Different outcomes among patients with intermediate-risk metastastic renal cell carcinoma treated with first-line tyrosine-kinase inhibitors

Introduction Systemic therapy of patients with metastatic renal cell carcinoma (mRCC) has improved in the past years, with the advent of new immunotherapy-based combinations as a standard treatment option for first-line therapy. Nevertheless, particularly in good-risk patients by IMDC criteria, tyrosine-kinase inhibitors (TKI) may remain as an option for some patients. We reviewed our experience with TKI as first-line therapy for mRCC patients, trying to identify subgroups of patients that may still benefit from this strategy. Material and methods All patients with mRCC treated with first-line TKI, and adequate follow-up, in University Hospital La Paz (Madrid, Spain) between 2007 and 2020 were analyzed. Patients treated inside a clinical trial were excluded from this analysis. Results A total of 90 patients treated with first-line TKI were included. Regarding IMDC criteria, 33 patients (36.7%) were good-risk, 41 patients (45.5%) intermediate-risk, and 16 patients (17.8%) poor-risk. With a median follow-up of 49 months, the median overall survival (OS) for good, intermediate, and poor-risk patients was 54, 24, and 16 months (p = 0.004). When intermediate-risk was divided into patients with 1 or 2 risk factors, differences in OS were also statistically significant: patients with 1 risk factor had a median OS of 33 months, while patients with 2 risk factors had a median OS of 16 months, the same as poor-risk patients (p = 0.003). In the multivariate analysis, trying to find out which of the IMDC factors had a more remarkable weight in the prognosis of the patients, both ECOG and hemoglobin levels by themselves were significantly associated with OS. Conclusion In our group of patients, survival outcomes were different among patients with intermediate-risk with 1 or 2 risk factors by IMDC criteria(AU)

Different outcomes among patients with intermediate-risk metastastic renal cell carcinoma treated with first-line tyrosine-kinase inhibitors.

INTRODUCTION: Systemic therapy of patients with metastatic renal cell carcinoma (mRCC) has improved in the past years, with the advent of new immunotherapy-based combinations as a standard treatment option for first-line therapy. Nevertheless, particularly in good-risk patients by IMDC criteria, tyrosine-kinase inhibitors (TKI) may remain as an option for some patients. We reviewed our experience with TKI as first-line therapy for mRCC patients, trying to identify subgroups of patients that may still benefit from this strategy. MATERIAL AND METHODS: All patients with mRCC treated with first-line TKI, and adequate follow-up, in University Hospital La Paz (Madrid, Spain) between 2007 and 2020 were analyzed. Patients treated inside a clinical trial were excluded from this analysis. RESULTS: A total of 90 patients treated with first-line TKI were included. Regarding IMDC criteria, 33 patients (36.7%) were good-risk, 41 patients (45.5%) intermediate-risk, and 16 patients (17.8%) poor-risk. With a median follow-up of 49 months, the median overall survival (OS) for good, intermediate, and poor-risk patients was 54, 24, and 16 months (p = 0.004). When intermediate-risk was divided into patients with 1 or 2 risk factors, differences in OS were also statistically significant: patients with 1 risk factor had a median OS of 33 months, while patients with 2 risk factors had a median OS of 16 months, the same as poor-risk patients (p = 0.003). In the multivariate analysis, trying to find out which of the IMDC factors had a more remarkable weight in the prognosis of the patients, both ECOG and hemoglobin levels by themselves were significantly associated with OS. CONCLUSION: In our group of patients, survival outcomes were different among patients with intermediate-risk with 1 or 2 risk factors by IMDC criteria. These could help select patients that may benefit from first-line treatment with a TKI, particularly in settings with difficult access to novel therapies, such as immunotherapy-based combinations.

[Laser in prostate cancer. Applicability.] / Láser en cáncer de próstata. Aplicaciones.

OBJECTIVES: In recent years, there has been a rise concerning the research and development of focal prostate cancer therapies as a consequence of the high percentage of low-risk and localized prostate cancers. These focal therapies aim at preserving the gland in selected patients to avoid overtreatment. The application of lasers for focal ablation and photodynamic therapy has shown promising results in exchange for a minimal rate of adverse events compared to radical treatments. MATERIAL AND METHODS: An extensive review of the available literature on focal laser treatments for localized prostate cancer was conducted. A search in PubMed and Embase was carried out by the following keywords: "Localised prostate cancer", "Low-risk prostate cancer", "Focal therapy", "Magnetic Resonance in localized prostate cancer", "Focal laser ablation" , "Photodynamic therapy" and "TOOKAD". RESULTS: Photodynamic therapy with TOOKAD is the only focal therapy evaluated in a phase III clinical trial,showing a lower rate of progression and a longer time to progression compared to active surveillance. Other studies carried out have revealed a percentage up to 80% of negative biopsies 6 months after TOOKAD. Likewise, the quality of life of patients treated using focal laser ablation techniques and photodynamic therapy has been minimally altered, as most adverse effects have been shown to be mild and transient, with dysuria and hematuria being the most frequent. CONCLUSIONS: Despite the fact that focal therapies are still not recommended outside the context of clinical trials and the lack of comparative studies between the different techniques, laser focal therapies seem to havea future within the new approaches for localized prostate cancer.

