Retzius-sparing robot-assisted radical prostatectomy: Perioperative and immediate continence outcomes of an initial series. / Prostatectomía radical robot-asistida con preservación del espacio de Retzius: resultados perioperatorios y de continencia inmediata en una serie inicial.

OBJECTIVE: The objective of this work is to present initial perioperative, immediate continence and oncological results in a series of 25 prostate cancer patients treated with Retzius-sparing robot-assisted radical prostatectomy. MATERIAL AND METHODS: We retrospectively analyzed a series of 25 patients treated with Retzius-sparing robot-assisted radical prostatectomy for cT1-T2b prostate cancer between 2018-2019. The 5 stages of surgery are described. We make a descriptive statistic of our initial series and its outcomes in terms of immediate continence, defined as the use of 0 pad/diapers or 1 safety pad/diaper every 24 hours, one week after catheter removal. RESULTS: Median follow-up, 6 months (3-18). Median PSA, 6.1 ng/ml (4-14.3). All surgeries were performed through a posterior intrafascial approach, and bilateral nerve-sparing was carried out in 84% of the cases. Affected surgical margins were present in 28%, being the apex the most frequent site of affectation. Surgical complications: 1 (4%) patient required transfusion of blood products in the immediate postoperative period. Mean hospital stay was 48 hours. Functional outcomes: 80% of the patients present immediate continence. 80% of continent patients do not require the use of any safety pads/diapers. Oncological outcomes: 84% are free of biochemical-progression in a median follow-up of 6 months. CONCLUSIONS: Initial functional results in terms of immediate continence are very satisfactory in patients who have undergone Retzius-sparing robot-assisted radical prostatectomy without negative impact on prognosis.

Urethral reconstruction in patients previously treated with Memokath™ urethral endoprosthesis. / Reconstrucción uretral en pacientes previamente tratados con endoprótesis uretral Memokath™.

PURPOSE: To evaluate the role and success rate of urethral reconstruction in patients with urethral stricture previously treated with thermos-expandable Memokath™ urethral endoprosthesis. MATERIALS AND METHOD: A case series of patients with urethral stricture and Memokath™ endoprosthesis treated with urethroplasty is presented. Reconstruction was decided due to stricture progression or complications derived from primary stent treatment. Age, stricture and stent length, time between stent placement and urethroplasty, mode of stent retrieval, type of urethroplasty, complications and voiding parameters before and after urethroplasty were evaluated. Successful outcome was defined as standard voiding, without need of any postoperative procedure. RESULTS: Eight cases with bulbar urethra stricture were included. Memokath™ was endoscopically retrieved before urethroplasty in 6 (75%) and by open urethrotomy at the time of urethroplasty in 2 (25%). Technique of urethroplasty was dorso-lateral onlay buccal mucosa graft in 5 (62.5%) cases and excision and primary anastomosis, anastomotic urethroplasty, and dorsal onlay buccal mucosa graft in one (12.5%) case each. There was no failure at 26±21.5 months median follow-up. Total IPSS, QoL, Qmax and postvoid residual significantly improved (P<.05). The only complication presented was epididymitis and penile shortening in one patient (12.5%). CONCLUSIONS: Urethroplasty after re-stricture or other complications in patients with temporary Memokath™ urethral stent is a viable and definite option of reconstruction with excellent results in the short term and few complications. One-side dorsolateral onlay buccal mucosa graft augmentation is the optimal technique for this indication.

Treatment of stress urinary incontinence after prostatectomy with the adjustable transobturator male system (ATOMS®) with preattached scrotal port. / Tratamiento de la incontinencia urinaria de esfuerzo tras prostatectomía con el sistema masculino transobturador ajustable (ATOMS®) con puerto escrotal premontado.

