[Learning laparoscopic radical prostatectomy with the Leipzig program. Analysis of the training module program]. / El aprendizaje de la prostatectomía radical laparoscópica según el modelo de Leipzig. Análisis de un programa tutelado progresivo.

INTRODUCTION AND OBJECTIVE: In most cases the learning curve of laparoscopic radical prostatectomy is not completed during the residency. This is why International Fellowship programs are becoming more popular. The aim of this paper is to evaluate the efficiency of the fellowship program of the German group. MATERIAL AND METHODS: We describe the evolution of our last fellow in the modular training program developed by the Leipzig group. We also evaluate the efficiency of this program by analyzing the results of 30 procedures performed by the fellow as first surgeon. In addition we have reviewed the literature and compared those outcomes with previous series of the clinic and other training programs. RESULTS: The training programme was completed in four months. After this time, the fellow performed 30 procedures without any assistance from a tutor. 46.67% of these procedures were nerve sparing. The time average was 2 hours and 27 minutes. The programme includes lymphadenectomy in 20 patients. Two patients had positive margins, all anastomosis were tight except for one. Urethral catheter was removed on the fifth day and there were no other intraopertive or early postoperative complications. Results may be compared to previous results of other residents of the department and also of other groups where a long-term tutor program was performed. CONCLUSION: The learning process of laparoscopic radical prostatectomy should follow a long-term tutorized model. Until the definitive expansion/development of this technique, the Leipzig Fellowship program is a complete and effective formation schedule.

[Cancer of the penis. Our experience in 15 years]. / Cáncer de pene. Nuestra experiencia en 15 años.

OBJECTIVE: To review and analysis the diagnosis, treatment, evolution, and risk factors of the penis cancer. MATERIAL AND METHODS: We carried out a retrospective study between 1992 and 2007. We included 47 patients with penis cancer diagnose of treated in our service. We analyzed risk factors, symptoms, diagnosis and treatment. The staging was done according to the TNM classification, taking into account the physical exam, radiology and the surgical findings. The average time of follow-up was 50 months {range 12 to 120 months). For univariate statistical analysis the Chi-square test was used, and for the survival the method of Kaplan Meir. RESULTS: Mean age was 60 years (28-91 years), being 95% older than 50. At the diagnosis 16 patients (34%) had lymphatic nodes, being the most frequent location was unilateral inguinal nodes (62%). Of the 27 cases (57%) who underwent blood calcium check at the time of diagnosis, we found hypercalcaemia in 8 patients (30%). The surgical treatment was the gold standard treatment. The technique more frequently employed was the partial penectomy 25 (53%). 4 patients received radiotherapy as initial treatment. Lymphadenectomy was performed in 14 patients, mostly bilateral inguinal lymphadenectomy (8 patients). The pathology finding at 100% of the cases was squamous cell carcinoma (80% well differentiated). Regarding to the TNM, most of the patients had a clinical stage located: T1N0M0 23%, T2N0M0 27%. The most significant adverse prognostic factors were the presence of lymph nodes, clinical stage at the diagnosis and the degree of cell differentiation (p = 0001). At the last review 36 (76%) cases were free of disease. There were 11 (24%) cases that presented recurrence and were treated: 3 patients with radiotherapy, surgery was used in 7 patients and 1 patient with chemotherapy. Eleven patients died during follow up, 9 of these from disease progression. CONCLUSIONS: The carcinoma of the penis remains a rare malignancy in our centre. Hypercalcemia is a common finding when patients have lymph nodes. The most significant adverse prognostic factors were the presence of lymph nodes, clinical stage at the diagnosis and the degree of cell differentiation. The most effective treatment for cancer of the penis is surgery reserving chemotherapy and radiation therapy for the recurrence.

[Comparative study between analgesic efficacy and safety of meperidine compared with lidocaine periprostatic infiltration in transrectal ultrasound guided prostate biopsy]. / Estudio comparativo entre la eficacia analgésica y seguridad de la meperidina intravenosa frente a la infiltración periprostática con lidocaína en biopsias transrectales de próstata.

