The role of multiparametric magnetic resonance in active surveillance of a low-risk prostate cancer cohort from clinical practice.

INTRODUCTION: Active surveillance (AS) is considered a suitable management practice for those patients with low-risk prostate cancer (PCa). At present, however, the role of multiparametric magnetic resonance imaging (mpMRI) in AS protocols has not yet been clearly established. OUTCOMES: To determine the role of mpMRI and its ability to detect significant prostate cancer (SigPCa) in PCa patients enrolled in AS protocols. MATERIALS AND METHODS: There were 229 patients enrolled in an AS protocol between 2011 and 2020 at Reina Sofía University Hospital. MRI interpretation was based on PIRADS v.1 or v.2/2.1 classification. Demographics, clinical, and analytical data were collected and analyzed. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for mpMRI in different scenarios. We defined SigPCa and reclassification/progression as a Gleason score (GS) ≥ 3 + 4, a clinical stage ≥T2b, or an increase in PCa volume. Kaplan-Meier and log-rank tests were used to estimate progression-free survival time. RESULTS: Median age was 69.02 (±7.73) at diagnosis, with a 0.15 (±0.08) PSA density (PSAD). Eighty-six patients were reclassified after confirmatory biopsy, with a suspicious mpMRI an indication for a clear reclassification and risk-predictor factor in disease progression (p < 0.05). During follow-up, 46 patients were changed from AS to active treatment mainly due to disease progression. Ninety patients underwent ≥2mpMRI during follow-up, with a median follow-up of 29 (15-49) months. Thirty-four patients had a baseline suspicious mpMRI (at diagnostic or confirmatory biopsy): 14 patients with a PIRADS 3 and 20 patients with ≥PIRADS 4. From 14 patients with a PIRADS 3 baseline mpMRI, 29% progressed radiologically, with a 50% progression rate versus 10% (1/10 patients) for those with similar or decreased mpMRI risk. Of the 56 patients with a non-suspicious baseline mpMRI (PIRADS < 2), 14 patients (25%) had an increased degree of radiological suspicion, with a detection rate of SigPCa of 29%. The mpMRI NPV during follow-up was 0.91. CONCLUSION: A suspicious mpMRI increases the reclassification and disease progression risk during follow-up and plays an important role in monitoring biopsies. In addition, a high NPV at mpMRI follow-up can help to decrease the need to monitor biopsies during AS.

Impacto de la visión 3D sobre la carga mental y el rendimiento laparoscópico en individuos sin experiencia / Impact of 3D vision on mental workload and laparoscopic performance in inexperienced subjects

Objetivo: Evaluar el efecto de la visión en 3 dimensiones (3D) en comparación con 2 dimensiones (2D) sobre la carga mental de trabajo soportada y el rendimiento laparoscópico en ejercicios de simulación. Material y métodos: Se llevó a cabo un estudio prospectivo aleatorizado cruzado en sujetos sin experiencia en laparoscopia. Se incluyeron 46 participantes, los cuales completaron 5 ejercicios en pelvitrainer basados en un programa validado usando ambos sistemas de visión. El rendimiento se evaluó mediante el tiempo transcurrido y el número de errores cometidos, y la carga mental de trabajo a través del cuestionario validado NASA-TLX. Resultados: Los participantes realizaron las actividades mejor con la visión 3D de forma global en términos de tiempo (3D = 1.006,08 ± 315,94 vs. 2D = 1.309,17 ± 300,28; p < 0,001) y número total de errores (3D = 0,84 ± 1,26 vs. 2D = 1,86 ± 1,60; p < 0,001). Cuando se analizó el tiempo de forma independiente por ejercicios, el uso de 3D mostró diferencias estadísticamente significativas en: «transferencia de objetos» (p = 0,001), «sutura» (p < 0,001), «clipar y cortar» (p < 0,05) y «manejo de la aguja» (p < 0,001). Además, el uso de la visión 3D produjo menos carga mental de trabajo de acuerdo con los resultados del NASA-TLX (p < 0,001), aunque se asoció con un mayor malestar visual (p < 0,01) y dolor de cabeza (p < 0,05). Conclusión: La incorporación de sistemas 3D en cirugía laparoscópica facilitaría la adquisición más temprana de habilidades laparoscópicas, ya que se asocia a un mejor rendimiento y menor carga mental de trabajo en sujetos sin experiencia, si bien existen inicialmente algunos efectos indeseables como malestar visual o dolor de cabeza (AU)

