Laparoscopic nephron sparing surgery and radical nephrectomy in cT1 renal tumors. Comparative analysis of complications and survival.

INTRODUCTION AND OBJECTIVES: Comparative analysis of postoperative complications and survival between laparoscopic partial nephrectomy (PN) and radical nephrectomy (RN) in cT1 renal cell carcinoma (RCC). MATERIAL AND METHOD: Retrospective study of patients with two kidneys and single renal tumor cT1 treated in our center between 2005 and 2018 by laparoscopic PN or RN. RESULTS: 372 patients met the inclusion criteria for the study. RN was performed in 156 (41.9%) patients and PN in 216 (58.1%). Clavien Dindo III-V complications were observed in 10 (4,6%) PN and 6 (3,9%) RN patients (p = 0.75). The comorbidity Charlson index (CCI) was identified as an independent predictor variable of complications (p = 0.02) and surgical approach did not affect multivariate analysis. Estimated overall survival (OS) was 81.2% and 56.8% at 5 and 10 years in the RN group and 90.2% and 75.7% in the PN group, respectively (p = 0.0001). Obesity (HR 2.77, p = 0.01), CCI ≥ 3 (HR 3.69, p = 0.001) and glomerular filtration rate (GFR) <60 mL/min/1.73 m2 at discharge (HR 1.87, p = 0.03) were identified as predictors of overall mortality. Nephrectomy approach showed no influence on OS. Estimated recurrence-free survival (RFS) was 86.1% at 5 and 10 years in the RN group and 93.5% and 83.6% in the PN group, respectively (p = 0.22). CONCLUSIONS: Laparoscopic PN is not inferior to RN in terms of oncologic and surgical safety in cT1 RCC. Nephrectomy approach did not influence patient OS, however, obesity, CCI ≥ 3 and GFR <60 mL/min/1.73 m2 at discharge did behave as predictors.

Evolution of renal function in patients with cT1 renal tumors after laparoscopic partial and radical nephrectomy. Predictive factors for renal function impairment.

INTRODUCTION AND OBJECTIVES: To analyze the evolution of kidney function after laparoscopic partial nephrectomy (PN) and radical nephrectomy (RN) and to identify predictive factors for renal function impairment. MATERIALS AND METHOD: Retrospective study of patients with two kidneys, glomerular filtration rate (GFR) > 60 mL/min/1.73 m2 and single renal tumor cT1, treated in our center between 2005 and 2018. RESULTS: A total of 372 patients met the inclusion criteria for the study; 156 (41.9%) were treated with RN and 216 (58.1%) with PN. There was a difference of 26.75 mL/min/1.73 m2 in GFR between RN and PN at discharge. Age >60 years, postoperative complications (OR 2.97, p = 0.005) and RN (OR 10.03, p = 0.0001) were predictors of GFR <60 mL/min/1.73 m2 at discharge. Only RN (OR 7.69, p = 0.0001) behaved as an independent prognostic factor for GFR <45 mL/min/1.73 m2 at discharge. The median follow-up of the series was 57 (IQR 28-100) months. At the end of the follow-up period, nine (6%) patients treated with RN developed severe chronic kidney disease (CKD) and three (2%) developed end stage renal disease (ESRD). Age >70 years, diabetes mellitus (DM) (HR 2.12, p = 0.001), arterial hypertension (AHT) (HR 1.73, p = 0.01) and RN (HR 2.88, p = 0.0001) behaved as independent predictors of GFR <60 mL/min/1.73 m2. The independent predictors for GFR <45 mL/min/1.73 m2 were age >70 years, DM (HR 1.99 CI 95% 1.04-3.83, p = 0.04) and RN (HR 5.88 CI 95% 2.57-13.45, p = 0.0001). CONCLUSIONS: RN is a short- and long-term risk factor for CKD although with a low probability of severe CKD or ESRD in patients with preoperative GFR >60 mL/min/1.73 m2. Age, DM and AHT contribute to worsening renal function during follow-up.

Comparison of surgical approaches to radical prostatectomy in our series beyond oncological and functional outcomes.

