Diagnostic evaluation and incorporation of PSA density and the prostate imaging and data reporting system (PIRADS) version 2 classification in risk-nomograms for prostate cancer.

PURPOSE: The diagnostic approach for prostate cancer still depends on PSA and DRE. OBJECTIVES: to evaluate the diagnostic validity of PSA-Density and PIRADSv2 as diagnostic tests regarding biopsy results, and to design nomograms that include all diagnostic variables for malignancy, significant tumor (ST) and high-grade tumor. METHODS: Cross-sectional study which included men with PSA ≥ 4 ng/ml and/or suspicious DRE, PIRADSv2 ≥ 3 lesions on multiparametric MRI and prostate biopsy. The gold standard test was the maximum ISUP of the targeted biopsy per patient (malignancy: ISUP ≥ 1, ST: ISUP ≥ 2, high-grade tumor: ISUP ≥ 4). Association and logistic regression tests were used and diagnostic validity parameters using PSA-Density and PIRADSv2 classification was analyzed. Nomograms were designed for malignancy, ST, and high-grade tumor using the best model selection procedure from all possible equations. RESULTS: 336 men with median age, PSA and PSA-Density of 67.7 years (IQR:12.6), 6.3 ng/ml (IQR:3.3) and 0.12 ng/ml/cc (IQR:0.10), respectively; 63 index lesions were PIRADS3, 204 PIRADS4, and 69 PIRADS5. 65.8% and 37.8% were malignant and ST, respectively. The significant positive association highlighted between malignancy and ST with age, DRE, PSA-Density and PIRADSv2. PSA-Density and PIRADSv2 ≥ 3 presented the highest sensitivity to detect malignancy, and their combination showed sensitivity nearly 95% (AUC:0.803). Nomograms for malignancy and ST included the variables age, DRE, PSA-Density, and PIRADSv2 with a sensitivity closely 91% (AUC:0.833), and a specificity of almost 85% for ST, exposing risk < 5% for ST when PSA-Density is < 0.15, not suspicious DRE and PIRADS3. CONCLUSION: PSA-Density and PIRADSv2 classification in risk nomograms can provide highly relevant information to increase the accuracy in the diagnosis of PC and ST.

Endothelial Dysfunction: An Intermediate Clinical Feature between Urolithiasis and Cardiovascular Diseases.

An epidemiological relationship between urolithiasis and cardiovascular diseases has extensively been reported. Endothelial dysfunction is an early pathogenic event in cardiovascular diseases and has been associated with oxidative stress and low chronic inflammation in hypertension, coronary heart disease, stroke or the vascular complications of diabetes and obesity. The aim of this study is to summarize the current knowledge about the pathogenic mechanisms of urolithiasis in relation to the development of endothelial dysfunction and cardiovascular morbidities. METHODS: A non-systematic review has been performed mixing the terms "urolithiasis", "kidney stone" or "nephrolithiasis" with "cardiovascular disease", "myocardial infarction", "stroke", or "endothelial dysfunction". RESULTS: Patients with nephrolithiasis develop a higher incidence of cardiovascular disease with a relative risk estimated between 1.20 and 1.24 and also develop a higher vascular disease risk scores. Analyses of subgroups have rendered inconclusive results regarding gender or age. Endothelial dysfunction has also been strongly associated with urolithiasis in clinical studies, although no systemic serum markers of endothelial dysfunction, inflammation or oxidative stress could be clearly related. Analysis of urine composition of lithiasic patients also detected a higher expression of proteins related to cardiovascular disease. Experimental models of hyperoxaluria have also found elevation of serum endothelial dysfunction markers. CONCLUSIONS: Endothelial dysfunction has been strongly associated with urolithiasis and based on the experimental evidence, should be considered as an intermediate and changeable feature between urolithiasis and cardiovascular diseases. Oxidative stress, a key pathogenic factor in the development of endothelial dysfunction has been also pointed out as an important factor of lithogenesis. Special attention must be paid to cardiovascular morbidities associated with urolithiasis in order to take advantage of pleiotropic effects of statins, angiotensin receptor blockers and allopurinol.

A Novel Penile Splint as Early Traction Therapy After Grafting Techniques for Peyronie's Disease.