Objective: To assess the effect of vision in three dimensions (3D) versus two dimensions (2D) on mental workload and laparoscopic performance during simulation-based training. Materials and methods: A prospective, randomized crossover study on inexperienced students in operative laparoscopy was conducted. Forty-six candidates executed five standardized exercises on a pelvitrainer with both vision systems (3D and 2D). Laparoscopy performance was assessed using the total time (in seconds) and the number of failed attempts. For workload assessment, the validated NASA-TLX questionnaire was administered. Results: 3D vision improves the performance reducing the time (3D = 1006.08 ± 315.94 vs. 2D = 1309.17 ± 300.28; P < .001) and the total number of failed attempts (3D = .84 ± 1.26 vs. 2D = 1.86 ± 1.60; P < .001). For each exercise, 3 D vision also shows better performance times: «transfer objects» (P = .001), «single knot» (P < .001), «clip and cut» (P < .05), and «needle guidance» (P < .001). Besides, according to the NASA-TLX results, less mental workload is experienced with the use of 3 D (P < .001). However, 3 D vision was associated with greater visual impairment (P < .01) and headaches (P < .05). Conclusion: The incorporation of 3 D systems in laparoscopic training programs would facilitate the acquisition of laparoscopic skills, because they reduce mental workload and improve the performance on inexperienced surgeons. However, some undesirable effects such as visual discomfort or headache are identified initially (AU)

Influence of surgical complications on kidney graft survival in recipients of simultaneous pancreas kidney transplantation.

PURPOSE: Simultaneous pancreas-kidney transplantation is the gold standard treatment for patients with end-stage renal failure secondary to insulin-dependent diabetes mellitus. This kind of transplantation is a complex operation associated with a high incidence of surgical complications and mortality risk which could influence graft survival. The aim of this study was to establish the influence of different grades of postoperative complications, classified according to Clavien-Dindo, on the rate of kidney graft loss. METHODS: We performed an observational retrospective review of all simultaneous transplantations performed between February 1989 and May 2012. Factors examined were related to recipient and donor characteristics, surgical procedures, and postoperative outcomes. For this purpose, Kaplan-Meier analyses and Cox-Regression tests are used. RESULTS: One hundred thirty-nine transplantations were performed. Complications grades I, II, and IIIa were experienced in 81 (58.3%) patients, and grades IIIb and IVa-b in 55 (39.6%). Multivariate analysis showed an influence of panel reactive antibody (hazard ratio [HR]: 10.79; P = .003), incidence of acute rejection (HR: 2.55; P = .03), and complications grouped into grades IIIb and IVa-b (HR: 3.63; P = .02). Kaplan Meier analysis showed worse kidney graft survival rate in groups grades IIIb and IVa-b compared to grades I, II, and IIIa (86.6% vs 98.7% at 1 year and 81.8% vs 97.3% at 5 years; P = .001). CONCLUSIONS: Despite being the gold standard treatment for these patients, pancreas and kidney transplantations have numerous complications which could influence the prognosis of graft kidney survival.

Impact of 3D vision on mental workload and laparoscopic performance in inexperienced subjects.

