Prognostic value of seminal vesicle involvement due to prostate cancer in radical prostatectomy specimens.

OBJECTIVE: To study the influence, in terms of prognosis, of the finding of seminal vesicle involvement in patients with prostate adenocarcinoma treated with radical prostatectomy. MATERIAL AND METHOD: We reviewed a series of patients with seminal vesicle involvement with clinically localized prostate adenocarcinoma who underwent radical prostatectomy between 1989 and 2009, focusing on their clinical-pathological characteristics, biochemical progression-free survival (BPFS) and specific survival (SS). We assessed the variables that influenced BPFS and designed a risk model. RESULTS: A total of 127 out of 1,132 patients who underwent surgery (11%) presented seminal vesicle invasion (i.e., pT3b). In the multivariate study of the entire series (Cox model), pT3b affects the BPFS (HR: 2; 95% CI: 1.4-3.3; P=.001). Other influential factors were the affected borders, initial prostate-specific antigen levels, pathological Gleason score and the presence of palpated tumor. The pT3b tumors have poorer clinical-pathological variables when compared with pT2 and pT3a tumors. Sixty-five percent of the patients evidenced biochemical progression. The BPFS was significantly poorer for pT3b (40 ± 4% and 28 ± 4% at 5 and 10 years, respectively) than for pT2 and pT3a (P<.0001). The SS was also poorer in patients with pT3b tumors (91 ± 2% and 76 ± 4% at 5 and 10 years, respectively) (P<.0001). The predictors within the pT3b patient group were: PSA levels >10 ng/mL (HR: 1.9; 95% CI: 1.04-3.6; P=.04) and pathological Gleason score 8-10 (HR: 2.1; 95% CI: 1.2-3.5; P=.03). We designed a risk model that accounts for the variables involved, which entails 2 groups with different BPFS (P=.004): Group 1 (0-1 variable), with a BPFS of 46 ± 7% and 27 ± 8% at 5 and 10 years, respectively; and Group 2 (2 variables), with a BPFS of 14 ± 7% and 5 ± 5% at 5 and 10 years, respectively. CONCLUSION: Seminal vesicle involvement severely and negatively affects the BPFS and SS. We designed a risk model with the independent influential variables in BPFS (pathological Gleason score 8-10 and PSA levels >10 ng/mL). This model confirms that pT3b tumors are a heterogeneous group, which includes an important group with better prognosis when surgical treatment is performed.

Optimizing D'Amico risk groups in radical prostatectomy through the addition of magnetic resonance imaging data.

OBJECTIVES: To improve the predictive efficacy of the D'Amico risk classification system with magnetic resonance imaging (MRI) of the pelvis. MATERIAL AND METHODS: We studied 729 patients from a series of 1310 radical prostatectomies for T1-T2 prostate cancer who underwent staging pelvic MRI. Each patient was classified with T2, T3a or T3b MRI, and N (+) patients were excluded. We identified the therapeutic factors that affected the biochemical progression-free survival (BPFS) time (prostate specific antigen [PSA] levels>0.4ng/mL) using a univariate and multivariate study with Cox models. We attempted to improve the predictive power of the D'Amico model (low risk: T1; Gleason 2-6; PSA levels<10ng/mL; intermediate risk: T2 or Gleason 7 or PSA levels 10-20ng/mL; high risk: T3 or Gleason 8-10 or PSA levels>20ng/mL). RESULTS: In the univariate study, the clinical factors that influenced BPFS were the following: Gleason 7 (HR: 1.7); Gleason 8-10 (HR: 2.9); T2 (HR: 1.6); PSA levels 10-20 (HR: 2); PSA levels>20 (HR: 4.3); D'Amico intermediate (HR: 2.1) and high (HR: 4.8) risk; T3a MRI (HR: 2.3) and T3b MRI (HR: 4.5). In the multivariate study, the only variables that affected BPFS were the following: D'Amico intermediate risk (HR: 2; 95% CI 1.2-3.3); D'Amico high risk (HR: 4.1; 95% CI 2.4-6.8); T3a MRI (HR: 1.9; 95% CI 1.2-2.9) and T3b MRI (HR: 3.9; 95% CI 2.5-6.1). Predictive model: Using the multivariate Cox models, we assessed the weight of each variable. A value of 1 was given to D'Amico low risk and T2 MRI; a value of 2 was given to D'Amico intermediate risk and T3a MRI and a value 3 was given to D'Amico high risk and T3b MRI. Each patient had a marker that varied between 2 and 6. The best model included 3 groups, as follows: 494 (67.7%) patients in group 1, with a score of 2-3 points (HR, 1), a BPFS of 86%±2% and 79%±2% at 5 and 10 years, respectively; 179 (24.6%) patients in group 2, with a score of 4 points (HR, 3), a BPFS of 60%±4% and 54%±5% at 5 and 10 years, respectively; and 56 (7.7%) patients in group 3, with a score of 5-6 points (HR, 9.3), a BPFS of 29%±8% and 19%±7% at 5 and 10 years, respectively. The median BPFS time was 1.5 years. CONCLUSION: MRI data significantly improves the predictive capacity of BPFS when using the D'Amico model data.

