An atypical presentation of renal mass associated with BAP-1 tumor predisposition syndrome: Case report and review of literature.

BCRA-associated protein-1 (BAP-1) mutation has been associated with the development of a familiar syndrome that predisposes to tumors with a higher incidence than in general population, including melanoma and renal carcinoma. We report a 47-year-old woman diagnosed with a BAPoma (melanocytic tumor characterized by the loss of BAP-1). Due to her extensive family history with multiple neoplasms, a FDG PET-CT was performed. Consequently, she was diagnosed with an atypical renal mass, which is rarely linked to this syndrome. We review and discuss the available literature on the screening, diagnosis and treatment of renal tumors associated with BAP-1 tumor predisposition syndrome.

Results of the spanish section of the European Randomized Study of Screening for Prostate Cancer (ERSPC). Update after 21 years of follow-up. / Resultados de la rama española del Estudio Randomizado Europeo de Screening del Cáncer de Próstata (ERSPC). Actualización tras 21 años de seguimiento.

INTRODUCTION AND OBJECTIVE: The objective of the European Randomized Study of Screening for Prostate Cancer (ERSPC) is to assess whether prostate cancer (PCa) screening leads to an improvement of cancer-specific survival. This multicenter study (eight European countries) has recruited more than 180,000 asymptomatic men. After a follow-up period of 16 years, it has been shown that PSA screening reduces PCa mortality by 20%, and that it does not affect all-cause mortality. This article provides updated the results of the Spanish arm of the ERSPC after 21 years of follow-up. MATERIALS AND METHODS: The study invited 18,612 men (aged 45 - 70) of the Spanish section (Getafe and Parla, Madrid) to participate. They were randomly assigned to the intervention arm (serum PSA-based screening) and to the control arm (follow-up without intervention). The diagnoses of PCa were recorded, as well as the PCa-specific and all-cause mortality rates. A comparison between the survival curves of both arms of the study and detailed analysis of the causes of death were performed. RESULTS: The study finally included 4,276 men (2,415 intervention arm, 1,861 control arm). The median age, serum PSA and follow-up time were 57 years, 0.9 ng/ml and 21.1 years, respectively. There were 285 cases with PCa diagnosis, 188 (7.8%) from the intervention arm and 97 (5.2%) from the control arm (p<,001). A total of 216 (75.8%) presented organ-confined disease. There were 994 deaths were recorded; 544 (22.5%) in the intervention arm and 450 (24.2%) in the control arm. No significant differences were detected between the arms of the study in terms of cancer-specific (p=.768) or all-cause (p=.192) mortality rates. The main cause of death was malignant tumors (492 patients, 49.5% of overall mortality), and the most frequent sites were lung and bronchus (29.5%), colon and rectum (14.8%), and hematologic (9.8%). Only 20 patients (0.4% of the patients recruited) died from PCa, with no significant difference between study arms. CONCLUSIONS: In this update of the results of the Spanish section of the ERSPC study after 21 years of follow-up, we have not detected a benefit of PCa screening in terms of overall and cancer-specific survival.

Predictors of urethral stricture recurrence after endoscopic urethrotomy. / Factores predictivos de recidiva de estenosis uretral tras uretrotomía endoscópica.

OBJECTIVE: The aim of the study was to analyse the clinical-demographic variables of the series and the predictors of urethral stricture recurrence after endoscopic urethrotomy. MATERIAL AND METHODS: We retrospectively analysed 67 patients who underwent Sachse endoscopic urethrotomy between June 2006 and September 2014. Those patients who had previously undergone endoscopic urethrotomy or urethroplasty were excluded. The other patients who presented urethral stricture were included. We analysed age, weight, smoking habit, and cardiovascular risk factors, as well as the number, location, length and aetiology of the strictures, previous urethrotomies, vesical catheter duration and postsurgical dilatations. A univariate and multivariate analysis was conducted using the chi-squared test or Fisher's test and logistic regression to identify the variables related to recurrence. RESULTS: Thirty-seven percent of the patients had a relapse. The majority of the patients were older than 60 years (56.7%), obese (74.6%), nonsmokers (88%) and had no cardiovascular factors (56.7%). The majority of the strictures were single (94%), <1cm (82%), bulbar urethral (64.2%), iatrogenic (67.2%) and with no prior urethrotomy (89.6%). The majority of the patients carried a vesical catheter for <15 days (85.1%) and did not undergo postsurgical dilatation (65.7%). Only the length of the stricture was an independent risk factor for recurrence (P=.025; relative risk, 5.7; 95% CI 1.21-26.41). CONCLUSIONS: In the treatment of urethral strictures through endoscopic urethrotomy, a stricture length >1cm is the only factor that predicts an increase in the risk of recurrence. We found no clinical or demographic factors that caused an increase in the incidence of recurrence. Similarly, technical factors such as increasing the bladder catheterisation time and urethral dilatations did not change the course of the disease. Their routine use is therefore unnecessary.

