Association between late-onset hypogonadism syndrome plus metabolic syndrome and prostate cancer and its aggressiveness. / Asociación del síndrome de hipogonadismo tardío y síndrome metabólico con el cáncer de próstata y su agresividad.

OBJECTIVE: To assess the relationship between prostate cancer (PC) and the presence of metabolic syndrome and late-onset hypogonadism (LOH) syndrome. MATERIAL AND METHOD: A retrospective study was conducted on 686 patients who underwent prostate biopsy. We analysed the demographic variables, clinical data and biopsy results. To diagnose metabolic syndrome, we employed the criteria of the American Heart Association. For the diagnosis of LOH syndrome, we employed the Androgen Deficiency in the Aging Male questionnaire and testosterone levels (TT). We evaluated the relationship between free testosterone (FT) and bioavailable testosterone (BT) on one hand and PC and its aggressiveness on the other, as well as the usefulness of the TT to prostate specific antigen (TT/PSA) ratio in the PC diagnosis. RESULTS: The patient's median age was 65 years. Metabolic syndrome is not associated with PC (39.4% vs. 35%; P=.1) but is associated with a PC Gleason score >7 (50.4% vs. 29.44%; P=.002). LOH, low FT and low BT are associated with an increased presence of PC (51% vs. 35%, P=.02; 44.86% vs. 33.33%, P=.03; and 46.46% vs. 33.08%, P=.01, respectively) and with an increased probability of a PC Gleason score >7 (61.54% vs. 37.5%, P=.02; 54.17% vs. 34.12%, P=.02; 54.35% vs. 34.48%, P=.02, respectively). Additionally, the median TT/PSA ratio was significantly lower in patients with positive biopsies (P=.022). CONCLUSIONS: Metabolic syndrome was not associated with the probability of having PC but was associated with a PC Gleason score >7. Moreover, LOH syndrome had a higher percentage of PC and a greater presence of PC Gleason scores >7, as did low levels of FT and low levels of BT.

Urinary tract symptoms and erectile function in patients at risk of prostate cancer.

INTRODUCTION AND OBJECTIVE: We estimate that more tan 63000 prostate biopsies are performed in our country each year. There are no functional status data of those patients and if there is a relationship between biopsy result and functional status. In order to solve that question we have performed this study. MATERIAL AND METHOD: 1,128 prostate biopsies were included. Patients fill in the IPSS, IIEF-5 and ICIQ-SF questionnaires before the prostate biopsy was performed. A prospective data collection of clinical, pathological and questionnaires results was done. A descriptive analysis was carried out. IPSS and IIEF-5 results were categorized. Results were compared depending on the biopsy result. In the subgroup of patients with prostate cancer, questionnaires results were stratify according to the clinical risk group. RESULTS: The mean age of the sample was 65. Prostate cancer detection rate was 32,71%, 52,2% of the sample had mild lower urinary tract symptoms (LUTS) and 13,4% had severe LUTS at the time of the biopsy. Regarding the impact of LUTS on quality of life (QOL), only 12,6% showed a perfect QOL. More than 50 percent of patients suffered from some degree of erectile dysfunction at the time of the biopsy. According to ICIQ-SF, 24% of the sample experienced some kind of urinary incontinence, although it is true that most of them classified it as small amount. Patients with a positive biopsy had a lower IPSS and IIEF-5 average score. There were no differences in the prostate cancer detection rate stratified by the severity of LUTS. CONCLUSIONS: Patients undergoing prostate biopsy have, with a high probability, LUTS. Approximately 50% suffer from some degree of erectile dysfunction and 24% had some kind of urinary leakage.

Nephrometry scores: interobserver reproducibility and perioperative factors prediction.

