Satisfaction assessment study in patients (and their partners) with/without Peyronie's disease and penile prosthesis implantation.

INTRODUCTION AND OBJECTIVE: Among the many treatments for erectile dysfunction, implantation of a penile prosthesis has been associated with high patient satisfaction rates. However, patients with coexistent Peyronie's disease (PD) and refractory erectile dysfunction and/or severe deformities may show different results. The aim of our study was to assess and to compare the level of satisfaction, with an inflatable penile prosthesis (IPP), in men with/without coexistent PD. MATERIAL AND METHODS: A survey study based on a five-item satisfaction questionnaire was submitted to all those live patients implanted in the period 1992-2022 at our center (n = 570) and their partners. Ninety-two percent of implants were inflatable devices. Surgeries were mainly performed by two surgeons. The main outcome measure used was the level of patient and partner satisfaction with sexual intercourse after IPP. RESULTS: Of the 570 eligible patients, 479 (84%) completed the survey (393 Non-PD: GROUP 1; 70 non-complex PD-Group 2; 16 complex PD). Eighty-six per cent of patients in Group 1 reported satisfactory sexual intercourse (very or moderately satisfied). Non-complex PD implanted patients (Group 2) reported a global 81% satisfactory sexual intercourse (very or moderately satisfied) (p > 0.05). However, when we evaluated the PD subgroup of patients with severe PD who require incision/excision/grafting at the time of implant (Group 3: n = 20), only 61% reported satisfactory sexual intercourse (p < 0.01) with predominance of moderately satisfied patients over very satisfied: 78% vs. 22%). Additionally, 84% (Group 1), 80% (Group 2) and 54% (Group 3) of partners reported satisfactory intercourses, respectively (p < 0.01). Overall, 84% of Group 1 implants and 79% of Group 2 reported that they would undergo the procedure again if the IPP failed (p > 0.05; ns). Only 50% of Group 3 patients would do it again. With regard to cosmetic aspects, 48% of the Group 3 implant reported penile shortness or soft glans as the main causes of their dissatisfaction. Only 2.4% of total PP patients expressed difficulty in manipulating the device. CONCLUSION: The presence of PD alone may not impact PP patient and partner satisfaction, but patients with more severe baseline deformity who require incision/grafting may be less satisfied with outcomes including penile length and glans sensation.

Opciones quirúrgicas de implante en pacientes con fibrosis peneana por infección o explantes previos / Surgical implant options in patients with penile fibrosis due to infection or previous explants

La fibrosis peneana por infección y/o explantes de prótesis peneanas previas condiciona situaciones de alta dificultad quirúrgica. El reimplante en estos casos debe seguir un esquema alternativo dirigido a minimizar las complicaciones peri y postoperatorias, así como conseguir la máxima eficacia del procedimiento y la mayor satisfacción postoperatoria del paciente y la pareja. En este artículo se revisan las principales alternativas quirúrgicas en estos casos

Penile fibrosis due to previous penile infection and/or prosthesis explants entails situations of high surgical complexity. In these cases, reimplantation should follow an alternative scheme, aimed at minimizing perioperative and postoperative complications, as well as achieving maximum efficiency of the procedure and greater postoperative satisfaction of the patient and his partner. This article reviews the main surgical alternatives for these cases

Surgical implant options in patients with penile fibrosis due to infection or previous explants. / Opciones quirúrgicas de implante en pacientes con fibrosis peneana por infección o explantes previos.

Penile fibrosis due to previous penile infection and/or prosthesis explants entails situations of high surgical complexity. In these cases, reimplantation should follow an alternative scheme, aimed at minimizing perioperative and postoperative complications, as well as achieving maximum efficiency of the procedure and greater postoperative satisfaction of the patient and his partner. This article reviews the main surgical alternatives for these cases.

Comparación del rendimiento entre biopsia transrectal clásica y biopsia "cognitiva" ecodirigida en la rebiopsia de la próstata / Comparison of classical transrectal prostate biopsy versus cognitive registration in rebiopsy