Cavernoplasty with oral mucosa graft for the surgical treatment of Peyronie's disease. / Cavernoplastia con injerto de mucosa oral para el tratamiento quirúrgico de la enfermedad de La Peyronie.

BACKGROUND: Peyronie's disease is a disorder of the tunica albuginea and causes penile curvature, requiring surgical correction when the deformity impedes penetration. MATERIAL AND METHODS: Retrospective analysis of the short-term results (penile length, angle of curvature and erectile function) of treating Peyronie's disease in 10 patients through cavernoplasty with oral mucosa graft. Essentially, the treatment included the incision of the fibrotic plaque with electrical scalpel and the subsequent coating of the cavernous defect using a patch of oral mucosa. At month 6, we measured the penile length and curvature and recorded the erectile function using the International Index of Erectile Function-5 (IIEF-5) questionnaire. Finally, the patients were asked "Would you undergo the same operation again?". RESULTS: The mean age was 53.4 years. The average and median follow-up was 22.7 months and 24 months, respectively. The mean preoperative curvature was 68.5° (50°-90°), the mean penile length was 11.2cm (9-15) and the mean IIEF-5 score was 16.1 (8-25). The mean postoperative penile length was 10.7cm, and the mean IIEF-5 score was 18.9. The differences between the preoperative and postoperative values were not statistically significant (P=ns). One patient developed erectile dysfunction. In all cases, the residual curvature was <20°. Nine patients (90%) stated that they would undergo the same operation. CONCLUSIONS: The short-term results suggest that cavernoplasty with oral mucosa graft can be an alternative to traditional grafts for surgically correcting Peyronie's disease.

Rotation of the corpora cavernosa for the treatment of congenital penile curvature.

INTRODUCTION: Congenital penile curvature (CPC) is caused by a disorder in the embryonic development of the urethra and corpora cavernosa. The condition causes difficulty for penetration, requiring surgical correction when it prevents intercourse. MATERIAL AND METHODS: We present the cases of 2 men in their 40s who had ventral curvature greater than 60° of 2 years of evolution, with maintained erections. The patients underwent surgery for rotation of the corpora cavernosa. After the complete denudation of the penis, athermal release of the neurovascular bundle of the penis from the ventral side to the dorsal was performed. Once the curvature was verified using artificial erection, an incision was performed in the tunica albuginea of both corpora cavernosa, continuously suturing both internal and external margins with resorbable monofilament. The rectification of the curvature was then checked, and the mucocutaneous plane was reconstructed. RESULTS: The surgical time was 120minutes and there were no intraoperative complications. Both patients were discharged 24h after the surgery. At 1 week, the patients experienced spontaneous night-time erections and were able to maintain sexual relations 1 month after the surgery. At 6 months, the residual curvature was less than 20°, the penile shortening was less than 1 centimeter and the International Index of Erectile Function-5 was 25 for both cases. CONCLUSIONS: Surgery for rotation of the corpora cavernosa helps correct CPC without significant penile shortening or erectile dysfunction. In our opinion, the procedure is an appropriate treatment for patients with CPC but requires studies with long-term follow-up in order to consider it the technique of choice.

Predicting factors for recurrence in low-grade Ta primary bladder tumours.