INTRODUCTION: Stress urinary incontinence (SUI) is a significant sequela of prostate cancer surgery. In this article, we present the surgical technique and safety and efficacy of the adjustable transobturator male system (ATOMS®) with preattached scrotal port. MATERIAL AND METHOD: An open prospective study was conducted at a university hospital with the main objective of changing the baseline condition after adjustment in the daily pad count and their wet weight (pad test). The secondary objectives were the quality-of-life assessment (International Consultation on Incontinence Questionnaire-Short Form [ICIQ-SF] and Incontinence Impact Questionnaire-7 [IIQ-7], baseline and after the adjustment), patient-perceived results (Patient Global Index [PGI] and Global Response Assessment [GRA] at 1 year) and assessment of complications according to Clavien-Dindo. The numerical values are expressed in median ± IQR. RESULTS: We analysed 60 consecutive patients with a follow-up of 21±22 months. The baseline pad-test was 465±450mL, and the pad-count was 5+3 pads/day. The baseline SUI was mild (11.6% of patients), moderate (25%) and severe (63.3%). The operative time was 60±25min, the hospital stay was 1±0 days, and the visual analogue scale of pain on day 1 after surgery was 0±1. The total filling was 16.5±7mL, and the number of refillings was 1±2. The pad-test and pad-count after the adjustment were 0±20mL and 0±1, respectively (both p<.0001 compared with baseline). SUI disappeared (81.7%) or remained mild (11.7%), moderate (5%) or severe (1.6%). We observed a reduction in the ICIQ-SF (p<.0001) and IIQ-7 scores (p=.0003). Both continence (p=.002) and satisfaction (p=.03) were lower in the irradiated patients. Complications occurred in 11 cases (18.6%), 8 (13.5%) of which were grade I and 3 (5.1%) of which were grade 3. The treatment satisfaction rate was 91.7%, and the patient-perceived overall improvement at 1 year was highly pronounced (PGI-I score, 1±1; GRA, 6±1). CONCLUSIONS: SUI treatment of men using third-generation ATOMS® is safe and effective in the short-term, even in patients with severe SUI. The rate of dry patients after the adjustment exceeded 80%, and the satisfaction rates exceeded 90%. The patients assessed this treatment highly positively.

Prospective study comparing laparoscopic and open radical cystectomy: Surgical and oncological results. / Estudio prospectivo comparativo entre cistectomía radical laparoscópica y abierta: resultados operatorios y oncológicos.

INTRODUCTION: Laparoscopic radical cystectomy with lymphadenectomy and urinary diversion is an increasingly widespread operation. Studies are needed to support the oncological effectiveness and safety of this minimally invasive approach. PATIENTS AND METHODS: A nonrandomised, comparative prospective study between open radical cystectomy (ORC) and laparoscopic radical cystectomy (LRC) was conducted in a university hospital. The main objective was to compare cancer-specific survival. The secondary objective was to compare the surgical results and complications according to the Clavien-Dindo scale. RESULTS: We treated 156 patients with high-grade invasive bladder cancer with either ORC (n=70) or LRC (n=86). The mean follow-up was 33.5±23.8 (range 12-96) months. The mean age was 66.9+9.4 years, and the male to female ratio was 19:1. Both groups were equivalent in age, stage, positive lymph nodes, in situ carcinoma, preoperative obstructive uropathy, adjuvant chemotherapy and type of urinary diversion. There were no differences between the groups in terms of cancer-specific survival (log-rank; P=.71). The histopathology stage was the only independent variable that predicted the prognosis. The hospital stay (P=.01) and operative transfusion rates (P=.002) were less for LRC. The duration of the surgery was greater for LRC (P<.001). There were no differences in the total complications rate (p=.62) or major complications (P=.69). The risk of evisceration (P=.02), surgical wound infection (P=.005) and pneumonia (P=.017) was greater for ORC. The risk of rectal lesion (P=.017) and urethrorectal fistulae (P=.065) was greater for LRC. CONCLUSION: LRC is an equivalent treatment to ORC in terms of oncological efficacy and is advantageous in terms of transfusion rates and hospital stays but not in terms of operating room time and overall safety. Studies are needed to better define the specific safety profile for each approach.

Comparative study of hybrid laparoendoscopic single-site (LESS) partial nephrectomy and conventional multiport laparoscopy. / Análisis comparativo entre nefrectomía parcial LESS híbrida y laparoscópica convencional multipuerto.

