Nefroureterectomía radical asistida por robot para el carcinoma urotelial del tracto urinario superior: resultados peri y postoperatorios / Robot-assisted radical nephroureterectomy for upper tract urothelial carcinoma: Peri and postoperative outcomes

Introducción La nefroureterectomía radical constituye el tratamiento de los tumores uroteliales del tracto urinario superior con alto riesgo de mortalidad específica. La nefroureterectomía radical laparoscópica asistida por robot (NURAR) todavía está siendo investigada para establecer de manera concluyente la seguridad del procedimiento en el tratamiento de los tumores uroteliales del tracto urinario superior. El objetivo principal es evaluar la seguridad intra y postoperatoria de la NURAR y, posteriormente, evaluar los resultados oncológicos a mediano plazo. Métodos Se trata de un estudio retrospectivo monocéntrico basado en una recopilación de NURAR realizadas entre el 1 de enero de 2015 y el 1 de octubre de 2021. Las NURAR se llevaron a cabo con la asistencia del robot Da Vinci Si® y, desde 2017, con el robot Da Vinci Xi®. Siempre que fue posible, la totalidad del procedimiento se llevó a cabo sin reacoplamiento (re-docking). Resultados Entre el 1 de enero de 2015 y el 1 de octubre de 2021, se realizaron 29 NURAR en nuestro centro. En el 80% de los casos se pudo realizar toda la cirugía sin reacoplamiento con el robot Da Vinci Xi®. Un paciente requirió conversión a cirugía abierta por dificultad en la disección. El 50% de los tumores se clasificaron como T3 o T4. La tasa de complicaciones a los 30 días fue del 31%. La duración media de la estancia hospitalaria fue de 5 días. La supervivencia libre de enfermedad en el tiempo medio de supervivencia (27,5 meses) fue del 75,2%. Un paciente tuvo una recidiva en el compartimento de la nefrectomía y ningún paciente tuvo recidiva peritoneal o en los orificios de los trocares. Conclusión La realización de NURAR para el tratamiento de los tumores del tracto urinario superior parece cumplir los criterios de seguridad quirúrgica y oncológica (AU)

Introduction The treatment of urothelial tumours of the upper urinary tract at high risk of specific mortality is based on radical nephroureterectomy. Robotic-assisted laparoscopic radical nephroureterectomy (RARNU) is still under investigation to definitively establish the safety of this procedure in the management of urothelial tumours of the upper urinary tract. The primary objective is to evaluate the intra- and postoperative safety of RARNU and, subsequently, to evaluate the medium-term oncological results. Methods Our study is a retrospective, mono-centric study with a collection of RARNUs conducted between 1st January 2015 and 1st October 2021. The RARNUs were performed with the assistance of the Da Vinci Si® robot, then from 2017 the Da Vinci Xi® robot. Whenever possible, the entire procedure was carried out without re-docking. Results Between 1st January 2015 and 1st October 2021, 29 RARNUs were carried out at our centre. Complete surgery without re-docking was possible in 80% of cases with the Da Vinci Xi® robot. One patient required conversion to open surgery due to difficult dissection. A percentage of 50 of tumours were classified as T3 or T4. The 30-day complication rate was 31%. The median length of hospitalisation was 5 days. The disease-free survival at the mean survival time (27.5 months) was of 75.2%. One patient had a recurrence in the nephrectomy compartment and no patient had a peritoneal or trocar orifice recurrence. Conclusion Performing RARNU for the management of tumours of the upper urinary tract appears to meet the criteria of surgical safety and those of oncological safety (AU)

Robot-assisted radical nephroureterectomy for upper tract urothelial carcinoma: Peri and postoperative outcomes.

INTRODUCTION: The treatment of urothelial tumours of the upper urinary tract at high risk of specific mortality is based on radical nephroureterectomy (RNU). Robotic-assisted laparoscopic radical nephroureterectomy (RARNU) is still under investigation to definitively establish the safety of this procedure in the management of urothelial tumours of the upper urinary tract. The primary objective is to evaluate the intra- and postoperative safety of RARNU and, subsequently, to evaluate the medium-term oncological results. METHODS: Our study is a retrospective, mono-centric study with a collection of RARNUs conducted between 1st January 2015 and 1st October 2021. The RARNUs were performed with the assistance of the Da Vinci Si® robot, then from 2017 the Da Vinci Xi® robot. Whenever possible, the entire procedure was carried out without re-docking. RESULTS: Between 1st January 2015 and 1st October 2021, 29 RARNUs were carried out at our centre. Complete surgery without re-docking was possible in 80% of cases with the Da Vinci Xi® robot. One patient required conversion to open surgery due to difficult dissection. 50% of tumours were classified as T3 or T4. The 30-day complication rate was 31%. The median length of hospitalisation was 5 days. The disease-free survival at the mean survival time (27.5 months) was of 75.2%. One patient had a recurrence in the nephrectomy compartment and no patient had a peritoneal or trocar orifice recurrence. CONCLUSION: Performing RARNU for the management of tumours of the upper urinary tract appears to meet the criteria of surgical safety and those of oncological safety.