OBJECTIVE: To assess the effect of vision in three dimensions (3D) versus two dimensions (2D) on mental workload and laparoscopic performance during simulation-based training. MATERIALS AND METHODS: A prospective, randomized crossover study on inexperienced students in operative laparoscopy was conducted. Forty-six candidates executed five standardized exercises on a pelvitrainer with both vision systems (3D and 2D). Laparoscopy performance was assessed using the total time (in seconds) and the number of failed attempts. For workload assessment, the validated NASA-TLX questionnaire was administered. RESULTS: 3D vision improves the performance reducing the time (3D = 1006.08 ± 315.94 vs. 2D = 1309.17 ± 300.28; P < .001) and the total number of failed attempts (3D = .84 ± 1.26 vs. 2D = 1.86 ± 1.60; P < .001). For each exercise, 3D vision also shows better performance times: "transfer objects" (P = .001), "single knot" (P < .001), "clip and cut" (P < .05), and "needle guidance" (P < .001). Besides, according to the NASA-TLX results, less mental workload is experienced with the use of 3D (P < .001). However, 3D vision was associated with greater visual impairment (P < .01) and headaches (P < .05). CONCLUSION: The incorporation of 3D systems in laparoscopic training programs would facilitate the acquisition of laparoscopic skills, because they reduce mental workload and improve the performance on inexperienced surgeons. However, some undesirable effects such as visual discomfort or headache are identified initially.

[State of acute phase markers and oxidative stress in patients with kidney stones in the urinary tract]. / Estado de los marcadores de fase aguda y estrés oxidativo en los enfermos con litiasis de la vía urinaria.

OBJECTIVE: This present study has aimed to assess the state of acute phase markers and oxidative stress in patients with kidney stones. MATERIAL AND METHODS: A prospective study was carried out on 100 patients with kidney stones and 25 healthy controls. Albumin, ß2 microglobulin, Gamma-glutamyl transpepsidase, Lactate dehydrogenase, Tumor necrosis factor alpha, Interleukin 1 and Interleukin-6 were evaluated as acute phase markers and lipid peroxidation products, Superoxide dismutase and Glutathione peroxidase levels acted as oxidative stress markers. RESULTS: An increase in renal cell damage markers as expressed by the ß2 microglobulin (p=0.04), albumin (p=0.004), Lactate dehydrogenase (p=0.001) and Gamma glutamyl transpepsidasa (p=0.01) was observed in the patient group. There was a direct correlation between levels of ß2 microglobulin and stone size (r=0.3, p=0.03). The association between stone size and cytokine activation was observed to be stronger in patients with staghorn calculi. In these patients, Tumor necrosis factor alpha (p=0.011), Interleukin 1 (p=0.004) and Interleukin 6 (p=0.004) were significantly higher. Patients with stones in the urinary tract showed data of significantly higher oxidative stress, expressed as an increase in levels of lipid peroxidation products (p=0.03) and a decrease in the antioxidant activity of Superoxide dismutase (p=0.03) and Glutathione peroxidase (p=0.002). CONCLUSIONS: Patients undergoing urolithiasis showed an elevation of acute phase markers, associated with oxidative stress as expressed by an increase in lipid peroxidation products and a decrease in the antioxidant enzyme activity.

[Review of cut-off points between stages T1 and T2 in the 1997 TNM classification of renal carcinoma]. / Revisión del punto de corte entre los estadios T1 y T2 en la clasificación TNM del carcinoma renal de 1997.

OBJECTIVE: We retrospectively review the patients treated at our institution for renal cell carcinoma (RCC). We compare the patients classified in TNM state T1N0M0 in the 1997 revision with the 1992 one in order to determine survival differences. We divide patients in three size related groups and compare its survival rates. MATERIAL AND METHODS: We review 168 surgically treated patients. 72 of them were classified into T1N0M0 stage. We compare cancer-free survival in patients included in 1997 and 1992 T1 stage. We divide patients in three groups: 1-3 cm, 3-5 cm, 5-7 cm and compare respective cancer-free survival. RESULTS: There is a survival difference between T1(1997)-T2(1992) (p = 0.478). There is an inferior survival in size group 5-7 cm compared with 1-3 cm and 3-5 cm ones (p = 0.02/0.0465). CONCLUSIONS: In our patients, 1997 revision of T1 size supposes a descent of cancer-free survival compared with 1992 one. We consider a better stage limit under 5 cm, instead of actual 7 cm.