OBJECTIVE: To investigate the surgical and oncological outcomes of hybrid laparoendoscopic single-site (LESS) in partial nephrectomy with reusable components compared with multiport laparoscopy. MATERIAL AND METHOD: Hybrid LESS technique with auxiliary 3.5mm trocar (n=20) was compared with conventional multiport laparoscopy (n=26) by a prospective, paired, nonrandomized, and comparative study in partially nephrectomized patients. RESULTS: Follow-up average was 31±18.6 months. In one case, LESS was converted to laparoscopy. No differences were found regarding age, sex, body mass index, laterality, localization, tumor size or use of double J stent. Dominance of Loop-I (P=0.09) and benign histology (P=0.05) were observed in the LESS group. Neither there were differences regarding operating time, ischemia time, use of hemostatic materials, estimated blood loss, postoperative hemoglobin levels, transfusion or other complications. In any case, to extend the skin incision for specimen extraction was not necessary. Drainage time (P=0.006) and hospital stay (P=0.003) were better in LESS patients. Concerning complications, no significant differences were observed according Clavien-Dindo scale. In laparoscopic group one patient died of pulmonary embolism after hospital discharge. No positive margins were observed in any case. During follow-up neither tumor recurrence nor disease progression were observed. CONCLUSIONS: Regarding surgical outcomes, partial nephrectomy by LESS technique does not imply improvements, excepting shorter hospital stay, probably due to accurate surgical hemostasis and/or selection of cases. No surgical and oncological risks are involved, as well as no improvement in ischemia time, blood loss or transfusion rate. We find no significant difference in cosmetic outcomes.

Treatment of long anterior urethral stricture associated to lichen sclerosus. / Tratamiento de la estenosis larga de uretra anterior asociada a liquen escleroso.

INTRODUCTION: Panurethral stricture associated with lichen sclerosus is a therapeutic challenge. We present the analysis of our results using two urethroplasty techniques based on oral mucosa graft. MATERIAL AND METHOD: Retrospective study in patients with long anterior urethral stricture (>8cm) associated with lichen sclerosus. Patients received urethroplasty with oral mucosa graft technique according Kulkarni (n=25) or two-step Johanson-Bracka urethroplasty (n=15). Demographics, operative time, complications (Clavien-Dindo), hospital stay, days with catheter, EAV postoperative pain, failure rate, need for retreatment and functional data including IPSS, QoL, Qmax, post void residual (PVR) are evaluated. RESULTS: In all cases there was involvement of glandular and penile urethra, and in 75% of bulbar urethra. A single graft was used in 22.5%, two in 72.5% and three in 5%. Patients treated at a single step were younger (P=.007). Although the length of the stenosis was equivalent in both techniques (P=.96), relapse and complication rates were higher in two-step surgery (P=.05 and P=.03; respectively) and so was operative time (P<.0001) and overall stay (P=.0002). There were no differences in preoperative IPSS, QoL, Qmax or PVR, neither in postoperative values of IPSS or Qmax; but there was a difference in QoL (P=.006) and PVR (P=.03) favouring single-step urethroplasty. VAS pain on postoperative day 1 was also lower in Kulkarni urethroplasty than in the first step of Johanson-Bracka technique (P<.0001). CONCLUSIONS: In patients with lichen sclerosus and long anterior urethral stricture Kulkarni urethroplasty provides more efficient and better patient reported outcomes than Johanson-Bracka urethroplasty. It also prevents cosmetic, sexual and voiding temporary deterioration inherent to 2-step surgery.

Total phallic reconstruction using radial forearm free flap after iatrogenic penile amputation. / Reconstrucción fálica total con colgajo libre antebraquial radial tras amputación peneana iatrogénica.

INTRODUCTION: The iatrogenic loss of the penis is a rare situation. We present a challenging case of deferred total penile reconstruction in a genetic male. MATERIAL AND METHODS: A 57-year-old man with the loss of the penis due to a penile abscess and necrosis secondary to penile curvature surgery. The reconstruction was performed over several operations using a radial forearm free flap (RFFF) and placement of a customised inflatable prosthesis a year later. RESULTS: During the first operation, the penile abscess was drained, the necrotic residues were debrided and placement of hypogastric drainage. Seven weeks later, phalloplasty was performed with RFFF and a tube-in-tube neourethra was constructed. Multiple microsurgical anastomosis was performed, and the donor site was coated with a skin graft from the thigh of partial thickness. The surgery lasted 10hours and had the complication of hair growth in the neourethra, which required mechanical endoscopic depilation on repeated occasions. The patient regained penile sensitivity. Eighteen months after the phalloplasty, a Zephyr single-body inflatable prosthesis (Geneva, Switzerland) was implanted, using the tunica albuginea of the proximal corpus cavernosum. The patient was satisfied with the aesthetics and urinary and sensory function. Four months later, the patient is gaining confidence to consider penetration. CONCLUSIONS: Despite the risk of postoperative complications and the need for multiple operations, phallic reconstruction with RFFF and the placement of a customised prosthetic implant can improve urinary and sexual function secondary to the loss of the penis.

