Beyond the Limits: How to Avoid a Surgical Nightmare in the Third and Subsequent Renal Transplantation Procedures.

PURPOSE OF REVIEW: Approximately, 25% of the patients with ESRD will enter the waiting list for kidney transplantation. Among these patients, almost 15% will require a retransplantation surgery. This review aims to summarize the most recent information on different controversial issues regarding retransplantation, to provide the reader with a clear and updated view on the topic. RECENT FINDINGS: Despite current evidence is mainly based on retrospective, small, single-center experiences, it seems clear that retransplantation remains a surgical and immunological challenge, for which the perioperative management still remains crucial to avoid mishaps. Different surgical approaches have been tested, but the general consensus advocates for the heterotopic extraperitoneal in first instance. Although higher immunological risk and complication rates are reported invariably in the available series, the benefits in terms of overall survival are superior to those obtained under dialysis, thus still representing the most recommended option for this group of patients.

[Recto-urethral fistula secondary to prostate cancer]. / Fístulas recto-uretrales secundarias a tratamiento de cáncer de próstata.

OBJECTIVES: There are various treatments forprostate cancer nowadays, including techniques that have been used for manyyears such as surgery and radiotherapy, and newer procedures that are gaining prominence in the Urological field like cryotherapy or HIFU (high intensity focused ultrasound). Rectourethral fistula is a rare complication that demands the urologist a great capacity; it may happen after either existent treatment. METHODS: PubMed literature review with articles published during the last 10 years using the terms "rectourethral fistula" and "prostate cancer". EVIDENCE SINTHESIS: We present the current situation of rectourethral fistula secondary to prostate cancer in terms of epidemiology, diagnosis and treatment, with special focus on the various types of fistulae and their management. We comment on general features in relation to surgical management of this pathology; type of approach, type of repair, use of flaps, concomitant fistula and urethralstenosis, delay of surgery and bowel diversion. We describe the surgical techniques more frequently used today and their limitations. We present the results published by different groups with each of these techniques, as well as the corresponding recommendations based on each group's experience. CONCLUSIONS: Rectourethral fistula is a surgical challenge for the urologist. We must choose the appropriate management in accordance to the characteristics of the fistula.

[Preoperative predictive model for biochemical recurrence in patients with localized prostate cancer treated with radical prostatectomy]. / Modelo predictivo preoperatorio para la recidiva bioquimica en pacientes con cáncer de próstata localizado tratados con prostatectomia radical en monoterapia.

OBJECTIVES: To identify pre-prostatectomy clinical prognostic factors for biochemical recurrence (BR) and to create a predictive model for BR based or predictive clinical variables prior to radical prostatectomy (RP). METHODS: a retrospective case-records study of patients with clinically localized prostate cancer treated with RPas monotherapy pN0-pNx and monitored at least for 12 months between 1996 and 2007. We considered BR the PSA persistence or elevation after RP greater than 0.4 ng/ml. The clinical variables analyzed were PSA, clinical stage and Gleason score from the biopsy (GS). Univariate and multivariate analysis were carried out using the chi squared test and logistic regression to determine the variables associated with BR. In order to estimate BR based on the variables identified we developed a mathematical model and designed an Excel spreadsheet to apply it. Calibration and discrimination were performed using the Hosmer-Lemeshow test and an ROC curve determining the area under the curve. RESULTS: We included 627 patients. The mean age was 64 years with a mean follow- up of 87 months. The mean PSA was 8 ng/ml. 68.6% of patients had a PSA ≤ 10 ng/ml, 53,1% had a GS ≤ 6 and 61,7% had a clinical stage of cT1a-c. BR was observed in 204 (32,5%) patients, 39 due to biochemical persistence. The mean time to BR was 28 months with 89,7% of instances occurring in the first 8 years. On the multivariate analysis, PSA and GS were independent predictors of BR ( p=0.001), while the cT2c stage had a tendency towards statistical significance ( p=0.06). The three variables were included in the equation for the model with different specific weight. Specificity was 93.6%, sensitivity was 36.8% and an overall precision of 75.1%. The model had a predictive capacity of 73% and a p-value < 0.001. CONCLUSIONS: PSA and GS are independent prognostic clinical variables associated with BR-free survival. The predictive model developed allows the risk of BR to be estimated with 73% reliability.

Post-radical prostatectomy predictive factors for biochemical recurrence.

