[Rectourethral fistula treatment using the modified York Mason technique: Failure factors assessment]. / Cure de fistule recto-urétrale par la technique modifiée de York Mason : évaluation des facteurs d'échec.

OBJECTIVES: To assess surgical outcomes and failure factors in the management of rectourethral fistulas treated surgically with the modified York Mason technique based on our center's 25 years of experience. METHODS: From 1997 to 2021, in a single center study, a total of 35 consecutive patients, underwent rectourethral fistula cure, using the modified York Mason technique. Preoperative patient data, surgical outcomes and failure factors were assessed. RESULTS: Of the 35 patients, 28 were successfully managed without the need of further intervention (80%). Median age was 67 years (IQR 62-72) and median follow-up time was 71 months (IQR 30-123). There was no significant difference between the patients that had recurrence or not after the first York Mason. CONCLUSIONS: The modified York Mason technique offers a high success rate for the cure of iatrogenic rectourethral fistulas. No predictive factor of failure, after a first cure of recto-uretral fistula by modified York-Mason technique was reported. LEVEL OF EVIDENCE: 3.

Robotic-Assisted Partial Nephrectomy: Techniques to Improve Clinical Outcomes.

PURPOSE OF REVIEW: To summarize current options available for robot-assisted partial nephrectomy RECENT FINDINGS: Partial nephrectomy (PN) is a standard treatment option for management of cT1 renal masses. It may be carried out by multiple approaches. Robot-assisted (RA) PN is one such option. The goal of treatment is both correct oncological (negative surgical margins) and functional (preservation of sufficient amount of renal parenchyma of the operated kidney) outcome. Appropriate outcomes depend on multiple factors. There are many, but among others tumor characteristics (size, location, i.e., tumor complexity), patient baseline renal function, patient comorbidities, and performance status etc. Based on all these, the surgeon adapts the intervention for each mass/patient by preoperative planning, absence/use/duration of warm or cold ischemia, perioperative imaging, resection technique adapted to tumor location and depth of invasion, use of hemostatics, type and degree of renal parenchymal closure and others details. Nephroprotective agents have not shown efficacy so far. It should not be forgotten that surgeon's experience plays a key role in the achievement of good results. Although multiple factors have a role in the RA partial nephrectomy, surgeon experience and adaptation of technique of intervention have the crucial role in the achievement of both functional and oncological results.

Renal Tumor Biopsy: Rationale to Avoid Surgery in Small Renal Masses.

PURPOSE OF REVIEW: The use of renal tumor biopsy (RTB) for small renal masses (SRMs) in daily practice, although safe and accurate, is unusual. Considering the large number of benign tumors in patients with renal masses < 4 cm, some patients with benign tumors are directly referred for surgery instead. This study aimed to report the diagnostic rates of RTB, determine the concordance with surgical pathology, and assess the number of procedures that could have been avoided. We retrospectively studied 255 patients who underwent RTB at our institution in 2010-2019. Of them, 73 were excluded from the analysis (exclusion criteria: > 4 cm, cystic lesion, missing data). The remaining 182 with undetermined SRMs ≤ 4 cm underwent RTB under computed tomography guidance. RECENT FINDINGS: Biopsies were diagnostic in 154/182 (84.6%) cases. Of the non-diagnostic biopsies, 11 were diagnostic when repeated. When RTB was performed of all undetermined SRMs, active treatment (surgery or cryotherapy) was avoided in 50/182 patients (27.5%) because of a benign diagnosis, while 9/182 patients (4.9%) underwent surveillance after a shared multidisciplinary decision. The overall diagnostic rate was 90.6%. All adverse events (approximately 4%) were Clavien-Dindo grade I and did not require active treatment. RTB histology results and nuclear grade were highly concordant with the final pathology (96% and 86.6%, respectively). On univariate logistic regression analysis, male sex was the only contributing factor of diagnostic biopsy. RTB of SRMs should be performed more frequently as part of a multidisciplinary decision-making process since it avoided unnecessary surgical treatment in 1 of 3 patients in our institution.

