Preguntas y respuestas sobre resonancia magnética multiparamétrica prostática: todo lo que el urólogo debe conocer / Questions and answers on prostate multiparameter magnetic resonance imaging: Everything a urologist should know

Contexto: Durante muchos años, la detección del carcinoma prostático (CaP) y su manejo terapéutico se basó fundamentalmente en el antígeno prostático específico, el tacto rectal y la biopsia prostática. Sin embargo, estos parámetros poseen conocidas limitaciones. La resonancia magnética multiparamétrica (RMmp) prostática ha tenido en los últimos años un extenso desarrollo, aportando información morfológica y funcional. El objetivo es presentar una revisión actualizada de los alcances y las limitaciones de la RMmp prostática en relación con el CaP, en el marco de una visión multidisciplinaria. Adquisición de evidencia: Se realizó una revisión de la literatura en PubMed, de los artículos referidos a «RMmp/Estadificación/CaP/detección/vigilancia activa/planificación terapéutica/posterapeútica». Se incluyeron 4 revisiones sistemáticas y otros artículos publicados en revistas de alto factor de impacto dentro del área de Radiología y Urología. Síntesis de evidencia: La RMmp aporta información morfológica y funcional respecto al CaP. Esta información está integrada en el modelo de lectura Prostate Imaging Reporting and Data System, clasificándose la probabilidad de carcinoma clínicamente significativo en una escala del 1 al 5. Actualmente está establecida la utilidad de la RMmp en pacientes con antígeno prostático específico elevado y biopsia prostática previa negativa; estadificación tumoral en casos seleccionados; evaluación en los pacientes candidatos a vigilancia activa; planificación de tratamientos focales y evaluación de la persistencia o recurrencia tumoral. Conclusiones: La RMmp actualmente cumple un papel relevante en el diagnóstico y la toma de decisiones terapéuticas del CaP. El uso aún más extendido de la técnica requerirá una valoración coste/beneficio

Context: For many years, the detection of prostate cancer (PC) and the management of its therapy have been based primarily on prostate-specific antigen, rectal examination and prostate biopsy. However, these parameters have known limitations. Multiparametric magnetic resonance imaging (mpMRI) for prostate cancer has undergone extensive development in recent years, providing morphological and functional information. The aim of this study is to present an updated review of the scope and limitations of prostatic mpMRI for PC, in the framework of a multidisciplinary vision. Acquisition of evidence: We conducted a literature review (in PubMed) of articles referencing «mpMRI/staging/ PC/detection/active surveillance/therapy planning/post-therapy». We included 4 systematic reviews and other articles published in high impact-factor journals within the field of radiology and urology. Summary of the evidence: MpMRI provides morphological and functional information concerning PC. This information is integrated into the Prostate Imaging Report and Date System, classifying the probability of clinically significant carcinoma on a scale from 1 to 5. The usefulness of mpMRI is currently being established for patients with high prostate-specific antigen levels and prior negative prostate biopsy; tumour staging in selected cases; assessment of patients who are candidates for active surveillance; the planning of focal treatments; and the assessment of tumour persistence and recurrence. Conclusions: MpMRI currently fills a relevant role in the diagnosis and therapeutic decision-making of PC. More widespread use of the technique requires a cost/benefit analysis

Questions and answers on prostate multiparameter magnetic resonance imaging: Everything a urologist should know. / Preguntas y respuestas sobre resonancia magnética multiparamétrica prostática: todo lo que el urólogo debe conocer.

CONTEXT: For many years, the detection of prostate cancer (PC) and the management of its therapy have been based primarily on prostate-specific antigen, rectal examination and prostate biopsy. However, these parameters have known limitations. Multiparametric magnetic resonance imaging (mpMRI) for prostate cancer has undergone extensive development in recent years, providing morphological and functional information. The aim of this study is to present an updated review of the scope and limitations of prostatic mpMRI for PC, in the framework of a multidisciplinary vision. ACQUISITION OF EVIDENCE: We conducted a literature review (in PubMed) of articles referencing "mpMRI/staging/ PC/detection/active surveillance/therapy planning/post-therapy". We included 4 systematic reviews and other articles published in high impact-factor journals within the field of radiology and urology. SUMMARY OF THE EVIDENCE: MpMRI provides morphological and functional information concerning PC. This information is integrated into the Prostate Imaging Report and Date System, classifying the probability of clinically significant carcinoma on a scale from 1 to 5. The usefulness of mpMRI is currently being established for patients with high prostate-specific antigen levels and prior negative prostate biopsy; tumour staging in selected cases; assessment of patients who are candidates for active surveillance; the planning of focal treatments; and the assessment of tumour persistence and recurrence. CONCLUSIONS: MpMRI currently fills a relevant role in the diagnosis and therapeutic decision-making of PC. More widespread use of the technique requires a cost/benefit analysis.

