El PSA basal en una población de varones españoles de 40-49 años anticipa la detección de cáncer de próstata / Baseline PSA in a Spanish male population aged 40-49 years anticipates detection of prostate cancer

Introducción: Investigamos en nuestro entorno la utilidad de optimizar el cribado de cáncer de próstata (CaP) mediante determinación de PSA basal en varones entre 40-49 años. Material y método: Estudio retrospectivo que analiza el PSA basal en la quinta década y su capacidad para predecir desarrollo de CaP en una población de Madrid (España). Se realiza curva ROC y se propone un punto de corte. Se compara la evolución del PSA desde basal en pacientes con determinaciones consecutivas mediante el test de Friedman. Se establecen rangos de PSA basal con diferente riesgo de desarrollo de cáncer y se evalúa la utilidad diagnóstica de la velocidad de PSA (VPSA) anual en esta población. Resultados: Un total de 4.304 varones de 40-49 años fueron sometidos a cribado oportunista a lo largo de 17 años, con al menos una determinación sérica de PSA (6.001 determinaciones) y con seguimiento medio de 57,1 ± 36,8 meses. A 768 se les practicó biopsia de algún órgano y a 104 biopsia prostática. Catorce pacientes (0,33%) fueron diagnosticados de cáncer de próstata. La mediana de PSA basal fue 0,74 ng/ml (0,01-58,5) para pacientes sin CaP y 4,21 ng/ml (0,76-47,4) con CaP. La mediana de tiempo desde la determinación hasta el diagnóstico fue 26,8 meses (1,5-143,8). El punto de corte óptimo para detectar CaP fue 1,9 ng/ml (sensibilidad 92,86%, especificidad 92,54%, VPP 3,9%, VPN 99,97%) y el área bajo la curva 92,8%. Respecto a las determinaciones repetidas, la evolución del PSA no mostró diferencias estadísticamente significativas entre pacientes sin cáncer (p = 0,56) o con cáncer (p = 0,64); pero un valor de VPSA > 0,3 ng/ml/año revela elevada especificidad para detectar cáncer en esta población. Conclusiones: Un PSA basal ≥ 1,9 ng/ml en varones españoles de 40-49 años predice el desarrollo de CaP, por lo que podría resultar de utilidad para el cribado oportunista en edad temprana. Se necesita definir un seguimiento apropiado adaptado al riesgo en esta población, pero una VPSA anual ≥ 0,3 ng/ml/año parece de utilidad para conseguir un diagnóstico temprano

Introduction: We researched the usefulness of optimizing prostate cancer (PC) screening in our community using baseline PSA readings in men between 40-49 years of age. Material and method: A retrospective study was performed that analyzed baseline PSA in the fifth decade of life and its ability to predict the development of PC in a population of Madrid (Spain). An ROC curve was created and a cutoff was proposed. We compared the evolution of PSA from baseline in patients with consecutive readings using the Friedman test. We established baseline PSA ranges with different risks of developing cancer and assessed the diagnostic utility of the annual PSA velocity (PSAV) in this population. Results: Some 4,304 men aged 40-49 years underwent opportunistic screening over the course of 17 years, with at least one serum PSA reading (6,001 readings) and a mean follow-up of 57.1 ± 36.8 months. Of these, 768 underwent biopsy of some organ, and 104 underwent prostate biopsy. Fourteen patients (.33%) were diagnosed with prostate cancer. The median baseline PSA was .74 (.01-58.5) ng/mL for patients without PC and 4.21 (.76-47.4) ng/mL for those with PC. The median time from the reading to diagnosis was 26.8 (1.5-143.8) months. The optimal cutoff for detecting PC was 1.9 ng/mL (sensitivity, 92.86%; specificity, 92.54%; PPV, 3.9%; NPV, 99.97%), and the area under the curve was 92.8%. In terms of the repeated reading, the evolution of the PSA showed no statistically significant differences between the patients without cancer (p=.56) and those with cancer (P = .64). However, a PSAV value > .3 ng/mL/year revealed high specificity for detecting cancer in this population. Conclusions: A baseline PSA level ≥ 1.9 ng/mL in Spanish men aged 40-49 years predicted the development of PC. This value could therefore be of use for opportunistic screening at an early age. An appropriate follow-up adapted to the risk of this population needs to be defined, but an annual PSAV ≥ .3 ng/mL/year appears of use for reaching an early diagnosis

Miniperc y Cirugía Retrógrada Intrarrenal: ¿cuándo y cómo? / Miniperc and retrograde intrarenal surgery: when and how?

Contexto: La Litotricia Extracorpórea por Ondas de Choque (LEOCH) y la Nefrolitotomía Percutánea (NLP) son procedimientos consolidados en el tratamiento de la litiasis renal, pero sus principales puntos débiles son la menor eficacia de la LEOCH, especialmente en litiasis de cáliz inferior, y la morbilidad de la NLP, derivada de la creación-dilatación del trayecto percutáneo. La creciente miniaturización del instrumental de cirugía percutánea, y el desarrollo de la cirugía retrógrada intrarrenal (CRIR) son innovaciones recientes. Adquisición de evidencia: Se ha llevado a cabo una revisión estructurada no sistemática, a través de una búsqueda bibliográfica de los artículos publicados entre 1997 y 2013, utilizando los términos litiasis renal, miniperc, mini-NLP, CRIR y ureteroscopia flexible en las bases de datos PubMed, Google Scholar y Scopus. Síntesis de evidencia: La CRIR consume mayor tiempo operatorio, precisa varios procedimientos en litiasis voluminosas e implica mayor coste hospitalario, derivado en parte de la relativa fragilidad del instrumental. Por otro lado, miniperc, precisa una estancia hospitalaria más prolongada, mayor necesidad de analgesia postoperatoria y mayor descenso de hemoglobina, aunque sin traducirse en una mayor tasa de transfusión. Conclusiones: El tratamiento contemporáneo de la litiasis renal emplea procedimientos mínimamente invasivos como miniperc y CRIR. Ambos son equivalentes en términos de eficacia (aclaramiento litiásico) y se asocian con mínimas complicaciones. Son necesarios estudios comparativos prospectivos que determinen la posición de cada una de estas técnicas en el tratamiento de la litiasis renal. En nuestra experiencia ambas resultan complementarias y deben formar parte del arsenal terapéutico actual urológico

Context: Extracorporeal shock wave lithotripsy (ESWL) and percutaneous nephrolithotomy (PCNL) are consolidated procedures for the treatment of kidney stones; however, their primary weak points are the lower efficacy of ESWL, especially for lower calyx stones, and the morbidity of PCNL resulting from the creation and dilation of the percutaneous trajectory. The increasing miniaturization of percutaneous surgery instrumentation and the development of retrograde intrarenal surgery (RIRS) are recent innovations. Acquisition of evidence: A structured nonsystematic review was conducted through a literature search of articles published between 1997 and 2013, using the terms kidney stones, miniperc, mini-PCNL, RIRS and flexible ureteroscopy in the PubMed, Google Scholar and Scopus databases. Summary of the evidence: RIRS requires greater surgical time, several procedures for voluminous stones and higher hospital costs, due in part to the relative fragility of the instruments. On the other hand, miniperc requires a longer hospital stay, an increased need for postoperative analgesia and a greater reduction in hemoglobin levels, although these do not translate into an increased rate of transfusions. Conclusions: The current treatment of kidney stones uses minimally invasive procedures such as miniperc and RIRS. The 2 procedures are equivalent in terms of efficacy (stone clearance) and are associated with minimal complications. Comparative prospective studies are necessary to determine the position of each of these techniques in the treatment of kidney stones. In our experience, the 2 techniques are complementary and should be part of the current urological therapeutic arsenal

