Deceased donor kidney procurement: Systematic review of the surgical technique.

INTRODUCTION: Kidney procurement procedure must be carried out following a standardized technique in order to optimize kidney grafts for their subsequent implantation. OBJECTIVES: Review of the available literature on kidney procurement procedure. MATERIAL AND METHODS: Narrative review of the available evidence on deceased donor kidney procurement technique after a search of relevant manuscripts indexed in PubMed, EMBASE and Scielo written in English and Spanish. RESULTS: Deceased donor kidney procurement can be divided into two groups, donation after brain death (DBD) and donation after circulatory death (DCD). Kidney procurement in DBD frequently includes other chest and/or abdominal organs, requiring multidisciplinary surgical coordination. During the harvesting procedure, the renal vascular pedicle must remain intact for subsequent implantation and reduced ischemia time. CONCLUSIONS: Adequate execution and perfect knowledge of the technique for surgical removal and anatomy reduces the rate of graft losses associated to inadequate harvesting techniques.

Influence of double J stent in the complications of ureterovesical anastomosis during kidney transplantation.

INTRODUCTION: Complications arising from ureterovesical anastomosis in kidney transplantation have an important influence on the success of the procedure. The most serious and frequent complications are fistula and stenosis of the ureterovesical junction. The placement of double J stents in anastomosis is currently recommended to reduce these complications. OBJECTIVE: The aim of the study is to evaluate whether the placement of a DJ stent affects complications of anastomosis. MATERIAL AND METHODS: Retrospective analysis of 697 patients treated with cadaveric donor renal transplant in our center from 1999 to 2018 was performed. Results were compared according to double J stent placement and the surgical technique employed for anastomosis. RESULTS: Transplantation was performed without DJ placement in 51.7% of the patients, compared to 48.3% who were treated with DJ stent placement. The most commonly used technique was Lich-Gregoir. Ureterovesical fistula occurred in 5% of cases, and ureterovesical stenosis in 4.2%. DJ stent behaved as a protective factor for ureterovesical fistula but did not significantly influence the development of stenosis. The Taguchi technique greatly increased the risk of developing both ureterovesical fistula and stenosis. The incidence of stenosis and fistula was significantly higher when the Taguchi technique was combined with no DJ stent placement. CONCLUSION: DJ stent placement acts as a protective factor for ureterovesical stenosis complications. The results of our study seem to agree with current literature.

Surgical management of horseshoe kidney tumors. Literature review and analysis of two cases.

INTRODUCTION: The horseshoe kidney is a rare congenital anomaly in the general population that combines renal ectopia, malrotation and abnormal vascular supply. The most frequently developed tumor in this case is renal cell carcinoma (50%). One of its main characteristics is great anatomical variation, especially in terms of vascular structures. MATERIAL AND METHODS: We present two cases of patients with diagnosis of renal tumor in horseshoe kidneys, both treated with laparoscopic partial nephrectomy in our department. Additionally, we have carried a review of the current literature. DISCUSSION: Indications for surgical treatment in this pathology are the same as in kidneys with normal anatomy. Traditionally, treatment has been open surgery, with heminephrectomy as surgery of choice. The current trend is to advocate nephron-sparing surgery, and the laparoscopic approach has been progressively gaining importance. CONCLUSION: A thorough imaging study is essential for proper surgical planning.

Mortality prediction model for patients with bladder urothelial tumor after radical cystectomy. / Modelo predictivo de mortalidad en pacientes con tumor urotelial de vejiga tras cistectomía radical.