OBJETIVO: En los últimos años, se ha visto un auge en la investigación y el desarrollo de las terapias focales del cáncer de próstata como consecuencia del alto porcentaje de cánceres localizados y de bajo riesgo diagnosticados. Estas terapias focales tienen como objetivo la preservación de la glándula en pacientes seleccionados para evitar un sobretratamiento. La aplicación de los láseres para la ablación focal y la terapia fotodinámica ha demostrado resultados prometedores a cambio de una mínima tasa de complicaciones comparado con los tratamientos radicales clásicos.MATERIAL Y MÉTODOS: Se realizó una revisión extensa de la literatura disponible sobre tratamientos focales con láser para el cáncer de próstata localizado. Se llevó a cabo una búsqueda bibliográfica en PubMed y Embase incluyendo las siguientes palabras clave: "Localised prostate cancer", "Low-risk prostate cancer", "Focaltherapy", "Magnetic Resonance in localised prostate cancer", "Focal laser ablation", "Photodynamic therapy" y "TOOKAD". RESULTADOS: La terapia fotodinámica con TOOKAD es la única terapia focal evaluada en un ensayo clínico fase III, habiendo demostrado una menor tasa de progresión y un mayor tiempo hasta la progresión comparado con la vigilancia activa. En otros de los estudios llevados a cabo, se ha objetivado un porcentaje de biopsias negativas a los 6 meses del tratamiento de hasta el 80%. Igualmente, la calidad de vida de los pacientes tratados mediante las técnicas de ablación focal con láser y terapia fotodinámica se ha visto mínimamente alterada al haberse demostrado que la mayoría de los efectos adversos son leves y transitorios, siendo los más frecuentes la disuria y la hematuria. CONCLUSIONES: A pesar de que las terapias focales siguen sin ser recomendadas fuera del contexto de los ensayos clínicos y de la falta de estudios comparativos entre las diferentes técnicas, las terapias focales con láser parecen tener un futuro dentro de los nuevos abordajes para el cáncer de próstata localizado.

Láser en cáncer de próstata. Aplicaciones / Laser in prostate cancer. Applicability

OBJETIVO: En los últimos años, se ha visto un auge en la investigación y el desarrollo de las terapias focales del cáncer de próstata como consecuencia del alto porcentaje de cánceres localizados y de bajo riesgo diagnosticados. Estas terapias focales tienen como objetivo la preservación de la glándula en pacientes seleccionados para evitar un sobretratamiento. La aplicación de los láseres para la ablación focal y la terapia fotodinámica ha demostrado resultados prometedores a cambio de una mínima tasa de complicaciones comparado con los tratamientos radicales clásicos. MATERIAL Y MÉTODOS: Se realizó una revisión extensa de la literatura disponible sobre tratamientos focales con láser para el cáncer de próstata localizado. Se llevó a cabo una búsqueda bibliográfica en PubMed y Embase incluyendo las siguientes palabras clave: "Localised prostate cancer", "Low-risk prostate cancer", "Focal therapy", "Magnetic Resonance in localised prostate cancer", "Focal laser ablation", "Photodynamic therapy" y "TOOKAD". RESULTADOS: La terapia fotodinámica con TOOKAD es la única terapia focal evaluada en un ensayo clínico fase III, habiendo demostrado una menor tasa de progresión y un mayor tiempo hasta la progresión comparado con la vigilancia activa. En otros de los estudios llevados a cabo, se ha objetivado un porcentaje de biopsias negativas a los 6 meses del tratamiento de hasta el 80%. Igualmente, la calidad de vida de los pacientes tratados mediante las técnicas de ablación focal con láser y terapia fotodinámica se ha visto mínimamente alterada al haberse demostrado que la mayoría de los efectos adversos son leves y transitorios, siendo los más frecuentes la disuria y la hematuria. CONCLUSIONES: A pesar de que las terapias focales siguen sin ser recomendadas fuera del contexto de los ensayos clínicos y de la falta de estudios comparativos entre las diferentes técnicas, las terapias focales con láser parecen tener un futuro dentro de los nuevos abordajes para el cáncer de próstata localizado

OBJECTIVES: In recent years, there has been a rise concerning the research and development of focal prostate cancer therapies as a consequence of the high percentage of low-risk and localized prostate cancers. These focal therapies aim at preserving the gland in selected patients to avoid overtreatment. The application of lasers for focal ablation and photodynamic therapy has shown promising results in exchange for a minimal rate of adverse events compared to radical treatments. MATERIAL AND METHODS: An extensive review of the available literature on focal laser treatments for localized prostate cancer was conducted. A search in PubMed and Embase was carried out by the following keywords: "Localised prostate cancer", "Low-risk prostate cancer", "Focal therapy", "Magnetic Resonance in localized prostate cancer", "Focal laser ablation" , "Photodynamic therapy" and "TOOKAD". RESULTS: Photodynamic therapy with TOOKAD is the only focal therapy evaluated in a phase III clinical trial, showing a lower rate of progression and a longer time to progression compared to active surveillance. Other studies carried out have revealed a percentage up to 80% of negative biopsies 6 months after TOOKAD. Likewise, the quality of life of patients treated using focal laser ablation techniques and photodynamic therapy has been minimally altered, as most adverse effects have been shown to be mild and transient, with dysuria and hematuria being the most frequent. CONCLUSIONS: Despite the fact that focal therapies are still not recommended outside the context of clinical trials and the lack of comparative studies between the different techniques, laser focal therapies seem to have a future within the new approaches for localized prostate cancer

Retroperitoneal fibrosis: a literature review / Fibrosis retroperitoneal. Revisión de la literatura

