[Current status of laparoscopic sacrocolpopexy in the treatment of pelvic organ prolapse.] / Estado actual de la Colposacropexia Laparoscópica (CSPL) en la corrección del Prolapso de Órganos Pélvicos (POP).

OBJECTIVES: Surgical restoration of pelvic floor anatomy in pelvic organ prolapse (POP) should avoid extensive areas that may injure healthy tissues and lead to scar fibrosis producing dysfunctional rigidity. Laparoscopic sacrocolpopexy corrects POP by lifting pelvic elements with a minimally invasive procedure.Various current strategies and approaches make it a diverse procedure. METHODS: We performed a bibliographic review on the published experience about abdominal sacrocolpopexy over the last 20 years. We analyze the philosophy of each technique, advantages, disadvantages, and results. RESULTS: Among current theories that explain how is the anatomy and function of the pelvic floor, the comprehensive theory of the pelvic floor announces that anatomical deviation produces pelvic dysfunction (diagnostic algorithm)(1). Surgical invasion with reconstructive purposes may hide results if the true physiopathology of the defects found is not known. Although current diagnostic tools cannot solve the problem as a whole, results of different techniques are much better than those of previous times. CONCLUSIONS: Laparoscopic sacrocolpopexy is an adequate strategy that restores anatomy in POP, mainly apical, and function with minimal invasion. Technical development and better knowledge of the female pelvis functional anatomy is enabling today a more precise understanding of its physiopathology, so it facilitates the design of site-specific operations. Various surgical approaches and techniques are offered depending on the defect, where combined procedures give good solutions. It is necessary to have an appropriate surgical training to obtain the better competence, and a safe and correct repair.

Estado actual de la Colposacropexia Laparoscópica (CSPL) en la corrección del Prolapso de Órganos Pélvicos (POP) / Current status of laparoscopic sacrocolpopexy in the treatment of pelvic organ prolapse

OBJETIVO: La restauración quirúrgica de la anatomía del suelo pélvico en el POP (Prolapso Órganos Pélvicos) debe evitar la disección de extensas áreas, que lesionan tejidos sanos y la fibrosis cicatricial que produce rigidez no funcionante. La colposacropexia laparoscópica (CSPL) corrige el POP al suspender los elementos pélvicos descendidos con mínima invasión (CMI). Distintas estrategias y abordajes actuales hacen que sea un procedimiento diverso. MÉTODOS: Se realiza revisión bibliográfica de la experiencia publicada sobre colposacropexia abdominal (CSPA) en los últimos 20 años. Se analiza la filosofía de cada técnica, ventajas, inconvenientes, y resultados. RESULTADOS: Dentro de las teorías actuales que explican cómo es la anatomía y la funcionalidad del suelo pélvico la Teoría Integral del Piso Pélvico (TSI) anuncia que la desviación anatómica produce disfunción pélvica (algoritmo diagnóstico) (1). La intrusión quirúrgica con fines reparadores puede enmascarar los resultados si no se conoce la verdadera fisiopatología de los defectos encontrados. Si bien las herramientas actuales de diagnóstico no logran resolver la problemática en su totalidad, los resultados de las diferentes técnicas hoy son mucho mejores que abordajes de épocas anteriores. CONCLUSIONES: La CSPL es una adecuada estrategia que consigue restaurar la anatomía del POP, principalmente apical, restaurando la función con invasión mínima. El desarrollo técnico y el mejor conocimiento de la anatomía funcional de la pelvis femenina esta hoy permitiendo comprender con mayor precisión su fisiopatología lo que facilita diseñar el tipo de cirugía sitio-específica. Se ofertan vías de abordajes y técnicas diferentes según el defecto, donde los procedimientos combinados ofrecen buenas soluciones. Es preciso un entrenamiento quirúrgico apropiado para obtener la mejor competencia, y una correcta y segura reparación