OBJECTIVES: Ta bladder tumors constitute 53% of primary bladder neoplasms, 70% of them being low-grade (G1). These tumors present a 15- 38% chance of recurrence during the first year. The aim of this paper is to identify the predicting factors of the first recurrence in a series of TaG1 primary bladder tumors. METHODS: We have retrospectively analyzed patients who were diagnosed with TaG1 primary bladder tumor by transurethral resection between 2004 and 2012. We established their tumor grade and pathological stage according to the WHO's classification guides for 1973 and 2004 as well as 2009's TNM. Those patients who were diagnosed before 2009 did not receive any adjuvant treatment. Those who were diagnosed later on received 40 mg of endovesical Mitomycin C during their immediate post operative period as their only treatment. We define recurrence as the presence of tumor after the first cystoscopy and relapse-free survival (RFS) as the period of time (in months) until the first recurrence appeared. Follow up constitutes the period of time (in months) until the last check-up or first recurrence. We also analyzed different variables: age, gender, smoking habits, muscular representation in the sample, size of the tumor (> or < 1 cm), multiple or single tumors and adjuvant treatment. The survival analysis was performed by the Kaplan-Meier method, using the long-rank test to evaluate the differences between groups. RESULTS: 68 patients were included in the study (73.5% men, 75% smokers). The average age was 61.9 years (the median being 58.5). Average follow up was 33.2 months (median 28.4). 35.3% of patients experienced recurrence. Average RFS was 19.2 ± 12.7 months (median 13.5). The majority of tumors were of a single nature (77.9%), with a size of less than 1 cm (55.9%) and with muscle representation (52.9%). 57.4% of patients did not receive adjuvant treatment. Only the absence of adjuvant treatment was associated with recurrence in uni and multivariate analysis (p<0,001), with a relative risk of 17,5 IC95% (7,6-30,2). CONCLUSION: The absence of adjuvant therapy with Mitomycin C is the only factor that, in a statistically significant way, increases the risk of recurrence, regardless of demographic factors and the characteristics of the tumor.

Predictive postoperative model for biochemical recurrence in patients with localized prostate cancer treated with radical prostatectomy as monotherapy.

OBJECTIVES: To identify the post-prostatectomy prognostic factors of biochemical recurrence (BCR) and develop a predictive model for BCR based on predictive pathological variables after radical prostatectomy (RP). METHODS: We retrospectively analysed patients with clinically localised prostate cancer treated with RP as monotherapy with a minimum follow up period of 12 months. We considered BCR to be the persistence or elevation of PSA levels after RP of> 0,4 ng/ml, and rising in the following determination. We performed uni-and multivariate analysis, using the logistic regression test to determine the variables associated with BCR. We developed a mathematical model to estimate BCR, based on the variables identified, with a logistic function equation and then designed an Excel spreadsheet to apply it. Calibration and discrimination were performed by way of a Hosmer-Lemeshow test and an ROC curve. RESULTS: 693 patients were included. Average age was 63.5 years and average follow up was 88.5 months. BCR was observed in 218 patients. The average time to BCR was 35.5 months, and 90% of the cases occurred in the first 7 years. In the multivariate analysis, the PSA, Gleason Score (GS) = 7(4+3), pathological stage pT3b and affectation of the surgical margin (SM) were identified as independent prognostic pathological variables related to BCR (p〈0,001). The above four variables were included into the equation of the model. Specificity and sensitivity were 90.6% and 50.2%. Its predictive capacity was 80.5% (CI 95% 76,80 -84.3). CONCLUSIONS: PSA, GS = 7(4+3), pathological stage pT3b and PSM were found to be the independent prognostic pathological variables related to BCR-free survival. The predictive model developed permits BCR risk estimation with a reliability of 80.5%

[Relational database for urinary stone ambulatory consultation. Assessment of initial outcomes]. / Una base de datos relacional para consulta de litiasis urinaria. Evaluación inicial de resultados.

OBJECTIVES: To create a relational database for monitoring lithiasic patients. We describe the architectural details and the initial results of the statistical analysis. METHODS AND MATERIALS: Microsoft Access 2002 was used as template. Four different tables were constructed to gather demographic data (table 1), clinical and laboratory findings (table 2), stone features (table 3) and therapeutic approach (table 4). For a reliability analysis of the database the number of correctly stored data was gathered. To evaluate the performance of the database, a prospective analysis was conducted, from May 2004 to August 2009, on 171 stone free patients after treatment (EWSL, surgery or medical) from a total of 511 patients stored in the database. Lithiasic status (stone free or stone relapse) was used as primary end point, while demographic factors (age, gender), lithiasic history, upper urinary tract alterations and characteristics of the stone (side, location, composition and size) were considered as predictive factors. An univariate analysis was conducted initially by chi square test and supplemented by Kaplan Meier estimates for time to stone recurrence. A multiple Cox proportional hazards regression model was generated to jointly assess the prognostic value of the demographic factors and the predictive value of stones characteristics. RESULTS: For the reliability analysis 22,084 data were available corresponding to 702 consultations on 511 patients. Analysis of data showed a recurrence rate of 85.4% (146/171, median time to recurrence 608 days, range 70-1758). In the univariate and multivariate analysis, none of the factors under consideration had a significant effect on recurrence rate (p=ns). CONCLUSIONS: The relational database is useful for monitoring patients with urolithiasis. It allows easy control and update, as well as data storage for later use. The analysis conducted for its evaluation showed no influence of demographic factors and stone features on stone recurrence.