Pelvic MRI findings in relapsed prostate cancer after radical prostatectomy.

PURPOSE/OBJECTIVE: Little is known about the clinical impact of using multiparametric MRI to plan early salvage radiotherapy after radical prostatectomy. We aimed to evaluate the incidence and location of recurrence based on pelvic multiparametric MRI findings and to identify clinical variables predictive of positive imaging results. MATERIALS AND METHODS: We defined radiological criteria of local and lymph node malignancy and reviewed records and MRI studies of 70 patients with PSA recurrence after radical prostatectomy. We performed univariate and multivariate analysis to identify any association between clinical, pathological and treatment-related variables and imaging results. RESULTS: Multiparametric MRI was positive in 33/70 patients. We found local and lymph node recurrence in 27 patients and 7 patients, respectively, with a median PSA value of 0.38 ng/ml. We found no statistically significant differences between patients with positive and negative multiparametric MRI for any variable. Shorter PSADT was associated with positive lymph nodes (median PSADT: 5.12 vs 12.70 months; p: 0.017). CONCLUSIONS: Nearly half the patients had visible disease in multiparametric MRI despite low PSA. Positive lymph nodes incidence should be considered when planning salvage radiotherapy, particularly in patients with a short PSADT.

Hematuria macroscópica gestacional: a propósito de un caso tratado con RIRS / Gestational gross hematuria: report of a case treated with RIRS

La hematuria, durante la gestación, es debida a causas urológicas comunes como la litiasis y la infección de orina, los tumores del riñón y la vejiga, y las malformaciones vasculares renales. Anomalías de la implantación de la placenta y complicaciones obstétricas pueden ocasionar sangrado en orina. Entre las causas nefrológicas figura el síndrome hemolítico urémico. Alteraciones hematológicas asociadas a la gestación como la plaquetopenia favorecen la hematuria, en especial si existe una patología urológica subyacente. Se presenta un caso clínico de hematuria recidivante en una gestante que requirió estudio con RM y URS, resuelto después del parto con cirugía endoscópica intrarrenal (RIRS) (AU)

Hematuria during pregnancy is due to common urological causes such as stones and urinary tract infection, kidney and bladder tumors, and renal vascular malformations. Abnormalities of placenta implantation and obstetric complications are the cause of bleeding in urine. Among nephrological causes is the hemolitic-uremic syndrome. Hematologic abnormalities as a thrombocytopenia favor gestational hematuria, especially if there is an underlying urologic pathology. A case report of recurrent hematuria in a pregnant is presented. MRI and URS was required to study it. The case was resolved after birth with intrarenal endoscopic surgery (RIRS) (AU)

Cancer de próstata: tratamiento focal de rescate post radioterapia / Prostate Cancer: post radiotherapy rescue focal treatment

El tratamiento de rescate posterior a radioterapia prostática es un reto. Las opciones terapéuticas en este grupo de pacientes ofrecen resultados oncológicos satisfactorios, hipotecando resultados funcionales. Presentamos un caso clínico de nuestro estudio piloto de crioterapia focal de rescate (AU)

Treatment of radiation failure prostate cancer remains a challenge. The treatment options in this group of patients offer acceptable oncological results at expense of poor functional results. We present a case of our series of focal cryotherapy in the setting of localized failure prostate cancer (AU)

Crioterapia renal percutánea ecoguiada: una opción en el tratamiento de cáncer renal / Percutaneous ultrasound-guided renal cryotherapy: an option in the treatment of renal cancer