OBJECTIVE: Based on preoperative clinical and postoperative pathological variables, we aim to build a prediction model of cancer specific mortality (CSM) at 1, 3, and 5 years for patients with bladder transitional cell carcinoma treated with RC. MATERIAL AND METHODS: Retrospective analysis of 517 patients with diagnosis of cell carcinoma treated by RC (1986-2009). Demographic, clinical, surgical and pathological variables were collected, as well as complications and evolution after RC. Comparative analysis included Chi square test and ANOVA technique. Survival analysis was performed using Kaplan-Meier method and log-rank test. Univariate and multivariate analyses were performed using logistic regression to identify the independent predictors of CSM. The individual probability of CSM was calculated at 1, 3 and 5 years according to the general equation (logistic function). Calibration was obtained by the Hosmer-Lemeshow method and discrimination with the elaboration of a ROC curve (area under the curve). RESULTS: BC was the cause of death in 225 patients (45%). One, three and five-year CSM were 17%, 39.2% and 46.3%, respectively. The pT and pN stages were identified as independent prognostic variables of CSM at 1, 3 and 5 years. Three prediction models were built. The predictive capacity was 70.8% (CI 95% 65-77%, p=.000) for the 1st year, 73.9% (CI95% 69.2-78.6%, p=.000) for the third and 73.2% (CI% 68.5-77.9%, p=.000) for the 5th. CONCLUSIONS: The prediction model allows the estimation of CSM risk at 1, 3 and 5 years, with a reliability of 70.8, 73.9 and 73.2%, respectively.

Recurrence risk groups after nephrectomy for renal cell carcinoma. / Clasificación en grupos de riesgo de recurrencia tras nefrectomía por cáncer renal.

INTRODUCTION: There is no consensus on the follow-up protocol after nephrectomy for renal cell carcinoma (RCC), and the identification of recurrence risk groups (RRG) is required. OBJECTIVE: Establish recurrence risk groups (RRG). MATERIAL AND METHOD: A retrospective analysis of 696 patients with renal cancer submitted to surgery between 1990-2010; 568 (81.6%) patients treated with radical nephrectomy and 128 (18.4%) treated with partial nephrectomy. Pathological variables were classified as: 1st-level variables (1LPV): pTpN stage and Fuhrman grade (FG); and 2nd level pathological variables (2LPV): sarcomatoid differentiation (SD), tumor necrosis (TN), microvascular invasion (MVI) and positive surgical margins (PSM). Univariate and multivariate analysis have been performed using Cox regression to determine 1LPV related to recurrence. Based on 1LPV, we classified patients into three RRG: Low (LRG)<25%; Intermediate (IRG) 26-50% and High (HRG)>50%. We performed univariate and multivariate analysis with the 2LPVs for each RRG. With these data, patients were reclassified as RRG+. ROC curves were used for comparison of RRG and RRG+. RESULTS: The median follow-up was 105 months (range 63 to 148). There were 177 (25.4%) patients with recurrence: 111 (15.9%) distant, 34 (4.9%) local and 32 (4.6%) distant and local. In the multivariable analysis, Fuhrman grade (HR=2,75; P=.0001) and pTpN stage (HR=2,19; P=.0001) behaved as independent predictive variables of recurrence. Patients were grouped as RRG (AUC=0,76; p=0,0001): - LRG (pT1pNx-0 G1-4; pT2pNx-0 G1-2): 456 (65,5%) patients. - IRG (pT2pNx-0 G3-4; pT3-4pNx-0 G1-2): 110 (15,8%) patients. - HRG (pT3-4pNx-0 G3-4; pT1-4pN+): 130 (18,6%) patients. After multivariate analysis with 2LPV, RRG were reclassified (RRG+) (AUC=.84, P=.0001): -LRG+(LRG without TN, SD and/or PSM(+)). -IRG+(IRG; LRG with TN) -HRG+(HRG; LRG with SD and/or PSM(+); IRG with TN and/or SD) CONCLUSIONS: The inclusion of 2LPV to the classification according to VP1N improves the discriminating capacity of RRG classification.

Evaluation of laparoscopic approach in radical cystectomy from implementation to consolidation: Internal validation. / Evaluación del abordaje laparoscópico en la cistectomía radical desde la implantación hasta su consolidación: validación interna.