OBJECTIVES: Surgical restoration of pelvic floor anatomy in pelvic organ prolapse (POP) should avoid extensive areas that may injure healthy tissues and lead to scar fibrosis producing dysfunctional rigidity. Laparoscopic sacrocolpopexy corrects POP by lifting pelvic elements with a minimally invasive procedure Various current strategies and approaches make it a diverse procedure. METHODS: We performed a bibliographic review on the published experience about abdominal sacrocolpopexy over the last 20 years. We analyze the philosophy of each technique, advantages, disadvantages, and results. RESULTS: Among current theories that explain how is the anatomy and function of the pelvic floor, the comprehensive theory of the pelvic floor announces that anatomical deviation produces pelvic dysfunction (diagnostic algorithm)(1). Surgical invasion with reconstructive purposes may hide results if the true physiopathology of the defects found is not known. Although current diagnostic tools cannot solve the problem as a whole, results of different techniques are much better than those of previous times. CONCLUSIONS: Laparoscopic sacrocolpopexy is an adequate strategy that restores anatomy in POP, mainly apical, and function with minimal invasion. Technical development and better knowledge of the female pelvis functional anatomy is enabling today a more precise understanding of its physiopathology, so it facilitates the design of site-specific operations. Various surgical approaches and techniques are offered depending on the defect, where combined procedures give good solutions. It is necessary to have an appropriate surgical training to obtain the better competence, and a safe and correct repair

Prognostic factors in patients with stage pT0/pT1/pTa in the radical cystectomy specimen.

OBJECTIVES: To identify risk factors for progression in patients with invasive bladder carcinoma who were pT0/pT1/pTa after cystectomy. METHODS: We analyzed the clinical records of 97 post-cystectomy pT0/pT1/pTa patients for the following variables: hydronephrosis, carcinoma in situ (CIS), lymphovascular invasion, history of non-muscular invasive disease, residual tumor in the specimen and lymphatic invasion (pN). pN+patients were excluded from definitive analysis. The quantitative and qualitative variables were analyzed using standard statistics. The chi-square test was used to analyze associations between categorical variables. Univariate Cox proportional hazard regression analysis (enter method) was performed. The Kaplan-Meier method was used to evaluate survival and the log-rank test to assess differences between groups. Statistical significance was set at p<0.05. The analysis was performed using SPSS version 15.0. RESULTS: The study sample included 97 cases. The specimen was staged at T2 in 97% of patients after transurethral resection (TUR); After cystectomy, the specimen was staged as pT0 (R0) in 44.3% and pT1/Ta (R1) in 55.7%. Median follow-up was 47 months. Lymph node metastasis were detected in 5.2% of patients (pN+rpar; and had a negative impact on survival (p=0.02). Overall survival was 59.8% and cancer-specific survival 76.6%. Univariate analysis showed a relationship between tumor progression and the presence of CIS (p < 0.001), lymphovascular invasion (p=0.049), and hydronephrosis(p < 0.001). In the multivariate analysis, only the presence of CIS in the transurethral resection was associated with reduced cancer-specific survival (HR 100.5; 95% CI, 10.8 to 933.1; pp<0.001). CONCLUSIONS: Although the prognosis of stage pT0/pT1/pTa carcinoma in the cystectomy specimen is excellent, some patients experience progression. The presence of CIS in the transurethral resection was an independent predictor of recurrence in these cases.

Factores de mal pronóstico en pacientes con estadio pT0/pT1/pTa en la pieza de cistectomía radical / Prognostic factors in patients with stage pT0/pT1/pTa in the radical cystectomy specimen