OBJECTIVES: Retroperitoneal fibrosis (RPF)is an uncommon disease due an inflammatory condition and deposit of fibrotic tissue that involves the retroperitoneal area over the lower four lumbar vertebrae. Very few epidemiologic studies exist that accurately characterize the incidence and prevalence of the disease. MATERIALS AND METHODS: A review of the English language literature was performed using the MEDLINE combining the keywords: "retroperitoneal fibrosis", "Ormond ' disease", "IG4 related disease". Additionally, hand search of bibliographies of included studies and previous reviews was also performed to include additional information. RESULTS: RPF develops insidiously, because the initial symptoms are non-specific. Pain is the most common presenting symptom. Various radiological diagnostic methods are used in the diagnosis of retroperitoneal fibrosis. Contrast-enhanced computerized tomography (CT) is a useful method for diagnosing retroperitoneal pathologies. Magnetic resonance imaging (MRI) is an important radiological method especially in the diagnosis of fibrotic tissue and in the examination of the retroperitoneal organ relation with fibrous tissue. Nuclear imaging is also a method used in renal function evaluation and patient follow-up. Various medical and surgical treatments would be used in the treatment of retroperitoneal fibrosis. In general, immunosuppressive agents such as corticosteroids, tamoxifen, azothiopurine, cyclophosphamide, cyclosporine, progesterone, mycophenolate mofetil are used in medical treatment. Surgical treatment methods are recommended in cases where medical treatment is not efficient. CONCLUSION: Unfortunately, despite a recent surge in the number of publications on this topic, a few progress has been made in our understanding of the classification, pathophysiology, and, most importantly, the most appropriate treatment for this disease

OBJETIVO: La fibrosis retroperitoneal (FPR) es una enfermedad poco común debido a una afección inflamatoria y depósito de tejido fibrótico que afecta el área retroperitoneal sobre las cuatro vértebras lumbares inferiores. Existen muy pocos estudios epidemiológicos que caractericen con precisión la incidencia y la prevalencia de la enfermedad. El objetivo de esta revisión es ofrecer una visión general de las características clínicas, los métodos de diagnóstico, los tratamientos y su eficacia en los pacientes con FPR. MATERIALES Y MÉTODOS: Se realizó una revisión de la literatura en idioma inglés utilizando las bases de datos MEDLINE, combinando las palabras clave: "fibrosis retroperitoneal", "enfermedad de Ormond", "enfermedad relacionada con IG4". Además, la búsqueda manual de bibliografías de estudios incluidos y revisiones anteriores también se realizó para incluir información adicional. RESULTADOS: La FRP se desarrolla insidiosamente, ya que los síntomas iniciales son inespecíficos. El dolor es el síntoma de presentación más común. Varios métodos de diagnóstico radiológico se utilizan en el diagnóstico de la fibrosis retroperitoneal. La tomografía computarizada (TC) con contraste es un método útil para diagnosticar patologías retroperitoneales. La resonancia magnética (RM) es un método radiológico importante, especialmente en el diagnóstico de tejido fibrótico y en la valoración de la relación del órgano retroperitoneal con el tejido fibroso. La imagen nuclear también es un método utilizado en la evaluación de la función renal y el seguimiento de los pacientes. Varios tratamientos médicos y quirúrgicos se usarían en el tratamiento de la fibrosis retroperitoneal. En general, los agentes inmunosupresores como los corticosteroides, el tamoxifeno, la azatioprina, la ciclofosfamida, la ciclosporina, la progesterona y el micofenolato mofetilo se usan en el tratamiento médico. Los métodos de tratamiento quirúrgico se recomiendan en casos donde el tratamiento médico no es eficiente. CONCLUSIÓN: Desafortunadamente, a pesar de un aumento reciente en el número de publicaciones sobre este tema, se ha avanzado poco en nuestra comprensión de la clasificación, la fisiopatología y, lo que es más importante, el tratamiento más adecuado para esta enfermedad

Retroperitoneal fibrosis: A literature review. / Fibrosis retroperitoneal. Revisión de la literatura.

OBJECTIVES: Retroperitoneal fibrosis (RPF) is an uncommon disease due an inflammatory condition and deposit of fibrotic tissue that involves the retroperitoneal area over the lower four lumbar vertebrae. Very few epidemiologic studies exist that accurately characterize the incidence and prevalence of the disease. MATERIALS AND METHODS: A review of the English language literature was performed using the MEDLINE combining the keywords: "retroperitoneal fibrosis", "Ormond´ disease", "IG4 related disease". Additionally, hand search of bibliographies of included studies and previous reviews was also performed to include additional information. RESULTS: RPF develops insidiously, because the initial symptoms are non-specific. Pain is the most common presenting symptom. Various radiological diagnostic methods are used in the diagnosis of retroperitoneal fibrosis. Contrast-enhanced computerized tomography (CT) is a useful method for diagnosing retroperitoneal pathologies. Magnetic resonance imaging (MRI) is an important radiological method especially in the diagnosis of fibrotic tissue and in the examination of the retroperitoneal organ relation with fibrous tissue. Nuclear imaging is also a method used in renal function evaluation and patient follow-up. Various medical and surgical treatments would be used in the treatment of retroperitoneal fibrosis. In general, immunosuppressive agents such as corticosteroids, tamoxifen, azothiopurine, cyclophosphamide, cyclosporine, progesterone, mycophenolate mofetil are used in medical treatment. Surgical treatment methods are recommended in cases where medical treatment is not efficient. CONCLUSION: Unfortunately, despite a recent surge in the number of publications on this topic, a few progress has been made in our understanding of the classification, pathophysiology, and, most importantly, the most appropriate treatment for this disease.

