Identifying prognostic parameters related to surgical technique in patients treated by robotic radical prostatectomy.

INTRODUCTION AND OBJECTIVE: The most frequently studied factors in patients treated by robotic radical prostatectomy are PSA and pathological features of the biopsy and prostatectomy specimen. Studies on the factors associated with the surgical technique are scarce and with controversial results. The objective is to identify all possible surgical factors and their relationship with disease-free and metastasis-free survival. PATIENTS AND METHOD: Prospective study approved by the Ethics Committee, including patients who underwent robotic radical prostatectomy since January 2009 with a minimum follow-up of 5 years. Surgeon, surgical time, blood loss, fascial access, continence techniques, preservation of the fascia, neurovascular bundles, bladder neck, urethra, learning curve and surgical complications, were analyzed as possible prognostic factors. We performed univariate and matched comparisons of survival using Kaplan-Meier estimation and long-rank tests. The significance level for multiple comparisons was established with False Discovery Rate-adjustment (adjusted p). RESULTS: Cohort of 667 patients with a median follow-up of 69 months. In univariate analysis, surgeon (adjp=0.018), preservation of puboprostatic ligaments (adjp=0.02), preservation of endopelvic fascia (adjp=0.001) and performing periurethral suspension (adjp<0.001) are poor prognostic factors for disease-free survival. Fascia preservation also negatively affects metastasis-free survival (adjp=0.04). Previous abdominal surgeries, prostate, surgical time, blood loss, type of residual urethra, middle lobe, fascial access, fascia or bladder neck preservation, have no statistical significance. CONCLUSIONS: The surgeon and specific aspects of the surgical technique are determining factors in disease-free survival. Preservation of the fascia is the only factor that negatively affects metastasis-free survival.

Cáncer de próstata resistente a la castración. Recomendaciones de consenso de la Asociación Española de Urología / Castrate resistant prostate cancer. Consensus recommendations of the Spanish Association of Urology

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Enucleación de quiste lateral de próstata con láser holmium: una excelente alternativa / Enucleation of a lateral prostatic cyst of the prostate with the holmium laser, an excellent therapeutical alternative

Presentar un caso de sintomatología del tracto urinario inferior provocada por obstrucción al fluido urinario por un quiste lateral de próstata y los resultados de la enucleación del mismo con láser Holmium. Presentamos el caso de un paciente joven con sintomatología miccional de 1 año de evolución. Diagnosticado mediante ecografía de quiste prostático. Ante el diagnóstico de quiste obstructivo, se plantea enucleación con láser holmium obteniendo resultadospost operatorios inmediatos y excelentes. Los quistes prostáticos simples son el tipo más frecuente, siendo asintomáticos en la mayoría de los casos y descubiertos incidentalmente. Dichos quistes adquieren importancia clínica si provocan sintomatología del tracto urinario inferior, infertilidad o son el asiento de neoplasia prostática. El tratamiento habitual es la resección transuretral. En este paciente planteamos enucleación del quiste con láser holmium. Esta técnica permite et alta hospitalaria sin sonda en menos de 24 horas, se evita el riesgo de síndrome de reabsorción, provoca un mínimo sangrado y rápida remisión de la sintomatología...

The purpose of this paper is to present a case of lower urinary tract symptomatology caused by flow obstruction due to a lateral cyst of the prostate and the results obtained by enucleating using the Holmium laser. We present the case of a young patient with one year of lower urinary-tract symptoms. The diagnosis of a prostatic cyst was confirmed by ultrasound examination. Having the finding of an obstructive prostatic cyst it was treated by means of Holmium laser enucleation with excellent postoperative results. Simple prostatic cysts are the most frequent type and are generally asymptomatic and are incidentally discovered during routine examination. These cysts become clinically relevant when they cause lower urinary tract symptoms, infertility or are associated with cancer. Usual treatment is endoscopic resection. ln this case we preformed an Holmium laser enuclation of the c yst, thus permitting the discharge of the patient without catheter in less than 24h. And minimizes reabsortion syndrome and bleeding, with a very fast resolution of the clinical symptomatology...

¿Podemos predecir el íleo postoperatorio tras cistectomía radical? / Is possible to predict postoperative ileus following radical cystectomy?

