Homogenizing the Teaching of Engaged Medical Examinations to Large Numbers of Students: the Experience of the Digital Rectal Examination.

This project aims to complement and homogenise the teaching of indications and technique of digital rectal examination (DRE) through the use of simulators, and subsequently analysed the level of satisfaction with the training and skills acquired. The students were distributed into small groups. One of the workshop's coordinators synthesised indications and procedures of DRE. A teaching video was made with all the contents and was distributed between the trainers. During the workshop, trainers explained the indications and the method of performing the DRE. Then, the selected clinical cases were presented, followed by the DRE by specific simulators. Once the students had completed each exploration, the trainers explained each case and discussed it with students. The following week, an anonymous questionnaire was given to participants to evaluate the workshop. Of the 232 participating students, 53 (23%) responded to the questionnaire. The overall level of satisfaction was higher than 98% (score 4-5), reaching 100% in the evaluation of the practical contents, and 93% of the students would recommend the continuity of the workshop in the next courses. The DRE workshop was well received among medical students, with a high degree of voluntary participation and response rate to the subsequent survey. With this project, we have achieved a greater homogenisation of teaching within the subject of Urology, and greater confidence for the students when facing their future clinical practice.

Recommendations on the treatment of metastatic hormone-sensitive prostate cancer: Patient selection.

The standard treatment for metastatic hormone-sensitive prostate cancer (mHSPC) is now a combination of androgen deprivation therapy plus an androgen receptor-targeted therapy (abiraterone, apalutamide, enzalutamide or darolutamide), with or without chemotherapy (docetaxel). The selection of suitable patients for each therapeutic approach has become a determining factor to ensure efficacy and minimize side effects. This article combines recent clinical evidence with the accumulated experience of experts in medical oncology, radiation oncology and urology, to provide a comprehensive view and therapeutic recommendations for mHSPC.

A multidisciplinary consensus statement on the optimal pharmacological treatment for metastatic hormone-sensitive prostate cancer.

Androgen deprivation therapy (ADT) is the mainstay treatment for metastatic hormone-sensitive prostate cancer (mHSPC). The addition of docetaxel or new hormone therapies (abiraterone, apalutamide, or enzalutamide) improves overall survival and is currently the standard of care. However, the decision on the specific regimen to accompany ADT should be discussed with the patient, considering factors such as possible associated toxicities, duration of treatment, comorbidities, patient preferences, as there is no sufficient evidence to recommend one regimen over the other in most cases. This paper summarizes the evidence on the management of mHSPC and provides consensus recommendations on the optimal treatment in combination with ADT in mHSPC patients, with special attention to the patient's clinical profile.

Role of PCA3 and SelectMDx in the optimization of active surveillance in prostate cancer.

INTRODUCTION & OBJECTIVES: A not negligible percentage of patients included in active surveillance (AS) for low and very low risk prostate cancer (PCa) are reclassified in the confirmatory biopsy or have disease progression during follow-up. Our aim is to evaluate the role of PCA3 and SelectMDx, in an individual and combined way, in the prediction of pathological progression (PP) in a standard AS program. MATERIALS & METHODS: Prospective and observational study comprised of 86 patients enrolled in an AS program from 2009 to 2019, with results for PCA3 and SelectMDx previous to PCa diagnosis or during their confirmatory period. Univariate and multivariate analysis were performed to correlate PCA3 and SelectMDx scores as well as clinical and pathological variables with PP-free survival (PPFS). The most reliable cut-offs for both biomarkers in the context of AS were defined. RESULTS: SelectMDx showed statistically significant differences related to PPFS (HR 1.035, 95%CI: 1.012-1.057) (p = 0.002) with a C-index of 0.670 (95%CI: 0.529-0.810) and AUC of 0.714 (95%CI: 0.603-0.825) at 5 years. In our series, the most reliable cut-off point for SelectMDx was 5, with a sensitivity and specificity for PP of 69.8% and 67.4%, respectively. Same figure for PCA3 was 65, with a sensitivity and specificity for PP of 51.16% and 74.42%, respectively. The combination of both biomarkers did not improve the prediction of PP, C-index 0.630 (95%CI: 0.455-0.805). CONCLUSIONS: In the context of low or very low risk PCa, SelectMDx > 5 predicted 5 years PP free survival with a moderate discrimination ability outperforming PCA3. The combination of both tests did not improved outcomes.

Genetic counseling in prostate cancer: How to implement it in daily clinical practice? / Asesoramiento genético en cáncer de próstata: ¿cómo implementarlo en la práctica clínica diaria?