Antecedentes de neoplasias urológicas previos al trasplante renal. Resultados oncológicos a largo plazo / History of urological malignancies before kidney transplantation, oncological outcome on the long term

Introducción: Nuestro objetivo ha sido informar de los resultados oncológicos de pacientes con ERET y antecedentes de neoplasias urológicas que fueron sometidos posteriormente a un trasplante renal (TR).Material y métodoEstudio retrospectivo llevado a cabo en el registro de la Fundación Puigvert (Barcelona) con 1.200 TR realizados entre 1988 y 2018. Se identificaron 85 neoplasias urológicas que recibieron tratamiento previo al TR en 81 pacientes: 15 (18%) cánceres de próstata, 49 (58%) carcinoma de células renales (CCR), 19 (22%) carcinomas uroteliales y 2 (2%) cánceres de testículo. Se registraron datos de las características basales, la estadificación del cáncer, el tratamiento y el seguimiento, y sobre la cronología del inicio de diálisis, la inscripción en la lista de espera y el TR. Los criterios de valoración fueron la recidiva del cáncer, la progresión metastásica, la muerte específica por cáncer y la supervivencia global.ResultadosEn una mediana de seguimiento de 13,1 años (2,2-32), se registraron 16/85 (19%) recidivas del cáncer, con 3 (4%) progresiones a metástasis y muerte por cáncer. La mediana de supervivencia global tras el tratamiento del cáncer fue de 25,3 años y la supervivencia por cáncer específica fue del 95% a los 25 años.La mediana de tiempo desde el tratamiento del cáncer hasta el trasplante de riñón fue de 4,8 años: 3,7 años en el cáncer de próstata, 3,9 años en el CCR y 8,8 años en el cáncer vesical. La mediana de tiempo desde el inicio de diálisis hasta el TR fue de 1,8 años en los pacientes con antecedentes de neoplasia urológica, frente a 0,5 años en la cohorte total de 1.200 trasplantes renales durante el mismo periodo. (AU)

Introduction: We aimed to report the oncological outcomes of ESRD patients with histories of urological malignancies who were subsequently submitted to kidney transplantation (KT).Material and methodRetrospective study lead in the Puigvert Foundation (Barcelona) registry of 1,200 KT performed from 1988 to 2018. Eighty-five urological malignancies that were treated before KT in 81 patients were identified: 15 (18%) prostate cancers, 49 (58%) RCC, 19 (22%) urothelial carcinomas and 2 (2%) testicular cancers. Baseline characteristics, cancer staging, treatment and follow-up were registered as well as the chronology of the start of dialysis, inscription on the waiting list and kidney transplantation. Endpoints included were cancer recurrence, metastatic progression, cancer-specific death and overall survival.ResultsIn a median follow-up of 13.1 years (2.2-32), 16/85 (19%) cancer recurrences were reported, with 3 (4%) who progressed to metastasis and died of cancer. Median overall survival after cancer treatment was 25.3 years and cancer-specific survival was 95% at 25 years.Median time from cancer treatment to kidney transplantation was 4.8 years: 3.7 years in prostate cancer, 3.9 years in RCC and 8.8 years in bladder cancer. The median time from start of dialysis to kidney transplantation was 1.8 years in patients with histories of urological malignancy versus 0.5 year in the total cohort of 1,200 renal transplanted over the same period. (AU)

History of urological malignancies before kidney transplantation, oncological outcome on the long term.

INTRODUCTION: We aimed to report the oncological outcomes of ESRD patients with histories of urological malignancies who were subsequently submitted to kidney transplantation (KT). MATERIAL AND METHOD: Retrospective study lead in the Puigvert Foundation (Barcelona) registry of 1,200 KT performed from 1988 to 2018. Eighty-five urological malignancies that were treated before KT in 81 patients were identified: 15 (18%) prostate cancers, 49 (58%) RCC, 19 (22%) urothelial carcinomas and 2 (2%) testicular cancers. Baseline characteristics, cancer staging, treatment and follow-up were registered as well as the chronology of the start of dialysis, inscription on the waiting list and kidney transplantation. Endpoints included were cancer recurrence, metastatic progression, cancer-specific death and overall survival. RESULTS: In a median follow-up of 13.1 years (2.2-32), 16/85 (19%) cancer recurrences were reported, with 3 (4%) who progressed to metastasis and died of cancer. Median overall survival after cancer treatment was 25.3 years and cancer-specific survival was 95% at 25 years. Median time from cancer treatment to kidney transplantation was 4.8 years: 3.7 years in prostate cancer, 3.9 years in RCC and 8.8 years in bladder cancer. The median time from start of dialysis to kidney transplantation was 1.8 years in patients with histories of urological malignancy versus 0.5 year in the total cohort of 1,200 renal transplanted over the same period. CONCLUSIONS: Well-selected patients with histories of urological malignancies greatly benefit from kidney transplantation with infrequent and late cancer recurrence. Waiting time could be optimized in low-risk prostate cancer and RCC, but more robust data are needed.

History of urological malignancies before kidney transplantation, oncological outcome on the long term. / Antecedentes de neoplasias urológicas previos al trasplante renal. Resultados oncológicos a largo plazo.

INTRODUCTION: We aimed to report the oncological outcomes of ESRD patients with histories of urological malignancies who were subsequently submitted to kidney transplantation (KT). MATERIAL AND METHOD: Retrospective study lead in the Puigvert Foundation (Barcelona) registry of 1,200 KT performed from 1988 to 2018. Eighty-five urological malignancies that were treated before KT in 81 patients were identified: 15 (18%) prostate cancers, 49 (58%) RCC, 19 (22%) urothelial carcinomas and 2 (2%) testicular cancers. Baseline characteristics, cancer staging, treatment and follow-up were registered as well as the chronology of the start of dialysis, inscription on the waiting list and kidney transplantation. Endpoints included were cancer recurrence, metastatic progression, cancer-specific death and overall survival. RESULTS: In a median follow-up of 13.1 years (2.2-32), 16/85 (19%) cancer recurrences were reported, with 3 (4%) who progressed to metastasis and died of cancer. Median overall survival after cancer treatment was 25.3 years and cancer-specific survival was 95% at 25 years. Median time from cancer treatment to kidney transplantation was 4.8 years: 3.7 years in prostate cancer, 3.9 years in RCC and 8.8 years in bladder cancer. The median time from start of dialysis to kidney transplantation was 1.8 years in patients with histories of urological malignancy versus 0.5 year in the total cohort of 1,200 renal transplanted over the same period. CONCLUSIONS: Well-selected patients with histories of urological malignancies greatly benefit from kidney transplantation with infrequent and late cancer recurrence. Waiting time could be optimized in low-risk prostate cancer and RCC, but more robust data are needed.