INTRODUCTION AND OBJECTIVES: The AEU Guidelines of 2017 consider laparoscopic and robot-assisted approaches as investigational procedures. The surgical learning curve is defined as the minimum number of cases that a surgeon has to perform in order to reproduce a technique considered as standard. The aim of this study is to analyze, within our department, the implementation of a laparoscopic radical cystectomy (LRC) program compared with a well consolidated and standardized open radical cystectomy (ORC) program. MATERIAL AND METHODS: Retrospective cohort analysis of two cystectomy groups: LRC (n=196) (20062016) vs. ORC (n=96) (2003-2005). Comparison of the evolution over time of the following parameters: operative time, blood transfusion rates, resection margins, postoperative complications, hospital stay and recurrence. Three time periods have been defined for LRC: implementation (2006-09) (LRC-I), development (2010-14) (LRC-D) and consolidation (2015-16) (LRC-C); comparing each of them with the control group (ORC). The chi-square test was used for the comparison of the qualitative variables and the Anova test for the numerical ones. RESULTS: When compared to ORC, LRC presented longer operative times in LRC-I and LRC-D periods. We observed a trend toward shorter operative time than ORC in the consolidation period (LRC-C). LRC also presented lower intraoperative transfusion rates in all periods and lower postoperative rates in CRL-D and CRL-C. Overall complications in LRC-D and LRC-C were lower in LRC, having fewer major complications (Clavien≥3) in the 3 periods. A decrease in mortality and hospital stay after the LRC-I phase was also observed. These results were consolidated during the two last periods of the study. We have not observed significant differences between ORC and LRC when comparing surgical margins and recurrence rates, neither in the total series, nor in the comparison between the different periods. These results endorse the oncologic safety of LRC from the beginning of the implementation process. CONCLUSIONS: When compared to ORC, LRC improves perioperative transfusion rates, complications and hospital stay from its implementation period, maintaining oncological safety. On the contrary, longer operative times during implementation and development were observed. However, in our series, we observed a trend toward shorter operative times than ORC approach in the consolidation period. We have validated the laparoscopic approach for radical cystectomy in our service.

Effect of adjuvant chemotherapy in locally advanced urothelial carcinoma of the bladder treated with cystectomy. / Efecto de la quimioterapia adyuvante en el carcinoma urotelial de vejiga localmente avanzado tratado con cistectomía.

INTRODUCTION: Currently, the role of adjuvant chemotherapy (ADJ) in muscle invasive bladder tumor remains controversial. OBJECTIVE: To evaluate the effect of ADJ on cancer specific survival of muscle invasive bladder tumor after radical cystectomy (RC). MATERIAL AND METHODS: Retrospective analysis of 292 patients diagnosed with urothelial bladder tumor pT3-4pN0 / + cM0 stage, treated with RC between 1986-2009. Total cohort was divided in two groups: 185 (63.4%) patients treated with ADJ and 107 (36.6%) without ADJ. Median follow-up was 40.5 months (IQR 55-80.5). Comparative analysis was performed with Chi-square test and Student's t test /ANOVA. Survival analysis was carried out with the Kaplan-Meier method and log-rank test. Multivariate analysis (Cox regression) was made to identify independent predictors of cancer-specific mortality (CSM). RESULTS: 42.8% of the series presented lymph node involvement after RC. At the end of follow-up, 22.9% were BC-free and 54.8% had died due to this cause. The median cancer specific survival was 30 months. No significant differences were observed in cancer specific survival regarding the treatment with ADJ in pT3pN0 (p=.25) or pT4pN0 (p=.29) patients, but it was significant in pT3-4pN+ (p=.001). Multivariate analysis showed pathological stage (p=.0001) and treatment with ADJ (p=.007) as independent prognostic factors for CSM. ADJ reduced the risk of CSM (HR:0.59,95% CI 0.40-0.87, p=.007). CONCLUSIONS: pT and pN stages were identified as independent predictors of CSM after RC. The administration of ADJ in our series behaved as a protective factor reducing the risk of CSM, although only pN+ patients were benefited in the stage analysis.

Post-surgical complications in patients with bladder cancer treated with cystectomy: Differences between open and laparoscopic approach. / Complicaciones posquirúrgicas en los pacientes con cáncer de vejiga tratados con cistectomía: Diferencias entre el abordaje abierto y laparoscópico.