Introducción: El objetivo es comparar el rendimiento de la secuencia resonancia magnética (RM) y biopsia transrectal «cognitiva» (BTRCog) frente a la biopsia transrectal clásica (BTRCl) en pacientes con al menos una biopsia de próstata (BP) negativa. Material y método: Análisis retrospectivo de 205 pacientes con al menos una BP negativa. A 144 (70,2%) pacientes se les realizó antes de la biopsia una RM y a 61 (29,8%) no. Los nódulos se clasificaron según la clasificación PI-RADS v2 agrupando pZa, pZpl y pZpm como zona periférica (ZP), Tza, Tzp y CZ como zona transicional (ZT) y áreas AS como zona anterior (ZA). A los pacientes con RM se les realizó BTRCog. A los pacientes sin RM se les realizó una BTRCl de la ZP y de la ZT. Comparación de variables cualitativas con test de la chi2 y de cuantitativas con t de Student. Análisis multivariante (regresión logística) para identificar variables predictoras. Resultados: La mediana de edad fue 68 (IQR 62-72%) años, de PSA 8,3 (IQR 6,2-11,7) ng/ml y del número de biopsias previas fue 1 (IQR 1-2). En 169 (82,4%) el tacto rectal (TR) fue normal, mientras que en 36 (17,6%) sospechoso (cT2a-b en 34 y cT2c en 2). La mediana del volumen prostático (VP) fue de 48 (IQR 38-65) cc. Existió diferencia en el PSAD (p = 0,03) entre ambos grupos. En la ETR se identificó nódulo hipoecoico en 8 (13,1%) pacientes con BTRCl y en 62(43,1%) (p = 0,0001) con BTRCog. La mediana de cilindros extraídos en BTRCl fue 10 (IQR 10-10) y en el grupo BTRCog fue 11 (IQR 9-13) (p = 0,75). Se diagnosticó cáncer en 74 (36,1%) pacientes. En BTRCl 10 (16,4%) y en BTRCog 64 (44,4%) (p = 0,0001). Los tumores diagnosticados fueron clasificados: ISUP-1: 34 (45,9%), ISUP-2: 21 (28,4%), ISUP-3: 9 (12,2%), ISUP-4: 7 (9,5%), ISUP-5: 3 (4,1%). No existieron diferencias (p = 0,89). La mediana de cilindros afectados en BTRCl fue 1 (IQR 1-5) frente a 2 (IQR 1-4) en el grupo BTRCog (p = 0,93). Variables predictoras independientes de cáncer: edad (OR = 12,05, p = 0,049). TR sospechoso (OR = 2,64, p = 0,04), nódulo hipoecoico en ecografía (OR = 2,20, p = 0,03) y la secuencia RM + BTRCog (OR = 3,49, p = 0,003). Conclusiones: La secuencia RMNmp + BTRCog en pacientes con al menos una BP previa negativa multiplica casi por 3,5 (OR = 3,49) la probabilidad de diagnosticar un cáncer frente a la BTRCl

Introduction: The aim of this study is to compare performance of two biopsy approaches in patients with at least one previous negative prostate biopsy (PB): classical transrectal biopsy (ClTB) versus cognitive registration biopsy (COG-TB). Material and methods: A retrospective study of 205 patients with at least one negative PB. 144 (70.2%) patients underwent a prior mpMRI and 61 (29.8%) patients did not. Nodule classification was carried out according PI-RADS version 2. Peripheral zone (PZ) grouped pZa, pZpl and pZpm areas, transition zone (TZ) Tza, Tzp and Cz areas, and anterior zone (AZ) AS areas. COG-TB was conducted in patients with previous mpMRI (144); while in the remaining 61 (29.8%) patients a ClTB of PZ and TZ was performed. Statistical analysis was performed using Chi square and T-student tests for qualitative and quantitative variables, respectively. Multivariate analysis was carried out in order to identify predictive variables of prostate cancer. Results: Median patient age was 68 (IQR 62-72) years, median PSA was 8.3 (IQR 6.2-11.7) ng/ml and median previous biopsies was 1 (IQR 1-2). Digital rectal examinations (DRE) findings were normal in 169 (82.4%) patients and suspicious in 36 (17.6%) patients (cT2a-b in 34 patients and cT2c in 2). Median prostate volume was 48 (IQR 38-65) cc. Statistically significant differences in PSAD between both groups were found (P = .03). Transrectal ultrasound (TRUS) showed hypoechoic nodules in 8 (13.1%) ClTB patients and in 62 (43.1%) COG-TB patients (P=.0001). The median number of biopsy cylinders per set of prostate biopsies was 10 (IQR 10-10) in ClTB group and 11 (IQR 9-13) in COG-TB group (P = .75). Cancer was diagnosed in 74 (36.1%) patients: of them, 10 (16.4%) were ClTB patients and 64 (44.4%) COG-TB (P = .0001). Tumors classification was as follow: ISUP-1: 34 (45.9%), ISUP-2: 21 (28.4%), ISUP-3: 9 (12.2%), ISUP-4: 7 (9.5%) and ISUP-5: 3 (4.1%). No significant statistical differences were found (P = .89). The median number of biopsy cylinders impaired per set of prostate biopsies was 1 (IQR 1-5) in ClTB group and 2 (IQR 1-4) in COG-TB group (P = .93). Regarding independent predictive variables for prostate cancer the results were: age (OR = 12.05; P = .049), suspicious DRE (OR = 2.64; P = .04), hypoechoic nodule (OR = 2.20; P = .03) and mpMRI + COG-TB sequence (OR = 3.49; P = .003). Conclusions: In patients with at least one negative PB, mpMRI + COG-TB sequence improves 3.5 (OR=3.49) times the diagnosis prostate vs. ClTB

Comparison of classical transrectal prostate biopsy versus cognitive registration in rebiopsy. / Comparación del rendimiento entre biopsia transrectal clásica y biopsia «cognitiva¼ ecodirigida en la rebiopsia de la próstata.