Laser transurethral resection of the prostate: Safety study of a novel system of photoselective vaporization with high power diode laser in prostates larger than 80mL.

OBJECTIVE: To present the feasibility of photoselective vaporization of the prostate (PVP) with of a new diode laser-resection system. Surgical treatment of benign prostatic hyperplasia (BPH) is constantly evolving. Laser techniques are increasingly used in prostates of large size. METHODS: A prospective study was performed to evaluate operative data and patient outcomes with PVP using high-power diode laser (HPD) and a novel quartz-head fiber with shovel shape in patients with prostate>80mL. Demographic data, operative time, hemoglobin loss, operative results (IPSS, quality of life (QoL), Qmax, post void residue (PVR), IIEF-5 and micturition diary) and complications following Clavien-Dindo classification are described. RESULTS: Thirty-one patients were included in the study. Sixteen (51.6%) were on active antiplatelet treatment and 12 (38.7%) had received anticoagulants before surgery. All cases were followed at least 6mo. No intraoperative or postoperative major complications occurred. Three patients (9.7%) had minor complications according to Clavien-Dindo classification. Twenty-seven (87.1%) were discharged on postoperative day one without catheter. There were significant improvements in IPSS, QoL, Qmax and PVR, both at 3 and 6mo (P<.0001), but sexual function according to IIEF-5 showed no differences. Urgency (any grade) increased at 3mo (48.4%; P=.002) and considerably decreased at 6mo (9.7%; P<.0001). CONCLUSION: This pilot experience with shovel shape fiber and HPD is encouraging. It shows that laser-resection is a safe procedure, achieving excellent results in terms of IPSS, QoL and Qmax in large prostates even in high-risk patients. Longer follow-up, comparative and randomized controlled studies are needed to widespread these results.

The best option: Umbilical LESS radical nephrectomy with vaginal extraction.

INTRODUCTION: Umbilical laparoendoscopic single-site (LESS) surgery represents an excellent alternative to laparoscopic or robotic multiport surgery. LESS surgery offers faster recovery, less postoperative pain and optimal cosmetic results. The reusable nature of its instruments also has significant economic advantages. PATIENT AND METHOD: We present a 34-year-old patient with a solid mesorenal lesion measuring 8 cm in the left kidney treated with pure LESS radical nephrectomy assisted by vaginal extraction of the specimen. The umbilical approach using a single-site multichannel KeyPort (Richard Wolf GmbH, Knittlingen, Germany) with DuoRotate curved instruments allows for minimum crushing and fewer spatial conflicts. Its perfect umbilical adaptation provides a hermetic system. The instrument's double rotation provides considerable movement precision. Vaginal extraction avoids damage to the abdominal wall and the need for widening the umbilical incision. RESULTS: After the placement of the device and triangulation of the clips, we proceeded to operate on posterior parietal peritoneum. The descending colon was mobilized to access the retroperitoneum and dissect the renal hilum. Hem-o-lok clips were placed on the artery and vein, which were subsequently sectioned. The specimen was inserted into a laparoscopic bag. Under direct vision, we placed a 15-mm trocar through the bottom of the vaginal posterior fornix to facilitate the extraction of the bag's thread. The incision was widened with the fingers, and the specimen was extracted, closing the vagina from the perineum with visualization from the navel. Abdominal drainage was not employed. The surgical time was 180 min. The patient was discharged the following day without needing analgesia. A year later, the patient was disease-free and had no complications. CONCLUSIONS: Umbilical LESS radical nephrectomy with vaginal extraction is feasible in selected cases. The procedure is oncologically safe, avoids scars and facilitates early recovery. From a practical point of view, this approach greatly simplifies natural orifice transluminal endoscopic surgery (NOTES) and enables a minimally invasive equivalent result.