Prostatectomía inmediata versus demorada en pacientes que progresan a una enfermedad de mayor riesgo en vigilancia activa / Immediate versus delayed prostatectomy and the fate of patients who progress to a higher risk disease on active surveillance

Introducción: Se debaten los resultados oncológicos de la prostatectomía radical (PR) en pacientes que progresan en vigilancia activa (VA). Comparamos los resultados de los pacientes elegibles para VA sometidos a PR inmediatamente después del diagnóstico con aquellos que lo hacían después de un retraso o progresión de la enfermedad en VA. Métodos: Entre 2000 y 2014, 961 pacientes fueron elegibles para VA según los criterios de la EAU. Se comparó la PR a los 6 meses del diagnóstico (PRI) o más allá (PRT), PR sin VA (PRTa) y pacientes en VA que progresan a PR (PRTb). Se registró PSA inicial, características clínicas y de biopsia. Los resultados oncológicos incluyeron patología adversa (PA) en la muestra de PR y recurrencia bioquímica (RBQ). Se realizó un análisis de pares emparejados entre los pacientes con PRTb y GS7 sometidos a PR inmediata (GS7PRI). Resultados: PRI, PRT, PRTa y PRTb tuvieron 820 (85%), 141 (15%), 118 (12,24%) y 23 (2,7%) pacientes respectivamente. PRI, PRTa y PRTb se sometieron a PR a una mediana de 3, 9 y 19 meses después del diagnóstico, respectivamente. Las características basales fueron comparables. PRT vs. PRI tuvieron una mediana de tiempo más temprana (31 vs. 43 meses; p < 0,001) y una mayor tasa de progresión a RBQ (7,6 vs. 3,9%; p = 0,045). PRTb mostró RBQ más alta (19 frente a 5%; p = 0,021) con una mediana de tiempo más temprana a RBQ, en comparación con PRI y PRTa (p = 0,038). No hubo diferencias en las tasas de PA y RBQ, pero el tiempo hasta RBQ fue significativamente menor en PRTb (49 frente a 6 meses; p<0,001), en comparación con GS7PRI. Conclusiones: Los pacientes que progresaron en VA tuvieron los peores resultados oncológicos. PR para progresión de GS7 y par coincidente de pacientes con GS7 tuvieron resultados similares. Peores resultados oncológicos en los progresores de VA no pueden explicarse por una mera demora en PR

Introduction: Oncological outcomes of radical prostatectomy (RP) in patients progressing on active surveillance (AS) are debated. We compared outcomes of AS eligible patients undergoing RP immediately after diagnosis with those doing so after delay or disease progression on AS. Methods: Between 2000 and 2014, 961 patients were AS eligible as per EAU criteria. RP within 6 months of diagnosis (IRP) or beyond (DRP), RP without AS (DRPa) and AS patients progressing to RP (DRPb) were compared. Baseline PSA, clinical and biopsy characteristics were noted. Oncological outcomes included adverse pathology in RP specimen and biochemical recurrence (BCR). Matched pair analysis was done between DRPb and GS7 patients undergoing immediate RP (GS7IRP). Results: IRP, DRP, DRPa and DRPb had 820 (85%), 141 (15%), 118 (12.24%) and 23 (2.7%) patients respectively. IRP, DRPa and DRPb underwent RP at a median of 3, 9 and 19 months after diagnosis respectively. Baseline characteristics were comparable. DRP vs. IRP had earlier median time (31 vs. 43 months; p < 0.001) and higher rate of progression to BCR (7.6 vs. 3.9%; p = 0.045). DRPb showed higher BCR (19 vs. 5%; p = 0.021) with earlier median time to BCR, compared to IRP and DRPa (p = 0.038). There was no difference in adverse pathology and BCR rates, but time to BCR was significantly lesser in DRPb (49 vs. 6 months; p < 0.001), compared to GS7IRP. Conclusions: Patients progressing on AS had worst oncological outcomes. RP for GS7 progression and matched pair of GS7 patients had similar outcomes. Worse oncological outcomes in AS progressors cannot be explained by a mere delay in RP

Resultados oncológicos y características patológicas de la sobrestadificación de cT1 a carcinoma de células renales pT3a en comparación con los tumores pT3a de novo / Oncological outcomes and pathological characteristics of cT1 upstaging to pT3a renal cell carcinoma compared with de novo pT3a tumors

