Opciones terapéuticas y factores predictivos de recurrencia y mortalidad cáncer-específica en pacients con tumor vesical después de traspante renal: análisis multiinstitucional / Treatment options and predictive factors for recurrence and cancer-specific mortality in bladder cancer after renal transplantation: A multi-institutional analysis

Objetivos: El tumor vesical (TV) en la población trasplantada representa un desafío debido al estado de inmunosupresión de los pacientes y a la mayor tasa de comorbilidades. El objetivo de este estudio fue analizar el tratamiento del TV tras el trasplante renal (TR), centrándose en el modo de presentación, diagnóstico, opciones de tratamiento, factores predictivos de recurrencia y mortalidad cáncer-específica. Material y métodos: Se realizó un estudio observacional prospectivo con un análisis retrospectivo de 88 pacientes con TV después de TR en 10 centros europeos. Se recogieron datos clínicos y oncológicos y se revisaron las indicaciones y los resultados del tratamiento adyuvante. Se aplicó el método de Kaplan-Meier para el análisis de la supervivencia y regresión de Cox uni- y multivariante para identificar los factores de riesgo. Resultados: En la revisión se incluyeron un total de 10.000 TR, identificando 87 pacientes con TV de novo, tras una mediana de seguimiento de 126 meses. La mediana del tiempo al diagnóstico fue 73 meses posterior al TR. Setenta y un pacientes (81,6%) fueron diagnosticados de TV no músculo-invasivo, de los cuales 29 (40,8%) recibieron tratamiento adyuvante: 6 de ellos (20,6%) recibieron el bacilo Calmette-Guérin (BCG) y 20 (68,9%) mitomicina C. En el análisis univariado los pacientes que recibieron BCG presentaron una tasa de recurrencia del TV significativamente menor (p = 0,043). En el análisis multivariante, el cambio de la inmunosupresión a inhibidores de mTOR redujo significativamente el riesgo de recurrencia (HR: 0,24; IC del 95%: 0,053-0,997; p = 0,049), mientras que la presencia de múltiples tumores lo aumentó (HR: 6,31; IC del 95%: 1,78-22,3; p = 0,004). Globalmente, 26 pacientes (29,88%) se sometieron a cistectomía, sin registrarse complicaciones mayores. La mortalidad global fue del 32,2% (28 pacientes) y la mortalidad cáncer-específica del 13,8%. Conclusiones: El tratamiento con bacilo Calmette-Guérin adyuvante y el cambio a inhibidores de mTOR reduce significativamente el riesgo de recurrencia de TV en TR, mientras que la presencia de tumores múltiples aumenta el riesgo

Objectives: Bladder cancer (BC) in the transplanted population can represent a challenge owing to the immunosuppressed state of patients and the higher rate of comorbidities. The objective was to analyze the treatment of BC after renal transplant (RT), focusing on the mode of presentation, diagnosis, treatment options and predictive factors for recurrence. Material and methods:We conducted an observational prospective study with a retrospective analysis f 88 patients with BC after RT at 10 European centers. Clinical and oncologic data were collected, and indications and results of adjuvant treatment reviewed. The Kaplan-Meier method and uni- and multivariate Cox regression analyses were performed. Results: A total of 10,000 RTs were performed. Diagnosis of BC occurred at a median of 73 months after RT. Median follow-up was 126 months. Seventy-one patients (81.6%) had non-muscle invasive bladder cancer, of whom 29 (40.8%) received adjuvant treatment; of these, six (20.6%) received bacillus Calmette-Guérin and 20 (68.9%) mitomycin C. At univariate analysis, patients who received bacillus Calmette-Guérin had a significantly lower recurrence rate (P = .043). At multivariate analysis, a switch from immunosuppression to mTOR inhibitors significantly reduced the risk of recurrence (HR 0.24, 95% CI: 0.053-0.997, P = .049) while presence of multiple tumors increased it (HR 6.31, 95% CI: 1.78-22.3, P = .004). Globally, 26 patients (29.88%) underwent cystectomy. No major complications were recorded. Overall mortality (OM) was 32.2% (28 patients); the cancer-specific mortality was 13.8%. Conclusions: Adjuvant bacillus Calmette-Guérin significantly reduces the risk of recurrence, as does switch to mTOR inhibitors. Multiple tumors increase the risk

Treatment options and predictive factors for recurrence and cancer-specific mortality in bladder cancer after renal transplantation: A multi-institutional analysis. / Opciones terapéuticas y factores predictivos de recurrencia y mortalidad cáncer-específica en pacientes con tumor vesical después de trasplante renal: análisis multiinstitucional.