Incidence of upper tract urothelial carcinoma in Spain. / Incidencia del carcinoma transicional del tracto urinario superior en España.

INTRODUCTION AND OBJECTIVES: The incidence of upper urinary tract tumors is currently unknown. The aim of this study is to determine the real incidence of upper tract urothelial carcinoma (UTUC) in Spain. MATERIAL AND METHODS: A descriptive, prospective and multicenter epidemiological study was conducted in 31 Spanish facilities by means of the Platform for Multicenter Studies of the Spanish Association of Urology. Recruitment was opened from May 1st, 2017 to April 30th, 2018. The original database was exported directly from the electronic Data Collection Logbook on December 15th, 2018, with a total of 404 cases registered (402 valid cases after depuration). Statistical analysis was performed using IBM SPSS software v 23 and EPIDAT v 3.4. RESULTS: The incidence adjusted to Spanish population from raw data was 3.27 cases per 100.000 inhabitants per year (2.93 - 3.61 95% CI) and 3,3 cases per 100.000 inhabitants per year (2.96-3.66 95%CI) when adjusted to European population by age. The mean age at diagnosis was 70 years, and 77% of patients were male. Thirty-four percent of patients had an incidental diagnosis. Tumors were most commonly located in the pyelocalyceal system (54%), followed by the distal ureter (22%). Prior ureteroscopy was performed in 114 patients: this technique modified the subsequent treatment indication in 58% of cases. Radical nephroureterectomy was performed in 311 patients. Kidney-sparing surgery was the elected treatment in 76 patients (20%). Complications were found in 69% of cases, most of them classified as Clavien 1 and 2 (86% of all complications). Postoperative mortality rate was 1.7%. CONCLUSIONS: UTUC adjusted incidence rate in Spain is 3.27 and 3.3 in Europe. Prior URS modified the treatment indication in 18% of patients. We found a 69% complication rate and a 1.7% mortality rate.

Carcinoma urotelial del tracto urinario superior: a propósito de un caso y revisión de la literatura / Upper urinary tract urothelial carcinoma: case report and review of the literature

El carcinoma urotelial (CU) del tracto urinario superior es infrecuente y representa solo del 5%-10% de todos los CU. Estas neoplasias crecen a partir del urotelio de los cálices renales hasta el tercio distal del uréter. Se reporta el caso de un paciente masculino de 68 años de edad quien presenta enfermedad actual de 3 meses de evolución caracterizada por dolor lumbar izquierdo, tipo cólico, de leve a moderada intensidad, el cual atenúa parcialmente con el uso de AINES, asociado a hematuria visible total de predominio nocturno. El uroanálisis mostró hematuria macroscópica y la citología urinaria evidenció atipias sugerentes de carcinoma. La TAC abdomino-pélvica contrastada evidenció un defecto de llenado en relación al cáliz inferior de riñón izquierdo y plastrón ganglionar paraaórtico izquierdo. Se practicó nefroureterectomía radical izquierda evidenciando tumor de 3 x 3 x 1 cm en relación a pelvis renal extensiva a cáliz inferior invadiendo parénquima renal. El estudio histopatológico mostró un carcinoma urotelial papilar infiltrativo de alto grado con márgenes sin lesiones y ganglios linfáticos con metástasis. El paciente evoluciona satisfactoriamente durante el período postoperatorio y actualmente recibe terapia adyuvante. A pesar de ser una patología poco frecuente, puede presentarse y el urólogo debe estar en capacidad para poder enfrentarla(AU)

Upper urinary tract urothelial carcinoma (UC) is infrequent and represents only 5%-10% of all UCs. These neoplasms grow from the urothelium of renal calyces to the distal third of the ureter. A case of UC of the upper urinary tract is reported in a 68-year-old male patient with a 3-month history of left lumbar mild to moderate pain, which partially mitigates with the use of NSAIDs associated with visible total predominantly nocturnal hematuria. Macroscopic hematuria was evident and urinary cytology reported carcinoma suggestive atypias. Contrasted CT of abdomen and pelvis showed filling defect in relation to lower calyx of the left kidney and left para-aortic ganglion plastron. Radical left nephroureterectomy was performed showing a 3 x 3 x 1 cm tumor in relation to the renal pelvis extending to the lower cavity and invading renal parenchyma. Histopathology showed high grade infiltrative papillary CU with margins without lesions and lymph nodes with metastasis. Patient evolves satisfactorily in the postoperative period and is currently in adjuvant therapy. Although this pathology is rare, it can occur and the urologist must be able to face it(AU)

[Analysis of the impact on the overall survival of laparoscopic Vs open nephroureterectomy in locally advanced upper tract urinary tumors (pT3-pT4).] / Análisis del impacto en la supervivencia global de la nefroureterectomía laparoscópica vs abierta en los tumores del tracto urinario superior localmente avanzados (pT3-pT4).