OBJETIVO: La fibrosis retroperitoneal (FPR) es una enfermedad poco común debido a una afección inflamatoria y depósito de tejido fibrótico que afecta el área retroperitoneal sobre las cuatro vértebras lumbares inferiores. Existen muy pocos estudios epidemiológicos que caractericen con precisión la incidencia y la prevalencia de la enfermedad. El objetivo de esta revisión es ofrecer una visión general de las características clínicas, los métodos de diagnóstico, los tratamientos y su eficacia en los pacientes con FPR.MATERIALES Y MÉTODOS: Se realizó una revisión de la literatura en idioma inglés utilizando las bases de datos MEDLINE, combinando las palabras clave: "fibrosis retroperitoneal", "enfermedad de Ormond", "enfermedad relacionada con IG4". Además, la búsqueda manual de bibliografías de estudios incluidos y revisiones anteriores también se realizó para incluir información adicional. RESULTADOS: La FRP se desarrolla insidiosamente, ya que los síntomas iniciales son inespecíficos. El dolor es el síntoma de presentación más común. Varios métodos de diagnóstico radiológico se utilizan en el diagnóstico de la fibrosis retroperitoneal. La tomografía computarizada (TC) con contraste es un método útil para diagnosticar patologías retroperitoneales. La resonancia magnética (RM) es un método radiológico importante, especialmente en el diagnóstico de tejido fibrótico y en la valoración de la relación del órgano retroperitoneal con el tejido fibroso. La imagen nuclear también es un método utilizado en la evaluación de la función renal y el seguimiento de los pacientes. Varios tratamientos médicos y quirúrgicos se usarían en el tratamiento de la fibrosis retroperitoneal. En general, los agentes inmunosupresores como los corticosteroides, el tamoxifeno, la azatioprina, la ciclofosfamida, la ciclosporina, la progesterona y el micofenolato mofetilo se usan en el tratamiento médico. Los métodos de tratamiento quirúrgico se recomiendan en casos donde el tratamiento médico no es eficiente.CONCLUSIÓN: Desafortunadamente, a pesar de un aumento reciente en el número de publicaciones sobre este tema, se ha avanzado poco en nuestra comprensión de la clasificación, la fisiopatología y, lo que es más importante, el tratamiento más adecuado para esta enfermedad.

Partial versus radical nephrectomy in very elderly patients: a propensity score analysis of surgical, functional and oncologic outcomes (RESURGE project).

PURPOSE: To compare the outcomes of PN to those of RN in very elderly patients treated for clinically localized renal tumor. PATIENTS AND METHODS: A purpose-built multi-institutional international database (RESURGE project) was used for this retrospective analysis. Patients over 75 years old and surgically treated for a suspicious of localized renal with either PN or RN were included in this database. Surgical, renal function and oncological outcomes were analyzed. Propensity scores for the predicted probability to receive PN in each patient were estimated by logistic regression models. Cox proportional hazard models were estimated to determine the relative change in hazard associated with PN vs RN on overall mortality (OM), cancer-specific mortality (CSM) and other-cause mortality (OCM). RESULTS: A total of 613 patients who underwent RN were successfully matched with 613 controls who underwent PN. Higher overall complication rate was recorded in the PN group (33% vs 25%; p = 0.01). Median follow-up for the entire cohort was 35 months (interquartile range [IQR] 13-63 months). There was a significant difference between RN and PN in median decline of eGFR (39% vs 17%; p < 0.01). PN was not correlated with OM (HR = 0.71; p = 0.56), OCM (HR = 0.74; p = 0.5), and showed a protective trend for CSM (HR = 0.19; p = 0.05). PN was found to be a protective factor for surgical CKD (HR = 0.28; p < 0.01) and worsening of eGFR in patients with baseline CKD. Retrospective design represents a limitation of this analysis. CONCLUSIONS: Adoption of PN in very elderly patients with localized renal tumor does not compromise oncological outcomes, and it allows better functional preservation at mid-term (3-year) follow-up, relative to RN. Whether this functional benefit translates into a survival benefit remains to be determined.

Ureteral injury during abdominal and pelvic surgery: immediate versus deferred repair.

INTRODUCTION: The incidence of ureteral damage during abdominal surgery is <1%. Repair of these lesions can be performed immediately when the injury is detected or deferred when it has been missed. MATERIAL AND METHODS: We retrospectively reviewed ureteral injuries that required surgical repair and were made during gynaecological and general surgery procedures between the years 2004 and 2016. We compared the clinical and functional outcomes between immediate and deferred repair. RESULTS: We registered 84 lesions after 4000 abdominal procedures (2.1%). A total of 20 injuries were noted during general surgery interventions (24%) and 64 during gynaecological procedures (76%). The approach was laparoscopic in 66 of these cases and open in the other 18. Mean time of follow-up was 24 months. Immediate repair was accomplished in 35 cases (41%) and deferred in 49 (59%), with a median time to repair of 5.7 months. The laparoscopic approach was more frequent in deferred repairs (76% vs. 16%), while the open approach was more common in immediate repairs (54% vs. 40%). Procedures used for ureteral repair included 62 ureteral reimplantations using a psoas hitch technique, 8 end-to-end ureteral anastomoses, 6 ureterorraphies and 6 ureteral catheterisations. Two nephrectomies were also performed. Success rates and complications were similar for both immediate and deferred procedures (68% vs. 73% and 26% vs. 23% respectively, both p >0.05). CONCLUSIONS: The occurrence of ureteral injury during abdominal surgery is low. Immediate repair is preferred when feasible, but delayed recognition of the injury is more common. We found no difference between immediate and deferred repair in terms of success rates.