[Immune response during laparoscopic and open living donor nephrectomy. An experimental pig model]. / Respuesta inmunohumoral durante la nefrectomía abierta y laparoscópica de donante vivo. Modelo porcino experimental.

INTRODUCTION: It's been demonstrated laparoscopic access determines a lower surgical stress, by measurement of several markers as different interleuquines (IL) or C-reactive protein (CRP). Endothelin 1 (ET-1) is a powerful vasoconstrictor produced in renal endothelium scarcely studied in laparoscopy. The objective of this study is to analyze immune response during laparoscopic and open donor nephrectomy, in a porcine experimental model by means of measuring IL-2, 10, tumoral necrosis factor alpha (TNFalpha), CRP and ET-1. METHODS: Twenty pigs underwent left nephrectomy, 10 by laparoscopy and 10 by open approach in an experimental model. Both groups were monitorized IL-2, 10, TNF alpha, ET-1 at basal, immediately post surgery, first, third, fifth and seventh days after procedure. RESULTS: The comparative analysis between groups demonstrated a significant increase in levels of CRP (1.44+/-0.88 vs 1.32+/-0.14 mg/dl, p=0.046), TNF alpha (131.14+/-41.37 vs 57.19+/-23.71 pg/ml, p>0.001) and ET-1 (0.91+/-0.49 vs 0.56+/-0.5 fmol/ml, p=0.001) of open nephrectomy group, as a higher levels of IL-2 in laparoscopic group. CONCLUSIONS: Open donor nephrectomy determines a higher immune response than laparoscopic approach. The importance of this fact over the ischemia-reperfusion syndrome or the immediate function of graft is not clearly established.

[Modification of the hemodynamic parameters and peripheral vascular flow in a porcine experimental of model of laparoscopic nephrectomy]. / Modificaciones de los parámetros hemodinámicos y de los distintos flujos vasculares periféricos en modelo experimental porcino de nefrectomía laparoscópica.

OBJECTIVES: It has been demonstrated that abdominal high-pressure and the use of CO2 pneumoperitoneum induce changes of the cardiovascular and respiratory systems, attributable to two factors: changes of the cardiac output (CO) and hypercarbia. Other modifications derived from these facts include changes of the systemic vascular resistances (SVR), blood pressure (BP), central venous pressure (CVP), vascular changes like modifications of the renal blood flow (RBF), carotid flow (CF), portal flow, and hepatic artery flow (HAF). Our objective is to analyze the hemodynamic modifications induced by pneumoperitoneum on renal blood flow, carotid flow, portal flow and hepatic artery flow in a porcine experimental model. METHODS: We compared two groups of pigs: CONTROL group (n = 10) and LAPAROSCOPIC group (n = 10), undergoing open or laparoscopic nephrectomy respectively. In every case, catheters were inserted into the right external jugular vein and femoral artery and cardiac output, CVP, blood pressure and systemic vascular resistances (calculated as RVS = (BP/CVP)x 80/CO); these measurements were taken at the following times: baseline, 5, 30, 60 min. and postoperatively. Renal blood flow, carotid flow, portal flow and hepatic artery flow were registered by means of an electromagnetic probe around the vessel 30 minutes after the start of surgery. RESULTS: Comparative analysis shows: an increase of cardiac output in the laparoscopic group, the difference which was maximal at 30 minutes (4.33 + 0.73 vs. 8 .54 + 1.26 l/min., p < 0.,001); a descent of the systemic vascular resistances (1118.81 + 302.52 vs. 663.37 + 81.45 dynes .s.cm5, p < 0.001) and an increase of blood pressure (66.5 + 11.52 vs. 80.25 + 2.49 mm Hg in the laparoscopic group. Flow analysis showed an increase of the carotid artery flow (125.73 + 41.69 vs. 291.7 + 51.52 ml/min., p < 0.001) and a decrease of portal flow (973.67 + 131.70 vs. 546.83 + 217.53 ml/min., p = 0.001) and hepatic artery flow (278.00 + 94.71 vs. 133.33 + 112.32 ml/min., p = 0.03) in the laparoscopic group. There were no significant differences in renal blood flow with the volume expansion used. CONCLUSIONS: Laparoscopic nephrectomy conditions an increase of carotid flow, probably secondary to the increase of cardiac output, and also a diminishment of hepatic perfusion, both arterial and portal. Nevertheless, volume expansion and the limitation of intra-abdominal pressure to 12 mm Hg enable to maintain similar renal blood flow in both groups.

