Evaluación de la teleconsulta en el paciente urológico durante la pandemia COVID-19 / Evaluation of teleconsultation system in the urological patient during the COVID-19 pandemic

INTRODUCCIÓN: La pandemia global de COVID-19 ha provocado una rápida implantación de la telemedicina, pero existe escasa información sobre la satisfacción percibida por el paciente como alternativa a la asistencia presencial. OBJETIVO: Se evalúa la satisfacción del paciente urológico con la teleconsulta durante la pandemia COVID-19. MATERIAL Y MÉTODOS: Estudio observacional, prospectivo transversal, no intervencionista, mediante encuesta telefónica durante el periodo considerado pico de pandemia (marzo-abril 2020). Se realiza una encuesta de calidad compuesta por 11 preguntas sobre la atención urológica durante la pandemia COVID-19 por los facultativos, seleccionando una muestra representativa de los pacientes atendidos en el periodo por teleconsulta. RESULTADOS: Doscientos pacientes fueron contactados telefónicamente para responder a una encuesta de calidad sobre teleconsulta. La distribución de pacientes encuestados entre las consultas monográficas fue homogénea entre el número de consultas citadas en el periodo, requiriendo el 18% de ellos ayuda por familiar. El 60% de los pacientes evitaron acudir a un centro médico durante la pandemia. El 42% de los pacientes encuestados tenían cancelada alguna prueba complementaria, el 59% alguna consulta médica, el 3,5% tratamientos y el 1% intervenciones. El 10% apreciaron un empeoramiento de su sintomatología urológica durante el confinamiento. La resolución subjetiva de la consulta por el facultativo fue alcanzada en el 72% de los casos, siendo la teleconsulta por el urólogo habitual en el 81%. El grado de satisfacción global con la teleconsulta fue de 9 (RIQ 8-10), considerando la teleconsulta como una «opción de asistencia sanitaria» pasada la crisis sanitaria por el 61,5% de los encuestados. CONCLUSIÓN: La teleconsulta ha sido valorada con un alto grado de satisfacción durante la pandemia COVID-19, ofreciendo asistencia continuada a los pacientes urológicos durante la crisis sanitaria. La calidad percibida ofrece un campo de asistencia telemática opcional en pacientes seleccionados, que debe reevaluarse fuera de una situación de confinamiento

INTRODUCTION: The global pandemic of COVID-19 has led to rapid implementation of telemedicine, but there is little information on patient satisfaction of this system as an alternative to face-to-face care. OBJECTIVE: To evaluate urological patient satisfaction with teleconsultation during the COVID-19 pandemic. MATERIAL AND METHODS: Observational, prospective, cross-sectional, non-interventional study carried out by telephone survey during the period considered as the peak of the pandemic (March-April 2020). A quality survey composed of 11 questions on urological care provided by physicians during the COVID-19 pandemic was conducted, selecting a representative sample of patients attended by teleconsultation. RESULTS: Two hundred patients were contacted by telephone to answer a survey on the quality of teleconsultation. The distribution of patients surveyed among the specialized consultations was homogeneous with the number of consultations cited in the period; 18% of them required assistance from family members. Sixty percent of patients avoided going to a medical center during the pandemic. Of the surveyed patients, 42% had cancelled diagnostic tests, 59% had cancelled medical consultations, 3.5% had cancelled treatments and 1% had cancelled interventions. Ten percent reported a worsening of urological symptoms during confinement. According to physicians, consultations were effectively delivered in 72% of cases, with teleconsultation being carried out by their usual urologist in 81%. Teleconsultation overall satisfaction level was 9 (IQI8-10), and 61.5% of respondents consider teleconsultation as a «health care option» after the healthcare crisis. CONCLUSION: Teleconsultation has been evaluated with a high level of satisfaction during the COVID-19 pandemic, offering continuous care to urological patients during the healthcare crisis. The perceived quality offers a field of optional telematic assistance in selected patients, which should be re-evaluated in a period without confinement measures

Evaluation of teleconsultation system in the urological patient during the COVID-19 pandemic. / Evaluación de la teleconsulta en el paciente urológico durante la pandemia COVID-19.