BACKGROUND: Some studies showed encouraging results on the efficacy and safety of penile traction therapy after Peyronie's disease (PD) surgery. The early traction therapy (ETT) could be an effective and safe approach to minimize penile shortening in patients undergoing PD surgery. AIM: To evaluate the feasibility, efficacy, and safety of a novel penile splint as ETT in patients with PD undergoing grafting techniques. METHODS: Patients with PD underwent plaque incision and grafting technique; at the end of the procedure, a novel penile splint (ETT) was applied to all patient. The device consisted of 2 10CH intubating stylets, self-adapted to each patient, that kept the penis stretched with the aid of non-absorbable sutures. The total expense for the materials needed to build each penile splint was less than 15 euros. This active traction was maintained for 1-3 weeks; then, we removed the stitches leaving the device on-site for a passive traction. Within 3-4 weeks from surgery, the penile splint was replaced by a standard penile traction device. OUTCOMES: The main outcomes evaluated at 6 months included stretched penile length (SPL), penile curvature, International Index of Erectile Function-erectile function (IIEF-EF) domain, patient satisfaction, and time to first satisfactory sexual intercourse. RESULTS: A total of 46 patients were enrolled. The median preoperative IIEF-EF, penile curvature, and SPL were 27 points, 70°, and 13 cm, respectively. The median follow-up was 15 months. The median postoperative IIEF-EF was 25 points (P < .001). The median residual penile curvature was 10° (P < .001). The median postoperative SPL was 13 cm (P = .269). 8 patients (17.4%) lost 1 cm of SPL; no shortening greater than 1 cm was recorded. The median time to first satisfactory sexual intercourse and patient satisfaction score was 6 weeks and 9 points, respectively. CLINICAL IMPLICATIONS: Our results could pave the way for a new line of research, which in turn could lead to an improvement in the postoperative management of the patient undergoing surgery for PD. STRENGTH & LIMITATIONS: This is the first study evaluating the ETT after PD surgery. The main limitation of this study is the lack of a randomized control group. Other weaknesses are the small sample size and the short follow-up time. CONCLUSION: Our novel penile splint is inexpensive, easy to assemble, and adaptable to the patient. ETT using this novel device, followed by standard traction therapy, seems to be feasible, effective, and safe. Fernández-Pascual E, Manfredi C, Cocci A, et al. A Novel Penile Splint as Early Traction Therapy After Grafting Techniques for Peyronie's Disease. J Sex Med 2020;17:1819-1824.

Impact of 68Ga-PSMA PET/CT in the treatment of prostate cancer: Initial experience in Spain.

AIM: To evaluate whether positron-emission tomography/computed tomography with 68Ga-PSMA (68Ga-PSMA PET/CT) influences the therapeutic management of patients with primary or recurrent prostate cancer (PCa). BACKGROUND: Although 68Ga-PSMA PET/CT is one of the best options for staging or restaging patients with PCa, its availability is still very limited in Spain. The present study reports the results of the first group of patients in Spain who underwent 68Ga-PSMA PET/CT imaging. MATERIALS AND METHODS: All patients (n = 27) with a histological diagnosis of PCa who underwent 68Ga-PSMA PET/CT prior to the definitive treatment decision at the only centre with this technology in Spain during 2017-2018 were included. Two nuclear medicine physicians and a radiologist reviewed the imaging studies. The clinical impact was assessed from a theoretical perspective, based on the treatment that would have been applied if no data from the 68Ga-PSMA PET/CT were available. RESULTS: Most patients (n = 26; 96%) had persistent disease or biochemical recurrence after radical prostatectomy, radiotherapy, or combined treatment. One patient underwent 68Ga-PSMA PET/CT imaging to stage high-risk PCa. Overall, 68Ga-PSMA PET/CT was positive in 19 patients (70.4%). In 68.75% of these patients, none of the other imaging tests-MRI, CT, or bone scans-performed prior to the 68Ga-PSMA PET/CT were able to detect the presence of cancerous lesions. Overall, the findings of the 68Ga-PSMA PET/CT led to a modification of the therapeutic approach in 62.96% of the patients in the study. CONCLUSIONS: 68Ga-PSMA PET/CT alters the therapeutic approach in a substantial proportion of patients with PCa.

Avanafil for the treatment of erectile dysfunction. An updated review.

OBJECTIVES: Avanafil is a highly selective phosfosdiesterase 5 inhibitor (PDE5 inhibitor), with rapid onset of action, approved by the Food and Drug Administration (FDA) and the European Medicines Agency for the treatment of erectile dysfunction (ED). It had been recently commercialized in Spain. This article presents a detailed review of the available literature, where the safety, tolerability and efficacy of avanafil were evaluated. METHODS: A systematic literature search using the Medline database was performed. The search included the terms Avanafil and erectile dysfunction. The pivotal studies of clinical development of the drug, and also those randomized, double-blind, placebo-controlled, well-designed studies were analyzed. We included those studies published in English up to January 2014. Likewise, studies of the pharmacokinetics and pharmacodynamics of the drug were also included. RESULTS: The avanafil pivotal studies, conducted in general population of patients with ED, patients with Diabetes mellitus type I and II and patients with ED secondary to nerve sparing radical prostatectomy were analyzed. In all these studies, avanafil demonstrated a statistically significant improvement in erectile function (IIEF), and all the coprimary outcomes (SEP2 and SEP3) compared to placebo. Also, a good tolerance profile and few side effects compared to placebo were evident. CONCLUSIONS: Avanafil is a selective PDE5 inhibitors, that is rapidly absorbed and that has a short time to peak response. It found to be effective in randomized, double-blind, placebo-controlled trials conducted in men with erectile dysfunction, including in patients with diabetes mellitus and after radical prostatectomy. It was generally well tolerated across trials, with very few patients withdrawing because of adverse effects. Similarly, avanafil had a significantly lower rate of hemodynamic side effects compared with sildenafil.