OBJECTIVES: To evaluate the outcomes of robot-assisted radical prostatectomy (RARP) compared to those of open (ORP) and laparoscopic (LRP) surgery. The interest lies fundamentally in the quality-of-life (QoL) evaluation, postoperative recovery, and personal satisfaction of patients with the intervention (PS) beyond oncological and functional outcomes. METHODS: Six hundred eighty-five RPs were performed in our center between 2011-2018 (17,8% ORP, 22,2% LRP and 60% RARP). Patients were prospectively assessed through follow-up until April 2020 and a multiple questionnaire at 12-months post-RP that included ICIQ-SF, SHIM, IPSS, IQL and questions about pain, postoperative recovery and PS. Also baseline and postoperative patient- and treatment-related data were collected, and binomial logistic regressions were performed for the 1 vs.1 comparisons (ORP vs. RARP and LRP vs. RARP). RESULTS: RARP patients have overall fewer comorbidities, less tumor aggressiveness, more operative time requirements and more positive surgical margins than ORP and LRP patients. Nevertheless, RARP outperforms ORP in: hospital stay (days) (OR 0,86; 95% CI: 0,80-0,94), hemoglobin loss (OR 0,38; 95% CI: 0,30-0,47), transfusion rate (OR 0,18; 95% CI: 0,09-0,34), early complications (p = 0,001), IQL (OR 0,82; 95% CI: 0,69-0,98), erectile function (OR 0,41; 95% CI: 0,21-0,79), pain control (OR 0,82; 95% CI: 0,75-0,89), postoperative recovery (p < 0,001) and choice of a different approach (OR 5,55; 95% CI: 3,14-9,80). RARP is superior to LRP in: urinary continence (OR 0,55; 95% CI: 0,37-0,82), IPSS (OR 0,96; 95% CI: 0,93-0,98), IQL (OR 0,76; 95% CI: 0,66-0,88), erectile function (OR 0,52; 95% CI: 0,29-0,93), postoperative recovery (p = 0,02 and 0,004), PS (p = 0,005; 0,002; and 0,03) and choice of a different approach (OR 7,79; 95% CI: 4,63-13,13). CONCLUSIONS: The findings of our study globally endorse a positive effectiveness of RARP over ORP and/or LRP, both on functional issues, postoperative recovery, QoL and PS. Oncologic results should still be improved.

Evolution of renal function in patients with CT1 renal tumors after laparoscopic partial and radical nephrectomy. Predictive factors for renal function impairment. / Evolución de la función renal en pacientes con cáncer renal cT1 después de nefrectomía parcial y radical laparoscópica. Factores predictores de deterioro de función renal.

INTRODUCTION AND OBJECTIVES: To analyze the evolution of kidney function after laparoscopic partial nephrectomy (PN) and radical nephrectomy (RN) and to identify predictive factors for deterioration in kidney function. MATERIALS AND METHOD: Retrospective study of patients with two kidneys, glomerular filtration rate (GFR) > 60 mL/min/1.73 m2, and single renal tumor cT1, treated in our center between 2005 and 2018. RESULTS: A total of 372 patients met the inclusion criteria for the study; 156 (41.9%) were treated by RN and 216 (58.1%) by PN. There was a difference of 26.75 mL/min/1.73 m2 in GFR between RN and PN at discharge. Age > 60 years, postoperative complications (OR 2.97, p = 0.005) and RN (OR 10.03, p = 0.0001) were predictors of GFR < 60 mL/min/1.73 m2 at discharge. Only RN (OR 7.69, p = 0.0001) behaved as an independent prognostic factor for GFR < 45 mL/min/1.73m2 at discharge. The median follow-up of the series was 57 (IQR 28-100) months. At the end of the follow-up period, nine (6%) patients treated with RN developed severe chronic kidney disease (CKD) and three (2%) developed end stage renal disease (ESRD). Age > 70 years, diabetes mellitus (DM) (HR 2.12, p = 0.001), arterial hypertension (AHT) (HR 1.73, p = 0.01) and RN (HR 2.88, p = 0.0001) behaved as independent predictors of GFR < 60 mL/min/1.73 m2. The independent predictors for GFR< 45 mL/min/1.73m2 were age >70 years, DM (HR 1.99 CI 95% 1.04-3.83, p = 0.04) and RN (HR 5.88 CI 95% 2.57-13.45, p = 0.0001). CONCLUSIONS: RN is a short- and long-term risk factor for CKD, although with a low probability of severe CKD or ESRD in patients with preoperative GFR > 60 mL/min/1.73 m2. Age, DM and AHT contribute to worsening renal function during follow-up.

Analysis of recurrence trends according to risk groups after renal cancer nephrectomy. / Evaluación de los patrones de recurrencia por grupos de riesgo tras nefrectomía por cáncer renal.

INTRODUCTION: Recurrence trends after renal cell cancer nephrectomy are not clearly defined. OBJECTIVE: To evaluate recurrence trends according to recurrence risk groups (RRG). MATERIAL AND METHOD: Retrospective analysis of 696 patients with renal cell cancer treated with nephrectomy between 1990-2010. Three RRG were defined according to the presence of anatomopathological variables (pTpN stage, nuclear grade, tumor necrosis [TN], sarcomatoid differentiation [SD], positive resection margin [RM]): -Low RG (LRG): pT1pNx-0 G1-4, pT2pNx-0 G1-2; no TN, SD and/or RM (+). -Intermediate RG (IRG): pT2pNx-0 G3-4; pT3-4pNx-0 G1-2; LRG with TN. -High RG (HRG): pT3-4pNx-0 G3-4; pT1-4pN+; IRG with TN and/or SD; LRG with SD and/or RM (+). The Kaplan-Meier method has been used to evaluate recurrence-free survival as a function of RRG. The log-rank test was used to evaluate differences between survival curves. RESULTS: The median follow-up was 105 (IQR 63-148) months. Of the total series, 177 (25.4%) patients presented recurrence: distant 15.9%, local 4.9% and 4.6% distant and local. The recurrence rate varied according to the RRG with values of 72.9% for HRG, 16.9% for IRG and 10.2% for LRG (p=.0001). Most cases in LRG presented single organ recurrence (72.2%) (p=.006). The LRG experienced recurrence as single metastasis in 50% of cases, compared to 30% and 18.6% in IRG and HRG, respectively (p=.009). The most common sites of recurrence were lung and abdomen. Lung recurrence predominated in the HRG (72.9%) (p=.0001) and abdominal, in the LRG (83.3%) with a tendency to significance (p=.15). CONCLUSIONS: Recurrence rates (especially bone and lung) increase with higher RG. Single organ recurrences and single metastases are more frequent in LRG.