INTRODUCTION: The aim of this study is to compare performance of two biopsy approaches in patients with at least one previous negative prostate biopsy (PB): classical transrectal biopsy (ClTB) versus cognitive registration biopsy (COG-TB). MATERIAL AND METHODS: A retrospective study of 205 patients with at least one negative PB. 144 (70.2%) patients underwent a prior mpMRI and 61 (29.8%) patients did not. Nodule classification was carried out according PI-RADS version 2. Peripheral zone (PZ) grouped pZa, pZpl and pZpm areas, transition zone (TZ) Tza, Tzp and Cz areas, and anterior zone (AZ) AS areas. COG-TB was conducted in patients with previous mpMRI (144); while in the remaining 61 (29.8%) patients a ClTB of PZ and TZ was performed. Statistical analysis was performed using Chi square and T-student tests for qualitative and quantitative variables, respectively. Multivariate analysis was carried out in order to identify predictive variables of prostate cancer. RESULTS: Median patient age was 68 (IQR 62-72) years, median PSA was 8.3 (IQR 6.2-11.7) ng/ml and median previous biopsies was 1 (IQR 1-2). Digital rectal examinations (DRE) findings were normal in 169 (82.4%) patients and suspicious in 36 (17.6%) patients (cT2a-b in 34 patients and cT2c in 2). Median prostate volume was 48 (IQR 38-65) cc. Statistically significant differences in PSAD between both groups were found (P=.03). Transrectal ultrasound (TRUS) showed hypoechoic nodules in 8 (13.1%) ClTB patients and in 62 (43.1%) COG-TB patients (P=.0001). The median number of biopsy cylinders per set of prostate biopsies was 10 (IQR 10-10) in ClTB group and 11 (IQR 9-13) in COG-TB group (P=.75). Cancer was diagnosed in 74 (36.1%) patients: of them, 10 (16.4%) were ClTB patients and 64 (44.4%) COG-TB (P=.0001). Tumors classification was as follow: ISUP-1: 34 (45.9%), ISUP-2: 21 (28.4%), ISUP-3: 9 (12.2%), ISUP-4: 7 (9.5%) and ISUP-5: 3 (4.1%). No significant statistical differences were found (P=.89). The median number of biopsy cylinders impaired per set of prostate biopsies was 1 (IQR 1-5) in ClTB group and 2 (IQR 1-4) in COG-TB group (P=.93). Regarding independent predictive variables for prostate cancer the results were: age (OR=12.05; P=.049), suspicious DRE (OR=2.64; P=.04), hypoechoic nodule (OR=2.20; P=.03) and mpMRI +COG-TB sequence (OR=3.49; P=.003). CONCLUSIONS: In patients with at least one negative PB, mpMRI +COG-TB sequence improves 3.5 (OR=3.49) times the diagnosis prostate vs. ClTB.

Efectividad de la biopsia "cognitiva" en el diagnóstico del cáncer de próstata en los pacientes con biopsia previa negativa / Effectiveness of the "cognitive" biopsy in the diagnosis of prostate cancer in patients with a previous negative biopsy