INTRODUCTION: Minimally invasive surgery regarding cystectomy has not had the same development as other urological surgeries. This could be due to the lack of published studies defining the advantages of this approach versus open surgery. OBJECTIVES: The main objective of this study is to establish the role of minimally invasive surgery, laparoscopic radical cystectomy, versus open surgery by analyzing their perioperative complications. MATERIAL AND METHOD: Retrospective cohort analysis of perioperative complications of 2homogeneous series of cystectomies: laparoscopic (n = 196) versus open (n = 197). Identification of independent predictors of perioperative complications by multivariate analysis. RESULTS: In the comparative analysis between laparoscopic cystectomies and open cystectomies we observed a lower rate of perioperative blood transfusion (P < 0.0001), a lower rate of global postoperative complications (P < 0.0001) and a lower rate of serious complications (Clavien > 3; P < 0.001) in the LRC group. There was also a lower mortality rate in the laparoscopic series compared to open ones (P < 0.0001). Surgical approach and surgical time (P < 0.001) were identified as independent predictors of complications. CONCLUSIONS: We have identified the laparoscopic approach as a complication shield for radical cystectomy. The open approach almost triples the risk of complications.

Influence of laparoscopic access in cancer-specific mortality of patients with pTa-2pN0R0 bladder cancer treated with radical cistectomy. / Influencia del acceso laparoscópico en la mortalidad cáncer-específica de los pacientes con cáncer de vejiga en un estadio pTa-2pN0R0 tratados con cistectomía radical.

INTRODUCTION AND OBJECTIVE: Minimally invasive surgery represents an attractive surgical approach in radical cystectomy. However, its effect on the oncological results is still controversial due to the lack of definite analyses. The objective of this study is to evaluate the effect of the laparoscopic approach on cancer-specific mortality. MATERIAL AND METHOD: A retrospective cohort study of two groups of patients in a pT0-2pN0R0 stage, undergoing open radical cystectomy (ORC) (n=191) and laparoscopic radical cystectomy (LRC) (n=74). Using Cox regression, an analysis has been carried out to identify the predictor variables in the first place, and consequently, the independent predictor variables related to survival. RESULTS: 90.9% were males with a median age of 65years and a median follow-up period of 65.5 (IQR27.75-122) months. Patients with laparoscopic access presented a significantly higher ASA index (P=.0001), a longer time between TUR and cystectomy (P=.04), a lower rate of intraoperative transfusion (P=.0001), a lower pT stage (P=.002) and a lower incidence of infection associated with surgical wounds (P=.04). When analyzing the different risk factors associated with cancer-specific mortality, we only found the ORC approach (versus LRC) as an independent predictor of cancer-specific mortality (P=.007). Open approach to cystectomy multiplied the risk of mortality by 3.27. CONCLUSIONS: In our series, the laparoscopic approach does not represent a risk factor compared to the open approach in pT0-2N0R0 patients.

Influence of the laparoscopic approach on cancer-specific mortality of patients with stage pt3-4 bladder cancer treated with cystectomy. / Influencia del acceso laparoscópico en la mortalidad cáncer específica de los pacientes con cáncer de vejiga en un estadio pT3-4 tratados con cistectomía.

INTRODUCTION AND AIM: The main aim of the study was to establish the oncological safety of the laparoscopic approach to radical cystectomy for high-risk, non-organ-confined urothelial tumours. MATERIAL AND METHODS: A retrospective cohort study of 216 stage pT3-4 cystectomies operated between 2003 and 2016; using an open approach (ORC, n=108), and using a laparoscopic approach (LRC, n=108). RESULTS: Both groups have similar pathological features except, in G3 TUR, there were more lyphadenectomies and greater pN+, and more adjuvant chemotherapies using the LRC. The median follow-up of the series was 15 (IQR: 8-10.5) months. Sixty-eight point one percent of the series relapsed, with no differences between either group (p=.11). The estimated differences for cancer-specific survival was greater in the LRC group (p=.03), as was overall survival (p=.009). There were no differences between either group in estimated recurrence-free survival (p=.26). The type of surgical approach (p=.03), pTpN stage (p=.0001), and administration of adjuvant chemotherapy (p=.003) were related to cancer-specific mortality (CSM) in the univariate analysis. Only the pTpN stage (p=.0001), and not giving adjuvant chemotherapy (p=.003) behaved as independent predictive factors of CSM. CONCLUSION: The type of surgical approach to cystectomy (ORC vs. LRC) did not influence CSM. Lymph node involvement and not giving adjuvant chemotherapy were identified as predictive factors of CSM. Our study supports the oncological safety of the laparascopic approach for cystectomy in patients with locally advanced muscle-invasive bladder tumours.