Survival analysis of patients with prostate cancer and unfavorable risk factors treated with radical prostatectomy and salvage radiotherapy after biochemical recurrence and persistence. / Análisis de supervivencia de los pacientes con cáncer de próstata con factores patológicos desfavorables tratados con prostatectomía radical y radioterapia de rescate tras la recidiva y persistencia bioquímica.

OBJECTIVE: Survival analysis of patients with prostate cancer (PCa) with adverse prognostic factors (APF) treated with radical prostatectomy (RP) and salvage radiotherapy (SRT) after biochemical recurrence (BR) or biochemical persistence (BP). MATERIALS AND METHODS: Retrospective analysis of 446 patients with at least one of the following APF: Gleason score ≥8, pathologic stage ≥pT3 and/or positive surgical margins. BR criteria used was PSA level over 0.4ng/ml. A survival analysis using Kaplan-Meier was performed to compare the different variable categories with log-rank test. In order to identify risk factors for SRT response and cancer specific survival (CSS) we performed univariate and multivariate analyses using Cox regression. RESULTS: Mean follow up: 72 (IQR 27-122) months, mean time to BR: 42 (IQR 20-112) months, mean PSA level at BR: 0.56 (IQR 0.42-0.96). BR was present in 36.3% of the patients. Biochemical response to SRT was observed in 121 (75.7%) patients. Recurrence-free survival (RFS) rates after SRT at 3, 5, 8 and 10years were 95.7%, 92.3%, 87.9%, and 85%; overall survival (OS) rates after 5, 10 and 15years was 95.6%, 86.5% and 73.5%, respectively. CSS rates at 5, 10 and 15years were 99.1%, 98.1% and 96.6%. Only time to BR <24months (HR=2.55, P=.01) was identified as an independent risk factor for RFS after SRT. CONCLUSIONS: In these patients, RP only controls the disease in approximately half of the cases. Multimodal sequential treatment (RP+SRT when needed) increases this control, achieving high CSS rates and biochemical control in over 87% of the patients. Patients with time to recurrence >24months responded better to rescue treatment.

Recurrence risk groups after nephrectomy for renal cell carcinoma. / Clasificación en grupos de riesgo de recurrencia tras nefrectomía por cáncer renal.

INTRODUCTION: There is no consensus on the follow-up protocol after nephrectomy for renal cell carcinoma (RCC), and the identification of recurrence risk groups (RRG) is required. OBJECTIVE: Establish recurrence risk groups (RRG). MATERIAL AND METHOD: A retrospective analysis of 696 patients with renal cancer submitted to surgery between 1990-2010; 568 (81.6%) patients treated with radical nephrectomy and 128 (18.4%) treated with partial nephrectomy. Pathological variables were classified as: 1st-level variables (1LPV): pTpN stage and Fuhrman grade (FG); and 2nd level pathological variables (2LPV): sarcomatoid differentiation (SD), tumor necrosis (TN), microvascular invasion (MVI) and positive surgical margins (PSM). Univariate and multivariate analysis have been performed using Cox regression to determine 1LPV related to recurrence. Based on 1LPV, we classified patients into three RRG: Low (LRG)<25%; Intermediate (IRG) 26-50% and High (HRG)>50%. We performed univariate and multivariate analysis with the 2LPVs for each RRG. With these data, patients were reclassified as RRG+. ROC curves were used for comparison of RRG and RRG+. RESULTS: The median follow-up was 105 months (range 63 to 148). There were 177 (25.4%) patients with recurrence: 111 (15.9%) distant, 34 (4.9%) local and 32 (4.6%) distant and local. In the multivariable analysis, Fuhrman grade (HR=2,75; P=.0001) and pTpN stage (HR=2,19; P=.0001) behaved as independent predictive variables of recurrence. Patients were grouped as RRG (AUC=0,76; p=0,0001): - LRG (pT1pNx-0 G1-4; pT2pNx-0 G1-2): 456 (65,5%) patients. - IRG (pT2pNx-0 G3-4; pT3-4pNx-0 G1-2): 110 (15,8%) patients. - HRG (pT3-4pNx-0 G3-4; pT1-4pN+): 130 (18,6%) patients. After multivariate analysis with 2LPV, RRG were reclassified (RRG+) (AUC=.84, P=.0001): -LRG+(LRG without TN, SD and/or PSM(+)). -IRG+(IRG; LRG with TN) -HRG+(HRG; LRG with SD and/or PSM(+); IRG with TN and/or SD) CONCLUSIONS: The inclusion of 2LPV to the classification according to VP1N improves the discriminating capacity of RRG classification.

Evaluation of laparoscopic approach in radical cystectomy from implementation to consolidation: Internal validation. / Evaluación del abordaje laparoscópico en la cistectomía radical desde la implantación hasta su consolidación: validación interna.