Treatment for long bulbar urethral strictures with membranous involvement using urethroplasty with oral mucosa graft.

INTRODUCTION: Urethroplasty with oral mucosa grafting is the most popular technique for treating nontraumatic bulbar urethral strictures; however, cases involving the membranous portion are usually treated using progressive perineal anastomotic urethroplasty. We assessed the feasibility of performing dorsal (or ventral) graft urethroplasty on bulbar urethral strictures with mainly membranous involvement using a modified Barbagli technique. MATERIAL AND METHODS: This was a prospective study of 14 patients with bulbomembranous urethral strictures who underwent dilation urethroplasty with oral mucosa graft between 2005 and 2013, performed using a modified technique Barbagli, with proximal anchoring of the graft and securing of the graft to the tunica cavernosa in 12 cases (85.7%) and ventrally in 2 (14.3%). The minimum follow-up time was 1 year. We evaluated the subjective (patient satisfaction) and objective (maximum flow [Qmax] and postvoid residual volume [PVRV], preoperative and postoperative) results and complications. Failure was defined as the need for any postoperative instrumentation. RESULTS: A total of 14 patients (median age, 64+13 years) underwent surgery. The main antecedent of note was transurethral resection of the prostate in 9 cases (64.3%). The median length of the stenosis was 45+26.5mm. Prior to surgery, 50% of the patients had been subjected to dilatations and 4% to endoscopic urethrotomy. The mean surgical time and hospital stay were was 177+76min and 1.5+1 day, respectively. The preoperative Qmax and PVRV values were 4.5+4.45mL/sec and 212.5+130 cc, respectively. The postoperative values were 15.15+7.2mL/sec and 6+21.5cc, respectively (P<.01 for both comparisons). Surgery was successful in 13 cases (92.9%). None of the patients had major complications. There were minor complications in 1 (7.1%) patient, but reintervention was no required. CONCLUSION: The repair of long bulbar urethral strictures with membranous involvement using urethroplasty with free oral mucosa grafts represents a viable alternative for patients with nontraumatic etiology and little fibrosis. The dilation of the urethral lumen achieves good results with minimum failure rates and little probability of complications. For many of these patients, the length of the stricture is too long to perform the tension-free anastomosis technique.

Effects of resveratrol and other wine polyphenols on the proliferation, apoptosis and androgen receptor expression in LNCaP cells.

PURPOSE: To address the effect of resveratrol and other red wine polyphenols on cell proliferation, apoptosis and androgen receptor (AR) expression in human prostate cancer LNCaP cells. MATERIALS AND METHODS: LNCaP cells (5 × 102) were cultured in microtiter plate modules and treated with gallic acid, tannic acid and quercetin (1, 5 and 10 µM), rutin and morin (25, 50 and 75 µM) and resveratrol (5, 10 and 25 µM). To address the extent of proliferation at 24, 48, 72 and 96 hours, a colorimetric immunoassay method was used. An activity caspase 3/7 detection assay was used to disclose apoptosis at 24, 48 and 72 hours. AR mARN levels were determined by real time RT-PCR. RESULTS: All polyphenols studied significantly inhibited (P<.05) cell proliferation compared to control. However, there were moderate differences between them. Resveratrol was the strongest inhibitor at different times and doses. Also, caspase-3 and caspase-7 activity was significantly higher (P<.05) than control in the presence of all the compounds, but the earlier response was achieved by resveratrol. Resveratrol, quercetin and morin were the only nutrients that significantly inhibited AR mRNA expression. Again resveratrol produced the highest inhibition (90-250 times less than control), followed by morin (67-100 times) and quercetin (55-91 times). CONCLUSIONS: All polyphenols studied showed important antiproliferative effects and induced apoptosis when added to LNCaP cells culture. We confirm that resveratrol, morin and quercetin may achieve such effect through reduced expression of AR. The synergistic effects of these compounds and their potential to prevent progression of hormone-dependent prostate cancer merit further study.

Analysis of the factors involved in the failure of urethroplasty in men.