OBJECTIVES: Bladder cancer (BC) in the transplanted population can represent a challenge owing to the immunosuppressed state of patients and the higher rate of comorbidities. The objective was to analyze the treatment of BC after renal transplant (RT), focusing on the mode of presentation, diagnosis, treatment options and predictive factors for recurrence. MATERIAL AND METHODS: We conducted an observational prospective study with a retrospective analysis of 88 patients with BC after RT at 10 European centers. Clinical and oncologic data were collected, and indications and results of adjuvant treatment reviewed. The Kaplan-Meier method and uni- and multivariate Cox regression analyses were performed. RESULTS: A total of 10,000 RTs were performed. Diagnosis of BC occurred at a median of 73 months after RT. Median follow-up was 126 months. Seventy-one patients (81.6%) had non-muscle invasive bladder cancer, of whom 29 (40.8%) received adjuvant treatment; of these, six (20.6%) received bacillus Calmette-Guérin and 20 (68.9%) mitomycin C. At univariate analysis, patients who received bacillus Calmette-Guérin had a significantly lower recurrence rate (P=.043). At multivariate analysis, a switch from immunosuppression to mTOR inhibitors significantly reduced the risk of recurrence (HR 0.24, 95% CI: 0.053-0.997, P=.049) while presence of multiple tumors increased it (HR 6.31, 95% CI: 1.78-22.3, P=.004). Globally, 26 patients (29.88%) underwent cystectomy. No major complications were recorded. Overall mortality (OM) was 32.2% (28 patients); the cancer-specific mortality was 13.8%. CONCLUSIONS: Adjuvant bacillus Calmette-Guérin significantly reduces the risk of recurrence, as does switch to mTOR inhibitors. Multiple tumors increase the risk.

Revisión sistemática de resultados perioperatorios y complicaciones después de cistectomía radical abierta, laparoscópica y asistida por robot / Systematic review of perioperative outcomes and complications after open, laparoscopic and robot-assisted radical cystectomy

La cistectomía radical y disección de los ganglios linfáticos regionales es el tratamiento estándar para el cáncer vesical músculo invasivo localizado y no músculo-invasivo de alto riesgo, y representa uno de los principales procedimientos quirúrgicos urológicos. El abordaje quirúrgico abierto es todavía ampliamente adoptado, aunque en las últimas 2 décadas se han hecho esfuerzos con el fin de evaluar si los procedimientos mínimamente invasivos, ya sean laparoscópicos o asistidos por robot, podrían mostrar un beneficio en comparación con la técnica estándar. La cistectomía radical abierta se asocia con una alta tasa de complicaciones, pero los datos de la serie quirúrgica laparoscópica y robótica no lograron demostrar una clara reducción en las tasas de complicaciones postoperatorias en comparación con la serie quirúrgica abierta. La cistectomía radical laparoscópica y robótica muestran una reducción en la pérdida de sangre, las tasas de estancia hospitalaria y de transfusión, pero un mayor tiempo operatorio, mientras que la cistectomía radical abierta se asocia típicamente con un tiempo operatorio más corto, pero con un ingreso más largo en el hospital y, posiblemente, una mayor tasa complicaciones de alto grado

Radical cystectomy and regional lymph node dissection is the standard treatment for localized muscle-invasive and for high-risk non-muscle-invasive bladder cancer, and represents one of the main surgical urologic procedures. The open surgical approach is still widely adopted, even if in the last two decades efforts have been made in order to evaluate if minimally invasive procedures, either laparoscopic or robot-assisted, might show a benefit compared to the standard technique. Open radical cystectomy is associated with a high complication rate, but data from the laparoscopic and robotic surgical series failed to demonstrate a clear reduction in post-operative complication rates compared to the open surgical series. Laparoscopic and robotic radical cystectomy show a reduction in blood loss, in-hospital stay and transfusion rates but a longer operative time, while open radical cystectomy is typically associated with a shorter operative time but with a longer in-hospital admission and possibly a higher rate of high grade complications

Systematic review of perioperative outcomes and complications after open, laparoscopic and robot-assisted radical cystectomy. / Revisión sistemática de resultados perioperatorios y complicaciones después de cistectomía radical abierta, laparoscópica y asistida por robot.