Objetivo: La cistectomía radical con derivación urinaria es un procedimiento en el cual la reducción de la morbilidad, una rehabilitación postoperatoria rápida, una estancia hospitalaria reducida y una reducción de costes son difíciles de conseguir. El íleo postoperatorio ha sido identificado como la causa más frecuente de retraso en la recuperación y de una mayor estancia hospitalaria. Con nuestro trabajo, intentamos establecer cuáles podrían ser sus principales causas. Material y métodos: Realizamos 154 cistectomías entre 1990–2008. Examinamos diferentes variables demográficas y perioperatorias de los pacientes con y sin íleo. Resultados: No se encontró significación estadística al relacionar el íleo con ninguno de los factores estudiados. Conclusiones: El íleo postoperatorio se presenta como una de las complicaciones más frecuentes que ocasionan una estancia hospitalaria prolongada. Se requieren otros estudios detallados que determinen regímenes perioperatorios destinados a reducir esta complicación (AU)

Objective: Radical cystectomy with urinary diversion is a procedure in which a reduction of morbidity, quick postoperative rehabilitation, limited length of stay and cost containment are difficult to achieve. Postoperative ileus has been identified as the most common cause of delayed recovery and prolonged length of stay. With our review, we try to establish the main causes. Material and methods: A total of 154 patients underwent radical cystectomy from 1990 to 2008. We examined demographic and perioperative variables of the patients who did and did not develop ileus. Results: No significant association was found between ileus and all the factors we studied. Conclusions: Postoperative ileus stands out as one of the most frecuent complications that causes increased length of stay. More detailed studies are required to determine perioperative regimens to reduce this complication (AU)

[Is it possible to predict postoperative ileus following radical cystectomy?]. / ¿Podemos predecir el íleo postoperatorio tras cistectomía radical?

OBJECTIVE: Radical cystectomy with urinary diversion is a procedure in which a reduction of morbidity, quick postoperative rehabilitation, limited length of stay and cost containment are difficult to achieve. Postoperative ileus has been identified as the most common cause of delayed recovery and prolonged length of stay. With our review, we try to establish the main causes. MATERIAL AND METHODS: A total of 154 patients underwent radical cystectomy from 1990 to 2008. We examined demographic and perioperative variables of the patients who did and did not develop ileus. RESULTS: No significant association was found between ileus and all the factors we studied. CONCLUSIONS: Postoperative ileus stands out as one of the most frequent complications that causes increased length of stay. More detailed studies are required to determine perioperative regimens to reduce this complication.

[Climacturia, a symptom to take into account after radical prostatectomy]. / Climacturia, un sintoma a tener en cuenta tras prostatectomía radical.

INTRODUCTION AND OBJECTIVES: Patients after radical prostatectomy describe sexual dysfunctions such as orgasm-associated incontinence also termed climacturia. Our aim is to analyse incidence and data in relation with this symptom. METHODS: 119 phone surveys carried out to patients after radical prostatectomy to Know about climacturia incidence. We are trying to show the relationship between this symptom and the degree and type of incontinence, affectation at bladder neck and apex, and the age. RESULTS: The climacturia incidence came to 20%. The average age of the patients with this symptom was 59 years, the same as for those without it. The patients with both, incontinence and climacturia perform stress incontinence basically but urgency-incontinence to a greater extent (20%) that those with no climacturia (5%). Most patients with climacturia suffer a light leakage (87%) and a 62% always associated to orgasm. Negative effect of the symptom in the patient's and partner's sexual life appeared only in 2 cases (13%). CONCLUSIONS: We suggest the same term in Spanish than in English. Age and affectation of the bladder neck and apex do not have an effect on climacturia. Stress incontinence is more often related to patients with climacturia and the degree of incontinence is higher than in those without it.