INTRODUCTION: Outcome of urethroplasty techniques in our environment and risk factors for recurrence of stenosis in these patients are studied in this paper. MATERIAL AND METHODS: Retrospective study on men with urethral strictures treated with urethroplasty in the period 2000-2012. Maximum flow (Qmax), post-void residual (PVR) urine and patient perception of voiding were obtained pre- and postoperatively. Complications were recorded according to the Clavien-Dindo scale. Recurrent stricture was defined according to clinical criteria and endoscopic or imaging confirmation (failure of urethroplasty). Univariate analysis (log-rank) and multivariate (Cox regression) were performed to define the variables implied in the recurrence. RESULTS: 82 patients with mean age 55.6 ± 17.4 (19-84 years) underwent surgery for urethroplasty. 28% of patients showed multiple stricture, 73.2% bulbar stricture, 41.54% penile stricture and 14.6% membranous stricture. End-to-end anastomosis was performed in 26 cases (31.7%), flap urethroplasty in 21 (25.6%), urethroplasty with free graft in 31 (37.8%) and two-time urethroplasty in 4 (4.9%). Graft urethroplasty showed a longer operative time (p = 0.02) and shorter hospital stay (P = 0.0035). The results were: mean ΔQmax (mean on baseline) 9.1 ± 7.5 and mean ΔPVR -65.8 ± 136 (both P < 0.0001). Minor early complications occurred in 8 (9.8%) and major in 3 (3.6%). Recurrence occurred at a mean time of 39.8 ± 39.2 months in 18 patients (21.9%). The percentage of recurrence-free patients was: 91.4% (1-year), 82.1% (5-year) and 78.1% (10-year). Univariate analysis assessed technique used (log-rank, P = 0.13), age (P = 0.2), length stricture (P = 0.003), previous Sachse (P = 0.18), associated lichen (P = 0.18), multiplicity (P = 0.36), year of surgery (P = 0.2), Qmax (P = 0.3) and RPM (P = 0.07) preoperative. End to end anastomosis (HR 4.98, P = 0.04) and length > 3 cm (HR 4.6, P = 0.01) were identified by regression analysis as independent variables associated with poor prognosis. CONCLUSION: Length stricture is both prognostic factor and criterion on choosing the type of urethroplasty, and it makes more complicated to compare the success rates of each surgical procedure. Whatever the stricture size is, the results of anastomotic urethroplasty are worse than those of urethroplasty with buccal mucosal-free grafts.

[Available evidence about efficacy of different restoring agents of glycosaminoglycans for intravesical use in interstitial cystitis]. / Evidencia disponible relativa a la eficacia de diferentes agentes endovesicales restituidores de glucosaminoglicanos empleados en cistitis intersticial.

OBJECTIVES: To compare the different endovesical therapeutic regimes in terms of clinical effectiveness based on glycosaminoglycan replenishment agents (RA-GAG) available on the market in Spain. MATERIAL AND METHODS: A bibliographic analysis was made of the studies published in Medline from 1996 to 2012 on RA-GAG of application in the bladder, placing emphasis on the clinical results. A post-hoc comparison was made of the efficacy of this treatment in the studies conducted in patients with interstitial cystitis in different conditions by calculating the effect sizes to analyze improvement on the pain visual analogue scale (VAS) and clinical response rate. The number of patients needed to treat (NNT) for the different agents was calculated based on the odds ratio and associated economic implications. RESULTS: The globally available evidence is scarce. There are 38 articles about RA-GAGs in different indications, 71 of them in interstitial cystitis and only 8 may assist in establishing a comparison between the results presented. The treatments used were placebo, 0.8% high molecular weight hyaluronic acid (Cystistat(®)), 2% chondroitin sulfate sodium (Uracyst(®)) and a combination of 1.6% low molecular weight hyaluronic acid plus 2% chondroitin sulfate (Ialuril(®)), between 6 and 12 instillations. Another low molecular weight hyaluronic acid preparation (Uromac(®)) lacks any scientific evidence. All the therapeutic elements studied show a mean score decrease on the pain VAS and increase in the rate of post-treatment response. The NNT for the treatments that are statistically more beneficial over placebo ranges from 1.6 and 4.1. The post-hoc comparison of the response rates has established that Cystistat(®) 12 instillations (OR 18.8; 95% CI 6.4-57.2; P=.001) or 10 instillations (OR 19.2; 95% CI 5.3-75.3; P=.001) are the treatment regimes that obtain maximum effectiveness. In both cases, the NNT was 1.6. CONCLUSIONS: This study has multiple limitations inherent to the nature of the design. However, although the available literature is scarce, it shows that there are differences regarding the clinical effectiveness of the different agents and regimes used for endovesical treatment of interstitial cystitis. These differences also entail economic type implications.

