Enuresis: clinical evolution of patients attended at specialized unit of paediatric urology.

OBJECTIVE: To analyse the clinical evolution, the therapeutic strategies and the characteristics of the patients presenting enuresis attended at our outpatient clinic. MATERIAL AND METHODS: Retrospective study of patients <14 years old(yo) diagnosed of enuresis attended at our outpatient clinic (2011-2019) and completed their follow-up (remission or aged 15). Urotherapy was offered to all patients as initial management. The therapeutic strategies were classified as: first line (desmopressin or clock alarm), second line (desmo-pressin+alarm) and third line(anticholinergics). The remission rate during follow-up, the number of consultations needed until remission and the treatments used were calculated. Statistical tests used:Kaplan-Meier, actuarial survival. Multivariate analysis:Cox regression.Statistical significance:p<0.05. RESULTS: Data were collected from 125 patients (mean age: 8.6±2.45yo). Family history of enuresis was present in 38.9%. The mean follow-up was 2.37±1.55yo and the average number of consultations was 7.54±5.06. The remission rate (RE) was 84%(n=105), with a median remission interval:2.66 years (2.34-2.991[95%CI]). The average number of treatments required for remission was 2.74±1.27. RE with urotherapy alone was 20%(n=25); RE with first line:19.3%(n=17) and second line:16.7(n=11). In the remaining patients, a RE of 78.18%(n=43) was achieved by adding an anticholinergic. Patients aged > 8.7 years at the beginning of the follow-up required less time to achieve remission (p=.025). These patients had a higher RE (hazard ratio 1.15 (1.05-1.25))(p=.004). No other variables were significant. CONCLUSION: Staged therapeutic strategies are necessary to achieve remission. Only 25% remitted with urotherapy as single treatment. RE are higher when patients are >8.7 yo once they initiate their follow up.

[Clinical usefulness of the non-invasive functional study of the lower urinary tract voiding phase as a predictor of resolution after the first endoscopic treatment of vesico-ureteral reflux in children older than 3 years.] / Utilidad del estudio funcional no invasivo de la fase de vaciado del tracto urinario inferior como factor predictor de la resolución tras el primer tratamiento endoscópico del reflujo vesico-ureteral en niños mayores de 3 años.

OBJECTIVES: To determine the usefulnessof voiding diary (VD), uroflowmetry with electromyography(UF-EMG), bladder wall thickness (before micturition)(VWTUS) and residual urine (PVR) (ultrasound measure)in predicting the outcome of the first endoscopic treatment(1ENDT) of vesicoureteral reflux (VUR) in children> 3 years. METHODS: Cross-sectional ambispective study of 48children with vesicoureteral reflux. Those with previousendoscopic treatment, age or neurological abnormalities and a history of urethralor abdominal surgery were excluded. The outcomevariable was the correctness (by isotopic cystography)three months after 1ENDT. Univariate and multivariateanalyses were performed through a Multilayer Perceptronnetwork and a logistic regression model EmpiricalBayesian penalized type LASSO Elastic net. Diagnosticaccuracy were determined. RESULTS: Mean age of the sample was 6.8 +/- 2.28years. The rate of VUR correction after 1ENDT was 77%.The variables selected by both methods were: VD-retentionist(OR 3.90), high PVR (OR 2.69), high VWTUS (OR4.44). Normal UF-EMG was a preventive variable (OR0.38). Diagnostic accuracy (pSp=48.7%), UF+EMG (Se=27.3%(Se=72.7% (AUC=0.8 cut point 20 ml),VWTUS (Se=81.8% (AUC=0.8 cut point4.6 mm). There were no statistical differences betweenPVR and VWTUS. Combined use of UF+EMG+PVR(Se=90.9%in predicting the persistence of VUR after 1ENDT inchildren > 3 years. After screening with a VD, UF-EMG+ RPM combination could be useful to detect these patientsand propose a treatment that improves bladdervoiding function prior to surgery.