La crioterapia es una opción terapéutica para el tratamiento del cáncer renal (CR). La indicación suele corresponder a estadios T1a situados preferentemente en cara posterior y de borde externo medio e inferior del riñón. La ecografía permite realizar el procedimiento de forma controlada, además de ahorrar irradiación y costes. No suele haber complicaciones intraoperatorias. El seguimiento se realiza con TC al mes y después cada 6 meses. Se considera criterio de buen resultado, la ausencia total de incorporación de contraste. La recurrencia es poco frecuente y representa uno de los aspectos negativos de esta técnica y para evitarla hay que elegir bien los casos (AU)

Cryotherapy is a option for the treatment of renal cancer. The indication generally correspond to stages T1a preferably located on the posterior aspect and lower half of the kidney. The procedure can be guided using ultrasonography as a controlled manner to avoid irradiation and saving costs. There are usually no intraoperative complications. Monitoring is done with TC a month and then every 6 months. Criterion of good result is total lack to catch contrast. Recurrence is rare and represents one of the negative aspects of this technique. To avoid this is necessary to choose good cases (AU)

DU en ancianos tratados con CR: cómo elegir bien / Urinary derivation in elderly patients treated with radical cistectomy: how to choose wel

Los objetivos de la DU (Derivación urinaria) después de la CR (Cistectomía radical) han evolucionado desde un sistema simple de drenaje a un concepto más avanzado en el que se contempla proteger el tracto urinario y lograr una restitución anatómica y funcional lo más similar posible a la fisiológica presente antes de la intervención. El conducto ileal es una derivación simple y efectiva, superior a la tradicional ureterostomía cutánea. Las diversas técnicas de reconstrucción vesical ortotópica (neovejiga) son una buena solución. Conservan la anatomía y la funcionalidad miccional del paciente. A menudo la comorbilidad asociada, la alteración del status mental obliga a utilizar la DU más simple posible. Los pacientes ancianos pueden recibir este tipo de derivación aunque hay que plantear la posibilidad de más complicaciones (AU)

The objectives of the urinary diversion after radical cystectomy have evolved from a simple drainage to a more advanced diversion in which it is contemplated to protect the upper urinary tract and achieve anatomical and functional restitution as similar as before intervention. The ileal conduit is a derivation simple and effective derivation but better than traditional cutaneous ureterostomy. Various techniques of orthotopic bladder reconstruction (neobladder) are a good solution. They preserve the anatomy and function of the patient voiding. Associated comorbidity and mental status are drawbacks in elderly patients. Elderly patients may receive this type of urinary diversion but we must consider the possibility of further complications (AU)

Aspectos quirúrgicos actuales de la nefrectomía de donante vivo / Surgical Aspects of Living Donor Nephrectomy

Contexto: La cirugía del trasplante renal de donante vivo ha evolucionado desde la clásica nefrectomía por lumbotomía a una cirugía menos invasiva, imponiéndose en la actualidad la nefrectomía laparoscópica y robótica. Resulta importante conocer la evidencia disponible acerca de si la nefrectomía en pacientes con múltiples arterias, riñón derecho y en pacientes obesos puede realizarse de manera segura ante una indicación correcta. Objetivo: Realizar una revisión de las diferentes técnicas quirúrgicas en nefrectomía de donante vivo, adaptada a la evidencia científica actual, y de otros aspectos que rodean la indicación. Adquisición de la evidencia: Se realizó una revisión sistemática en PubMed (1997-2011), que incluye revisiones previas, estudios clínicos aleatorizados controlados, estudios de cohortes y metanálisis de los aspectos quirúrgicos de la nefrectomía de donante vivo. Conclusiones: Actualmente existe suficiente evidencia para considerar la nefrectomía laparoscópica de donante vivo como técnica de elección, aunque el papel de la técnica mano-asistida y la retroperitoneoscopia todavía no está del todo claro. Las técnicas de cirugía abierta por mini incisión representan una alternativa aceptable para los centros que no hayan implementado todavía la cirugía laparoscópica. La nefrectomía de riñón derecho, de aquellos casos que presentan pedículos múltiples y en los donantes obesos está justificada en casos seleccionados (AU)