Introducción: La importancia de la sobrestadificación de tumores renales cT1 a pT3a no está clara. Evaluamos la incidencia de la sobrestadificación, identificamos factores predictivos y analizamos los resultados oncológicos de estos pacientes frente a aquellos que no sobrestadificaron. También comparamos los resultados oncológicos de la sobrestadificación de cT1 a pT3a con tumores renales pT3a de novo. Métodos: De una base de datos de 1.021 tumores renales con datos de seguimiento completos disponibles, 517 pacientes tenían cT1. Los pacientes que sobrestadificaron a pT3a se compararon con aquellos que no lo hicieron. Se analizaron los resultados de las características clínicas, perioperatorias, histopatológicas y oncológicas iniciales. Resultados: De 517 pacientes con cT1, 105 (20,3%) sobrestadificaron a pT3a y 412 (79,7%) no lo hicieron. La proporción de pacientes en cada grupo tratados mediante nefrectomía parcial y radical, el tamaño del tumor postoperatorio, la histología, el estado de los márgenes, y la afectación de ganglios linfáticos fueron similares. Entre los que sobrestadificaron, 9 pacientes (8,6%) desarrollaron la primera recurrencia en comparación con solo 3 (0,7%) en aquellos que no sobrestadificaron (p < 0,001). La mediana del tiempo hasta la recurrencia (57 frente a 107 meses; p < 0,001) fue menor en los tumores renales pT3a de novo. Conclusiones: La sobrestadificación patológica de cT1 a pT3a y la necrosis en la histopatología se asociaron con la recurrencia. La edad avanzada, el tabaquismo, la necrosis en la histopatología, la histología de células claras y grados más altos de Fuhrman contribuyeron a la sobrestadificación patológica de los tumores cT1. El CCR pT3a de novo tuvo una supervivencia peor cuando se comparó con los pacientes con cT1 que sobrestadificaron a CCR pT3a

Introduction: The significance of upstaging of cT1 renal tumors to pT3a is not clear. We evaluate the incidence of upstaging, identify predictors and analyze oncological outcomes of these patients versus those who did not upstage. We also compared the oncological outcomes of cT1 upstaging to pT3a with de novo pT3a renal tumors. Methods: From a database of 1021 renal tumors with complete available follow-up data, 517 patients had cT1. Patients upstaging to pT3a were compared to those who did not. Baseline clinical, perioperative, histopathologic features and oncological outcomes were analysed. Results: Out of 517 cT1 patients, 105 (20.3%) upstaged to pT3a and 412 (79.7%) did not. Proportion of patients in each group undergoing partial and radical nephrectomy, postoperative tumor size, histology, margin status and lymph node involvement were similar. Among upstaged, 9 patients (8.6%) developed first recurrence as compared to only 3 (0.7%) in those not upstaging (P < 0.001). The median time to recurrence (57 vs. 107 months; P < 0.001) was lesser in de novo pT3a renal tumors. Conclusions: Pathological upstaging from cT1 to pT3a and necrosis on histopathology were associated with recurrence. Advanced age, smoking, necrosis on histopathology, clear cell histology and higher Fuhrman grades contributed to pathological upstaging of cT1 tumors. De novo pT3a RCC had worse survival when compared to cT1 patients upstaging to pT3a RCC

Immediate versus delayed prostatectomy and the fate of patients who progress to a higher risk disease on active surveillance. / Prostatectomía inmediata versus demorada en pacientes que progresan a una enfermedad de mayor riesgo en vigilancia activa.

INTRODUCTION: Oncological outcomes of radical prostatectomy (RP) in patients progressing on active surveillance (AS) are debated. We compared outcomes of AS eligible patients undergoing RP immediately after diagnosis with those doing so after delay or disease progression on AS. METHODS: Between 2000 and 2014, 961 patients were AS eligible as per EAU criteria. RP within 6 months of diagnosis (IRP) or beyond (DRP), RP without AS (DRPa) and AS patients progressing to RP (DRPb) were compared. Baseline PSA, clinical and biopsy characteristics were noted. Oncological outcomes included adverse pathology in RP specimen and biochemical recurrence (BCR). Matched pair analysis was done between DRPb and GS7 patients undergoing immediate RP (GS7IRP). RESULTS: IRP, DRP, DRPa and DRPb had 820 (85%), 141 (15%), 118 (12.24%) and 23 (2.7%) patients respectively. IRP, DRPa and DRPb underwent RP at a median of 3, 9 and 19 months after diagnosis respectively. Baseline characteristics were comparable. DRP vs. IRP had earlier median time (31 vs. 43 months; p<.001) and higher rate of progression to BCR (7.6 vs. 3.9%;p=.045). DRPb showed higher BCR (19 vs. 5%;p=.021) with earlier median time to BCR, compared to IRP and DRPa (p=.038). There was no difference in adverse pathology and BCR rates, but time to BCR was significantly lesser in DRPb (49 vs. 6 months;p<.001), compared to GS7IRP. CONCLUSIONS: Patients progressing on AS had worst oncological outcomes. RP for GS7 progression and matched pair of GS7 patients had similar outcomes. Worse oncological outcomes in AS progressors cannot be explained by a mere delay in RP.

