Assessing the Clinical Benefit of UBC Rapid in the Surveillance and Initial Diagnosis of Bladder Cancer.

INTRODUCTION: Several studies have shown that abnormal urine levels of cytokeratins 8 and 18 are associated with bladder cancer. However, the clinical benefit of the UBC (urinary bladder cancer) Rapid assay has remained unclear. PATIENTS AND METHODS: We performed the UBC Rapid assay and voided cytology in 336 patients-297 in surveillance for non-muscle-invasive bladder cancer and 39 with newly diagnosed bladder cancer. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated by contingency. We also controlled for the patients with positive UBC Rapid findings but negative cystoscopy findings to prove the former's ability to provide an anticipatory diagnosis. RESULTS: We diagnosed 27 recurrences (9.8%). Overall, the sensitivity of the UBC Rapid assay was better for the higher risk groups and after adding the cytology findings. The only independent predictor of a positive UBC Rapid assay was the tumor size. Of the 81 patients with positive UBC Rapid findings without positive cystoscopy findings, 8 (10%) had developed a recurrence within the first year. Avoiding cystoscopy for the patients with UBC Rapid negative results could avoid 184 cystoscopies (66%) but would result in missing 7 of 13 high-risk recurrences. CONCLUSIONS: The performance of the UBC Rapid assay improved with increasing tumor size. Limiting cystoscopies to patients with UBC Rapid positive results could result in a reduction in surveillance cystoscopies but could result in missing high-risk recurrences. Finally, the UBC Rapid assay was not useful for anticipatory diagnoses.

[Optimization of follow up in prostate cancer active surveillance]. / Optimizacion del seguimiento de cancer de prostata en vigilancia activa.

OBJECTIVES: Prostate cancer is a highly prevalent disease but with reduced cause-specific mortality. Active surveillance represents an alternative to postpone or avoid the potential sequelae derived from curative treatments in selected patients. The objective of this article is to review the diagnostic and follow-up methods for patients included in active surveillance programs. METHODS: We performed an exhaustive bibliographic review with the terms "Prostate cancer", "Active surveillance", "expectant management", including the greatest series published since 2007. CONCLUSIONS: Awaiting for genetic markers that help us to predict diagnosis and evolution of prostate cancer, PSA kinetics, digital rectal examination and repeated biopsies continue being the inclusion and follow up criteria for patients in active surveillance programs. Emerging complementary tests such as multi parametric MRI, PCA3 and Phi seem to add specificity to the existing clinical criteria. The reduced number of patients included, the limited follow up and the great disparity of inclusion and follow up criteria between different groups make the implementation of consensus guidelines that could help a more widespread application of this alternative difficult.

Optimización del seguimiento de cáncer de próstata en vigilancia activa / Optimization of follow up in prostate cancer active surveillance

OBJETIVO: El cáncer de próstata es una patología con una alta prevalencia pero con una reducida mortalidad causa-específica. La vigilancia activa, representa una alternativa para posponer o evitar las posibles secuelas derivadas de los tratamientos con intención curativa en pacientes seleccionados. Objetivo: Revisar los métodos de diagnóstico y seguimiento de los pacientes incluidos en programas de vigilancia activa. MÉTODO: Se ha realizado una revisión bibliográfica exhaustiva con los términos "prostate cáncer", "active surveillance", "expectant management", incluyendo las publicaciones con mayores series desde 2007. CONCLUSIONES: En espera de marcadores genéticos que nos ayuden a predecir el diagnóstico y la evolución del cáncer de próstata, los criterios para la inclusión y seguimiento de los pacientes en programas de vigilancia activa siguen siendo la cinética de PSA, el tacto rectal y las biopsias de repetición. La aparición de exploraciones complementarias como la resonancia magnética multiparamétrica, el PCA3 y el Phi parecen añadir especificidad a los criterios clínicos existentes. El reducido número de pacientes incluidos, el seguimiento limitado de los mismos y la gran disparidad de criterios de inclusión y seguimiento entre los diferentes grupos, dificultan la creación de unas guías de consenso que puedan facilitar una aplicación más amplia de esta alternativa

