[Treatment of locally advanced renal tumors]. / Tratamiento de los tumores renales localmente avanzados.

INTRODUCTION: Locally advanced renal tumors show a high progression rate after surgery. Surgical treatment of renal tumors has some unique characteristics related to involvement of the adrenal gland, vena cava, or regional lymph nodes. OBJECTIVE: To review the current treatment of locally advanced renal tumors. MATERIALS AND METHODS: A review is made of both the different drugs used and the different therapeutic possibilities in these tumors. RESULTS: Systemic treatment with angiogenesis inhibitors may improve the natural history of these patients. Systemic treatment may be administered before surgery or as an adjuvant to surgical treatment. Early studies showed a decrease in tumor mass when treatment is administered before surgery, but no prospective randomized studies providing adequate evidence for recommending neoadjuvant treatment are available. CONCLUSIONS: Availability of systemic treatment with angiogenesis inhibitors may open an important field in the treatment of these tumors in both the neoadjuvant setting and as adjuvants to surgery, but no sufficiently solid scientific evidence as to recommend their use is currently available. Randomized studies with sunitinib and sorafenib will probably suggest the adequate approach to be used when their final results are reported.

Tratamiento de los tumores renales localmente avanzados / Treatment of locally advanced renal tumors

Introducción: los tumores renales localmente avanzados presentan un alto porcentaje de progresión tras el tratamiento quirúrgico. El tratamiento quirúrgico de estos tumores renales presenta algunas peculiaridades en relación con la afectación de la glándula suprarrenal, de la vena cava o de la afectación de ganglios regionales. Objetivo: revisar el tratamiento actual de los carcinomas renales localmente avanzados. Material y métodos: se realiza una revisión de los distintos fármacos utilizados, así como de las distintas posibilidades terapéuticas en estos tumores. Resultados: el tratamiento sistémico con inhibidores de la angiogénesis puede mejorar la historia natural de estos pacientes. La pauta de tratamiento sistémico puede ser preoperatoria o adyuvante al tratamiento quirúrgico. Los primeros estudios realizados muestran una disminución de la masa tumoral cuando se realiza tratamiento preoperatorio, aunque no existen estudios prospectivos aleatorizados que nos den suficiente evidencia para recomendarla neoadyuvancia. Conclusiones: la aparición de los tratamientos sistémicos con inhibidores de la angiogénesis puede abrir un campo importante en el tratamiento de estos tumores, tanto en neoadyuvancia como en adyuvancia a la cirugía, pero en la actualidad no tenemos evidencias científicas suficientemente sólidas para recomendar su uso de forma indiscriminada. Probablemente serán los estudios aleatorizados con sunitinib y/o sorafenib los que marcarán la pauta a seguir cuando se completen los resultados definitivos (AU)

Introduction: Locally advanced renal tumors show a high progression rate after surgery. Surgical treatment of renal tumors has some unique characteristics related to involvement of the adrenal gland, vena cava, or regional lymph nodes. Objective: To review the current treatment of locally advanced renal tumors. Materials and methods: A review is made of both the different drugs used and the different therapeutic possibilities in these tumors. Results: Systemic treatment with angiogenesis inhibitors may improve the natural history of these patients. Systemic treatment may be administered before surgery or as an adjuvant to surgical treatment. Early studies showed a decrease in tumor mass when treatment is administered before surgery, but no prospective randomized studies providing adequate evidence for recommending neoadjuvant treatment are available. Conclusions: Availability of systemic treatment with angiogenesis inhibitors may open an important field in the treatment of these tumors in both the neoadjuvant setting and as adjuvants to surgery, but no sufficiently solid scientific evidence as to recommend their use is currently available. Randomized studies with sunitinib and sorafenib will probably suggest the adequate approach to be used when their final results are reported (AU)

[Laparoscopic adrenalectomy. Reflections after 24 procedures]. / Adrenalectomía laparoscópica. Consideraciones a propósito de 24 procedimientos.