[Evolution of radical prostatectomy in the Autonomous Community of Madrid.] / Evolución de la prostatectomía radical en el tratamiento del cáncer de próstata en la Comunidad de Madrid.

OBJECTIVES: To analyze the implantation of laparoscopic radical prostatectomy (LRP) in the Public Health System in the Autonomous Community of Madrid (CAM) and to investigate the different results between laparoscopic and open radical prostatectomy. METHODS: We performed a retrospective analysis over a database containing data from 25 hospitals in CAM. We chose 8225 patients treated by radical prostatectomy (open or laparoscopic). Data were collected using a questionnaire including hospital, length of stay, readmissions and mortality. Values are shown in number, percentage and rank. Statistical significance is shown with p<0.05. RESULTS: Increase of LRP is shown in the period of study, representing only a 11.9% of the radical prostatectomies in 2004 and reaching 56.8% in 2012. There were no significant statistical differences in age, severity or readmissions when stratified by hospital or by technique. We found a 1.05 days increase in length of stay in long-standing hospitals compared to newer hospitals. We also found a decrease in length of stay in LRP group compared to open retropubic prostatectomy (ORP): 4.84 days vs 6.79 days, (p<0.001). CONCLUSIONS: RP is consolidated as a therapy in CAM. LRP has been successfully implemented in CAM, offering advantage over ORP in terms of hospital stay. We observed statistically significant difference in length of stay in advantage of recent hospitals regarding longstanding.

Evolución de la prostatectomía radical en el tratamiento del cáncer de próstata en la Comunidad de Madrid / Evolution of radical prostatectomy in the Autonomous Community of Madrid

OBJETIVO: Analizar la implantación de la prostatectomía radical de abordaje laparoscópico (PRL) en el Sistema Público de Salud de la Comunidad Autónoma de Madrid (CAM) así como valorar diferencias en cuanto a resultados entre prostatectomía radical laparoscópica y abierta. MÉTODOS: Se realizó un análisis retrospectivo sobre una base de datos que comprendía datos procedentes de 25 centros de la CAM. Fueron seleccionados 8225 pacientes tratados mediante prostatectomía radical abierta (PRA) o PRL. Los datos fueron recogidos usando un cuestionario que incluyó hospital, estancia hospitalaria, reingresos y mortalidad. Los valores se muestran en números, porcentaje y rango. La significancia estadística se demuestra con una p < 0,05. RESULTADOS: El crecimiento de la PRL se demuestra en los años de estudio, pues en 2004 representaba un 11,9% del total y en 2012 un 56,8%. No se han encontrado diferencias significativas en edad, complejidad o reingresos al estratificar por tipo de hospital o técnica elegida. Al analizar la estancia media hospitalaria, ésta resultó mayor en 1,05 días en los hospitales antiguos frente a los de nueva creación. El grupo de PRL presentó menor estancia media que el grupo de PRA (4,84 días vs 6,79 días, p < 0,001). CONCLUSIONES: La PR está consolidada como terapia en la CAM. La Prostatectomía Radical (PR) se ha implantado en la CAM, ofreciendo ventaja en cuanto a la estancia hospitalaria respecto de la PRA. Se ha observado diferencia en la estancia hospitalaria estadísticamente significativas a favor de los hospitales de nueva apertura vs antiguos

OBJECTIVES: To analyze the implantation of laparoscopic radical prostatectomy (LRP) in the Public Health System in the Autonomous Community of Madrid (CAM) and to investigate the different results between laparoscopic and open radical prostatectomy. METHODS: We performed a retrospective analysis over a database containing data from 25 hospitals in CAM. We chose 8225 patients treated by radical prostatectomy (open or laparoscopic). Data were collected using a questionnaire including hospital, length of stay, readmissions and mortality. Values are shown in number, percentage and rank. Statistical significance is shown with p < 0.05. RESULTS: Increase of LRP is shown in the period of study, representing only a 11.9% of the radical prostatectomies in 2004 and reaching 56.8% in 2012. There were no significant statistical differences in age, severity or readmissions when stratified by hospital or by technique. We found a 1.05 days increase in length of stay in long-standing hospitals compared to newer hospitals. We also found a decrease in length of stay in LRP group compared to open retropubic prostatectomy (ORP): 4.84 days vs 6.79 days, (p < 0.001). CONCLUSIONS: RP is consolidated as a therapy in CAM. LRP has been successfully implemented in CAM, offering advantage over ORP in terms of hospital stay. We observed statistically significant difference in length of stay in advantage of recent hospitals regarding longstanding

[Oncological results in high grade prostate cancer treated surgically]. / Resultados oncológicos en el cáncer de próstata de alto riesgo tratado quirúrgicamente.

OBJECTIVES: Prostate cancer is considered a tumour with a long natural history. However, its high-risk variants exhibit variable behaviour. We analyse the factors that affect BR and CSS (multivariate, Kaplan Meier). METHODS: From 1997 to 2013, 657 patients were operated of a high-grade prostate cancer (pT2b 7.2%, pT3a 73%, pT3b 18.3%, pT4 1.5%). Gleason score was ≥8 in 23% of cases. Percentage of PSMs was 46.1%. Mean follow-up was 113 months (24-192). RESULTS: BR occurred in 36.5%. Patients with Gleason score <8, 31.7% had BR, Gleason ≥8 had BR in 48% (p<0.05). PSMs recurrence occurred in 48.9%, whereas 26.1% in NSM (p<0.05). If lymphadenectomy, BR occurred in 48.7%, if not 30.9% (p<0,05). In multivariate analysis, stage, Gleason≥8 and PSMs were independent factors for BR. Treatment of BR was 36.5% radiotherapy, 24.1% HT, and 21.2% both simultaneously. Active surveillance was performed in 13.3%. Disease progression (biochemical or radiological) occurred in 23.5%. CSS was 98.93%, pT4 was the stage with the greatest mortality (10%), followed by pT3b (3.4%), p<0.05. Patients with a Gleason score ≥8 accounted for 71% CSM (p<0,05). PSMs and lymphadenectomy didn't have repercussions for survival. In multivariate analysis, Gleason≥8 was independent factor for CSM. CONCLUSIONS: Radical prostatectomy plays an important role in multi-modal approach with good oncological control at medium follow up. Gleason score ≥8 was the factor with the greatest effect on CSM. Lymphadenectomy didn't affect CSS.