OBJETIVO: Los pacientes con estadio pT0-1-a post-cistectomía tienen una elevada supervivencia, pero un porcentaje de ellos presentará progresión tumoral y muerte por esta causa. Identificación de los factores de riesgo de progresión en pacientes con carcinoma vesical infiltrante que fueron pT0-1-a post-cistectomía. MÉTODOS: Se recogieron 97 pacientes pT0-1 post-cistectomía. Se analizaron las siguientes variables: hidronefrosis, CIS, invasión linfovascular, antecedente de TVNMI, tumor residual en la pieza e invasión linfática (pN). Los pacientes con pN+ fueron excluidos del análisis. Los pacientes con pN+ (5 casos) fueron excluidos del análisis final, que se realizó sobre 92 casos. Las variables cuantitativas y cualitativas se analizaron mediante los estadísticos habituales. La Chi cuadrado se utilizó para evaluar asociaciones entre variables categóricas. Se realizó un análisis univariante y posteriormente se ajustó mediante un modelo de riesgos proporcionales de Cox (método enter). El método de Kaplan-Meier se ha utilizado para evaluar la supervivencia y el test de long-rank para evaluar las diferencias entre los distintos grupos. La significación estadística se consideró cuando existió una p<0,05. Todos los cálculos se han realizado con el programa estadístico SPSS versión 15.0 en castellano. RESULTADOS: 97 casos cumplían los criterios de inclusión. El 97% fueron T2 y el resto T3 en la RTU. El 44,3% fueron pT0 (R0) y el 55,7% pT1-a (R1). La mediana de seguimiento fue de 47 meses. El 5,2% de los pacientes fueron pN+, con un impacto negativo en la supervivencia (p=0,02). La supervivencia global fue del 59,8% y la cáncer-específica del 76,6%. En el análisis univariante se observó una relación entre la progresión tumoral y la presencia de CIS (p<0,001), invasión linfovascular (p=0,049) e hidronefrosis (p<0,001). En el análisis multivariante, solo la presencia de CIS en la RTU se asoció a una menor supervivencia cáncer-específica (HR 100,5; 95% IC 10,8-933,1; p<0,001). CONCLUSIONES: Aunque el pronóstico de los pacientes pT0/pT1/pTa en la pieza de cistectomía es excelente, algunos presentan progresión. La presencia de CIS en la RTU ha demostrado ser un factor predictor de recidiva y progresión independiente de recidiva en estos casos (AU)

OBJECTIVES: To identify risk factors for progression in patients with invasive bladder carcinoma who were pT0/pT1/pTa after cystectomy. METHODS: We analyzed the clinical records of 97 post-cystectomy pT0/pT1/pTa patients for the following variables: hydronephrosis, carcinoma in situ (CIS), lymphovascular invasion, history of non-muscular invasive disease, residual tumor in the specimen and lymphatic invasion (pN). pN+ patients were excluded from definitive analysis. The quantitative and qualitative variables were analyzed using standard statistics. The chi-square test was used to analyze associations between categorical variables. Univariate Cox proportional hazard regression analysis (enter method) was performed. The Kaplan-Meier method was used to evaluate survival and the log-rank test to assess differences between groups. Statistical significance was set at p<0.05. The analysis was performed using SPSS version 15.0. RESULTS: The study sample included 97 cases. The specimen was staged at T2 in 97% of patients after transurethral resection (TUR); After cystectomy, the specimen was staged as pT0 (R0) in 44.3% and pT1/Ta (R1) in 55.7%. Median follow-up was 47 months. Lymph node metastasis were detected in 5.2% of patients (pN+) and had a negative impact on survival (p=0.02). Overall survival was 59.8% and cancer-specific survival 76.6%. Univariate analysis showed a relationship between tumor progression and the presence of CIS (p<0.001), lymphovascular invasion (p=0.049), and hydronephrosis (p<0.001). In the multivariate analysis, only the presence of CIS in the transurtethral resection was associated with reduced cancer-specific survival (HR 100.5; 95% CI, 10.8 to 933.1; p<0.001). CONCLUSIONS: Although the prognosis of stage pT0/pT1/pTa carcinoma in the cystectomy specimen is excellent, some patients experience progression. The presence of CIS in the transurethral resection was an independent predictor of recurrence in these cases (AU)

Factores de riesgo de recidiva bioquímica después de prostatectomía radical en pacientes con cáncer de próstata clínicamente localizado. Implicaciones en el tratamiento adyuvante / Risk factors for biochemical recurrence after radical prostatectomy in patients with clinically localized prostate cancer. Implications of adjuvant treatment