OBJECTIVES: To identify post-prostatectomy prognostic factors for biochemical recurrence (BR). METHODS: We retrospectively analyze a series of patients with clinically localized prostate cancer who were treated with radical prostatectomy (RP)as monotherapy between 1996 and 2007, pN0-pNx, with a minimum of 12 months of follow-up. BR is considered to be persistence or elevation in PSA after RP greater than 0.4 ng/ml on the subsequent determination. Analyzed variables were Gleason Score, pathological stage, surgical margin involvement, capsular involvement, and perineural involvement. We performed univariate and multivariate analysis using the chi squared test and proportional Cox risk model in order to determine the variables associated with BR. RESULTS: We included 693 patients. Mean age was 63.5 years with a mean follow-up of 88.5 months. Mean PSA was 9.2 ng-ml. BR was observed in 218 patients, 43 due to biochemical persistence. More common pathological findings were Gleason score 7 (47.1%), and pathological stage pT2c (60.1%). Mean time to BR was 35.5 months with 91.2% occurring in the first 8 years. On multivariate analysis, Gleason score ≥ 7(4+3), pathological stage pT3b and positive surgical margin were independent predictors of BR. CONCLUSIONS: Gleason Score ≥ 7(4+3), positive surgical margins and pathological stage pT3 are independent prognostic factors associated with BR-free survival.

Usefulness of the Memorial Sloan Kettering Cancer Center nomogram in the prognosis of patients treated with radical cystectomy for invasive bladder cancer.

OBJECTIVES: To evaluate the usefulness of the Memorial Sloan Kettering Cancer Center (MSKCC) nomogram for prediction of recurrence probability in our series of patients who have undergone radical cystectomy for bladder cancer. METHODS: 397 patients underwent radical cystectomy for bladder cancer between 1986 and 2005. 165 patients were excluded:21 due to exitus in the immediate postoperative period, 32 due to previous radiation therapy, 6 due to neoadjuvant chemotherapy, 5 due to inability to complete follow-up, 15 that did not undergo lymphadenectomy and 86 who were alive at the time of review with less than 5 years of follow-up. Patients were classified into recurrence risk groups: organ-confined tumors (pT0-2 pN0 ), extra-bladder involvement (pT3-4 pN0) and lymph node involvement (pN+). Survival analysis was performed using the Kaplan-Meier method. Five-year recurrence-free survival by risk groups in our series was compared with the one estimated using the MSKCC nomogram using a ROC curve. RESULTS: We analyzed 232 patients. Follow-up in patients who died of cancer was 25 ± 25 months. For alive patients and those who died of other causes, follow-up was 120 ± 39 months. Pathology studies revealed 42.7% organ-confined tumors , 33.2% with extra-bladder involvement and 24.1% with lymph node involvement. The five-year recurrence free survival analysis according to the Kaplan-Meier method stratified by risk groups was: pT0-2 76%, pT3-4 51%, pN+ 31%. The probability of recurrence free survival according to the MSKCC nomogram in the same risk groups was: 85% ± 5%, 62% ± 10% and 25% ± 13%, respectively. The area under the ROC curve was 0.795 (95% CI 0.739-0.852) CONCLUSION: In our series, the MSKCC nomogram constitutes a useful tool for predicting 5-year cancer free survival in patients who undergo radical cystectomy.

Prognostic factors in patients with stage pT0/pT1/pTa in the radical cystectomy specimen.

OBJECTIVES: To identify risk factors for progression in patients with invasive bladder carcinoma who were pT0/pT1/pTa after cystectomy. METHODS: We analyzed the clinical records of 97 post-cystectomy pT0/pT1/pTa patients for the following variables: hydronephrosis, carcinoma in situ (CIS), lymphovascular invasion, history of non-muscular invasive disease, residual tumor in the specimen and lymphatic invasion (pN). pN+patients were excluded from definitive analysis. The quantitative and qualitative variables were analyzed using standard statistics. The chi-square test was used to analyze associations between categorical variables. Univariate Cox proportional hazard regression analysis (enter method) was performed. The Kaplan-Meier method was used to evaluate survival and the log-rank test to assess differences between groups. Statistical significance was set at p<0.05. The analysis was performed using SPSS version 15.0. RESULTS: The study sample included 97 cases. The specimen was staged at T2 in 97% of patients after transurethral resection (TUR); After cystectomy, the specimen was staged as pT0 (R0) in 44.3% and pT1/Ta (R1) in 55.7%. Median follow-up was 47 months. Lymph node metastasis were detected in 5.2% of patients (pN+rpar; and had a negative impact on survival (p=0.02). Overall survival was 59.8% and cancer-specific survival 76.6%. Univariate analysis showed a relationship between tumor progression and the presence of CIS (p < 0.001), lymphovascular invasion (p=0.049), and hydronephrosis(p < 0.001). In the multivariate analysis, only the presence of CIS in the transurethral resection was associated with reduced cancer-specific survival (HR 100.5; 95% CI, 10.8 to 933.1; pp<0.001). CONCLUSIONS: Although the prognosis of stage pT0/pT1/pTa carcinoma in the cystectomy specimen is excellent, some patients experience progression. The presence of CIS in the transurethral resection was an independent predictor of recurrence in these cases.