OBJECTIVES: To assess the efficacy of intravenous analgesia with meperidine compared to periprostatic plexus infiltration with lidocaine, and safety of periprostatic local anesthesia. MATERIALS AND METHODS: A prospective randomized study with 100 patients undergoing first or second prostate biopsy. We distribute patients in two groups, group A (50 patients) which was administered 50 mg of intravenous meperidine and group B (50 patients) receiving 5 mL of lidocaine 2% in the angle between prostate and seminal vesicles. Pain was assessed by Visual Analog Scale (VAS) and a questionnaire about the emotional impact. Procedure safety was obtained by telephone questionnaire about prostate biopsy complications. The statistical analysis used was chi square test, Student's t test and Kruskal-Wallis no parametric test. RESULTS: Median age was 66 years (47-80) and both groups were homogeneous with regard to: PSA, prostate volume, core's number and educational level without significant differences. 74 patients (74%) had their first biopsy and 26 (26%) had their second one. The average number of core biopsy was 10,9 +/- 2, and VAS mean score for group A was 3,6 +/- 1,8 versus 3,2 +/- 2 Group B without significant differences (p>0,05). We found significant differences (p<0,05) between transducer introduction (3,9 +/- 1,9 group A/B group 4,3 +/- 2,2) and core biopsy (3,6 +/- 1,8 group A/B group 3,2 +/- 2,2). There were no differences between the data obtained with emotional impact test, age and educational level comparing to pain caused by prostate biopsy. Regard to the number of cores obtained there were no differences (p>0,05). Complications appeared in 12 patients (12%), 5 in the group of meperidine compared with 7 in the lidocaine without differences between them. CONCLUSION: Periprostatic plexus blocked with lidocaine does not offer advantages respect to meperidine, despite the fact that this is a safe method that does not increase the number of complications. Placing transrectal transducer causes more pain than biopsy cores.

El aprendizaje de la Prostatectomía Radical Laparoscópica según el modelo de Leipzig. Análisis de un programa tutelado progresivo / Learning laparoscopic radical prostatectomy with the Leipzig program. Analysis of the training module program

Introducción y objetivo: En la mayoría de los casos el aprendizaje de la prostatectomía radical laparoscópica no se completa durante la residencia. Ante esta problemática internacional surgen las becas o “fellow ships” de los centros de excelencia europeos y norteamericanos. El objetivo del presente trabajo es evaluar la eficiencia de la beca de formación propuesta por el grupo alemán. Material y método: Describimos la evolución de un becario durante el entrenamiento progresivo, tutorizado por módulos descrito por el grupo de Leipzig, evaluamos la eficiencia del modelo describiendo los resultados de las primeras 30 prostatectomías radicales del becario como cirujano autónomo, comparamos los resultados con la serie histórica del centro, con la curva de aprendizaje de residentes del mismo centro y de otros centros. Resultados: El becario cumplimentó el entrenamiento por módulos en 7 meses posteriormente se le asignaron 30 prostatectomías radicales sin la obligatoriedad de ser ayudado por un cirujano experto. En el 46,67% de los pacientes se aplicó una técnica intrafascial. El tiempo quirúrgico medio fue de 2h y 27 minutos, incluida la linfadenectomía (realizada en 20/30 pacientes). Dos pacientes presentaron márgenes positivos, todas las anastomosis, menos un paciente, fueron estancas. La sonda se retiró al quinto día (mediana). No se detectaron complicaciones intraoperatorias ni en el posoperatorio tardío. Los resultados de éstas, se superponen a la de los residentes del mismo centro y a la de otros urólogos que siguen un entrenamiento tutelado de larga duración. Conclusiones: El aprendizaje de la prostatectomía radical laparoscópica debe seguir un modelo tutorizado progresivo de larga duración. Hasta la expansión definitiva de la técnica, el programa de formación tipo “fellow” que imparte el grupo de Leipzig es un modelo de formación completo y efectivo (AU)

Introduction and objective: In most cases the learning curve of laparoscopic radical prostatectomy is not completed during the residency. This is why International Fellowship programs are becoming more popular. The aim of this paper is to evaluate the efficiency of the fellowship program of the German group. Material and methods: We describe the evolution of our last fellow in the modular training program developed by the Leipzig group. We also evaluate the efficiency of this program by analyzing the results of 30 procedures performed by the fellow as first surgeon. In addition we have reviewed the literature and compared those outcomes with previous series of the clinic and other training programs. Results: The training programme was completed in four months. After this time, the fellow performed 30 procedures without any assistance from a tutor. 46,67% of these procedures were nerve sparing. The time average was 2 hours and 27minutes. The programme includes lymphadenectomy in 20 patients. Two patients had positive margins, all anastomosis were tight except for one. Urethral catheter was removed on the fifth day and there were no other intraoperative or early postoperative complications. Results may be compared to previous results of other residents of the department and also of other groups where a long term tutor program was performed. Conclusion: The learning process of laparoscopic radical prostatectomy should follow a long term tutorized model. Until the definitive expansion/development of this technique, the Leipzig Fellowship program is a complete and effective formation schedule (AU)