INTRODUCTION: The global pandemic of COVID-19 has led to rapid implementation of telemedicine, but there is little information on patient satisfaction of this system as an alternative to face-to-face care. OBJECTIVE: To evaluate urological patient satisfaction with teleconsultation during the COVID-19 pandemic. MATERIAL AND METHODS: Observational, prospective, cross-sectional, non-interventional study carried out by telephone survey during the period considered as the peak of the pandemic (March-April 2020). A quality survey composed of 11 questions on urological care provided by physicians during the COVID-19 pandemic was conducted, selecting a representative sample of patients attended by teleconsultation. RESULTS: Two hundred patients were contacted by telephone to answer a survey on the quality of teleconsultation. The distribution of patients surveyed among the specialized consultations was homogeneous with the number of consultations cited in the period; 18% of them required assistance from family members. Sixty percent of patients avoided going to a medical center during the pandemic. Of the surveyed patients, 42% had cancelled diagnostic tests, 59% had cancelled medical consultations, 3.5% had cancelled treatments and 1% had cancelled interventions. Ten percent reported a worsening of urological symptoms during confinement. According to physicians, consultations were effectively delivered in 72% of cases, with teleconsultation being carried out by their usual urologist in 81%. Teleconsultation overall satisfaction level was 9 (IQI8-10), and 61.5% of respondents consider teleconsultation as a «health care option¼ after the healthcare crisis. CONCLUSION: Teleconsultation has been evaluated with a high level of satisfaction during the COVID-19 pandemic, offering continuous care to urological patients during the healthcare crisis. The perceived quality offers a field of optional telematic assistance in selected patients, which should be re-evaluated in a period without confinement measures.

Indicación de cistectomía precoz en el cáncer vesical no músculo infiltrante. Revisión de la literatura / Indication for early cystectomy in nonmuscle-invasive bladder cancer. Literature review

Contexto: El cáncer vesical no músculo infiltrante de alto riesgo es una enfermedad que integra un grupo heterogéneo de pacientes, en los que se recomienda un seguimiento estrecho debido al riesgo de progresión a tumor músculo infiltrante. El tratamiento de elección de estos tumores es la resección transuretral de vejiga seguido de un programa de instilaciones con BCG. Existe un subgrupo de pacientes que tiene un mayor riesgo de progresión, y que se benefician de un tratamiento radical de inicio. Objetivo: Identificar qué grupo de pacientes con cáncer vesical no músculo infiltrante se benefician de un tratamiento radical precoz. Búsqueda de la evidencia: Se realizó una revisión bibliográfica para identificar los factores de riesgo de progresión de estos pacientes, y así poder recomendar un tratamiento que mejore su tasa de supervivencia. Síntesis de la evidencia: Se identificaron los diferentes factores pronósticos asociados a progresión tumoral: la persistencia de tumor T1 en la re-resección transuretral de vejiga, la presencia de carcinoma in situ, refractariedad al tratamiento con BCG, los mayores de 70 años, los tumores mayores 3cm, la subestadificación de los tumores T1, la presencia de invasión linfovascular y la presencia de tumor en la uretra prostática. Igualmente se comentan las ventajas del tratamiento radical frente al conservador, apreciando que la realización de una cistectomía precoz por un tumor vesical no infiltrante de alto riesgo tiene un mejor pronóstico oncológico en comparación con aquellos en los cuales se difiere la realización de la misma hasta la progresión. Conclusiones: En esta enfermedad es importante individualizar a los pacientes, para así ofrecerles un tratamiento personalizado. En pacientes con las características mencionadas previamente se recomienda no demorar la cistectomía precoz