OBJECTIVES: To validate the relation of the nephrometry scores in a series of patients who underwent partial nephrectomy with perioperative parameters and the urologist-radiologist reproducibility. MATERIAL AND METHODS: A retrospective study of open and laparoscopic partial nephrectomy patients performed between 2005 and 2012 registered in prospective filled out database. An urologist and a radiologist calculated the R.E.N.A.L., PADUA and C-index for 86 patients. We carried out a comparative study of the results using the Spearman and Pearson correlation indexes. RESULTS: Distribution according to the complexity of the tumors with the RENAL calculation was: 42 (49%) low, 35 (41%) moderated and 9 (11%) high complexity. According to PADUA: 35 (41%) low complexity, 32 (37%) intermediate and 19 (22%) high. No statistically significant correlation was found for the appearance of operative complications and the pathology results in case of RENAL and PADUA. A correlation was found in the case of PADUA in relation to the warm ischemia time. Positive correlation according to Spearman's index was found in RENAL, PADUA and C-index between urologist and radiologist evaluations. CONCLUSIONS: Nephrometry scores can be a useful tool to plan the surgical technique or approach. However, it is not clear if they are really predictors of surgical or pathologic parameters. The correlation between the urologist and radiologist seems to be sufficient to recommend their use by both specialties.

Focal therapy for prostate cancer. Alternative treatment.

CONTEXT: The great controversy surrounding the treatment of localized prostate cancer is related with its possibilities of radical treatment or active surveillance. The objective of this paper is to analyze the rationale selection among current focal therapy modalities regarding tumor and patient selection. EVIDENCE ACQUISITION: Current articles about advantages and disadvantages on the treatment of localized prostate cancer as well as information about focal therapy regarding tumour selection, characteristics and indications cited in MEDLINE search were reviewed. SUMMARY OF EVIDENCE: Focal therapy standardized criteria must be: low risk tumors, PSA<10-15, Gleason score ≤ 6, and unilateral presentation all supported by image-guided biopsy and nuclear magnetic resonance (NMR). There are doubts about the suitability of focal therapy in cases of bilateralism or in those with Gleason score 3+4 or PSA>15. CONCLUSIONS: Focal therapy is an alternative for localized prostate cancer treatment. However, some aspects of their diagnosis and selection criteria should be defined by prospective studies which should provide knowledge about the indication for focal therapy.

Factors that predict the development of bone metastases due to prostate cancer: Recommendations for follow-up and therapeutic options.

CONTEXT: Prostate cancer is a public health problem in Spain and in the Western world. Bone involvement, associated to significant morbidity, is practically constant in the advanced stages of the disease. This work aims to review the prognostic factors used in the usual clinical practice that predict the development of bone metastases and to analyze the follow-up and treatment option in these patient profiles. ACQUIRING OF EVIDENCE: We performed a review of the literature on the useful factors in the context of therapy with intention to cure. We included the classical clinical values in the diagnosis (PSA, clinical stage, Gleason score on the biopsy) pathological factors (pT stage, margins, bladder invasion, tumor volume, lymph node involvement) and PSA kinetics in their different contexts and the histological and molecular parameters. SYNTHESIS OF EVIDENCE: The tumor differentiation "Gleason" score and PSA are the most important predictive factors in the prediction of bone metastases in patients with intention to cure. Kinetic factors such as PSA doubling time (TDPSA) < 8 months or PSA > 10 ng/ml in the case of castration-resistant prostate cancer (CPRC), are predictive factors for the development of metastasis. Zoledronic acid and denosumab have demonstrated their effectiveness for the treatment of bone disease in randomized studies. CONCLUSIONS: There are predictive factors within the usual clinical practice that make it possible to recognize the "patient at risk" to develop bone metastatic disease. The currently available treatments, zoledronic acid or denosumab, can help us in the management of the patient at risk of developing metastasis or metastatic patient, increasing the quality of life and decreasing skeletal events.

Treatment of non muscle invasive bladder tumor related to the problem of bacillus Calmette-Guerin availability. Consensus of a Spanish expert's panel. Spanish Association of Urology.