INTRODUCTION AND OBJECTIVES: Laparoscopic adrenalectomy has gained rapid recognition since publication of the first case in 1992. Currently it is the technique of choice for the surgical treatment of the adrenal gland. Our objective in this paper is to share our experience with this technique and offer some practical advice on how to approach it. MATERIALS AND METHODS: Between May 1998 and August 2006 we did a total of 24 laparoscopic adrenalectomies in 22 patients (15 men, 7 women). The right gland was removed in 13 cases and the left in 11. Surgery was bilateral in two cases (one was MEN II, the other bilateral cortical hyperplasia). Average age was 49.5 +/- 14.3 years (range 24 to 78). Clinical diagnosis was: Pheochromocytoma (n = 10), Cushing (n = 6), Conn (n = 4), metastases from lung carcinoma (n = 2) and non-functioning tumor (n = 2). For surgery, all patients were in total lateral decubitus with a pillow to increase the costal-iliac space. We used four trocars on the right side and three on the left. Abdominal access was by Hasson trocar after minilaparotomy. We kept pneumoperitoneal pressure below 12 mmHg; a Veress needle was not used for this procedure. RESULTS: Open surgery was required in one case. Time operation was between 59 and 400 minutes (mean 182 +/- 98 min.). In the first 12 cases average time was 261 +/- 77 minutes and in the final 12 cases was 103 +/- 21 minutes (p < 0.001). Tumour diameter was between 1.3 and 6 cm (mean 3.08 +/- 1.25 cm) and tumour weight was between 8 and 92g (mean 30.13 +/- 21 g). Except in one case with 600 ml blood loss, bleeding was less than 100 ml (n = 23, range: 10-100, mean 43.26 +/- 25ml). We only had intraoperative complications in two cases: perforation of the liver by the laparoscope retractor (at the beginning of the series) and injury to the spleen capsule. Both complications were resolved laparoscopically. Cases by histologic type were: nine cortical adenomas, nine pheochromocytomas, three nodular hyperplasias, two metastases from lung carcinoma, and one adrenal pseudocyst. Discharge from hospital was between three and five days (mean 3.62 +/- 0.82) with a statistical difference (p < 0.001) between twelve first cases and the last ones. CONCLUSIONS: The adrenal laparoscopic approach is currently the technique of choice for removing adrenal tumours although with malign tumours or over 7 cm in diameter there are some contraindications and disadvantages relative to open surgery. There is inevitably a learning curve but satisfactory results are quickly attainable.

[Laparoscopic radical prostatectomy. Only at centers of expertise]. / Prostatectomía radical laparoscópica. Sólo en centros de excelencia?

OBJECTIVES: To present and evaluate our experience and initial results in radical laparoscopic prostatectomy which we have been using for two and an half years in our General Hospital (covering a total population of 200.000 inhabitants). MATERIAL AND METHODS: Between December 2002 and August 2005, were selected 26 patients for radical laparoscopic prostatectomy (25 transperitoneal and 1 extraperitoneal). Mean age was 62.3 +/- 5.3 years (range 52-69). Mean PSA level was 9.16 +/- 4.20 ng/mL (range 5.26 to 24.3). Pre-operative classification was Tlc in 10 patients (38.4%), T2a in 8 (30.8%) and T2b in 8. Mean Gleason Score was 6 +/- 0.8 (range 4-7). Three patients had undergone preoperatively neo-adjuvant hormonal blockage (11.5%). Simultaneous bilateral inguinal lymphadenectomy was performed in two patients. In no case did we consider a nerve sparing approach. RESULTS: The procedure was accomplished in 20 patients. Mean follow-up was 12.4 +/- 8.6 months (range 3 - 34). There was no perioperative mortality. Conversion to open surgery was required six times in the ten first cases but not thereafter. Mean operating time for the whole series was 303 +/- 95 minutes (range 150-540) but with a distinct difference between the first fourteen and the last six cases: 332 +/- 92.58 versus 236.6 +/- 66.5 (p<0.02). Mean blood loss was 90.25 +/- 46.5 ml. There were early postoperative complications in 4 patients (15.38%). Final pathological staging was: T2a in three patients (15%), T2b (50%) in 10, T3a (15%) in three and T3b (20%) in four. Positive margins were found in three cases (11.5%): T2b, T3a and T3b. Mean hospitalisation time was 4.7 +/- 3.1 days. Provided there was no urinary leakage, the urinary catheter was removed at 12.7 +/- 2.7 days. Full continence at three months was achieved in 17 of the patients (85%) who had undergone the full laparoscopic procedure. CONCLUSIONS: Our previous experience in other major laparoscopic procedures has allowed us to perform radical laparoscopic prostatectomy with a fast learning curve even in a setting of a relatively low population. Initial long term results seem similar to those achieved with conventional surgery.