Context: High-risk nonmuscle-invasive bladder cancer is a disease that includes a heterogeneous group of patients, for whom close follow-up is recommended due to the risk of progression to a muscle-invasive tumour. The treatment of choice for these tumours is transurethral resection of the bladder tumour followed by a programme of bacillus Calmette-Guerin instillations. There is a subgroup of patients who have a greater risk of progression and who benefit from early radical treatment. Objective: To identify which patient group with nonmuscle-invasive bladder cancer will benefit from early radical treatment. Searching the evidence: We performed a literature review to identify the risk factors for progression for these patients and thereby recommend a treatment that improves their survival rate. Synthesis of the evidence: We identified the various prognostic factors associated with tumour progression: the persistence of T1 tumour in re-resection of the bladder tumour, the presence of carcinoma in situ, patients refractory to bacillus Calmette-Guerin treatment, patients older than 70 years, tumours larger than 3 cm, the substaging of T1 tumours, the presence of lymphovascular invasion and the presence of a tumour in the prostatic urethra. Similarly, we comment on the advantages of radical versus conservative treatment, considering that the performance of an early cystectomy due to a high-risk noninvasive vesical tumour has a better cancer prognosis than those in which the operation is deferred until the progression. Conclusions: In this disease, it is important to individualise the patients to provide them personalized treatment. For patients with the previously mentioned characteristics, it is recommended that early cystectomy not be delayed

Indication for early cystectomy in nonmuscle-invasive bladder cancer. Literature review. / Indicación de cistectomía precoz en el cáncer vesical no músculo infiltrante. Revisión de la literatura.

CONTEXT: High-risk nonmuscle-invasive bladder cancer is a disease that includes a heterogeneous group of patients, for whom close follow-up is recommended due to the risk of progression to a muscle-invasive tumour. The treatment of choice for these tumours is transurethral resection of the bladder tumour followed by a programme of bacillus Calmette-Guerin instillations. There is a subgroup of patients who have a greater risk of progression and who benefit from early radical treatment. OBJECTIVE: To identify which patient group with nonmuscle-invasive bladder cancer will benefit from early radical treatment. SEARCHING THE EVIDENCE: We performed a literature review to identify the risk factors for progression for these patients and thereby recommend a treatment that improves their survival rate. SYNTHESIS OF THE EVIDENCE: We identified the various prognostic factors associated with tumour progression: the persistence of T1 tumour in re-resection of the bladder tumour, the presence of carcinoma in situ, patients refractory to bacillus Calmette-Guerin treatment, patients older than 70 years, tumours larger than 3cm, the substaging of T1 tumours, the presence of lymphovascular invasion and the presence of a tumour in the prostatic urethra. Similarly, we comment on the advantages of radical versus conservative treatment, considering that the performance of an early cystectomy due to a high-risk noninvasive vesical tumour has a better cancer prognosis than those in which the operation is deferred until the progression. CONCLUSIONS: In this disease, it is important to individualise the patients to provide them personalized treatment. For patients with the previously mentioned characteristics, it is recommended that early cystectomy not be delayed.

Perfil hormonal preoperatorio en pacientes sometidos a prostatectomía radical por cáncer de próstata / Preoperative Hormonal Pattern in Patients Undergoing Radical Prostatectomy due to Prostate Cancer

Objetivos: Los niveles preoperatorios de testosterona (T) relacionados con factores de mal pronóstico después de la prostatectomía radical (PR) han sido motivo de controversia. Nuestro objetivo fue determinar la relación entre los niveles preoperatorios de T, los resultados anatomopatológicos y la recidiva bioquímica tras la PR. Material y métodos: Analizamos de manera prospectiva 143 pacientes sometidos a PR desde febrero de 2008 a junio de 2010 en nuestro centro. Se determinaron los niveles preoperatorios de T y globulina transportadora de hormonas sexuales como parte de nuestro protocolo clínico. La T libre (Tl) y la biodisponible (Tbio) fueron calculadas usando la formula de Vermeulen. Se definieron niveles bajos de testosterona sérica como T menor o igual a 346 ng/dL. Se realizó un análisis comparativo analizando las variables pTNM, márgenes positivos, tamaño tumoral,escala de Gleason, multifocalidad, recidiva bioquímica (usando los 2 cortes de PSA > 0,4 ng/dLy PSA > 0,2 ng/dL como valores de corte) en función de los niveles preoperatorios de T. Resultados: Las variables Gleason, la tasa y número de márgenes positivos, el tamaño tumoral, la multifocalidad, el tiempo a recidiva bioquímica y el estadio patológico final no se correlacionaron con los niveles preoperatorios hormonales. Los niveles preoperatorios bajos de T (< 346 ng/dL) no se relacionaron con recidiva bioquímica (PSA > 0,4 ng/dL de log-rank, p = 0,512),aunque sí se observó una tendencia cuando PSA > 0,2 ng/dL (log-rank, p = 0,097).Conclusión: Los niveles preoperatorios de T no se relacionaron con las características anatomopatológicas del cáncer de próstata ni con la presencia de recidiva bioquímica (AU)