INTRODUCTION AND OBJECTIVES: The AEU Guidelines of 2017 consider laparoscopic and robot-assisted approaches as investigational procedures. The surgical learning curve is defined as the minimum number of cases that a surgeon has to perform in order to reproduce a technique considered as standard. The aim of this study is to analyze, within our department, the implementation of a laparoscopic radical cystectomy (LRC) program compared with a well consolidated and standardized open radical cystectomy (ORC) program. MATERIAL AND METHODS: Retrospective cohort analysis of two cystectomy groups: LRC (n=196) (20062016) vs. ORC (n=96) (2003-2005). Comparison of the evolution over time of the following parameters: operative time, blood transfusion rates, resection margins, postoperative complications, hospital stay and recurrence. Three time periods have been defined for LRC: implementation (2006-09) (LRC-I), development (2010-14) (LRC-D) and consolidation (2015-16) (LRC-C); comparing each of them with the control group (ORC). The chi-square test was used for the comparison of the qualitative variables and the Anova test for the numerical ones. RESULTS: When compared to ORC, LRC presented longer operative times in LRC-I and LRC-D periods. We observed a trend toward shorter operative time than ORC in the consolidation period (LRC-C). LRC also presented lower intraoperative transfusion rates in all periods and lower postoperative rates in CRL-D and CRL-C. Overall complications in LRC-D and LRC-C were lower in LRC, having fewer major complications (Clavien≥3) in the 3 periods. A decrease in mortality and hospital stay after the LRC-I phase was also observed. These results were consolidated during the two last periods of the study. We have not observed significant differences between ORC and LRC when comparing surgical margins and recurrence rates, neither in the total series, nor in the comparison between the different periods. These results endorse the oncologic safety of LRC from the beginning of the implementation process. CONCLUSIONS: When compared to ORC, LRC improves perioperative transfusion rates, complications and hospital stay from its implementation period, maintaining oncological safety. On the contrary, longer operative times during implementation and development were observed. However, in our series, we observed a trend toward shorter operative times than ORC approach in the consolidation period. We have validated the laparoscopic approach for radical cystectomy in our service.

[Mucin-producing urothelial type prostatic adenocarcinoma with signet ring cells and increased Ca 19.9 and Cea. Case report and literature review.] / Adenocarcinoma mucinoso de próstata tipo urotelial con células en anillo de sello y elevación del Ca 19.9 y Cea. Revisión de la literatura a propósito de un caso.

OBJECTIVE: Primary Mucin-producing Urothelial-type Adenocarcinoma of Prostate is extremely infrequent. The presence of signet ring cells is exceptional, more atypical in its mucinous variant. Anatomopathological and immunohistochemical study play a key role. METHODS: Bibliographic review and case report of a 66-year-old man with Ca 19.9 and CEA elevation, and normal PSA levels, associated with lower urinary tract symptoms (mucosuria, hesitancy and hematuria). He was diagnosed with mucin-producing urothelial- type adenocarcinoma of the prostate with signet ring cells by transrectal prostate biopsy after multiparametic MRI. RESULTS: We found 23 cases described in our review. No case diagnosed following an elevation of Ca 19.9 was found in the literature. In our case, after diagnosis, he was treated with retropubic radical prostatectomy and bilateral ilio-obturator lymph node dissection, with subsequent normalization of tumor markers; however, he presented secondary pulmonary involvement and pelvic tumor progression despite chemotherapy treatment. CONCLUSIONS: The elevation of associated tumor markers (Ca 19.9, CEA) is extraordinary. There is no treatment algorithm, however surgery (radical prostatectomy) with or without adjuvant chemotherapy treatment represents an alternative in its therapeutic management.

OBJETIVO: El adenocarcinoma primario de próstata de tipo urotelial es extremadamente infrecuente. La presencia de células en anillo de sello es excepcional, siendo más atípica aún en su variante mucinosa. Su estudio anatomopatológico e inmunohistoquímico juegan un papel fundamental.MÉTODOS: Revisión de la literatura a propósito del caso de un varón de 66 años con elevación de Ca 19.9 y CEA, y niveles de PSA normales, asociado a sintomatología del tracto urinario inferior (mucosuria, estranguria y hematuria) diagnosticado mediante biopsia prostática transrectal tras RMN multiparamétrica de un adenocarcinoma mucinoso de próstata tipo urotelial con células en anillo de sello. RESULTADOS: En la revisión efectuada se han encontrado descritos 23 casos. No se ha encontrado en la literatura ningún caso diagnosticado a raíz de una elevación del Ca 19.9. En nuestro caso, tras el diagnóstico fue tratado mediante prostatectomía radical retropúbica con linfadenectomía ilio-obturatriz bilateral, con normalización posterior de los marcadores tumorales; sin embargo, presentó afectación secundaria pulmonar y progresión tumoral pélvica a pesar de tratamiento quimioterápico. CONCLUSIONES: La elevación de marcadores tumorales asociada (Ca 19.9, CEA) es extraordinaria en este tipo de tumores. No existe un algoritmo de tratamiento, sin embargo la cirugía (prostatectomía radical) con o sin tratamiento adyuvante quimioterápico representa una alternativa en su manejo terapéutico.