Urachal adenocarcinoma. Case report and bibliographic review.

OBJECTIVE: Literature review of adenocarcinoma of the urachus in connection with two cases recently diagnosed and treated in our center. METHODS/RESULTS: We report 2 cases of urachus Adenocarcinoma treated in our institution, both underwent extended partial cystectomy including excision of the urachus up to the umbilicus. CONCLUSION: Urachal adenocarcinoma is an exceptional tumor, of poor prognosis, the treatment of which is surgical (partial cystectomy), and the main predictors of disease-free survival are the degree of tumor differentiation and the free margins of the surgical specimen.

En Bloc Resection of Right Renal Cell Carcinoma and Inferior Vena Cava Tumor Thrombus Without Caval Reconstruction: Is It Safe to Divide the Left Renal Vein?

Introduction: It has been suggested that inferior vena cava (IVC) reconstruction following resection of retroperitoneal tumors with IVC tumor thrombus (TT) is not required when adequate collateral circulation is present. There are no reports evaluating mid-term effects on renal function in these patients. The purpose of this study was to assess renal function after en bloc resection of right renal cell carcinoma (RCC) with obstructing IVC TT and the possible risks that may arise after left renal vein division. Materials and Methods: A bi-institutional retrospective review was performed over a 15-year period, assessing patients with right RCC and obstructing level II-IV TT. All patients underwent extensive evaluation and cardiology clearance, and informed consent was obtained for right radical nephrectomy and thrombectomy with or without IVC reconstruction with possible cardiopulmonary bypass (CPB). Patient demographics, tumor characteristics, intraoperative factors, complications, length of stay, and patient survival were evaluated. Preoperative creatinine was recorded, as was creatinine on the day of discharge and at 6 and 12 months postoperatively. Results: Twenty-two patients were included in the study. Median age at surgery was 62.5 (range: 45-79) years, and 19 (86%) of the patients were men. One patient (5%) had a level II thrombus, 14 patients (64%) had a level III thrombus (IIIa, n = 3; IIIb, n = 6; IIIc, n = 3; IIId, n = 2), and seven patients (32%) had a level IV thrombus. Intraoperatively, median estimated blood loss was 1.35 (range: 0.2-25) L. The median length of hospital stay was 11 (range: 5-50) days. Median preoperative creatinine was 1.20 (range: 0.40-2.70) mg/dl, and postoperatively, median creatinine was 1.3 (range: 0.86-2.20) mg/dl. Median creatinine levels at 6 months and 12 months postoperatively were 1.10 (range: 0.5-1.8) mg/dl and 1.40 (range: 0.6-2.0) mg/dl, respectively. Four patients died (range: 0.1-1.3 years), and median postoperative follow-up among the 18 ongoing survivors (at last follow-up) was 1.5 (range: 0.5-7.0) years. Conclusions: Resection of right RCC with an obstructing level II-IV TT without reconstruction of the IVC appears to not have a significant adverse effect on mid-term renal function after division of the left renal vein.

Cadaver donor kidney retransplantation in the pediatric patient: complications and long-term outcome.

PURPOSE: We compared the outcome of second and third kidney allografts with that of the first kidney allograft in pediatric recipients. MATERIALS AND METHODS: We classified 173 cadaveric kidney recipients into 2 groups. Group 1 comprised 120 first transplants and group 2 comprised 53 retransplants, including 43 second and 10 third transplants. We compared demographic characteristics and survival in groups 1 and 2. RESULTS: Group 1 consisted of 78 boys and 42 girls with a mean ± SD age of 11.5 ± 4.2 years. Group 2 consisted of 37 boys and 16 girls with a mean age of 10.4 ± 4.7 years. One, 5, 10 and 15-year graft survival rates were 78.7%, 64.3%, 54.5% and 50.7% for first transplants vs 82.8%, 57.8%, 57.8% and 41.3%, respectively, for retransplants (p = 0.757). Patient survival at 1, 5 and 15-year was 95.8%, 89.6%, 84.9% in the first transplant group vs 93.6%, 93.6% and 93.6%, respectively, in the retransplant group (p = 0.0.63). Graft survival was significantly higher in patients who did vs did not receive calcineurin inhibitors in the 2 groups (p = 0.02). CONCLUSIONS: Kidney retransplantation in the pediatric population can yield excellent long-term outcomes, especially in patients treated with calcineurin inhibitors.

Radical prostatectomy versus external-beam radiotherapy for localized prostate cancer: long-term effect on biochemical control-in search of the optimal treatment.