Prostate cancer plays an undeniably prominent role in public health in our days and health systems. Its epidemiological impact is quantitatively very close to that of other tumors such as colon cancer and breast cancer, in which genetic counseling is part of their routine clinical practice, both in the initial evaluation and in the selection of therapeutic strategies. Hereditary cancer syndromes, breast/ovarian and Lynch syndrome are part of genetic counseling in these tumors. Currently, we also know that they can be associated to prostate cancer. The time has come to implement genetic counseling in prostate cancer from the earliest stages of its approach, from initial suspicion to the most advanced tumors. We present an updated review carried out by our interdisciplinary working group on scientific literature, clinical practice guidelines and consensus documents, aimed at the creation and drafting of a'Protocol for genetic counseling in prostate cancer' for the study of germline, with easy application in different healthcare settings. This protocol is currently being implemented in our routine practice and provides answers to 3 specific questions: Who should receive genetic counseling for prostate cancer? Which gene panel should be analyzed? How should counseling be done according to the results obtained? Other aspects about who should perform genetic counseling, ethical considerations and regulations are also collected.

Update and optimization of active surveillance in prostate cancer in 2021. / Actualización y optimización de la vigilancia activa en cáncer de próstata en 2021.

INTRODUCTION AND OBJECTIVES: Within the paradigm shift of the last decade in the management of prostate cancer (PCa), perhaps the most relevant event has been the emergence of active surveillance (AS) as a mandatory strategy in low-risk disease. We carry out a critical review of the clinical, pathological and radiological improvements that allow optimizing AS in 2021. MATERIAL AND METHODS: Critical narrative review of the literature on improvement issues and controversial aspects of AS. RESULTS: Adequate use of traditional criteria, optimized by enhanced biopsy and calculation of the prostate volume technique thanks to multiparametric magnetic resonance imaging (mpMRI) allow a better selection of patients for AS. This management should not be limited to patients under 60years of age, and patients with intermediate-risk PCa should be carefully selected to be included. Biopsies are still required in the follow-up, which can be personalized according to risk patterns. The pathologist must identify the cribriform or intraductal histology on biopsies in order to exclude these patients from AS, in the same way as with patients with alterations in DNA repair genes. CONCLUSIONS: Controversial indications such as the inclusion of patients from intermediate-risk groups, or the transition to active treatment due to exclusive progression in tumor volume, should be further optimized. It is possible that the future competition of tissue biomarkers, the refinement of objective parameters of mpMRI and the validation of PSA kinetics calculators may sub-stratify risk groups.

Variability in the multicentre National Registry in Active Surveillance; a questionnaire for urologists. / Variabilidad dentro del Registro Nacional multicéntrico en Vigilancia Activa; cuestionario a urólogos.

BACKGROUND: Our main objective was to report the current use of active surveillance in Spain and to identify areas for potential improvement. METHODS: A questionnaire generated by the Platform for Multicentre Studies of the Spanish Urology Association (AEU/PIEM/2014/0001, NCT02865330) was sent to all associate researchers from January to March 2016. The questionnaire included 7 domains covering various aspects of active surveillance. RESULTS: Thirty-three of the 41 associate researchers responded to the questionnaire. Active surveillance is mainly controlled by the urology departments (87.9%). There was considerable heterogeneity in the classical clinical-pathological variables as selection criteria. Only 36.4% of the associate researchers used prostate-specific antigen density (PSAd). Multiparametric magnetic resonance imaging (mpMRI) was clearly underused as initial staging (6%). Only 27.3% of the researchers stated that their radiology colleagues had a high level of experience in mpMRI. In terms of the confirmation biopsy, most of the centres used the transrectal pathway, and only 2 out of 33 used the transperineal pathway or fusion software. Half of the researchers interviewed applied active treatment when faced with disease progression to Gleason 7 (3+4). There was no consensus on when to transition to an observation strategy. CONCLUSIONS: The study showed the underutilisation of informed consent and quality-of-life questionnaires. PSAd was not included as a decisive element in the initial strategy for most researchers. There was a lack of confidence in the urologists' mpMRI experience and an underutilisation of the transperineal pathway. There was also no consensus on the follow-up protocols and active treatment criteria, confirming the need for prospective studies to analyse the role of mpMRI and biomarkers.

[Consults by scrotum mass: epididymo lesions]. / Consulta por masa escrotal: lesiones epidimarias.