OBJECTIVES: Prostate cancer is a highly prevalent disease but with reduced cause-specific mortality. Active surveillance represents an alternative to postpone or avoid the potential sequelae derived from curative treatments in selected patients. The objective of this article is to review the diagnostic and follow-up methods for patients included in active surveillance programs. METHODS: We performed an exhaustive bibliographic review with the terms "Prostate cancer", "Active surveillance", "expectant management", including the greatest series published since 2007. CONCLUSIONS: Awaiting for genetic markers that help us to predict diagnosis and evolution of prostate cancer, PSA kinetics, digital rectal examination and repapeated biopsies continue being the inclusion and follow up criteria for patients in active surveillance programs. Emerging complementary tests such as multi parametric MRI, PCA3 and Phi seem to add specificity to the existing clinical criteria. The reduced number of patients included, the limited follow up and the great disparity of inclusion and follow up criteria between different groups make the implementation of consensus guidelines that could help a more widespread application of this alternative difficult

Skeletal complications of ADT: disease burden and treatment options.

Therapy based on androgenic deprivation is one of the standard treatments that many prostate cancer patients receive. Moreover, its use is increasing owing to a clear expansion of the indications for this therapy in patients with localized prostate cancer. Despite classically being considered to be well tolerated, androgenic deprivation has adverse effects. Of these, the loss of mineral bone mass is particularly notable and can lead to osteoporosis, as well as an increased risk of bone fracture. Some fractures, such as hip fractures, may have serious consequences. Useful procedures such as bone densitometry can aid in the diagnosis of these conditions. Once diagnosed, decreases in mineral bone mass can be managed by dietary recommendations, general changes in lifestyle or medication. We review the most important randomized controlled trials evaluating different drugs (bisphosphonates, denosumab and toremifene) in the prevention of bone loss and in the reduction in fracture risk in prostate cancer patients treated with androgen-deprivation therapy. Following the applicable recommendations, urologists must carefully monitor the bone health of prostate cancer patients subjected to androgenic deprivation to obtain an early diagnosis and apply the appropriate general and/or therapeutic measures if necessary.

Key areas in the learning curve for robotic urological surgery: a Spanish multicentre survey.

BACKGROUND: The number of robotic-assisted procedures offered in Spain is rapidly increasing despite a lack of consensus criteria for training and credentialling. OBJECTIVE: This national multicentre study was designed to analyze the different areas of the robotic urological surgery learning curve. MATERIAL AND METHODS: A questionnaire was sent to all 13 urology units in Spain with an active robotics programme requesting information on training and problems encountered. RESULTS: In most centres (n = 11, 84.6%), training programmes were animal-based; cadavers were used at only 2 (15.4%). Proctoring in initial procedures was practiced by 12 groups (92.3%). When initiating the robotics programme, the console was shared at 8 units (61.5%). Prior experience in open and/or laparoscopic surgery was reported by 10 of the groups (76.9%), and experience in open surgery only by 2 (15.4%) or robotic surgery alone by 1 (7.7%). The procedure with which the robotics programme was started in all 13 participating units was radical prostatectomy. The number of cases needed to complete the learning curve for this procedure was 20-25 cases according to 8 (61.5%) surgery teams. CONCLUSIONS: Up until March 26, 2010, 1,692 operations, mostly radical prostatectomies, were conducted using the da Vinci robot in our country.

[Open versus laparoscopic pyeloplasty: review of our series and description of our laparoscopic pyeloplasty procedure]. / Pieloplastia abierta frente a laparoscópica: revisión de nuestra serie y descripción de nuestra técnica de pieloplastia laparoscópica.