Resultados oncológicos en el cáncer de próstata de alto riesgo tratado quirúrgicamente / Oncological results in high grade prostate cancer treated surgically

OBJETIVO: El cáncer de próstata se considera un tumor con una historia natural prolongada. Sin embargo, la variante de alto riesgo muestra un comportamiento variable. Analizaremos aquellos factores que afectan a la Recidiva Bioquímica (RB) y la Supervivencia Cáncer Específica (SCE) en pacientes tratados quirúrgicamente. MÉTODOS: Desde 1997-2013 se han operado un total de 657 pacientes con cáncer de próstata con criterios de alto grado según la Asociación Europea de Urología (pT2b 7,2%, pT3a 73%, pT3b 18,3%, pT4 1,5%). El índice de Gleason fue ≥ 8 en 23%. El porcentaje de márgenes quirúrgicos positivos (MQP) fue 46,1%. El seguimiento medio fue 113 meses (24-192). RESULTADOS: En 36,5% se produjo RB. En Gleason < 8, la RB fue 31,7%, en Gleason ≥ 8 del 48% (p < 0,05). La RB en MQP fue 48,9%, por 26,1% en los negativos (p < 0,05). En pacientes con linfadenectomía, la RB se produjo en 48,7%, por 30,9% en los que no se realizó (p < 0,05). En el estudio multivariante, el estadio, el Gleason ≥ 8, MQP, TR y PSA fueron factores independientes de RB. El tratamiento de la RB fue radioterapia 36,5%, Hormonoterapia 24,1%, ambas 21,2%. La vigilancia activa se realizó en 13,3%. La progresion (bioquímica o radiológica) se produjo en el 23,5%. La SCE fue del 98,93%, siendo pT4 el estadio con mayor mortalidad (10%), seguido de pT3b (3,4%), p < 0,05. Pacientes con Gleason ≥ 8 la mortalidad fue del 71% (p < 0,05). MQP y linfadenectomía no tuvieron repercusion en la SCE. En el análisis multivariante, Gleason≥8 fue factor independiente de MCE (Mortalidad cancer específica). CONCLUSIONES: La prostatectomía radical juega un papel importante en el tratamiento multimodal del cáncer de próstata, con un buen control oncológico a medio plazo. El Gleason ≥ 8 es el factor más importante en la SCE. En nuestro trabajo, la linfadenectomía no afectó la SCE

OBJECTIVES: Prostate cancer is considered a tumour with a long natural history. However, its highrisk variants exhibit variable behaviour. We analyse the factors that affect BR and CSS (multivariate, Kaplan Meier). METHODS: From 1997 to 2013, 657 patients were operated of a high-grade prostate cancer (pT2b 7.2%, pT3a 73%, pT3b 18.3%, pT4 1.5%). Gleason score was ≥ 8 in 23% of cases. Percentage of PSMs was 46.1%. Mean follow-up was 113 months (24-192). RESULTS: BR occurred in 36.5%. Patients with Gleason score <8 31.7% had BR, Gleason ≥ 8 had BR in 48% (p < 0.05). PSMs recurrence occurred in 48.9%, whereas 26.1% in NSM (p < 0.05)- If lymphadenectomy, BR occurred in 48.7%, if not 30.9% (p < 0.05). In multivariate analysis, stage, Gleason ≥ 8 and PSMs were independent factors for BR. Treatment of BR was 36.5% radiotherapy, 24.1% HT, and 21.2% both simultaneously. Active surveillance was performed in 13.3%. Disease progression (biochemical or radiological) occurred in 23.5%. CSS was 98.93%, pT4 was the stage with the greatest mortality (10%), followed by pT3b (3.4%), p < 0.05. Patients with a Gleason score ≥ 8 accounted for 71% CSM (pz<0.05)- PSMs and lymphadenectomy didn't have repercussions for survival. In multivariate analysis, Gleason ≥ 8 was independent factor for CSM. CONCLUSIONS: Radical prostatectomy plays an important role in multi-modal approach with good oncological control at medium follow up. Gleason score ≥ 8 was the factor with the greatest effect on CSM. Lymphadenectomy didn't affect CSS

Biochemical recurrence risk factors in surgically treated high and very high-risk prostate tumors.