La cirugía retrógrada intrarrenal con litotricia láser holmium-YAG en el tratamiento primario de la litiasis renal / Retrograde intrarenal surgery with holmium-YAG laser lithotripsy in the primary treatment of renal lithiasis

Introducción: La cirugía retrógrada intrarrenal (CRIR), en constante desarrollo y renovación, se presenta como una técnica eficaz y segura, y una buena alternativa terapéutica a la litotricia extracorpórea (LEOC) y la nefrolitotomía percutánea (NLP). Material y métodos: Estudio descriptivo de 50 pacientes intervenidos entre noviembre del 2012 y abril del 2013. Se recogieron datos demográficos, operatorios y postoperatorios, así como complicaciones precoces y tardías. Los pacientes fueron seguidos durante un periodo mínimo de un año. La técnica quirúrgica empleada se realizó bajo anestesia general, empleando ureteroscopio flexible, con vaina de acceso ureteral y energía de fragmentación láser. El éxito de la cirugía se definió como la ausencia de carga litiásica (stone free rate) en la prueba de control postoperatoria y a los 3 meses de la intervención (radiografía simple, ecografía o TC abdominal sin contraste). Resultados: La media ± desviación estándar de edad fue 51,1 ± 15,5 años. La localización más frecuente fue grupo calicial inferior (26%), un 58% fueron únicas y un 42%, múltiples. En un 44% la carga litiásica fue baja (< 2 cm) y en un 22% alta (> 3 cm). La media de aclaramiento litiásico en esta serie fue 89,7 ± 17,5. El tiempo quirúrgico medio fue 96,6 ± 35,2 min. Se produjeron complicaciones en 4 pacientes (8%), todas precoces y de carácter menor. Conclusiones: La CRIR es una opción eficaz y segura, comparable a LEOC y NLP, que puede considerarse de primera línea. Numerosas series corroboran estos resultados, pero se necesitan estudios prospectivos centrados en calidad de vida, estancia media, complicaciones y coste-efectividad de los diferentes tratamientos que permitan afianzar estas conclusiones

Introduction: retrograde intrarenal surgery (RIRS) appears as a safe and effective technique as well as a good therapeutic alternative to extracorporeal shock wave lithotripsy (ESWL) and percutaneous nephrolithotomy (PNL). Material and methods: descriptive study in 50 patients surgically treated between November 2012 and April 2013. Demographic, operative and postoperative data as well as early and late complications data were collected. The minimum follow-up of patients was one year. Surgery was performed under general anesthesia. Flexible ureteroscopy with ureteral access sheath and laser fragmentation were employed. Surgery success was defined as stone free rate in postoperative control test and at three months after surgery (simple radiography, abdominal ultrasound or CT without contrast). Results: mean age was 51.1±15.5 years old. The highest-frequency location was the lower calyceal group (26%), single stones were described in 58% of patients whilst multiple lithiasis were found in the 42%. Regarding the stone burden in 44% of the patients was low (<2 cm), and high (>3 cm) in 22% of the patients. The stone clearance rate was 89.7±17.5. Average surgery time was 96.6±35.2min. Complications were reported in 4 patients (8%), all of them early ones and minor in nature. Conclusions: RIRS is an effective and safe option whose results are comparable to ESWL and PCNL. RIRS can be considered as first-line treatment. These results are corroborated by numerous studies. To strengthen these findings, prospective studies focusing on quality of life, length of stay, complications and cost-effectiveness of different treatments are needed

Linfadenectomía retroperitoneal laparoendoscópica por puerto único en tumor germinal no seminomatoso / Laparoendoscopic single-site retroperitoneal lymph node dissection in non-seminomatous germ cell malignancy

Introducción: La cirugía laparoendoscópica a través de puerto único (LESS) umbilical constituye una excelente alternativa a la cirugía laparoscópica o robótica multipuerto. Implica menos dolor postoperatorio, rápida recuperación y óptimo resultado cosmético. Prácticamente, resulta posible practicar cualquier cirugía urológica a través de este abordaje. Paciente y método: Presentamos a un varón de 38 años con BMI 31,2 y antecedentes de tumor germinal mixto no seminomatoso estadio i en vigilancia que presenta recidiva ganglionar interaortocava sin elevación de marcadores. Se practicó una linfadenectomía retroperitoneal LESS (LDRP-LESS) derecha mediante abordaje umbilical por puerto único multicanal KeyPort (Richard Wolf GmbH, Knittingen, Alemania). Resultados: Tras la colocación del dispositivo y la triangulación de las pinzas, se incidió el peritoneo parietal posterior y se movilizó el colon ascendente para acceder al retroperitoneo. Se llevó a cabo una disección ganglionar retroperitoneal completa del lado derecho desde los vasos ilíacos hasta los vasos renales, incluyendo el espacio paracava e interaortocava. El espécimen se introdujo en una bolsa laparoscópica, que se extrajo junto con el sistema multicanal. No se colocó drenaje abdominal. El tiempo operatorio fue 85 min y el sangrado estimado 50 cc. El paciente se mostró muy satisfecho, con una herida absolutamente invisible, y fue dado de alta tras un día de ingreso hospitalario sin necesidad alguna de analgesia. El informe anatomopatológico reveló seminoma metastásico en 5 de 11 ganglios linfáticos, por lo que recibió 4 ciclos de quimioterapia sistémica (VP16-CDDP), con buena tolerancia. Un año después se encuentra libre de enfermedad y sin complicaciones. Conclusiones: Es posible llevar a cabo LDRP-LESS primaria mediante abordaje exclusivamente umbilical con excelente resultado oncológico y cosmético en casos seleccionados. Este abordaje podría ser la opción quirúrgica menos invasiva económicamente ventajosa, gracias a la naturaleza reutilizable de los instrumentos empleados

Introduction: Umbilical laparoendoscopic single-site (LESS) surgery represents an excellent alternative to laparoscopic or robotic multiport surgery. LESS surgery offers faster recovery, less postoperative pain and optimal cosmetic results. LESS is possible in virtually any urologic surgery. Patient and method: We present a 38-year-old male with BMI 31.2 and with history of stage I nonseminomatous mixed germ cell tumor showing interaortocaval lymph node recurrence without elevation of tumor markers. Patient was undergone to right laparoendoscopic single-site retroperitoneal lymph node dissection (LDRP-LESS) by umbilical approach using a single-site multichannel KeyPort (Richard Wolf GmbH, Knittlingen, Germany). Results: After the placement of the device and triangulation of the clips, we proceeded to operate on posterior parietal peritoneum. The descending colon was mobilized to access the retroperitoneum. Complete retroperitoneal lymph node dissection on the right side from iliac vessels to renal vessels, including the paracaval and interaortocaval space, was performed. The specimen was inserted into a laparoscopic bag and was removed together with multichannel system. Abdominal drainage was not employed. Surgical time was 85 min and estimated bleeding 50 cc. The patient was very satisfied with the cosmetic results and was discharged the following day without needing analgesia. The pathology report revealed metastatic seminoma in 5 of 11 lymph nodes receiving systemic chemotherapy (VP16-CDDPs) for 4 cycles with good tolerance. A year later, the patient was disease-free and had no complications. Conclusions: Umbilical primary LDRP-LESS, with excellent oncologic and cosmetic results, is feasible in selected cases. This approach could be considered the least invasive surgical option economically advantageous due to the reusable nature of the instruments used

Estudio comparativo entre abordaje abierto y laparoscópico en la cistectomía radical con reservorio ortotópico ileal continente / A comparative study between open and laparoscopic approach in radical cystectomy with orthotopic ileal neobladder