Objective: There is controversial evidence regarding preoperative testosterone (T) levels related to poor prognosis factors after radical prostatectomy (RP). The aim of this manuscript is to determine the relationship between preoperative T levels and final pathologic report together to biochemical recurrence after RP. Materials and methods: We prospectively analysed 143 patients submitted to RP from February 2008 to June 2010 in our centre. Pretreatment T and sex hormone-binding globulin levels were determined as part of our clinical protocol. Free calculated (fT) and bioavailable (bioT) T were calculated using Vermeulen’s formula. Low T levels were defined as 346 ng/dL or less. A comparative analysis with variables pTNM, positive margins, tumour burden, Gleason score, multifocality and biochemical recurrence (using both PSA > 0.4 ng/dL and PSA > 0.2 ng/dL as cut-off values) was performed, according to preoperative levels of T. Results: Variables Gleason score, rate and number of positive margins, tumour burden, tumour multifocality, time to biochemical recurrence and pathological stage were not related to preoperative hormonal levels. Preoperative T < 346 ng/dL was not found to be related to PSA recurrence (PSA > 0,4 ng/dL log-rank, P = 0.512), although a trend was observed whenPSA > 0,2 ng/dL (log-rank, P =0 .097). Conclusion: Preoperative T levels were not related to final pathological report or to biochemical recurrence (AU)

Preoperative hormonal pattern in patients undergoing radical prostatectomy due to prostate cancer.

OBJECTIVE: There is controversial evidence regarding preoperative testosterone (T) levels related to poor prognosis factors after radical prostatectomy (RP). The aim of this manuscript is to determine the relationship between preoperative T levels and final pathologic report together to biochemical recurrence after RP. MATERIALS AND METHODS: We prospectively analysed 143 patients submitted to RP from February 2008 to June 2010 in our centre. Pretreatment T and sex hormone-binding globulin levels were determined as part of our clinical protocol. Free calculated (fT) and bioavailable (bioT) T were calculated using Vermeulen's formula. Low T levels were defined as 346 ng/dL or less. A comparative analysis with variables pTNM, positive margins, tumour burden, Gleason score, multifocality and biochemical recurrence (using both PSA>0.4 ng/dL and PSA>0.2 ng/dL as cut-off values) was performed, according to preoperative levels of T. RESULTS: Variables Gleason score, rate and number of positive margins, tumour burden, tumour multifocality, time to biochemical recurrence and pathological stage were not related to preoperative hormonal levels. Preoperative T<346 ng/dL was not found to be related to PSA recurrence (PSA>0,4 ng/dL log-rank, P=.512), although a trend was observed when PSA>0,2 ng/dL (log-rank, P=.097). CONCLUSION: Preoperative T levels were not related to final pathological report or to biochemical recurrence.

[Complications and incidences in our first 250 robotic radical prostatectomies]. / Incidencias y complicaciones en nuestras primeras 250 prostatéctomias radicales robóticas.