OBJECTIVE: To compare the impact onoverall survival (OS) of laparoscopic nephroureterectomy (LNU) vs open nephroureterectomy (ONU) in patients with locally advanced upper tract transitional cell carcinoma (UTTCC) (pT3-pT4). MATERIAL AND METHODS: Sixty-six patients underwent LNU/ONU at our institution between March 2001 and August 2016 (36 ONU and 30 LNU) with confirmed UTTCC diagnosis. Demographic, histological and survival variables were extracted. The statistical analysis was performed using Chi-square test, Exact Ficher test,log-rank test and Cox regression analysis. RESULTS: The median time of follow-up was 14.3 months (Q1-Q3 6.6, 38.8). No differences were found between both groups in terms of demographic or pathology variables. The median survival time was 11.6 months (IQR 5.0- 18.2) in the ONU group and 33.8 months (IQR 2.5-65.2) in the LNU group. The 5y OS rate was 14% in the ONU group and 37% in the LNUgroup. Surgical approach, ASA or pT and the multifocality showed a statistically significant association with OS. CONCLUSION: Our study shows an association between the surgical approach and OS, with increased mortality associated to the ONU.

OBJETIVO: Comparar el impacto en la supervivencia global (SG) de la nefroureterectomía laparoscópica (NUL) Vs Nefroureterectomía abierta (NUA) en pacientes afectados de carcinoma urotelial del tracto urinario superior (CUTUS) localmente avanzado (pT3-pT4).MATERIAL Y MÉTODOS: Se estudiaron 66 pacientes intervenidos en nuestro centro entre marzo de 2001 y agosto de 2016 (36 NUA y 30 NUL) y con diagnóstico anatomopatológico de CUTUS. Se recogieron variables demográficas, histológicas y de supervivencia. El análisis estadístico se realizó empleando los test chi-cuadrado, test exacto de Ficher, log-rank test y análisis de regresión de Cox. RESULTADOS: El tiempo mediano de seguimiento fuede 14,3 meses (Q1-Q3: 6,6-38,8). No se encontraron diferencias entre ambos grupos en cuanto a las variables demográficas ni anatomopatológicas. El tiempo mediano de supervivencia fue de 11,6 meses (Q1-Q3:5,0-18,2) en el grupo NUA y de 33,8 meses (Q1-Q3:2,5-65,2) en el grupo NUL. La tasa de supervivencia global estimada a 5 años fue de 14% en el grupo NUA y de 37% en el grupo NUL. El tipo de abordaje quirúrgico,la clasificación de riesgo anestésico de la American Society of Anesthesiologists (ASA), el estadío local (pT) y la multifocalidad mostraron una asociación estadísticamente significativa con la SG.CONCLUSIÓN: Nuestro estudio muestra una asociación entre el abordaje quirúrgico y la SG, con una mayor mortalidad asociada al abordaje convencional.

[Confocal laser endomicroscopy for the treatment of upper urinary tract transitional cellcarcinoma.] / Endomicroscopía láser confocal en el tratamiento del tumor urotelial del tracto urinario superior.

OBJECTIVES: Confocal lasser endomicroscopy (CLE) is an optical technique that enables in vivo cytological characterization of a tissue. Previous studies have shown it useful in the evaluation of urinary and respiratory tracts for a better characterization of mucosal lesions, showing a high concordance between in vivo and final histopathological results. Recently, the use of CLE has been proposed for the study of transitional cell carcinoma of the upper urinary tract (UUT) during ureteroscopy, because it enables real time information about tumor grade and supplements the information of ureteroscopic biopsies, which may understimate the grade and stage of the lesion up to 43% of the cases due to its limitiations. METHODS: We performed a systematic review of the literature in the Pubmed/Medline database following the PRISMA standard. We selected 20 articles that complied with the inclusion criteria for evidence synthesis. RESULTS: Equipment miniaturization has enabled CLE as part of the diagnostic options in upper urinary tract tumors. This technique performs in vivo cytological characterization of the evaluated tissue, accomplishing differentiation between tumor and normal tissue, as well as tumor grade identification. Its communicated sensitivity and specificity reach 79%/78% respectively for low grade tumors and 67%/79% for high grade, with a substantial inter observer concordance (surgeon/pathologist; k = 0.64). No complications have been communicated in the literature with the use of fluorescein or confocal laser microscopy probes in patients undergoing this technique. CONCLUSIONS: CLE represents a useful and safe tool, capable of providing cytological real time information of UUT tumors that enables tumor grade identification with substantial concordance between in vivo tumor typifying and the final histopathological analysis. For this, CLE is currently considered a tool for conservative management of UUT transitional cell carcinoma in the European Association of Urology (EAU) guidelines.

OBJETIVOS: La endomicroscopía láser confocal (CLE) es una técnica óptica que permite la caracterización citológica en vivo de un tejido. Estudios previos en lesiones del tracto digestivo y respiratorio han mostrado una alta concordancia entre el resultado en vivo y el resultado histopatológico. Recientemente, se ha propuesto el uso de la CLE en el estudio del tracto urinario superior (TUS) durante la ureteroscopia, ya que permite obtener información a tiempo real del grado tumoral y complementa la información de las biopsias ureteroscópicas, que dadas sus limitaciones, pueden infraestimar el grado y el estadío de la lesión hasta en un 43% de los casos.MÉTODOS: Se llevó a cabo una revisión de la literatura en la base de datos Pubmed/Medline siguiendo las normas PRISMA. Se utilizaron 21 artículos que cumplieron los criterios de inclusión para la síntesis de la evidencia. RESULTADOS: La sensibilidad y especificidad descrita, alcanza el 79%/78% y 67%/79% para tumores de bajo y alto grado respectivamente, con una concordancia sustancial entre observadores (cirujano/anatomopatólogo; K = 0,64). No se han reportado complicaciones asociadas a la utilización de la fluoresceína ni sondas de CLE. CONCLUSIONES: La CLE representa una herramienta útil y segura, capaz de proporcionar información citológica de tumores del TUS en tiempo real que permite la identificación del grado tumoral con sustancial grado de acuerdo entre la tipificación en vivo y su análisis histopatológico final. Por este motivo, actualmente, la CLE es considerada como una herramienta en el manejo conservador del carcinoma del TUS en las guidelines de la European Association of Urology (EAU).