Incidence of second tumours in high risk prostate cancer patients according to the primary treatment applied. / Incidencia de segundos tumores en pacientes con cáncer de próstata de alto riesgo según el tratamiento primario aplicado.

INTRODUCTION AND OBJECTIVES: The onset of second primary tumours should be considered in high-risk prostate cancer patients in the natural course of the disease. Our aim was to evaluate the influence of primary treatment with curative intent for these patients on the development of second primary tumours. MATERIAL AND METHODS: A retrospective study of 286 patients diagnosed between 1996 and 2008, treated by radical prostatectomy (n=145) or radiotherapy and androgen blockade (n=141). The homogeneity of both series was analysed using the Chi-squared test for the qualitative variables, and the Student's t-test for the quantitative variables. A multivariate Cox regression analysis was performed to assess whether the type of primary treatment influenced the development of second tumours. RESULTS: The median age was 66 years, and the median follow-up was 117.5 months. At the end of follow-up, 60 patients (21%) had developed a second primary tumour. In the prostatectomy group it was located in the pelvis in 13 (9%) cases, and those treated with radiotherapy and hormonotherapy in 8 (5.7%) cases (P=.29). The most common organ sites were: colo-rectal in 17 (28.3%) patients, the lung in 11 (18.3%), and the bladder in 6 (10%) patients. In the multivariable analysis, the risk of a second tumour doubled for those treated with radiotherapy and hormonotherapy (HR=2.41, 95%CI: 1.31-4.34, P=.005) compared to the patients treated by prostatectomy. Age and rescue radiotherapy did not behave as independent predictive factors. CONCLUSIONS: The onset of a second primary tumour was related with the primary treatment given; thus the risk for those treated with radiotherapy and androgen deprivation therapy more than doubled.

Port site and peritoneal metastasis following laparoscopic radical prostatectomy and salvage radiotherapy for prostate adenocarcinoma. / Metástasis peritoneal y en puerto de laparoscopia tras prostatectomía radical laparoscópica y radioterapia de rescate por adenocarcinoma prostático.

OBJECTIVE: Metastatic involvement in the port site used to perform laparoscopic radical prostatectomy (LRP) is very infrequent. METHODS: We report the case of a patient with port site and peritoneal metastasis after laparoscopic radical prostatectomy and salvage radiotherapy. RESULTS: 60-year-old male with a history of LRP due to Gleason score 7 (3+4) prostate adenocarcinoma with posterior salvage radiotherapy after biochemical recurrence. Appearance of metastatic lesion at one of the laparoscopic port site followed by third left rib and peritoneal metastasis, treated with local excision and subsequent hormonotherapy and chemotherapy (HT+QT). CONCLUSIONS: Metastatic extension of prostate adenocarcinoma at a port site after performing laparoscopic radical prostatectomy is a highly exceptional situation. The elevation of PSA levels and image tests (PET-CT) help in the diagnosis. Histopathological confirmation must be performed using Fine Needle Aspiration(FNA). Surgical excision is the treatment of choice. Adjuvant therapy (HT+QT) can help complete the treatment scheme.

OBJETIVO: La afectación metastásica a nivel de los puertos de laparoscopia utilizados para la realización de prostatectomía radical laparoscópica (PRL) es muy infrecuente.MÉTODO: Presentamos el caso de un paciente con afectación metastásica peritoneal y a nivel del puerto de laparoscopia tras PRL y radioterapia de rescate. RESULTADOS: Varón de 60 años, tratado con PRL por adenocarcinoma prostático con score Gleason 7(3+4) y radioterapia de rescate tras recidiva bioquímica. Aparición de afectación metastásica a nivel del puerto de laparoscopia, 3ª costilla izquierda y peritoneal consecutivamente, tratado con resección local y hormonoterapia+quimioterapia (HT+QT) posterior.CONCLUSIÓN: La afectación metastásica por adenocarcinoma prostático a nivel del puerto de laparoscopia tras la realización de PRL es un hecho altamente infrecuente. La elevación de PSA, así como las pruebas de imagen (PET-TC) ayudan a su diagnóstico. Su confirmación anatomopatológica ha de realizarse mediante PAAF. La escisión quirúrgica es el tratamiento imperativo. El tratamiento adyuvante (HT+QT) ayuda a completar el esquema terapéutico.

Post-surgical complications in patients with bladder cancer treated with cystectomy: Differences between open and laparoscopic approach. / Complicaciones posquirúrgicas en los pacientes con cáncer de vejiga tratados con cistectomía: Diferencias entre el abordaje abierto y laparoscópico.

INTRODUCTION: Minimally invasive surgery regarding cystectomy has not had the same development as other urological surgeries. This could be due to the lack of published studies defining the advantages of this approach versus open surgery. OBJECTIVES: The main objective of this study is to establish the role of minimally invasive surgery, laparoscopic radical cystectomy, versus open surgery by analyzing their perioperative complications. MATERIAL AND METHOD: Retrospective cohort analysis of perioperative complications of 2homogeneous series of cystectomies: laparoscopic (n = 196) versus open (n = 197). Identification of independent predictors of perioperative complications by multivariate analysis. RESULTS: In the comparative analysis between laparoscopic cystectomies and open cystectomies we observed a lower rate of perioperative blood transfusion (P < 0.0001), a lower rate of global postoperative complications (P < 0.0001) and a lower rate of serious complications (Clavien > 3; P < 0.001) in the LRC group. There was also a lower mortality rate in the laparoscopic series compared to open ones (P < 0.0001). Surgical approach and surgical time (P < 0.001) were identified as independent predictors of complications. CONCLUSIONS: We have identified the laparoscopic approach as a complication shield for radical cystectomy. The open approach almost triples the risk of complications.