[Opportunities and risks of 5α reductase inhibitors in the medical management of Active surveillance for localized prostate cancer]. / Oportunidad y riesgos de los inhibidores de la 5α reductasa en el manejo medico de la Vigilancia Ativa en cancer de prostata localizado.

Active surveillance (AS) as a therapeutic option is already integrated as a primary treatment strategy in low risk localized prostate cancer (PCa). There is a recent interest for the search of therapeutic interventions that result in a delay in the progression of such indolent cancers. The evaluation of the possible implication of 5 ARI drugs in the reduction of the risk of progression of PCa was enacted by the results of the clinical trials PCPT (Prostate Cancer Prevention Trial) and REDUCE (Reduction by Dutasteride of Prostate Cancer Events study). The results of the REDEEM clinical trial (Reduction by Dutasteride of clinical progression events in expectant management trial) revealed a delay in PCa progression favoring Dutasteride in comparison with placebo, being advanced age and PSA Density independent predictive factors for pathologic progression. Evidences regarding the influence of 5 ARIs in the evolution of AS patients come from few studies with limited follow up. Thus, the conclusions probably are far from being consiidered as definitive.

mpMRI-US Fusion-Guided Targeted Cryotherapy in Patients with Primary Localized Prostate Cancer: A Prospective Analysis of Oncological and Functional Outcomes.

Targeted therapy (TT) for prostate cancer (PCa) aims to ablate the malignant lesion with an adequate margin of safety in order to obtain similar oncological outcomes, but with less toxicity than radical treatments. The main aim of this study was to evaluate the recurrence rate (RR) in patients with primary localized PCa undergoing mpMRI/US fusion targeted cryotherapy (FTC). A secondary objective was to evaluate prostate-specific antigen (PSA) as a predictor of recurrences. We designed a prospective single-center single-cohort study. Patients with primary localized PCa, mono or multifocal lesions, PSA ≤ 15 ng/mL, and a Gleason score (GS) ≤ 4 + 3 undergoing FTC were enrolled. RR was chosen as the primary outcome. Recurrence was defined as the presence of clinically significant prostate cancer in the treated areas. PSA values measured at different times were tested as predictors of recurrence. Continuous variables were assessed with the Bayesian t-test and categorical assessments with the chix-squared test. Univariate and logistic regression assessment were used for predictions. A total of 75 cases were included in the study. Ten subjects developed a recurrence (RR: 15.2%), while fifty-six (84.8%) patients showed a recurrence-free status. A %PSA drop of 31.5% during the first 12 months after treatment predicted a recurrence with a sensitivity of 53.8% and a specificity of 79.2%. A PSA drop of 55.3% 12 months after treatment predicted a recurrence with a sensitivity of 91.7% and a specificity of 51.9%. FTC for primary localized PCa seems to be associated with a low but not negligible percentage of recurrences. Serum PSA levels may have a role indicating RR.

Efficacy and Tolerability of 6-Month Treatment with Tamsulosin Plus the Hexanic Extract of Serenoa repens versus Tamsulosin Plus 5-Alpha-Reductase Inhibitors for Moderate-to-Severe LUTS-BPH Patients: Results of a Paired Matched Clinical Study.

The objective of this subset analysis was to evaluate and compare the efficacy and tolerability of two combination treatments for men with moderate-to-severe lower urinary tract symptoms associated with benign prostatic hyperplasia (LUTS/BPH). Data were from a real-world, open-label, prospective, and multicenter study performed in outpatient urology clinics. Men with moderate-to-severe LUTS/BPH received 6-month treatment with tamsulosin (TAM) in combination with either the hexanic extract of S. repens (HESr) or a 5-alpha-reductase inhibitor (5ARI). Changes in urinary symptoms and quality of life were measured using the IPSS and BII questionnaires, respectively. Treatment tolerability was assessed by recording adverse effects (AEs). Patients in the two study groups were matched using iterative and propensity score matching approaches. After iterative matching, data were available from 136 patients (n = 68 treated with TAM + 5ARI, n = 68 with TAM + HESr). After 6 months of treatment, mean (SD) IPSS total score improved by 7.7 (6.3) and 6.7 (5.0) points in the TAM + 5ARI and TAM + HESr groups, respectively (p = 0.272); mean BII total scores improved by 3.1 (2.9) and 2.9 (2.4) points (p = 0.751), respectively. AEs were reported by 26.5% and 10.3% of patients in the same groups, mostly affecting sexual function (p < 0.027). When used in a real-world setting to treat patients with moderate-severe LUTS/BPH, 6-month treatment with TAM + HESr was as effective as TAM + 5ARI, but with better tolerability.