INTRODUCTION AND OBJECTIVES: Pyeloplasty has always been the treatment of choice for ureteropelvic junction obstruction at our center, where a laparoscopic approach has been used in the last 4 years to perform this procedure. Results of open pyeloplasty (OP) and laparoscopic pyeloplasty (LP) performed at our center in the past 8 years are compared, and our laparoscopic procedure is described. MATERIALS AND METHODS: Pyeloplasties performed at our center from June 2000 to June 2008 were retrospectively reviewed. Clinical presentation, involved kidney function, operating time, intraoperatory bleeding, presence of kidney stones or crossing vessels, length of hospital stay, possible complications, and results obtained were analyzed in each case. RESULTS: Thirty pyeloplasties were performed, 15 OP and 15 LP (50%). Mean operating time was 167.6 minutes for LP (100-240) and 106 minutes for OP (75-180) (P< .0001). Mean hospital stay was 6.6 days (4-16) for LP and 9.1 days for OP (5-26) (P.05). Intraoperative bleeding was negligible in all patients and no peroperative complications occurred. However, 9 patients (30%) experienced postoperative complications, 5 out of 15 LPs (33.3%) and 4 out of 15 OPs (26.7%) (P.05). Urinary fistula was the most common complication, occurring in 3 of the 30 patients (10%). Procedure was successful in all 15 patients undergoing OP (100%) and in 14 of the 15 patients undergoing LP (93.3%) (P.05). CONCLUSIONS: LP is currently the procedure of choice at our center because of its lower morbidity and similar results to OP, despite the need for a certain laparoscopic skill and a usually longer operating time.

Pieloplastia abierta frente a laparoscópica: revisión de nuestra serie y descripción de nuestra técnica de pieloplastia laparoscópica / Open versus laparoscopic pyeloplasty: review of our series and description of our laparoscopic pyeloplasty procedure

Introducción y objetivos: La pieloplastia ha sido desde siempre el tratamiento de elección en nuestro centro para la estenosis pieloureteral y, desde hace 4 años, hemos optado por el abordaje laparoscópico a la hora de llevar a cabo esta técnica. Queremos comparar el resultado de las pieloplastias abiertas (PA) y laparoscópicas (PL) llevadas a cabo en nuestro centro durante los últimos 8 años, así como describir nuestra técnica de PL. Material y métodos: Revisamos de forma retrospectiva las pieloplastias llevadas a cabo en nuestro centro entre junio de 2000 y junio de 2008, analizando en cada caso el motivo de consulta, la funcionalidad del riñón afectado, el tiempo quirúrgico, el sangrado intraoperatorio, la presencia de litiasis renal o de vaso polar, los días de estancia, las posibles complicaciones y el resultado obtenido. Resultados: Se han practicado un total de 30 pieloplastias, 15 PA y 15 PL (50%). El tiempo quirúrgico fue de media de 167,6 minutos para las PL (100-240) y de 106 min para las PA (75-180) (p < 0,0001). La estancia media en el caso de las PL fue de 6,6 días (4-16) frente a 9,1 días para las PA (5-26) (p > 0,05). El sangrado intraoperatorio fue desdeñable en todos los casos y no hubo complicaciones intraoperatorias, si bien 9 (30%) pacientes presentaron complicaciones postoperatorias: 5 de 15 PL (33,3%) y 4 de 15 PA (26,7%) (p > 0,05). La fístula urinaria fue la complicación más frecuente, presentándose en 3 de los 30 pacientes (10%).El éxito de la intervención se confirmó en los 15 pacientes intervenidos de PA (100%) y en14 de los 15 pacientes intervenidos de PL (93,3%) (p > 0,05).Conclusiones: Por su menor morbilidad y sus resultados equivalentes a la PA, la PL es hoy día la técnica de elección en nuestro centro a pesar de requerir de una cierta habilidad en el manejo de la laparoscopia y de un tiempo quirúrgico habitualmente más largo (AU)