INTRODUCTION: High and very high-risk prostate cancers are tumors that display great variation in their progression, making their behaviour and consequent prognosis difficult to predict. We analyse preoperative and postoperative risk factors that could influence biochemical recurrence of these tumors. MATERIAL AND METHODS: We carried out univariate and multivariate analyses in an attempt to establish statistically significant preoperative (age, rectal examination, PSA, biopsy Gleason score, uni/bilateral tumor, affected cylinder percentage) and postoperative (pT stage, pN lymph node affectation, Gleason score, positive surgical margins, percentage of tumor affectation, perineural infiltration) risk factors, as well as their relationship with biochemical recurrence (PSA >0.2 ng/mL). RESULTS: We analysed 276 patients with high and very high-risk prostate cancer that were treated with laparoscopic radical prostatectomy (LRP) between 2003-2007, with a mean follow-up of 84 months. Incidence of biochemical recurrence is 37.3%. Preoperative factors with the greatest impact on recurrence are suspicious rectal exam (OR 2.2) and the bilateralism of the tumor in the biopsy (OR 1.8). Among the postoperative factors, the presence of a LRP positive surgical margins (OR 3.4) showed the greatest impact, followed by the first grade of the Gleason score (OR 3.3). CONCLUSIONS: The factor with the greatest influence on biochemical recurrence when it comes to surgery and high and very high-risk prostate cancer is the presence of a positive margin, followed by the Gleason score. Preoperative factors (PSA, biopsy Gleason score, rectal examination, number of affected cylinders) offered no guidance concerning the incidence of BCR.

Lesiones genitourinarias en cirugía ginecológica y general. Una revisión de 3 años / Genitourinary injuries in gynecological and general surgery. A 3-year review

Objetivos: Las lesiones urológicas son frecuentes en la cirugía abdominal y pélvica compleja; a menudo pasan inadvertidas durante la cirugía, siendo motivo de morbilidad añadida. Nosotros exponemos nuestra serie de casos recogidos durante 3 años en los servicios de ginecología y cirugía general de nuestro hospital. Material y métodos: Analizamos los casos registrados de cualquier lesión genitourinaria durante los años 2009-2012, que fueron un total de 41 lesiones en 39 pacientes. En nuestro hospital se realizaron 736 cirugías por carcinoma colorrectal y 870 histerectomías. Resultados: La lesión más frecuente fue la ureteral, con el 52,5% de los casos, seguida de la vesical, con el 47,5%. El momento del diagnóstico fue intraoperatorio en el 65% y posterior en el 35%. El 33,3% de las lesiones estudiadas fueron en cirugías del aparato digestivo y el 66,6%, en intervenciones de ginecoobstetricia. Conclusiones: Las lesiones genitourinarias son una frecuente causa de complicaciones en la cirugía abdominal y pélvica. En la experiencia clínica el retraso en el diagnóstico conlleva consecuencias a corto y a largo plazo en la recuperación de la lesión, además de ser la causa de un aumento claro en la morbilidad de la intervención quirúrgica realizada, y muchas veces presentan un impacto importante sobre la calidad de vida del paciente en la esfera social y sexual (AU)

Objectives: Iatrogenic ureteral injury can occur during abdominal or pelvic surgeries, and they often go unnoticed during the surgical procedure, thus being a reason of added morbidity. We present a series of cases collected during 3 years in the departments of General Surgery and Gynecology from our hospital. Materials and methods: We analyzed registered cases of any genitourinary injury during the 2009-2012 period, with a total of 41 injuries in 39 patients. In our hospital 736 surgeries due to colorectal carcinoma and 870 hysterectomies were performed. Results: The most frequent injury was of the urethra, 52,5% of the total, followed by the bladder injury, 47,5%. Diagnosis was intraoperative in 65% and postoperative in 35%. 33% of the injuries were found in surgeries performed by the general surgery department and 66,6% in gynecology surgeries. Conclusions: Genitourinary injuries are a common cause of complication in abdominal and pelvic surgery. Based on clinical experience, the delay in diagnosis involves short and long term consequences in the recovery from the injury; furthermore, it is the cause of a clear rise in the morbidity of the performed surgery and also many times they present a important impact in the quality of the patient's life, and his or her sexual health (AU)

Consideraciones actuales acerca de la enfermedad hipertensiva del embarazo y el puerperio / Current issues on hypertensive disorders of pregnancy and puerperium

La enfermedad hipertensiva del embarazo afecta entre el 5-7 por ciento de las gestaciones y figura entre las principales causas de morbilidad y mortalidad materna mundialmente. Esta enfermedad varía desde formas leves hasta preeclampsia grave/eclampsia. Aunque recientemente se ha observado un auge en las investigaciones, aún quedan muchos puntos por esclarecer, fundamentalmente en el campo de la patogenia, la profilaxis y el tratamiento. La presente revisión se basa en las más recientes evidencias disponibles sobre la enfermedad hipertensiva del embarazo. Aspectos relacionados con la clasificación, el diagnóstico y el tratamiento específico de la hipertensión arterial en el embarazo y sus principales complicaciones se analizan en el presente artículo(AU)

Laparoscopy in elderly patients.

OBJECTIVES: Aging of the current population is an evident fact, and the surgical treatment of these patients is something we find in our daily practice. In this sense, all doubts that may arise when it comes to carrying out this technique in patients with important comorbidities appear to be cleared, as even patients with prior respiratory or heart disease benefit from the laparoscopic approach. METHODS: An analysis was carried out on a total of 99 patients over 70 years of age who underwent renal laparoscopic surgery, compared, on one hand, to 173 patients under 70 years of age undergoing the same procedure, and on the other, to 95 patients over 70 years of age who underwent open surgery We collected and compared all complications described intraoperatively and in the immediate postoperative period, as well as hospital stay. RESULTS: Patients over 70 years of age have a greater comorbidity compared to patients under 70 (ICH 1.46 vs. 0.89 p<0.05), but there are no statistical differences in terms of intraoperative or postoperative complications, or mean hospital stay. When compared to patients over 70 years of age with a similar comorbidity who underwent classic surgery, (ICH 1.46 vs. 1.45), we found a lower rate of complications (12.2 vs. 28.4% transfusion, 1.4 vs. 4.0% fever, p<0.05) and a shorter hospital stay (4.9 vs. 7.1%p<0.002). CONCLUSION: Patient age does not seem to have a determining effect on complications or on the postoperative period of kidney disease when laparoscopy is used, which is why this method of treatment seems adequate in such cases.