[Laparoendoscopic radical cystectomy with orthotopic ileal neobladder through umbilical single port]. / Cistectomía radical laparoendoscópica con neovejiga íleal ortotópica a través de puerto único umbilical.

CONTEXT: Radical cystectomy with orthotopic derivation is one of the most complex urological techniques, although laparoscopic surgery has made this procedure increasingly less invasive. OBJECTIVE: To provide an up-dated review of the single port approach to carry out radical surgery due to bladder cancer. EVIDENCE ACQUISITION: A comprehensive review of the literature was performed using Medline and Embase to discover the accumulated experience of the viability of carrying out laparoendoscopic radical cystectomy, pelvic lymphadenectomy and orthotopic neobladder using the laparoendoscopic single site surgery (LESS) approach. Our experience with this approach is also presented and the technique used with the reusable KeyPort(®) system developed by Richard Wolf is described. EVIDENCE SYNTHESIS: Radical treatment of bladder cancer is possible in men and women using a single port and even performance of ileal neobladder, as reconstructive procedure in these patients. The surgical technique, post-operative cares and result obtained in our center are described. The accumulated experience worldwide describes 25 cases of radical cystectomy performed using different single port systems, 14 of them with orthotopic intestinal neobladder. CONCLUSION: The KeyPort(®) umbilical cystectomy constitutes in our setting the least possible invasive alternative to efficiently treat muscle-invasive bladder cancer, with excellent esthetic result, minimum post-operative pain and short hospital stay. The umbilical scar decreases the analgesic requirements and it ends up being practically invisible. This supposes an important step in the development of the minimally invasive surgery for bladder cancer.

[Urodynamic aspects of feminine urinary incontinence treated with slings]. / Aspectos urodinámicos de la incontinencia urinaria femenina tratada con cabestrillos.

OBJECTIVES: Treatment of feminine stress urinary incontinence (SUI) with slings aims to supplement the function of the damaged ligaments, favoring the correct transmission of the tensions. Our objective is to determine which preoperative variables could predict the outcome of surgical treatment of SUI and to study the urodynamic changes produced by the surgery. MATERIAL AND METHODS: 139 women (age X =61.7; σ=10.88) operated on due to SUI were studied retrospectively. In 118 cases (84.8%), sling techniques (TVT, TOT, TVT-Safyre, REEMEX) were used. Clinical evaluation and complete preoperative video -urodynamics were made pre-operatively and at 3 months of surgery. A statistical study (Fisher's test, Wilcoxon, Friedman, Student's T and Pearson's χ(2)) and analysis of multivariant logistic regression analysis by step elimination method were performed. RESULTS: Post-operatively, the SUI (p=0.000) and bladder hyperactivity syndrome decreased. The success percentages (urodynamic absence of SUI) for each technique were: TVT-Safyre (75%), TOT (73%), TVT (60%) and REEMEX (57%), without significant differences. Age (ROC cut-off: 61 years) was a prognostic factor of success (p=0.024). Preoperative maximum flow (Qmax) (16 ml/s) constituted the only urodynamic parameter with a predictive value for success (p=0.026). An open bladder neck was a risk factor for persistence of postoperative SUI (RR=2.78). A significant decrease of the postsurgical Qmax (p=0.017) was verified, without increase of the post micturation residue or of the Wmax. An increase of the postsurgical urethral resistance (UR) was also observed (p=0.004). CONCLUSIONS: The pre-operative Qmax is the most important urodynamic prognostic parameter in feminine SUI surgery, its normality being associated to a greater probability of cure of the incontinence. In the cases of decreased preoperative flow, use of slings that increase urethral resistance more (REEMEX) is not recommended. Hyperactivity of the preoperative detrusor does not significantly modify the results of surgery of the SUI.