Influential factors in the response to salvage radiotherapy after radical prostatectomy.

OBJECTIVE: To analyze the influential factors in the response in prostatectomized patients with subsequent biochemical relapse (BCR) and treated with salvage radiotherapy (RTP). MATERIAL AND METHODS: We analyzed 313 patients with pT2/pT3 prostate cancer who were receiving salvage therapy due to biochemical relapse (from a series of 1,310 radical prostatectomies between 1989-2012). Of the 313 patients; 159 (50.8%) only received androgen deprivation (AD), 63 (20.1%) Radiotherapy (RTP) plus concomitant AD and 91 (29.1%) only RTP. Of these, 57 (62.6%) have maintained complete response and 34 (37.4%) had failure response with post-RTP BCR. RESULTS: Study of the group treated exclusively with salvage RTP. Ninety-one patients were treated with salvage RTP. Median follow-up was 6.4 years and median to recurrence 11 months. Post-RTP biochemical relapse-free survival (PRBRFS) was 68 ± 7% and 30 ± 10% in 5 to 10 years. Median PRBRFS was 7.3 years (6.3-8.3). Initial PSA (HR: 1.08; 95% CI: 1.01-1.1 P=.02) with best PSA cut-off point PSA>20 ng/ml (HR: 13.6; 95% CI: 2.1-86 P=.005) and PSA pre-RTP (HR: 1.9; 95% CI: 1.2-3.3; P=.009), best PSA cut-off point PSA preRTP 0.92 ng/ml (HR: 4.5; 95% CI: 1.3-15.6; P=.01) showed independent influence in the response in the multivariate study. PRBRFS at 5 years, 81 ± 9% versus 58 ± 9% with initial PSA <20 or >20 ng/ml (P=.03). PRBRFS at 5 years, 93 ± 5% versus 53 ± 10% according to PSA pre-RTP <0.9 or >0.9 ng/ml (P=.02). CONCLUSIONS: In patients treated with salvage RTP after radical prostatectomy, the preoperative PSA>20 ng/ml and PSA preRTP>0.92 ng/ml shows an independent influence on the response.

[Plasmacytoid variant of urothelial carcinoma: a case report]. / Variante plasmocitoide del carcinoma urotelial: a propósito de un caso.

Plasmacytoid urothelial carcinoma is an extremely rare pathological finding. We report our experience of one case. A 60 year old male with hematuria of two years evolution, with frequency and dysuria. A tumor was found and he received surgical treatment by TURB at first. The pathology result was a plasmacytoid urothelial carcinoma. Subsequently a radical cystectomy with urinary diversion was performed. The patient received follow-up until his death.

Course of the type of patient who is candidate for radical prostatectomy over 2 decades (1989-2009).