Efficacy and Safety of the Hexanic Extract of Serenoa repens vs. Watchful Waiting in Men with Moderate to Severe LUTS-BPH: Results of a Paired Matched Clinical Study.

We investigated changes in symptoms and quality of life (QoL) in men with moderate-to-severe lower urinary tract symptoms associated with benign prostatic hyperplasia (LUTS/BPH) receiving the hexanic extract of Serenoa repens (HESr) and compared results with a matched group on watchful waiting (WW). Data was from a real-world, open-label, prospective, multicenter study. This sub-group analysis included patients with moderate-to-severe symptoms receiving either the HESr 320 mg/daily for six months (HESr) or who remained untreated for LUTS/BPH (WW). Changes in urinary symptoms and QoL were measured by IPSS and BII questionnaires. Two statistical approaches (iterative matching and propensity score pairing) were used to maximize between-group comparability at baseline. Tolerability was assessed in the HESr group. After iterative matching, data for analysis was available for 783 patients (102 WW, 681 HESr). IPSS scores improved by a mean (SD) of 3.8 (4.4) points in the HESr group and by 2.2 (4.5) points in the WW group (p = 0.002). Changes in BII score were 1.8 (2.4) points and 1.0 (2.2) points, respectively (p < 0.001). Three patients (0.9%) treated with the HESr reported mild adverse effects. Moderate-severe LUTS/BPH patients treated for six months with the HESr showed greater improvements in symptoms and QoL than matched patients on WW, with a very low rate of adverse effects.

[Epidemiological fundamentals of clinically localized prostate cancer]. / Fundamentos epidemiológicos en cancer de próstata.

Prostate cancer is the sixth most common cancer in the world (in the number of new cases), the third most common cancer in men, and the most common cancer in men in Europe, North America, and some parts of Africa. Different geographical regions have varying incidence and mortality. The risk of prostate cancer is increased by African-American ethnicity, increasing age, positive family history, and other factors such as diet. Nonetheless, the causes of prostate cancer are not well understood compared with other common cancers like lung and breast cancer. The introduction of prostate-specific antigen (PSA) screening made an enormous impact on the incidence of prostate cancer, which increased in the early 1990s and is currently down to pre-PSA screening levels. Screening has caused a change in pattern of disease to an earlier stage but not lower grade. Yet we know little about what causes this disease, in the past 10 years interest in and funding for prostate cancer research have increased and several promising risk modifiers have been identified-eg, genetic predisposition, insulin growth factor (IGF) concentrations, and lycopene consumption.

[Prostate biopsy: Diagnostic responsibility and recent changes]. / Biopsia prostática: responsabilidad diagnóstica y cambios recientes.

In this bibliographic review we reexamine the different features in relation to indication, performance and interpretation of prostatic biopsy (PB). The main objective is to place methodological features involving PB in the current scientific scenario, establishing the correlation between the most relevant and analyzing the historic evolution this procedure has followed, particularly over the last two decades. Prostate biopsy has evolved to be a regular element in urologists` daily practice and its learning process has been simplified to the point it can be approached with adequacy during the first years of residency in Urology. This privileged position PB enjoys in daily practice and the performance obtained from it would have not been a reality without optimization of transrectal ultrasound or local anesthesia techniques, yet reviled in some forums, the real responsible of such success. The consensus reached in the various scientific associations, the clinical guidelines of which are widely consulted worldwide, is the best to support the current state of the art, being the starting point for the addition of new improvements to PB.

Efficacy and tolerability of the hexanic extract of Serenoa repens compared to tamsulosin in moderate-severe LUTS-BPH patients.

In a subset analysis of data from a 6-month, multicenter, non-interventional study, we compared change in symptoms and quality of life (QoL), and treatment tolerability, in men with moderate to severe lower urinary tract symptoms associated with benign prostatic hyperplasia (LUTS/BPH) receiving tamsulosin (TAM, 0.4 mg/day) or the hexanic extract of Serenoa repens (HESr, 320 mg/day) as monotherapy. Symptoms and QoL were assessed using the IPSS and BII questionnaires, respectively. Patients in the treatment groups were matched using two statistical approaches (iterative and propensity score matching). Within the iterative matching approach, data was available from a total of 737 patients (353 TAM, 384 HESr). After 6 months, IPSS scores improved by a mean (SD) of 5.0 (4.3) points in the TAM group and 4.5 (4.7) points in the HESr group (p = 0.117, not significant). Improvements in QoL were equivalent in the two groups. TAM patients reported significantly more adverse effects than HESr patients (14.7% vs 2.1%; p < 0.001), particularly ejaculation dysfunction and orthostatic hypotension. These results show that HESr is a valid treatment option for men with moderate/severe LUTS/BPH; improvements in urinary symptoms and QoL were similar to those observed for tamsulosin, but with considerably fewer adverse effects.