OBJECTIVE: To review the incidence of and analyze the factors contributing to perioperative complications in patients undergoing robotic radical prostatectomy in our experience of 250 procedures. MATERIALS AND METHODS: An analytical, descriptive, retrospective study was conducted of 250 consecutive patients who underwent robotic radical prostatectomy during a period of three years and two months (January 06-March 09). Data recorded included age, preoperative Gleason grade and PSA, and prostate volume. All procedures were performed by three surgeons through a transperitoneal approach using a four-arm da Vinci robotic system. Microsoft Excel support was used. Surgical variables recorded included setup time, console operation time, mean bleeding, transfusion rate, hospital stay, and urethral catheterization time. Incidences and intraoperative and postoperative late and early complications in these patients were reviewed. RESULTS: Demographic data recorded included: mean age, 61.5 years (47-74); mean preoperative PSA, 8.18 ng/mL (2.6-34 ng/mL); mean Gleason grade, 6.8 (2-9); and mean prostate volume 34.9 mL (12-124). Surgical variables recorded included: console setup time, 10.8 min (6-47): console operation time, 125 min (90-315); mean bleeding, 150 mL (50-1150); and a 3.6% (9/250) transfusion rate. There was no peroperative mortality, and no conversion to open or laparoscopic surgery was required. Ninety-six percent of patients (240/250) had an adequate postoperative course, with a mean hospital stay of 4.2 days (3-35) and urinary catheter removal after 8 (5-28) days. Overall complication rate was 10.6%, with major complications occurring in only 3.2% of patients (8/250) and consisting of five surgical and three medical complications. Repeat surgery was required in 1.6% of cases (4/250) due to late peritonitis for cecal perforation, bleeding from epigastric artery, perineal percutaneous drainage of retrovesical hematoma, and pelvic urinoma after bladder catheter dislodgment. One patient required selective arterial embolization for persistent hematuria due to vesical artery fistula. Medical complications included acute renal failure due to thrombotic purpura resolved with hemodialysis in one patient and late pulmonary embolism managed with anticoagulation in two patients. Robot malfunction with no surgical implications or need for surgical conversion occurred in four patients (1.6%). Surgical maneuvers required to resolve late complications included one umbilical hernia repair, one meatotomy for meatal stenosis, one bladder neck endoscopic incision after contracture, and one endoscopic extraction of Hem-o-lok and vascular clip following erosion-migration into the bladder. CONCLUSIONS: Robotic radical prostatectomy is a safe and reproducible procedure with optimal functional and oncological results, a shorter learning curve, greater comfort and vision for surgeons, and a complication rate similar to and even better than reported for open and laparoscopic surgery series. Complications decrease with the learning curve, but surgical team experience continues to be the key factor to achieve better results.

Incidencias y complicaciones en nuestras primeras 250 prostatéctomias radicales robóticas / Complications and incidences in our first 250 robotic radical prostatectomies

Objetivo: EL objetivo del estudio es revisar la incidencia y analizar los factores que puedan contribuir a las complicaciones perioperatorias en los pacientes a los que se realiza una prostatectomía radical robótica basados en nuestra experiencia sobre 250 procedimientos. Material y métodos: Realizamos un estudio retrospectivo, descriptivo y analítico sobre 250 pacientes consecutivos a los que realizamos prostatectomía radical robótica durante un periodo de 3 años y 2 meses (enero 06–marzo 09). Se registran datos demográficos como: edad, PSA y grado de Gleason preoperatorio y volumen prostático. Todas las intervenciones fueron realizadas por tres cirujanos. Realizamos un abordaje laparoscópico transperitoneal con sistema robótico daVinci de 4 brazos. Empleamos un soporte informático Microsoft Excel. Los parámetros quirúrgicos recogidos son: tiempo de instalación, tiempo de consola, volumen de hemorragia, tasa de transfusión, estancia media y tiempo de sondaje uretral. Revisamos las incidencias y complicaciones intraoperatorias y postoperatorias precoces y tardías en esta serie de pacientes. Resultados: Los datos demográficos de la serie fueron: edad media de 61,15 años (47–74), PSA medio preoperatorio de 8,18ng/ml (2,6–34ng/ml), Gleason preoperatorio de 6,8 (2–9) y volumen prostático de 34,9cc (12–124cc). Los parámetros quirúrgicos recogidos son: tiempo de instalación: 10,2min (6–47min), tiempo de consola 125min (90–315min), hemorragia media de 150ml (50–1150ml) con una tasa de transfusión del 3,6% (9/250). No se registró mortalidad perioperatoria, ni fue preciso realizar ninguna reconversión a cirugía abierta o laparoscópica en los 250 procedimientos. Un total del 96% pacientes (240/250) tuvieron un curso postoperatorio adecuado sin incidencias reseñables con una estancia media de 4,2 días (3–35 días) y retirada de sonda vesical a los 8 días (5–28días). La tasa global de complicaciones es del 10,4% con solo 3,2% de complicaciones mayores (8/250): 5 complicaciones quirúrgicas y 3 médicas. La tasa de reintervención del 1,6% (4/250): una peritonitis tardía por perforación cecal, 1 hemorragia por lesión de arteria epigástrica, 1 drenaje perineal percutáneo de hematoma retrovescial y una revisión por urinoma tras desalojo accidental de sonda vesical. Un paciente preciso embolización arterial selectiva por hematuria tardía persistente tras fistula de arteria vesical superior. Entre las complicaciones médicas: 1 caso de fracaso renal agudo por púrpura trombótica trombocitopénica resuelto mediante hemodiálisis, y 2 embolias pulmonares tardía resueltas mediante anticoagulación. Se registraron 4 fallos del sistema robótico (1,6%) sin implicación ni necesidad de reconversión quirúrgica. Entre las complicaciones tardías que precisaron alguna maniobra quirúrgica para su resolución destacan: una reparación de hernia umbilical, una meatotomía por estenosis de meato uretral, una incisión endoscópica de esclerosis de anastomosis y una extracción endoscópica de clip vascular metálico y Hem-o-lock tras erosión-migración vesical. Conclusiones: La prostatectomía radical robótica es una técnica segura y reproducible con óptimos resultados oncológicos y funcionales, con curva de aprendizaje más corta, con excelente ergonomía y visión para el cirujano y con una incidencia de complicaciones comparable e incluso favorable a las series de cirugía abierta y laparoscópica. Las complicaciones se reducen con la curva de aprendizaje sin olvidar que es la experiencia del equipo quirúrgico el factor clave para conseguir mejores resultados (AU)