Evaluar las variables patológicas predictivas de recidiva bioquímica después de prostatectomía radical y sus implicaciones en la toma de decisiones en el tratamiento adyuvante. MÉTODO: 684 pacientes con cáncer de próstata localizado a los que se les realizó prostatectomía radical entre 1996 y 2007. Previamente a la cirugía fueron clasificados según los grupos de riesgo de recidiva de D'Amico. Posteriormente a la prostatectomía se recogieron las siguientes variables: score de Gleason, estadio patológico, invasión capsular, márgenes quirúrgicos, invasión perineural y porcentaje de afectación en la pieza. Se realizó un análisis univariante y posteriormente se ajustó mediante un modelo de riesgos proporcionales de Cox (método enter). RESULTADOS: La mediana de seguimiento de la serie fue de 61 meses. El 29,1% de los pacientes presentaron recidiva bioquímica. La mortalidad global de la serie fue del 4,9% y del 1,2% la cáncer específica. En el análisis univariante el score de Gleason de la pieza quirúrgica, la invasión capsular, la invasión perineural, la afectación de los márgenes quirúrgicos, el estadio patológico y el porcentaje de afectación de la pieza se relacionaron de forma estadísticamente significativa (p < 0,001) con la recidiva bioquímica. En el análisis multivariante el score de Gleason ≥ 8 en la pieza quirúrgica (HR=3,08), la existencia de márgenes quirúrgicos afectados (HR=2,98), el estadio pT3 (HR=1,61) y la afectación por cáncer de más del 50% de la pieza (HR=3,39) se identificaron como variables predictivas independientes de recidiva bioquímica. Al estratificar según los factores predictivos independientes de recidiva bioquímica (pT, Gleason y margen), los pacientes con al menos 2 de estos factores presentaron una incidencia de recidiva bioquímica a los 5 años superior al 50%(AU)

CONCLUSIONES: Los pacientes que después de la prostatectomía tenían un score de Gleason ≥ 8, afectación de los márgenes, estadio pT3 o un porcentaje de tumor > 50% presentaron un riesgo aumentado de recidiva bioquímica. Los pacientes con al menos 2 factores predictores de recidiva tendrán una probabilidad de recidiva superior al 50% en los primeros 5 años de recidiva y por lo tanto deberían de ser candidatos a radioterapia adyuvante(AU)

To evaluate the pathological variables predictive of biochemical recurrence after radical prostatectomy and their implications for decision making in the adjuvant setting. METHODS: 684 patients with localized prostate cancer who were treated with radical prostatectomy between 1996 and 2007. Before surgery they were classified according to D’Amico risk groups for recurrence. Following prostatectomy the following variables were collected: Gleason score, pathological stage, capsular invasion, surgical margins, perineural invasion and percentage of involvement in the piece. Univariate analysis was performed and subsequently adjusted using a Cox proportional hazards model (method enter). RESULTS: The median follow up of the series was 61 months. 29.1% of patients had biochemical recurrence. Overall mortality of the series was 4.9% and cancer-specific mortality 1.2%. In univariate analysis the Gleason score of surgical specimens, capsular invasion, perineural invasion, involvement of surgical margins, pathological stage and percentage of involvement of the piece had statistically significant (p <0.001) relation with biochemical recurrence. In multivariate analysis, a Gleason score ≥ 8 in the surgical specimen (HR = 3.08), existence of affected surgical margins (HR = 2.98), pT3 stage (HR = 1.61) and involvement of more than 50% of the piece by cancer (HR = 3.39) were identified as independent predictors of biochemical recurrence. Stratifying by independent predictors of biochemical recurrence (pT, Gleason score and margin), patients with at least 2 of these factors had an incidence of biochemical recurrence at 5 years exceeding 50%(AU)

CONCLUSIONS: Patients who have a Gleason score ≥ 8, positive margins, pT3 tumour or a percentage of >50% after prostatectomy have an increased risk of biochemical recurrence. Patients with at least 2 predictors of relapse have a probability of recurrence over 50% in the first 5 years of recurrence and should therefore be candidates for adjuvant radiotherapy(AU)