[Adrenal pseudocyst. Report of a new case and review of the literature]. / Pseudoquiste adrenal. Aportación de un nuevo caso y revisión de la literatura.

Adrenal pseudocyst is the commonest type of benign lesions of adrenal gland althought is a very rare entity. Most of them are found as "incidentalomas" during imaging studies. A case of a patient with a left non-functioning and asymptomatic adrenal pseudocyst is reported. The diagnostic and therapeutic options are discussed and the literature is reviewed.

[Effect of polyphenols from the Mediterranean diet on proliferation and mediators of in vitro invasiveness of the MB-49 murine bladder cancer cell line]. / Efecto de polifenoles de la dieta mediterránea sobre la proliferación y mediadores de la invasividad "in vitro" de la linea de cancer vesical murino MB-49.

OBJECTIVE: To evaluate the effect of different polyphenols on the proliferation and invasive capacity of MB-49 murine bladder tumor cell lines and to identify the mediators involved in this process. MATERIALS AND METHODS: MB-49 murine bladder cancer cells were cultured in media supplemented with resveratrol, rutin, morin, quercetin, gallic acid and tannic acid (all of them are polyphenols usually present in Mediterranean diet) for periods of 24, 48 and 72 hours to quantify the expression of urokinase-type plasminogen activator (uPA) and its receptor (uPAR) in the culture medium, as well as of metalloproteinase-9 (MMP-9) and cell proliferation. RESULTS: All the polyphenols studied significantly inhibited proliferation of MB-49 cells, varying according to the time periods and doses used. The cells in the media supplemented with the nutrients to study did not show inhibition of mRNA expression of urokinase-type plasminogen activator (uPA) or its high affinity receptor (uPAR). It was even slightly increased in certain cases. However, mRNA expression of metalloproteinase-9 was strongly inhibited. CONCLUSIONS: The polyphenols present in our usual diet exert an effect on the proliferation and mediators of bladder tumor invasiveness in MB-49 cells.

[Natural history of localized prostate cancer. Preliminary data on progression and mortality]. / Historia natural del cáncer de próstata localizado. Datos preliminares de progresión y mortalidad.

OBJECTIVE: To address the effect of therapy options and other factors on the natural history of localized prostate cancer (PCa). METHODS: Men with diagnosed clinically localized PCa who underwent radical prostatectomy (RP), radiotherapy (RT) or watchful waiting (WW). Rates of biochemical progression (BQP) and clinical progression (CLP) were calculated. The effects of therapy, initial PSA, presence of palpable tumor and Gleason score were assessed with Kaplan-Meier analysis and log-rank test. Similar methods were used to study overall and disease-specific survival. RESULTS: A total of 228 patients were studied (135 underwent RP, 46 RT, and 47 WW). Median followup time was 2.5 years. Forty patients presented with BQP. The probability of being free from BQP after 2 and 5 years was 76.8% and 57.9% respectively for the whole population, 70.9% and 57.6% for RP patients, 100% and 100% for RT, and 87.1% and 47.2% for WW (p = 0.031). Nineteen patients presented with CLP, with no significant differences with regard to therapy option. A poorly differentiated Gleason score favoured the probability of presenting with CLP (p = 0.022) and shift to metastatic disease (p < 0.001). No cancer-specific mortality was recorded in the studied population. CONCLUSIONS: Short and medium-term prognosis is excellent for localized prostate cancer in terms of survival. Nevertheless, some patients show a higher risk of progressing to metastatic disease (poorly differentiated Gleason score).

