Beyond the Briganti nomogram: Individualisation of lymphadenectomy using selective sentinel node biopsy during radical prostatectomy for prostate cancer. / Más allá del nomograma de Briganti: individualización de la linfadenectomía utilizando la biopsia selectiva del ganglio centinela durante la prostatectomía radical por cáncer de próstata.

OBJECTIVE: To validate the technique of selective sentinel node biopsy for diagnosing and staging intermediate to high-risk prostate cancer by comparing the technique with conventional extended lymphadenectomy (eLFD) in a prospective, longitudinal comparative study. METHODS: We applied the technique to 45 patients. After an intraprostatic injection of 99mTc-nanocolloid and preoperative single-photon emission computed tomography (SPECT/CT), we extracted the sentinel lymph nodes, guided by a portable Sentinella® gamma camera and a laparoscopic gamma-ray detection probe. The eLFD was completed to establish the negative predictive value of the technique. RESULTS: SPECT/CT showed radiotracer deposits outside the eLFD territory in 73% of the patients and the laparoscopic gamma probe in 60%. The mean number of active foci per patient was 4.3 in the SPECT/CT and 3.2 in the laparoscopic gamma probe. The mean number of extracted sentinel lymph nodes was 4.3 (0-14), with 26% outside the eLFD territory. The lymph nodes were metastatic in 10 patients (22%), 6/40 (15%) when the prostatectomy was the primary treatment. In all cases with metastatic lymph nodes, there was at least one positive sentinel node. Metastatic sentinel lymph nodes were found outside the eLFD territory in 3/10 patients (30%). The sensitivity was 100%, the specificity was 94.73%, the positive predictive value was 81.81%, and the negative predictive value was 100%. CONCLUSION: Selective sentinel node biopsy is superior to eLFD for diagnosing lymph node involvement and can avoid eLFD when metastatic sentinel lymph nodes are not found (85%), with the consequent functional advantages.

[Factors affecting the PSA:alpha 1 antichymotrypsin/total PSA ratio]. / Factores que influencian el cociente PSA:alpha 1 antiquimotripsina/PSA-total.

OBJECTIVES: To evaluate the influence of several factors, including age, prostate volume, total PSA (PSA-T), clinical stage and Gleason on the PSA:alpha 1ACT/PSA-T (C/T) ratio. MATERIAL AND METHODS: Using in-house assays, we measured plasma levels of PSA-T and PSA:alpha 1ACT complex in 622 patients with benign prostate hyperplasia (BPH) (455 with hystological confirmation and 167 with clinical evidence of absence of malignance) and in 255 patients with prostate cancer (CaP), and determined the correlation between different parameters. RESULTS: In BPH patients, PSA-T and PSA:alpha 1ACT significantly increased with age. There was a positive correlation between age and PSA-T (r = 0.161, p < 0.0001) and PSA:alpha 1ACT (r = 0.141, p = 0.001). In contrast, the C/T ratio remained constant and below 70% in all decades. Similar results were obtained in CaP patients. In BPH patients, there was a positive correlation between prostate volume and PSA-T and PSA:alpha 1ACT, but not with the C/T ratio. In CaP patients, however, there was a negative correlation between prostate volume and the C/T ratio. An excellent correlation was found between PSA-T and PSA:alpha 1ACT, and a good correlation between PSA-T and the C/T ratio and between PSA:alpha 1ACT and C/T ratio. A multiple regression analysis showed that, in HBP and CaP patients, PSA-T and PSA:alpha 1ACT complex were the only parameters that significantly and independently influenced the C/T ratio. CONCLUSIONS: The C/T ratio is independent of age, prostate volume, Gleason and clinical stage. Therefore, these factors need not to be considered when using the C/T ratio.

[PSA:alpha 1-antichymotrypsin ratio/total PSA in the diagnosis of prostatic cancer in the range of total PSA from 4 to 10 ng/ml]. / El cociente PSA:alpha 1 antiquimotripsina/PSA total (C/T) en el diagnóstico del cáncer de próstata en el rango de PSA total entre 4 y 10 ng/ml.