Radical cystectomy and regional lymph node dissection is the standard treatment for localized muscle-invasive and for high-risk non-muscle-invasive bladder cancer, and represents one of the main surgical urologic procedures. The open surgical approach is still widely adopted, even if in the last two decades efforts have been made in order to evaluate if minimally invasive procedures, either laparoscopic or robot-assisted, might show a benefit compared to the standard technique. Open radical cystectomy is associated with a high complication rate, but data from the laparoscopic and robotic surgical series failed to demonstrate a clear reduction in post-operative complication rates compared to the open surgical series. Laparoscopic and robotic radical cystectomy show a reduction in blood loss, in-hospital stay and transfusion rates but a longer operative time, while open radical cystectomy is typically associated with a shorter operative time but with a longer in-hospital admission and possibly a higher rate of high grade complications.

Estudio prospectivo de crioterapia renal percutánea ecoguiada: selección de casos como factor de optimización de una técnica / Prospective study of ultrasound-guided percutaneous renal cryotherapy: Case selection as an optimization factor for a technique

Objetivo: Evaluar la efectividad técnica y oncológica de la crioterapia renal percutánea (CP) ecoguiada en un grupo seleccionado de pacientes con tumor renal. Material y métodos: Se realizó un estudio prospectivo de 28 pacientes con tumores renales T1a de cara posterior y de borde externo medio e inferior. A todos se les realizó CP ecoguiada. El seguimiento fue con TC al mes y después cada 6 meses, considerándose como criterio de buen resultado la ausencia total de incorporación de contraste. Realizamos un estudio descriptivo y de supervivencia mediante Kaplan-Meier. Resultados: Se trata de 28 pacientes con una edad media (DE) de 68,3 (10,1) años, en los que se realizaron 28 procedimientos. La media (DE) de tamaño fue de 25,5 mm (7,5) nephrometry score 1,41 (0,52) y creatinina preoperatoria 133,5 mmol/l (144,1). No hubo ninguna complicación intraoperatoria. Como complicaciones postoperatorias solo un caso (3,5%) de lesión cutánea al tratar un tumor en riñón trasplantado (Clavien II). La mediana de seguimiento fue de 25 meses, y la creatinina media (DE) postoperatoria fue de 135,5 mmol/l (110,3). Presentaron recurrencia radiológica 2 casos (eficacia del 93%), con un tiempo medio hasta la recurrencia de 12 y 19 meses respectivamente. No se produjo ninguna muerte relacionada con el tumor. Conclusiones: Nuestra serie, hasta el momento la más larga de CP en nuestro país, muestra que con una adecuada selección de tumores la CP es una técnica segura y con mínima morbilidad. La ecografía permite realizar el procedimiento de forma controlada, además de ahorrar irradiación y costes

Objective: To evaluate the technical and oncological effectiveness of ultrasound-guided percutaneous renal cryotherapy (PRC) in a selected group of patients with renal cancer. Material and methods: We conducted a prospective study of 28 patients with posterior-facing T1a renal tumors with middle and inferior external borders. All patients underwent ultrasound-guided PRC. Follow-up was conducted with computed tomography at 1 month and then every 6 months, with a good result defined as the total absence of contrast incorporation. We performed a descriptive and survival study using the Kaplan-Meier estimator. Results: The 28 patients had a mean age (SD) of 68.3 (10.1) years, and the group underwent 28 procedures. The mean (SD) size of the tumors was 25.5 (7.5) mm, the mean nephrometry score was 1.41 (0.52) and the mean preoperative creatinine level was 133.5 (144.1) mmol/L. There were no intraoperative complications. In terms of postoperative complications, there was only 1 case (3.5%) of a skin lesion resulting from treating a tumor in a transplanted kidney (Clavien II). The median follow-up was 25 months, and the mean (SD) postoperative creatinine level was 135.5 (110.3) mmol/L. Two cases presented radiological recurrence (93% efficacy), with a mean time to recurrence of 12 and 19 months, respectively. There were no tumor-related deaths. Conclusions: Our series (the largest on PRC in our country to date) shows that, with an appropriate selection of tumors, PRC is a safe technique with minimal morbidity. Ultrasonography enables the controlled performance of the procedure and saves the patient from radiation and reduces costs

Prospective study of ultrasound-guided percutaneous renal cryotherapy: case selection as an optimization factor for a technique.