Oncological outcomes and pathological characteristics of cT1 upstaging to pT3a renal cell carcinoma compared with de novo pT3a tumors. / Resultados oncológicos y características patológicas de la sobrestadificación de cT1 a carcinoma de células renales pT3a en comparación con los tumores pT3a de novo.

INTRODUCTION: The significance of upstaging of cT1 renal tumors to pT3a is not clear. We evaluate the incidence of upstaging, identify predictors and analyze oncological outcomes of these patients versus those who did not upstage. We also compared the oncological outcomes of cT1 upstaging to pT3a with de novo pT3a renal tumors. METHODS: From a database of 1021 renal tumors with complete available follow-up data, 517 patients had cT1. Patients upstaging to pT3a were compared to those who did not. Baseline clinical, perioperative, histopathologic features and oncological outcomes were analysed. RESULTS: Out of 517 cT1 patients, 105 (20.3%) upstaged to pT3a and 412 (79.7%) did not. Proportion of patients in each group undergoing partial and radical nephrectomy, postoperative tumor size, histology, margin status and lymph node involvement were similar. Among upstaged, 9 patients (8.6%) developed first recurrence as compared to only 3 (0.7%) in those not upstaging (P <0.001). The median time to recurrence (57 vs. 107 months; P <0.001) was lesser in de novo pT3a renal tumors. CONCLUSIONS: Pathological upstaging from cT1 to pT3a and necrosis on histopathology were associated with recurrence. Advanced age, smoking, necrosis on histopathology, clear cell histology and higher Fuhrman grades contributed to pathological upstaging of cT1 tumors. De novo pT3a RCC had worse survival when compared to cT1 patients upstaging to pT3a RCC.

Factores predictivos de recidiva bioquímica temprana, intermedia y tardía tras prostatectomía radical mínimamente invasiva en una cohorte unicéntrica con seguimiento medio de 8 años / Predictors of early, intermediate and late biochemical recurrence after minimally invasive radical prostatectomy in a single-centre cohort with a mean follow-up of 8 years

Objetivo: Determinar factores predictivos de recidiva bioquímica (RB) temprana, intermedia y tardía después de prostatectomía radical mínimamente invasiva en pacientes con cáncer de próstata localizado. Material y métodos: Se incluyeron 6.195 pacientes con cáncer de próstata cT1-3N0M0 intervenidos mediante prostatectomía radical laparoscópica (PRL) y robótica en nuestra institución entre 2000 y 2016. Ninguno recibió tratamiento adyuvante. La RB se definió como PSA ≥ 0,2 ng/dl. El tiempo hasta RB se dividió en terciles para identificar variables asociadas con recidiva temprana (< 12 meses), intermedia (12-36 meses) y tardía (> 36 meses). Se utilizaron modelos de regresión logística para determinar los factores de riesgo asociados en cada intervalo. Resultados: Se identificaron 1.148 (18,3%) pacientes con RB. La mediana de tiempo hasta la RB fue de 24 meses (RIQ: 0,98-53,18). El análisis multivariable mostró que el PSA preoperatorio, la invasión ganglionar, los márgenes positivos y la PRL se asociaron con recidiva precoz (todos p ≤ 0,029). La cirugía laparoscópica fue el único predictor de recidiva intermedia (p = 0,001). Los predictores de recidiva tardía incluyeron un score de Gleason patológico ≥7, estadio ≥pT3, márgenes positivos y PRL (todos con p ≤ 0,02). Conclusiones: Los pacientes con cáncer de próstata de alto riesgo pueden desarrollar recurrencia tardía y precisar un seguimiento a largo plazo. La identificación de pacientes con mayor PSA e invasión ganglionar tiene un importante papel predictivo en el primer año tras la cirugía. La asociación entre PRL y RB merece una evaluación adicional