OBJECTIVE: To evaluate the usefulness of the ratio PSA:alpha-1-antichymotrypsin/total PSA (C/T) in the diagnosis of prostate cancer in the range of total PSA between 4 and 10 ng/mL. MATERIAL AND METHODS: By using home-made ELISAs we have determined plasmatic concentrations of total PSA and complex PSA:alpha-1-ACT in 300 patients with total PSA between 4-10 ng/mL. All samples were obtained before any manipulation that could interfere the PSA levels. RESULTS: By prostatic biopsy 85 patients (28.3%) were diagnosed of prostate cancer (CaP) and 215 (71.6%) of benign prostatic hyperplasia (BPH). The mean values of the complex PSA:alpha-1-ACT (4.2 ng/mL in the BPH patients vs 5.0 ng/mL in the CaP patients) and of the C/T ratio (0.70 vs 0.82, respectively) showed significant differences between both groups (p = < 0.0001). The total PSA did not show differences (6.1 ng/mL vs 6.0 ng/mL; p = 0.79). From all three parameter evaluated, the ratio C/T had the biggest area under the ROC (0.884) and statistically significant differences in comparison with total PSA (0.490; p = < 0.001) and the complex PSA:alpha-1-ACT (0.696: p = < 0.001). Therefore, by using a ratio C/T > 0.62 to decide the performance of a biopsy, 27% of the patients with BPH could have avoided this procedure with a 100% sensitivity. Increasing the ratio to 0.68 the specificity is 47% and the sensitivity is 95.2%. Rectal examination did not have influence on the cut-off, sensitivity, specificity and area under the ROC of the ratio C/T. CONCLUSIONS: Our results confirm that the ratio C/T improve the diagnostic capacity of the total PSA between 4-10 ng/ml. Moreover, the rectal examination does not influence the selection of ratio C/T cut-off suggestives of CaP neither the diagnostic efficacy.

[Subcutaneous metastasis as the first manifestation of kidney cancer dissemination]. / Metástasis subcutáneas como primera manifestación de la diseminación del cáncer renal.

Presentation of an uncommon form of distant primary dissemination of renal adenocarcinoma (RA) 5 years after radical surgery, the subcutaneous metastasis. The patient underwent surgical resection of metastasis, and later developed early pulmonary, mediastinal and new skin metastasis. A review is made of the incidence, therapeutical approach and prognostic value of skin metastasis due to RA.

[Treatment of benign prostatic hyperplasia with finasteride. Results after 7 years of follow-up]. / Tratamiento de la hiperplasia benigna de próstata con Finasteride. Resultados a los siete años de seguimiento.

Our centre took part in an international, multicentre, Phase III trial with Finasteride (MK-906) in the treatment of BPH. In the first year, this was a double-blind, randomised, placebo-controlled study which included 25 patients who were randomly assigned: 9 to treatment with placebo, 8 to finasteride 1 mg and 8 to finasteride 5 mg. After the first year, all patients were assigned to finasteride 5 mg as a single daily dose taken before breakfast. Of the 25 patients who started the trial, 7 have completed 7 years treatment (28%): 1 from the placebo group. 1 from finasteride 1 mg, and 5 who took finasteride 5 mg throughout the study. Total symptoms score, assessed by the modified Boyarsky questionnaire, improved during the first year 4.97 points (51%) and remained unchanged up to year 7 with a final reduction of 6.2 points (64%). Percentual increase in peak urinary flow during follow-up ranged between 21 and 45.9% with an absolute increase at 7 years of 4.2 mL/seg (47.5%) and a reduction in prostate volume of 26%. Finasteride tolerance was excellent at all times, and no serious clinical reaction was seen in laboratory parameters. Two patients reported decreased libido and sexual potency and 1 decreased libido. In summary, since after 7 years of treatment efficacy is maintained in at least 30% of patients with an excellent safety profile, finasteride can be considered an alternative in the medical treatment of BPH.

[Factors influencing variability of PSA blood concentration in patients with prostate benign hyperplasia]. / Factores que influyen en la variabilidad de la concentración sérica de PSA en pacientes con hiperplasia benigna de próstata.