CONTEXT: Since June 2012, the has been a worldwide lack of available of the Connaught strain. In December 2012, a group of experts met in the Spanish Association of Urology to analyze this situation and propose alternatives. OBJECTIVE: To present the work performed by said committee and the resulting recommendations. ACQUISITION OF EVIDENCE: An update has been made of the principal existing evidence in the treatment of middle and high risk tumors. Special mention has been made regarding the those related with the use of BCG and their possible alternative due to the different availability of BCG. EVIDENCE SYNTHESIS: In tumors with high risk of progression, immediate cystectomy should be considered when BCG is not available, with dose reduction or alternating with chemotherapy as methods to economize on the use of BCG when availability is reduced. In tumors having middle risk of progression, chemotherapy can be used, although when it is associated to a high risk of relapse, BCG would be indicated if available with the mentioned savings guidelines. BCG requires maintenance to maintain its effectiveness, it being necessary to optimize the application of endovesical chemotherapy and to use systems that increase its penetration into the bladder wall (EMDA) if they are available. CONCLUSIONS: Due to the scarcity of BCG, it has been necessary to agree on a series of recommendations that have been published on the web page of the Spanish Association of Urology.

Margin status is a very important prognostic factor for patients with pT3b prostate cancer.

OBJECTIVE: Despite early diagnosis of prostate cancer, seminal vesicle invasion is still a common clinical scenario nowadays. The objective of this study is to evaluate clinical and pathological prognostic factors in that subgroup of patients. MATERIAL AND METHODS: After approval of our Ethical Committee, we selected all pT3b prostate cancer patients operated between 1987 and 2010. Neoadjuvant treatment patients were excluded. The biochemical free survival periods BFS and the period free of complementary treatment were calculated with the Kaplan Meier method. Cox regression model was used to select those variables associated with biochemical failure and the need for complementary treatment. We considered complementary treatment when radiotherapy or hormone therapy in an adjuvant or salvage scheme was required. RESULTS: 101 patients were selected from 1470 procedures. Among these, 28 patients died (27,7%), 18 due to tumor, and 74 showed biochemical relapse (73,3%). The median follow up was of 4 years and 4 months. The five years BFS was 30.2% (IC 95%: 20.2-40.1), whereas the 5 year period free of complementary treatment was 16.9% (IC 95%: 8.1-25.8%). In the multivariate analysis, margin status (R) was independently and significantly associated with biochemical relapse and the need for complementary treatment. Likewise, the preoperative PSA was associated to biochemical relapse and N1 tumours were clearly associated to complementary treatment. CONCLUSION: pT3b prostate cancer patients with R1 disease have a worse biochemical prognosis and higher probability of complementary treatment.

[Molecular biology of the clear cell renal cell carcinoma: principles for a selective treatment]. / Biología molecular del carcinoma de células claras renales: principios para un tratamiento selectivo.

Renal cell carcinoma (RCC) and its most frequent subtype, the clear cell hystology type, has shown resistance to chemotherapy and radiotherapy treatment when disease was already spread in patients. Recently, a huge advance in the molecular biology of this tumor has been performed. This fact allowed a deeper and better knowledge of the disease and the development of new drugs that work against the growth factors involved in tumor origin. In this review article it is summarized the molecular milestones that are involved in the development of clear cell renal cell carcinomas.

[Radical laparoscopic nephrectomy]. / Nefrectomía radical laparoscópica.

In this article, we review the different surgical approaches to carry out radical laparoscopic nephrectomy: transperitoneal approach, retroperitoneal approach and hand-assisted approach. We describe the advantages and drawbacks of each alternative and summarize the most important references in the medical literature. In spite of this being a relatively new surgical approach, less than 15 years old, it has become a standard treatment and, today, is considered as the elective surgical treatment for T1 and T2 renal tumours in many centres.