Revisión del punto de corte entre los estadios T1 y T2 en la clasificación TNM del carcinoma renal de 1997 / Cut-off point revision between 1997 TNM classification stages T1 and T2 o renal carcinoma

OBJETIVO: Realizamos un estudio retrospectivo de los pacientes tratados en nuestra institución por carcinoma de células renales (CCR). Comparamos los pacientes clasificados en el estadio T1N0M0 según la revisión TNM de 1997 con la clasificación según la revisión de 1992 para establecer diferencias de supervivencia. Comparamos diferentes cortes por tamaño tumoral y valoramos su implicación en la supervivencia. MATERIAL Y MÉTODOS: Análisis retrospectivo de una serie de 168 pacientes intervenidos por CCR, de ellos 72 clasificados en estadio T1N0M0. Comparamos supervivencia según las dos últimas revisiones TNM y en tres grupos de tamaño: 1-3 cm, 3-5 cm y 5-7 cm. RESULTADOS: Hallamos menor supervivencia en los pacientes T11997 (p=0,0478) y en grupo de tamaño 5-7 cm, con respecto al 1-3 cm (p=0,02) y al de 3-5 cm (p=0,0465).CONCLUSIONES: En nuestra serie, la revisión de 1997 en el estadio T1 supone un descenso de supervivencia. El límite en 7 cm es excesivo, lo consideramos más apropiado por debajo de 5 cm (AU)

Combined treatment with vitamin E and colchicine in the early stages of Peyronie's disease.

OBJECTIVE: To assess the effectiveness of the combination of colchicine and vitamin E (which has anti-fibrotic, anti-mitotic and anti-inflammatory effects) in modifying the early stages of Peyronie's disease, by evaluating pain relief, correction of deformities and plaque size. PATIENTS AND METHODS: In all, 45 patients were divided into two groups and treated from January 1998 to November 2001. Their mean (range) age was 53.4 (40-62) years, the time from onset of the disease < 6 months and they had penile deformity of < 30 degrees; no patient had erectile dysfunction. Twenty-two patients were given ibuprofen 400 mg/day for 6 months, whilst 23 received a combination of vitamin E 600 mg/day plus colchicine 1 mg every 12 h. Pain, plaque size and penile deformity were assessed at 6 months. RESULTS: There were no statistically significant differences between the groups at baseline in age, time from onset of the disease until the initial evaluation or plaque size. Although the proportion of patients reporting pain relief was higher amongst those receiving colchicine plus vitamin E (91% vs 68%) this was not significantly different, but differences in plaque size and penile curvature were significant. CONCLUSIONS: The use of colchicine plus vitamin E during the early stages of Peyronie's disease (time from onset < 6 months) in patients with penile curvature of < 30 degrees and no erectile dysfunction is an effective and well-tolerated way to stabilize the disease. A more extensive study is needed, comparing these results with other oral therapies.

[Encrusted pyelitis. Lithiasic disease with infectious etiology]. / Pielitis incrustada. Una enfermedad litiásica de etiología infecciosa.

We report on two new cases of encrusted pielitis, a lithiasic disease of infectious ethiology--Corynebacterium of D group-. The clinic diagnostic is difficult and this disease develops in immunosuppressed patients, mainly in renal transplanted ones. One of our two cases is diagnosed in a patient with a transplanted kidney and the other one develops the disease within her native kidneys. We remark on the clinic features and therapeutic options.

Pielitis incrustada. Una enfermedad litiasica de etiologia infecciosa / Encrusted pyelitis. A renal lithiasic disease of infectious ethiology

Presentamos dos nuevos casos de pielitis incrustada, una enfermedad litiásica de etiología infecciosa relacionada con el Corynebacterium del grupo D. El diagnóstico clínico es difícil y se desarrolla en enfermos inmunodeprimidos, sobre todo en aquellos sometidos a trasplante renal. Nuestros pacientes desarrollan la enfermedad en un caso en un enfermo trasplantado y en el otro en riñones no trasplantados. Detallamos las características clínicas y las opciones terapéuticas (AU)

[Renal abscess in patients with HIV infection in the era of highly active antiretroviral therapy]. / Absceso renal en el paciente con infección por VIH en la era de la terapia antiretroviral de alta eficacia.