Natural progression of embryonal carcinoma.

OBJECTIVE: We report a rare case of advanced testicular cancer that describes the natural progression of testicular cancer without medical treatment. This study also describes the effectiveness of chemotherapy, which was the approach used for treatment. METHODS: 37 year old male with history of mental retardation, presented to the emergency room with an ulcer on his right scrotum that had been present for a few months. He was diagnosed of pT4 embryonal carcinoma by biopsy. CT scan showed multiple lung nodes. He was treated with five cycles of Bleomycin/Etoposide/Cisplatin with complete response after treatment. RESULTS: Testicular tumors are the most frequent solid tumors in males between the ages of 20 and 39 years old. Testicular tumors represent 1% of all neoplasias diagnosed in males and 0.1% of all male deaths due to cancer. Several studies have reported the current real incidence rate of testicular tumors has increased to 3%, which accounts for the diagnosis of 450 new cases of testicular cancer a year in Spain. CONCLUSIONS: The cure rate for patients with intermediate risk non-seminoma is around 70% following a conventional treatment approach of four cycles of BEP. The present case is noteworthy because, in our experience, testicular tumors are diagnosed at an early stage without extensively affecting the skin or simulating another type of epithelial tumor. As a result, the present study describes the natural progression of testicular cancer.

[Benign prostatic hyperplasia management during COVID-19 pandemia.] / Manejo de la hiperplasia benigna de próstata durante la pandemia COVID-19.

OBJECTIVES: The pandemic caused by the new SARS / Cov-2 Coronavirus represents an unprecedented scenario in modern medicine that affects many aspects of daily healthcare. Lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH) has a high prevalence and is related to high consumption of health resources. For this reason, we performed a revision of the management of LUTS and HBP during and after COVID-19 pandemic. MATERIAL AND METHODS: A group of experts in benign prostatic hyperplasia from different regions of Spain were selected to design a strategy to reorganize the management of benign prostatic hyperplasia and lower urinary tract symptoms during the pandemic. A comprehensive review of the literature was undertaken and a set of recommendations are generated. RESULTS: Recommendations for the management of LUTS-BPH during and after the SARS/CoV2 coronavirus pandemic outbreak consist of promoting telemedicine and developing joint protocols with Primary Care Attention .Clear diagnostic and treatment criteria and referral criteria must be established. Referral of patients for risk complications such as kidney failure, recurrent hematuria and obstructive uropathy are a priority. Surgeries due to BPH are generally potentially delayed until phases I and II of the pandemic, in which the percentage of hospitalized patients with COVID-19 does not exceed 25%, and it is necessary to determine COVID19 negativity. The surgical technique that associates the least complications and the shortest stay should be selected. CONCLUSIONS: The diagnosis and prescription of treatment for BPH during the COVID-19 pandemic should be based on telemedicine and joint protocols for primary care attention and urology. Elective surgical treatment can be delayed until we are in phases I or II, individualizing the surgical and anaesthetic technique of choice to minimize risks.

OBJETIVOS: La pandemia causada por el nuevo Coronavirus SARS/Cov-2 supone un escenario sin precedentes en la medicina moderna que afecta de manera indirecta en numerosos aspectos de nuestra actividad diaria como sanitarios. La hiperplasia benigna de próstata (HBP) es una patología con una elevada prevalencia y consumo de recursos sanitarios. Por ello, es necesaria una revisión en el manejo de la misma con el fin de adecuarlo a las necesidades impuestas por los acontecimientos recientes.MATERIAL Y MÉTODOS: Un grupo de expertos en hiperplasia benigna de próstata de distintas comunidades autónomas de España fueron contactados para diseñar una estrategia para reorganizar el manejo de la hiperplasia benigna de próstata y los síntomas del tracto urinario inferior durante la pandemia. Se realiza una revisión narrativa de la literatura publicada y se generan una serie de recomendaciones de manejo. RESULTADOS: Entre las recomendaciones para el manejo de HBP en tiempos de pandemia por coronavirus SARS/CoV2 se incluyen la promoción de teleconsulta y la realización de protocolos conjuntos con Atención Primaria estableciendo criterios de diagnóstico, tratamiento y derivación claros y homogéneos. Deben priorizarse las derivaciones pacientes complicaciones de riesgo tales como insuficiencia renal, hematuria recidivante y uropatía obstructiva. Desde el punto de vista quirúrgico, se trata generalmente de cirugías potencialmente demorables hasta fases I y II de la pandemia, donde el porcentaje de pacientes hospitalizados con Covid-19 no supera el 25%, siendo preciso determinar negatividad de COVID19. Debe seleccionarse la técnica quirúrgica que asocie una menor tasa de complicaciones así como una estancia más baja. CONCLUSIONES: El diagnóstico y el inicio del tratamiento médico de la HBP durante la pandemia debe basarse en la instauración de la telemedicina y protocolos conjuntos con atención primaria y urología. El tratamiento quirúrgico electivo se puede demorar hasta encontrarnos en fases I o II, individualizando la técnica quirúrgica y anestésica de elección para minimizar riesgos.