Objetivo: La cistectomía radical laparoscópica con neovejiga ileal y anastomosis neovesicouretral realizada por laparoscopia posiblemente sea uno de los procedimientos más complejos de la cirugía mínimamente invasiva. Material y métodos: Estudio prospectivo realizado entre enero de 2008 y octubre de 2013 con 72 pacientes afectos de neoplasia vesical infiltrante, intervenidos mediante cistectomía radical con neovejiga ileal (33 mediante técnica abierta y 39 laparoscópica). Evaluamos de forma comparativa los resultados quirúrgicos, la tasa de continencia y las complicaciones postoperatorias. Resultados: La edad media fue 63,5 ± 9 años (64,3 abierta vs. 62,7 laparoscópica, p = 0,46), el tiempo medio quirúrgico 323,6 ± 78,7 min (321,3 vs. 326,5, p = 0,77), la estancia media 14,8 ± 8,1 días (16,2 vs. 13,6, p = 0,2), la tasa de transfusión 40,3% (66,7% vs. 17,9%, p < 0,0001), la tasa de complicaciones 47,2% (63,6% vs. 33,3%, p = 0,01). Sucedieron complicaciones mayores en 29,1% (39,4% abierta vs. 20,5% laparoscópica, p = 0,07). La media de seguimiento fue 42,5 + 19,2 meses (rango 15-70); 50 pacientes (69,4%) estaban vivos y libres de enfermedad y pudieron ser evaluados con respecto al estado de continencia. La tasa de continencia total fue 38% (50% vs. 27%, p = 0,09) y la tasa de continencia diurna 58% (70,8% vs. 46,1%, p = 0,07). La proporción de pacientes con autocateterismo fue 8% (4,2% vs. 11,5%, p = 0,67). La tasa de incontinencia total fue 34% (25% vs. 42,3%, p = 0,19). Conclusión: En nuestra experiencia la tasa de transfusión, el número y severidad de complicaciones es menor en la cistectomía radical con neovejiga realizada mediante abordaje laparoscópico, sin claro impacto en el tiempo quirúrgico y en la estancia hospitalaria. La tasa de continencia de los pacientes intervenidos mediante abordaje laparoscópico es inferior, aunque sin alcanzar significación estadística

Objective: Probably, laparoscopic radical cystectomy with ileal neobladder and neovesicourethral anastomosis is one of the most complex procedures in minimally invasive surgery. Material and methods: Prospective study carried out in 72 patients surgically treated for invasive bladder neoplasia between January 2008 and October 2013. Patients were undergone to radical cystectomy with ileal neobladder (open approach in 33 patients and laparoscopic approach in 39). The study assessed comparatively surgical outcomes, continence rate and postoperative complications. Results: Mean age was 63.5 ± 9 years (64.3 open vs. 62.7 laparoscopic, P = .46) mean surgery time 323.6 ± 78.7 minutes (321.3 vs. 326.5, P = .77), average hospital stay 14.8 days ± 8,1 (16.2 vs. 13.6, P = .2), transfusion rate 40.3% (66.7% vs. 17.9%, P < .0001) and complications rate 47.2% (63.6% vs. 33.3%, P = .01). Major complications were reported in 29.1% of cases (39.4% open vs. 20,5% laparoscopic, P = .07). With a mean follow-up rate of 42.5 ± 19.2 months (range 15-70), 50 (69.4%) patients remain alive and free of disease. Continence was evaluated in these patients: total continence rate was 38% (50% vs. 27%, P = .09) and diurnal continence rate 58% (70.8% vs. 46.1%, P = .07). Self-catheterization rate was 8% (4.2% vs. 11.5%, P = .67). Total incontinence rate was 34% (25% vs. 42.3%, P = .19). Conclusion: According to our experience, transfusion rate, number and severity of complications are lower in laparoscopic cystectomy with ileal neobladder. No statistically significant impact on operative time and on hospital stay was observed. In patients undergone to laparoscopic approach, continence rate is lower but not statistically significant

Adenomectomía laparoscópica extraperitoneal «sin nudos» / «Knotless» Laparoscopic Extraperitoneal Adenomectomy

Introducción: La adenomectomía laparoscópica es una cirugía factible y efectiva. Progresivamente simplificamos el procedimiento empleando sutura barbada, mediante una técnica que denominamos adenomectomía laparoscópica «sin nudos». Presentamos un estudio prospectivo multicéntrico descriptivo que refleja eficacia y seguridad de dicha técnica en una situación de práctica clínica real reproducible. Métodos: Un total de 26 pacientes con hipertrofia prostática benigna de gran tamaño (> 80 cc) fueron sometidos a adenomectomía laparoscópica «sin nudos». Se trata de una técnica laparoscópica extraperitoneal con 4 trocares basada en la enucleación controlada y hemostática del adenoma empleando bisturí ultrasónico, sección uretral precisa bajo visión asistida por una bujía uretral, trigonización empleando sutura barbada que cubre la pared posterior de la celda prostática, capsulorrafia con sutura barbada y extracción del adenoma morcelado a través de la incisión umbilical. Resultados: La mediana de la edad fue de 69 (54-83) años, el volumen prostático 127 (89-245) cc, el tiempo operatorio 136 (90-315) min, el sangrado estimado 200 (120-500) cc, la estancia hospitalaria 3 (2-6) días. Todos los pacientes presentaron mejoría funcional objetivada por uroflujometría, cuestionario de IPSS y calidad de vida. Hubo complicaciones en 6 pacientes, 5 fueron menores. Conclusiones: La adenomectomía laparoscópica «sin nudos» es un procedimiento de escasa complejidad que combina las ventajas de la cirugía abierta (resultados funcionales duraderos y extracción completa del adenoma) con los procedimientos laparoscópicos (disminución del sangrado y de transfusiones, menor estancia hospitalaria, morbilidad y complicaciones relacionadas con la pared abdominal). El empleo de bisturí ultrasónico y sutura barbada simplifica el procedimiento y permite realizar la técnica de forma segura y hemostática

Introduction: Laparoscopic adenomectomy is a feasible and effective surgical procedure. We have progressively simplified the procedure using barbed sutures and a technique we call «knotless» laparoscopic adenomectomy. We present a prospective, multicenter, descriptive study that reflects the efficacy and safety of this technique in an actual, reproducible clinical practice situation. Methods: A total of 26 patients with benign prostatic hyperplasia of considerable size (> 80 cc) underwent «knotless» laparoscopic adenomectomy. This is an extraperitoneal laparoscopic technique with 4 trocars based on the controlled and hemostatic enucleation of the adenoma using ultrasonic scalpels, precise urethral sectioning under direct vision assisted by a urethral plug, trigonization using barbed suture covering the posterior wall of the fascia, capsulorrhaphy with barbed suture and extraction of the morcellated adenoma through the umbilical incision. Results: The median patient age was 69 (54-83) years, the mean prostate volume was 127 (89-245) cc, the mean operative time was 136 (90-315) min, the mean estimated bleeding volume was 200 (120-500) cc and the hospital stay was 3 (2-6) days. All patients experienced improved function in terms of uroflowmetry and International Prostate Symptom Score and quality of life questionnaires. There were complications in 6 patients, 5 of which were minor. Conclusions: «Knotless» laparoscopic adenomectomy is a procedure with low complexity that combines the advantages of open surgery (lasting functional results and complete extraction of the adenoma) with laparoscopic procedures (reduced bleeding and need for transfusions, shorter hospital stays and reduced morbidity and complications related to the abdominal wall). The use of ultrasonic scalpels and barbed sutures simplifies the procedure and enables a safe and hemostatic technique

Miniperc and retrograde intrarenal surgery: when and how?