Objective: To determine the predictors of early, intermediate and late biochemical recurrence (BR) following minimally invasive radical prostatectomy in patients with localised prostate cancer (PC). Material and methods: We included 6195 patients with cT1-3N0M0 prostate cancer treated using radical laparoscopic prostatectomy (RLP) and radical robot-assisted prostatectomy at our institution between 2000 and 2016. None of the patients underwent adjuvant therapy. BR is defined as PSA levels ≥0.2 ng/dL. The time to BR is divided into terciles to identify the variables associated with early (< 12 months), intermediate (12-36 months) and late (> 36 months) recurrence. We employed logistic regression models to determine the risk factors associated with each interval. Results: We identified 1148 (18.3%) patients with BR. The mdian time to BR was 24 months (IQR, 0.98-53.18). The multivariate analysis showed that preoperative PSA levels, lymph node invasion, positive margins and RLP are associated with early recurrence (P≤ .029 for all). Laparoscopic surgery was the only predictor of intermediate recurrence (P = .001). The predictors of late recurrence included a pathological Gleason score ≥ 7, stage ≥ pT3, positive margins and RLP (P≤.02 for all). Conclusions: The patients with high-risk prostate cancer can develop late recurrence and require long-term follow-up. Identifying patients with higher PSA levels and lymph node invasion has an important predictive role in the first year after surgery. The association between RLP and BR warrants further assessment

Predictive factors and the important role of detectable prostate-specific antigen for detection of clinical recurrence and cancer-specific mortality following robot-assisted radical prostatectomy

Purpose: To evaluate predictive factors associated with detectable prostate-specific antigen (PSA) and describe clinical recurrence (CR) and cancer-specific mortality (CSM) after robot-assisted radical prostatectomy (RARP). Methods: The study included 2500 patients who were treated with RARP at a single institution between 2000 and 2016. All patients had clinically localized PCa. Patients were divided into two groups according to PSA value at 6 weeks after surgery: undetectable (n = 2271; PSA < 0.1 ng/dl) and persistently elevated (n = 229; PSA ≥ 0.1 ng/dl). The association between various covariates and: (1) detectable PSA and (2) CR was evaluated. Kaplan-Meier analyses estimated CR and CSM rates according to PSA persistence. Results: Inside the group of detectable PSA, 146 men (63.75%) received adjuvant treatments, 44 patients (19.21%) salvages therapies and 38 men (16.5%) experienced CR. Factors associated with aggressive disease predicted PSA persistence. Within patients with detectable PSA, pathologic stage ≥ pT3a (HR 2.71; p < 0.029) and to received adjuvant androgen deprivation therapy (ADT) due to bad prognosis tumors (HR 13.36; p < 0.001) were associated with CR. Overall 14 (0.56%) died of PCa. 5 and 10-year CSM rates were higher for patients with CR (9.6 and 23.7%, p < 0.001), and Gleason ≥ 8 (5.7 and 6.9%, p = 0.003). Conclusions: A detectable PSA is affected by factors associated with aggressive prostate cancer. Within men with persistent PSA, those with higher pathologic stage and who received adjuvant ADT are more likely to have CR. Patients with CR, Gleason ≥ 8, and those who received adjuvant ADT must have a close monitoring due to the high rate of mortality

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Predictors of early, intermediate and late biochemical recurrence after minimally invasive radical prostatectomy in a single-centre cohort with a mean follow-up of 8 years. / Factores predictivos de recidiva bioquímica temprana, intermedia y tardía tras prostatectomía radical mínimamente invasiva en una cohorte unicéntrica con seguimiento medio de 8 años.