BACKGROUND: The optimal management of patients with clinically localized prostate carcinoma remains undefined due in part to the absence of well-designed, randomized trials. METHODS: This retrospective study comprised 505 patients diagnosed with low- or intermediate- risk prostate cancer in 1998-2005 and treated at Hospital Gregorio Marañón (Spain) with radical prostatectomy (RP) or external-beam radiotherapy (EBRT). No adjuvant therapy was administered. Biochemical relapse was defined as a prostate-specific antigen (PSA) level ≥0.4 ng/ml for RP cases and nadir + 2 for EBRT cases. RP was performed in 271 patients (53.6%) and EBRT in 234 patients (46.4%). The median follow-up was 60 months. The analysis end point was to compare the biochemical recurrence-free survival (bRFS) between the two groups. RESULTS: The 5-year bRFS rates for RP and EBRT were 79 ± 2% and 86 ± 2%, respectively (P = 0.48). Multivariate analysis indicated that initial PSA (P = 0.00), perineural invasion in the biopsy specimen (P = 0.00), Gleason score (P = 0.04), EBRT dose (P = 0.02), and positive margins (P = 0.00) were independent predictors of relapse. A decision tree model was constructed with these variables. In the EBRT cohort, a nadir PSA of <0.3 ng/ml was associated with the best 5-year bRFS (96.6 vs. 56.5% if nadir PSA > 1.3 ng/ml). Late biochemical failure (>5 years) was more frequent in the RT group and with low-dose EBRT (≤72 Gy). CONCLUSIONS: The biochemical failure rates were similar between PR and EBRT in low- and intermediate-risk subgroups. Outcome was determined by classic pre-treatment features, perineural invasion, low-dose EBRT (≤72 Gy), and nadir PSA value in the RT cohort.

[The diagnosis of prostate cancer from the clinical guidelines]. / El diagnóstico del cáncer de próstata desde las guías de práctica clínica.

OBJECTIVES: To compare methodology and recommendations for the diagnosis of prostate cancer between the different clinical Guidelines currently existent. METHODS: We searched for clinical practice Guidelines published in the period 2007-2009 in the web pages of the urological scientific associations, National Guideline clearinghouse, CMA infobase, and Trip database, as well as Pub Med. We found 4 clinical practice guidelines matching the search criteria. RESULTS: All guidelines have been developed by a multidisciplinary team, performing a previous systematic review. All of them except the AUA translate the scientific evidence in recommendations, although each of them uses a different classification. Only one of them has been evaluated using the AGREE method. There are differences in the recommendation and use of diagnostic tests (PSA, digital rectal examination and prostatic biopsy) due to the fact that as a general rule they are based on low level scientific evidence. CONCLUSIONS: Recommendations for the diagnosis of prostate cancer in all clinical practice guidelines are based on low levels of evidence, except in the use of antibiotic prophylaxis and anesthesia to perform a biopsy.

Comparative analysis of six months formulation of LHRH analogues for prostate cancer treatment.

SUMMARY OBJECTIVES: To perform comparative analysis of the efficacy and the safety of six months formulation of LHRH analogues indicated for prostate cancer treatment. METHOD: Search in the PubMed database for clinical trials published between 2006 and 2009 using the following key words: "prostate cancer", "triptorelin or leuprorelin" and "66-month depot". RESULTS: The efficacy of all 3 six months formulation of LHRH analogues currently approved is high (96-98%) for reducing testosterone levels down to below 50 ng/dl. As the patients included in the three trials are quite heterogeneous, and due to the variability in the way of presenting results, it is not possible to compare testosterone escapes and their effect on PSA levels. The incidence of adverse events (AE) reported across the three trials was high, but only 0.9% to 15.8% were severe. Only one trial reported patient withdrawal (2.5%) because of drug-related AEs. CONCLUSION: Even though all the studies show and important variability in the analysis and data management, no significant efficacy and safety differences seem to exist.

Effectiveness of two ultrasound-guided transrectal biopsy schemes in the diagnosis of prostate cancer. A randomized study.

OBJECTIVE: To determine whether a 10-core prostate biopsy scheme is superior to the sextant scheme in diagnosing prostate cancer in patients programmed for a first biopsy, with negative rectal digital examination and PSA between 3.5-20 ng/ml. METHODS: A randomized prospective study was performed comparing two prostate biopsy schemes, with randomization stratification according to prostate volume (< or = 50 ml and > 50 ml). Sample size predetermination yielded a minimum of 304 patients in order to achieve the primary objective. Statistical analysis was carried out on an intent-to-treat basis, using the chi-squared test and uni- and multivariate analysis via logistic regression. RESULTS: Cancer was detected in 27.3% of the cases. A significant association was observed between cancer diagnosis and age (p=0.03), prostate volume (p=0.0001) and ultrasound nodule identification (p=0.0001). No correlation was observed with the total number of cores in the series (p=0.37) or with prostate volume < or = 50 ml (p=0.87) or > 50 ml (p=0.09). In the multivariate analysis, age > 70 years (p=0.005), prostate volume < or = 50 ml (p=0.001), and ultrasound nodule identification (p=0.003) were identified as independent variables associated to cancer diagnosis. CONCLUSION: No statistically significant differences were found between the two prostate biopsy schemes. In glands over 50 ml in size, the sextant scheme may prove to be insufficient.