CONTEXT: Extracorporeal shock wave lithotripsy (ESWL) and percutaneous nephrolithotomy (PCNL) are consolidated procedures for the treatment of kidney stones; however, their primary weak points are the lower efficacy of ESWL, especially for lower calyx stones, and the morbidity of PCNL resulting from the creation and dilation of the percutaneous trajectory. The increasing miniaturization of percutaneous surgery instrumentation and the development of retrograde intrarenal surgery (RIRS) are recent innovations. ACQUISITION OF EVIDENCE: A structured nonsystematic review was conducted through a literature search of articles published between 1997 and 2013, using the terms kidney stones, miniperc, mini-PCNL, RIRS and flexible ureteroscopy in the PubMed, Google Scholar and Scopus databases. SUMMARY OF THE EVIDENCE: RIRS requires greater surgical time, several procedures for voluminous stones and higher hospital costs, due in part to the relative fragility of the instruments. On the other hand, miniperc requires a longer hospital stay, an increased need for postoperative analgesia and a greater reduction in hemoglobin levels, although these do not translate into an increased rate of transfusions. CONCLUSIONS: The current treatment of kidney stones uses minimally invasive procedures such as miniperc and RIRS. The 2 procedures are equivalent in terms of efficacy (stone clearance) and are associated with minimal complications. Comparative prospective studies are necessary to determine the position of each of these techniques in the treatment of kidney stones. In our experience, the 2 techniques are complementary and should be part of the current urological therapeutic arsenal.

Comentario editorial a: «Tendencia en los tratamientos invasivos en la litiasis urinaria en un Hospital de 3. er nivel» / Comment to «Invasive treatment trends in urinary calculi in at third level hospital»

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Retrograde intrarenal surgery with holmium-YAG laser lithotripsy in the primary treatment of renal lithiasis.

INTRODUCTION: retrograde intrarenal surgery (RIRS) appears as a safe and effective technique as well as a good therapeutic alternative to extracorporeal shock wave lithotripsy (ESWL) and percutaneous nephrolithotomy (PNL). MATERIAL AND METHODS: descriptive study in 50 patients surgically treated between November 2012 and April 2013. Demographic, operative and postoperative data as well as early and late complications data were collected. The minimum follow-up of patients was one year. Surgery was performed under general anesthesia. Flexible ureteroscopy with ureteral access sheath and laser fragmentation were employed. Surgery success was defined as stone free rate in postoperative control test and at three months after surgery (simple radiography, abdominal ultrasound or CT without contrast). RESULTS: mean age was 51.1±15.5 years old. The highest-frequency location was the lower calyceal group (26%), single stones were described in 58% of patients whilst multiple lithiasis were found in the 42%. Regarding the stone burden in 44% of the patients was low (<2 cm), and high (>3 cm) in 22% of the patients. The stone clearance rate was 89.7±17.5. Average surgery time was 96.6±35.2min. Complications were reported in 4 patients (8%), all of them early ones and minor in nature. CONCLUSIONS: RIRS is an effective and safe option whose results are comparable to ESWL and PCNL. RIRS can be considered as first-line treatment. These results are corroborated by numerous studies. To strengthen these findings, prospective studies focusing on quality of life, length of stay, complications and cost-effectiveness of different treatments are needed.

Laparoendoscopic single-site retroperitoneal lymph node dissection in non-seminomatous germ cell malignancy.

INTRODUCTION: Umbilical laparoendoscopic single-site (LESS) surgery represents an excellent alternative to laparoscopic or robotic multiport surgery. LESS surgery offers faster recovery, less postoperative pain and optimal cosmetic results. LESS is possible in virtually any urologic surgery. PATIENT AND METHOD: We present a 38-year-old male with BMI 31.2 and with history of stage I nonseminomatous mixed germ cell tumor showing interaortocaval lymph node recurrence without elevation of tumor markers. Patient was undergone to right laparoendoscopic single-site retroperitoneal lymph node dissection (LDRP-LESS) by umbilical approach using a single-site multichannel KeyPort (Richard Wolf GmbH, Knittlingen, Germany). RESULTS: After the placement of the device and triangulation of the clips, we proceeded to operate on posterior parietal peritoneum. The descending colon was mobilized to access the retroperitoneum. Complete retroperitoneal lymph node dissection on the right side from iliac vessels to renal vessels, including the paracaval and interaortocaval space, was performed. The specimen was inserted into a laparoscopic bag and was removed together with multichannel system. Abdominal drainage was not employed. Surgical time was 85 min and estimated bleeding 50 cc. The patient was very satisfied with the cosmetic results and was discharged the following day without needing analgesia. The pathology report revealed metastatic seminoma in 5 of 11 lymph nodes receiving systemic chemotherapy (VP16-CDDPs) for 4 cycles with good tolerance. A year later, the patient was disease-free and had no complications. CONCLUSIONS: Umbilical primary LDRP-LESS, with excellent oncologic and cosmetic results, is feasible in selected cases. This approach could be considered the least invasive surgical option economically advantageous due to the reusable nature of the instruments used.

A comparative study between open and laparoscopic approach in radical cystectomy with orthotopic ileal neobladder.

OBJECTIVE: Probably, laparoscopic radical cystectomy with ileal neobladder and neovesicourethral anastomosis is one of the most complex procedures in minimally invasive surgery. MATERIAL AND METHODS: Prospective study carried out in 72 patients surgically treated for invasive bladder neoplasia between January 2008 and October 2013. Patients were undergone to radical cystectomy with ileal neobladder (open approach in 33 patients and laparoscopic approach in 39). The study assessed comparatively surgical outcomes, continence rate and postoperative complications. RESULTS: Mean age was 63.5±9 years (64.3 open vs. 62.7 laparoscopic, P=.46) mean surgery time 323.6±78.7 minutes (321.3 vs. 326.5, P=.77), average hospital stay 14.8 days±8,1 (16.2 vs. 13.6, P=.2), transfusion rate 40.3% (66.7% vs. 17.9%, P<.0001) and complications rate 47.2% (63.6% vs. 33.3%, P=.01). Major complications were reported in 29.1% of cases (39.4% open vs. 20,5% laparoscopic, P=.07). With a mean follow-up rate of 42.5±19.2 months (range 15-70), 50 (69.4%) patients remain alive and free of disease. Continence was evaluated in these patients: total continence rate was 38% (50% vs. 27%, P=.09) and diurnal continence rate 58% (70.8% vs. 46.1%, P=.07). Self-catheterization rate was 8% (4.2% vs. 11.5%, P=.67). Total incontinence rate was 34% (25% vs. 42.3%, P=.19). CONCLUSION: According to our experience, transfusion rate, number and severity of complications are lower in laparoscopic cystectomy with ileal neobladder. No statistically significant impact on operative time and on hospital stay was observed. In patients undergone to laparoscopic approach, continence rate is lower but not statistically significant.

"Knotless" laparoscopic extraperitoneal adenomectomy.

INTRODUCTION: Laparoscopic adenomectomy is a feasible and effective surgical procedure. We have progressively simplified the procedure using barbed sutures and a technique we call "knotless" laparoscopic adenomectomy. We present a prospective, multicenter, descriptive study that reflects the efficacy and safety of this technique in an actual, reproducible clinical practice situation. METHODS: A total of 26 patients with benign prostatic hyperplasia of considerable size (>80cc) underwent "knotless" laparoscopic adenomectomy. This is an extraperitoneal laparoscopic technique with 4 trocars based on the controlled and hemostatic enucleation of the adenoma using ultrasonic scalpels, precise urethral sectioning under direct vision assisted by a urethral plug, trigonization using barbed suture covering the posterior wall of the fascia, capsulorrhaphy with barbed suture and extraction of the morcellated adenoma through the umbilical incision. RESULTS: The median patient age was 69 (54-83)years, the mean prostate volume was 127 (89-245)cc, the mean operative time was 136 (90-315)min, the mean estimated bleeding volume was 200 (120-500)cc and the hospital stay was 3 (2-6)days. All patients experienced improved function in terms of uroflowmetry and International Prostate Symptom Score and quality of life questionnaires. There were complications in 6 patients, 5 of which were minor. CONCLUSIONS: "Knotless" laparoscopic adenomectomy is a procedure with low complexity that combines the advantages of open surgery (lasting functional results and complete extraction of the adenoma) with laparoscopic procedures (reduced bleeding and need for transfusions, shorter hospital stays and reduced morbidity and complications related to the abdominal wall). The use of ultrasonic scalpels and barbed sutures simplifies the procedure and enables a safe and hemostatic technique.