[Estimation of the cost in the medical treatment of benign prostatic hyperplasia in Navarre, Spain]. / Aproximación al coste del tratamiento médico de la hiperplasia benigna de próstata en la Comunidad Foral de Navarra.

We evaluate the cost and trends in the medical treatment of out patients suffering from lower urinary tract symptoms suggestive of clinical benign prostatic hyperplasia in Navarre (Spain) between 1998/2002. The estimated number of patients increased each year, to 10% of the male population over the age of 50 in 2002, with a cost of Euros 2,557,236 equivalent to 2.4% of the total drug expenditure spending of out patients (Euros 106.6 million). The use of tamsulosin tripled and the cost doubled to Euros 807,467 (31.5%) of the total), while the rest of alpha-blockers, wit the exception of doxazosin, was stationary. Phytotherapy decreased by a third and finasteride follows a slow upward trend. The introduction of reference prices set by the Health Department in 2001 to reduce medical budget, led to an initial decrease in cost, offsetted in the following year due to the incorporation of new patients. In this period, surgery for prostate adenoma diminished from 382 patients in 1998 to 270 in 2002 (-30%).

Aproximación al coste del tratamiento médico de la hiperplasia benigna de próstata en la comunidad foral de Navarra / Estimation of the cost in the medical treatment of bening prostatic hyperplasia in Navarra, Spain

Se estudia el coste y evolución del tratamiento médico ambulatorio de los pacientes afectos de clínica de prostatismo sugestiva de hiperplasia benigna de próstata en la Comunidad Foral de Navarra en el periodo 1998/2002. El número estimado de pacientes en tratamiento se incrementa cada año, llegando al 10% de la población masculina mayor de 50 años en el 2002, con un coste para el ente gestor de 2.557.236 € , el 2,4% del gasto médico farmacéutico extrahospitalario total (106,6 millones €). En dicho periodo, la tamsulosina triplica su uso y dobla el coste hasta los 807.467 € (31,5% del total) mientras que el resto de alfa-bloqueantes, con la excepción de la doxazosina, prácticamente se estacionan. La fitoterapia baja su utilización en casi un tercio y el coste en un 50%. El finasteride mantiene una línea ascendente con una cuota de mercado actual del 15%. La introducción de los precios de referencia el año2001 disminuye inicialmente el gasto, pero esta reducción queda sin efecto ya el año siguiente ante la incorporación de nuevos pacientes en tratamiento. En el mismo periodo, la cirugía por adenoma de próstata (cerrada y abierta) pasó de 265 y 117 pacientes en 1998 a 195 y 75, respectivamente, en el año 2002 (-30%) (AU)