Introducción: Evaluación de la efectividad de la biopsia cognitiva (BC) en los pacientes con sospecha clínica de cáncer de próstata (caP) y al menos una biopsia negativa (BTR). Material y método: Análisis retrospectivo de 144 pacientes con al menos una BTR y una resonancia magnética nuclear (RMN) previa. Los nódulos de la RMN se clasificaron según la clasificación PI-RADS v2 agrupando pZa, pZpl y pZpm como zona periférica (ZP), Tza, Tzp y CZ como zona transicional (ZT) y áreas AS como zona anterior (ZA). Se indicó biopsia en nódulos ≥ PI-RADS 3. Se llevó a cabo análisis uni y multivariante (regresión logística) tratando de identificar variables relacionadas con tumor en biopsia de PI-RADS 3. Resultados: La mediana de edad fue de 67 (IQR: 62-72) años, la de PSA 8,2 (IQR: 6,2-12)ng/ml. Se identificó nódulo en la RMN en la ZP en 97 (67,4%) casos, en la ZT en 29 (20,1%) casos y en ZA en 41 (28,5%) casos. Se diagnosticó caP en la biopsia en 64 (44%) pacientes. En PI-RADS 3 se obtuvo un 17,5% (7/40) de cáncer, PI-RADS 4 un 47,3% (35/73) y en los PI-RADS 5 un 73,3% (22/29) (p = 0,0001). Análisis multivariable con variables que pudieran influir en el resultado de la biopsia en pacientes con PI-RADS 3: ninguno (edad, PSA, número de biopsias previas, tacto rectal, PSAD, volumen prostático ni número de cilindros extraídos) se comportó como factor predictor independiente de tumor. Conclusiones: El rendimiento diagnóstico de la BC en pacientes con al menos una biopsia previa negativa fue del 44% incrementándose según el grado de PI-RADS, siendo en PI-RADS 3 bajo. No se identificó ninguna variable clínica predictora de caP en pacientes con PI-RADS 3

Introduction: Evaluation of the effectiveness of cognitive biopsy (CB) in patients with clinical suspicion of prostate cancer (PC), and at least one negative biopsy (TRB). Material and method: Retrospective study of 144 patients with at least one previous TRB and magnetic resonance imaging (MRI). The MRI nodules were classified based on PI-RADS v2 grouping pZa, pZpl and pZpm as the peripheral zone(PZ), Tza, Tzp and CZ as the transitional zone (TZ), and the AS zones as the anterior zone (AZ). A biopsy was indicated for nodules ≥ PI-RADS 3. Uni and multivariate analysis was undertaken (logistic regression) to identify variables relating to a PI-RADS 3 tumour on biopsy. Results: The median age was 67 (IQR: 62-72) years, the median PSA was 8.2 (IQR: 6.2-12) ng/ml. A nodule was identified on MRI in the PZ in 97 (67.4%) cases, in the TZ in 29 (20.1%), and in the AZ in 41 (28.5%). PC was diagnosed on biopsy in 64 (44%) patients. The cancer rate in the PI-RADS 3 lesions was 17.5% (7/40), in the PI-RADS 4 47.3% (35/73), and in the PI-RADS 5 lesions it was 73.3% (22/29) (p = .0001). Multivariable analysis with variables that could influence the biopsy result in patients with PI-RADS 3: None (age, PSA, number of previous biopsies, rectal examination, PSAD, prostate volume or number of extracted cylinders) behaved as an independent tumour predictor. Conclusions: The diagnostic performance of CB in patients with at least one previous negative biopsy was 44%, increasing according to the PI-RADS grade, and low in PI-RADS 3. No clinical variable predictive of cancer was found in patients with PI-RADS 3

Effectiveness of the «cognitive¼ biopsy in the diagnosis of prostate cancer in patients with a previous negative biopsy. / Efectividad de la biopsia «cognitiva¼ en el diagnóstico del cáncer de próstata en los pacientes con biopsia previa negativa.

INTRODUCTION: Evaluation of the effectiveness of cognitive biopsy (CB) in patients with clinical suspicion of prostate cancer (PC), and at least one negative biopsy (TRB). MATERIAL AND METHOD: Retrospective study of 144 patients with at least one previous TRB and magnetic resonance imaging (MRI). The MRI nodules were classified based on PI-RADS v2 grouping pZa, pZpl and pZpm as the peripheral zone(PZ), Tza, Tzp and CZ as the transitional zone (TZ), and the AS zones as the anterior zone (AZ). A biopsy was indicated for nodules ≥PI-RADS 3. Uni and multivariate analysis was undertaken (logistic regression) to identify variables relating to a PI-RADS 3 tumour on biopsy. RESULTS: The median age was 67 (IQR: 62-72) years, the median PSA was 8.2 (IQR: 6.2-12) ng/ml. A nodule was identified on MRI in the PZ in 97 (67.4%) cases, in the TZ in 29 (20.1%), and in the AZ in 41 (28.5%). PC was diagnosed on biopsy in 64 (44%) patients. The cancer rate in the PI-RADS 3 lesions was 17.5% (7/40), in the PI-RADS 4 47.3% (35/73), and in the PI-RADS 5 lesions it was 73.3% (22/29) (p=.0001). Multivariable analysis with variables that could influence the biopsy result in patients with PI-RADS 3: None (age, PSA, number of previous biopsies, rectal examination, PSAD, prostate volume or number of extracted cylinders) behaved as an independent tumour predictor. CONCLUSIONS: The diagnostic performance of CB in patients with at least one previous negative biopsy was 44%, increasing according to the PI-RADS grade, and low in PI-RADS 3. No clinical variable predictive of cancer was found in patients with PI-RADS 3.

