Outcomes of an enhanced recovery after radical cystectomy program in a prospective multicenter study: compliance and key components for success.

OBJECTIVE: To investigate the effect of an Enhanced Recovery After Surgery (ERAS) program on complications and length of stay (LOS) after radical cystectomy (RC) and to assess if the number and type of components of ERAS play a key role on the decrease of surgical morbidity. MATERIALS AND METHODS: We analyzed the data of 277 patients prospectively recruited in 11 hospitals undergoing RC initially managed according to local practice (Group I) and later within an ERAS program (Group II). Two main outcomes were defined: 90-day complications rate and LOS. As secondary variables we studied 90-day mortality, 30-day readmission and transfusion rate. RESULTS: Patients in Group II had a higher use of ERAS measures (98.6%) than those in Group I (78.2%) (p < 0.05). Patients in Groups I and II experienced similar complications (70.5% vs. 66%, p = 0.42). LOS was not different between Groups I and II (12.5 and 14 days, respectively, p = 0.59). The risk of having any complication decreases for patients having more than 15 ERAS measures adopted [RR = 0.815; 95% confidence interval (CI) 0.667-0.996; p = 0.045]. Avoidance of transfusion and nasogastric tube, prevention of ileus, early ambulation and a fast uptake of a regular diet are independently associated with the absence of complications. CONCLUSIONS: Complications and LOS after RC were not modified by the introduction of an ERAS program. We hypothesize that at least 15 measures should be applied to maximize the benefit of ERAS.

Spanish consensus document for acceptance and rejection of kidneys from expanded criteria donors.

In the recent years, more than 60% of available deceased donors are either older than 50 yr or have significant vascular comorbidities. This makes the acceptance and rejection criteria of renal allografts very rigorous, especially in cases of younger recipients, and at the same time encourages live donations. In our country, there is a lack of homogeneity in the percentages of use of expanded criteria donor (ECD) allografts between the different autonomous communities. Furthermore, the criteria vary greatly, and in some cases, great importance is given to the biopsy while in others very little. In this study, we present a unified and homogenous criteria agreed upon by consensus of a 10-member Panel representing major scientific societies related to renal transplantation in Spain. The criteria are to be used in accepting and/or rejecting kidneys from the so-called ECDs. The goal was to standardize the use of these organs, to optimize the results, and most importantly to provide for the maximum well being of our patients. Finally, we believe that after taking into account the Panel's thorough review of specific scientific literature, this document will be adaptable to other national renal transplant programmes.

Urological complications after simultaneous pancreas-kidney transplantation.

OBJECTIVE: We evaluated the incidence of urological complications after simultaneous renal and pancreatic transplantation. PATIENTS AND METHODS: We retrospectively reviewed urological complications following 107 simultaneous kidney-pancreas transplantations performed at our institution between March 1995 and June 2008. The 46 women and 61 men were of mean age 37.8 years (range, 25-66). The mean duration of diabetes mellitus was 23.0 years (range, 9-48) and the mean duration of dialysis was 19.9 months (range, 0-70). The exocrine pancreatic secretions were drained to bladder in 58 cases, or enterically in 49 patients. The mean length of follow-up was 51.7 months. RESULTS: The most frequent urological complication was urinary tract infection, reported in 63.8% of patients: 42 bladder-drained and 25 enteric-drained (P = .011). Hematuria occurred in 13 patients (12.5%): 12 bladder-drained and 1 enteric-drained (P = .002). Five bladder-drained patients developed bladder calculi. Among 58 bladder-drained patients, reflux pancreatitis occurred in 28 patients and urine leaks related to the pancreatic graft occurred in 7 patients. Conversion of exocrine secretions from bladder to enteric diversion was required in 6 patients. One- and 3-year patient survival rates were 92.7% and 89.1%, respectively. Moreover, 1 and 3-year kidney graft survival rates were 90.6% and 84.4%, and pancreas graft survival rates were 78.1 and 70.3%, respectively. CONCLUSION: Simultaneous kidney-pancreas transplantation with bladder drainage is associated with a high frequency of urological complications. Appropriate treatment can resolve most complications. In our opinion, both enteric and bladder drainage seemed to be safe and effective alternatives to manage pancreatic exocrine secretions.

Evaluation of the specificity and sensitivity of indirect immunofluorescence tests for IgG to human herpesviruses-6 and -7.