We evaluate the cost and trends in the medical treatment of out patients suffering from lower urinary tract symptoms suggestive of clinical benign prostatic hyperplasia in Navarre (Spain) between 1998/2002.The estimated number of patients increased each year, to 10% of the male population over the age of 50in 2002, with a cost of € 2.557.236 equivalent to 2.4% of the total drug expenditure spending of outpatients (€ 106.6 million). The use of tamsulosin tripled and the cost doubled to € 807.467 (31.5%) of the total), while the rest of alpha-blockers, wit the exception of doxazosin, was stationary. Phytotherapy decreased by a third and finasteride follows a slow upward trend. The introduction of reference prices set by the Health Department in 2001 to reduce medical budget, led to an initial decrease in cost, offsetted in the following year due to the incorporation of new patients. In this period, surgery for prostate adenoma diminished from 382 patients in 1998 to 270 in 2002 (-30%) (AU)

[Therapeutic approach in adrenal melanoma. Review of the literature]. / Actitud terapéutica en el melanoma suprarrenal. Revisión de la literatura.

OBJECTIVE: To review the treatment strategies for adrenal melanoma and to emphasize the role of curative surgical resection and adjuvant treatment in selected patients with melanoma metastatic to the adrenal gland versus chemotherapy alone in the treatment of patients with advanced malignant melanoma. METHODS: A case of adrenal gland metastasis of a cutaneous melanoma (Clark IV, Breslow 5 mm.) treated by excision one year before that was referred to the Urology Department for Wünderlich syndrome is presented. RESULTS: The analyzed series of programmed adrenalectomy for adrenal metastases from melanoma describe survivals of 26 (3), 36 (9), 59 (3) and 72 (5) months. In our case the patient died at home one month later due to stroke, although concomitant brain metastasis is suspected. Autopsy was not performed. CONCLUSIONS: In the differential diagnosis of an incidentaloma, metastatic disease is likely in a patient with a history of malignant disease. The frequency of malignant melanoma among metastatic adrenal disease varies between 1% and 8.6%; the majority are asymptomatic and incidental findings. We believe that in selected patients with advanced malignant melanoma, with no major coexisting morbidity factors who have isolated melanoma metastatic to the adrenal gland or with limited extra-adrenal sites of disease, curative surgical resection and adjuvant treatment may improve their survival. It must be emphasized that all patients should be followed after surgical resection of the primary tumor because it will facilitate staging of the disease and avoid emergency situations of ruptured friable metastases that make complete resection difficult.

Presentación sincrónica de papiloma invertido con foco de carcinoma transicional en pelvis renal derecha y carcinoma urotelial vesical / Synchronous presentation of inverted papilloma and transitional cell carcinoma of the right renal pelvis associated to urothelial carcinoma of the bladder

Presentamos un caso de asociación sincrónica de papiloma invertido (P.I) con foco de carcinoma transicional en pelvis renal derecha (pT 2 G 1 ) y carcinoma urotelial en pared lateral izquierda de vejiga (T 1 G 2 ).El papiloma invertido urotelial es un tumor poco frecuente, generalmente benigno que constituye el 2,2 por ciento de los tumores uroteliales. Aunque su localización más frecuente es la vesical (90 por ciento), y dentro de ella en trígono y cuello, también puede aparecer en T.U.S "tracto urinario superior" (7-8 por ciento) o en uretra (3 por ciento).Aconsejamos un seguimiento cercano tras su tratamiento conservador ya que existe la posibilidad de recidivas y asociación a carcinoma transicional tanto de forma sincrónica como asincrónica (AU)

[Synchronous presentation of inverted papilloma with transitional carcinoma focus in right kidney pelvis and bladder urothelial carcinoma]. / Presentación sincrónica de papiloma invertido con foco de carcinoma transicional en pelvis renal derecha y carcinoma urotelial vesical.

We report a case with synchronous presentation of inverted papilloma (I.P) and transitional cell carcinoma of the right renal pelvis (pT2G1) associated to urothelial carcinoma on left lateral wall of the bladder (T1G2). Urothelial inverted papilloma is an uncommon, generally benign tumor that account for 2.2% of all urothelial tumors. Although the preferred location is the bladder (90%), above all in trigone and bladder neck, also can be located at the UUT "upper urinary tract" (7-8%) and urethra (3%). A close follow-up is recommended after conservative therapy, mainly endoscopic procedure, due to likelihood of recurrence and synchronous or metachronous association with transitional cell carcinoma.