Spontaneous upper urinary tract rupture caused by ureteric stones: A prospective high-volume single centre observational study and proposed management. / Rotura espontanea del tracto urinario superior causada por litiasis ureteral: Estudio prospectivo observacional en un único centro de alto volumen y propuesta de manejo.

OBJECTIVE: To evaluate incidence, clinical, radiological and laboratory features of spontaneous upper urinary tract rupture (s-UUTR) due to ureteric stones and discuss their management. METHODS: Out of 1629 patients admitted to the Emergency Department (ED) for renal colic from January 2015 to December 2016 and studied by kidney US and contrast enhanced CT (CECT), 31 patients had a s-UUTR categorized in 3 stages: a) local spread, b) free fluid, c) urinoma. Presentation, therapeutic procedures and outcomes were registered. RESULTS: S-UUTR is reported in 1.9% of renal colic. The stone was most commonly identified at the vesicoureteric junction (VUJ) (61.3%) and mean (standard deviation, SD) stone size was 5.71 mm (2.31). S-UUTR was most frequently located in a calyx (54.84%). 26 patients (83.87%) had a clinical presentation of a renal colic, 3 cases (9.68%) had an atypical presentation and 2 (6.45%) presented an acute abdomen. In 26 cases a J-J stent (83,87%) was placed, 3 patients underwent primary ureteroscopic lithotripsy (9.67%); in 1 patient (3.23%) a nephrostomy was inserted and in 1 case (3.23%) active surveillance was adopted. Cases who underwent sole urinary derivation were revaluated after 30 days: ureteroscopic lithotripsy was performed in 48.15% of the cases; extracorporeal shock wave lithotripsy in 3.7%; in 22.2% of cases a CT demonstrated the spontaneous expulsion of the stone. 7 patients were lost at follow-up. The patient undergoing an active surveillance spontaneously expelled the stone. CONCLUSIONS: S-UUTR is a rare radiological sign of a renal colic most commonly located in a calyceal fornix. A high incidence of s-UUTR is caused by small distal ureteral stones in which a spontaneous passage is reasonable. Clinical presentation usually does not arise the suspicion of s-UUTR. In our experience, most patients were actively treated with good results but a conservative approach can be offered in selected cases.

OBJETIVO: Evaluar la incidencia, las características clínicas, radiológicas y de laboratorio de la rotura espontanea del tracto urinario superior (re-TUS) debido a litiasis ureterales y discutir su manejo. MÉTODOS: De 1629 pacientes admitidos en el Departamento de Urgencias por cólico renal entre enero 2015 y diciembre 2016 estudiados con ecografía renal y TAC con contraste, 31 pacientes presentaron re-TUS categorizada en 3 estadios: a) difusión local, b) líquido libre y c) urinoma. Se registraron la presentación, los procedimientos terapéuticos y los resultados. RESULTADOS: Se comunica la re-TUS en 1,9% de los cólicos renales. La localización más frecuente de la litiasis es la unión ureterovesical (61,3%) y el tamaño medio (DE) fue de 5,71 mm (2,31). La localización más frecuente de la re-TUS fue en un cáliz (54,84%). En 26 pacientes (83,87%) la presentación clínica fue cólico renal, 3 (9,68%) una presentación atípica y 2 (6,45%) abdomen agudo. En 26 casos (83,87%) se colocó un catéter doble J, 3 pacientes fueron sometidos a ureteroscopia y litotricia in situ (9,67%); en 1 paciente (3,23%) se insertó una nefrostomía y en otro (3,23%) se adoptó la vigilancia activa. Los casos con derivación urinaria fueron reevaluados a los 30 días: se realizó ureteroscopia con litotricia en 48,15%, litotricia extracorporea por ondas de choque (LEOC) en 3,7%; en el 22,2% de los pacientes la TAC demostró la expulsión espontánea de la litiasis. 7 pacientes se perdieron en el seguimiento. El paciente sometido a vigilancia activa expulsó la litiasis espontáneamente. CONCLUSIONES: La re-TUS es un signo radiológico raro del cólico renal localizado con mayor frecuencia en un fornix calicial. Las litiasis pequeñas del uréter distal en las que una expulsión espontanea es razonable, causan una alta incidencia de re-TUS. La presentación clínica no levanta habitualmente la sospecha de re-TUS. En nuestra experiencia, la mayoría de los pacientes fueron tratados activamente con buenos resultados, aunque se puede ofrecer tratamiento conservador en casos seleccionados.

Evaluation of upper tract urothelial carcinomas by contrast-enhanced ultrasound. / Valoración del carcinoma urotelial de vías superiores mediante ecografía con contraste.