Sera from 118 children aged up to 4 years were tested by indirect immunofluorescence for human herpesvirus-6 and -7 (HHV-6 and HHV-7) antibodies. Antibody results were confirmed as true positives if the relevant viral DNA was detected in saliva or, in some cases of primary infection, by the finding of the relevant DNA in cerebrospinal fluid or serum. Results from samples taken from the 15 children less than 6 months old showed that HHV-6 and/or HHV-7 antibody was either absent or present at low titre suggesting persistent maternal antibody rather than true infection. The sensitivity, specificity, positive and negative predictive values of the HHV-6 IgG test were therefore based on the data from the 103 children older than 6 months and the results were 95, 84, 91 and 90%, respectively. Likewise, the sensitivity, specificity, positive and negative predictive values of the HHV-7 IgG test were 95, 76, 84 and 93%, respectively. There was limited cross-reactivity between HHV-6 and HHV-7 antibodies; where both HHV-6 and HHV-7 antibodies are detected, titres above 32 may be accepted as true positives but lower titres require confirmation by detection of the relevant viral DNA or, in the case of primary infection, by a rising antibody titre.

Primary cisplatin, methotrexate and vinblastine chemotherapy with selective bladder preservation for muscle invasive carcinoma of the bladder: long-term followup of a prospective study.

PURPOSE: We evaluate the efficacy and bladder preservation rate of combined modality therapy consisting of deep transurethral resection of the primary bladder tumor followed by cisplatin, methotrexate and vinblastine chemotherapy in patients with muscle invasive transitional cell carcinoma of the bladder. MATERIALS AND METHODS: A total of 40 consecutive patients with clinical stage T2-T4 NX M0 bladder cancer were included in the study and treated with transurethral resection followed by 3 courses of chemotherapy. Chemotherapy consisted of 100 mg./m.2 cisplatin intravenously on day 1, 30 mg./m.2 methotrexate intravenously on days 1 and 8, and 4 mg./m.2 vinblastine intravenously on days 1 and 8 administered every 21 days. Patients with disease in complete clinical remission after cycle 3 of therapy received 3 additional chemotherapy courses. Patients in whom complete clinical remission persisted after cycle 6 were closely followed with no further therapy until disease progression. RESULTS: A complete clinical remission was achieved in 21 patients (53%) after the first 3 cycles of therapy and a partial response occurred in 10 (25%), for an overall response rate of 78% (95% confidence interval [CI] 62% to 89%). With a median followup of 78 months (range 70 to 109) the estimated 7-year progression-free and overall survival rates were 40% (95% CI 25% to 55%) and 35% (95% CI 20% to 50%), respectively. The 7-year survival rate with a functional bladder for complete clinical remission cases was 52% (95% CI 30% to 74%). Low grade, small tumor, absence of concomitant carcinoma in situ and response to therapy were all significant predictors for an increased probability of bladder preservation in univariate analysis. However, response to therapy was the only variable with independent prognostic value in the multivariate analysis (p = 0.002). CONCLUSIONS: Transurethral resection of bladder tumor followed by cisplatin, methotrexate and vinblastine chemotherapy results in long-term bladder preservation in a significant proportion of responding patients, and may be an acceptable alternative to radical surgery in select patients with muscle invasive bladder cancer.

Suramin blocks hepatitis C binding to human hepatoma cells in vitro.

It was demonstrated recently that the binding of dengue virus to its target cell receptor could be effectively blocked by both heparin and by the polysulphonate pharmaceutical, Suramin [Chen et al. (1997) Nature Medicine 3:866-871]. Because both dengue and hepatitis C virus (HCV) belong to the Flaviviridae and because the HCV envelope is predicted to possess a heparin-binding motif, we tested heparin, Suramin, and a number of other polyanionic compounds for their ability to block HCV binding in vitro. The compounds, at concentrations ranging from 0.5 to 5,000 microg/ml, were tested using the human hepatoma cell line HepG2 cultured under conditions designed to enhance hepatocyte differentiation. Cells were harvested at 2 weeks postinoculation and HCV-RNA was quantified by means of a chemiluminescent reverse transcription polymerase chain reaction (PCR) assay. Suramin was found to be capable of blocking HCV binding in this system at a concentration similar to that reported to be effective against dengue virus. Removal of the viral envelope by treatment with chloroform also prevented HCV infection. Neither chondroitin sulphate nor the Suramin analogue CPD14 were able to block HCV under these conditions.

[Tuberculous prostatic abscess in a patient with AIDS]. / Absceso prostático tuberculoso en paciente con SIDA.