OBJECTIVE: To determine the predictors of early, intermediate and late biochemical recurrence (BR) following minimally invasive radical prostatectomy in patients with localised prostate cancer (PC). MATERIAL AND METHODS: We included 6195 patients with cT1-3N0M0 prostate cancer treated using radical laparoscopic prostatectomy (RLP) and radical robot-assisted prostatectomy at our institution between 2000 and 2016. None of the patients underwent adjuvant therapy. BR is defined as PSA levels ≥0.2 ng/dL. The time to BR is divided into terciles to identify the variables associated with early (<12 months), intermediate (12-36 months) and late (>36 months) recurrence. We employed logistic regression models to determine the risk factors associated with each interval. RESULTS: We identified 1148 (18.3%) patients with BR. The median time to BR was 24 months (IQR, 0.98-53.18). The multivariate analysis showed that preoperative PSA levels, lymph node invasion, positive margins and RLP are associated with early recurrence (P≤.029 for all). Laparoscopic surgery was the only predictor of intermediate recurrence (P=.001). The predictors of late recurrence included a pathological Gleason score ≥7, stage ≥pT3, positive margins and RLP (P≤.02 for all). CONCLUSIONS: The patients with high-risk prostate cancer can develop late recurrence and require long-term follow-up. Identifying patients with higher PSA levels and lymph node invasion has an important predictive role in the first year after surgery. The association between RLP and BR warrants further assessment.

Complicaciones viscerales y gastrointestinales en la cirugía urológica robótica / Visceral and gastrointestinal complications in robotic urologic surgery

Introducción: Con el uso generalizado de técnicas mínimamente invasivas la cirugía urológica asistida por robot ha sido ampliamente adoptada. A pesar de su infrecuencia, las complicaciones viscerales y gastrointestinales podrían poner en peligro la vida. Objetivos: Identificar las principales lesiones gastrointestinales que ocurren en una cirugía urológica asistida por robot. Conocer la incidencia general y cómo es su manejo. Adquisición de la evidencia: Búsqueda en PubMed de artículos relacionados con complicaciones viscerales y gastrointestinales en cirugía urológica asistida por robot, escritos en inglés o español. Se revisaron publicaciones relevantes, así como revisiones de literatura y capítulos de libros. Síntesis de la evidencia: Junto con las lesiones vasculares, las lesiones viscerales y gastrointestinales se encuentran entre las complicaciones más peligrosas. Un estudio preoperatorio completo para individualizar las características de cada paciente y el uso correcto de la toma de imágenes podría ayudarnos a evitar complicaciones en primer lugar. Conocer todos los pasos arriesgados en los diferentes procedimientos urológicos robóticos nos permitirá anticipar los daños. El conocimiento de las lesiones principales y más peligrosas en los diferentes órganos abdominales y pélvicos es altamente recomendable. El diagnóstico precoz y la evaluación de las lesiones nos permitirán un manejo agudo durante la cirugía. El retraso en el reconocimiento podría convertir una lesión reparable a una situación potencialmente mortal. Conclusiones: A pesar de los beneficios innegables del enfoque robótico, hay lesiones gastrointestinales menores y mayores que todos los cirujanos urológicos deben saber. Los relacionados con la colocación de trocares son especialmente importantes. El diagnóstico y el manejo inmediatos son obligatorios

Introduction: with the widespread use of minimally invasive techniques, robot-assisted urologic surgery has become widely adopted. Despite their infrequency, visceral and gastrointestinal complications could be life-threatening. Objectives: To identify the main gastrointestinal injuries that occur in a robot-assisted urologic surgery. To know the overall incidence and how is their management. Acquisition of the evidence: Search in PubMed of articles related to visceral and gastrointestinal complications in robot-assisted urology surgery, written in English or Spanish. Relevant publications as well literature reviews and chapters from books were reviewed. Synthesis of the evidence: Along with vascular injuries, visceral and gastrointestinal lesions are among most dangerous complications. A complete preoperative study to individualize each patient characteristics and the correct use of imaging could help us to avoid complications in the first place. To know all the risky steps in the different robotic urologic procedures will let us anticipate the damage. Knowledge of main and most dangerous injuries in the different abdominal and pelvic organs is fully recommended. Early diagnosis and evaluation of lesions will let us an acute management during surgery. Recognition delay could change a repairable injury into a life-threatening situation. Conclusions: Despite the undeniable benefits of robotic approach, there are minor and major gastrointestinal injuries that all urologic surgeons must know. Those related with trocar placement are especially important. Immediate diagnosis and management is mandatory

Visceral and gastrointestinal complications in robotic urologic surgery. / Complicaciones viscerales y gastrointestinales en la cirugía urológica robótica.