OBJETIVOS: Determinar la utilidad deldiario miccional (DIM), la flujometría asociada a laelectromiografía (UF-EMG) y los parámetros ecográficoscomo son el espesor de la pared vesical premiciconal(EPVECO) y el residuo postmiccional (RPM) en la prediccióndel resultado del primer tratamiento endoscópico(1TEND) del Reflujo Vesico-Ureteral (RVU) en niños > 3años.MATERIAL Y MÉTODOS: Estudio transversal ambispectivode 48 niños con RVU. Criterios de exclusión: 1TENDprevio, edad y cirugía uretral o abdominal previas. Variableresultado: corrección del RVU (cistografía isotópica realizadatres meses después del 1TEND). Se realizaronanálisis univariante y multivariante mediante una red perceptrón multicapa y un modelo de regresión logísticapenalizada tipo Empirical Bayesian LASSO Elastic net.Se consideraron significativas las variables elegidas porambos métodos estadísticos. Se estudió el rendimientodiagnóstico de las pruebas individuales y combinadas. RESULTADOS: Media de edad: 6,8 +/- 2,28 años.Tasa de corrección del RVU traspredictoras de la persistencia del RVU tras 1TENDseleccionadas por ambos métodos: DIM-hábito retencionista(OR 3,90), RPM elevado (OR 2,69), EPVECOaumentado (OR 4,44). La UF-EMG sin alteracionesen el trazado se comportó como variable preventiva(OR 0,38). Rendimiento diagnóstico (p(Se=98% (Se=27,3%RPM (Se=72,7% (AUC=0,8 punto decorte óptimo 20 ml), EPVECO (Se=81,8%(AUC=0,8 punto de corte óptimo 4,6 mm).No existierondiferencias entre el uso del RPM y el EPVECO(p>0,05). Uso conjunto de UF-EMG+RPM (Se=90,9%Es=92%) (pCONCLUSIONES: El estudio funcional no invasivo dela fase de vaciado es útil en la predicción de la persistenciade RVU tras el 1TEND en niños >3 años. Trasel cribado con un diario miccional, la UF-EMG+RPMpodrían ser útiles para detectar a estos pacientes y plantearun tratamiento que mejore el vaciado vesical previoa la cirugía.

Utilidad del estudio funcional no invasivo de la fase de vaciado del tracto urinario inferior como factor predictor de la resolución tras el primer tratamiento endoscópico del reflujo vesico-ureteral en niños mayores de 3 años / No disponible

Objetivos: Determinar la utilidad del diario miccional (DIM), la flujometría asociada a la electromiografía (UF-EMG) y los parámetros ecográficos como son el espesor de la pared vesical premiciconal (EPVECO) y el residuo postmiccional (RPM) en la predicción del resultado del primer tratamiento endoscópico (1TEND) del Reflujo Vesico-Ureteral (RVU) en niños > 3 años. Material y métodos: Estudio transversal ambispectivo de 48 niños con RVU. Criterios de exclusión: 1TEND previo, edad y cirugía uretral o abdominal previas. Variable resultado: corrección del RVU (cistografía isotópica realizada tres meses después del 1TEND). Se realizaron análisis univariante y multivariante mediante una red perceptrón multicapa y un modelo de regresión logística penalizada tipo Empirical Bayesian LASSO Elastic net. Se consideraron significativas las variables elegidas por ambos métodos estadísticos. Se estudió el rendimiento diagnóstico de las pruebas individuales y combinadas. Resultados: Media de edad: 6,8 +/- 2,28 años. Tasa de corrección del RVU tras predictoras de la persistencia del RVU tras 1TEND seleccionadas por ambos métodos: DIM-hábito retencionista (OR 3,90), RPM elevado (OR 2,69), EPVECO aumentado (OR 4,44). La UF-EMG sin alteraciones en el trazado se comportó como variable preventiva (OR 0,38). Rendimiento diagnóstico (p(Se=98% (Se=27,3% RPM (Se=72,7% (AUC=0,8 punto de corte óptimo 20 ml), EPVECO (Se=81,8% (AUC=0,8 punto de corte óptimo 4,6 mm).No existieron diferencias entre el uso del RPM y el EPVECO (p>0,05). Uso conjunto de UF-EMG+RPM (Se=90,9% Es=92%). Conclusiones: El estudio funcional no invasivo de la fase de vaciado es útil en la predicción de la persistencia de RVU tras el 1TEND en niños >3 años. Tras el cribado con un diario miccional, la UF-EMG+RPM podrían ser útiles para detectar a estos pacientes y plantear un tratamiento que mejore el vaciado vesical previo a la cirugía