[Effect of surgical approach on radical nephrectomy outcomes: Comparative study between open and laparoscopic nephrectomy.] / Influencia de la vía de acceso para la nefrectomía radical en el tratamiento del cáncer renal: estudio comparativo entre cirugía abierta y cirugía laparoscópica.

OBJECTIVE: The aim of this study is to evaluate the influence of laparoscopy in patients with renal cancer treated with radical nephrectomy in terms of surgical time, hospital stay, postoperative complications and survival.MATERIAL AND METHODS: Retrospective study of 570 patients with renal cancer treated with radical nephrectomyin stage ≤pT3a. Differences between groups were analysed using ANOVA test for quantitative variables and Chi squared test for qualitative. In order to evaluate possible risk factors for longer hospital stay and surgical time, multivariate analysis was performed (lineal regression). For complications we performed binary logistic regression. Overall survival (OS), recurrence free survival (RFS) and cancer specific survival (CSS) were estimated using Kaplan Meier and compared using Log Rank test. Univariate and multivariate analysis was performed using Cox regression in order to identify independent risk factors for overall, cancer specific and recurrence mortality. RESULTS: Two cohorts: 361 (63.3%) open radical nephrectomies (ORN) and 209 (36.7%) laparoscopic (LRN). Surgical time was longer in LRN (p=0.001) globally. After the period when the learning curve was over these differences were no longer significant. Hospital stay was shorter in LRN (p=0.0001). cT stage (p=0.005) and surgical access (p=0.001) acted as independent risk factors for longer surgical time. 33,5% (121 patients) of the ORN had some sort of postoperative complication vs. 11% (23 patients) in the LRN group (p=0.0001). These differences were observed in the Clavien-Dindo's grade II group. Independent risk factors for postoperative complications observed were: ASA≥III (OR=1.82, p=0.004) and stage pT3a (OR=2.29,p=0.0001). Laparoscopy acted as a protective factor for complications (OR=0,26, p=0.0001). Surgical access did not influence RFS (HR=0.87, p=0.50), CSS(HR=0.69, p=0.12). CONCLUSIONS: Laparoscopic access to RN in patients with renal cancer in ≤pT3a stage increased surgical time only in the first years, reduced hospital stayand postoperative complications and did not influence RFS, OS or CSS.

OBJETIVO: El objetivo del estudio es evaluarla influencia de la laparoscopia en pacientes concáncer renal tratados con nefrectomía radical (NR) en términos de tiempo quirúrgico, estancia media, complicaciones postoperatorias y supervivencia.MATERIAL Y MÉTODO: Análisis retrospectivo de 570 pacientes con cáncer renal tratados con NR en estadio ≤pT3a comparando cohorte de acceso abierto (NRA) y laparoscópico (NRL). Contraste de variables cualitativas con el test de Chi cuadrado y cuantitativas con ANOVA. Para identificar factores de riesgo (FR) de tiempo quirúrgico y estancia media se utilizó regresión lineal multivariante y para complicaciones la regresión logística binaria. Estimación de la supervivencia libre de recidiva (SLR), global (SG) y cáncer específica (SCE) mediante Kaplan-Meier y test de log-rank para analizar las diferencias. Análisis multivariante mediante regresión de Cox para identificar variables predictoras independientes (VPI) de SLR y SCE. Todos los cálculos se han realizado con el paquete estadístico IBM® SPSS® statisticsv-21. RESULTADOS: Dos cohortes: 361 (63,3%) NRA y 209(36,7%) NRL. El tiempo de cirugía fue mayor en NRL (p=0,001) de forma global siendo las diferencias entre ambas en el periodo tras la curva de aprendizaje no significativas. La estancia media fue menor en NRL(p=0,0001). El estadio cT (p=0,005) y la vía de acceso (p=0,001) se comportaron como VPI de prolongación del tiempo quirúrgico. El 33,5% (121 casos) de las NRA presentaron algún tipo de complicación en el postoperatorio, frente al 11% (23 casos) de las NRL (p=0,0001). Esta diferencia se observó en complicaciones tipo II de Clavien. VPI de complicaciones postoperatorias: ASA≥III (OR=1,82, p=0,004) y el estadio pT3a (OR=2,29, p=0,0001). La laparoscopia se comportó como factor protector de complicaciones (OR=0,26, p=0,0001). La vía de acceso no influyó en la SLR (HR=0,87, p=0,50) ni en la SCE (HR=0,69,p=0,12). CONCLUSIONES: El acceso laparoscópico a la nefrectomía radical en pacientes con cáncer renal en estadio ≤pT3a aumentó el tiempo quirúrgico pero solo en los primeros años, presentó menor estancia y complicacionespostoperatorias y no influyó en la SG,SLR y SCE.