OBJECTIVE: To know the changes experienced by the patient profile candidate for radical prostatectomy over the last 2 decades in our institution.. MATERIAL AND METHODS: We analyze retrospectively a series of 1.132 patients with prostate cancer stadium T1-T2, submitted to radical prostatectomy during the period 1989-2009. The series divides in five homogeneous groups as for the number of patients and arranged chronologically. There uses the free survival of biochemical progression (SLPB) as criterion principal forecast. RESULTS: In spite of the changes in the diagnosis and treatment of the disease, from the point of view of the forecast (SLPB) we estimate two groups different from patients: the first 250 controlled ones and the rest. The point of chronological cut places in this series in 1.999. We find significant differences in the majority of the clinical-pathological variables as PSA's level to the diagnosis (P <0,001), percentage of palpable tumors (P <0,001), clinical stadium (P <0,001), Gleason in the prostate biopsy (P =0,004), groups at risk of D'Amico (P <0,001), pathological stage (P <0,001), and percentage of patients with lymph node (P <0,001). Nevertheless, there are not detected differences of statistical significance in the Gleason of the specimen of prostatectomy (P =0,06) and in the percentage of surgical margins (P =0,6). CONCLUSIONS: This study analyzes a patients' wide proceeding sample from the whole Spanish geography and presents some important information that reflect the evolution that has suffered the cancer of prostate located, so much regarding the diagnosis as to the forecast, in our country in the last 20 years.

Intraoperative EBRT and resection for renal cell carcinoma : twenty-year outcomes.

PURPOSE: We report the outcomes of a multimodality treatment approach combining maximal surgical resection and intraoperative electron radiotherapy (IOERT) with or without external beam radiation therapy (EBRT) in patients with locoregionally (LR) recurrent renal cell carcinoma (RCC) after radical nephrectomy or LR advanced primary RCC. PATIENTS AND METHODS: From 1983 to 2008, 25 patients with LR recurrent (n = 10) or LR advanced primary (n = 15) RCC were treated with this approach. Median patient age was 60 years (range, 16-79 years). Fifteen patients (60%) received perioperative EBRT (median dose, 44 Gy). Surgical resection was R0 (negative margins) in 6 patients (24%) and R1 (residual microscopic disease) in 19 patients (76%). The median dose of IOERT was 14 Gy (range, 9-15). Overall survival (OS) and relapse patterns were calculated using the Kaplan-Meier method. RESULTS: Median follow-up for surviving patients was 22.2 years (range, 3.6-26 years). OS and DFS at 5 and 10 years were 38% and 18% and 19% and 14%, respectively. LR control (tumor bed or regional lymph nodes) and distant metastases-free survival rates at 5 years were 80% and 22%, respectively. The death rate within 30 days of surgery and IOERT was 4% (n = 1). Six patients (24%) experienced acute or late toxicities of grade 3 or higher according to the National Cancer Institute Common Toxicity Criteria (NCI-CTCAE) v4. CONCLUSION: In patients with LR recurrent or LR advanced primary RCC, a multimodality approach consisting of maximal surgical resection and IOERT with or without adjuvant EBRT yielded encouraging local control results, justifying further evaluation.

[Radical prostatectomy for high risk localized prostate cancer. Prognosis and study of influential variables]. / Cáncer de próstata localizado de alto riesgo tratado mediante prostatectomía radical. Pronóstico y estudio de variables influyentes.

BACKGROUND: To study the biochemical progression-free survival (BPFS) achieved by a group of high risk patients in accordance with D'Amico's classification treated with radical prostatectomy. To identify the clinical-pathological variables which are influential in biochemical progression-free survival and, if possible, use them to design a prognostic model. MATERIAL AND METHODS: The study involves 232 patients, out of a series of 1,054, diagnosed with clinically localized prostate cancer, qualified as high risk on D'Amico's classification (PSA>20 ng/ml or Gleason score 8-10 or T3) treated with radical prostatectomy. The BPFS is studied and the clinical-pathological variables obtained (PSA, Gleason score of the biopsy and of the piece, clinical and pathological study, unilateral or bilateral affectation, margins of the prostatectomy piece, Ki-67 expression) are analyzed to identify whether they influenced the BPFS. Contingency tables and tables for survival analysis: Kaplan-Meyer, log-rank and Cox models were used for the statistical study. RESULTS: Descriptive study: PSA: 23.3 ng/ml (median); cGleason 2-6: 33%; 7: 13%; 8-10: 54%; T2: 58%; Bilateral affectation in the diagnostic biopsy: 59%; RNM T2: 60%; RNM T3: 40%. pGleason 2-6: 24%; 7: 28%; 8-10: 48%; pT2: 43%; pT3a: 30%; pT3b: 27%; Affected margin: 51%; N1:13%. Progression-free survival: with a mean and median follow-up of 64 months; 53% show biochemical progression. The median until progression: 42 months. Progression-free survival at 5 and 10 years is 43±3% and 26±7%. The multivariate study (Cox models) shows that the variables that are independently influential in the BPFS are the affectation of margins (HR: 3.5; 95% IC.1.9-6.7; p<0001); and Ki67 >10% (HR: 2.3; 95% IC: 1.2-4.3; P: 0.009). Risk groups: using the two influential variables and employing Cox models, three risk groups emerged as the best model: Group 1 (0 variables present); Group 2 (1 variable); Group 3 (2 variables). The progression-free survival is 69±8%; 27±6% and 18±11% at 5 years. The differences amongst the three groups are significant. CONCLUSION: The high risk group according to the D'Amico classification is heterogeneous in relation to biochemical progression and can be broken down into three risk groups using the two independently influential variables (affected margins and Ki67 percentage).