AIM: To describe the findings and behaviour of contrast-enhanced ultrasound in the study of upper tract urothelial tumours and to assess its usefulness for diagnosis. MATERIAL AND METHODS: We reviewed our hospital's database over a period of 45 months to identify patients diagnosed with upper tract urothelial carcinomas. We reviewed the findings on mode B-ultrasound, contrast-enhanced ultrasound (location and qualitative assessment of intensity and washout of enhancement), and made a comparison with other techniques (computed tomography or magnetic resonance), and with the surgical specimen. RESULTS: We found 42 patients with a diagnosis of upper tract urothelial carcinoma confirmed with surgery over the period reviewed. Twenty-eight (67%) patients underwent contrast-enhanced ultrasound. Baseline ultrasound showed hydronephrosis with or without ureteral dilatation with echogenic content occupying the renal calyx (6), pelvis (10) or ureter (12). After injection of contrast, enhancement was noticed in 100% of the lesions, with similar intensity to the cortex in 23, and less in 5. Twenty-four lesions showed early washout, before the cortex, between 40 and 55seconds after the injection. The diagnosis was correct in 27 cases. Localisation coincided with the histological specimen in 28 cases, and 3 patients had additional distal carcinoma foci. CONCLUSION: Contrast-enhanced ultrasound is a useful technique for diagnosing upper tract urothelial tumours that increases confidence in the diagnosis.

Laparoscopic nephroureterectomy with laser endoscopic transuretral disinsertion in lateral decubitus: progressive adaptation to retroperitoneocopic approach. / Nefroureterectomía y desinserción transuretral láser-endoscópica en decúbito lateral sin cambio de posición: adaptación progresiva al abordaje por retroperitoneoscopia.

BACKGROUND: The ureteral disinsertion with bladder cuff technique continues to evolve. We present the endoscopic laser transurethral technique combined with a transperitoneal and retroperitoneal laparoscopic approach in lateral decubitus, without patient repositioning, for treating urothelial carcinomas of the upper urinary tract. MATERIALS AND METHODS: We present 3 laparoscopic nephroureterectomies: 1 transperitoneal and 2 retroperitoneal. Disinsertion was performed in lateral decubitus using a flexible cystoscope and a 365-µm holmium laser fiber. The endoscopic technique was progressively adapted to 3-port and single-port retroperitoneoscopic approaches. Before laparoscopic handling of the kidney, ureter was clamped below the tumour. The endoscopic technique was then started. Both approaches were simultaneously employed. RESULTS: Nephroureterectomies were achieved performing en bloc endoscopic disinsertion of the bladder cuff and ensuring a closed system comparable to open technique. The second case required reconversion due to technical problems and extension of the surgical time. No relapses were diagnosed during follow-up. CONCLUSION: Results are comparable to open surgery, technique ensured compliance to oncology principles, enabled disinsertion in lateral decubitus and avoid patient repositioning saving surgical time. The results reflect the benefits of minimally invasive surgery in all cases.

Factores Pronósticos de Recurrencia y Mortalidad en los Pacientes con Tumor de Urotelio Superior Tratados con Cirugía / Prognostic Factors for Recurrence and Mortality in Upper Urinary Tract Tumor

Objetivo Identificar factores pronósticos de recurrencia y mortalidad cáncer-específica en pacientes con tumor de urotelio superior tratados con cirugía. Material y Métodos Análisis retrospectivo de pacientes con tumor de urotelio superior operados entre 1999 y 2011 (139 pacientes). Se recogieron variables demográficas, clínicas, diagnósticas y patológicas así como el tratamiento, las complicaciones y la evolución. Análisis descriptivo mediante la prueba de la Chi cuadrado para variables categóricas y el test ANOVA para variables continuas. Análisis univariante y multivariante mediante modelo de riesgos proporcionales de Cox. Significación estadística si p < 0,05. Cálculos realizados con SPSS statistics v-21. Resultados En el análisis multivariante se identificaron como factores predictores independientes de recurrencia: crecimiento sólido tumoral (HR = 4,02; p < 0,001) y alto grado citológico (G3) (HR = 3,42; p = 0,01). La presencia de tumor vesical previo o concomitante (HR = 1,84; p = 0,07) presentó una tendencia a la significación. Se identificaron como factores predictores independientes de mortalidad cáncer-específica: presencia de tumor vesical previo o concomitante (HR = 2,23; p = 0,02), crecimiento sólido tumoral (HR = 2,73; p = 0,008), presencia de hidronefrosis (HR = 2,46; p = 0,02) y estadio patológico avanzado pT3-pT4 (HR = 2,74; p = 0,01). Conclusión En nuestra serie, la existencia de tumor vesical previo o sincrónico, el crecimiento tumoral sólido y el alto grado citológico se comportaron como factores pronósticos de recurrencia. La hidronefrosis, el tumor vesical previo o sincrónico, el estadio pT3­4 y el crecimiento tumoral sólido, se comportaron como factores pronósticos de mortalidad cáncer-específica.