In this review we try to update the knowledge about the tumors of epididymis, describing problems in diagnosis and treatment. We present a case of a 39 years old patient who consults by left testicular mass, before the sonogarphy suspect of tumor was made magnetic resonance imaging , wich aimed towards tumorlike injury. Excision of the injury via inguinal was made and the pathologic diagnosis was of adenomatoid tumor. Owing to the few series that appear in literature, and being the commentaries of these tumors about isolated cases, we expose the characteristics of this illustrated case to value the characteristics in diagnosis and treatment to compare them with other cases.

[Incidental prostatic cancer: T1a-T1b. Our experience after observation/radical surgery and literature review]. / Cáncer de próstata incidental: T1a-T1b. Nuestra experiencia tras observación/intervención radical y revisión de la literatura.

OBJECTIVES: To analyse the progress of T1a and T1b prostate cancer diagnosed in our hospital. MATERIAL AND METHODS: Retrospective study of 40 patients in T1a-T1b clinical stage diagnosed with prostate adenocarcinoma in our hospital, from 1986 to 1999. A restaging biopsy was performed on the 16 T1a patients after initial diagnosis and control. A radical prostatectomy was performed on the 24 T1b patients. They were all monitored every six months with rectal exam and PSA. We analysed biological and/or clinical progression, time to progression, mortality caused by the tumour and survival. RESULTS: None of the 16 patients with T1a clinical stage presented tumour progression, with a median follow-up of 90 months. 12,5% of the 24 T1b cases presented tumour progression, with a median follow-up of 70 months. Cancer-specific mortality was one patient (4,16 %) in the T1b group. CONCLUSIONS: Observation and follow-up with PSA and rectal exam appears to be a good option for T1a clinical stage, given the good prognosis. Our results show that patients with T1a clinical stage and good prognostic factors could be at a similar risk of suffering from a new prostate cancer as the normal population, although prospective studies are required to validate these results. T1b cases require active treatment and closer monitoring.

A Preliminary Study of the Ability of the 4Kscore test, the Prostate Cancer Prevention Trial-Risk Calculator and the European Research Screening Prostate-Risk Calculator for Predicting High-Grade Prostate Cancer.

INTRODUCTION: To prevent the overdiagnosis and overtreatment of prostate cancer (PC), therapeutic strategies have been established such as active surveillance and focal therapy, as well as methods for clarifying the diagnosis of high-grade prostate cancer (HGPC) (defined as a Gleason score ≥7), such as multiparametric magnetic resonance imaging and new markers such as the 4Kscore test (4KsT). By means of a pilot study, we aim to test the ability of the 4KsT to identify HGPC in prostate biopsies (Bx) and compare the test with other multivariate prognostic models such as the Prostate Cancer Prevention Trial Risk Calculator 2.0 (PCPTRC 2.0) and the European Research Screening Prostate Cancer Risk Calculator 4 (ERSPC-RC 4). MATERIAL AND METHODS: Fifty-one patients underwent a prostate Bx according to standard clinical practice, with a minimum of 10 cores. The diagnosis of HGPC was agreed upon by 4 uropathologists. We compared the predictions from the various models by using the Mann-Whitney U test, area under the ROC curve (AUC) (DeLong test), probability density function (PDF), box plots and clinical utility curves. RESULTS: Forty-three percent of the patients had PC, and 23.5% had HGPC. The medians of probability for the 4KsT, PCPTRC 2.0 and ERSPC-RC 4 were significantly different between the patients with HGPC and those without HGPC (p≤.022) and were more differentiated in the case of 4KsT (51.5% for HGPC [25-75 percentile: 25-80.5%] vs. 16% [P 25-75: 8-26.5%] for non-HGPC; p=.002). All models presented AUCs above 0.7, with no significant differences between any of them and 4KsT (p≥.20). The PDF and box plots showed good discriminative ability, especially in the ERSPC-RC 4 and 4KsT models. The utility curves showed how a cutoff of 9% for 4KsT identified all cases of HGPC and provided a 22% savings in biopsies, which is similar to what occurs with the ERSPC-RC 4 models and a cutoff of 3%. CONCLUSIONS: The assessed predictive models offer good discriminative ability for HGPCs in Bx. The 4KsT is a good classification model as a whole, followed by ERSPC-RC 4 and PCPTRC 2.0. The clinical utility curves help suggest cutoff points for clinical decisions: 9% for 4KsT and 3% for ERSPC-RC 4. This preliminary study should be interpreted with caution due to its limited sample size.

[Which is the most appropriate diagnostic algorithm for prostate cancer screening?]. / Cuál es el algoritmo diagnóstico más apropiado para el cribado del cáncer de próstata?