Introduction and objectives: Pyeloplasty has always been the treatment of choice for ureteropelvic junction obstruction at our center, where a laparoscopic approach has been used in the last 4 years to perform this procedure. Results of open pyeloplasty (OP) and laparoscopic pyeloplasty (LP) performed at our center in the past 8 years are compared, and our laparoscopic procedure is described. Materials and methods: Pyeloplasties performed at our center from June 2000 to June 2008were retrospectively reviewed. Clinical presentation, involved kidney function, operating time, intraoperatory bleeding, presence of kidney stones or crossing vessels, length of hospital stay, possible complications, and results obtained were analyzed in each case. Results: Thirty pyeloplasties were performed, 15 OP and 15 LP (50%). Mean operating time was 167.6 minutes for LP (100-240) and 106 minutes for OP (75-180) (P<0.0001). Mean hospitalstay was 6.6 days (4-16) for LP and 9.1 days for OP (5-26) (P>.05). Intraoperative bleeding was negligible in all patients and no peroperative complications occurred. However, 9 patients (30%) experienced postoperative complications, 5 out of 15 LPs (33.3%) and 4 out of 15 Ops (26.7%) (P>0.05). Urinary fistula was the most common complication, occurring in 3 of the30 patients (10%).Procedure was successful in all 15 patients undergoing OP (100%) and in 14 of the 15patients undergoing LP (93.3%) (P>0.05). Conclusions: LP is currently the procedure of choice at our center because of its lower morbidity and similar results to OP, despite the need for a certain laparoscopic skill and ausually longer opertating time (AU)

[Implantation technique of the artificial urinary sphincter "FlowSecure" in the bulbar urethra]. / Técnica de implantación del esfínter urinario artificial "FlowSecure" en uretra bulbar.

BACKGROUND: Artificial urinary sphincter "FlowSecure" is a prosthesis designed for stress urinary incontinence that has achieved excellent results. Although implantation is easy, some urologist used to other prosthesis may find difficult the change to this new technique. This article shows how easily and quickly this new sphincter can be implanted and discuss the differences with the artificial sphincter AMS-800. METHODS: Following the case of a patient who was implanted artificial urinary sphincter "FlowSecure" in our center we describe with pictures the technique of implantation and give some advices to make this quicker and easier. RESULTS: Surgical time was 90 minutes. Patient presented uneventful recovery, urethral catheter was removed 24 hours after surgery and discharge was done 72 hours after surgery. Three months after implantation patient describes complete resolution of his stress urinary incontinence. CONCLUSIONS: Artificial urinary sphincter "FlowSecure" is easy and quick to implant, and as its use is extended we would compare if results are better than those of the AMS-800 model.

[Closure of a neobladder-vaginal fistula in a patient with Studer's type neobladder using a transvaginal approach with interposition of a Martius' flap]. / Cierre de fístula neovésico-vaginal en paciente con neovejiga tipo Studer mediante abordaje transvaginal con interposición de colgajo de Martius.

OBJECTIVE: We report a case of neobladder-vaginal fistula in a patient, and its closure using a Martius flap interposition. METHODS: A 51-year-old patient required cystectomy and Studer's neobladder for invasive bladder adenocarcinoma. After urethral catheter removal she presented constant leakage and was diagnosed by cystoscopy of neobladder-vaginal fistula. RESULTS: This complication was successfully treated using a vaginal approach with closure in two layers and interposition of a Martius flap. CONCLUSIONS: Neobladder is a rare indication in women, as it is the eventuality of presenting this type of fistula. The adequate approach to treat it is still controversial. In our experience and after reviewing literature we think vaginal closure using a Martius flap interposition is a good technique to treat a neobladder-vaginal fistula.