Anatomía y vascularización de la uretra masculina / Anatomy and vascularization of the male urethra and penis

En la presente revisión presentamos una actualización de la anatomía y vascularización de la uretra masculina. En realidad con esta revisión intentamos que los próximos capítulos del monográfico sean más accesibles a la compresión, tanto para conocer los mecanismos fisiopatológicos de la patología uretral como para ayudarnos al manejo quirúrgico de la misma

In this review we present an update on the anatomy and vascularization of the male urethra. The real objective of this review is to make the following chapters more understandable, both to know the physio-pathological mechanisms of urethral pathology and also to help us in their surgical management

Factores predictores de recidiva en el carcinoma epidermoide de pene clínicamente localizado. Análisis de nuestra serie / Predictive factors for recurrence in clinically localized squamous cell carcinoma of the penis. Analisys of our case series

OBJETIVO: Evaluar los factores predictores de recidiva del carcinoma epidermoide de pene clínicamente localizado tratado con cirugía.MÉTODOS: 49 pacientes fueron diagnosticados de cáncer de pene en nuestro servicio entre 1999 y 2009. Excluimos 18 pacientes: 9 por adenopatías palpables, 6 por histologías diferentes al epidermoide, 2 por pérdida del seguimiento y 1 por fallecimiento al diagnóstico.El diagnóstico se estableció mediante exploración y biopsia de la lesión. La lesión primaria fue tratada mediante circuncisión, cirugía parcial o penectomía total.Se definió como recidiva la afectación ganglionar o metastásica a partir del tercer mes tras la cirugía.Realizamos un análisis uni y multivariante mediante chi cuadrado y regresión logística para identificar los factores implicados en la recidiva.RESULTADOS: 31 pacientes fueron incluidos en el estudio. El seguimiento medio fue de 36 meses con una mediana de 29.El análisis histopatológico evidenció 55% pT1, 32% pT2 y 13% pT3. El grado histológico fue G1: 29%, G2: 32%, G3: 39%.Las tasas de recidiva y mortalidad fueron 38,7%, y 35,5% respectivamente.En el análisis univariante la localización de la lesión (p=0,004), el tipo de cirugía (p=0,008), el estadio (p=0,003) y el grado celular (p<0,001) se relacionaron de forma estadísticamente significativa con la recidiva.En el análisis multivariante solo el grado celular resultó estadísticamente significativo (p=0,01).CONCLUSIÓN: En nuestra serie, solo el grado histológico puede considerarse factor predictivo independiente de recidiva(AU)

OBJECTIVE: To evaluate the predictive factors for relapse in clinically localized squamous cell car-cinoma of the penis undergoing surgical treatment.METHODS: Forty-nine patients were diagnosed with cancer of the penis in our Service between 1999 and 2009. In the present study we excluded 18 subjects: 9 due to the presence of palpable adenopathies, 6 due to histological characteristics other than squamous cell carcinoma, two lost to follow-up, and one due to death at the time of diagnosis. Diagnosis was based on physical examination and biopsy findings. The primary lesion was treated by circumcision, partial surgery or total penectomy. Disease relapse was defined by lymph node or metastatic involvement after three months from surgery.Univariate and multivariate analysis were carried out using the chi-squared test and logistic regression to identify the factors involved in tumor relapse.RESULTS: Thirty-one patients were included in the study. Mean follow-up was 36 months (median 29). The histopathological study yielded the following profile: 55% pT1 cases, 32% pT2 cases and 13% pT3 tumors. Regarding histological grade, the distribution was G1: 29%, G2: 32%, G3: 39%. Recurrence and mortality rates were 38.7% and 35.5%, respectively.In the univariate analysis, location of the lesion (p=0.004), type of surgery (p=0.008), tumor stage (p=0.003) and cellular grade (p<0.001) were significantly correlated to disease relapse.In the multivariate analysis, only cellular grade proved statistically significant (p=0.01)(AU)

Predictive factors for recurrence in clinically localized squamous cell carcinoma of the penis. Analisys of our case series.

