a 2-year period. RESULTS: Of the 126 evaluable patients at a mean followup of 79 months there were no significant differences in recurrence nor progression. A total of 16 patients (26.2%) in the control and 10 (15.1%) in the maintenance group had superficial relapse at a mean of 24 and 20 months, respectively (p = 0.07). Eight patients underwent radical cystectomy due to bladder contraction in 1, high grade superficial recurrence in 4 and disease progression in 3. Of the 65 patients on maintenance therapy 22 (33.85%) completed the planned 2-year treatment. CONCLUSIONS: Six-month maintenance therapy in patients treated initially for carcinoma in situ and/or high grade superficial bladder tumors who are disease-free at 6 months did not significantly decrease recurrence or progression.

Polytetrafluoroethylene and autologous fat endoscopic injection for a prostato-perineal fistula.

PURPOSE: Prostato-perineal fistula is a rare abnormality. We present a simple endoscopic technique to manage this complicated problem. MATERIALS AND METHODS: We report on a 34-year-old man with a prostato-perineal fistula after multiple surgeries for imperforate anus. The patient underwent an endoscopic injection of polytetrafluoroethylene and autologous fat in the fistulous tract. RESULTS: Two endoscopic procedures with the injection of polytetrafluoroethylene and autologous fatty tissue around the prostatic urethral orifice were necessary to occlude the fistula. CONCLUSIONS: The endoscopic injection of polytetrafluoroethylene and autologous fat was an easy, well tolerated and long lasting solution in this patient.

Prognostic value of cystocopically pseudotumoral lesions (inflammation/granuloma) in primary stage T1 grade 3 bladder tumors treated with BCG.

OBJECTIVE: The aim of this study is to find out whether the pseudotumoral lesions (inflammation/granuloma) seen at the follow-up cystoscopy performed three to six months after transurethral resection of primary stage T1 grade 3 bladder tumor and instillations of BCG therapy might have some prognostic value as far as recurrence and/or long term progression are concerned. MATERIAL AND METHODS: From the first group of one hundred and thirteen patients with primary stage of T1 grade 3 bladder tumor treated with 81 mg of BCG Connaught (weekly/during six weeks), those with recurrent tumor at the 3rd and 6th month were excluded, so we evaluated 99 patients. We identified 13 patients with cystoscopically pseudotumoral lesions. RESULTS: of the 13 cystoscopically pseudotumoral lesions, we observed recurrence in two cases (15%), while among the rest of the 86 patients, we observed 22 recurrences (26%) (p = 0.9; not significant). Concerning progression, eight cases were reported out of 86 patients (9%) within the cistocopically normal group. No cases of progression were reported among the 13 patients with cystoscopically pseudotumoral lesions. This difference was not statistically significant (p = 0.5). CONCLUSIONS: The patients with cystoscopically pseudotumoral lesions (inflammation/granuloma) are a reduced group (13%) with less tendency to recurrence and without progression, even though this relationship is not significant.

Intravesical treatment of severe bacillus Calmette-Guerin cystitis.

OBJECTIVE: Intravesical instillation of bacillus Calmette-Guerin (BCG) is an established treatment of carcinoma in situ and recurrent superficial bladder tumours. The inflammatory reaction due to BCG provokes cystitis of short duration as a frequent side effect. When the symptomatology is severe and long-lasting, different systemic treatments have been administered with varying degrees of efficacy. MATERIAL AND METHODS: We have studied the treatment of severe BCG cystitis with a anaesthetic anti-inflammatory solution administered by intravesical instillations to 16 patients. RESULTS: Good results were obtained in 94% of the cases, with immediate clinical improvement in terms of pain and urinary symptoms, and with no side effects. CONCLUSIONS: This treatment is inexpensive and easy to administer. We consider that it offers a useful option to solve an infrequent but very annoying problem for the patients.

[Initial superficial bladder tumors: our experience. Our criteria. Study Group of Bladder Tumors]. / Tumores vesicales superficiales iniciales: nuestra experiencia. Nuestro criterio. Grupo de Estudio de Tumores Vesicales.

OBJECTIVES: Evaluation of a homogeneous series of Superficial Primary TCC of the Bladder. Utility of randomized biopsies (BMN). Study of risk factors and risk groups as a basis for determining treatment and followup patterns. MATERIALS AND METHODS: Survey of 1,529 PSBT cases that underwent TURB and BMN, with a mean followup of 4.2 years. Strict statistical treatment: multivariate analysis using Cox logistic regression according to Kaplan-Meier curves. RESULTS: Tumor features of note: single tumor (65%), smaller than 1.5 cm (45%), high grade (G3: 26%), and high stage (T1: 64%). BMN showed associated CIS in 284 cases (19%). Main risk factors for recurrence were multiplicity, size > 3 cm and association with CIS. The main risk factor for progression was grade 3 (OR 19.9). Grade 3 and association with CIS were found to increase mortality risk. On the basis of this data, we grouped tumors according to low-, middle-, and high-risk, and established our proposed treatment and followup for each group. CONCLUSIONS: This multivariate analysis of a homogeneous cohort of 1,529 primary superficial bladder tumor cases allowed vs to determine risk groups for treatment and followup.

Upper urinary tract tumors after primary superficial bladder tumors: prognostic factors and risk groups.