Objective: To review the incidence of and analyze the factors contributing to perioperative complications in patients undergoing robotic radical prostatectomy in our experience of 250 procedures. Materials y methods: An analytical, descriptive, retrospective study was conducted of 250 consecutive patients who underwent robotic radical prostatectomy during a period of three years and two months (January 06–March 09). Data recorded included age, preoperative Gleason grade and PSA, and prostate volume. All procedures were performed by three surgeons through a transperitoneal approach using a four-arm daVinci robotic system. Microsoft Excel support was used. Surgical variables recorded included setup time, console operation time, mean bleeding, transfusion rate, hospital stay, and urethral catheterization time. Incidences and intraoperative and postoperative late and early complications in these patients were reviewed. Results: Demographic data recorded included: mean age, 61.5 years (47–74); mean preoperative PSA, 8.18ng/mL (2.6–34ng/mL); mean Gleason grade, 6.8 (2–9); and mean prostate volume 34.9mL (12–124). Surgical variables recorded included: console setup time, 10.8min (6–47): console operation time, 125min (90–315); mean bleeding, 150mL (50–1150); and a 3.6% (9/250) transfusion rate. There was no peroperative mortality, and no conversion to open or laparoscopic surgery was required. Ninety-six percent of patients (240/250) had an adequate postoperative course, with a mean hospital stay of 4.2 days (3–35) and urinary catheter removal after 8 (5–28) days. Overall complication rate was 10.6%, with major complications occurring in only 3.2% of patients (8/250) and consisting of five surgical and three medical complications. Repeat surgery was required in 1.6% of cases (4/250) due to late peritonitis for cecal perforation, bleeding from epigastric artery, perineal percutaneous drainage of retrovesical hematoma, and pelvic urinoma after bladder catheter dislodgment. One patient required selective arterial embolization for persistent hematuria due to vesical artery fistula. Medical complications included acute renal failure due to thrombotic purpura resolved with hemodialysis in one patient and late pulmonary embolism managed with anticoagulation in two patients. Robot malfunction with no surgical implications or need for surgical conversion occurred in four patients (1.6%). Surgical maneuvers required to resolve late complications included one umbilical hernia repair, one meatotomy for meatal stenosis, one bladder neck endoscopic incision after contracture, and one endoscopic extraction of Hem-o-lok and vascular clip following erosion-migration into the bladder. Conclusions: Robotic radical prostatectomy is a safe and reproducible procedure with optimal functional and oncological results, a shorter learning curve, greater comfort and vision for surgeons, and a complication rate similar to and even better than reported for open and laparoscopic surgery series. Complications decrease with the learning curve, but surgical team experience continues to be the key factor to achieve better results (AU)