[Conservative surgery in renal adenocarcinoma]. / Cirugía conservadora en el adenocarcinoma renal.

Conservative surgery in renal adenocarcinoma has originated a growing interest over the last few years for several reasons: 1. Refinement in renal imaging techniques. 2. Improvement in surgical techniques. 3. Greater number of tumours discovered incidentally usually at low stage, and 4. Good long-term results in patients treated this way. We conducted a retrospective analysis of 8 patients diagnosed with renal adenocarcinoma and treated with conservative surgery over a 5-year period, between January 85 and December 90. Complete tumour removal by enucleation was achieved in all patients, with low morbidity rates since only 1 patient had to be re-operated due to late haemorrhage. Since follow-up is short in most patients, no long-term results are provided. We conclude that enucleation is a simple technique which allows complete removal of small size renal adenocarcinoma with low morbidity and no mortality.

[Variability of rectal examination of the prostate among various groups of observers]. / Variabilidad del tacto rectal de la próstata entre distintos groupos de observadores.

Rectal examination (RE) of the prostate gland is compulsory to rule out the presence of prostate cancer (PC). Empirically, it is defined as an examination burdened with a high degree of subjectivity and difficult to reproduce. The objective of this retrospective study is to evaluate RE concordance between different groups of researchers. In 133 patients referred to our Centre with suspected PC, RE was performed by three groups of experimented urologists (2 in-hospital and 1 out-hospital). Concordance between the different groups was evaluated using Kappa's index (K). Kappa's index between out- and in-hospital urologists was 70%, 71% and 78%. Concordance of RE findings between the different groups of urologists can be considered good, since no significant differences were found relative to ER positive predictive value.

[Laparoscopic bilateral nephrectomy of native kidney in kidney transplantation carriers]. / Nefrectomía bilateral laparoscópica de riñones nativos en trasplantado renal.

Severe vesicouretheral reflux sometimes causes terminal renal failure which then requires renal transplantation. In these patients it may be necessary to perform bilateral nephrectomy when associated to serious hypertension or urinary infections with a significant clinical impact. This paper presents the clinical picture of a patient with a corpse renal transplantation, due to terminal renal failure secondary to reflex nephropathy, in whom it was necessary to perform bilateral nephrectomy due to the uncommon urinary infections requiring hospitalization for treatment. The bilateral nephrectomy was done through transperitoneal laparoscopic approach, using seven points for trocars introduction. The procedure lasted 4 hours and the patients was discharged within 48 hours with no complications. Accumulate experience in the use of laparoscopy in urology has allowed this technique to be feasible. After designing the experimental model, our group has had the chance to accomplish laparoscopic nephrectomies in humans. We believe that this is the first case of bilateral nephrectomy conducted in our country using the laparoscopic approach.

[Ultrasonographic and pathologic differences between non-palpable prostate cancer (T1c) and palpable lesions detected with rectal examination]. / Diferencias ecográficas y patológicasógicas entre los cánceres de próstata no palpables (T1c) y los palpables al tacto rectal.

OBJECTIVE: To determine whether non-palpable cancers (T1c) have different ultrasound and pathological features from other palpable cancers of the prostate gland. MATERIAL AND METHOD: PSA levels, ultrasound features and Gleason score in 178 patients diagnosed with prostate cancer between 1994-1995 were compared. Correlation of pathological findings in surgical sections from 47 patients undergoing radical prostatectomy. RESULTS: 22% tumours were non-palpable. No difference was observed between both age groups (p = 0.5) and PSA levels (p = 0.09). Differences were noted in favour of palpable cancer in PSAD (p = 0.01), incidence of ultrasound nodes (p < 0.001), capsule changes (p < 0.001), seminal vesicles (p < 0.001), Gleason score (p = 0.006) and bone scan (p < 0.05). Two (14%) patients with non-palpable cancer showed no tumour in the prostatectomy section. Apart from these 2 patients, no differences were found between both groups in terms of Gleason score (p = 0.3), local stage (p = 0.7) and node involvement (p = 0.4) in patients undergoing radical prostatectomy. CONCLUSIONS: 86% patients with non-palpable prostate cancer has clinically significant tumours and showed no differences from the rest of tumours undergoing radical prostatectomy.