Estudio comparativo entre cirugía retrógrada intrarrenal y micro-nefrolitotomía percutánea en el tratamiento de la litiasis renal de tamaño intermedio / Comparative study of retrograde intrarenal surgery and micropercutaneous nephrolithotomy in the treatment of intermediate-sized kidney stones

Objetivo: La cirugía retrógrada intrarrenal (CRIR) muestra eficacia contrastada con mínima morbilidad en el tratamiento de la litiasis renal de tamaño intermedio. Se pretende estudiar la viabilidad de micro-nefrolitotomía percutánea (microperc) en esta indicación y evaluar sus resultados de forma comparativa a CRIR. Material y métodos: Desde septiembre a diciembre de 2013 realizamos un estudio comparativo prospectivo entre CRIR y microperc, en 20 pacientes consecutivos con litiasis renal de tamaño intermedio (1-3 cm). Se empleó ureteroscopio flexible de doble canal (Cobra, Richard Wolf GmbH) y Microperc 4,85/8 Fr en posición supino con fibra óptica flexible de 0,9 mm y 120º, 10.000 píxeles (PolyDiagnost GmbH). Las variables analizadas fueron: datos demográficos, características del cálculo, porcentaje de eliminación de litiasis, complicaciones (Clavien-Dindo), tiempo quirúrgico, estancia hospitalaria y necesidad de procedimientos auxiliares. Resultados: Los pacientes recibieron CRIR (n = 12) o microperc (n = 8). No existieron diferencias demográficas ni en las características de la litiasis entre ambos grupos. El porcentaje de eliminación de litiasis con CRIR fue 91,7% y con microperc 87,5% (p = 1). Un paciente tratado con CRIR (8,3%) tuvo fiebre postoperatoria y otro con microperc (12,5%) dolor cólico postoperatorio (ambos Clavien I). Los tiempos operatorios fueron similares: CRIR 120 min (111,2-148,7) y microperc 120 min (88,7-167,5) (p = 0,8). Ningún paciente necesitó transfusión sanguínea. La estancia hospitalaria fue también equivalente: CRIR 1 día (1-2) y microperc 1,5 días (1-3,5) (p = 0,33). Dos pacientes tratados con microperc (25%) necesitaron procedimientos accesorios (CRIR simultánea y nefroscopia flexible tras dilatación del trayecto percutáneo para tratar en ambos casos un fragmento significativo migrado a un cáliz no accesible) y uno en el grupo CRIR (8,3%) precisó nefrolitotomía percutánea por anatomía infundíbulo-calicial desfavorable (p = 0,54). Conclusiones: Microperc es un método mínimamente invasivo emergente, eficaz y seguro para tratar litiasis renal de tamaño intermedio. Se precisan estudios que evalúen mejor coste-efectividad, la necesidad de tratamientos complementarios y su posible complementariedad con CRIR cuando se trabaja en posición supina

Objective: Retrograde intrarenal surgery (RIRS) has proven efficacy with minimal morbidity in the treatment of intermediate-sized kidney stones. The aim of this study was to examine the feasibility of micropercutaneous nephrolithotomy (microperc) for this indication and evaluate its results compared with those of RIRS. Material and methods: From September to December 2013, we performed a comparative prospective study between RIRS and microperc, with 20 consecutive patients with intermediate-sized (1-3 cm) kidney stones. We employed a flexible dual-channel ureteroscope (Cobra, Richard Wolf GmbH) and a Microperc 4.85/8 Fr (with the patient supine) with flexible fiberoptics (0.9 mm, 120° and 10,000 pixels) (PolyDiagnost GmbH). The study variables were demographic data, stone characteristics, percentage of stone elimination, complications (Clavien-Dindo), surgical time, hospital stay and need for auxiliary procedures. Results: The patients underwent RIRS (n = 12) or microperc (n = 8). There were no differences in the demographics or stone characteristics between the 2 groups. The percentage of stone elimination with RIRS and microperc was 91.7% and 87.5% (P = 1), respectively. One of the patients who underwent RIRS (8.3%) experienced postoperative fever; one of the patients who underwent microperc (12.5%) experienced postoperative colic pain (both cases were classified as Clavien I). The operative times were similar: 120 min (111.2-148.7) and 120 (88.7-167.5) min for RIRS and microperc (P = .8), respectively. None of the patients required a blood transfusion. The hospital stays were also equivalent: 1 day (1-2) and 1.5 days (1-3.5) for RIRS and microperc (P = .33), respectively. Two patients treated with microperc (25%) required auxiliary procedures (simultaneous RIRS and flexible nephroscopy after percutaneous trajectory dilation to treat, in both cases, a significant fragment that had migrated to an inaccessible calyx), and 1 patient in the RIRS group (8.3%) required percutaneous nephrolithotomy due to unfavorable infundibular-calyceal anatomy (P = .54). Conclusions: Microperc is a minimally invasive method that is emerging as an effective and safe treatment for intermediate-sized kidney stones. Studies are needed to better evaluate its cost-effectiveness, the need for complementary treatments and its possible complementarity with RIRS when working with patients in the supine position

Genes reparadores del ADN y pronóstico en formas esporádicas de carcinoma urotelial del tracto urinario superior / DNA repair genes and prognosis in sporadic forms of urothelial carcinoma of the upper urinary tract

Introducción: El síndrome de Lynch o cáncer colorrectal hereditario no polipósico se debe a mutaciones en los genes de reparación de ADN, conocidos como mismatch repair (MMR), y se asocian a inestabilidad de microsatélites. El carcinoma urotelial de la pelvis renal también se asocia a este síndrome, e incluso estas anomalías genéticas se han descrito en formas esporádicas de carcinoma urotelial del tracto superior (CU-TUS). Material y método: Estudio descriptivo y análisis de supervivencia en una serie de 80 pacientes con CU-TUS esporádico sin metástasis al diagnóstico (N0/Nx M0) tratados mediante nefroureterectomía exclusivamente. Se evalúa la expresión de genes MMR (hMLH1, hPMS2, hMSH2 y hMSH6) en secciones realizadas con microarray de tejido (TMA) y su asociación con parámetros clínico-patológicos. Se analiza el valor pronóstico de la pérdida de expresión de estos genes en CU-TUS. Resultados: No se detectó pérdida de MSH2 ni de MSH6, pero se evidenció pérdida de MLH1 en 11 casos (13,8%) y de PMS2 en 21 (26,3%). La expresión de hMLH1 y hPMS2 se encuentra fuertemente asociada (p < 0,0001) y este fenotipo de expresión conlleva importantes implicaciones clínicas. Pérdida de MLH1 se asocia con bajo grado (p = 0,02). Pérdida de PMS2 se asocia con menor estadio (p = 0,05), patrón empujante sin borde invasivo (p = 0,008) y menos angiogénesis (p = 0,008). La inactivación dehPMS2 o hMLH1es un factor protector independiente (HR 0,309) y junto con el grado histológico (HR 5,561) define el pronóstico de estos pacientes. Conclusión: En nuestra experiencia la inactivación de hPMS2 o hMLH1 es un marcador independiente de buen pronóstico y sucede en la cuarta parte de los CU-TUS esporádicos. El estudio IHQ de estos pacientes puede emplearse para valorar el cribado de formas ocultas de síndrome de Lynch