Renal abscess is a very rare complication of HIV infection, usually occurs in patients with severe immune deficiency. The immune status is the main factor that predict disease advancement. Highly activate antiretroviral therapy (HAART) improve the CD4 cell count. We present a case of renal abscess for Aspergillus niger in a HIV+ patient who complained of right flank mass and fever. We review relevant literature and the management of these patients.

Treatment with sildenafil citrate in renal transplant patients with erectile dysfunction.

OBJECTIVE: To assess the safety and efficacy of sildenafil citrate in renal transplant patients with erectile dysfunction, as up to half of men with renal failure may be affected and only 60-75% recover potency after transplantation. PATIENTS AND METHODS: Fifty patients with erectile dysfunction and a functioning renal transplant were treated using sildenafil (mean age 54 years, mean time on dialysis 35 months, mean time from transplantation 20 months). The hypogastric artery was not used during transplantation in any patient. Sildenafil citrate was prescribed at doses of 25 or 50 mg depending on baseline creatinine values and on the response, and plasma levels of cyclosporin/FK506 were monitored. RESULTS: Thirty patients (60%) had a satisfactory response, with a mean time on dialysis of 23 months. Six patients (12%) did not take the sildenafil and in 14 (28%) the drug was ineffective. The mean time on dialysis in this group was 43 months. Six patients (12%) had side-effects that in no case led to withdrawal of treatment. Plasma levels of cyclosporin/FK506 remained within the safety and efficacy limits in all patients. CONCLUSIONS: Treatment with sildenafil citrate in renal transplant patients with erectile dysfunction is an effective and safe option, with few side-effects. Plasma levels of immunosuppressants are unchanged. The response was more effective in patients with a shorter time on dialysis, as penile vascular disease is less advanced.

Absceso renal en el paciente con infección por VIH en la era de la terapia antiretroviral de alta eficacia / Renal abscess in the patient with HIV infection in the era of highly antiretroviral therapy

El absceso renal es una rara complicación en la infección por VIH y normalmente ocurre en pacientes con severa inmunodeficiencia. El estado inmunitario del paciente es el factor determinante de la progresión de la enfermedad. La terapia antiretroviral de alta eficacia (HAART) mejora el recuento de subpoblaciones linfocitarias CD4. Presentamos un caso de absceso renal por Aspergillus niger en un paciente VIH+, que debutó con una masa en flanco derecho y fiebre. Realizamos una revisión de la literatura y analizamos el manejo en este tipo de pacientes (AU)

[Pneumocysts, unusual infective complication in diabetics]. / Pneumocistos, una rara complicación infecciosa en diabéticos.

We report on a case of fully gas-filled bladder with no evidence of intramural gas, fistula between bladder and gastrointestinal tract or instrumentation. The patient is diagnosed of a diabetic neurogenic bladder. We comment the causes of this rare finding and its relation with emphysematous cystitis.

Pneumocistos, una rara complicación infecciosa en diabéticos / Pneumositos, a rare infectious complication in diabetics

Publicamos un caso en el cual la luz vesical aparece completamente ocupada por gas en ausencia de gas intramural, fístula con tracto gastrointestinal o instrumentación previa, en una paciente afectada por vejiga neurógena diabética. Comentamos las causas de esta rara complicación infecciosa y su relación con la cistitis enfisematosa, más frecuente (AU)

[Incidence of high grade prostatic intraepithelial neoplasia in urologic practice]. / Incidencia de la neoplasia intraepitelial prostática de alto grado en la práctica urológica.