[Controversies in the prostate surgical anatomy. A literature review]. / Controversias en la anatomía quirúrgica prostática. Revisión de la literarura.

INTRODUCTION: Radical prostatectomy technique has improved in the last years based on accumulated surgical experience and new anatomical findings. We think it is time to update anatomical concepts to standardized the criteria formentioning structures related with radical prostatectomy MATERIAL AND METHOD: With the followings key words: "cavernosal nerves, prostatectomy, anatomy, neurovascular bundle" we search in Medline/PubMed database selecting papers fulfilling the search criteria. CONCLUSIONS: The prostate does not have a true capsule but rather an incomplete fibromuscular band as an intrinsic part of the gland. Periprostatic fascia seems to be a different structure from this fibromuscular band. Histologically Denonvilliers's fascia is formed by two thin layers that cannot be separated during surgery. The longitudinal smooth muscle fibres located beneath the posterior bladder neck corresponds to the posterior longitudinal fascia of the detrusor muscle. Cavernosal nerves are located between the two layers of the endopelvic fascia, the inner layer could be named periprostatic fascia and the outer, levator ani fascia. Cavernosal nerves merged from the pelvic plexus running within a neurovascular bundle around the prostate that could be found as a singular bundle or spread all around the anterolateral surface of this gland. There are overlapping terms to designate the pelvic fascia, therefore it could be useful for Urologists to standardized them.

[Prognostic factors for survival in patients with transitional bladder cancer treated with radical cystectomy]. / Factores pronósticos en la supervivencia de los pacientes con carcinoma transicional de vejiga tratados con cistectomía radical.

PURPOSE: To recognize clinical and pathological variables that influence in bladder cancer specific mortality in patients with transitional bladder cancer treated with radical cystectomy. MATERIAL AND METHOD: Retrospective analysis of 333 patients with transitional bladder cancer treated with radical cystectomy. Variables included during pre-cystectomy, peri-cystectomy and post-cystectomy period were analyzed. Four groups were defined based on pathological state: a) Organ-confine bladder cancer without lymph node metastasis (pT0-2, pN0); b) Extravesical desease without lymph node metastasis (pT3-4, pN0); c) Bladder cancer with lymph node metastasis (pT0-4, pN+); d) No data of lymph node affection (pT0-4, pNx). Univariate analysis and two models of multivariate analysis were performed including the risk group as a variable in one the latest. RESULTS: Mean follow up was 52.6 +/- 51 (2-221) months with a median of 31 months. Pathological state pT0 was observed in 7.2% of the patients, 12% were pT1, 26.7% pT2, 34.5% pT3 and 10.5% pT4. Lymph node metastasis was detected in 20.7% of the patients. Lymph node metastasis increased according to pathological state rises. Five and 10 years specific survival was 57% and 54% respectively. CONCLUSIONS: Local pathological state, lymph node status and risk groups were independent predictive factors for bladder cancer specific survival. Risk group association is a reliable method to predict bladder cancer specific survival and to identify the suitable patient group to get benefit from adjuvant therapy.

[Mucin-producing urothelial type prostatic adenocarcinoma with signet ring cells and increased Ca 19.9 and Cea. Case report and literature review.] / Adenocarcinoma mucinoso de próstata tipo urotelial con células en anillo de sello y elevación del Ca 19.9 y Cea. Revisión de la literatura a propósito de un caso.

OBJECTIVE: Primary Mucin-producing Urothelial-type Adenocarcinoma of Prostate is extremely infrequent. The presence of signet ring cells is exceptional, more atypical in its mucinous variant. Anatomopathological and immunohistochemical study play a key role. METHODS: Bibliographic review and case report of a 66-year-old man with Ca 19.9 and CEA elevation, and normal PSA levels, associated with lower urinary tract symptoms (mucosuria, hesitancy and hematuria). He was diagnosed with mucin-producing urothelial- type adenocarcinoma of the prostate with signet ring cells by transrectal prostate biopsy after multiparametic MRI. RESULTS: We found 23 cases described in our review. No case diagnosed following an elevation of Ca 19.9 was found in the literature. In our case, after diagnosis, he was treated with retropubic radical prostatectomy and bilateral ilio-obturator lymph node dissection, with subsequent normalization of tumor markers; however, he presented secondary pulmonary involvement and pelvic tumor progression despite chemotherapy treatment. CONCLUSIONS: The elevation of associated tumor markers (Ca 19.9, CEA) is extraordinary. There is no treatment algorithm, however surgery (radical prostatectomy) with or without adjuvant chemotherapy treatment represents an alternative in its therapeutic management.