Oncological control in high-risk prostate cancer after radical prostatectomy and salvage radiotherapy compared to radiotherapy plus primary hormone therapy. / Control oncológico en cáncer de próstata de alto riesgo tras prostatectomía radical y radioterapia de rescate en comparación con radioterapia más hormonoterapia primaria.

INTRODUCTION: In patients with high-risk localized prostate cancer (HRPCa), multimodal treatment plays a fundamental role. OBJECTIVE: To compare relapse-free survival (RFS) in patients with HRPCa, treated primarily with radiotherapy (RT)+hormone therapy (HT) versus radical prostatectomy (RP) and salvage RT (sRT)±HT when biochemical recurrence (BCR) appears. MATERIAL AND METHODS: Retrospective analysis of 226 patients with HRPCa (1996-2008), treated primarily with RT+HT (n=137) or RP (n=89). The Kaplan-Meier method has been used to evaluate survival and the log-rank test has been used to evaluate the contrast between the different categories of the variables. Multivariate analysis has been performed using Cox regression to determine variables with an impact on RFS with statistical significance (P<0.05). RESULTS: The median follow-up of the series was 111 (IQR 85-137.5) months. After RT+HT, 32 (23.4%) patients relapsed, and after RP (P=0.0001), 41 (46.1%) cases. When comparing the primary treatments, the RFS at 5 and 10 years was higher after RT+HT versus RP in monotherapy (P=0.001). The primary treatment with RT+HT reduced the risk of BCR when compared to the RP (HR=0.41, P=0.002). The estimation of the RFS at 5 and 10 years after RP+sRT±HT was 89.7 and 87.1%, while after primary RT+HT was 91.6 and 71.1%, respectively (P=0.01). The only factor that behaved as an independent predictor of RFS was the multimodal treatment with RP+sRT±HT when BCR showed up (HR=2.39, P=0.01). CONCLUSION: In HRPCa, multimodal treatment with RP+sRT±HT if BCR, significantly improves RFS with respect to treatment with RT+HT.

Influence of venous tumour extension on local and remote recurrence of stage pT3a pN0 cM0 kidney tumours. / Influencia de la extensión tumoral venosa en la recidiva local y a distancia de los tumores renales en un estadio pT3a pN0 cM0.

INTRODUCTION AND OBJECTIVE: One of the inherent features of kidney tumours is the capacity to spread inside the venous system as tumour thrombi. The aim of this study was to assess in patients with stage pT3apN0cM0 kidney cancer whether venous tumour involvement influenced tumour recurrence. MATERIALS AND METHODS: A retrospective analysis of patients with stage pT3apN0cM0 kidney cancer treated with radical nephrectomy between 1990-2015. Univariate and multivariate Cox regression analysis to identify predictive variables and independent predictive variables relating to recurrence. RESULTS: The results of 153 patients were studied. The median follow-up was 82 (IQR 36-117) months. Recurrence-free survival at 5 years was 58.9% with a median of 97 (95% CI 49.9-144.1) months. Seventy-seven (50.3%) patients recurred. Seventy cases 70 (90.9%) had distant metastases, 17 (14.2%) of these patients had local recurrence in the bed of nephrectomy. Tumour necrosis (p=.0001), and microvascular invasion (p=.001) were identified as independent predictors of tumour recurrence in the multivariable analysis. CONCLUSIONS: In our series, after multivariable analysis, venous tumour extension was not related to recurrence. Tumour necrosis and microvascular infiltration did behave as independent predictive factors of tumour recurrence.

Differences in overall survival and cancer-specific survival in high-risk prostate cancer patients according to the primary treatment. / Diferencias en la supervivencia global y supervivencia cáncer específica en pacientes con cáncer de próstata de alto riesgo según el tratamiento primario aplicado.

INTRODUCTION AND OBJECTIVES: There is no high-level evidence as to which primary treatment provides an overall survival (OS) or cancer-specific survival (CSS) advantage in high-risk localised prostate cancer (HRLPC). Our aim was to analyse the differences in survival and predictive factors in this group of patients, according to their primary treatment (radical prostatectomy (RP) or radiotherapy and androgen blockade (RT+HT)). MATERIAL AND METHODS: A retrospective study of 286 HRLPC patients diagnosed between 1996-2008, treated by RP (n=145) or RT+HT(n=141). Survival was assessed using the Kaplan-Meier method. Significant differences between the different variables were analysed using the log-rank test. A uni and multivariate Cox regression analysis was performed to identify risk factors. RESULTS: the median follow-up was 117.5 (IQR 87-158) months. The OS was longer (p=.04) in the RP patients, while there were no differences (P=.44) in CSS between either group. The type of primary treatment was not related to OS or CSS. Age (P=.002), the onset during follow-up of a 2nd tumour (P=.0001), and stage cT3a (P=.009) behaved as independent predictive variables of OS. None of the variables behaved as an independent predictive variable of CSS, although biochemical recurrence after rescue treatment (P=.058), and the onset of a 2nd tumour during follow-up showed a significant trend to statistical significance, the latter reducing specific cancer mortality (HR .16, 95%CI .02-1.18, P=.07). CONCLUSIONS: Primary treatment did not relate to OS or CSS in patients with HRPC.