OBJECTIVE: To evaluate the predictive factors for relapse in clinically localized squamous cell carcinoma of the penis undergoing surgical treatment. METHODS: Forty-nine patients were diagnosed with cancer of the penis in our Service between 1999 and 2009. In the present study we excluded 18 subjects: 9 due to the presence of palpable adenopathies, 6 due to histological characteristics other than squamous cell carcinoma, two lost to follow-up, and one due to death at the time of diagnosis. Diagnosis was based on physical examination and biopsy findings. The primary lesion was treated by circumcision, partial surgery or total penectomy. Disease relapse was defined by lymph node or metastatic involvement after three months from surgery. Univariate and multivariate analysis were carried out using the chi-squared test and logistic regression to identify the factors involved in tumor relapse. RESULTS: Thirty-one patients were included in the study. Mean follow-up was 36 months (median 29). The histopathological study yielded the following profile: 55% pT1 cases, 32% pT2 cases and 13% pT3 tumors. Regarding histological grade, the distribution was G1: 29%, G2: 32%, G3: 39%. Recurrence and mortality rates were 38.7% and 35.5%, respectively. In the univariate analysis, location of the lesion (p=0.004), type of surgery (p=0.008), tumor stage (p=0.003) and cellular grade (p<0.001)were significantly correlated to disease relapse. In the multivariate analysis, only cellular grade proved statistically significant (p=0.01). CONCLUSION: In our series, only histological grade could be regarded as an independent predictor of tumor relapse.

[Current state of high intensity focused ultrasound (HIFU) as treatment of prostatic carcinoma]. / Estado actual del ultrasonido de alta frecuencia (HIFU) en el tratamiento del adenocarcinoma prostático.

OBJECTIVE: To evaluate the current state of high intensity focused ultrasound as therapeutical option of prostatic carcinoma (PCa) METHODS: We completed an extense review of urologic literature on the role of HIFU on the treatment of PCa. RESULTS: This technique is nowadays usually being indicated in Europe as treatment of many cases of either primary or relapsed PCa after radiotherapy. Although some reports suggest that HIFU is very effective as treatment for low and medium risk localized PCa patients, no randomized series comparing this technique with conventional therapies have been presented yet. Great disparity in criteria to define free-disease survival is detected, which make difficult the interpretation of results. CONCLUSIONS: Experience of some groups in HIFU is highly promising. Local tumour destruction is evident both in primary and relapsed PCa cases. To make conclusions in the long-term, controlled-randomized trials must be designed, with follow-up to measure benefits in global survival and quality of live. Comparisons must be completed with conventional techniques, and a uniform definition of disease free-survival is necessary.

Estado actual del ultrasonido de alta frecuencia (HIFU) en el tratamiento del adenocarcinoma prostático / Current state of high intensity focused ultrasound (HIFU) as treatment of prostatic carcinoma

Objetivo. Evaluar el estado actual de la utilización del Ultrasonido de Alta Intensidad (HIFU) en el tratamiento del adenocarcinoma prostático (Cap). Método. Hemos llevado a cabo una revisión del papel actual del HIFU en el tratamiento del Cap. Resultados. La tecnología HIFU está actualmente siendo aplicada ya de forma habitual en Europa en el tratamiento del Cap. Las indicaciones principales en la actualidad son dos: la aplicación del HIFU como primer escalón terapéutico y como terapia de rescate en recidivas post-radioterapia. Los trabajos actuales están basados en equipos clínicos en desarrollo. Aunque las últimas publicaciones sugieren que HIFU es una forma de tratamiento útil para el Cap bien y moderadamente diferenciado, existe todavía falta de comparaciones de esta terapia menos invasiva con los tratamientos estándar. Seguimos detectando en los trabajos disparidad en la definición de supervivencia libre de enfermedad (SLE), lo que dificulta la interpretación de resultados y la extracción de conclusiones definitivas. Conclusiones. La experiencia de los grupos de trabajo especializados en HIFU es altamente prometedora. Entre los aspectos a destacar está su gran capacidad de destrucción tumoral local tanto en los casos primarios como en las recidivas post-radioterapia. Para extraer conclusiones a medio y largo plazo debemos generar ensayos clínicos randomizados y controlados con seguimiento suficiente para medir beneficios en términos de supervivencia global y calidad de vida (balance efectos adversos / beneficios), realizar comparaciones con las terapias estándar y homogeneizar los criterios de definición de la SLE

Objective. To evaluate the current state of high intensity focused ultrasound as therapeutical option of prostatic carcinoma (PCa) Methods. We completed an extense review of urologic literature on the role of HIFU on the treatment of PCa. Results. This technique is nowadays usually being indicated in Europe as treatment of many cases of either primary or relapsed PCa after radiotherapy. Although some reports suggest that HIFU is very effective as treatment for low and medium risk localized PCa patients, no randomized series comparing this technique with conventional therapies have been presented yet. Great disparity in criteria to define free-disease survival is detected, which make difficult the interpretation of results. Conclusions. Experience of some groups in HIFU is highly promising. Local tumour destruction is evident both in primary and relapsed PCa cases. To make conclusions in the long-term, controlled-randomized trials must be designed, with follow-up to measure benefits in global survival and quality of live. Comparisons must be completed with conventional techniques, and a uniform definition of disease free-survival is necessary

¿Es posible una ética común en urología? / Is it possible a global ethics in urology?