Objective To identify predictors of recurrence and cancer-specific mortality in patients with upper urinary tract carcinoma treated with surgery. Material and Methods Retrospective analysis of patients with upper urinary tract urothelial carcinoma getting surgery between 1999 and 2011 in our institution (139 patients). We collected demographic, clinical, pathological and diagnostic variables as well as the treatment performed, the occurred complications and the evolution. A descriptive analysis was performed using the Chi square test for categorical variables and the ANOVA test for continuous variables. We performed an univariate and multivariate analysis using a proportional Cox risks model. Statistical significance was considered when p < 0.05. All calculcations were performed with SPSS statistics v-21. Results In the multivariate analysis, the solid tumor growth (HR = 4.02; p < 0.001) and a high cytological grade (G3) (HR = 3.42; p = 0.01) were identified as independent predictors; the presence of previous or concomitant bladder tumor (HR = 1.84; p = 0.07) showed a trend to statistical significance. In the multivariate analysis, the presence of previous or concomitant bladder tumor (HR = 2.23; p = 0.02), the solid tumor growth (HR = 2.73; p = 0.008), the presence of hydronephrosis (HR = 2.46; p = 0.02) and the advanced pathological stage pT3-pT4 (HR = 2.74; p = 0.01) were identified as independent predictors of cancer-specific mortality. Conclusion The existence of previous or concomitant bladder cancer at the diagnosis of upper urinary tract carcinoma, solid growth pattern and high cytological grade (G3) were identified as independent predictors of recurrence in our series. The existence of hydronephrosis at diagnosis, prior or concomitant bladder tumor, pathologic stage pT3­4 and the solid growth pattern were identified as independent predictors of cancerspecific mortality.

Predictors, pathological characteristics and outcomes of bladder recurrences following nephroureterectomy.

OBJECTIVES: To analyze the predictors for bladder recurrence (BR) after nephroureterectomy (NU) for upper urinary tract tumors (UUTT), as well as its pathological characteristics, outcomes and impact on survival. MATERIAL AND METHODS: Retrospective study of 117 patients who underwent laparoscopic nephroureterectomy by UUTT between 2007-2012 at our center. The potential predictors for BR were analyzed using Cox regression; Kaplan-Meier curves were employed to study survival. RESULTS: The sample was composed of 85 men (73%) and 32 women (27%), with a mean age of 70 years. After a mean follow-up of 26 months, 23 patients presented BR (19.6%). In the multivariate analysis, sex (p=.003; HR [female], 3.8) and the location of the UUTT in the distal ureter (p=.002; HR, 4.8) were independent predictors for BR. The median time to BR was 8 months. Fifteen patients presented a nonmuscle-invasive BR (65.2%), and 8 presented a muscle-invasive BR (34.8%). All BRs, except for 2, appeared during the first 2 years. Five cases with nonmuscle-invasive BR presented a new BR. Six patients with muscle-invasive BR died before it could be determined whether cause of death was the BR or an UUTT relapse. The onset of BR showed no repercussion on the survival of patients with UUTT. CONCLUSIONS: Sex (female) and the location of the UUTT (distal ureter) are predictors for BR after NU. Patients with these characteristics might benefit from adjuvant intravesical treatment and closer monitoring. The onset for RV has no impact on the survival of patients with UUTT.

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.

Advances in uro-oncology "OncoForum": the best of 2013.

OBJECTIVE: To present the new findings in oncologic urology with impact on clinical practice which were displayed at 2013 major annual meetings (EAU, ESTRO, AUA, ASCO and ASTRO). METHODS: The abstracts on prostate kidney, bladder and upper tract urothelial cancer with the highest scores by the OncoForum committee, presented in 1013 Congresses are included in this paper. RESULTS: the following messages were considered as important by the OncoUrology Forum committee. In renal tumors T1a, comorbidities should be evaluated by its impact on overall and specific cancer survival, especially in men over 65. In metastatic renal tumors, the benefit of Everolimus vs. Sunitinib has not been demonstrated. Patients with non-muscle invasive bladder cancer of high risk, with three or more risk factors, should be considered for radical cystectomy. The ERSPC study' data demonstrate the benefit of the systematic screening in prostate cancer. In metastatic disease, the results of the Ra-223 and enzalutamide studies show benefit in pain control and overall survival in metastatic disease. CONCLUSIONS: Localized renal and non-muscle invasive bladder of high-risk tumors, should be assessed according to comorbidities or oncologic risk factors, to determinate the adequate treatment options. New data from metastatic prostate cancer clinical trials have shown promising results in the control of the disease.

Impact of p53, MIB-1 and PECAM-1 expression on the prognosis of urothelial carcinoma of the renal pelvis.

OBJECTIVE: Determine whether the overexpression 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. MATERIAL AND METHOD: 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, 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=.028), histological variety (P<.0001), growth pattern (P<.0001), grade (P<.0001), pT (P=.01), vascular invasion (P=.025), necrosis (P=.004) and overexpression of p53 (P=.0006), PECAM-1 (P=.0036) and MIB-1 (P=.0038). The Cox regression model showed that high-grade (HR, 4.2; 95% CI 1.28-13.79; P=.018), flat growth pattern (HR, 2.52; 95% CI 1.05-6.03; P=.038) and p53 overexpression (HR, 2.8; 95% CI 1.22-6.44; P=.015) were independent predictors. CONCLUSION: Histological grade, tumor growth pattern and p53 overexpression 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.

Conducta médica posnatal ante la dilatación del tracto urinario superior fetal / Postnatal medical behavior in face a dilatation of fetal high urinary tract

El seguimiento sistemático del embarazo normal mediante el estudio ultrasonográfico materno-fetal ha demostrado que por cada 500 embarazos debemos esperar una anomalía importante del tracto urinario. La anomalía detectada con mayor frecuencia es la dilatación del tracto urinario superior, que si bien la mayoría de las veces no se traduce en una alteración importante, obliga a su estudio posnatal para poder valorar su significación. Una dilatación del tracto urinario superior puede ser la traducción de una hidronefrosis obstructiva por estenosis ureteropiélica, una hidronefrosis no obstructiva, un reflujo vesicoureteral o una pielectasia, y menos frecuentemente, puede ser la imagen de un doble sistema excretor con el superior obstruido, un megauréter obstructivo o no obstructivo, o una valva de uretra posterior en el sexo masculino. En esta revisión se presentan los criterios diagnósticos y el tratamiento clínico de las hidronefrosis y pielectasias, así como el estudio de los casos en que se sospecha reflujo vesicoureteral, y se relatan las anomalías encontradas en 318 niños en que el ultrasonido materno-fetal detectó alguna alteración del tracto urinario. Aunque no tan frecuente como las pielectasias y las hidronefrosis no obstructivas, las estenosis pieloureterales que producen obstrucción, pueden traer serias consecuencias sobre la función renal, que obligan a tomar decisiones médicas, y, en ocasiones, quirúrgicas, para mejorar la calidad de vida de estos niños.