Context: Living donor renal transplant surgery has evolved from the classical nephrectomy by lumbotomy to less invasive surgery, the laparoscopic and robotic nephrectomy currently being the most important. It is important to know the available evidence on whether nephrectomy in patients with multiple arteries, right kidney and in obese patients can be performed safely when there is a correct indication. Objective: To perform a review of the different surgical techniques in living donor nephrectomy, adapted to the current surgical evidence and other aspects related to the indication. Evidence acquisition: A systematic review was made in PubMed (1997-2011). This included previous reviews randomized controlled clinical studies, cohort studies, and meta-analyses of this surgical aspects of living donor nephrectomy. Conclusions: Currently, there is sufficient evidence to consider living donor laparoscopic nephrectomy as the technique of choice, although the role of hand-assisted retroperitoneoscopic technique is still not totally clear. Open surgery techniques using mini-incision are an acceptable alternative for the sites that have not yet implemented laparoscopic surgery. Right kidney nephrectomy, of those cases that present multiple pedicles and in obese donors, is justified in selected cases (AU)

[Surgical aspects of living donor nephrectomy]. / Aspectos quirúrgicos actuales de la nefrectomía de donante vivo.

CONTEXT: Living donor renal transplant surgery has evolved from the classical nephrectomy by lumbotomy to less invasive surgery, the laparoscopic and robotic nephrectomy currently being the most important. It is important to know the available evidence on whether nephrectomy in patients with multiple arteries, right kidney and in obese patients can be performed safely when there is a correct indication. OBJECTIVE: To perform a review of the different surgical techniques in living donor nephrectomy, adapted to the current surgical evidence and other aspects related to the indication. EVIDENCE ACQUISITION: A systematic review was made in PubMed (1997-2011). This included previous reviews randomized controlled clinical studies, cohort studies, and meta-analyses of this surgical aspects of living donor nephrectomy. CONCLUSIONS: Currently, there is sufficient evidence to consider living donor laparoscopic nephrectomy as the technique of choice, although the role of hand-assisted retroperitoneoscopic technique is still not totally clear. Open surgery techniques using mini-incision are an acceptable alternative for the sites that have not yet implemented laparoscopic surgery. Right kidney nephrectomy, of those cases that present multiple pedicles and in obese donors, is justified in selected cases.

Relevancia de los factores predictivos clínico-patológicos vigentes en el carcinoma renal de células cromófobas / Relevance of the Clinical-Pathological Predictive Factors in Force in Chromophobe Renal Cell Cancer

Introducción: La identificación de nuevos subtipos de carcinoma de células renales (CCR) ha hecho que sea necesaria una reevaluación de los factores predictivos clínico-patológicos vigentes (estadio, grado de Fuhrman, necrosis, invasión linfo-vascular [ILV] intrarrenal y componente sarcomatoide) en estos nuevos subtipos. El carcinoma renal de células cromófobas (CRCC) se considera un subtipo de CCR menos agresivo. Este artículo pretende evaluar la utilidad de los actuales factores predictivos clínico patológicos del CCR en nuestra serie de CRCC. Material y métodos: Se realizó una revisión retrospectiva de las características clínico-patológicas de 63 pacientes que fueron tratados mediante nefrectomía radical por CRCC. Los parámetros analizados fueron la extensión TNM, el grado de Fuhrman, ILV, necrosis, trombo tumoral, márgenes quirúrgicos y compromiso del sistema colector. Los resultados (recurrencia de enfermedad) se valoraron mediante regresión de Cox con análisis uni y multivariante. Resultados: Con una mediana de seguimiento de 60,2 meses (0,37-160,2), 8 (11%) pacientes presentaron recurrencia, con un tiempo medio hasta la recurrencia de 31,7 meses (5,37-124,33). En el análisis univariante la extensión TNM (p=0,0001), grado Fuhrman III o IV (p=0,031), la ILV (p=0,0001) y la presencia de márgenes quirúrgicos positivos (p=0,0001) fueron variables estadísticamente significativas para recurrencia. En el análisis multivariante solo el estadio se confirmó como factor predictivo independiente de recurrencia, pT1 versus pT2 (p=0,02; OR 0,27; IC 95%: 0,03-0,258) y en pT2 versus estadio superior (p=0,037; OR: 0,173; IC 95%: 0,033-0,896). Conclusiones: El estadio tumoral predice agresividad en el CCRC. La clasificación del grado nuclear de Fuhrman no es útil para este subtipo histológico (AU)