[Genitourinary cancer incidence in a health geographic area of 300,000 people]. / Incidencia del cáncer urológico en un área sanitaria de 300,000 habitantes.

OBJECTIVE: To provide descriptive information on site-specific urological cancer occurrence we computed 10-year cancer incidence rates in the geographic area of Getafe (Madrid, Spain, 300,000 people). MATERIALS AND METHODS: Only histologically confirmed genitourinary cancer (bladder, prostate, kidney, testicle and penis) throughout 1992-2001 was considered. Cancers were classified according to the international rules. 10 years age-standardized population-adjusted incidence rates per 100,000 people (or per 100,000 men when appropriate) were calculated. Overall and cancer-specific yearly increments were also evaluated. The most recent release of National Statistics (2001) was used for population adjusting. RESULTS: Prostate cancer (PC) accounted for the majority of diagnostics. A strong correlation was detected between the total number of new cancer diagnostics and the overall population. While the correlation was frail between the number of new cancer diagnostics in females and the female population, the association remained significant in males. Nevertheless, only the number of new prostate cancer diagnostics was firmly and significantly associated with the population. CONCLUSIONS: Incidence rates of every cancer type increased throughout the last decade. Nevertheless, this increases didn't parallel the population increment perhaps translating environmental factors.

[Detection of prostatic cancer in the PSA range between 3 and 3.9 ng/ml]. / Deteccion del cáncer de próstata en el rango de PSA entre 3 y 3,9 ng/ml.

OBJECTIVE: In our study, we analyze the benefit of lowering the PSA cutoff point for which a prostate biopsy is indicated from 4 to 3 ng/ml. MATERIALS AND METHODS: We have considered 4.278 individuals coming from a prostate cancer screening program. We studied 1.217 interventions in which PSA was determined, indicating the prostate biopsy with PSA > or = 3 ng/ml. Digital rectal examination was never the indication for the biopsy. All biopsies were sextant and assisted by transrectal ultrasound. We compared the performance of the biopsy using 4 and 3 ng/ml as cut points. RESULTS: Of the 1.217 interventions performed, 947 had PSA values lower than 3 ng/ml, 80 between 3 and 3.9 ng/ml and 190 over 4 ng/ml. A total of 189 patients (70% of these two last groups) underwent a prostate biopsy. With 4 ng/ml as the cut point, 134 biopsies were indicated, detecting 28 cancers (positive predictive value 20.9%). However 189 biopsies were indicated and 34 cancers detected by lowering the cut point to 3 ng/ml (positive predictive value 17.9%). The reduction in the biopsy performance was not statistically significant (OR = 0.89). None of the 6 additional cancers detected was palpable or ecographically visible (T1c), all of them had a Gleason score under 7 and half of them could be considered clinically relevant. CONCLUSIONS: Lowering PSA cutoff point from 4 to 3 ng/ml improved the detection rate in 21.4% not jeopardizing the biopsy performance. Therefore we think that the group of patients with PSA between 3 and 3.9 ng/ml as candidates for prostate biopsy, should be included in screening programs.

[Selective bladder sparing with transrectal resection of muscle-infiltrating tumors]. / Preservación vesical selectiva mediante resección transuretral de los tumores músculo-infiltrantes.

OBJECTIVE: To disclose te ability of TUR as monotherapy in muscle invasive bladder cancer. MATERIAL AND METHODS: 27 patients with muscle-invasive bladder cancer recruited throughout 1991-1999 were allocated into a protocol based on TUR. 30-45 days after the first TUR a second procedure was performed. The number of recurrences and progressions was registered. Progression-free survival and survival were analyzed using Kaplan-Meier estimates. RESULTS: Two patients were excluded due to persistence of muscle-invasive disease after the second resection. 8 subjects (32%) were lost in follow-up. 17 were eventually evaluable. 12 patients (70.5%) had recurrences. Eventually, 4 more cystectomies were undertaken for invasive recurrences (4/17, 23.5%). During the study period, 3 deaths were recorder (3/17, 17.6%). The actuarial probability of progression at 93 months was estimated on 60%. CONCLUSIONS: 75% of patients retained their bladders. The proportion of patients lost in follow-up was very high. Patients must commit to a close surveillance.