Laparoscopia renal en pacientes añosos / Laparoscopy in elderly patients

OBJETIVO: El envejecimiento de la población actual es un hecho evidente y el tratamiento quirúrgico de estos pacientes es una situación que nos encontramos en nuestro ejercicio habitual. En este sentido, las dudas que nos puede surgir en realizar esta técnica en enfermos con importante comorbilidad parece despejarse, ya que incluso en pacientes con patología respiratoria o cardiológica previa se benefician del abordaje laparoscópico. MÉTODOS: Se analiza un total de 99 pacientes mayores de 70 años operados por laparoscopia renal comparados por una parte a los 173 menores de 70 años sometidos a la misma técnica y por otra parte a los 95 pacientes mayores de 70 años operados por cirugía abierta. Recogemos y comparamos las complicaciones intraoperatorias descritas, postoperatorias inmediatas y estancia hospitalaria. RESULTADOS: Los pacientes mayores de 70 años presentan una mayor comorbilidad respecto a los menores de 70 (Indice de Charlson 1,46 vs 0,89 p <0,05), pero no hay diferencias estadisticas en cuanto a complicaciones intraoperatorias, postoperatorias ni estancia media. Al comparar con los pacientes mayores de 70 años intervenidos por cirugía clásica, con una comorbilidad similar (Indice de Charlson 1,46 vs 1,45) encontramos una menor tasa de complicaciones (12,2 vs 28,4% transfusión, 1,4 vs 4,9% fiebre, p< 0,05) y una menor estancia hospitalaria (4,9 vs 7,1% p< 0,002). CONCLUSIÓN: La edad no parece ser un factor de riesgo que aumente las complicaciones intraoperatorias y postoperatorias en los pacientes sometidos a cirugía renal laparoscópica(AU)

OBJECTIVES: Aging of the current population is an evident fact, and the surgical treatment of these patients is something we find in our daily practice. In this sense, all doubts that may arise when it comes to carrying out this technique in patients with important comorbidities appear to be cleared, as even patients with prior respiratory or heart disease benefit from the laparoscopic approach. METHODS: An analysis was carried out on a total of 99 patients over 70 years of age who underwent renal laparoscopic surgery, compared, on one hand, to 173 patients under 70 years of age undergoing the same procedure, and on the other, to 95 patients over 70 years of age who underwent open surgery. We collecteded and compared all complications described intraoperatively and in the immediate postoperative period, as well as hospital stay. RESULTS: Patients over 70 years of age have a greater comorbidity compared to patients under 70 (ICH 1.46 vs. 0.89 p<0.05), but there are no statistical differences in terms of intraoperative or postoperative complications, or mean hospital stay. When compared to patients over 70 years of age with a similar comorbidity who underwent classic surgery, (ICH 1.46 vs. 1.45), we found a lower rate of complications (12.2 vs. 28.4% transfusion, 1.4 vs. 4.0% fever, p<0.05) and a shorter hospital stay (4.9 vs. 7.1% p<0.002). CONCLUSION: Patient age does not seem to have a determining effect on complications or on the postoperative period of kidney disease when laparoscopy is used, which is why this method of treatment seems adequate in such cases(AU)

Positive surgical margin appears to have negligible impact on survival of renal cell carcinomas treated by nephron-sparing surgery.

BACKGROUND: The occurrence of positive surgical margins (PSMs) after partial nephrectomy (PN) is rare, and little is known about their natural history. OBJECTIVE: To identify predictive factors of cancer recurrence and related death in patients having a PSM following PN. DESIGN, SETTING, AND PARTICIPANTS: Some 111 patients with a PSM were identified from a multicentre retrospective survey and were compared with 664 negative surgical margin (NSM) patients. A second cohort of NSM patients was created by matching NSM to PSM for indication, tumour size, and tumour grade. MEASUREMENTS: PSM and NSM patients were compared using student t tests and chi-square tests on independent samples. A Cox proportional hazards regression model was used to test the independent effects of clinical and pathologic variables on survival. RESULTS AND LIMITATIONS: Mean age at diagnosis was 61+/-12.5 yr. Mean tumour size was 3.5+/-2 cm. Imperative indications accounted for 39% (43 of 111) of the cases. Some 18 patients (16%) underwent a second surgery (partial or total nephrectomy). With a mean follow-up of 37 mo, 11 patients (10%) had recurrences and 12 patients (11%) died, including 6 patients (5.4%) who died of cancer progression. Some 91% (10 of 11) of the patients who had recurrences and 83% of the patients (10 of 12) who died belonged to the group with imperative surgical indications. Rates of recurrence-free survival, of cancer-specific survival, and of overall survival were the same among NSM patients and PSM patients. The multivariable Cox model showed that the two variables that could predict recurrence were the indication (p=0.017) and tumour location (p=0.02). No other variable, including PSM status, had any effect on recurrence. None of the studied parameters had any effect on the rate of cancer-specific survival. CONCLUSIONS: PSM status occurs more frequently in cases in which surgery is imperative and is associated with an increased risk of recurrence, but PSM status does not appear to influence cancer-specific survival. Additional follow-up is needed.