Objectives: To determine the usefulness of voiding diary (VD), uroflowmetry with electromyography (UF-EMG), bladder wall thickness (before micturition) (VWTUS) and residual urine (PVR) (ultrasound measure) in predicting the outcome of the first endoscopic treatment (1ENDT) of vesicoureteral reflux (VUR) in children > 3 years. Methods: Cross-sectional ambispective study of 48 children with vesicoureteral reflux. Those with previous endoscopic treatment, age <4 years, anatomical or neurological abnormalities and a history of urethral or abdominal surgery were excluded. The outcome variable was the correctness (by isotopic cystography) three months after 1ENDT. Univariate and multivariate analyses were performed through a Multilayer Perceptron network and a logistic regression model Empirical Bayesian penalized type LASSO Elastic net. Diagnostic accuracy were determined. Results: Mean age of the sample was 6.8 +/- 2.28 years. The rate of VUR correction after 1ENDT was 77%. The variables selected by both methods were: VD-retentionist (OR 3.90), high PVR (OR 2.69), high VWTUS (OR 4.44). Normal UF-EMG was a preventive variable (OR 0.38). Diagnostic accuracy (p<0.005): VD (Se=98% Sp=48.7%), UF+EMG (Se=27.3% Sp=94.6%), PVR (Se=72.7% Sp=97.3%) (AUC=0.8 cut point 20 ml), VWTUS (Se=81.8% Sp=73%) (AUC=0.8 cut point 4.6 mm). There were no statistical differences between PVR and VWTUS. Combined use of UF+EMG+PVR (Se=90.9% Sp=92%) (p<0.05). Conclusions: Noninvasive voiding study is useful in predicting the persistence of VUR after 1ENDT in children > 3 years. After screening with a VD, UF-EMG + RPM combination could be useful to detect these patients and propose a treatment that improves bladder voiding function prior to surgery

Immunohistochemical expression of Ki-67, Cyclin D1, p16INK4a, and Survivin as a predictive tool for recurrence and progression-free survival in papillary urothelial bladder cancer pTa / pT1 G2 (WHO 1973).

OBJECTIVES: To investigate the expression of several immunohistochemical (IHC) markers and their predictive ability for the recurrence-free and progression-free survival of papillary urothelial bladder cancer (UBC) pTa/pT1 G2 (WHO 1973) compared to classical anatomo-clinical variables using a multidimensional analysis. MATERIALS AND METHODS: A population-based cohort of 213 primary stage UBC (pTa/pT1) G2 (WHO 1973) was evaluated by classic anatomopathological variables and characterized by immunohistochemistry (23 IHC markers, representative of different oncogenic pathways). The most important variables as a predictor of recurrence-free and progression-free survival were selected using multidimensional statistical models, such as random survival forests and least absolute shrinkage and selection operator (. Recurrence and progression-free survival of the previously selected variables were also calculated. RESULTS: Mean follow-up was 58 ± 33.5 months. Recurrence and progression rates were 54.5% (n = 116) and 17,4% (n = 37), respectively. The most influential variables in the low recurrence-free survival were in order: number of resected tumors, high expression of Ki67 (>10%), Cyclin D1 (>10%), and low cytoplasmic staining of p16INK4a. Regarding low progression-free survival, the most important variables were Ki67 (>15%), multicentric tumor arrangement and Survivin nuclear expression (>20%). Kaplan-Meier and cox-regression model analyses showed that the variables selected by multidimensional models were able to discriminate the clinical outcome. CONCLUSIONS: Ki67 index is the most useful IHC marker, since it can improve the prediction of both recurrence and progression-free survival in papillary UBC pTa/pT1 G2 (WHO 1973). There are other markers, whose utility is specific to recurrence-free survival, such as Cyclin D1 and p16INK4a or in progression-free survival, such as Survivin.

[Paratesticular sarcoma: An infrequent genitourinary tumor]. / Un tumor genitourinario infrecuente: sarcomas paratesticulares.

