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.

Transición de vigilancia activa a observación en pacientes mayores de 75 años con cáncer de próstata en una serie de largo seguimiento / Transition from active surveillance to observation in prostate cancer patients older than 75 years. A long follow-up series

Introducción: La población mundial va envejeciendo y la esperanza de vida va siendo cada vez mayor; esta situación va a conllevar un gran impacto en el manejo de los pacientes con cáncer de próstata, sobre todo en aquellos de bajo riesgo susceptibles de un manejo conservador mediante la vigilancia activa (VA). En estos pacientes es necesario responder a las preguntas de hasta cuándo se ha de continuar con el esquema de VA, con qué pruebas y si es posible realizar una transición a observación con seguridad oncológica. El objetivo de este trabajo es analizar aquellos pacientes con cáncer de próstata que han estado en VA con 75 años o más y valorar la seguridad de la observación en una serie de VA con un largo seguimiento. Material y métodos: Se analizó nuestra cohorte prospectiva de pacientes en VA entre los años 1999 y 2018, seleccionando aquellos que hubieran estado bajo seguimiento con 75 años o más. Se ofreció tratamiento con intención curativa cuando existían criterios de progresión y paso a observación a criterio del urólogo. Se incluyeron algunos pacientes de riesgo intermedio en el análisis. Los cambios de comorbilidad se analizaron teniendo en cuenta el Charlson a la entrada y salida de VA. Se estudió la progresión y la mortalidad en los pacientes según el manejo por el que se hubiera optado. Resultados: De un total de 347 pacientes en VA, 90 cumplían los criterios mencionados anteriormente, de los cuales 15 (16,7%) eran de riesgo intermedio. La mediana de seguimiento era de 6,4 años y 73 (81,1%) tenían baja comorbilidad (Charlson < 2). Hubo 40 (44,4%) pacientes que salieron de VA, de los cuales 17 (18,9%) pasaron a observación; del resto, 21 (23,3%) recibieron tratamiento curativo. Se observó una diferencia significativa en el cambio de comorbilidad, medida por el índice de Charlson, a la entrada y salida de VA (p < 0,05) entre los pacientes sometidos a tratamiento activo y los sometidos a observación. No se observó ningún caso de muerte dependiente del cáncer ni progresión en el grupo de observación. Conclusión: La transición desde un programa de VA a observación del cáncer de próstata en pacientes añosos, así como la decisión de llevar a cabo un tratamiento con intención curativa, resulta controvertida. En nuestra serie esta transición en pacientes mayores de 75 años no aumenta el riesgo oncológico

Introduction. The world population is ageing, and life expectancy is increasing. This situation will have a great impact on the management of patients with prostate cancer, especially in those of low risk, susceptible to a conservative management under active surveillance (AS). Regarding these patients’ profile, it is necessary to answer the following questions: ¿for how long to continue with the AS scheme?, ¿which tests will be required?, ¿is it possible to carry out a transition to observation with oncological safety? The objective of this work is to analyse those patients with prostatic cancer who have been in AS with 75 years of age or more and assess the safety of the observation in an AS series with a long follow-up. Material and methods: We analysed our prospective cohort of AS patients between the years 1999 and 2018,including those who had been in follow-up with 75 years or more. They were offered treatment with curative intent when there were progression criteria and transition to observation under the urologist's decision. Some intermediate risk patients were included in the analysis. Comorbidity changes were analysed with the Charlson comorbidity index at entry and exit of AS. The progression and mortality of the patients were studied according to the management they received. Results: From 347 AS patients, 90 patients fulfilled the afore mentioned criteria and 15 (16.7%) were intermediate risk. The median follow-up was 6.4 years and 73 (81.1%) had low comorbidity (Charlson < 2).There were 40 (44.4%) patients who left AS, 17 (18.9%) of them went to observationand the rest, 21 (23.3%), received curative treatment. There was a significant difference in comorbidity, measured by the Charlson index, at entry and exit of AS (P < .05) among patients receiving active treatment and the ones submitted to observation.No case of cancer-specific death or progression was observed in the observation group. Conclusion: The transition from an active surveillance management to observation of prostate cancer elderly patients, as well as the decision to carry out a treatment with curative intent, seems controversial. In our series, this transition in patients older than 75 years does not increase the oncological risk

Transition from active surveillance to observation in prostate cancer patients older than 75 years. A long follow-up series. / Transición de vigilancia activa a observación en pacientes mayores de 75 años con cáncer de próstata en una serie de largo seguimiento.

INTRODUCTION: The world population is ageing, and life expectancy is increasing. This situation will have a great impact on the management of patients with prostate cancer, especially in those of low risk, susceptible to a conservative management under active surveillance (AS). Regarding these patients' profile, it is necessary to answer the following questions: ¿for how long to continue with the AS scheme?, ¿which tests will be required?, ¿is it possible to carry out a transition to observation with oncological safety? The objective of this work is to analyse those patients with prostatic cancer who have been in AS with 75 years of age or more and assess the safety of the observation in an AS series with a long follow-up. MATERIAL AND METHODS: We analysed our prospective cohort of AS patients between the years 1999 and 2018,including those who had been in follow-up with 75 years or more. They were offered treatment with curative intent when there were progression criteria and transition to observation under the urologist's decision. Some intermediate risk patients were included in the analysis. Comorbidity changes were analysed with the Charlson comorbidity index at entry and exit of AS. The progression and mortality of the patients were studied according to the management they received. RESULTS: From 347 AS patients, 90 patients fulfilled the afore mentioned criteria and 15 (16.7%) were intermediate risk. The median follow-up was 6.4 years and 73 (81.1%) had low comorbidity (Charlson<2).There were 40 (44.4%) patients who left AS, 17 (18.9%) of them went to observationand the rest, 21 (23.3%), received curative treatment. There was a significant difference in comorbidity, measured by the Charlson index, at entry and exit of AS (P<.05) among patients receiving active treatment and the ones submitted to observation.No case of cancer-specific death or progression was observed in the observation group. CONCLUSION: The transition from an active surveillance management to observation of prostate cancer elderly patients, as well as the decision to carry out a treatment with curative intent, seems controversial. In our series, this transition in patients older than 75 years does not increase the oncological risk.

Diagnosis challenge of atypical spindle cells neoplasm of the spermatic cord. / Reto diagnóstico de neoplasia de células fusiformes atípicas del cordón espermático.

OBJECTIVE: To report an unusual case of softtissue neoplasm and to review the literature on this type of tumour. METHODS: We report an accidentally found tumour closely related to the spermatic cord that was diagnosed in a 70 year-old man when he was being operated on for an inguinal hernia repair. RESULTS: After thorough analysis by experienced pathologists it was not possible to determine the nature of the tumour that was removed at surgery. CONCLUSIONS: Soft tissues neoplasms of the spermatic cord may occur in an unusual way and they may be a real challenge to diagnose.