Cáncer de pene. Nuestra experiencia en 15 años / Cancer of the penis. Our experience in 15 years

Objetivos: Revisión y análisis de los factores de riesgo, diagnóstico, tratamiento y evolución del cáncer de pene. Material y Métodos: Realizamos un estudio descriptivo retrospectivo desde 1992 hasta el 2007, en el que se incluyeron 47 pacientes con diagnóstico de cáncer de pene tratados en nuestro servicio. Se analiza factores de riesgo, síntomas, diagnóstico, tratamiento, y evolución de los pacientes. El estadiaje clínico y anatomopatológico se hizo acorde a la clasificación TNM, teniendo en cuenta el examen físico, pruebas de diagnóstico por imagen y hallazgos de la pieza quirúrgica. El tiempo medio de seguimiento es de 50 meses (rango 12 a 120 meses).Para el análisis estadístico univariante se utilizo la prueba de Chi-cuadrado, y para el análisis de la supervivencia el método de Kaplan Meir. Resultados: La edad media de los pacientes fue de 60 años (28-91 años), siendo el 95% de ellos mayores de 50.Presentaron adenopatías al diagnóstico 16 pacientes (34%) siendo las más frecuente (62%) las adenopatías unilaterales inguinales. Ningún caso presentó metástasis a distancia. De los 27 casos (57%) a los que se les realizó calcio en sangre al momento del diagnostico, encontramos hipercalcemia en 8 (30%). El tratamiento fue quirúrgico en la mayoría (95%), siendo la técnica más empleada la penectomía parcial en 25 (53%). En 4 sujetos se decidió la radioterapia como tratamiento inicial. A 14 se les realizó una linfaadenectomía, siendo la técnica más frecuente la inguinal bilateral profunda (8 pacientes). Respecto al estadio TNM, la mayoría de pacientes presentaron un estadio clínico localizado: T1N0M0 23 %, T2N0M027%. El diagnóstico anatomopatológico en el 100% de los casos fue carcinoma epidermoide (80% fue bien diferenciado) En la última revisión 31 casos (76%) estaban libres de enfermedad. Hubo 11 (24%) casos que presentaron recidiva y fueron tratados: 3 con radioterapia, 7 cirugía de rescate y 1 de ellos con quimioterapia. Los factores pronósticos adversos más importantes son la presencia de adenopatías, el estadio clínico al diagnóstico y el grado de diferenciación celular (p=0,001) Once pacientes fallecieron a lo largo del seguimiento, 9 de los cuales por progresión de la enfermedad. Conclusiones: El carcinoma de pene sigue siendo una enfermedad maligna poco frecuente en nuestro medio. Los factores pronósticos adversos más importantes son la presencia de adenopatías, el estadio clínico al diagnóstico y el grado de diferenciación celular. El tratamiento más eficaz del cáncer de pene es quirúrgico, reservando la quimioterapia y radioterapia para adyuvancia o terapia de rescate. La hipercalcemia es un hallazgo frecuente cuando los pacientes presentan adenopatías (AU)