Since the use of PSA to detect prostate cancer was generalised in the late 1980's, prostate cancer diagnosis has increased considerably. Although there is now indirect evidence pointing to the beneficial effect of screening, there are no data justifying PSA screening in the general population. There is also a controversy concerning the most appropriate algorithm, should screening be performed. Therefore, our aim was to review the literature and, based on our experience, attempt to define the best algorithm for prostate cancer screening. We have made a search on Medline using the following terms: prostate biopsy, screening, algorithms, radical prostatectomy, PSA and prostate cancer. After analysing the literature, we can confirm that there is no "definitive" algorithm, due to the rapid appearance and use of new technical and biological breakthroughs, although it appears that at this time, without ceasing to include a rectal examination, more value should be given to personal risk factors, including PSA, at ages under 50, with individual monitoring based on these factors. The algorithms applied to a population have first to be validated for the population concerned.

[Renal teratoma, case report and review of the literature]. / Teratoma renal, aportación de un caso y revisión de la literatura.

We report a case of intrarenal teratoma in a 39-year-old female patient. The clinical course after three years of follow-up has been satisfactory, finding the patient totally asymptomatic. Extragonadal teratoma occurs predominantly along the median line of the body. Intrarenal teratoma is extremely rare; however, it should be distinguished from other cystic lesions.

[Penile fracture: report of a case]. / Fractura de pene: aportación de un caso.

Traumatic rupture of the corpus cavernosum of the penis is rare, and has been reported infrequently. We present a case with this type of trauma, with immediate surgical management, with good morphologic and functional results.

[Penile curvature secondary to cavernous body abscess]. / Incurvación peneana secundaria a absceso de cuerpo cavernoso.

A case of unilateral cavernosal body abscess appears after fifteen days of 40 degrees C fever, without urological symptoms. The diagnosis started from a big scrotum aedema, related of a local septic focus in the left cavernosal body. ECO and TAC confirmed the diagnosis, and a surgical treatment was required. After a successful evolution, the patient presents a left penile incurvation with pain and difficulties during the sexual relations, but he did not accept any treatment.

[Stage pT3 prostatic cancer after radical prostatectomy. Results in progression and survival]. / Cáncer de próstata estadio pT3 tras prostatectomía radical. Resultados en progresión y supervivencia.

PURPOSE: To analyse progression and survival after radical prostatectomy in patients with stage pT3 carcinoma of the prostate. MATERIAL AND METHODS: Between 1986 and November 1998, we performed 372 radical prostatectomies, 74 of which were pT3N0 (19.8%), 43 pT3a and 31 pT3b (TNM 97). RESULTS: In patients with pathological stage pT3, we found any progression in 24 patients (32%), 8 in pT3a, and 16 in pT3b. In 10 of 24 pT3, there was local relapse or distant metastases. About the freedom from biochemical relapse survival rate, we found statistically differences between pT3a and pT3b (p < 0.0001). In pT3a patients, we found no differences between PSA levels > 20 ng/ml, versus < 20 (p = 0.415), and statistically differences between pathological Gleason 6 or greater, versus < 6 (p = 0.048). However, we found no differences when we used both criteria (PSA and Gleason) (p = 0.195). CONCLUSIONS: We support for early adjuvant hormonal therapy in pT3b patients. In pT3a, the hormonotherapy may be used if appears biochemical failure, specially with adverse prognostic factors (PSA and Gleason).

[Cervico-urethro-suspension by the Raz's technique in the treatment of stress urinary incontinence in women]. / Cervicouretrosuspensión según técnica de Raz en el tratamiento de la incontinencia urinaria de esfuerzo en la mujer.

Presentation of our results in the treatment of urinary exertional incontinence in women using Raz's cervicourethral suspension. From January 1991 through December 1995, 87 patients were operated (mean age: 55.64 years; range 36-74). Mean follow-up was 29.4 months. Recovery from incontinence or permanence of minimal occasional leaks due to major exertion were rated as good results and were achieved in 75 cases (86.20%). Percentage of success in patients with mild incontinence was 93.33%; 88.88% in moderate incontinence; and 58.33% in severe incontinence, differences being statistically significant (p < 0.01). No statistical significance was found relative to age, prior incontinence corrective surgery, hysterectomy or association with urgency incontinence. Prior to surgery, 21 patients also had a component of urgency incontinence which disappeared post-surgery in 18 (85.71%) cases. De novo urgency incontinence appeared in 4 (6.06%) cases. Complications seen were 3 vesical perforations (3.44%). 1 urethrovaginal perforation (1.15%), 2 enterocele (3.44%) and 24 patients with transient urinary retention (27.58%). We believe this technique offers long-term successful results with a moderate morbidity rate.