No disponible

[Ethics and training in laparoscopic surgery]. / Etica y aprendizaje en cirugía laparoscópica.

Teaching operative skills are of paramount importance to urology training, specially in the period of time of the residency. Because of that, the introduction of laparoscopy in our surgical activity must be followed by a careful planning of progressive training as an answer to this new need that would be well designed trying not to damage in whatever possible way to the patients operated with this new modality of surgical intervention. In this sense, each case and each indication of laparoscopy must be clarified individually, taking into account the basic principles of medical ethics (beneficency, no maleficency, justice and autonomy). So, it will be neccesary to decide about possible risks due to the experience of the surgeon or due to the modality of surgery. In this article, different options of training plannings in laparoscopy are mentioned taking as a reference the experience in laparoscopic prostatectomy, reasons of "prepared reconversion" are exposed and, finally, the authors explain the discussion about the subject and the extent of information offered to the patients looking for the best possibilities of decision making by the patients.

[Volume determinations of the whole prostate and of the adenoma by transrectal ultrasound: correlation with surgical specimen]. / Correlación ecográfico-anatómica de la medición del volumen prostático total y de la zona transicional mediante ecografía transrectal.

OBJECTIVE: We evaluated whether preoperative transrecta ultrasound (TRUS) mesaurements of the transition zone (TZ) and total prostate volumen predict real prostatic weight. MATERIAL AND METHODS: We compare estimated TRUS volumes with surgical specimen weight, in surgically treated patients with localized prostate cancer (group A, n = 33) or benign prostatic hyperplasia (group B, n = 37). The volume was calculated by the ellipsoid formula. Both measurements were compared with surgical specimen weight, assuming 1 as specific prostate weight. RESULTS: Group A: mean prostate measured volume was 38.6 cc. (SD 22.7), mean RP specimen weight was 54,2 g (SD 27.2) (p = 0.001). Total estimated prostate volume underestimated prostatectomy specimen weight by 29%. In order to adequate the estimated volume to the specimen weight, we calculated the formula: estimated prostate weight = 0.95 x prostatic measured volume + 17,657 (p = 0.005). Group B: mean TZ measured volume was 62.8 cc. (SD 23.3), mean adenomectomy specimen weight was 79.9 g (SD 45.9) (p = 0.001). TZ estimated volume underestimated adenomectomy specimen weight by 21%. In order to adequate the estimated volume to the specimen weight, we calculated the formula: estimated TZ weight = 1.67 x TZ measured volume - 24,768 (p = 0.04). CONCLUSIONS: We found significative differences between TRUS measured volumes and real weight of surgical specimen. These differences could be corrected by simple formulas that allow to minimize the observed underestimations.

Ética y aprendizaje en cirugía laparoscópica / Ethics and training in laparoscopic surgery

La adquisición de habilidades quirúrgicas es un asunto de la mayor importancia durante el periodo de aprendizaje que supone la realización de la especialidad de Urología. Por ello, la progresiva implantación de la laparoscopia en nuestra actividad asistencial debe ir seguida de un plan de aprendizaje escalonado, como respuesta a esta nueva necesidad de formación, que debería ser cuidadosamente diseñado para no causar perjuicio alguno, en ningún caso, a los pacientes intervenidos con esta nueva modalidad de abordaje quirúrgico. Partiendo de la aceptación de esta premisa, se debe enfocar cada caso y cada indicación en particular, asegurando que se preservan los principios básicos de la ética médica (beneficencia, no maleficencia, justicia y autonomía). Para ello, habrá que sopesar los riesgos probables conforme a la propia experiencia o directamente relacionados con el tipo de intervención. Con respecto a esto, en el presente artículo se esbozan las diferentes opciones para llevar a cabo un plan éticamente aceptable de formación en laparoscopia urológica, tomando como punto de referencia la experiencia en prostatectomía laparoscópica. Asimismo, se exponen las razones justificativas de la denominada “reconversión programada” y, finalmente, se plantea la discusión respecto a qué se debe informar y qué cantidad de información se debe dar para que los pacientes puedan ejercer su capacidad de decisión de modo real

Teaching operative skills are of paramount importance to urology training, specially in the period of time of the residency. Because of that, the introduction of laparoscopy in our surgical activity must be followed by a careful planning of progressive training as an answer to this new need that would be well designed trying not to damage in whatever possible way to the patients operated with this new modality of surgical intervention. In this sense, each case and each indication of laparoscopy must be clarified individually, taking into account the basic principles of medical ethics (beneficency, no maleficency, justice and autonomy). So, it will be neccesary to decide about possible risks due to the experience of the surgeon or due to the modality of surgery. In this article, different options of training plannings in laparoscopy are mentioned taking as a reference the experience in laparoscopic prostatectomy, reasons of “prepared reconversion” are exposed and, finally, the authors explain the discussion about the subject and the extent of information offered to the patients looking for the best possibilities of decision making by the patients

[Validity of digital rectal examination in the era of prostate specific antigen]. / Validez diagnóstica del tacto rectal en la era del antígeno específico de la próstata.