Introduction: The identification of new subtypes of renal cell carcinoma (RCC) has made it necessary to re-evaluate the current clinical and pathological predictive factors (stage, Fuhrman nuclear grade, necrosis, lymphovascular invasion [LVI] and sarcomatoid component) in these new subtypes. The chromophobe renal cell carcinoma (CRCC) is considered a less aggressive subtype of RCC. The purpose of this article is to evaluate the usefulness of current clinicopathologic predictors of RCC in our series of CRCC. Material and methods: We retrospectively reviewed the clinicopathologic features of 63 patients with CRCC treated with radical nephrectomy. The parameters analyzed were tumor extension with the TNM, grade according to Fuhrman classification, LVI, tumor necrosis, tumor thrombus, surgical margin status, and involvement of the collecting system. The results (disease recurrence) were evaluated by Cox regression model with univariate and multivariate analysis. Results: With a median follow up of 60.2 months (0.37-160.2), 8 (11%) patients had recurrence, with median time to recurrence of 31.7 months (5.37-124.33). In the univariate analysis, TNM extension (p=0.0001), Fuhrman grade III or IV (p=0.031), LVI (p=0.0001) and the presence of positive surgical margins (p=0.0001) were statistically significant variables for recurrence. In the multivariate analysis, only tumor stage was confirmed as an independent predictor of recurrence, pT1 versus pT2 (p=0.02, OR 0.27 95% CI 0.03-0.258) and pT2 versus higher stage (p=0.037, OR 0.173 95% CI 0.033-0.896). Conclusions: The tumor stage predicts aggressiveness in the CCRC. The classification of Fuhrman nuclear grade is not useful for this histological subtype (AU)

Seguimiento del tratamiento hormonal en cáncer de próstata / Monitoring of hormone therapy in prostate cancer

Introducción: La deprivación androgénica ha demostrado ser efectiva en el tratamiento del carcinoma prostático (CP). La determinación del PSA no es suficiente para verificar la correcta respuesta al tratamiento. Para ello es necesario medir los niveles de testosterona. Caso clínico: Presentamos en caso de un varón de 76 años con PSA de 79 y una próstata sugestiva de T3 al tacto. Se realiza biopsia prostática confirmando el diagnóstico de CP de próstata afectando en 90% de la glándula Gleason 8 LD y 9 LI. Se inicia tratamiento hormonal con análogos de LHRH y antiandrógenos por 21 días. A los 3 meses el PSA es de 12. ¿Es suficiente contar con los niveles de PSA? Discusión: La testosterona es esencial para el crecimiento y proliferación de las células prostáticas. La terapia hormonal se basa en bloquear tanto la producción testicular (orquiectomía y análogos o antagonistas LHRH), como la respuesta de los receptores prostáticos a los andrógenos de origen suprarrenal (antiandrógenos). La supresión de los andrógenos de origen testicular disminuye significativamente los niveles de testosterona, persistiendo un bajo nivel de la misma conocido como nivel de castración. Múltiples estudios han demostrado que niveles más bajos de testosterona se asocian con mayor supervivencia. Aunque el PSA suele preceder a la aparición de los síntomas en varios meses, no es un marcador fiable de escape y no puede ser empleado como única prueba de seguimiento. Conclusión: el PSA y la concentración sérica de testosterona deben solicitarse en el seguimiento de los pacientes con CP en tratamiento hormonal (AU)

Introduction: Androgen deprivation has proved effective in the treatment of prostatic carcinoma (PC). The determination of PSA is not sufficient to verify the correct response to treatment. This requires measuring the levels of testosterone. Case report: We present in case of a man of 76 years with PSA of 79 and a prostate suggestive of T3 to the touch. Prostate biopsy was performed confirming the diagnosis of prostate affecting PC in 90% of the gland Gleason 8 and 9 LD LI. Hormonal treatment was started with LHRH analogs and antiandrogens for 21 days. At 3 months, the PSA is 12. Is it enough to have PSA levels? Discussion: Testosterone is essential for growth and proliferation of prostate cells. Hormone therapy is based on block both testicular production (orchiectomy and LHRH analogs or antagonists), such as prostatic response to androgen receptors of adrenal origin (antiandrogens). Suppression of androgens of testicular origin significantly decreased testosterone levels (castration level). Múltiple studies have shown that lower testosterone levels are associated with longer survival. Although the PSA usually precedes the onset of symptoms in months, it is not a reliable marker of escape and can not be used as the only follow-up test. Conclusion: PSA and serum testosterone must be requested to monitoring patients with PC on hormone treatment (AU)

[Relevance of the clinical-pathological predictive factors in force in chromophobe renal cell cancer]. / Relevancia de los factores predictivos clínico-patológicos vigentes en el carcinoma renal de células cromófobas.