[Time-influencing factors for biochemical progression following radical prostatectomy]. / Factores influyentes en el tiempo hasta la progresión bioquímica después de prostatectomía radical.

INTRODUCTION: We assessed the time-influencing clinical-pathological factors for biochemical progression of an equal series of patients from a single institution. MATERIALS AND METHODS: Retrospective analysis of 278 patients with biochemical progression following prostatectomy. We considered biochemical progression to be PSA>0.4 ng/ml. We performed the trial using the Cox model (univariate and multivariate) and using the Student's t-test to compare averages. RESULTS: With a mean follow-up of 4 (±3 DE) years, the univariate study showed a mean until progression for the Gleason score 2-6 in the biopsy of 824 days and 543 for the Gleason score 7-10 (p=0.003). For negative surgical margins, the mean was 920 days and 545 for positive margins (p=0.0001). In the case of a Gleason score 2-7 in the specimen, the mean was 806 days and 501 for a Gleason score 8-10 (p=0.001). Lastly, the mean for the cases with Ki-67 negative in the specimen (< 10%) was 649 days and 345 for Ki-67 positive (> 10%) (p=0.003). In the multivariate study, Ki-67 (OR 1.028; IC 95% 1-1.01; p=0.0001) and Gleason score 8-10 (OR 1.62; IC 95% 1.5-2.45; p=0.026) in the specimen, and initial PSA >10 ng/ml (OR 1.02; IC 95% 1.01-1.04; p=0.0001) were independent variables. Using these variables, we designed a predictive model with three groups. The time until the progression of each group was 1,081, 551 and 218 days respectively. CONCLUSION: The Gleason score 7-10 in the prostate biopsy, the presence of Ki-67, the positive margins and the Gleason score 8-10 in the specimen, and the initial PSA > 10 ng/ml are time-influencing factors until biochemical progression. Pathological Gleason score 8-10, PSA > 10 ng/ml and Ki-67 are independent factors.

Anterior compartment prolapse repair with a hybrid biosynthetic mesh implant technique.

The aim of the present study is to assess the safety and feasibility of a new technique for cystocele repair using a hybrid biosynthetic graft fixed by the transobturator approach. This is a retrospective study of 13 women diagnosed with symptomatic anterior compartment prolapse that were in stages II and IV, using Pelvic Organ Prolapse Quantification score and treated between 2003 and 2006. The surgical procedure was carried out through a vaginal approach, exposing the arcus tendineus and the posterior surface of the obturator foramen from the ischial spine to the inferior pubic ramus bone. The patients were followed-up after 3, 6 and 12 months. The anatomical cure rate was 85% (stage 0), although two patients had a recurrence 8 months after surgery. All patients would repeat the procedure, if necessary. No de novo dyspareunia was observed in these small series. The results suggest that this technique is safe and feasible and is a comprehensive surgical approach for anterior compartment prolapse, without postoperative morbidity.

PET and prostate cancer.