Clinical Benefit of Tamsulosin and the Hexanic Extract of Serenoa Repens, in Combination or as Monotherapy, in Patients with Moderate/Severe LUTS-BPH: A Subset Analysis of the QUALIPROST Study.

To investigate whether tamsulosin (TAM) and the hexanic extract of Serenoa repens (HESr) are more effective in combination than as monotherapy in men with moderate-to-severe lower urinary tract symptoms associated with benign prostatic hyperplasia (LUTS/BPH). Subset analysis of data from a 6-month, multicenter observational study. Patients received either tamsulosin (0.4 mg/day) or HESr (320 mg/day) alone or in combination. Primary endpoints were change in symptoms and quality of life. Tolerability was also assessed. Seven hundred and nine patients were available for intention to treat (ITT) analysis, 263 treated with tamsulosin, 262 with HESr, and 184 with TAM + HESr. After 6 months, International Prostate Symptom Score (IPSS) scores improved by a mean (standard deviation) of 7.2 (5.0) points in the TAM + HESr group compared to 5.7 (4.3) points with TAM alone and 5.4 (4.6) points with HESr (p < 0.001). Quality of life showed greatest improvement with combination therapy (p < 0.02). Adverse effects were reported by 1.9% of patients receiving HESr, 13.3% receiving TAM, and 12.0% receiving TAM + HESr (p < 0.001). In men with moderate/severe LUTS/BPH, combination treatment with TAM + HESr produced more effective symptom relief and greater improvement in quality of life than with either treatment alone, with acceptable tolerability.

Cavoscopy in the surgical treatment of renal cell carcinoma with vena cava thrombus. Systematic review. / Utilización de la cavoscopia en la cirugía del carcinoma de células renales con trombo en cava. Revisión de conjunto.

OBJECTIVE: To perform a literature review on the use of cavoscopy during surgery for renal cell carcinoma with vena cava thrombus (RCCVCT), according to the criteria of Evidence-Based Medicine. MATERIAL AND METHODS: We performed a Pubmed search for studies published with the following keywords: "renal tumor thrombus", "renal tumor cavoscopy" and "cystoscopy thrombus", without time limit and in English. With these criteria, 5 articles were identified with a total of 41 patients. All studies found are case series and expert opinions, so the degree of evidence in the use of cavoscopy in RCCVCT is low. RESULTS: RCCVCT surgery is a complex technique, which can reach over 50% 5-year survival, when a complete oncological resection is achieved. One of the keys for surgical success is complete resection of tumor thrombus, having used different techniques for its verification. One of them is cavoscopy, which consists on the introduction of a flexible cystoscope through the cavotomy incision after thrombectomy, checking the lumen of the vena cava with saline serum irrigation. In two series of clinical cases, cavoscopy detected thrombus persistence in 22% and 43% of patients respectively, allowing resection. The entire resected thrombus showed malignancy in several cases. CONCLUSION: Cavoscopy is a technique that improves detection of tumor remnants after thrombectomy in comparison to indirect review methods. Although oncological impact of caval thrombus is controversial, the use of cavoscopy allows a more complete resection of the thrombus, and it may offer a possible increase in the recurrence-free survival of these patients.

OBJETIVO: Realización de una revisión bibliográfica sobre la utilización de la cavoscopia en la cirugía del carcinoma de células renales con trombo en cava (CCRTC), según los criterios de la Medicina Basada en la Evidencia. MATERIAL Y  MÉTODOS: Búsqueda en Pubmed de los estudios publicados con las siguientes palabras clave: "renal tumor thrombus", "renal tumor cavoscopy" y "cystoscopy thrombus", sin límite de tiempo y en inglés. Con estos criterios se identificaron 5 artículos con un total de 41 pacientes. Todos los estudios encontrados son series de casos y opiniones de expertos, por lo que el grado de evidencia en la utilización de la cavoscopia en el CCRTC es baja. RESULTADOS: La cirugía del CCRTC se trata de una técnica compleja, que puede alcanzar una supervivencia a los 5 años de más del 50% cuando se consigue una resección oncológica completa. Una de las claves del éxito de la cirugía es la resección completa del trombo tumoral, habiéndose utilizado diferentes técnicas para su comprobación. Una de ellas es la cavoscopia, que se basa en la introducción de un cistoscopio flexible a través de la cavotomía, revisando la luz de la vena cava con irrigación de suero salino tras la trombectomía. Su realización en dos series de casos clínicos detectó persistencia de trombo en el 22% y 43% de los pacientes respectivamente, permitiendo su resección. La totalidad del trombo resecado demostró malignidad en varios casos.CONCLUSIÓN: La cavoscopia es una técnica que mejora la detección de restos tumorales tras la trombectomía respecto a los métodos indirectos de revisión. Aunque el impacto oncológico del trombo en cava continúa siendo debatido, la utilización de la cavoscopia permite una resección más completa del trombo en cava, pudiendo ofrecer un posible aumento en la supervivencia libre de recurrencia de estos pacientes.