Técnica de implantación del esfínter urinario artificial FlowsecureTM en uretra bulbar / Implantation technique of the artificial urinary sphincter “flow secure™” in the bulbar urethra

OBJETIVO: El esfínter urinario FlowSecureTM es una prótesis para la incontinencia urinaria de esfuerzo que ha proporcionado unos excelentes resultados hasta el día de hoy. Si bien su colocación es sencilla, los urólogos acostumbrados a la colocación de otros tipos de prótesis pueden encontrar inconveniente el cambio a esta nueva técnica. Este artículo pretende demostrar que este nuevo esfínter se puede colocar de forma rápida y sencilla, así como discutir las diferencias respecto del modelo AMS-800TM.MÉTODOS: A raíz de un paciente al que se colocó el esfínter urinario FlowSecureTM en nuestro centro se describe mediante dibujos la técnica de colocación y se apuntan ciertos consejos prácticos que hacen más fácil y rápida su colocación.RESULTADO: El tiempo quirúrgico fue de 90 minutos. El paciente presentó un postoperatorio correcto, retirándose la sonda vesical a las 24 horas y siendo dado de alta a las 72 horas. A los 3 meses de la intervención el paciente refiere resolución completa de su incontinencia urinaria de esfuerzo.CONCLUSIONES: El esfínter urinario FlowSecureTM resulta una prótesis de colocación rápida y sencilla, y a medida que su utilización se vaya extendiendo podremos valorar si sus resultados a largo plazo son mejores que los del modelo AMS-800TM(AU)

OBJECTIVES: Artificial urinary sphincter “FlowSecureTM” is a prosthesis designed for stress urinary incontinence that has achieved excellent results. Although implantation is easy, some urologist used to other prosthesis may find difficult the change to this new technique. This article shows how easily and quickly this new sphincter can be implanted and discuss the differences with the artificial sphincter AMS-800TM.METHODS: Following the case of a patient who was implanted artificial urinary sphincter “FlowSecureTM” in our center we describe with pictures the technique of implantation and give some advices to make this quicker and easier RESULTS: Surgical time was 90 minutes. Patient presen-ted uneventful recovery, urethral catheter was removed 24 hours after surgery and discharge was done 72 hours after surgery. Three months after implantation patient describes complete resolution of his stress urinary incontinence.CONCLUSIONS: Artificial urinary sphincter “FlowSecu-reTM” is easy and quick to implant, and as its use is extended we would compare if results are better than those of the AMS-800TM model(AU)

Cierre de fístula neovésical-vaginal en paciente con neovejiga tipo Studer mediante abordaje transvaginal con interposición de colgajo de Martius / Closure of a neobladder-vaginal fistula in a patient with Studer’s type neobladder using a transvaginal approach with interposition of a Martius’ flap

OBJETIVO: Presentamos el caso de una fístula neovésico-vaginal en una paciente, así como su cierre mediante interposición de colgajo de Martius. Se realiza una revisión bibliográfica de este tipo de complicaciones.MÉTODOS: Paciente de 51 años que requirió de una cistectomía y neovejiga tipo Studer por adenocarcinoma vesical infiltrante. Tras la retirada de la sonda uretral presentó incontinencia urinaria y fue diagnosticada mediante cistoscopia de una fístula neovésico-vaginal RESULTADOS: Dicha complicación se resolvió de forma exitosa por abordaje vaginal mediante el cierre en dos planos y la interposición de un colgajo de Martius.CONCLUSIONES: La creación de una neovejiga es una indicación poco frecuente en mujeres, como también lo es la eventualidad de presentar este tipo de fístulas, y la mejor vía de abordaje para tratarlas es aún tema de discusión. En nuestra experiencia y tras revisar la literatura pensamos que el cierre vaginal con interposición de colgajo de Martius es una buena técnica para tratar la fístula neovésico-vaginal(AU)

OBJECTIVE: We report a case of neobladder-vaginal fistula in a patient, and its closure using a Martius flap interposition.METHODS: A 51 year old patient required cystectomy and Studer’s neobladder for invasive bladder adenocarcinoma. After urethral catheter removal she presented constant leakage and was diagnosed by cystoscopy of neobladder-vaginal fistula.RESULTS: This complication was successfully treated using a vaginal approach with closure in two layers and interposition of a Martius flap .CONCLUSIONS: Neobladder is a rare indication in women, as it is the eventuality of presenting this type of fistula. The adequate approach to treat it is still controversial. In our experience and after reviewing literature we think vaginal closure using a Martius flap interposition is a good technique to treat a neobladder-vaginal fistula(AU)

[Laparoscopic radical cystectomy in clinically localized (T2) bladder tumors]. / Cistectomía radical laparoscópica en los tumores vesicales clínicamente localizados (T2).