INTRODUCTION: The identification of new subtypes of renal cell carcinoma (RCC) has made it necessary to re-evaluate the current clinical and pathological predictive factors (stage, Fuhrman nuclear grade, necrosis, lymphovascular invasion [LVI] and sarcomatoid component) in these new subtypes. The chromophobe renal cell carcinoma (CRCC) is considered a less aggressive subtype of RCC. The purpose of this article is to evaluate the usefulness of current clinicopathologic predictors of RCC in our series of CRCC. MATERIAL AND METHODS: We retrospectively reviewed the clinicopathologic features of 63 patients with CRCC treated with radical nephrectomy. The parameters analyzed were tumor extension with the TNM, grade according to Fuhrman classification, LVI, tumor necrosis, tumor thrombus, surgical margin status, and involvement of the collecting system. The results (disease recurrence) were evaluated by Cox regression model with univariate and multivariate analysis. RESULTS: With a median follow up of 60.2 months (0.37-160.2), 8 (11%) patients had recurrence, with median time to recurrence of 31.7 months (5.37-124.33). In the univariate analysis, TNM extension (p=0.0001), Fuhrman grade III or IV (p=0.031), LVI (p=0.0001) and the presence of positive surgical margins (p=0.0001) were statistically significant variables for recurrence. In the multivariate analysis, only tumor stage was confirmed as an independent predictor of recurrence, pT1 versus pT2 (p=0.02, OR 0.27 95% CI 0.03-0.258) and pT2 versus higher stage (p=0.037, OR 0.173 95% CI 0.033-0.896). CONCLUSIONS: The tumor stage predicts aggressiveness in the CCRC. The classification of Fuhrman nuclear grade is not useful for this histological subtype.

Modalidades de preservación vesical en el carcinoma vesical músculo invasivo / Bladder preservation in muscle-invasive bladder cancer

La cistectomía radical es el tratamiento de elección para el carcinoma vesical músculo invasivo T2-4NxM0 (1). Las tasas de supervivencia global van desde el 67-84% para pacientes con estadio pT2 hasta el 32-58% en los pT3-4 (2). Con el advenimiento de la cirugía robótica con preservación de las bandeletas neurovasculares y la evolución de las técnicas de sustitución vesical, se han mejorado en gran medida la continencia y la función sexual, sin embargo, la sustitución vesical no es posible realizarla en todos los pacientes. Existen diferentes estrategias de conservación vesical, combinando la resección transuretral (RTU), radioterapia y quimioterapia, aunque los resultados a largo plazo por el momento no han sido concluyentes. El beneficio real de cada modalidad es difícil de evaluar, ya que por el momento no existen criterios de inclusión claros; sin embargo un RTU con mínimo tumor residual en ausencia de dilatación del tramo urinario superior se han mostrado con buenos factores predictivos (AU)

Radical cystectomy is the primary treatment for T2-4NxM0 muscle invasive bladder cáncer (1). Contemporary series report that in patients with negative lymph nodes OS is 67-84% in pT2 cases and 32%-58% in pT3-pT4 cases (2). Advances in urinary diversion and nerve-sparing cystectomy have improved patients quality of life, but bladder substitution is not technically feasible or suitable for all patients. There are several means of bladder preservation using single-and multimodal treatment strategies; however, some doublets and controversies remain. Multimodal treatment combining systemic chemotherapy and external beam therapy (EBT) aims to achieve a significantly higher initial response but with long-term follow up the advantage is controversial. The real benefit of each scheme is difficult to determine because no specific inclusion criteria have been established; however, a complete TUR with minimal residual tumour and absence of upper tract dilatation have been reported to be prognostic factors (AU)

Actualización en el tratamiento médico del carcinoma renal avanzado / Update on the medical treatment of advanced kidney cancer