INTRODUCTION: with the widespread use of minimally invasive techniques, robot-assisted urologic surgery has become widely adopted. Despite their infrequency, visceral and gastrointestinal complications could be life-threatening. OBJECTIVES: To identify the main gastrointestinal injuries that occur in a robot-assisted urologic surgery. To know the overall incidence and how is their management. ACQUISITION OF THE EVIDENCE: Search in PubMed of articles related to visceral and gastrointestinal complications in robot-assisted urology surgery, written in English or Spanish. Relevant publications as well literature reviews and chapters from books were reviewed. SYNTHESIS OF THE EVIDENCE: Along with vascular injuries, visceral and gastrointestinal lesions are among most dangerous complications. A complete preoperative study to individualize each patient characteristics and the correct use of imaging could help us to avoid complications in the first place. To know all the risky steps in the different robotic urologic procedures will let us anticipate the damage. Knowledge of main and most dangerous injuries in the different abdominal and pelvic organs is fully recommended. Early diagnosis and evaluation of lesions will let us an acute management during surgery. Recognition delay could change a repairable injury into a life-threatening situation. CONCLUSIONS: Despite the undeniable benefits of robotic approach, there are minor and major gastrointestinal injuries that all urologic surgeons must know. Those related with trocar placement are especially important. Immediate diagnosis and management is mandatory.

Predictive factors and the important role of detectable prostate-specific antigen for detection of clinical recurrence and cancer-specific mortality following robot-assisted radical prostatectomy.

PURPOSE: To evaluate predictive factors associated with detectable prostate-specific antigen (PSA) and describe clinical recurrence (CR) and cancer-specific mortality (CSM) after robot-assisted radical prostatectomy (RARP). METHODS: The study included 2500 patients who were treated with RARP at a single institution between 2000 and 2016. All patients had clinically localized PCa. Patients were divided into two groups according to PSA value at 6 weeks after surgery: undetectable (n = 2271; PSA < 0.1 ng/dl) and persistently elevated (n = 229; PSA ≥ 0.1 ng/dl). The association between various covariates and: (1) detectable PSA and (2) CR was evaluated. Kaplan-Meier analyses estimated CR and CSM rates according to PSA persistence. RESULTS: Inside the group of detectable PSA, 146 men (63.75%) received adjuvant treatments, 44 patients (19.21%) salvages therapies and 38 men (16.5%) experienced CR. Factors associated with aggressive disease predicted PSA persistence. Within patients with detectable PSA, pathologic stage ≥ pT3a (HR 2.71; p < 0.029) and to received adjuvant androgen deprivation therapy (ADT) due to bad prognosis tumors (HR 13.36; p < 0.001) were associated with CR. Overall 14 (0.56%) died of PCa. 5 and 10-year CSM rates were higher for patients with CR (9.6 and 23.7%, p < 0.001), and Gleason ≥ 8 (5.7 and 6.9%, p = 0.003). CONCLUSIONS: A detectable PSA is affected by factors associated with aggressive prostate cancer. Within men with persistent PSA, those with higher pathologic stage and who received adjuvant ADT are more likely to have CR. Patients with CR, Gleason ≥ 8, and those who received adjuvant ADT must have a close monitoring due to the high rate of mortality.

[Evaluation and results of ablative therapies in prostate cancer]. / Modalités d'évaluation et résultats des traitements ablatifs dans le cancer de la prostate.

OBJECTIVE: To perform a state of the art about methods of evaluation and present results in ablative therapies for localized prostate cancer. METHODS: A review of the scientific literature was performed in Medline database (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) using different associations of keywords. Publications obtained were selected based on methodology, language and relevance. After selection, 102 articles were analysed. RESULTS: Analyse the results of ablative therapies is presently difficult considering the heterogeneity of indications, techniques and follow-up. However, results from the most recent and homogeneous studies are encouraging. Oncologically, postoperative biopsies (the most important criteria) are negative (without any tumor cells in the treated area) in 75 to 95%. Functionally, urinary and sexual pre-operative status is spared (or recovered early) in more than 90% of the patients treated. More and more studies underline also the correlation between the results and the technique used considering the volume of the gland and, moreover, the "index lesion" localization. CONCLUSION: The post-treatment pathological evaluation by biopsies (targeted with MRI or, perhaps in a near future, with innovative ultrasonography) is the corner stone of oncological evaluation of ablative therapies. Ongoing trials will allow to standardize the follow-up and determine the best indication and the best techniques in order to optimize oncological and functional results for each patient treated.