Influence of the laparoscopic approach on cancer-specific mortality of patients with stage pt3-4 bladder cancer treated with cystectomy. / Influencia del acceso laparoscópico en la mortalidad cáncer específica de los pacientes con cáncer de vejiga en un estadio pT3-4 tratados con cistectomía.

INTRODUCTION AND AIM: The main aim of the study was to establish the oncological safety of the laparoscopic approach to radical cystectomy for high-risk, non-organ-confined urothelial tumours. MATERIAL AND METHODS: A retrospective cohort study of 216 stage pT3-4 cystectomies operated between 2003 and 2016; using an open approach (ORC, n=108), and using a laparoscopic approach (LRC, n=108). RESULTS: Both groups have similar pathological features except, in G3 TUR, there were more lyphadenectomies and greater pN+, and more adjuvant chemotherapies using the LRC. The median follow-up of the series was 15 (IQR: 8-10.5) months. Sixty-eight point one percent of the series relapsed, with no differences between either group (p=.11). The estimated differences for cancer-specific survival was greater in the LRC group (p=.03), as was overall survival (p=.009). There were no differences between either group in estimated recurrence-free survival (p=.26). The type of surgical approach (p=.03), pTpN stage (p=.0001), and administration of adjuvant chemotherapy (p=.003) were related to cancer-specific mortality (CSM) in the univariate analysis. Only the pTpN stage (p=.0001), and not giving adjuvant chemotherapy (p=.003) behaved as independent predictive factors of CSM. CONCLUSION: The type of surgical approach to cystectomy (ORC vs. LRC) did not influence CSM. Lymph node involvement and not giving adjuvant chemotherapy were identified as predictive factors of CSM. Our study supports the oncological safety of the laparascopic approach for cystectomy in patients with locally advanced muscle-invasive bladder tumours.

Comparison of classical transrectal prostate biopsy versus cognitive registration in rebiopsy. / Comparación del rendimiento entre biopsia transrectal clásica y biopsia «cognitiva¼ ecodirigida en la rebiopsia de la próstata.

INTRODUCTION: The aim of this study is to compare performance of two biopsy approaches in patients with at least one previous negative prostate biopsy (PB): classical transrectal biopsy (ClTB) versus cognitive registration biopsy (COG-TB). MATERIAL AND METHODS: A retrospective study of 205 patients with at least one negative PB. 144 (70.2%) patients underwent a prior mpMRI and 61 (29.8%) patients did not. Nodule classification was carried out according PI-RADS version 2. Peripheral zone (PZ) grouped pZa, pZpl and pZpm areas, transition zone (TZ) Tza, Tzp and Cz areas, and anterior zone (AZ) AS areas. COG-TB was conducted in patients with previous mpMRI (144); while in the remaining 61 (29.8%) patients a ClTB of PZ and TZ was performed. Statistical analysis was performed using Chi square and T-student tests for qualitative and quantitative variables, respectively. Multivariate analysis was carried out in order to identify predictive variables of prostate cancer. RESULTS: Median patient age was 68 (IQR 62-72) years, median PSA was 8.3 (IQR 6.2-11.7) ng/ml and median previous biopsies was 1 (IQR 1-2). Digital rectal examinations (DRE) findings were normal in 169 (82.4%) patients and suspicious in 36 (17.6%) patients (cT2a-b in 34 patients and cT2c in 2). Median prostate volume was 48 (IQR 38-65) cc. Statistically significant differences in PSAD between both groups were found (P=.03). Transrectal ultrasound (TRUS) showed hypoechoic nodules in 8 (13.1%) ClTB patients and in 62 (43.1%) COG-TB patients (P=.0001). The median number of biopsy cylinders per set of prostate biopsies was 10 (IQR 10-10) in ClTB group and 11 (IQR 9-13) in COG-TB group (P=.75). Cancer was diagnosed in 74 (36.1%) patients: of them, 10 (16.4%) were ClTB patients and 64 (44.4%) COG-TB (P=.0001). Tumors classification was as follow: ISUP-1: 34 (45.9%), ISUP-2: 21 (28.4%), ISUP-3: 9 (12.2%), ISUP-4: 7 (9.5%) and ISUP-5: 3 (4.1%). No significant statistical differences were found (P=.89). The median number of biopsy cylinders impaired per set of prostate biopsies was 1 (IQR 1-5) in ClTB group and 2 (IQR 1-4) in COG-TB group (P=.93). Regarding independent predictive variables for prostate cancer the results were: age (OR=12.05; P=.049), suspicious DRE (OR=2.64; P=.04), hypoechoic nodule (OR=2.20; P=.03) and mpMRI +COG-TB sequence (OR=3.49; P=.003). CONCLUSIONS: In patients with at least one negative PB, mpMRI +COG-TB sequence improves 3.5 (OR=3.49) times the diagnosis prostate vs. ClTB.