OBJECTIVE: To expose the features related to the diagnosis, therapy and follow-up of paratesticular sarcomas, through the presentation of three cases with different histologies. METHODS: Description of the clinical cases, surgical management, and pathological results of the surgical specimens. RESULTS: We present three cases of paratesticular sarcomas, one case being a rhabdomyosarcoma and two liposarcomas. Two patients underwent a single successful surgery, while the third one required a second intervention after recurrence. Today all three patients are free of disease. CONCLUSIONS: Malignant paratesticular sarcomas are infrequent neoplasias in urology. It is essential that the urologist is aware of this possibility when faced with a paratesticular tumor, since radicalness of surgery will be the most decisive factor in the success of the treatment. Adjuvant therapies must be individualized in each case, and the follow-up after surgery should be close, given the poor evolution of these tumors in many cases.

Intractable hematuria secondary to systemic amyloidosis with bladder involvement.

OBJECTIVE: To present the therapeutic management of intractable hematuria secondary to systemic amyloidosis with bladder involvement. METHODS: We describe the clinical case, the medical management, the endo-urological technique used, and the results supported by relevant published literature. RESULTS: A 50-year-old woman with a 20-year history of rheumatoid arthritis in chronic treatment with corticosteroids and non-steroidal anti-inflammatory drugs in addition to chronic renal insufficiency not requiring hemodialysis. Twenty-four hours after resection of a hepatic hydatid cyst she presented intractable hematuria. The ultrasound and CT scan showed the formation of a large blood clot in the bladder not affecting the upper urinary tract. An intra-operative cystoscopy revealed a distended bladder showing signs of inflammation with diffuse, widespread bleeding. Hemostasis was achieved and a biopsy of the mucosa was taken, associated to bladder irrigation with potassium alum as a hemostatic. Given the persistence of the hematuria, further revision in the operating room as well as blood transfusion were carried out and, due to the hemodynamic instability that could not be controlled, finally selective embolization was performed. Intravesical instillation of dimethyl sulphoxide every 72 hours was used to control any remaining hematuria. The biopsy showed bladder amyloidosis. The addition of intravenous steroids and orally administered colchicine successfully controlled the patient's clinical status. CONCLUSIONS: Secondary amyloidosis of the bladder is a condition associated with hematuria that is difficult to manage. Hematuria control is often difficult, requiring aggressive treatment in addition to more conservative approaches.

Hematuria incoercible generada en la amiloidosis sistémica con afectación vesical / Intractable hematuria secondary to systemic amyloidosis with bladder involvement

OBJETIVO: Presentar el manejo terapéutico de la hematuria incoercible generada en la amiloidosis sistémica con afectación vesical. MÉTODO: Descripción del caso clínico, el manejo médico, la técnica endourológica utilizada y de los resultados con apoyo de la literatura publicada al respecto. RESULTADOS: Mujer de 50 años con antecedentes personales de artritis reumatoide (AR) de 20 años de evolución en tratamiento crónico con corticoides y AINES así como insuficiencia renal crónica sin necesidad de hemodiálisis, que tras 24 horas de la resección de un quiste hidatídico hepático presenta hematuria incoercible. Ecografía y TAC revelan gran coágulo vesical organizado sin repercusión de la vía urinaria. La cistoscopia intraoperatoria muestra una vejiga distendida de aspecto inflamatorio con sangrado difuso generalizado. Se realiza hemostasia y toma de biopsias de la mucosa asociando al lavado vesical alumbre potásico como hemostático. Dada la persistencia de la hematuria se procede a nueva revisión en quirófano más transfusión de hemoderivados en vista de la inestabilidad hemodinámica sin lograr control de la misma por lo que se realiza embolización selectiva. Se asocia instilación vesical con DMSO cada 72 hrs. para el control de la hematuria remanente. La biopsia revela el hallazgo de amiloidosis vesical agregándose al tratamiento corticoide intravenoso y colchicina oral controlando satisfactoriamente la clínica de la paciente. CONCLUSIONES: La amiloidosis vesical secundaria es una entidad que cursa con hematuria de difícil manejo. El control de la hematuria suele ser difícil por lo que además de los tratamientos conservadores a veces requiere de tratamientos más agresivos