[Differential diagnosis of epididymal leiomyoma. Report of a new case]. / Diagnósticos diferenciales del leiomioma de epidídimo. Aportación de un nuevo caso.

OBJECTIVE: A case of epididymal leiomyoma is presented. This lesion is uncommon and sometimes misdiagnosed. The literature is briefly reviewed. METHODS/RESULTS: A 29-year-old patient presented with a tumor in the tail of the right epididymis that was initially diagnosed as scrotal hematoma or complex cyst in the tail of the epididymis. RESULTS/CONCLUSIONS: Ultrasound has an important role in distinguishing testicular from epididymal tumors. However, if the diagnosis is unclear, surgical resection and subsequent anatomopathological analysis must be performed.

[Primary neuroectodermal tumor (PNET) of the kidney: 26 cases. Current status of its diagnosis and treatment]. / Tumor neuroectodérmico primitivo renal (PNET): 26 casos. Estado actual de su diagnóstico y tratamiento.

OBJECTIVE: To report a case of primitive neuroectodermal tumor (PNET) of the kidney and review the literature and the 25 cases previously reported as PNET. METHODS: A 39-year-old man who consulted for nephric colic is described. Ultrasound evaluation disclosed a mass arising from the left kidney. The clinical, radiological and pathologic features, treatment and differential diagnosis of small cell tumors are discussed, as well as the important role of immunohistochemical techniques (positive staining with O13 or 12E7 antibodies) and cytogenetic analysis [a characteristic chromosomal translocation t(11;22) (q24;q12) or variant translocation, such as t(21;22) (q22;q12), may be detected by fluorescence in situ hybridization (FISH) or polymerase chain reaction-reverse transcriptase (PCR-RT)]. RESULTS: Survival of our patient was 20 months. Only three of the 25 previously reported cases had a longer survival: 60, 48 and 24 months. Mean survival was 10 months. 95.24% of the cases were positive for NSE. Immunostaining (CD99) was performed in 16 patients and was found to be positive in all cases. Cytogenetic and molecular analyses were performed in 11 cases; PCR-RT was negative in two, as well as in the case described herein. CONCLUSIONS: PNET is a highly aggressive neoplasm that tends to recur locally and to metastasize. Despite the poor response to standard therapy combining surgical resection, postoperative irradiation and chemotherapy, the results might change due to current research on genetic therapy based on creating antisense oligonucleotides against the EWS-FLI 1 fusion gene.

[Stromal tumor of the rectum and leiomyosarcoma of the prostate as a cause of urinary syndrome attributable to BPH]. / Tumor estromal de recto y leiomiosarcoma de próstata como causa de síndrome miccional atribuible a HBP.

OBJECTIVE: To discuss the classifications of patients with lower urinary tract symptoms ascribed to BPH, in order to define the indication for treatment for patients with similar features but of a different etiology. The literature is also reviewed. METHODS/RESULTS: Two patients, aged 62 and 63 years, diagnosed as having BPH were found to have a gastrointestinal stromal tumor (GIST) and a leiomyosarcoma of the prostate, respectively. The first patient had undergone retropubic resection. Frozen section analysis revealed a GIST. The second patient had undergone TURP twice. A perineal biopsy at the last medical examination showed a leiomyosarcoma of the prostate. This patient finally underwent pelvic tumorectomy. The international classification of BPH is discussed: PQSF (P: prostatic weight determined by transrectal US or DRE; Q: quality of life assessment; S: international prostate symptom score (IPSS); F: maximum urinary flow rate by uroflowmetry--Qmax). CONCLUSIONS: The classifications are practical, but should be improved. In our view, details useful in orienting the diagnosis could be lost by oversimplification.