Virtual reality and intracorporeal navigation in urology. / Realidad virtual y navegación intraquirúrgica en urología.

OBJECTIVE: To provide an overview of the meaning and types of virtual reality (VR) system, its current applications in the field of urology and future implications. SYNTHESIS OF THE EVIDENCE: The concept of VR involves the generation of computer environments with which a user can interact directly. Urology technologies and surgical practices are constantly evolving and RV simulation has become an important complement in urologist training curricula, taking into account not only simulations in surgical techniques, but also in non-surgical techniques such as communication and decision making. VR approaches for image-guided surgery have demonstrated potential in the field of urology by supporting guidance for various disorders. An increasing number of pre and intraoperative imaging modalities have been used to create detailed surgical route maps. The tracing of these surgical roadmaps with the surgical vision of real life has been produced in different ways (electromagnetic, acoustic, optical ...), recommending the combination of several approaches to provide a superior result. One of the disadvantages of navigation systems is soft tissue deformations, requiring confirmatory images. Although early studies report that navigation surgeries provide results equal to or greater than conventional approaches, most of the work has been done in relatively small groups of patients, thus requiring studies with larger sample sizes. CONCLUSIONS: The development of VR offers urologists many opportunities, with surgical simulation being one of its most important applications today. Likewise, the first clinical studies have demonstrated the potential of augmented reality (2D and 3D models) to improve surgical accuracy, describing different navigation systems for different urological surgical interventions.

OBJETIVO: Proporcionar una visión general sobre el significado y tipos de sistemas de realidad virtual (RV), sus aplicaciones actuales en el campo de la urología y las implicaciones futuras.SÍNTESIS DE LA EVIDENCIA: El concepto de RV implica la generación de entornos informáticos con los que un usuario puede interactuar directamente. Las tecnologías de urología y las prácticas quirúrgicas están en constante evolución y la simulación de RV se ha convertido en un complemento importante en los planes de estudio de formación de urólogos, teniendo en cuenta no sólo simulaciones en técnicas quirúrgicas, sino también en técnicas no quirúrgicas como comunicación y toma de decisiones.Los enfoques de la RV para la cirugía guiada por imagen han demostrado potencial en el campo de la urología, al apoyar la orientación para diversos trastornos. Se ha utilizado un número cada vez mayor de modalidades de imagen pre e intraoperatorias para crear mapas de ruta quirúrgicos detallados. El rastreo de estas hojas de ruta quirúrgicas, con la visión quirúrgica de la vida real, se ha producido de diferentes formas (electromagnético, acústico, óptico….), recomendándose la combinación de varios enfoques para proporcionar un resultado superior. Uno de los inconvenientes de los sistemas de navegación son las deformaciones de los tejidos blandos, precisando imágenes confirmatorias. Aunque los primeros estudios reportan que las cirugías con navegación proporcionan resultados iguales o superiores a los enfoques convencionales, la mayoría de los trabajos se han realizado en grupos de pacientes relativamente pequeños, precisando por tanto, estudios con mayor tamaño muestral. CONCLUSIONES: El desarrollo de la RV ofrece a los urólogos muchas oportunidades, siendo la simulación quirúrgica una de sus aplicaciones más importantes actualmente. Así mismo, los primeros estudios clínicos han demostrado el potencial de la realidad aumentada (modelos 2D y 3D) para mejorar la precisión quirúrgica, describiéndose diferentes sistemas de navegación para diferentes intervenciones quirúrgicas urológicas.

[Partial orchiectomy in testicular tumor: Surgical technique and role of intraoperatory ecography.] / Orquiectomía parcial en tumor testicular: técnica quirúrgica y papel de la ecografía intraoperatoria.