[Usefulness of bcl-2 expression as a new basal cell marker in prostatic pathology]. / Utilidad de bcl-2 como nuevo marcador de expresión de células basales en patología prostática.

INTRODUCTION AND OBJECTIVES: The diagnosis of invasive adenocarcinoma of the prostate is often difficult in needle prostatic cores, where, additionally, the assessment of the presence of basal cells has demonstrated to be of paramount importance. Currently, the immunohistochemical expression of 34betaE12 antigen and p63 protein are the most utilized markers. In our study, we analyzed comparatively the expression of 34betaE12, p63, bcl-2 and alpha-methylacyl-CoA racemase in order to evaluate the usefulness of bcl-2 as a new marker of the basal cells in prostatic pathology. METHODS AND RESULTS: This study comprises radical prostatectomy specimens from 48 patients which were studied in order to determine the lack of staining of basal cells in invasive tumor areas together with the expression of racemase. Likewise, the presence of basal cells in areas of atrophy, hyperplasia, adenosis, and high-grade prostatic intraepithelial neoplasia (PIN) was also examined. Within the areas of adenosis and PIN a discontinuous pattern of basal cell expression was found in some cases. In 2 out of 48 cases (4,2%) of invasive carcinoma a weak bcl-2 expression without a basal cell distribution was found. Moreover, the expression of bcl-2 in the stromal lymphocytes appeared to be essential as an internal positive control of the technique. CONCLUSIONS: In addition to classical markers, we demonstrated the diagnostic value of bcl-2 as a new basal cell marker.

[Radiation-induced infiltrating transitional cell carcinoma]. / Tumor transicional infiltrante de urotelio radioinducido.

INTRODUCTION: The increased risk of developing a transitional cell carcinoma (TCC) among patients irradiated for other pathologies in a known fact, but many times forgotten due to its low incidence. Our aim is to review the association between radiotherapy (RT) and muscle-infiltrating TCC among our patients. MATERIAL AND METHODS: Clinical survey among our muscle-infiltrating TCC data base since 1975. Descriptive analysis of found cases. RESULTS: We found 5 patients who developed muscle-infiltrating TCC with a mean time of 19.2 years since radiotherapy (three of them more than 20 years and the other two less than 10 years). Three patients also developed other tumours or pathologies related to radiotherapy. Two of them had an upper tract muscle-infiltrating TCC and required nephroureterectomy. All of them had high risk TCC of the bladder and one developed distant metastasis. CONCLUSIONS: Patients under abdomino-pelvic RT and a prolongued follow-up, can be considered a risk group for developing muscle-infiltrating TCC. Thus, either micro or macrohaematuria or irritative symptoms should lead us to think in this possibility, demanding complete and exhaustive study to rule out TCC in all the urothelium.

[Usefulness of serum markers in renal cell carcinoma]. / Utilidad de marcadores séricos del carcinoma renal.

OBJECTIVES: To select a group of useful serum markers in renal cell carcinoma (RCC) with investigational purpose in future. MATERIAL AND METHODS: Periodic determination in serum of 21 RCC patients of the following markers: EGR, RPC, hemogram and leucocyte differential count (LDC), standard biochemist parameters, beta-2 microglobuline, CEA, CA 12.5, CA 50, CA 15.3, ferritin, interleukin-6, serum interleukin-2 receptor, TNF-alpha and TPSA. RESULTS: Different elements within the LDC had relations with the presence of symptoms/signs, tumour size, pathological stage and disease progression. There was a significant increase of beta-2 microglobuline and sIL-2 receptor when disease progressed, as well as a similar statistical trend with RPC and alkaline phosphatases. Beta-2 microglobuline and sIL-2 receptor also decreased after treatment of the disease progression. CONCLUSIONS: We will keep analysing hemogram, LDC and standard byochemics, RPC, ferritin, beta-2 microglobuline and sIL-2 receptor only with investigational purposes, obviating the determination of the rest of the tested markers.