Objective: To review and analysis the diagnosis, treatment, evolution, and risk factors of the penis cancer. Material and Methods: We carried out a retrospective study between 1992 and 2007. We included 47 patients with penis cancer diagnose of treated in our service. We analyzed risk factors, symptoms, diagnosis and treatment. The staging was done according to the TNM classification, taking into account the physical exam, radiology and the surgical findings. The average time of follow-up was 50 months (range 12 to 120 months). For univariate statistical analysis the Chi-square test was used, and for the survival the method of Kaplan Meir. Results: Mean age was 60 years (28-91 years), being 95% older than 50.At the diagnosis 16 patients (34%) had lymphatic nodes, being the most frequent location was unilateral inguinal nodes (62%).Of the 27 cases (57%) who underwent blood calcium check at the time of diagnosis, we found hypercalcaemia in 8 patients (30%).The surgical treatment was the gold standard treatment. The technique more frequently employed was the partial penectomy 25 (53%). 4patients received radiotherapy as inicial treatment. Lymphadenectomy was performed in 14 patients, mostly bilateral inguinal lymphadenectomy (8 patients).The pathology finding at 100% of the cases was squamous cell carcinoma (80% well differentiated). Regarding to the TNM, most of the patients had a clinical stage located: T1N0M0 23%, T2N0M0 27%.The most significant adverse prognostic factors were the presence of lymph nodes, clinical stage at the diagnosis and the degree of cell differentiation(p = 0001).At the last review 36 (76%) cases were free of disease. There were 11 (24%) cases that presented recurrence and were treated: 3 patients with radiotherapy, surgery was used in 7 patients and 1 patient with chemotherapy. Eleven patients died during follor up, 9 of thes from disease progression. Conclusions: The carcinoma of the penis remains a rare malignancy in our centre. Hypercalcemia is a common finding when patients have lymph nodes. The most significant adverse prognostic factors were the presence of lymph nodes, clinical stage at the diagnosis and the degree of cell differentiation. The most effective treatment for cancer of the penis is surgery reserving chemotherapy and radiation therapy for the recurrence (AU)

Estudio comparativo entre la eficacia analgésica y seguridad de la meperidina intravenosa frente a la infiltración periprostática con lidocaína en biopsias transrectales de próstata / Comparative study between analgesic efficacy and safety of meperidine compared with lidocaine periprostatic infiltration in transrectal ultrasound guided prostate biopsy

Objetivo: Evaluar la eficacia de la analgesia intravenosa con meperidina frente a la infiltración del plexo periprostático con lidocaína, y seguridad de la anestesia local periprostática. Material y métodos: Estudio prospectivo aleatorizado con 100 pacientes sometidos a primera o segunda biopsia de próstata. Distribuimos a los pacientes en dos grupos; grupo A (50 pacientes) al que se le administra 50 mg de meperidina intravenosa y grupo B (50 pacientes) que reciben 5 mL de lidocaína al 2% en el ángulo prostatoseminal. El dolor fue evaluado mediante la Escala Analógico Visual (VAS) y un cuestionario a cerca del impacto emocional de la prueba. La seguridad del procedimiento se obtuvo mediante cuestionario telefónico sobre las complicaciones aparecidas tras la biopsia. Para el análisis estadístico se uso el test de chi cuadrado, la t de Student y test no paramétrico de Kruskal-Wallis. Resultados: La mediana de edad fue 66 años (47-80) siendo ambos grupos homogéneos respecto a: PSA, volumen prostático, número de cilindros y nivel de estudios, sin diferencias significativas. Se trató de una primera biopsia en 74 pacientes (74%) y 26 (26%) de una segunda. El número medio de cilindros fue de 10,9±2. La puntuación media del VAS para el grupo A fue 3,6±1,8 frente a 3,2±2 del grupo B sin diferencias significativas (p>0,05). Si comparamos el dolor con la introducción del transductor (grupo A 3,9±1,9 / grupo B 4,3±2,2) frente a la toma de cilindro (grupo A 3,6±1,8/grupo B 3,2±22) sí encontramos diferencias significativas (p<0,05). No se observan diferencias ente los datos obtenidos con el test de impacto emocional, la edad y el nivel de estudios frente al dolor producido por la prueba. Respecto al número de cilindros obtenidos tampoco existen diferencias (p>0,05). Aparecieron complicaciones en 12 pacientes (12%); 5 en el grupo de meperidina frente a 7 en el de lidocaína sin observar diferencias entre ambos. Conclusión: El bloqueo del plexo periprostático con lidocaína no ofrece ventajas analgésicas respecto a la meperidina, a pesar de que se trata de un método seguro que no aumenta el número de complicaciones. El paso del transductor transrrectal produce más dolor que la propia toma de los cilindros (AU)