OBJETIVO: El adenocarcinoma primario de próstata de tipo urotelial es extremadamente infrecuente. La presencia de células en anillo de sello es excepcional, siendo más atípica aún en su variante mucinosa. Su estudio anatomopatológico e inmunohistoquímico juegan un papel fundamental.MÉTODOS: Revisión de la literatura a propósito del caso de un varón de 66 años con elevación de Ca 19.9 y CEA, y niveles de PSA normales, asociado a sintomatología del tracto urinario inferior (mucosuria, estranguria y hematuria) diagnosticado mediante biopsia prostática transrectal tras RMN multiparamétrica de un adenocarcinoma mucinoso de próstata tipo urotelial con células en anillo de sello. RESULTADOS: En la revisión efectuada se han encontrado descritos 23 casos. No se ha encontrado en la literatura ningún caso diagnosticado a raíz de una elevación del Ca 19.9. En nuestro caso, tras el diagnóstico fue tratado mediante prostatectomía radical retropúbica con linfadenectomía ilio-obturatriz bilateral, con normalización posterior de los marcadores tumorales; sin embargo, presentó afectación secundaria pulmonar y progresión tumoral pélvica a pesar de tratamiento quimioterápico. CONCLUSIONES: La elevación de marcadores tumorales asociada (Ca 19.9, CEA) es extraordinaria en este tipo de tumores. No existe un algoritmo de tratamiento, sin embargo la cirugía (prostatectomía radical) con o sin tratamiento adyuvante quimioterápico representa una alternativa en su manejo terapéutico.

[Prognostic factors of mortality in patients with urothelial bladder tumor treated with radical cistectomy.] / Factores pronósticos de mortalidad en pacientes con tumor urotelial de vejiga tratados con cistectomía radical.

INTRODUCTION: Radical cystectomy (RC) with pelvic lymphadenectomy is the treatment of choice in patients with muscle invasive bladder cancer (MIBC). OBJECTIVE: To identify clinical and pathological variables that influence global mortality (GM) and cancer specific mortality (CSM) in patients with urothelial bladder tumor (UBT) treated with RC. METHODS: Retrospective analysis of 517 patients diagnosed with UBT and treated with RC between 1986 and 2009. Demographic, clinical, surgical and pathological variables, as well as complications and evolution after RC were collected. A comparative analysis was carried out with Chi square and ANOVA test. Survival analysis was performed with the Kaplan-Meier method and the long-rank test. Univariate and multivariate analysis were performed using Cox regression to identify independent predictors of GM and CSM. RESULTS: 91% of the patients were males with a median age of 66 years. The most frequent local pathological stage was pT3 (32.6%), with lymph node involvement in 23.8% of the patients. After a median follow-up of 34 months, 170 patients were alive and 311 had died from any cause (63.5%), being UBT the cause of death in 225 patients (45%). Rates of global survival and cancer specific survival at 5 and 10 years were 45%/34.3% and 52.5%/46.6% respectively. On the multivariate analysis age ( p = 0.004), ASA ( p = 0.000), the existence of hydronephrosis ( p = 0.01), pT ( p = 0.000) and pN ( p = 0.003) were identified as independent predictors of GM, as well as pT ( p = 0.000) and pN ( p = 0.002) for CSM. CONCLUSIONS: Age, anesthetic risk, presence of hydronephrosis, pT and pN stage were identified as independent predictors of GM, as well as pT and pN stage for CSM.