PURPOSE: We evaluated the prognostic factors of primary superficial bladder cancer that may predict a metachronous upper urinary tract tumor. We also determined whether the incidence of upper urinary tract disease varies according to risk group based on primary superficial bladder tumor classification. MATERIALS AND METHODS: We studied disease evolution in a cohort of 1,529 patients with a primary superficial bladder tumor. To determine the prognostic factors of upper urinary tract cancer we performed multivariate analysis using Cox regression. Independent variables were grade, T stage, multiplicity, tumor size, carcinoma in situ association, previous or synchronous upper urinary tract tumor and intravesical instillation. We also performed the chi-square test and Kaplan-Meier survival analysis to assess the variable incidence of upper urinary tract tumors according to primary superficial bladder tumor risk group classification. RESULTS: The incidence of upper urinary tract cancer was 2.6%. The only factor prognostic for an upper urinary tract tumor was multiplicity (relative risk 2.7, 95% confidence interval [CI] 1.06 to 6.84). All patients with an upper urinary tract tumor had a previously recurrent primary superficial bladder tumor. In the low, intermediate and high risk groups the incidence of upper urinary tract cancer was 0.6% (relative risk 1), 1.8% (relative risk 3.1, 95% CI 0.4 to 23.9) and 4.1% (relative risk 8.3, 95% CI 1.1 to 61.6), respectively (chi-square and log rank tests p = 0.007 and p <0.05, respectively). CONCLUSIONS: A higher risk of upper urinary tract cancer must be expected in cases of multiple primary superficial bladder tumors. This finding supports the multicentricity theory of transitional cell carcinoma. Primary superficial bladder tumor classification by risk group is also useful for predicting the various risks of metachronous upper urinary tract cancer.

Primary superficial bladder cancer risk groups according to progression, mortality and recurrence.

PURPOSE: We identified risk groups in primary superficial bladder cancer according to progression, mortality and recurrence rates. MATERIALS AND METHODS: The prognostic factors of progression, mortality and recurrence were identified by multivariate analysis in a cohort of 1,529 patients with primary superficial bladder cancer. Risk groups were designed by combining the relative risk of these prognostic factors. We performed survival analysis of progression, tumor mortality and recurrence by risk group using the Kaplan-Meier method. Relative risk in each group was calculated by Cox regression. We present timetables of progression, mortality and recurrence by risk group. RESULTS: Risk groups were classified as low-grade 1 stage Ta disease and a single grade 1 stage T1 tumor, intermediate-multiple grade 1 stage T1 tumors, grade 2 stage Ta disease and a single grade 2 stage T1 tumor, and high-multiple grade 2 stage T1 tumors, grade 3 stages Ta and T1 disease, and any stage disease associated with carcinoma in situ. Survival analysis of progression, mortality and recurrence revealed a statistically significant difference among the 3 risk groups. The rates of recurrence, progression and mortality were 37%, 0% and 0% in the low, 45%, 1.8% and 0.73% in the intermediate, and 54%, 15% and 9.5% in the high risk group, respectively. The relative risks of recurrence, progression and mortality in the low versus the intermediate and high risk groups were 1.37, 2.84 and 1, and 1.87, 24.76 and 14.69, respectively. CONCLUSIONS: Risk group classification based on prognostic factors defines progression, mortality and recurrence rates in primary superficial bladder cancer. It may be useful for designing treatment and followup strategies.

Multivariate analysis of the prognostic factors of primary superficial bladder cancer.

PURPOSE: We evaluate the prognostic factors of recurrence, progression and disease specific mortality in patients with primary superficial Ta and T1 transitional cell carcinoma of the bladder. MATERIALS AND METHODS: We studied a cohort of 1,529 patients with primary superficial transitional cell carcinoma of the bladder treated with transurethral resection and random bladder biopsies. Mean followup was 4.2 years. Statistical analysis was performed using the Kaplan-Meier method and multivariate analysis was done with the Cox proportional hazards model with stepwise forward selection. All p values were 2-sided, with odds ratios and 95% confidence intervals. RESULTS: Multiple tumors (odds ratio 2), tumor greater than 3 cm. (1.65) and carcinoma in situ (1.6) increased, whereas intravesical bacillus Calmette-Guerin (BCG) instillations (0.39) decreased the risk of recurrence. Grade 3 disease (odds ratio 19.9), multiple tumors (1.9), tumor greater than 3 cm. (1.7) and carcinoma in situ (2.1) increased, whereas BCG (0.3) decreased the risk of progression. Grade 3 disease (odds ratio 14) and carcinoma in situ (odds ratio 3) increased the risk of disease specific mortality. CONCLUSIONS: Neither tumor stage nor dysplasia influenced tumor evolution. Multiple tumors, tumor greater than 3 cm. and intravesical BCG instillations were risk factors of recurrence and progression. Carcinoma in situ influenced recurrence, progression and disease specific mortality. Finally, the main predictor of progression and mortality was grade 3 disease.

[Encrusted cystitis. Is it always alkaline?]. / Cistopatía incrustante. Siempre alcalina?

OBJECTIVE: To report on our series of encrusted cystopathy. METHODS: The clinical records of 37 patients (25 males, 67%; 12 females, 33%) with a histological diagnosis of encrusted cystopathy were reviewed. RESULTS: Only 11 patients (29.7%) met the classical criteria for alkaline encrusted cystitis. They had an initial or predisposing bladder lesion, irritative symptoms, passed calcareous material, a demonstrated or suspected urinary infection from ureolytic pathogens and alkaline urine. The remaining 26 patients (70.2%) with histologically demonstrated encrustations on the bladder wall did not meet the foregoing criteria. Fifty-seven percent of the patients had a previous history of bladder tumor resection and treatment with intravesical instillations. CONCLUSIONS: Alkaline encrusted cystopathy is an uncommon condition. Encrusting cystopathy can develop in the absence of ureolytic pathogens or alkaline urine. The bladder lesion on which the encrusting cystopathy is established, is determinant in the subsequent evolution.