First-line Management of Metastatic Urothelial Cancer: Current and Future Perspectives After the EV-302 and CheckMate-901 Studies.

The standard of care for the first-line management of metastatic urothelial carcinoma has been recently challenged, with the combination of pembrolizumab and enfortumab vedotin (P-EV) strongly arising as a practice-changing option from classical platinum-based chemotherapies. With this paradigm shift on the horizon new questions, including the most suitable second line of treatment for these patients, and the role that the molecular characterization of these tumours will have when selecting these therapies will inevitably arise. Furthermore, after the negative results of the Keynote 361 and IMvigor 130 trials, the combination of nivolumab with platinum-based chemotherapy followed by nivolumab maintenance (Nivo GC-Nivo) has also shown positive results when compared with chemotherapy alone. Translational studies at a molecular, cellular, and functional level will be key to better explain these discordant results. In this Current Perspective, we discuss the potential impact of these results in clinical practice and propose specific guidance for prospective translational research.

Umbilical laparoendoscopic urological surgery with a novel reusable device.

OBJECTIVE: The aims of this study were to present cumulative experience with umbilical laparoendoscopic urological surgery using a reusable device and to evaluate outcomes and complications in the first 100 patients. MATERIAL AND METHODS: Patients undergoing umbilical surgery with the KeyPort system and DuoRotate instruments (Richard Wolf, Knittlingen, Germany) were evaluated prospectively. Demographic, intraoperative and postoperative data were assessed. RESULTS: Between October 2011 and July 2012, 79 pelvic (66 radical prostatectomy, 10 radical cystectomy, one diverticulectomy, one bilateral orchiectomy, one ureter reimplantation) and 21 renal (seven radical nephrectomy, six partial nephrectomy, five nephroureterectomy, two pyeloplasty, one pyelolithotomy) surgeries were performed through the umbilicus using this platform. Follow-up was 56.7 ± 12.6 weeks (mean ± SD). Mean age was 64.3 ± 10.3 years, body mass index 29 ± 4.6 kg/m(2), operative time 232 ± 106 min and estimated blood loss 260 ± 95 ml. Conversion to standard multiport laparoscopy was not necessary. An accessory port was used in 87 cases to facilitate suturing and conduct drainage extraction. Postoperative complications occurred in 24 cases (six Clavien grade I, 12 grade II, one grade IIIa, two grade IIIb, two grade IVa, one grade IVb). Mean hospital stay was 4.2 ± 4 days. Total transfusion rate was 10%. Mean visual analogue pain scale at day 2 was 2.1 ± 1.3 (0-10). Visual analogue wound satisfaction scale at month 1 was 9.2 ± 0.6 (0-10). No cancer-related events occurred during follow-up. Late complications (4%) were not related to the surgical approach. CONCLUSIONS: Umbilical KeyPort surgery is technically feasible for a great variety of procedures, both ablative and reconstructive. This access offers adequate surgical outcomes, scarce postoperative pain and security for the patient in the short term. Its reusable nature implies a noticeable economic advantage.

Adenomectomía extraperitoneal laparoscópica: descripción de la técnica quirúrgica / No disponible

Históricamente el tratamiento quirúrgico de la Hiperplasia Benigna de Próstata (HBP) se ha realizado mediante abordaje quirúrgico convencional empleando las técnicas descritas por Terence Millin y Peter Freyer, en aquellas glándulas de volumen superior a los 75-80 gramos,Debido al avance tecnológico durante las tres últimas décadas, en la actualidad, se aplican varias técnicas mínimamente invasivas con buenos resultados en el tratamiento de la HBP. La incorporación del abordaje laparoscópico a la cirugía pelviana ha permitido el desarrollo técnico de la adenomectomía siguiendo las mismas directrices empleadas en los abordajes convencionales.El objetivo de este artículo es describir detalladamente, paso a paso, la técnica quirúrgica de la adenomectomía laparoscópica para el tratamiento de la HBP, en glándulas con un tamaño superior a 60 cc., realizando un estudio retrospectivo y descriptivo de los resultados preliminares obtenidos en el postoperatorio inmediato de nuestra serie inicial(AU)

Historically, the surgical treatment of benign prostatic hyperplasia (BPH) in glands with volumes over 75-80 grams was performed using the conventional surgical approaches described by Terence Millin and Peter Freyer.Due to technological advancement over the past three decades, at present, minimally invasive techniques are being used with good results in the treatment of BPH. The incorporation of the laparoscopic approach to urologic surgery has allowed the technical development of adenomectomy using the same guidelines followed by conventional approaches.The aim of this paper is to describe in detail, step by step, the surgical technique of laparoscopic prostatectomy to treat BPH in glands larger than 60 cc., and to perform a re-trospective analysis of preliminary results obtained in the immediate postoperative period of our initial series(AU)

[Erectile dysfunction after radial prostatectomy. Response to treatment with sildenafil citrate]. / Disfunción eréctil postprostatectomía radical. Respuesta al tratamiento con citrato de sildenafilo.