El tratamiento quirúrgico del cáncer de células renales (CCR) avanzado se ve reforzado por la aplicación de fármacos con capacidad citorreductora. La inmunodependencia del CCR lo hace sensible a terapias como la Interleukina e el Interferón, aunque los resultados son discretos. Nuevas terapias médicas han conseguido mejores resultados. Dentro del grupo de los inhibidores de las multiquinasas, el Sunitinib bloquea los receptores del VEGF, PDGFR, C-Kit, FLT-3 tirosina quinasa que juegan un papel en la carcinogénesis del CCR; y el Sarafenib bloquea VEGFR-2 y PDGFR por inhibición de RAF-1. Por su parte de anticuerpos anti-VEGF, como el Bavicizumab neutralizan la actividad de VEGF-A. Los inhibidores de mTOR, como el Tensirolimus, y el Everolimus, inhiben a la rapamicina-quinasa, responsable de la proliferación y la hipoxia celular. Se presenta un caso de CCR avanzado con buena respuesta al tratamiento médico (AU)

Surgical treatment of renal cell cancer (RCC) is reinforced by the application of drugs with cytoreductive capacity. The CRC inmunomodulation makes it amenable to therapies such as interleukin and interferon, although the results are discrete. New medical therapies have better results. Within the group of the multi-kinase inhibitors, Sunitinib blocks the receptors of VEGF, PDGFR, C-kit and FLT-3 tyrosine kinase that plays a role in carcinogenesis soft RCC, while Sorafenib blocks VEGFR-2 and PDGFR through inhibition RAF—1. Anti-VEGF antibodies such as Bevacizumab neutralize the activity of VEGF-A. MTOR inhibitors, such as Tensirolimus and Everolimus, inhibits rapamycin-kinase responsible for proliferation and cellular hypoxy. A case of advanced RCC with good response to treatment is presented (AU)

Revisión crítica del uso de radiación como tratamiento inicial del cáncer de próstata localizado / Critical review of use of radiation as initial treatment for localized prostate cancer

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Crioterapia como tratamiento del cancer renal / Cryotherapy as a treatment for kidney cáncer

El diagnóstico precoz de pequeñas masas renales ha aumentado gracias a la masiva utilización de técnicas de imagen como ecografía, TAC y RMN. Frente a estas lesiones, muchas de ellas incidentales, se plantean diversas posibilidades de tratamiento, teniendo cada vez más tendencia a la realización de técnicas conservadoras como la nefrectomía parcial laparoscópica y técnicas ablativas con crioterapia o radiofrecuencia. Presentamos un caso de mas renal de pequeño tamaño tratada con crioterapia, revisando algunos aspectos técnicos de su realización (AU)

Early diagnosis of small renal masses has increased thanks to the massive use of imaging techniques like ultrasound, CT and MRI. To treat these masses, many of which are incidental, there are various treatment options, taking increasing trend towards conducting conservative techniques such as laparoscopic partial nephrectomy and ablative techniques with cryotherapy or radiofrequency. We report a case of a small renal mass treated with cryotherapy, reviewing some technical aspects of your implementation (AU)

[Robotic radical prostatectomy: overview of our learning curve]. / Prostatectomía radical robótica: revisión de nuestra curva de aprendizaje.

OBJECTIVE: We present the first cases of our robotic radical prostatectomy with Da Vinci (RRPdaV) that corresponds to the learning curve (LC) of the surgeon that has initiated with this technique. METHODS: We reviewed the first 20 patients that underwent RRPdaV, performed by an expert surgeon, without previous laparoscopic training, but with a wide experience in retropubic and perineal prostatectomy (HV). We analyzed: Surgical time, blood loss, conversion rate, intra and postoperative complications, hospital stay and days of bladder catheterization. Also: rates and location of surgical margins, as well as functional outcomes with an average follow up of 10 months. RESULTS: Mean operating time was 140 minutes (100-211) and blood loss 180 mL (80-360), and none required a blood transfusion. There were no intraoperative complications and neither any conversion to open surgery. The only postoperative outstanding fact was mean hospital stay were 3,35 days. (3-5). We had 6 cases of positive surgical margins (30%). The most frequent location was postero-lateral. Eighteen out of 20 patients (90%) were early totally continent, 2 (10%) required the use of one pad during the first six months due slight stress incontinence that stopped spontaneously. From 20 cases, two of them (10%) had preoperative erectile dysfunction; 12 out of the remaining 18 (66.6%) preserved potency at review and 6 (33.4%) had postoperative erectile dysfunction. CONCLUSIONS: It has been demonstrated that robotic surgery for radical prostatectomy is clearly an advantage technique (easy maneuver although it is a minimally invasive technique, comfortable and ergonomic position for the surgeon, 3D visualization and short learning curve). The RRPDAv learning curve is significantly shorter if the surgeon has a wide previous surgical experience in open and/or laparoscopic surgery.