The systematic follow-up of the normal pregnancy by means of a mother-fetus ultrasonography study has demonstrated that for each 500 pregnancies, we must to expect a significant anomaly of urinary tract. The more frequent anomaly detected is the high urinary tract dilatation, which if not always it is a significant alteration, leads to a postnatal study to assess its significance. A high urinary tract dilatation may to give rise to an obstructive hydronephrosis due to ureteropyelitis anastomosis; a non-obstructive hydronephrosis, a vesicoureteral reflux or a pyelectasia and less frequently may be an image of double excretory system with the superior one obstructed, an obstructive or not megaureter, or a valve or the posterior urethra in male sex. In present review are showed the diagnostic criteria and the clinical treatment of the hydronephrosis and the pyelectasia, as well as the study cases with suspicion of vesicoureteral reflux mentioning the anomalies founded in 318 children in whom the mother-fetus ultrasound detected some alteration of the urinary tract. Although not so frequent as the non-obstructive pyelectasia and the hydronephrosis, the pyeloureteral stenosis producing obstruction, may give rise to serious consequences on the renal function leading to make a medical decision, and occasionally, of surgical type to improve the quality of life of these children.

Conducta médica posnatal ante la dilatación del tracto urinario superior fetal / Postnatal medical behavior in face a dilatation of fetal high urinary trac

El seguimiento sistemático del embarazo normal mediante el estudio ultrasonográfico materno-fetal ha demostrado que por cada 500 embarazos debemos esperar una anomalía importante del tracto urinario. La anomalía detectada con mayor frecuencia es la dilatación del tracto urinario superior, que si bien la mayoría de las veces no se traduce en una alteración importante, obliga a su estudio posnatal para poder valorar su significación. Una dilatación del tracto urinario superior puede ser la traducción de una hidronefrosis obstructiva por estenosis ureteropiélica, una hidronefrosis no obstructiva, un reflujo vesicoureteral o una pielectasia, y menos frecuentemente, puede ser la imagen de un doble sistema excretor con el superior obstruido, un megauréter obstructivo o no obstructivo, o una valva de uretra posterior en el sexo masculino. En esta revisión se presentan los criterios diagnósticos y el tratamiento clínico de las hidronefrosis y pielectasias, así como el estudio de los casos en que se sospecha reflujo vesicoureteral, y se relatan las anomalías encontradas en 318 niños en que el ultrasonido materno-fetal detectó alguna alteración del tracto urinario. Aunque no tan frecuente como las pielectasias y las hidronefrosis no obstructivas, las estenosis pieloureterales que producen obstrucción, pueden traer serias consecuencias sobre la función renal, que obligan a tomar decisiones médicas, y, en ocasiones, quirúrgicas, para mejorar la calidad de vida de estos niños(AU)

The systematic follow-up of the normal pregnancy by means of a mother-fetus ultrasonography study has demonstrated that for each 500 pregnancies, we must to expect a significant anomaly of urinary tract. The more frequent anomaly detected is the high urinary tract dilatation, which if not always it is a significant alteration, leads to a postnatal study to assess its significance. A high urinary tract dilatation may to give rise to an obstructive hydronephrosis due to ureteropyelitis anastomosis; a non-obstructive hydronephrosis, a vesicoureteral reflux or a pyelectasia and less frequently may be an image of double excretory system with the superior one obstructed, an obstructive or not megaureter, or a valve or the posterior urethra in male sex. In present review are showed the diagnostic criteria and the clinical treatment of the hydronephrosis and the pyelectasia, as well as the study cases with suspicion of vesicoureteral reflux mentioning the anomalies founded in 318 children in whom the mother-fetus ultrasound detected some alteration of the urinary tract. Although not so frequent as the non-obstructive pyelectasia and the hydronephrosis, the pyeloureteral stenosis producing obstruction, may give rise to serious consequences on the renal function leading to make a medical decision, and occasionally, of surgical type to improve the quality of life of these children(AU)

Carcinoma de células transicionales del tracto urinario superior: opciones de tratamiento actual y abordajes mínimamente invasivos / Upper urinary tract transitional cell carcinoma: current treatment overview of minimally invasive approaches

Las indicaciones para el manejo mínimamente invasivo de los tumores del tracto urinario superior están en constante expansión. El desarrollo de equipamiento endoscópico cada vez más sofisticado ha llevado a un cambio en la práctica diaria y a una tendencia al manejo conservador. Nuestro objetivo es revisar las diferentes opciones de manejo mínimamente invasivo para el manejo de los tumores del tracto urinario superior, con énfasis en laparoscopia, ureteroscopia y cirugía percutánea.

The indications for minimally invasive treatment for are expanding. The development of more sophisticated endoscopic equipment has led to changes in everyday practice and a trend towards more conservative management. Our objective is to make a review of the different options for management UUT-TCC, with emphasis in laparoscopy, ureteroscopy and percutaneous surgery.