[Yield of transrectal ultrasonography in the diagnosis of prostatic cancer in symptomatic patients with normal rectal digital test]. / Rendimiento de la ecografía transrectal en el diagnóstico del cáncer de próstata en los pacientes sintomáticos con tacto rectal normal.

The purpose of this retrospective study is to evaluate the incidence of prostate cancer in symptomatic patients with non-suspect rectal examination and its correlation to PSA, PSAD levels and ultrasound findings. A total of 235 patients with non-suspect rectal examination underwent transrectal ultrasound and echo-guided prostate biopsy to assess an echographic node, PSA > 10 ng/mL and/or PSAD > 0.15 Incidence of prostate cancer was 16% and no correlation was seen to either PSA (95CI = 5%, 14.9%) or the existence of ecographic nodes (95CI = 5.2%, 22.2%), mainly in the subgroup of patients with PSA > 10 ng/mL and no identifiable echographic node (95CI = 5.5%, 29.5%). A PSA > 10 ng/mL or identifiable echographic nodes in symptomatic patients with non-suspect rectal examination did not involve a risk factor for prostate cancer, however a PSAD > 0.15 within the group with PSA > 10 ng/mL with no echographic nodes did involve a risk factor.

[The diagnostic effectiveness of repeat echo-guided transrectal biopsy as a function of the clinical and anatomicopathological findings]. / Rentabilidad diagnóstica de la biopsia transrectal ecodirigida repetida en función de los hallazgos clínicos y anatomopatológicos.

OBJECTIVE: To evaluate the incidence of false negatives in our series of ultrasound-guided prostate biopsies. MATERIAL AND METHOD: 106 patients (79% with high PSA and the remainder with suspicion digital rectal examination) with cancer-free transrectal biopsy underwent at least a second biopsy limited to the peripheral area: mean age 68 +/- 6.4 years, mean number of biopsy punctures 5 +/- 1, 95% patients with biopsies from both lobes. Re-biopsy indication was the result of persistently high PSA in 84 patients (13 with glandular atypia and 3 with PIN 3), or suspicion digital rectal examination in 22 patients (4 with glandular atypia and 2 with PIN 3). Second biopsy was performed in 89% patients, third in 10% and fourth in just one patient. RESULTS: 14% patients were found to have cancer, tumour diagnosis being made on the second biopsy in 93.3% cases. In patients with suspicion digital rectal examination only, cancer was detected in 31%, and 7.3% patients with high PSA had cancer; 40% patients with PIN 3 and 18% patients with glandular atypia had cancer. In patients with high PSA only, PSA (p = 0.6) and PSAD (p = 0.3) levels and the presence of changes in the ultrasound (p = 0.8) were not enough to detect cancer patients. Deobstructive prostate surgery was performed in 15 patients after re-biopsy, cancer being found in the transitional area in 20% cases. CONCLUSIONS: Our recommendation is that all patients with suspicion digital rectal examination, high grade PIN or glandular atypia should undergo re-biopsy which should include the transitional area. Due to the low incidence of cancer in patients with persistently high PSA and the inefficiency of biochemical and ultrasound parameters to detect patients with cancer, we suggest that each case should be assessed on an individual basis.

[Non-specific granulomatous prostatitis diagnosed with ultrasonography-guided transrectal biopsy]. / Prostatitis granulomatosa no específica diàgnosticada mediante biopsia transrectal ecodirigida.