[Indications and limits of ablative therapies in prostate cancer]. / Indications et limites actuelles des traitements ablatifs dans le cancer de la prostate.

OBJECTIVE: To perform a state of the art about indications and limits of ablative therapies for localized prostate cancer. METHODS: A review of the scientific literature was performed in Medline database (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) using different associations of keywords. Publications obtained were selected based on methodology, language and relevance. After selection, 107 articles were analysed. RESULTS: The objective to combine reduction of side effects and oncological control has induced recent development of several ablative therapies. Beyond this heterogeneity, some preferential indications appear: unilateral cancer of low risk (but with significant volume, excluding active surveillance) or intermediate risk (excluding majority of grade 4); treatment targeted the index lesion, by quarter or hemi-ablation, based on biopsy and mpMRI. In addition, indications must considered specific limits of each energy, such as gland volume and tumor localization. CONCLUSION: Based on new imaging and biopsy, ablative therapies will probably increased its role in the future in management of localize prostate cancer. The multiple ongoing trials will certainly be helpful to better define their indications and limits.

[Management of ablative therapies in prostate cancer]. / Traitements ablatifs pour cancer de prostate : modalités de prise en charge.

OBJECTIVES: To describe the specific modalities of ablative therapies management in prostate cancer. MATERIALS AND METHODS: A review of the scientific literature was performed in Medline database (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) using different associations of keywords. Publications obtained were selected based on methodology, language and relevance. After selection, 61 articles were analysed. RESULTS: Development of innovations such as ablative therapies in prostate cancer induces specific modalities in their management, during pre-, per- and post-procedure. More than for classical and well-known treatments, the decision to propose an ablative therapy requires analysis and consensus of medical staff and patient's agreement. Patient's specificities and economical aspects must also be considered. Procedures and follow-up must be realized by referents actors. CONCLUSION: Indication, procedure and follow-up of ablative therapies in prostate cancer require specific modalities. They must be respected in order to optimize the results and to obtain a precise and objective evaluation for defining future indications.

Revisión sistemática de resultados perioperatorios y complicaciones después de cistectomía radical abierta, laparoscópica y asistida por robot / Systematic review of perioperative outcomes and complications after open, laparoscopic and robot-assisted radical cystectomy

La cistectomía radical y disección de los ganglios linfáticos regionales es el tratamiento estándar para el cáncer vesical músculo invasivo localizado y no músculo-invasivo de alto riesgo, y representa uno de los principales procedimientos quirúrgicos urológicos. El abordaje quirúrgico abierto es todavía ampliamente adoptado, aunque en las últimas 2 décadas se han hecho esfuerzos con el fin de evaluar si los procedimientos mínimamente invasivos, ya sean laparoscópicos o asistidos por robot, podrían mostrar un beneficio en comparación con la técnica estándar. La cistectomía radical abierta se asocia con una alta tasa de complicaciones, pero los datos de la serie quirúrgica laparoscópica y robótica no lograron demostrar una clara reducción en las tasas de complicaciones postoperatorias en comparación con la serie quirúrgica abierta. La cistectomía radical laparoscópica y robótica muestran una reducción en la pérdida de sangre, las tasas de estancia hospitalaria y de transfusión, pero un mayor tiempo operatorio, mientras que la cistectomía radical abierta se asocia típicamente con un tiempo operatorio más corto, pero con un ingreso más largo en el hospital y, posiblemente, una mayor tasa complicaciones de alto grado

Radical cystectomy and regional lymph node dissection is the standard treatment for localized muscle-invasive and for high-risk non-muscle-invasive bladder cancer, and represents one of the main surgical urologic procedures. The open surgical approach is still widely adopted, even if in the last two decades efforts have been made in order to evaluate if minimally invasive procedures, either laparoscopic or robot-assisted, might show a benefit compared to the standard technique. Open radical cystectomy is associated with a high complication rate, but data from the laparoscopic and robotic surgical series failed to demonstrate a clear reduction in post-operative complication rates compared to the open surgical series. Laparoscopic and robotic radical cystectomy show a reduction in blood loss, in-hospital stay and transfusion rates but a longer operative time, while open radical cystectomy is typically associated with a shorter operative time but with a longer in-hospital admission and possibly a higher rate of high grade complications