Introduction: Lynch syndrome or hereditary nonpolyposis colorectal cancer is caused by mutations in DNA repair genes, known as mismatch repair (MMR) genes, and is associated with microsatellite instability. Urothelial carcinoma of the renal pelvis is also associated with this syndrome. These genetic abnormalities have been described in sporadic forms of upper tract urothelial carcinoma (UTUC). Material and method: This was a descriptive study and survival analysis of a series of 80 patients with sporadic UTUC with no metastases at diagnosis (N0/Nx M0) treated exclusively with nephroureterectomy. We evaluated the expression of MMR genes (hMLH1, hPMS2, hMSH2 and hMSH6) in sections performed with tissue microarray (TMA) and their association with clinical-pathological parameters. We analyzed the prognostic value of the loss of expression of these genes in UTUC. Results: We detected no loss of MSH2 or of MSH6, but there was a loss of MLH1 in 11 cases (13.8%) and of PMS2 in 21 cases (26.3%). The expression of hMLH1 and hPMS2 were strongly associated (P < .0001), and this phenotype expression entails significant clinical implications. The loss of MLH1 was associated with a low grade (P = .02). Loss of PMS2 was associated with a lower stage (P = .05), a pushing pattern with no invasive edges (P = .008) and less angiogenesis (P = .008). The inactivation ofhPMS2 or hMLH1 is an independent protective factor (HR, 0.309) and, along with the histologic grade (HR, 5.561), defines the patients’ prognosis. Conclusion: In our experience, the inactivation of hPMS2 or hMLH1 is an independent marker of good prognosis and occurs in a quarter of sporadic UTUC cases. The immunohistochemical study of these patients can be used to assess the screening of hidden forms of Lynch syndrome

Impacto de la expresión de p53, MIB-1 y PECAM-1 en el pronóstico del carcinoma urotelial de la pelvis renal / Impact of p53, MIB-1 and PECAM-1 expression on the prognosis of urothelial carcinoma of the renal pelvis

Objetivo: Investigar si la sobreexpresión de los niveles proteicos de p53, MIB-1 y PECAM-1 ocupa un lugar de interés en la predicción de pronóstico del carcinoma de células transicionales del tracto urinario superior (CCT-TUS) de asiento primario en la pelvis renal. Material y método: Análisis uni y multivariante para la predicción de pronóstico en una serie de 82 pacientes con CCT-TUS de pelvis renal sin metástasis al diagnóstico (N0/Nx M0) tratados mediante nefroureterectomía exclusivamente. Se evalúan parámetros clínico-patológicos (edad, sexo, grado, extensión tumoral, variedad histológica, patrón de crecimiento, invasión vascular, infiltración del parénquima renal, necrosis tumoral) y expresión inmunohistoquímica (IHQ) de p53, MIB-1 (ki-67) y PECAM-1 (CD31) en secciones realizadas con microarray de tejido (TMA). Resultados: El 47,6% fueron lesiones de alto grado según la clasificación USIP-OMS. El patrón de crecimiento fue plano en 15,85%. La distribución por categoría T fue: 3,7% pTa, 51,2% pT1, 11% pT2, 29,3% pT3 y 4,9% pT4. El seguimiento medio fue 46,8 + 38,5 (rango: 4-172) meses. La mediana de supervivencia se alcanzó a los 57 (IC 95%: 44-63) meses. El análisis univariante reveló que la supervivencia en estos pacientes se asocia a tamaño tumoral (p = 0,028), variedad histológica (p < 0,0001), patrón de crecimiento (p < 0,0001), grado (p < 0,0001), pT (p = 0,01), invasión vascular (p = 0,025), necrosis (p = 0,004) y sobreexpresión de p53 (p = 0,0006), PECAM-1 (p = 0,0036) y MIB-1 (p = 0,0038). El modelo de regresión de Cox mostró que alto grado (HR = 4,2 [IC 95%: 1,28-13,79]; p = 0,018), patrón de crecimiento plano (HR = 2,52 [IC 95%: 1,05-6,03]; p = 0,038) y sobreexpresión de p53 (HR = 2,8 [IC 95%: 1,22-6,44]; p = 0,015) fueron variables predictivas independientes. Conclusión: El grado histológico, el patrón de crecimiento tumoral y la sobreexpresión de p53 se establecen como los principales factores predictivos de pronóstico en CCT-TUS primario de pelvis renal. No se reproduce el valor independiente de MIB-1 objetivado en otros estudios

Objective: Determining whether the overexpression of p53, MIB-1 and PECAM-1 of protein levels is of interest in predicting the prognosis of transitional cell carcinoma of the upper urinary tract (TCC-UUT) with the primary seat in the renal pelvis. Materials and methods: A univariate and multivariate analysis was conducted for prognosis prediction in a series of 82 patients with TCC-UUT of the renal pelvis who had no metastases at diagnosis (N0/Nx M0) and were treated exclusively with nephroureterectomy. We assessed clinicopathological parameters (age, gender, tumor grade and extent, histological variety, growth pattern, vascular invasion, infiltration of the renal parenchyma, and tumor necrosis) and the immunohistochemical expression of p53, MIB-1 (ki-67) and PECAM-1 (CD31) in sections performed with tissue microarray (TMA). Results: A total of 47.6% of the patients had high-grade lesions according to the USIP-WHO classification. The growth pattern was flat in 15.85%. The distribution by T category was: 3.7% pTa, 51.2% pT1, 11% pT2, 29.3% pT3 and 4.9% pT4. The mean follow-up was 46.8 ± 38.5 (range 4-172) months. The median survival was reached at 57 (95% CI 44-63) months. The univariate analysis revealed that survival in these patients is associated with tumor size (p = 0.028), histological variety (p < 0.0001), growth pattern (p < 0.0001), grade (p < 0.0001), pT (p = 0.01), vascular invasion (p = 0.025), necrosis (p = 0.004) and overexpression of p53 (p = 0.0006), PECAM-1 (p = 0.0036) and MIB-1 (p = 0.0038). The Cox regression model showed that high-grade (HR, 4.2; 95% CI 1.28-13.79; p = 0.018), flat-growth pattern (HR, 2.52; 95% CI 1.05-6.03; p = 0.038) and p53 overexpression (HR, 2.8; 95% CI 1.22-6.44; p = 0.015) were independent predictors. Conclusion: Histological grade, tumor growth pattern and p53 over expression were established as the primary predictors of prognosis for primary TCC-UUT of the renal pelvis. The independent value of MIB-1 observed in other studies was not reproduced in this study

Los polifenoles del vino ejercen su efecto antineoplásico sobre la línea celular PC-3 andrógeno resistente a través de la inhibición de la actividad transcripcional del promotor de COX-2 mediada por NF-kBeta / Wine Polyphenols Exert Antineoplasic Effect on Androgen Resistant PC-3 Cell Line Through the Inhibition of the Transcriptional Activity of COX-2 Promoter Mediated by NF-kBeta