Study conducted in 107 patients with prostate benign hyperplasia to establish the influence that prostate volume, age, sexual activity, extent of obstruction and presence of urethral catheter have on PSA serum levels, using a linear regression model. In simple linear regression studies, a good correlation was seen between PSA serum concentration and prostate volume calculated by transrectal ultrasound (r = 0.57), which decreases when age in used as an independent variable (r = 0.40). In multiple linear regression studies where all the variables are included, correlation increases slightly (r = 0.60), and only prostate volume and sexual activity are significant. Prostate volume in the single most influential factor on PSA levels in prostate benign hypertrophy although it is not the only parameter to be taken into account in serum level variations of this marker. Age influence can be secondary to other factors such as sexual activity.

[Verrucous carcinoma of the penis]. / Carcinoma verrucoso de pene.

Verrucous carcinoma includes approximately 5% of all neoplasias of the penis and is a tumoral variety of benign behaviour and differentiated histology. Our 10-case experience of penial verrucous carcinoma is reported here. In nearly all cases, partial penectomy was the definitive approach. No dissemination, locorregional or distant, was found in any of the report cases. Since prognosis of these tumours is good, we see no justification in performing lymphadenectomy, although it is advisable to adopt and expectant attitude when faced to inguinal adenopathies.

[Burned-out testicular tumor]. / Tumor testicular fundido.

Burned-out testicular tumour is an uncommon entity defined by the spontaneous regression of the testicular tumoral site after spread to metastasis, leaving behind a scarring lesion with typical histological changes. This paper reports one case of burned-out testicular tumour diagnosed and treated initially as an embryonic carcinoma with areas of extragonadal malignant immature teratoma that after nine years of follow-up reveals the primary testicular site. Physical examination and detailed ultrasound study of the testes is of the greatest significance in stem cells tumours with extragonadal location, given the prospect of identifying the primary testicular lesion as a burned-out tumoral site and performing radical treatment of these tumours.

[Treatment of prostatic benign hyperplasia with endoscopically controlled laser fiber]. / Tratamiento de la hiperplasia benigna de próstata con fibra de láser bajo control endoscópico.

Between October 1992 and February 1993, 12 patients with benign prostate hyperplasia (BPH) were treated with Neodymium-YAG laser through an endoscopically-guided right angle fibre, and follow-up is now over 1 year. Follow-up consisted in the symptomatic assessment using I-PSS questionnaires, vesicoprostate ultrasound with flowmetry and residue measurement and urethrocystometry at least every 3 months. Mean time for suprapubic catheter withdrawal was 23.4 days (range 9-34), and one patient did not resumed micturition spontaneously. Symptomatology improved after the first month. remaining stable after 6 months, with a mean score decrease at one year of 11,2 (p < 0,001). All flowmetry parameters improved although only peak and mid-stream flow showed statistical differences, peak flow increasing at one year by an average of 5,9 ml/sec (P < 0,001). In 4 of the 12 patients surgery was performed; 1 underwent early surgery due to absence of spontaneous micturition and was excluded from the results assessment, and 3 due to persistence of symptomatology at 16, 18 and 21 months post-laser. In spite of the advantages presented by the laser when compared to conventional surgical approaches, such as short time application, absence of haemorrhage and likely used in an ambulatory setting, the major initial irritative symptomatology and the need for a suprapubic catheter during at least three weeks, are in general poorly tolerated and limit its use. The apparent improvement in symptomatology after one month is not accompanied by objective changes in flowmetry, since in our series only 1 patient presented Qmax greater than 15 ml/sec with no residues. Therefore, we consider that treatment with endoscopically-guided laser fibre in BPH has, with the technology currently available. a very limited use.

[Perirenal abscess following lithotripsy]. / Absceso perirrenal post-litotricia.

Presentation of one case of perirenal abscess secondary to lithotrity on a calcified cyst simulating a pyelic lithiasis. A pathogenic hypothesis and the importance of urography in the confirmation diagnosis of the lithiasic disease is raised.

[Extracorporeal shock-wave lithotripsy in polycystic kidneys]. / Litotricia extracorporea por ondas de choque en riñones poliquísticos.

Presentation of 6 cases (8 renal units) of lithiasis in polycystic kidneys treated with extracorporeal shockwave lithotrity (ESWL). One patient required puncture of a compressing cyst, prior to ESWL, to facilitate the stones removal. No complications were seen in any of the cases. Therefore, stones in polycystic kidneys can be safely and effectively treated by ESWL.