Climacturia, un síntoma a tener en cuenta tras prostatectomía radical / Climaturia, a symptom to take into account after radical prostatectomy

Introducción y objetivos: Los pacientes a los que se les ha realizado una prostatectomía radical describen disfunciones sexuales entre las que se encuentra el orgasmo asociado a incontinencia. Pretendemos valorar la incidencia y datos relacionados con este síntoma. Métodos: Realizamos a 119 pacientes a los que se había realizado una prostatectomía radical, una encuesta telefónica dirigida a conocer la incidencia de climacturia. Pretendemos establecer la relación de éste síntoma con el grado y tipo de incontinencia, afectación a nivel de cuello vesical y apex, y la edad. Resultados: La incidencia de climacturia fue del 20%. La edad media de presentación del síntoma fue de 59 años, la misma que para los pacientes sin climacturia. Los pacientes con incontinencia y climacturia presentan fundamentalmente incontinencia de esfuerzo pero urgencia -incontinencia en mayor proporción (20%) que los pacientes sin climacturia (5%). El paciente que tiene climacturia la presenta en forma de unas gotas en un 87% y siempre que llegan al orgasmo en un 62%. La influencia negativa del síntoma en la vida sexual del paciente y de su pareja solo se presentó en 2 casos (13%). Conclusiones: Proponemos el uso del mismo término en lengua castellana que en lengua inglesa. La edad y la afectación en cuello vesical y apex no influyen en la aparición de climacturia. En los pacientes con climacturia se asocia mas frecuentemente incontinencia de esfuerzo y el grado de incontinencia es mayor que en los que no la padecen

Introduction and objectives: Patients after radical prostatectomy describe sexual dysfunctions such as orgasm-associated incontinence also termed climacturia. Our aim is to analyse incidence and data in relation with this symptom. Methods: 119 phone surveys carried out to patients after radical prostatectomy to Know about climacturia incidence. We are trying to show the relationship between this symptom and the degree and type of incontinence, affectation at bladder neck and apex, and the age. Results: The climacturia incidence came to 20%.The average age of the patients with this symptom was 59 years, the same as for those without it. The patients with both, incontinence and climacturia perform stress incontinence basically but urgency-incontinence to a greater extent (20%) that those with no climacturia (5%). Most patients with climacturia suffer a light leakage (87%) and a 62% always associated to orgasm. Negative effect of the symptom in the patient´s and partner´s sexual life appeared only in 2 cases (13%). Conclusions: We suggest the same term in Spanish than in English. Age and affectation of the bladder neck and apex do not have an effect on climacturia. Stress incontinence is more often related to patients with climacturia and the degree of incontinence is higher than in those without it

[Meningeal carcinomatosis in bladder tumor]. / Carcinomatosis meníngea en un tumor vesical.

We report a strange case of a bladder whose first metastasic manifestation, after two years of the diagnosis, was a peripheric polyneuropathia. This patient was treated with immunotherapy with BCG for superficial carcinoma of the bladder during one year. Gradually central neurological symptoms appeared and the patient died one month later. A meningeal carcinomatosis was identify as the cause. No bone metastases existed, which is the most frequent way of tumours extension towards leptomeninges. We argue about the way to arrive at meninges.

[Medical treatment of bladder instability. Our experience]. / Tratamiento médico de la inestabilidad vesical. Nuestra experiencia.

OBJECTIVE: To identify the factors that influence response to treatment of vesical instability. METHODS: A retrospective study was conducted to assess the efficacy of drug therapy with oxybutinin and imipramine in 89 patients with urodynamically demonstrated detrusor hyperreactivity. Control evaluations were performed at 2, 5 and 8 months. Evaluation of the results took into account the etiology, pressure and volume at which the wave of instability appeared. RESULTS: The results were evaluated according to patient subjective criteria. We observed a positive response (cure and improvement) to treatment with oxybutinin alone or oxybutinin+imipramine in 66.25% of the cases; side effects were observed in 44%. There was a 20% improvement in the positive response rate when the wave intensity was greater than 55 cm H2O and the bladder volume at which this occurred was greater than 150 ml. No patient treated with second line drug therapy (flavoxate, nifedipine and trospium chloride) cured. CONCLUSIONS: The etiology of vesical instability did not influence response to therapy. Waves with a greater intensity and those that appeared at higher volumes responded better to treatment. Nearly half of the patients with side effects required a reduction of the dosage or withdrawal of the drug. Our results and those reported elsewhere indicate that non-responders to treatment with oxybutinin alone or in combination with imipramine are unlikely to improve with currently available drug therapy.

[Suburethral sling in the treatment of urinary incontinence: our experience]. / Cabestrillo suburetral en el tratamiento de la incontinencia urinaria: nuestra experiencia.