Prostatectomía radical robótica: revisión de nuestra curva de aprendizaje / Robotic radical prostatectomy: overview of our learning curve

Objetivo: Presentamos los primeros casos de nuestra serie de prostatectomía radical robótica con Da Vinci (PRRdaV), que corresponden a la curva de aprendizaje (CA) del cirujano que se ha iniciado en la técnica. Métodos: Se revisan los 20 primeros pacientes sometidos a PRRdaV y realizados por un cirujano experto, sin entrenamiento laparoscópico previo, pero con amplia experiencia en prostatectomía radical retropúbica y perineal (HV). Se analiza: tiempo operatorio, pérdidas hemáticas, tasa de conversión, complicaciones intra y postoperatorias, estancia hospitalaria y días de sonda vesical. También: las tasas y la localización de los márgenes positivos, así como los resultados funcionales con un seguimiento medio de 10 meses. Resultados: La media de tiempo operatorio fue de 140 minutos (100-211) y la pérdida hemática media de 180 mL (80- 360), no requiriendo transfusión sanguínea en ningún caso. No se presentaron complicaciones intraoperatorias, y tampoco ninguna reconversión. Como acontecimientos postoperatorios sólo destaca una retención aguda urinaria tras retirada de sonda vesical. La estancia hospitalaria media fue 3,35 días (3-5). Se obtuvieron 6 casos con márgenes quirúrgicos positivos (30%). La localización más frecuente fue postero-lateral. Dieciocho de los 20 pacientes (90%) son completamente continentes de forma precoz, 2 (10%) requirieron utilizar una compresa de seguridad durante los 6 primeros meses por incontinencia leve de esfuerzo que se resolvió espontáneamente. De los 20 casos, 2 de ellos (10%) presentaban disfunción eréctil preoperatoria; de los 18 restantes, 12 (66.6%) conservaban potencia en el momento de la revisión y 6 (33.4%) presentaron disfunción eréctil postoperatoria. Conclusiones: La prostatectomía radical mediante cirugía robótica se ha demostrado claramente ventajosa (excelente maniobrabilidad para una técnica mínimamente invasiva, postura más cómoda y anatómica, visión tridimensional y corta curva de aprendizaje). Una amplia experiencia quirúrgica previa en cirugía abierta y/o laparoscópica, acortan de forma significativa esta curva de aprendizaje de la PRRdav

Objective: We present the first cases of our robotic radical prostatectomy with Da Vinci (RRPdaV) that corresponds to the learning curve (LC) of the surgeon that has initiated with this technique. Methods: We reviewed the first 20 patients that underwent RRPdaV, performed by an expert surgeon, without previous laparoscopic training, but with a wide experience in retropubic and perineal prostatectomy (HV). We analyzed: Surgical time, blood loss, conversion rate, intra and postoperative complications, hospital stay and days of bladder catheterization. Also: rates and location of surgical margins, as well as functional outcomes with an average follow up of 10 months. Results: Mean operating time was 140 minutes (100-211) and blood loss 180 mL (80-360), and none required a blood transfusion. There were no intraoperative complications and neither any conversion to open surgery. The only postoperative outstanding fact was mean hospital stay were 3,35 days. (3-5). We had 6 cases of positive surgical margins (30%). The most frequent location was postero-lateral. Eighteen out of 20 patients (90%) were early totally continent, 2 (10%) required the use of one pad during the first six months due slight stress incontinence that stopped spontaneously. From 20 cases, two of them (10%) had preoperative erectile dysfunction; 12 out of the remaining 18 (66.6%) preserved potency at review and 6 (33.4%) had postoperative erectile dysfunction. Conclusions: It has been demonstrated that robotic surgery for radical prostatectomy is clearly an advantage technique (easy maneuver although it is a minimally invasive technique, comfortable and ergonomic position for the surgeon, 3D visualization and short learning curve). The RRPDAv learning curve is significantly shorter if the surgeon has a wide previous surgical experience in open and/or laparoscopic surgery