OBJECTIVE: To evaluate the technical and oncological effectiveness of ultrasound-guided percutaneous renal cryotherapy (PRC) in a selected group of patients with renal cancer. MATERIAL AND METHODS: We conducted a prospective study of 28 patients with posterior-facing T1a renal tumors with middle and inferior external borders. All patients underwent ultrasound-guided PRC. Follow-up was conducted with computed tomography at 1 month and then every 6 months, with a good result defined as the total absence of contrast incorporation. We performed a descriptive and survival study using the Kaplan-Meier estimator. RESULTS: The 28 patients had a mean age (SD) of 68.3 (10.1) years, and the group underwent 28 procedures. The mean (SD) size of the tumors was 25.5 (7.5) mm, the mean nephrometry score was 1.41 (0.52) and the mean preoperative creatinine level was 133.5 (144.1) mmol/L. There were no intraoperative complications. In terms of postoperative complications, there was only 1 case (3.5%) of a skin lesion resulting from treating a tumor in a transplanted kidney (Clavien II). The median follow-up was 25 months, and the mean (SD) postoperative creatinine level was 135.5 (110.3) mmol/L. Two cases presented radiological recurrence (93% efficacy), with a mean time to recurrence of 12 and 19 months, respectively. There were no tumor-related deaths. CONCLUSIONS: Our series (the largest on PRC in our country to date) shows that, with an appropriate selection of tumors, PRC is a safe technique with minimal morbidity. Ultrasonography enables the controlled performance of the procedure and saves the patient from radiation and reduces costs.

[Batson's paravertebral venous plexus and single vertebral metastases from renal cell carcinoma]. / Circolo venoso paravertebrale di Batson e metastasivertebrali singole da carcinoma renale.

OBJECTIVES: The presence of a single site bone metastasis in patients with renal cell carcinoma (RCC) is a rare clinical event. We report a single case of RCC with solitary vertebral metastasis and review of literature about renal tumor spreading in order to understand the anatomic explanation for this peculiar clinical case. METHODS: We have considered the single case and reviewed current and past literature to describe the anatomic and functional background of this clinical situation. RESULTS: There are rare cases of single vertebral metastasis from RCC and these are characterized from a contemporary neoplastic thrombus. The neoplastic thrombus could justify the tumoral back-flow into the paravertebral anasthomoses and so into vertebral venous sinusoids. The rich anasthomotic system that surrounds kidneys and the experimental evidence of anasthomotic links among perirenal Lejars venous system and paravertebral Batson's venous system could explain these clinical evidences. CONCLUSION: Enrolment of para-vertebral Batson's venous system could have a major role in the RCC vertebral metastatic diffusion.

[The role of non-invasive urodynamics in bladder outlet obstruction diagnosis in male patients]. / Il ruolo dell'urodinamica non-invasiva nella diagnosidell'ostruzione cervico-uretrale nell'uomo.

PURPOSE: Many methods have been suggested to assess bladder outlet obstruction, as defined by the gold standard of pressure flow studies. A comprehensive review of the literature on the different methods used to diagnose bladder outlet obstruction by non-invasive means was performed in order to compare those methods to invasive urodynamics in terms of sensitivity and specificity. MATERIALS AND METHODS: A MEDLINE search was done of the published literature covering from December 2003 on non-invasive methods, including only single measures to diagnose bladder outlet obstruction. We performed a comparison between all methods in terms of sensitivity and specificity for each test. For many techniques these values were calculated directly from the data presented in the article. RESULTS: There has been applied many methods to diagnose bladder outlet obstruction. Those methods were divided into uroflowmetry, condom-catheter method, penile cuff method and Doppler ultrasonography urodynamics. Each method has been described and discussed in terms of its role in adding information to the diagnostic work-up for bladder outlet obstruction. CONCLUSIONS: Pressure flow studies still remain the gold standard for assessing bladder outlet obstruction. However non-invasive urodynamics is a promising branch. Probably the most reliable information is given by the association of numerous methods together.