Objectives: To assess the efficacy of intravenous analgesia with meperidine compared to periprostatic plexus infiltration with lidocaine, and safety of periprostatic local anesthesia. Materials and methods: A prospective randomized study with 100 patients undergoing first or second prostate biopsy. We distribute patients in two groups, group A (50 patients) which was administered 50 mg of intravenous meperidine and group B (50 patients) receiving 5 mL of lidocaine 2% in the angle between prostate and seminal vesicles. Pain was assessed by Visual Analog Scale (VAS) and a questionnaire about the emotional impact. Procedure safety was obtained by telephone questionnaire about prostate biopsy complications. The statistical analysis used was chi square test, Student’s t test and Kruskal-Wallis no parametric test. Results: Median age was 66 years (47-80) and both groups were homogeneous with regard to: PSA, prostate volume, core’s number and educational level without significant differences. 74 patients (74%) had their first biopsy and 26 (26%) had their second one. The average number of core biopsy was 10,9±2, and VAS mean score for group A was 3,6±1,8 versus 3,2±2 Group B without significant differences (p>0,05). We found significant differences (p<0,05) between transducer introduction (3,9±1,9 group A/B group 4,3±2,2) and core biopsy (3,6±1,8 group A/B group 3,2±2,2). There were no differences between the data obtained with emotional impact test, age and educational level comparing to pain caused by prostate biopsy. Regard to the number of cores obtained there were no differences (p>0,05). Complications appeared in 12 patients (12%), 5 in the group of meperidine compared with 7 in the lidocaine without differences between them. Conclusion: Periprostatic plexus blocked with lidocaine does not offer advantages respect to meperidine, despite the fact that this is a safe method that does not increase the number of complications. Placing transrectal transducer causes more pain than biopsy cores (AU)

Wilms' tumor in adults

WilmsÆ tumor is an uncommon neoplasm in adults. We report the clinical manifestations, complementary explorations, treatment, and results from 3 males aged 16, 21, and 22 years. Computed tomography commonly suggests the diagnosis. Despite its aggressive treatment, such as radical surgery, chemo- and radiotherapy, the prognosis is worse than in children

Wilms' tumor in adults.

Wilms' tumor is an uncommon neoplasm in adults. We report the clinical manifestations, complementary explorations, treatment, and results from 3 males aged 16, 21, and 22 years. Computed tomography commonly suggests the diagnosis. Despite its aggressive treatment, such as radical surgery, chemo- and radiotherapy, the prognosis is worse than in children.

The proportion of prostate-specific antigen (PSA) complexed to alpha(1)-antichymotrypsin improves the discrimination between prostate cancer and benign prostatic hyperplasia in men with a total PSA of 10 to 30 microg/L.

BACKGROUND: The aim of this study was to assess the diagnostic accuracy of the proportion of prostate-specific antigen (PSA) complexed to alpha(1)-antichymotrypsin (PSA-alpha(1)ACT:PSA ratio) in the differential diagnosis of prostate cancer (CaP) and benign prostatic hyperplasia (BPH) in men with total PSA of 10-30 microg/L. METHODS: We used our immunoassays (ELISAs) for total PSA and PSA-alpha(1)ACT complex to study 146 men. In 123, total PSA was between 10 and 20 microg/L; 66 of these had CaP and 57 BPH. In 23 men, total PSA was between 20 and 30 microg/L; 14 of these had CaP and 9 BPH. We calculated the area under the ROC curves (AUC) for total PSA, PSA-alpha(1)ACT complex, and PSA-alpha(1)ACT:PSA ratio, and determined the cutoff points that gave sensitivities approaching 100%. RESULTS: In the total PSA range between 10 and 20 microg/L, the AUC was significantly higher for the PSA-alpha(1)ACT:PSA ratio (0.850) than for total PSA (0.507) and PSA-alpha(1)ACT complex (0.710; P <0.0001). A cutoff ratio of 0.62 would have permitted diagnosis of all 66 patients with CaP (100% sensitivity) and avoided 19% of unnecessary biopsies (11 of 57 patients). In the total PSA range between 20 and 30 microg/L, the AUC for the PSA-alpha(1)ACT:PSA ratio (0.980; 95% confidence interval, 0.82-0.99) was greater than the AUC for total PSA (0.750; 95% confidence interval, 0.51-0.89; P = 0.042). In this range, a cutoff point of 0.64 would have permitted the correct diagnosis of all 14 patients with CaP and 6 of the 9 with BPH. CONCLUSIONS: The diagnostic accuracy of the PSA-alpha(1)ACT:PSA ratio persists at high total PSA concentrations, increasing the specificity of total PSA. Prospective studies with large numbers of patients are needed to assess whether the ratio of PSA-alpha(1)ACT to total PSA is a useful tool to avoid unnecessary prostatic biopsy in patients with a total PSA >10 microg/L.