The diagnosis of prostate cancer leaves some questions without answers. The different diagnostic techniques are limited in three situations: (1) staging of the tumour: identification of node involvement, (2) quantification of the tumour volume and its location inside the gland, (3) premature identification of relapse after radical treatment. These are the three problems that we need to consider in the diagnosis of prostate carcinoma. Imaging techniques can tell us the morphological alterations in the structures and organs. Positron emission tomography (PET) introduces a new way of identifying damage by counting metabolic activity. The tracers are substances that are marked with a radioactive molecule that is picked up more readily by the tumours. The presence of these substances in a set anatomic zone means higher consumption and therefore more metabolic activity. The radiotracer most frequently used in PET is glucose marked with fluoride 18. The first studies with marked glucose and prostate tumours started at the end of the 1990s. There are many contradictions in the results of these studies due to renal elimination, which produces an accumulation in the urinary tract and does not correctly show the prostate zone and iliobturator nodes area, and its capitation by zones with inflammatory process or prostatic hyperplasia. Choline is a substance that is present in cellular membranes. When it is marked with carbon 11, it changes to a new tracer. This radiotracer has affinity with prostate damage and allows the better differentiation of malignant from benign processes. It also has the advantage of the absence of renal elimination. Trials that used choline marked with carbon 11 (11C choline) are beginning to obtain very promising results. This union of a method that identifies metabolic activity with an imaging technique increases the sensitivity in the diagnostic test and can help find the exact location of the 11C choline deposits. The PET-CT combines the PET with computerised tomography. The 11C choline PET-CT is presented as a promising technique for answering the three problems mentioned above.

[Female incontinence: urodynamic evaluation]. / Incontinencia femenina: evaluación urodinámica.

OBJECTIVE: To evaluate the functional studies in women with stress urinary incontinence. METHODS: Emphasis is placed on comprehensive understanding of stress urinary incontinence in women as well as Urodynamic techniques and findings which apply to women with this condition. RESULTS: Although prospective randomized controlled trials to evaluate the clinical efficacy, cost-effectiveness and effect on quality of life of a pre-operative Urodynamic assessment are necessary, to date only Urodynamic Investigation (Non-invasive uroflowmetry, filling cystometrogram, valsalva leak point pressure, pressure-flow studies and urethral profile) provide enough information for treatment decisions and prognosis in cases of female urinary incontinence.

18F-fluoro-2-deoxyglucose-positron emission tomography in the evaluation of nonseminomatous germ cell tumours at relapse.

OBJECTIVES: To compare the performance of 18F-fluoro-2-deoxyglucose-positron emission tomography (FDG-PET) and computed tomography (CT) in the follow-up of nonseminomatous germ cell tumours (NSGCT) in the retroperitoneum. PATIENTS AND METHODS: FDG-PET was used 25 times in 15 patients diagnosed with NSGCT. At the time of diagnosis five patients each were in stage I, II and III. Five patients had pure embryonal carcinoma, two had yolk sac tumours, one choriocarcinoma and seven had mixed tumours. RESULTS: Eleven patients either presented with retroperitoneal disease or this did not disappear after chemotherapy. The results of both examinations coincided in 18 cases and were contradictory in the other seven, the difference being statistically significant (P=0.042). CONCLUSION: In these patients FDG-PET detected the retroperitoneal relapse of NSGCT, in advanced stages treated with surgery plus chemotherapy, earlier than did CT; it also detected the presence of mature teratoma in residual retroperitoneal masses more accurately than CT. More extensive trials are needed before making conclusions about FDG-PET imaging as a routine method for NSGCT.

[Molecular biology of bladder cancer]. / Biología molecular del cáncer vesical.

OBJECTIVE: To analyze the factors that influence tumor progression and response to therapy. METHODS: The new prognostic factors involved in the progression of bladder tumors that have been described in the literature, such as tumor antigen expression, molecular growth factors, cell adhesion molecules, oncogenes, tumor suppressor genes and mechanisms of tumor angiogenesis, are reviewed. RESULTS/CONCLUSIONS: The etiopathogenesis of bladder cancer remains unknown and treatment is based on the clinical stage of the disease. The new tumor markers will permit a more individualized prognosis and treatment can be instituted according to the biological characteristics of the tumor.

[Cystic pyeloureteritis]. / Pieloureteritis quística.

The pyelitis or cystic pyeloureteritis is a rare disease of unknown etiology. The clinic is unspecific and the treatment, medical and expectant. The importance of this disease consists of a correct differential diagnosis with other repletion defect imaging in the excretory tract and its frequent association to other diseases.

[Epidemiology of tumors of the renal parenchyma]. / Epidemiología de los tumores del parénquima renal.