Review of 17 female patients who underwent placing of Suburethral Sling as anti-incontinence procedure with the purpose of assessing the results obtained. The most frequent complications were urinary retention and post-surgical urgency. A larger proportion of patients with Stress Urinary Incontinence had retention and during more days than those with Mixed Urinary Incontinence. In most cases of mixed urinary incontinence, asymptomatic prior to surgery, the placing of a suburethral sling provokes signs and symptoms of urgency, and even of post-surgical urgency-incontinence. Both complications were attenuated in all cases using measures such as conservation of urinary by-pass or administration of anti-cholinergics. Results at 2 years have been successful in 68.75% cases, thus encouraging us to reduce the number of indications for this technique.

[Trigono-cervico-prostatotomy (TCP) versus transurethral resection of the prostate (TURP). Our experience]. / Trigonocervicoprostatotomía (TCP) versus resección transuretral de próstata (RTU). Nuestra experiencia.

OBJECTIVE: Trigonocervicoprostatotomy (TCP) has been considered up to now an alternative treatment to transurethral resection of the prostate (TURP) when evaluating the size of the prostate. This paper demonstrates that endoscopic visualization is more important when choosing the surgical procedure and that both techniques can achieve satisfactory results. METHODS: The prostate volume is evaluated by ultrasound and according to the endoscopic findings, TURP or TCP is performed. The prostatic lobes are routinely biopsied if the latter procedure is chosen. RESULTS: We compared the results of 34 TCP and 30 TURP procedures using the values of I-PSS and uroflowmetry before and after surgery. In 86.2% of the TCPs and 80% of the TURPs, the patients are asymptomatic with I-PSS less than 7 and significantly improved uroflowmetry data. Biopsy disclosed adenocarcinoma in one patient submitted to TCP. CONCLUSIONS: TCP represents an alternative to TURP not only for small prostates (30 gm) but also for medium-sized prostates (50-60 gms), depending on the endoscopic findings. TCP is not indicated for lateral lobes that fall on the prostate floor. Performing a biopsy routinely in TCP does not prolong the operating time significantly and permits detecting subclinical adenocarcinoma of the prostate.

[Renal-cell adenocarcinoma as an incidental finding. Its diagnosis and tumor evolution]. / Adenocarcinoma renal como hallazgo incidental. Diagnóstico y evolución tumoral.

OBJECTIVES: We attempted to determine whether or not incidental renal cell carcinoma had a better prognosis. METHODS: We reviewed 53 cases of renal cell carcinoma that had been surgically treated over the periods 1985-1988 and 1989-1993. The form of presentation, stage of the incidental tumors, sex, compromised side and the diagnostic imaging technique utilized were analyzed. RESULTS: GI pathology most frequently led to the diagnosis of the tumor. Tumor stages were A or B with a slightly higher prevalence for the incidental tumors. However, the prognosis was not better than that of clinically suspected renal cell carcinoma. The male to female ratio was 1.17:1, the mean age was 63 years, the tumors were frequently right-sided and ultrasound was superior in the diagnosis of incidental tumors. CONCLUSIONS: No prognostic difference was observed between clinically suspected and incidental renal cell carcinoma of the same tumor stage.

[Cysts of the ejaculatory ducts. Diagnosis and clinical course after treatment]. / Quistes de conducto eyaculador. Diagnóstico y evolución tras tratamiento.

Confusion surrounding diagnosis of central prostate cysts is explained for the rarity of the condition. Deferento-vesiculography is diagnostic and must be performed independently (right-left) for a better anatomical evaluation of the area. The endoscopic images do not allow differential diagnosis from other prostate cysts. Recovery of bearer's fertile ability following endoscopic resection does not result, in our experience, as effective as it could be expected from resolving the obstructive cause.

[Bladder leiomyoma: report of a case]. / Leiomioma vesical: a propósito de un caso.

We report a case of leiomyoma of the bladder in a male patient who presented with cystitic syndrome and hematuria. The literature is briefly reviewed and the benign nature of this condition is underscored. The prognosis is excellent with correct treatment.

[Bladder hernia. Report of 4 cases]. / Hernias vesicales. Aportación de cuatro casos.

Four cases of vesicoscrotal herniation are described. The different etiology and forms of presentation (from an incidental finding to one requiring emergency treatment) of this condition are discussed. Surgical treatment is based on its size, location and coexisting pathology (prostatic hyperplasia, calculus, bladder tumor, etc.).