[Penile cancer]. / Cáncer de pene.

Penile carcinoma is a tumoral condition of inconsistent incidence. Its biological and etiological features are under permanent scientific review. Such circumstance is increased by the growing awareness of a greater demand of anything related with the patients' quality of life. This paper reviews the latest controversies guiding current therapeutic approaches in penile cancer. An analysis is made through a revision of the lymphadenectomy indication and its therapeutic value, criteria related to technical aspects and indications. At the same time, the criteria that should preside over the choice between conservative or radical options are established and emphasis is placed on the growing role of prevention in tumoral conditions and the contribution of innovative gene therapy regimes.

[Assessment of the basal membrane status as prognostic factor in renal carcinoma]. / Valoración del estado de la membrana basal como factor pronóstico en el carcinoma renal.

OBJECTIVES: To know the basal membrane (BM) integrity in renal cell carcinoma (RC) and its importance as prognostic factor. MATERIAL AND METHODS: 73 patients with RC were selected. Immunohistochemistry with monoclonal antibodies against basal proteins laminin and collagen IV was performed. Percentage for BM fragmentation in the whole tumour was considered taking 75% as cut off. RESULTS: Follow-up was 6.3 +/- 4.3 years and 27 patients progressed. Correlation between laminin and collagen IV was significative (p = 0.000). A BM fragmentation expressed with laminin bigger than 75% was related to tumoural symptoms (p = 0.019), worse grade (p = 0.004) and necrosis in more than 10% of the tumour (p = 0.000). Fragmentation observed with collagen IV was associated to tumours greater than 7 cm (p = 0.014). Those patients whose tumours displayed more than 75% of BM fragmentation, measured with collagen IV, presented worse survival (p = 0.042). A similar trend was observed in the case of laminin, but it did not reach statistic significance (p = 0.119). In the unvariated analysis grade III-IV, more than 10% of necrosis within the tumour, tumoural symptoms and BM fragmentation bigger than 75% measured with collagen IV were prognostic, while only grade and necrosis did so in the multivariate analysis. CONCLUSIONS: Collagen IV and laminin represent nicely, with a similar expression pattern, the BM fragmentation in RC. Within a battery of immunohistochemical markers to study RC at least one of them should be included because their prognostic implication.

[Surgical treatment of stage I germ cell tumor of the testis]. / Tratamiento quirúrgico del tumor germinal de testículo estadio I.

OBJECTIVE: To analyze the current role of surgery in the treatment of stage I testicular germ cell tumors. METHODS: We reviewed the literature on stage I testicular germ cell tumors. The technique of orchidectomy, the arguments in favor of retroperitoneal lymphadenectomy, the evolution of this technique and the prognostic factors that might be useful in determining the therapeutic approach to stage I testicular germ cell tumors are analyzed. RESULTS/CONCLUSIONS: Treatment of testicular germ cell tumors should be performed in specialized centers that can offer all the therapeutic possibilities with a maximum guarantee so that the patient can decide on the treatment after receiving all the information on the advantages and disadvantages of each modality. Retroperitoneal lymphadenectomy with preservation of sympathetic innervation preserves ejaculation. Its cure rate is similar to that of other therapeutic options, it carries a minimum morbidity, follow-up is simplified, patient anxiety is reduced and there are long-term savings on costs.

[Molecular biology in testicular cancer]. / Biología molecular en el cáncer de testículo.

OBJECTIVE: To review the advancements in basic molecular biology and current insight into the pathogenesis of germ cell tumors of the testis, as well as the utility of the different genetic and molecular markers in the management of these tumors. METHODS: The literature on this subject was reviewed. The epidemiological data related to the pathogenesis of this tumor type, the cytogenetic and molecular alterations that could serve as a prognostic factor in these tumors were analyzed. RESULTS/CONCLUSIONS: The prenatal estrogenic effect together with the pubertal hypergonadotrophism could be responsible for the pathogenesis of germ cell testicular tumors. The cytogenetic changes of chromosome 12, although typical of the phenotype of these tumors, do not appear to be useful as a prognostic factor. However, cell proliferation, particularly of Ki-67, appears to be useful as a prognostic factor, although further studies are warranted.