Effectiveness of the «cognitive¼ biopsy in the diagnosis of prostate cancer in patients with a previous negative biopsy. / Efectividad de la biopsia «cognitiva¼ en el diagnóstico del cáncer de próstata en los pacientes con biopsia previa negativa.

INTRODUCTION: Evaluation of the effectiveness of cognitive biopsy (CB) in patients with clinical suspicion of prostate cancer (PC), and at least one negative biopsy (TRB). MATERIAL AND METHOD: Retrospective study of 144 patients with at least one previous TRB and magnetic resonance imaging (MRI). The MRI nodules were classified based on PI-RADS v2 grouping pZa, pZpl and pZpm as the peripheral zone(PZ), Tza, Tzp and CZ as the transitional zone (TZ), and the AS zones as the anterior zone (AZ). A biopsy was indicated for nodules ≥PI-RADS 3. Uni and multivariate analysis was undertaken (logistic regression) to identify variables relating to a PI-RADS 3 tumour on biopsy. RESULTS: The median age was 67 (IQR: 62-72) years, the median PSA was 8.2 (IQR: 6.2-12) ng/ml. A nodule was identified on MRI in the PZ in 97 (67.4%) cases, in the TZ in 29 (20.1%), and in the AZ in 41 (28.5%). PC was diagnosed on biopsy in 64 (44%) patients. The cancer rate in the PI-RADS 3 lesions was 17.5% (7/40), in the PI-RADS 4 47.3% (35/73), and in the PI-RADS 5 lesions it was 73.3% (22/29) (p=.0001). Multivariable analysis with variables that could influence the biopsy result in patients with PI-RADS 3: None (age, PSA, number of previous biopsies, rectal examination, PSAD, prostate volume or number of extracted cylinders) behaved as an independent tumour predictor. CONCLUSIONS: The diagnostic performance of CB in patients with at least one previous negative biopsy was 44%, increasing according to the PI-RADS grade, and low in PI-RADS 3. No clinical variable predictive of cancer was found in patients with PI-RADS 3.

Postsurgical complications in patients with renal tumours with venous thrombosis treated with surgery. / Complicaciones posquirúrgicas en los pacientes con tumor renal con trombosis venosa tratados con cirugía.

BACKGROUND AND OBJECTIVE: Surgery on renal tumours with venous thrombosis suffers a high rate of complications and non-negligible perioperative mortality. Our objective was to analyse the postoperative complications, their relationship with the level of the thrombus and its potential predisposing factors. MATERIALS AND METHODS: A retrospective analysis was conducted of 101 patients with renal tumours with venous thrombosis operated on between 1988 and 2017. Two patients were excluded because of intraoperative pulmonary thromboembolism and exitus (2%). The postsurgical complications were classified according to Clavien-Dindo. To compare the qualitative variables, we employed the chi-squared test. We performed a multivariate analysis using binary logistic regression to identify the independent predictors. RESULTS: Some type of postsurgical complication occurred in 34 (34.3%) patients, 11 (11.1%) of which were severe (Clavien III-V). There were significant differences in the total complications (P=.003) and severe complications (Clavien≥III; P=.03) depending on the level of the tumour thrombus.

Infiltrating bladder cancer: prognostic factors, follow-up and treatment of relapses. / Cáncer vesical infiltrante: factores pronósticos, seguimiento y tratamiento de las recidivas.

CONTEXT: Bladder cancer is the cause of more than 150,000 deaths per year. The overall rate of survival is approximately 45%, with a 10-year recurrence-free rate of 50-59%, with no changes in the last decade. OBJECTIVE: Due to a lack of agreement on the follow-up of cystectomy or on a uniform treatment when faced with the various types of recurrence, we have analysed the most recent literature in an attempt to unify the criteria for the diagnosis and treatment of bladder cancer. ACQUISITION OF EVIDENCE: Review of Spanish and English publications in the medical literature in the last 10 years, highlighting the most significant series in terms of the number of patients, follow-up time, as well as the existing meta-analyses. SYNTHESIS OF THE EVIDENCE: Recurrence after cystectomy can occur in the urinary apparatus (upper urinary tract or distal urethra) and local (cystectomy bed) and/or distant metastases. Despite strict control, more than 60% of the relapses are discovered based on symptoms and not by the routine follow-up test. Locoregional and distant relapses are more common the more advanced the stage at the time of cystectomy, going from 11-21% in pT2N0 to 52-72% when there is lymphocytic N+ involvement. Recurrence in the urethra and/or upper urinary track has other prognostic factors such as multiplicity, the presence of Cis and involvement of prostatic stroma. There are various treatments for tumour relapses. Increasingly, the patient's comorbidity is considered when deciding on the therapeutic strategy. Treatments are typically multimodal and include surgery, radiotherapy and chemotherapy. CONCLUSION: The follow-up of patients who undergo cystectomy should be individualised, taking into account the prognostic factors of recurrence and the patient's comorbidity, assuming that in some cases, multimodal treatment is indicated.