OBJECTIVES: Systematic review of the treatment of small testicular masses (STM) by testicular sparing surgery (TSS), including indications, surgical techniques and complications, as well as the correlation of the analysis of frozen sections (FSE) with the final tumor histology. As a secondary objective we report the initial experience of our center in TSS. MATERIAL AND METHODS: A systematic literature search of the Medline/PubMed database for studies published until June 30, 2019 with the following keywords: "testis sparing surgery", "conservative surgery", "partial orquiectomy" "testicular neoplasms", "testis tumour", "Sex cord tumor", "intraoperative ultrasonography", "enucleation", "excision" or "resection" without time limits, in English and Spanish, identifying 20 articles with a total of 204 TSS, being the series with the largest sample size of 28. In our service, 8 TSS were performed in 6 patients (two bilateral tumor) distributed between 2016-2019. RESULTS: No randomized controlled trials comparing TSS with radical orchiectomy have been reported. The indications for TSS are controversial, especially for patients with normal contralateral testicles. Tumor size has been identified as an important predictor of malignant disease and although there is no approved cut-off point, STM ≤2 cm are the ones that can benefit most from TSS. The use of intraoperative ultrasound (IU) is essential for the location of STM, whether a macroscopic or microsurgical resection is being performed, helping to reduce the rate of complications of the procedure, described in < 6%. The FSE is key at the time of the TSS, discriminating between benign and malignant neoplasms, maintaining a good correlation with the final histology. CONCLUSIONS: TSS for STM allows greater preservation of healthy parenchyma, but should be performed only in selected cases and in experienced centers. The surgical technique is safe and viable, the use of the IU and the FSE of the lesion being essential to facilitate the surgical decision making.

OBJETIVO: Revisión sistemática del tratamiento de pequeñas masas testiculares (PMT) mediante cirugía conservadora testicular (CCT), incluyendo indicaciones, técnicas quirúrgicas y complicaciones, así como la correlación del examen de secciones congeladas (ESC) con la histología final tumoral. Como objetivo secundario reportamos la experiencia inicial de nuestro centro en CCT.MATERIAL Y MÉTODOS: Búsqueda en Pubmed/Medline de estudios publicados hasta el 30 de junio de 2019 con las siguientes palabras clave: "testis sparing surgery", "conservative surgery", "partial orquiectomy" "testicular neoplasms", "testis tumour", "sex cord tumor", "intraoperative ultrasonography", "enucleation", "excision" o" resection" sin límites de tiempo, en inglés y castellano, identificándose 20 artículos con un total de 204 CCT, siendo la serie con mayor tamaño muestral de 28. En nuestro servicio se realizaron 8 CCT en 6 pacientes (dos tumores bilaterales) distribuidos entre 2016-2019. RESULTADOS: No se han informado de ensayos aleatorizados controlados que comparen CCT con orquiectomía radical. Las indicaciones para CCT son controvertidas, especialmente para pacientes con testículos contralaterales normales. Se ha identificado el tamaño tumoral como un predictor importante de enfermedad maligna y aunque no existe un punto de corte aprobado, las PMT ≤2 cm son las que más se pueden beneficiar de CCT. La utilización de ecografía intraoperatoria (EI) es esencial para la localización de PMT, ya se esté realizando una resección macroscópica o con microcirugía, ayudando a disminuir la tasa de complicaciones del procedimiento, descrita en < 6%. El ESC es clave en el momento de la CCT, discriminando entre neoplasias benignas y malignas, manteniendo una buena correlación con la histología final. CONCLUSIONES: La CCT para PMT permite mayor preservación de parénquima sano, pero debe realizarse sólo en casos seleccionados y en centros experimentados. La técnica quirúrgica es segura y viable, siendo claves la utilización de la EI y el ESC de la lesión para facilitar la decisión quirúrgica.

[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.

[Buccal mucosa graft for the treatment of long ureteral stenosis: Bibliographic review.] / Uso de injerto de mucosa oral en el tratamiento de estenosis ureterales extensas: revisión de conjunto.

OBJECTIVE: To perform a literature review on the use of buccal mucosa graft (BMG) in the treatment of extensive ureteral stenosis, according to the criteria of Evidence Based Medicine. METHODS: Pubmed search of published studies with the following keywords: "ureteral stricture treatment", "buccal mucosa graft ureteral treatment" and "buccal mucosa graft ureteroplasty", without time limits, in English and Spanish; 12 articles were identified with a total of 48 cases (46 patients) of BMG use in ureteral repair. RESULTS: The main etiologies of ureteral stenosis, where BMG has been applied, have been iatrogenic and inflammatory strictures. This graft has been used complicamainly in proximal or middle ureter stenosis, as a patch according to onlay technique or as a tubularized graft. Early and late complications of the procedure have been reported in 16.7% and 10.4%, respectively, with a restenosis rate of 6.25%. A 91.6% success rate was observed with this technique, with an average follow-up time of 22 (3-85) months. CONCLUSIONS: The findings of the present review do not justify the universal use of BMG in all ureteral strictures, particularly in the absence of long-term followup, but still provide evidence that BMG can be effectively used in extensive ureteral strictures.