OBJECTIVE: To evaluate the incidence of non-specific granulomatous prostatitis (GP) in our series of prostate biopsies and to verify whether there were differences in the features of DRE, PSA and ultrasound findings in patients with GP and patients with prostate cancer that could be used as clinical indications in GP diagnosis. MATERIAL AND METHODS: Between 1994 and 1996, 835 patients with prostatic syndromes underwent echoguided transrectal biopsy. Neoplasia was diagnosed in 323 (39%) patients, non-specific GP in 11 (1.5%), whereas no malignancy signs were found in the remaining 501 (59.7%). A retrospective comparison of DRE features, PSA levels and the existence of echographic nodes was conducted between cancer patients and GP patients. RESULTS: 55% GP patients had suspicious DRE; in 64% at least one node with different echogeneicity was identified in the transrectal ultrasound, and the mean PSA value was 17.3 ng/ml. When they were compared to the group of patients with prostate cancer, no significant differences were found. CONCLUSION: In our experience we have not found any specific feature in DRE. PSA levels or ultrasound examination that allows to differentiate GP from prostate cancer. Transrectal biopsy of the gland is essential for the differential diagnosis of both entities.

[Incidence of prostatic cancer in symptomatic patients with non-suspicious rectal palpation and PSA levels greater than 10 ng/ml]. / Incidencia de cáncer de próstata en los pacientes sintomáticos con tacto rectal no sospechoso y niveles de PSA mayores de 10 ng/ml.

OBJECTIVE: To evaluate the overall incidence of prostate cancer in patients with symptoms of prostatism, no suspicious DRE and PSA > 10 ng/ml. MATERIAL AND METHOD: 397 eligible patients based on the above criteria, mean age 69.3 +/- 7.7 years and mean PSA level of 21.3 +/- 29.3 ng/ml, underwent ultrasound-guided transrectal biopsy of the peripheral and central areas. Patients with no cancer in the biopsy and surgery indication underwent prostate surgery. Incidence of cancer in the transitional area was evaluated in these patients. RESULTS: Biopsy was found to be positive for cancer in 15.4% patients. Patients with prostate cancer had PSA concentrations (p = 0.06) and PSAD (p < 0.0001) lower than cancer-free patients. Thirteen (21%) of these patients underwent radical prostatectomy; an extracapsular tumour was found in 46% of the surgical specimens. Of the 336 patients with benign histology in the biopsy, 94 (28%) underwent prostate surgery. Cancer in the transitional zone was found in 15% cases (5 T1a and 8 T1b), with significant differences between PSA (0.03) and PSAD (0.04) concentrations between patients with BPH or T1b tumour in the surgical specimen but not among patients with BPH and T1a cancer. CONCLUSIONS: Approximately 30% of these patients had prostate cancer, half of them found in the transitional area. PSA and PSAD did not show enough diagnostic strength to identify these patients. Most patients with cancer had clinically significant tumours. Therefore, we believe that prior to deciding the course of therapy these patients should undergo another series of biopsies including the transitional area, mainly in those with long-term life expectancy.

[Local recurrence after radical cystectomy for cancer of the bladder]. / Recidiva local después de cistectomía radical por cáncer de vejiga.

OBJECTIVE: The objective of the present study is to analyze the incidence, pathoanatomical characteristics, form of presentation and evolution of local relapses in patients undergoing radical cystectomy due to bladder cancer. MATERIAL AND METHOD: Analysis of our series of 170 bladder cancer cystectomies performed between 1986 and 1997 with a follow-up median of 51 months. 91% patients received no pre-operative treatment, 58% had localized disease (pT1-pT3a) while the remaining 42% had locally advanced disease (pT3b-pT4a). In 94% cases, a staging lymphadenectomy was performed which was pN0 in 84% instances, 21% patients underwent adjuvant chemotherapy. RESULTS: The incidence of local relapse was 6.5%, 45.5% of which already showed distant metastasis at the time of diagnosis. Preoperative (9% vs 6.5%) or adjuvant (8.3% vs 6.7%) treatment did not decrease the incidence of relapse. Local relapse was more frequent in patients with higher histologic degree (p < 0.05) and in patients with locally advanced disease (9.7% vs 4%). Mean time between cystectomy and relapse detection was 10.5 (4-23) months and mean survival 3.8 (1-15) months. CONCLUSIONS: Incidence of local relapse was 6.5%, half of the patients showing distant spread at the time of diagnosis. The type of pre- or post-operative treatment had not influence on the incidence of relapse. Patients with higher degrees and locally advanced stages had local relapse more frequently. The appearance of a local recurrence implies a bad prognosis with a medial survival of 3.8 months.