Renal cell carcinoma is responsible for about 2% of all cancer deaths in developed countries and represents 80-85% of all tumors of the kidney. Its etiology is still largely undefined. Its incidence varies among countries, with the highest rates in North Americans and Scandinavians. Its incidence is steadily rising in the last ten years. The location of the tumor suppressor gene on chromosome 3p has contributed to the understanding of tumor pathogenesis. Renal cell carcinoma occurs nearly twice as often in men as in women. Patients are generally more than 40 years old at diagnosis, usually in the fifth to seventh decade of life. This tumor is more common among urban than rural residents, but it was not a consistent association with education or socio-economic status. Recently large epidemiologic studies showed an increased risk of renal-cell cancer in relation to tobacco smoking, with a relative risk of about 2 for current smokers. Other established risk factors are elevated body mass index (mainly in women) and a family history of the disease. Occupational exposure to chemicals appears to have little significance, although associations with specific products, such as asbestos fibres, have been reported. Some relationship has been observed between renal-cell cancer and hypertension, use of anti-hypertensives and kidney diseases, although this issue remains open to discussion. Data are inconsistent on the role of nutrition, mainly for fats and proteins, while vegetable and fruit consumption seems to convey some protection on renal-cell cancer risk. The risk of renal-cell cancer was not materially elevated in relation to coffee, tea and alcohol intake and, in women, oral contraceptive use, hormone replacement therapy, and menstrual factors.

Surgical management of retroperitoneal tumors with vena caval thrombus in the inferior cava using cardiopulmonary bypass, arrested circulation and profound hypothermia.

OBJECTIVE: It was our aim to review our surgical experience with retroperitoneal tumors extending to the vena cava by using cardiopulmonary bypass, deep hypothermia and circulatory arrest. METHOD: We performed this procedure in 15 patients. The ages ranged between 16 and 70 years. The primary malignancies were renal cell carcinoma (n = 13), Wilms' tumor (n = 1) and paratesticular rhabdomyosarcoma (n = 1). RESULTS: There were no operative deaths. One patient died on the fourth postoperative day because of pulmonary embolization. The most common postoperative complications were: 1 patient required surgical reexploration because of hemorrhage, there was transitory renal failure in 3 patients, 1 patient developed a postoperative reactive psychosis and 1 patient developed a subclinical pericarditis. CONCLUSION: We believe that the resection of retroperitoneal malignancies with venous tumor thrombus extension offers, in selected patients, the only chance of reasonable long-term survival. The application of a cardiopulmonary bypass and hypothermia in high level vena cava thrombi is an important advance that has improved the safety and technical efficacy of a difficult surgical undertaking.

[Bilateral synchronous adrenal metastasis of renal adenocarcinoma]. / Metástasis suprarrenales bilaterales sincrónicas de adenocarcinoma renal.

Contribution of one case of renal adenocarcinoma with synchronous metastasis in both adrenal glands. Treatment was radical surgery with palliative resolution and steroid replacement therapy. Brief comments on this uncommon clinical situation and review of other author's experience.

[Urothelial inverted papilloma]. / Papiloma invertido urotelial.

Review of 60 cases of inverted urothelial papilloma published in our country in different urological journals. Analysis of clinical, diagnostic and therapeutical issues. Also an analysis is made of the possible association with other neoplasias or their malignant development.

[TPS in prostate cancer]. / TPS en cáncer de próstata.

A study of the tumour proliferation marker TPS in prostate cancer has been carried out. The levels of this marker were determined in the following groups: controls (n = 51), prostate hyperplasia (n = 17), prostate cancer in clinical remission (n = 15), and progressive prostate cancer (n = 13). An upper normal limit of 129 U/l (percentile 95) was established. When the progressive disease group was compared with the other groups, a significant difference (p < 0.001) was found. Sensitivity, specificity and positive predictive value obtained in order to dismiss progression were 71%, 94% and 62% respectively.

[Surgical aspects of renal transplantation]. / Algunos aspectos quirúrgicos del trasplante renal.

Expansion of donor criteria and more efficient use of the donor pool are needed to address the current organ shortage. Results of renal transplantation in older patients support broader recipient selection. To improve intraoperative donor and recipient management, and decrease the rate of delayed graft function, and refine surgical techniques to address more complicated patients are also attempts to expand donor pool. Use of hepatitis-C-positive donors is not safe in hepatitis-C-positive recipients for non-life-saving organs.