High grade (PIN AG) intraepithelial neoplasia of the prostate is a likely precursor of prostate adenocarcinoma (PA) because of their association. Since the risk to suffer PA increases in patients with no previous PIN AG, its finding requires an arduous search for PA. This paper reviews the incidence of PIN AG in 499 histological studies in prostate transrectal biopsies, prostate TUR and adenomectomy specimens and radical prostatectomy (RP) sections. Evaluation of data obtained, type of presentation and association to prostate carcinoma, indicating the approach taken in the various cases.

[Wolfram syndrome. Urologic implications]. / Síndrome de Wolfram. Implicaciones urológicas.

OBJECTIVES: We report on four new cases of Wolfram's Syndrome. We emphasize in urological aspects of this disease. PATIENTS AND METHODS: Three male siblings. The other patient is also a male, without familiar relation with the other ones. All four patients presents different levels of urological alterations, mainly urinary collecting system dilation and decrease in detrusor muscle contractility. CONCLUSIONS: Urological findings are cardinal aspects in Wolfram syndrome. Due to its high frequency and prognostic value in natural history of disease. Urological disease seems to be within a systemic neurological tissues affectation of etiology that remains unknown.

[Malignant fibrohistiocytoma of the bladder]. / Fibrohistiocitoma maligno de vejiga.

We report on new case of a rare vesical tumour. We result the importance of immunohistochemistry and ultrastructural study to support the diagnosis of malignant fibrous histiocytoma of the urinary bladder. There has been described another 16 cases of this tumour in the literature, however, only four of them -five with ours- reports an extensive immunohistochemical and ultrastructural study. The rarity of vesical localization of this tumour may delay its diagnosis. It must be supported by a immunohistochemistry and/or ultrastructural study, in order to differentiate from other tumours with fibrohistiocytoma-like pattern: leiomyosarcoma and sarcomatoid carcinoma of the bladder. After radical removal of tumour, adjuvant therapy is recommended both systemic chemotherapy and local radiotherapy, although survival rates are over 5.3 months after first therapeutical actuation.

Fibrohistiocitoma maligno de vejiga / Malignant fibrous histiocytoma of the bladder

Aportamos un nuevo caso de un tumor cuya localización primaria en vejiga es extremadamente rara. Destacamos la importancia de apoyar el diagnóstico histológico con la inmunohistoquímica y/o el estudio ultraestructural para llegar a la certeza de encontrarnos ante un fibrohistiocitoma maligno. Existen en la literatura sólo 16 casos publicados de este tumor. Sin embargo sólo existen cuatro casos, con el que aportamos suman cinco, que documenten un completo estudio inmunohistoquímico y por microscopía electrónica. En conclusión, la rareza de la localización vesical del fibrohistiocitoma maligno hace esquivo su diagnóstico, que debe apoyarse en la inmunohistoquímica y el estudio estructural, para diferenciarlo del carcinoma sarcomatoide y del leiomiosarcoma de vejiga. Tras el diagnóstico se aconseja cirugía radical y terapia adyuvante. Los resultados de supervivencia son malos, con una media de 5.3 meses tras el inicio del tratamiento (AU)

Incidencia de la neoplasia intraepitelial prostática de alto grado en la práctica urológica / Incidence of high grade intraepithelial neoplasia of the prostate in the urologic practice

La neoplasia intraepitelial prostática de alto grado (PIN AG) es un probable precursor del adeno-carcinoma de próstata (AP) por su asociación con el mismo. Su hallazgo obliga a una búsqueda intensa de AP, ya que incrementa el riesgo de padecer éste último en relación a los pacientes sin PIN AG previo. Revisamos nuestra incidencia de PIN AG en 499 estudios histológicos correspondientes a biopsias transrectales de próstata, especímenes de RTU de próstata y adenomectomía y piezas de prostatectomía radical (PR).Se evalúan los datos obtenidos, su tipo de presentación asi como su asociación con carcinoma de próstata, mostrando la actitud posterior a tomar en los diferentes casos (AU)