INTRODUCCIÓN: La cistectomía radical (CR) con linfadenectomía pélvica es el tratamiento de elección en los pacientes con tumor vesical músculoinfiltrante (TVMI). OBJETIVO: Identificar variables clínicas y patológicas que influyen en la mortalidad global (MG) y cáncer-específica (MCE) en pacientes con tumor urotelial vesical (TUV) tratados con CR. MATERIAL Y MÉTODOS: Análisis retrospectivo de 517 pacientes diagnosticados de TUV y tratados con CR entre 1986 y 2009. Se recogieron variables demográficas, clínicas, quirúrgicas y patológicas, así como complicaciones acontecidas y evolución tras CR. Análisis comparativo con test de Chi Cuadrado y ANOVA. Cálculo de supervivencia con el método de Kaplan-Meier y test de long-rank. Análisis univariante y multivariante mediante regresión de Cox para identificar variables predictoras independientes de MG y MCE. RESULTADOS: El 91% de los pacientes fueron varones con mediana de edad de 66 años. El estadio patológico local más frecuente fue el pT3 (32,6%), con afectación ganglionar en el 23,8% de los pacientes. Tras mediana de seguimiento de 34 meses, 170 pacientes estaban vivos y 311 habían fallecido por cualquier causa (63,5%), siendo el TUV la causa de muerte en 225 pacientes (45%). Se objetivaron tasas de supervivencia global y cáncer específica a 5 y 10 años del 45/34,3% y del 52,5/46,6% respectivamente. En el análisis multivariante se identificaron la edad ( p = 0,004), el ASA ( p = 0,000), la existencia de hidronefrosis ( p = 0,01), el pT ( p = 0,000) y el pN ( p = 0,003) como variables predictoras independientes de MG, así como el pT ( p = 0,000) y pN ( p = 0,002) para MCE. CONCLUSIONES: La edad, el riesgo anestésico, la presencia de hidronefrosis, el estadio pT y pN se identificaron como variables predictoras independientes de MG, así como el estadio pT y pN para MCE.

[Locally advanced prostate cancer. Definition, diagnosis and treatment.] / Cáncer de próstata localmente avanzado. Definición, diagnóstico y tratamiento.

Prostate cancer is a disease that presents a wide spectrum from low aggressiveness localized to disseminated cancer. Locally advanced prostate cancer (LAPC) is a particularly difficult to manage phase of this spectrum. OBJECTIVES: We review the definition, diagnosis and treatment of this phase of the disease. METHODS: We performed a non systematic literature review of the most relevant features of this pathology. RESULTS: LAPC is more aggressive than organ confined disease. Its clinical diagnosis is not always easy. Local treatment, in spite of being aggressive with potential sequelae, seems to be advantageous in terms of patient survival. CONCLUSIONS: Prostate cancer local staging is currently based on multiparametric magnetic resonance imaging (mpMRI). Local radical treatment with surgery or radiotherapy, with probable addition of systemic treatment, offers promising results for disease control and quality of life improvement.

[Intense urethrorrhagia after retropubic radical prostatectomy with selective embolization of the internal pudendal artery.] / Uretrorragia intensa tras prostatectomía radical retropúbica tratada con embolización selectiva de la arteria pudenda interna.

OBJECTIVE: Urethrorrhagia after radicalprostatectomy(RP) is very uncommon, regardless of the surgicalapproach used. Arterio-urethral fistula formation betweeninternal pudendal artery branches(IPA) and bulbarurethra is an exceptional finding. METHODS: We report what we consider the first series oftwo cases (one has already been published) of urethrorrhagiaafter open retropubic RP due to urethrovascular fistulaformation with its origin in the IPA or in one of its terminalbranches. RESULTS: Both cases were diagnosed with contrast-enhancedCT, confirmed with arteriography, and they weretreated with superselective transarterial embolization(STE)with spongostan. After 5 years, the first case maintainserectile function using tadalafil on demand. The other caseis in the 2nd postoperative month. CONCLUSION: Severe urethrorrhagia after RP is an exceptionalcomplication. The existence of an arterio-urethralfistula must be considered when both urethrorrhagia andabnormal bulbar enhancement in CT are present. Arteriographyallows to confirm the diagnosis, most frequently involvingIPA distal branches. STE is an effective and safetreatment.

OBJETIVO: La uretrorragia tras prostatectomía radical (PR) es muy infrecuente, independientemente del abordaje quirúrgico utilizado. La formación de fístulas arterio-uretrales entre ramas de la arteria pudenda interna (API) y la uretra bulbar, es un hallazgo excepcional.MATERIAL Y MÉTODOS: Presentamos la primera serie de 2 casos (uno ya publicado) de uretrorragia tras PR retropúbica abierta debidos a la formación de una fístula vascular con origen en la API o una de sus ramas terminales. RESULTADOS: Ambos casos fueron diagnosticados mediante TC con contraste intravenoso, confirmados con arteriografía, y tratados con embolización transarterial supraselectiva (STE) con espongostán. Tras 5 años, el primer caso conserva la función eréctil con tadalafilo a demanda. El 2º caso se encuentra en el 2º mes postoperatorio.CONCLUSIÓN: La uretrorragia severa tras PR es una complicación excepcional. Se debe sospechar la presencia de una fístula arterio-uretral ante la coexistencia de uretrorragia y realce bulbar anómalo en la TC, que suele ser la prueba de elección en el enfoque diagnóstico. La arteriografía permite confirmar los hallazgos, que suelen interesar a ramas dislates del territorio de la API. La STE es un tratamiento efectivo y seguro.