[Predicting factors of tumor organ-confinement in adenocarcinoma of the prostate]. / Factores predictores de organoconfinación tumoral en el adenocarcinoma de próstata.

OBJECTIVE: Difficulties for a precise staging of patients with prostate cancer are huge. This article presents the initial results from a study to investigate the contribution that various clinical and analytical parameters, together with the study of prostate biopsy for staging, could have on our environment. MATERIAL AND METHODS: 70 patients undergoing curative radical prostatectomy were studied through an analysis of their PSA. PSAD, and PSAD ad pre-operative levels and, in the biopsy cylinders, the tumour unilateral or bilateral nature, Gleason grade, percentage and total number of involved cylinders, and percentage of cancer length over the cylinders' total length. This data was then correlated to the pathological stage. Gleason's grade and tumoral volume of the surgical specimen. RESULTS: 97% of patients studied showed clinical organ confinement versus only 64.28% after examination of the surgical specimen. (I Kappa = 0.1). Concordance between the biopsy's Gleason grade and the prostatectomy specimens was moderate (I Kappa = 0.34). Pre-operative PSA showed no statistically significant difference (SSD) between organ-confined and non-organ-confined tumours (p = 0.15), opposite to PSAD (p = 0.039) and PSAD ad (p = 0.038) which did. The tumour's unilateral or bilateral nature in the cylinders, and the total number or percentage of affected cylinders showed no SSD with regard to organ confinement of tumours. Neither the length percentage of the affected cylinders showed SSD in relation to the tumour's organ confinement. The specimen's tumoral volume was significantly correlated to the length percentage of cancer and positive biopsies, as well as with clinical stage, PSA, PSAD, and PSAD ad. CONCLUSIONS: Both PSAD and PSAD ad, and the sum of the biopsy's Gleason may contribute to predict the pathological stage. The percentage and total number of biopsy cylinders affected by the tumour, as well as the total length percentage of cancer affected cylinders are correlated to the tumoral volume but not to the organ confinement of the tumoral disease, not meeting the clinical stage in our patients (selected according to our group's staging algorithm). These findings must be ratified by further study of larger series.

[Positive margins. Surgical techniques and progression after radical prostatectomy]. / Márgenes positivos. Técnica quirúrgica y progresión tras prostatectomía radical.

OBJECTIVE: Repercussion of positive surgical borders (SB+) after radical prostatectomy (RP) in the oncological management of this condition is not yet well defined. The article analyzes their incidence and relevance for tumoral progression. MATERIAL AND METHODS: A review of 204 RPs is made. The erectors' preservation technique has been preferentially used until 1994, while the extracapsular standard technique was used afterwards. SB+ have been correlated to pre-operative PSA, Gleason grade, pathological stage and surgical technique. Also, status of borders has been correlated to progression. RESULTS: SB+ have been detected in 88 patients (43.13%) and were significantly correlated to the pathological stage and Gleason, but not to pre-operative PSA. Although no relation has been ascribed to the surgical technique used in terms of incidence, a decrease of posterolateral borders from 51.8% to 26.2% has been noticed using the extracapular standard technique. Progression is greater in SB+ patients (27.2% vs. 19.2%) but the difference is not statistically significant. SB+ patients who have progressed had all extracapsular tumour, 66% poorly differentiated. CONCLUSIONS: There is a decrease of posterolateral SB+ when the extracapsular standard technique is used. A correlation between presence of SB+ and progression has not been established. No patients with intracapsular tumour and SB+ has progressed. Therefore, it can be inferred his factor has little influence on the evolution of these patients.

[Quality of life after radical prostatectomy]. / Calidad de vida tras prostatectomía radical.

OBJECTIVE: To evaluate the quality of life of our prostatectomized patients relative to the following factors: continence, mictional quality, sexual potency and psychological repercussion. MATERIAL AND METHODS: The study includes a series of 204 patients undergoing radical prostatectomy between June 1986 and October 1996, where a personal questionnaire was administered to 112 of them. The questionnaire consisted of 25 questions dealing with various aspects related to their quality of life. RESULTS: The overall rating on continence shows the following results: total continence 59.8%, minimal incontinence grade I 17.8%, moderate incontinence grade II 13.3% and total incontinence grade III 8%. Only 2.6% retains sexual potency after surgery. 29.3% of impotent patients consulted for their dysfunction. 91% declared to be satisfied with the results of the surgical procedure. CONCLUSIONS: In our experience, continence (total + grade I incontinence) is acceptable for 77.6%, the level of mictional satisfaction being very high. There is a high index of impotence after surgery. However, most patients appear to be impervious to this fact. Overall, quality of life of our patients has not changed significantly as a result of the intervention.