OBJECTIVES: Laparoscopic radical cystectomy has been developed after the expansion of laparoscopic radical prostatectomy. This technique makes possible a minimally invasive approach to muscle-invasive bladder cancer with less blood loss and faster postoperative recovery. METHODS: From September 2004 to January 2007, 54 laparoscopic radical cystectomies were performed, 48 of them in stage T2, from which 43 (90%) were male and 5 (10%) female patients. Mean age was 64 years (27-881. Lymphadenectomy was carried out by laparoscopic approach in all cases, with a mean of 13 nodes obtained (4-24). Urinary diversion was done through the incision needed to extract the specimen in all cases but one that was completed completely intracorporeally; constructing a Bricker-type ureteroileostomy in 30 (62%) cases, orthotopic neobladder (Vesica Ileale Padovana) in 17 cases (35%), and cutaneous ureterostomy in 1 case (2%). RESULTS: Mean surgical time for the whole procedure was 287 minutes (180-480), 270 minutes for Bricker-type derivation cases and 316 minutes for neobladder cases. Blood transfusion rate was 25%. Mean ileal paralysis was 5 days (2-10) with a mean hospital stay of 13 days (6-34) for Bricker cases and 16 days (8-30) for neobladder cases. Oncological control, after a mean follow-up of 10,8 months (0,4-30), showed a cancer-specific survival of 90% with a mean survival time of 28 months (95% CI 26-30). Global mean survival was 79% with a mean survival of 26 months (95% CI 23-29). CONCLUSIONS: Laparoscopic radical cystectomy is a feasible technique that offers some advantages. It allows excision with less blood loss and an easier postoperative period. Randomized studies should demonstrate these advantages to confirm this approach as the technique of choice. Urinary diversion performed through the laparotomy incision, necessary to extract the specimen, optimizes derivation results and whole surgical time without reducing the beneficial effects of the laparoscopic exeresis.

¿Ha pasado la época del antígeno prostático específico? / Is the era of prostatic specific antigen over?

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[Arterial embolization in the treatment of renal trauma of a horseshoe kidney]. / Embolizacion arterial para el tratamiento del traumatismo del riñon en herradura.

OBJECTIVES: To report one case of renal trauma in a patient with horseshoe kidney treated conservatively by superselective embolization. METHODS: We report the case of a 19 year old male presenting at the emergency room with macroscopic hematuria and severe abdominal pain after a motor vehicular accident. RESULTS: IV contrast CT scan showed a horseshoe kidney with a fracture in the area between the lower pole of the left kidney and the isthmus, with active bleeding and a big retroperitoneal hematoma extended to pelvis. Retarded exams showed contrast extravasation compatible with significant urinoma. Renal arteriography was performed, showing a double renal pedicle on each kidney and a common caudal lumbar-renal trunk giving accessory branches to both kidneys' lower poles and contrast extravasation compatible with active bleeding. The lumbar-renal trunk was selectively catheterized reaching the left kidney and isthmus branches which were embolized. Retrograde catheterization of the urinary tract with a straight ureteral catheter was performed to facilitate drainage of the urinoma. This catheter was subsequently removed after control CT scan showing complete resolution of the urinoma and no bleeding. Control CT scan three months after embolization demonstrated complete resolution of the hematoma. No late complications appeared. Renal function and blood pressure have been completely normal after 12 months of follow-up. CONCLUSIONS: Horseshoe kidney is a rare congenital malformation. This clinical case demonstrates that conservative treatment is a still the gold standard treatment for renal trauma, even in kidneys with congenital anomalies.