Objetivo: La dieta mediterránea puede tener un papel en la prevención del desarrollo y progresión del cáncer de próstata (CaP). La expresión de ciclooxigenasa-2 (COX-2) se asocia con proliferación celular aumentada, previene la apoptosis y favorece la invasión tumoral. Se intenta clarificar si el resveratrol y otros polifenoles del vino inhiben de forma efectiva la actividad de COX-2 e inducen apoptosis en la línea celular PC-3 de cáncer hormonorrefractario. Material y método: Células PC-3 fueron cultivadas y tratadas con diferentes concentraciones de ácido gálico, ácido tánico, quercetina y resveratrol en presencia del éster de forbol PMA (50 μg/ml) que induce la expresión de COX-2. Se extrajo ARN total y se analizó la expresión de COX-2 mediante cuantificación relativa por PCR a tiempo real (método ΔΔCt). La actividad COX-2 se determinó mediante detección de PGE-2 por ELISA. Se empleó ensayo de luminiscencia Caspasa 3/7 para evaluar la apoptosis. La transfección transitoria con plásmidos short human COX-2 (phPES2 –327/+59) y p5xNF-kβ-Luc determinó la actividad del promotor de COX-2 y de forma particular la dependiente de NF-kβ. Resultados: La expresión de COX-2 no se modificó en ausencia de PMA. No obstante, bajo la inducción con PMA, ácido tánico (2,08 ± 0,21), ácido gálico (2,46 ± 0,16), quercetina (1,78 ± 0,14), y especialmente resveratrol (1,15 ± 0,16) inhibieron significativamente la expresión de COX-2 respecto al control (3,14 ± 0,07), causando una reducción del 34, 23, 46 y 61%. La inhibición en los niveles de PGE-2 siguió un patrón similar. Todos los compuestos estudiados indujeron apoptosis a las 48 h, aunque en diferente proporción. PMA causó un aumento de la actividad de 7,4 ± 0,23 veces phPES2 -327/+59 y 2,0 ± 0,1 veces p5xNF-kβ-Luc a 6 h sobre los niveles basales. El resveratrol suprimió estos efectos 17,1 ± 0,21 y 32,4 ± 0,18 veces, respectivamente. De forma similar, aunque en menor medida, el resto de polifenoles evaluados disminuyeron el efecto inductor de PMA sobre la actividad de ambos promotores. Conclusiones: Los polifenoles inhiben la actividad transcripcional del promotor de COX-2 mediada por NF-kβ. Este efecto podría explicar, al menos en parte, la inducción in vitro de apoptosis por estas sustancias en CaP resistente a la castración

Objective: Mediterranean diet may play a role in the prevention of prostate cancer (PCa) development and progression. Cyclooxygenase-2 (COX-2) expression is associated with increased cellular proliferation, prevents apoptosis and favors tumor invasion. We intend to clarify whether resveratrol and other polyphenols effectively inhibit COX-2 activity and induce apoptosis in hormone-resistant PC-3 cell line. Material and method: PC-3 cells were cultured and treated with different concentrations of gallic acid, tannic acid, quercetin, and resveratrol in presence of phorbol myristate acetate (PMA; 50 μg/ml) that induces COX-2 expression. Total RNA was extracted and COX-2 expression was analyzed by relative quantification real-time PCR (ΔΔCt method). COX-2 activity was determined by PGE-2 detection using ELISA. Caspase 3/7 luminescence assay was used to disclose apoptosis. Transitory transfection with short human COX-2 (phPES2 −327/+59) and p5xNF-κβ-Luc plasmids determined COX-2 promoter activity and specifically that dependant of NF-κβ. Results: COX-2 expression was not modified in media devoid of PMA. However, under PMA induction tannic acid (2.08 ± 0.21), gallic acid (2.46 ± 0.16), quercetin (1.78 ± 0.14) and resveratrol (1.15 ± 0.16) significantly inhibited COX-2 mRNA with respect to control (3.14 ± 0.07), what means a 34%, 23%, 46% and 61% reduction, respectively. The inhibition in the levels of PGE-2 followed a similar pattern. All compounds studied induced apoptosis at 48 h, although at a different rate. PMA caused a rise in activity 7.4 ± 0.23 times phPES2 −327/+59 and 2.0 ± 0.1 times p5 × NF-κβ-Luc at 6 h compared to basal. Resveratrol suppressed these effects 17.1 ± .21 and 32.4 ± .18 times, respectively. Similarly, but to a lesser extent, the rest of evaluated polyphenols diminished PMA inductor effect on the activity of both promoters. Conclusions: Polyphenols inhibit transcriptional activity of COX-2 promoter mediated by NF-κβ. This effect could explain, at least in part, the induction of apoptosis in vitro by these substances in castration resistant PCa

Simulador de realidad virtual para el entrenamiento en vaporización fotoselectiva de la próstata con láser de diodo 980 nm y curva de aprendizaje de la técnica / Virtual reality simulator for training on photoselective vaporization of the prostate with 980 nm diode laser and learning curve of the technique

Objetivo: Se investiga la utilidad de un simulador de realidad virtual para el entrenamiento de la vaporización fotoselectiva de la próstata con láser de diodo. Material y método: Se han practicado 2 experimentos con un simulador (VirtaMed AG, Zürich, Suiza) con software para entrenamiento específico en vaporización prostática modo de contacto con fibra Twister (Biolitec AG, Jena, Alemania). Dieciocho cirujanos realizaron ablación prostática (55 cc) por duplicado y se comparó la puntuación obtenida (190 puntos eficacia y 80 seguridad) en la segunda de ellas por grupos de experiencia (alumnos médicos, residentes, especialistas). También realizaron prueba de orientación espacial con puntuaciones de 0 a 6. Posteriormente 6 de estos cirujanos repitieron 15 ablaciones prostáticas (55 y 70 ml). Se evalúa la mejora de los parámetros obtenidos para definir la curva de aprendizaje y cómo influye la experiencia, las habilidades de orientación espacial y el tipo de secuencia realizada. Resultados: La puntuación global de eficacia y seguridad fue diferente según el grado de experiencia (p = 0,005). Al comparar por pares se detectaron diferencias especialista-alumno (p = 0,004), pero no especialista-residente (p = 0,12) o residente-alumno (p = 0,2). Con respecto a la eficacia del procedimiento se detectan diferencias especialista-alumno (p = 0,0026) y residente-alumno (p = 0,08). Los indicadores parciales diferentes en términos de eficacia fueron tasa de ablación (p = 0,01), tiempo de procedimiento (p = 0,03) y cantidad de cápsula no expuesta (p = 0,03). No se observaron diferencias entre grupos en seguridad (p = 0,5). Con respecto a la curva de aprendizaje la mediana del porcentaje sobre la puntuación total superó el 90% tras realizar 4 procedimientos para próstatas de 55 ml y 10 para glándulas de 70 ml. Esta evolución no se modificó por experiencia previa (residente-especialista; p = 0,6), pero sí según la secuencia de repetición (progresiva-aleatoria; p = 0,007). Los cirujanos con orientación espacial inferior a la mediana del grupo (valor 2,5) no superaron el 90% de puntuación a pesar de la repetición del procedimiento. Conclusión: La simulación para la ablación prostática con láser de diodo de contacto es un buen modelo de aprendizaje con validez discriminativa, al correlacionar resultados métricos con niveles de experiencia y habilidades. La repetición secuencial del procedimiento en niveles crecientes de dificultad favorece el aprendizaje

Objective: The utility of a virtual reality simulator for training of the photoselective vaporization of the prostate with diode laser was studied. Materials and methods: Two experiments were performed with a simulator (VirtaMed AG, Zürich, Switzerland) with software for specific training in prostate vaporization in contact mode with Twister fiber (Biolitec AG, Jena, German). Eighteen surgeons performed ablation of the prostate (55 cc) twice and compared the score obtained (190 points efficacy and 80 safety) in the second one of them by experience groups (medical students, residents, specialists). They also performed a spatial orientation test with scores of 0-6. After, six of these surgeons repeated 15 ablations of the prostate (55 and 70 ml). Improvement of the parameters obtained was evaluated to define the learning curve and how experience, spatial orientation skills and type of sequences performed affects them. Results: Global efficacy and safety score were different according to the grade of experience (P = 0.005). When compared by pairs, specialist-student differences were detected (p = 0.004), but not specialist-resident (P = 0.12) or resident-student (P = 0.2). Regarding efficacy of the procedure, specialist-student (p = 0.0026) and resident-student (P = 0.08) differences were detected. The different partial indicators in terms of efficacy were rate of ablation (P = 0.01), procedure time (P = 0.03) and amount of unexposed capsule (p = 0.03). Differences were not observed between groups in safety (P = 0.5). Regarding the learning curve, percentage median on the total score exceeded 90% after performing four procedures for prostates of 55 ml and 10 procedures for prostate glands of 70 ml. This course was not modified by previous experience (resident-specialist; P = 0.6). However, it was modified according to the repetition sequence (progressive-random; P = 0.007). Surgeons whose spatial orientation was less than the median of the group (value 2.5) did not surpass 90% of the score in spite of repetition of the procedure. Conclusion: Simulation for ablation of the prostate with contact diode laser is a good learning model with discriminative validity, as it correlates the metric results with levels of experience and skills. The sequential repetition of the procedure on growing levels of difficulty favors learning