OBJECTIVE: To present the therapeutic management of intractable hematuria secondary to systemic amyloidosis with bladder involvement. METHODS: We describe the clinical case, the medical management, the endo-urological technique used, and the results supported by relevant published literature. RESULTS: A 50-year-old woman with a 20-year history of rheumatoid arthritis in chronic treatment with corticosteroids and non-steroidal anti-inflammatory drugs in addition to chronic renal insufficiency not requiring hemodialysis. Twenty-four hours after resection of a hepatic hydatid cyst she presented intractable hematuria. The ultrasound and CT scan showed the formation of a large blood clot in the bladder not affecting the upper urinary tract. An intra-operative cystoscopy revealed a distended bladder showing signs of inflammation with diffuse, widespread bleeding. Hemostasis was achieved and a biopsy of the mucosa was taken, associated to bladder irrigation with potassium alum as a hemostatic. Given the persistence of the hematuria, further revision in the operating room as well as blood transfusion were carried out and, due to the hemodynamic instability that could not be controlled, finally selective embolization was performed. Intravesical instillation of dimethyl sulphoxide every 72 hours was used to control any remaining hematuria. The biopsy showed bladder amyloidosis. The addition of intravenous steroids and orally administered colchicine successfully controlled the patient’s clinical status. CONCLUSIONS: Secondary amyloidosis of the bladder is a condition associated with hematuria that is difficult to manage. Hematuria control is often difficult, requiring aggressive treatment in addition to more conservative approaches

Anti-angiogenic therapies in prostate cancer.

Prostate cancer (PCa) is the second most common type of cancer among men in Western societies. Once in the castrate-resistant metastatic setting therapeutic options are limited. The importance of angiogenesis in the progression of PCa has been widely reported providing a rationale to test anti-angiogenic compounds for PCa treatment in clinical trials (CTs). However, in spite of the promising results shown in preclinical models and some anti-tumor activity observed in CTs, to date, no angiogenic inhibitor has been approved for use in PCa. This editorial outlines the latest clinical evidence regarding anti-angiogenic therapies in PCa treatment.

Válvulas ureterales en el niño. Tratamiento minimamente invasivo mediante laser holmium / Conservative treatmet of ureteral valve with holmium laser in a child

OBJETIVOS: Presentar el manejo terapéutico mínimamente invasivo de la obstrucción unilateral del tracto urinario superior producida por una válvula ureteral.MÉTODO: Descripción del caso clínico, la técnica endourológica utilizada y de los resultados a medio plazo, con apoyo de la literatura publicada al respecto.RESULTADOS: Paciente de 12 años con clínica de dolor en flanco derecho. En la ecografía presentó ureterohidronefrosis derecha con parénquima conservado. La Uro-resonancia magnética reveló la presencia de un defecto de repleción en el tercio medio del uréter derecho y descartó una compresión extrínseca. En la ureterorrenoscopia se observó la válvula ureteral que fue resecada mediante laser holmium. La derivación ureteral se mantuvo 3 semanas. Tras 12 meses del tratamiento la paciente presentó ausencia de clínica y de ureterohidronefrosis derecha en ecografías de control.CONCLUSIONES: El tratamiento endourológico mediante resección de la válvula ureteral obstructiva usando el laser Holmium Dormier es un método poco invasivo seguro y eficaz a corto-medio plazo(AU)

OBJECTIVES: To present the minimally invasive management of an annular ureteric valve causing upper urinary tract obstruction.METHODS: A case report description: endourological technique and medium-term results with review of the published reports.RESULTS: A 12 year old patient with right flank pain was attended. Ultrasound showed right ureterohydronephrosis with conserved parenchyma. Uro-MRI (axial plane) showed dilation down to the middle of the right ureter with a filling defect, without extrinsic compression. Ureterorenoscopy showed a ureteral valve that was resected by holmium laser. Ureteral stent was maintained for 3 weeks. Twelve months after treatment patient has no symptoms and the following ultrasounds did not reveal right ureterohydronephrosis.CONCLUSIONS: Obstructive ureteral valve resection by endourological treatment using a Dornier holmium laser is a safe and effective minimally invasive method according to short and medium term results(AU)