OBJECTIVES: Erectile dysfunction is one of the sequelae after radical prostatectomy most concerning for the patient, its appearance being influenced by factors such as surgical technique, or patient's age. Thus, around 40% of the patients younger than 70 years and over 90% of the patients older than 70 present with erectile dysfunction after prostatectomy. We studied the response to sildenafil citrate in patients who underwent non nerve sparing radical prostatectomy. METHODS: Medical records of 100 patients who underwent radical prostatectomy at our department between 1985 and 1998 were retrospectively reviewed and telephone interviews were done to investigate the degree of erectile dysfunction following surgery. All patients were offered to start a two-month therapeutic trial with sildenafil citrate, in dose escalation up to a maximum of 100 mg. Therapeutic response was evaluated by personal interviews. RESULTS: 5 out of 100 patients interviewed showed similar potency than preoperatively. Among 95 patients with erectile dysfunction 63 (66.3%) did not wish treatment for erectile dysfunction. 22 of the remainder 32 patients initiated treatment with sildenafil citrate, whereas 10 preferred trying intracavernous PGE1 injections only. In the intracavernous injections group 5 patients abandoned because of pain with injections and refused any further treatment with oral drugs; 5 patients are satisfied with intracavernous therapy and they do not want to try sildenafil. In the sildenafil group form 22 patients starting treatment 14 (63.6%) are satisfied, with a subjective improvement. Only 5 patients (22%) show an erectile response enough to have sexual intercourse with penetration. 8 (36.5%) abandon treatment because of lack of efficiency. CONCLUSIONS: 5% of the patients who undergo non nerve sparing radical prostatectomy maintain sexual potency without treatment postoperatively. Most patients with postoperative erectile dysfunction (63/95 = 66.3%) do not want any treatment. From 22 patients initiating treatment with sildenafil 5 can have sexual intercourse with penetration (5/22 = 22%), all of them with 100 mg doses of sildenafil.

Disfunción eréctil postprostatectomía radical. Respuesta al tratamiento con citrato de sildenafilo / Erectile dysfunction after radical prostatectomy. Results with sildenafil citrate treatment

OBJETIVOS: La disfunción eréctil es una de las secuelas que más preocupa a los pacientes sometidos a prostatectomía radical, dependiendo su aparición de diversos factores como la técnica empleada o la edad del paciente. Así, alrededor del 40 per cent de los pacientes menores de 70 años y más del 90 per cent de los mayores de 70 años presentan disfunción eréctil postprostatectomía. En este trabajo estudiamos la respuesta al sildenafilo de los pacientes sometidos a prostatectomía radical sin intento de conservación de nervios erectores. MÉTODOS: Se revisaron las historias clínicas de 100 pacientes sometidos a prostatectomía radical en nuestro servicio desde 1995 a 1998 y se les entrevistó telefónicamente con el fin de averiguar el grado de disfunción eréctil que siguió a la cirugía. A todos los pacientes se les propuso realizar un tratamiento de prueba con citrato de sildenafilo durante dos meses, a dosis creciente, hasta alcanzar la dosis máxima de 100 mg. La respuesta al tratamiento se evaluó mediante entrevista personal. RESULTADOS: De los 100 pacientes entrevistados, 5 presentaban una potencia sexual similar a la preoperatoria. De los 95 pacientes con disfunción eréctil postoperatoria, 63 (66,3 per cent) no deseaban tratamiento para su disfunción eréctil. De los 32 pacientes restantes 22 inician tratamiento con sildenafilo, mientras que 10 prefieren probar sólo PGE1 intracavernosa. De estos últimos, 5 presentan dolor importante a la inyección del producto y abandonan el tratamiento y cualquier intento de tratamiento ulterior por vía oral.5 están satisfechos con las inyecciones intracavernosas y no desean probar el sildenafilo. De los 22 que inician tratamiento con sildenafilo 14 (63,6 per cent) están satisfechos, con mejoría subjetiva. Sólo 5 pacientes (22 per cent) presentan una respuesta eréctil suficiente como para mantener relaciones sexuales con penetración. 8 (36,4 per cent) abandonan el tratamiento por ser ineficaz. CONCLUSIONES: Un 5 per cent de los pacientes sometidos a prostatectomía radical sin intento de conservar nervios erectores mantienen la potencia sexual postoperatoriamente sin tratamiento. La mayoría de los pacientes con disfunción eréctil postoperatoria (63/95=66,3 per cent), no desean ningún tratamiento. De los 22 pacientes que inician tratamiento con sildenafilo 5 consiguen mantener relaciones sexuales con penetración (5/22=22 per cent), todos ellos con dosis de 100 mg de sildenafilo (AU)