Eficacia y seguridad de fosfomicina-trometamol en la profilaxis de la biopsia transrectal de la próstata: estudio prospectivo aleatorizado comparativo con ciprofloxacino / Efficacy and safety of Fosfomycin-trometamol in the prophylaxis for transrectal prostate biopsy. Prospective randomized comparison with ciprofloxacin

Objetivo: La biopsia de próstata constituye el estándar de diagnóstico del cáncer de próstata. No existe un protocolo estandarizado, pero sí recomendaciones que ayudan a disminuir la incidencia de complicaciones. El objetivo de este trabajo es evaluar la eficacia y seguridad de la profilaxis antibiótica en biopsia prostática comparando 2 dosis de fosfomicina-trometamol (FMT) 3 g (cada 48 h) con 10 de ciprofloxacino oral 500 mg (cada 12 h, 5 días). Material y métodos: Estudio prospectivo aleatorizado con 671 pacientes sometidos a biopsia prostática transrectal ecodirigida ambulante. El grupo A (n = 312) recibió ciprofloxacino y el B (n = 359) FMT. Se comparó la eficacia de ambos regímenes y tolerabilidad del tratamiento. Se practicó cultivo de orina a las 2 semanas de la biopsia. Los pacientes con bacteriuria asintomática no recibieron tratamiento antibiótico inicialmente, y se les practicó un nuevo cultivo de orina al mes, tratándose la bacteriuria persistente según el antibiograma. Resultados: No existieron diferencias entre grupos respecto a la edad (p = 0,78), presencia de cáncer (p = 0,9) o número de cilindros (p = 0,93). El número medio de cilindros obtenidos fue 11,3 + 3,25 (rango: 6-20). Nueve pacientes (2,9%) en A y 10 (2,8%) en B presentaron intolerancia digestiva. Un caso (0,3%) en A presentó reacción alérgica severa. En total 167 (24,6%) presentaron complicaciones: 16 (2,4%) fiebre, 47 (6,9%) hemospermia, 81 (11,9%) hematuria, 7 (1%) rectorragia y 16 (2,4%) retención urinaria. No se detectaron diferencias entre grupos (27,6 vs. 22,6%; p = 0,17), pero sucedió más hemospermia en A (9,9 vs. 4,5%; p = 0,006). En 44 (6,6%) se detectó bacteriuria tras la biopsia, más frecuente en B (4,2 vs. 8,6%; p = 0,02), aunque sin precisar mayor número de segundos tratamientos (53,9 vs. 29%; p = 0,17). La probabilidad de resistencia a ciprofloxacino en pacientes con bacteriuria en A fue mayor que la de FMT en B (69,2 vs. 41,9%; p = 0,0004). Conclusiones: La profilaxis antibiótica en la biopsia prostática con FMT (2 dosis de 3 g) es una opción igual de eficaz y segura que ciprofloxacino (10 dosis de 500 mg), que conlleva menor tasa de resistencias. En nuestra experiencia la profilaxis con este fármaco es una opción segura, bien tolerada y de cómoda administración, lo que facilita su cumplimiento. Se necesitan estudios multicéntricos prospectivos que confirmen estos hallazgos

Objective: Prostate biopsy is the standardized diagnostic method for prostate cancer. However, although there is not a standardized protocol, there are recommendations in order to reduce the incidence of complications. The objective of the present work is to assess the efficacy and safety of antibiotic prophylaxis in the prostate biopsy by comparing two antibiotic regimes: two doses of fosfomycin-trometamol 3 g (FMT) every 48 h with 10 doses of oral ciprofloxacin 500 mg every 12 h for 5 days. Material and methods: Randomized prospective study was performed with 671 patients who had undergone to walking transrectal ultrasound guided prostate biopsy. Patients of group A (n = 312) were treated with ciprofloxacin, and patients of group B (n = 359) with FMT. Efficacy and tolerability of two prophylactic regimes were compared. Urine culture was carried out at 2 weeks after biopsy. Initially, patients with asymptomatic bacteriuria were not treated with antibiotics; urine culture was repeated after 1 month, persistent bacteriuria was treated according to antibiogram. Results: No differences between groups were found in age (p = 0.78), cancer presence (p = 0.9) or number of biopsy cylinders (p = 0.93). The mean number of cores obtained was 11.3 ± 3.25 (range 6-20). Digestive intolerance was observed for 9 patients (2.9%) of group A and 10 patients (2.8%) in group B. One patient (0.3%) of group A showed severe allergic reaction. In total, 167 patients (24.6%) had complications: 16 (2.4%) fever, 47 (6.9%) hemospermia, 81 (11.9%) hematuria, 7 (1%) rectal bleeding and 16 (2.4%) urinary retention. No statistically differences between groups were observed (27.6% vs. 22.6%; p = 0.17). However, hemospermia was more frequent in group A (9.9% vs. 4.5%; p = 0.006). Bacteriuria after biopsy was detected in 44 patients (6.6%), being more frequent in group B patients (4.2% vs. 8.6%; p = 0.02) although a higher number of second treatment cycles were not needed (53.9% vs. 29%; p = 0.17). The likelihood of resistance to ciprofloxacin in patients with bacteriuria in A was greater than that of FMT in B (69.2% vs. 41.9%; p = 0.0004). Conclusions: Antibiotic prophylaxis with FMT (2 doses of 3 g) in prostate biopsy is an alternative as effective and safe as ciprofloxacin (10 doses of 500 mg), which carries lower rate of resistance. According to our experience, this drug is a safe, well-tolerated, and easily manageable prophylactic option, facilitating patient compliance. More prospective multicenter studies are necessary to confirm these findings

DNA repair genes and prognosis in sporadic forms of urothelial carcinoma of the upper urinary tract.

INTRODUCTION: Lynch syndrome or hereditary nonpolyposis colorectal cancer is caused by mutations in DNA repair genes, known as mismatch repair (MMR) genes, and is associated with microsatellite instability. Urothelial carcinoma of the renal pelvis is also associated with this syndrome. These genetic abnormalities have been described in sporadic forms of upper tract urothelial carcinoma (UTUC). MATERIAL AND METHOD: This was a descriptive study and survival analysis of a series of 80 patients with sporadic UTUC with no metastases at diagnosis (N0/Nx M0) treated exclusively with nephroureterectomy. We evaluated the expression of MMR genes (hMLH1, hPMS2, hMSH2 and hMSH6) in sections performed with tissue microarray (TMA) and their association with clinical-pathological parameters. We analyzed the prognostic value of the loss of expression of these genes in UTUC. RESULTS: We detected no loss of MSH2 or of MSH6, but there was a loss of MLH1 in 11 cases (13.8%) and of PMS2 in 21 cases (26.3%). The expression of hMLH1 and hPMS2 were strongly associated (P<.0001), and this phenotype expression entails significant clinical implications. The loss of MLH1 was associated with a low grade (P=.02). Loss of PMS2 was associated with a lower stage (P=.05), a pushing pattern with no invasive edges (P=.008) and less angiogenesis (P=.008). The inactivation of hPMS2 or hMLH1 is an independent protective factor (HR, 0.309) and, along with the histologic grade (HR, 5.561), defines the patients' prognosis. CONCLUSION: In our experience, the inactivation of hPMS2 or hMLH1 is an independent marker of good prognosis and occurs in a quarter of sporadic UTUC cases. The immunohistochemical study of these patients can be used to assess the screening of hidden forms of Lynch syndrome.