Despite of prostate abscesses having become an uncommon disease, a number of cases has been described lately specially in immunodepressed patients caused by infrequent agents, such as Mycobacterium tuberculosis. This paper describes the case of one HIV-positive patient, diagnosed with a prostate abscess within a tuberculous dissemination. The best diagnostic method is considered to be the transrectal ultrasound (TRU), the choice therapy being drainage by ultrasound-guided transperineal percutaneous puncture.

[Volumetric correlations of prostatic adenoma by transrectal ultrasonography]. / Correlaciones volumétricas del adenoma prostático mediante ecografía transrectal.

Estimation of prostate volume is one of the key elements in the study and management of both prostate benign diseases and prostate cancer. Of the available techniques, transrectal ultrasound presents greater reliability in prostatic imaging due to its degree of resolution. The present study conducted in 40 patients undergoing suprapubic adenectomy piedes with the echographic dimensions and 14 different volumetric formulae obtained by the multiple combination of the three prostate axis. The two best correlations are obtained when the cross-sectional measurement is combined with the anteroposterior (r = 0.84..0.83), and the worse when the longitudinal measure is used in isolation or combined with the anteroposterior one (r = 0.64..0.43). The exact formula is the ellipsoid [formula: see text] Contrary to what could be expected, the size of the "internal gland" (cross-sectional and anteroposterior) scarcely correlates to the adenoma weight, both with regard to the main axes (cross-sectional, r = 5.25; anteroposterior, r = 0.28) and the theoretical volume (r = 0.69).

[Granulomatous prostatitis. An infrequent diagnosis. Review of our series]. / La prostatitis granulomatosa. Un diagnóstico infrecuente. Revisión de nuestra serie.

Granulomatous prostatitis is an inflammatory condition of the prostate which presents rarely in the urological practice. It is caused by several specific and unspecific infectious agents, and can also be secondary to prostate surgery or a local reflection of a systemic granulomatous disease. With regard to clinical manifestations and treatment, it is an unspecific entity which has a characteristic histopathology. Its major interest consists on the possibility of it being mistaken for a prostate cancer during physical examination. This paper reviews a series of 7 granulomatous prostatitis, with special emphasis on their histology and ultrasound findings.

[Renal cystic carcinoma: report of five cases]. / Carcinoma renal quístico: presentación de cinco casos.

Of 204 renal adenocarcinomas seen in the Urology Service at the Hospital "12 de Octubre", from January 1974 to December 1992, we found five cases (2.5%) of cystic renal carcinoma in patients with an average age of 51.8 years (range 35-69), with a female vs male ratio of 3:2, and a right-sided vs left sided ratio of 4:1. The article describes the signs and symptoms, diagnostic methods used, treatment and subsequent evolution of our series, and includes a revision of the published literature.

Interactions between interferon gamma and retinoic acid with transforming growth factor beta in the induction of immune recognition molecules.

The cell-surface expression of major histocompatibility (MHC) antigens and the adhesion molecule intercellular adhesion molecule 1 (ICAM-1) is essential for target cell recognition by T lymphocytes. The expression of both classes of molecule is induced by various cytokines, notably interferon gamma (IFN gamma). Since transforming growth factor beta (TGF beta) has been recently reported to antagonise HLA-DR induction by IFN gamma we have examined, using a number of murine and human cell lines, the effect of TGF beta on IFN gamma-induced MHC class I and class II and ICAM-1 expression. All of the cell lines tested expressed elevated class I MHC following IFN gamma treatment. Class II MHC induction was seen on most but not all of the cells, the exceptions being among a panel of human colorectal carcinoma cell lines. A striking difference between cells of different origin was noted in the response to TGF beta. TGF beta was found to antagonise IFN gamma-induced class I and class II MHC expression on C3H 10T1/2 murine fibroblasts, early-passage BALB/c mouse embryo fibroblasts, a murine oligodendroglioma cell line, and on MRC5 human fibroblasts and two human glioblastoma cell lines. Class II MHC was much more strongly inhibited (sometimes completely) than class I MHC. TGF beta also inhibited induction of class I MHC expression by IFN alpha. However, TGF beta did not inhibit class I or class II MHC induction by IFN gamma in any of the nine colorectal carcinoma cell lines, although two of five of the lines tested were growth-inhibited by TGF beta. On the other hand, human ICAM-1 induction by IFN gamma was not affected by simultaneous treatment with TGF beta in any of the cell lines. The down-regulation of IFN gamma-induced MHC antigens by TGF beta is not, therefore, the result of a general antagonism of IFN gamma. Retinoic acid has recently been reported to induce ICAM-1 expression on human tumour cells. We have confirmed this observation on MRC5, and the two human glioblastoma cell lines, however six colorectal carcinoma cell lines tested did not respond. In contrast to IFN gamma-induced ICAM-1 expression, retinoic-acid-induced ICAM-1 expression was inhibited by TGF beta on two of the three responsive lines.