[Surgical treatment of urinary bladder cancer. Indications, technics, and general results]. / Tratamiento quirúrgico del cáncer de la vejiga urinaria. Indicaciones, técnicas y resultados generales.

OBJECTIVE: To analyze the results and indications of the three surgical techniques commonly utilized alone or as part of other treatments for infiltrating bladder tumors. METHODS: Our series of patients with infiltrating bladder tumors are analyzed and the literature reviewed. RESULTS: Transurethral resection (TUR) is essential for tumor staging and is controversial as a therapeutic approach. However, using stringent selection criteria and careful follow-up, retrospective studies have reported survival rates of 82-83%, which are similar to those of radical cystectomy in similar cases, but with bladder preservation rates of 67%-75%. However, only 19-21% of patients can benefit from this surgical technique and the selection criteria are relatively subjective. Partial cystectomy achieves a considerable survival rate of 40-80%, but very stringent selection criteria must be met, which are partly similar to those of the previously mentioned technique, therefore it is not an alternative to TUR since it is a more aggressive surgical procedure. It could be an alternative to radical cystectomy in the more advanced stages of the disease, but although it may be technically biologically feasible, there is a high risk of local and cicatricial recurrence and difficulty in the early detection of recurrence caused by the anatomical disturbance in the bladder wall. For all the foregoing, partial cystectomy is utilized only for very specific cases of urachal carcinoma, as a palliative approach instead of cystectomy, or for areas that are not accessible to TUR. However, although it has specific indications, it has been demonstrated to be effective in the evaluation of the response to chemotherapy and systematically utilized in bladder preservation programs. CONCLUSIONS: Radical cystectomy continues to be the standard treatment for infiltrating bladder tumors with overall 5-year survival rates in recent series ranging from 56%-72%, and is related with the pathological stage and particularly nodal involvement. The morbidity has dropped and the operative mortality rate is about 2%. Quality of life has also improved with the new techniques of urinary diversion, especially orthotopic diversion.

[Adrenal gland incidentaloma in the oncologic patient: is its histologic study obligatory?]. / Incidentalomas suprarrenales en el paciente oncólogico: es obligado suestudio histólogico?

OBJECTIVES: To analyze the need for histological study in suprarenal incidentalomas in the specific status of the oncological patient. MATERIAL AND METHODS: 21 patients with tumoral suprarenal masses, 12 diagnosed in the initial study and 9 during the follow-up RESULTS: 16 masses were benign in nature and 5 were metastatic. Neither the location nor the staging of the initial tumour, the time of diagnosis, or the hormonal study were of any use to separate the primitive tumour from the metastasis. All metastasis were equal to or greater than 5 cm in size. Radiological study only confirmed the nature of the tumour in a few cases. Percutaneous biopsy was resolutive in 4/8 cases (50%). Suprarenalectomy was performed in 15 occasions, associated in 10 to surgical treatment of the primary therapy with not added morbidity. CONCLUSION: When incidentaloma is detected in tumoral patients at the time of diagnosis, it requires an histological study which in 1 out of 3 cases will modify the therapeutic attitude in the presence of metastasis. If the incidentaloma is detected during follow-up, it may be monitored in terms of evolution as we would only be delaying a palliative treatment.

[Bladder carcinosarcoma. Report of 2 cases]. / Carcinosarcoma vesical. A propósito de dos casos.

Two additional cases of this rare bladder tumor are described. The immunohistochemical analyses confirmed the histological diagnosis of this aggressive tumor type. The choice of treatment for the tumor and its metastasis is influenced by its rarity.