CMV front-line chemotherapy in transitional bladder carcinoma.

BACKGROUND: Despite standard treatment, surgery and/or radiotherapy, most patients with muscle invasive bladder carcinoma die early of distant metastasis. CMV chemotherapy has demonstrated a high response rate with moderate toxicity in advanced bladder carcinoma. In an attempt to eradicate undetectable metastatic disease and to avoid cystectomies, 36 patients were given up-front CMV. MATERIALS AND METHODS: The patients were 34 males and 2 females with a median age of 62 years (45-75); performance status 0-1 (WHO) in 34 patients; histology: 34 transitional carcinomas and 2 anaplastic carcinomas (grade II: 8, grade III: 28). Clinical staging was T2-3a: 19 patients, T3b: 14 patients and T4: 3 patients. Nineteen patients had complete trans-urethral resections (TUR) at diagnosis. The multimodal protocol started with 3 CMV courses (cisplatin 100 mg/m2 i.v. d 1, methotrexate 30 mg/m2 i.v. d 1, 8 and vinblastine 4 mg/m2 i.v. d 1, 8 every 3 weeks). Patients who yielded clinical complete responses (cCR) by cystoscopy, TUR biopsies and imaging techniques were given 3 additional courses. Cystectomy was performed in non-cCR patients and as salvage treatment. RESULTS: Following 3 CMV cycles, 29 patients (81%) responded (20 cCR and 9 cPR) and 7 (19%) did not (NR). Currently, with a median follow-up of 23.5 months (13-59), 13 have died and 23 are alive, 12 of whom retain their bladders. The projected overall survival is 51% at 4.5 years. Grade 3-4 hematological toxicity was presented in 8% of the cycles. No toxic deaths were observed. CONCLUSION: The CMV regimen, after TUR, produces a high response rate with tolerable toxicity. Bladders could be preserved in half of the CR patients.

[Neoplasm invasion of the renal vein by transitional cell carcinoma of the kidney pelvis]. / Invasión neoplásica de la vena renal por Ca. de células transicionales de pelvis renal.

We present two cases of renal pelvis transitional cell carcinoma with invasion of the renal vein. We emphasize the importance of preoperative diagnosis and review the diagnostic methods available for revealing this uncommon eventuality. Owing to the prognostic importance and subsequent surgical treatment, this possibility should be evaluated in those cases of renal pelvis transitional cell carcinoma with extensive parenchymatous invasion or in those cases in which kidney function cancellation occurs in the excretory urograph.

[Intravesical echography. I. Anatomical correlation]. / Ecografía intravesical. I: Correlación anatómica.

The scan images of the normal bladder were obtained by intravesical ultrasonography (IVU) and the ultrasonographic-anatomic correlation were defined based on 179 procedures. Except in bladder cancer, IVU did not prove to be useful in the evaluation of other bladder conditions or adjacent structures, including gynecological disorders.

[Intravesical echography. II. Staging]. / Ecografía intravesical. II: Estadiaje.

We evaluated 137 patients with bladder cancer submitted to surgery in order to determine the usefulness of intravesical ultrasonography (IVU) in tumor staging. The characteristic scan images were defined for each tumor stage. The application of the ultrasound patterns yielded an accuracy rate of 91% for tumors Ta"1 and 71% for T4. Based on the results of this study, IVU does not appear to be useful as an intraoperative monitoring technique.

[Emphysematous cystitis]. / Cistitis enfisematosa.

Emphysematous cystitis constitutes an uncommon clinical radiological entity. (Approximately 160 cases in the literature). We offer five cases of emphysematous cystitis, all of which occurred in women aged 60-80 (X = 74.2). All of them except one proved to be known diabetics and the glycemia figures at the time of being attended were above the limits of normality. In no case was pneumaturia observed, and the main symptoms displayed were those of the cystitis type together with pain in the hypogastrium and macroscopic hematuria. Simple abdomen radiology was the diagnosis procedure in all cases. The treatment applied permitted the favourable evolution and resolution of the process.