OBJECTIVE: To determine the presence of a possible correlation between prostate specific antigen (PSA) and the findings from digital rectal examination (DRE) in patients with prostate cancer or benign prostatic hyperplasia. DESIGN: Retrospective, longitudinal, and observational study of diagnostic tests. SETTING: Gregorio Marañón Hospital, Madrid, Spain. PARTICIPANTS: It included 706 patients with a PSA in the range 4.1-20 ng/mL, studied owing to suspected prostate cancer localised using DRE and transrectal ultrasound, in whom randomised prostate biopsies were performed. MAIN MEASUREMENTS: Total PSA and free/total PSA ratio and DRE normal or suspicious were studied as main variables. The outcome variable was the diagnosis of prostatic cancer by biopsy. RESULTS: With a detection of cancer of 28.2%, there were no statistically significant differences in the PSA or free/total PSA ratio mean values between patients with or without suspicious DRE. The analysis using ROC curves (with a 95% confidence interval) between both groups of patients found the same sensitivity of 95% with a similar specificity of 6% and 10%, respectively, for a PSA of 4.8 ng/mL. CONCLUSIONS: In the PSA range of 4.1-20 ng/mL, the findings of DRE appeared as a variable unrelated to the increase in PSA or the free/total PSA ratio and, therefore are not indicative of a lesser or greater volume of a tumour producing PSA. The performing of this examination could be considered as optional.

Correlación ecográfico-anatómica de la medición del volumen prostático total y de la zona transicional mediante ecografía transrectal / Volume determinations of the whole prostate and of the adenoma by transrectal ultrasound: correlation with surgical specimen

Objetivo: Determinar la fiabilidad de la ecografía transrectal (ECOTR) en la medición del volumen prostático total y de la zona transicional (ZT) y buscar coeficientes de correlación capaces de mejorar la equiparación entre ambas medidas y el peso real prostático. Material y Métodos: Comparamos los volúmenes estimados mediante ECOTR con el peso de la pieza quirúrgica en pacientes con cáncer prostático localizado (grupo A, n=33) o HBP (grupo B, n= 37) sometidos a cirugía. El volumen se calculó mediante la fórmula del elipsoide. Ambas medidas se comparan con el peso de la pieza quirúrgica, asumiendo el peso específico próstatico igual a 1. Resultados: Grupo A: volumen prostático medio medido fue 38,6 cc. (DE 22,7), peso medio de la pieza de PR fue 54,2 g (DE 27,2) (p=0,001). El volumen prostático total estimado infravaloró el peso de la pieza de prostatectomía un 29%. Calculamos la fórmula para adecuar el volumen medido al peso real: peso estimado=0,95 x volumen medido prostático + 17,657 (p=0,005). Grupo B: volumen medio de ZT medido fue 62,8 cc (DE 23,3), peso medio de la pieza de adenomectomía fue 79,9 g (DE 45,9) (p=0,001). El volumen estimado del adenoma infravalora el peso de la pieza de adenomectomía un 21%. Calculamos la fórmula para adecuar el volumen medido al peso del adenoma: peso estimado=1,67 x volumen medido ZT - 24,768 (p=0,04). Conclusión: Encontramos diferencias significativas entre los volúmenes medidos por ECOTR y el peso real de la pieza quirúrgica. Estas diferencias pueden ser corregidas utilizando unas sencillas fórmulas, que permiten minimizar las infraestimaciones observadas

Objective: We evaluated whether preoperative transrecta ultrasound (TRUS) mesaurements of the transition zone (TZ) and total prostate volumen predict real prostatic weight. Material y Methods: We compare estimated TRUS volumes with surgical specimen weight, in surgically treated patients with localized prostate cancer (group A, n=33) or benign prostatic hyperplasia (group B, n=37). The volume was calculated by the ellipsoid formula. Both measurements were compared with surgical specimen weight, assuming 1 as specific prostate weight. Results: Group A: mean prostate measured volume was 38,6 cc. (SD 22,7), mean RP specimen weight was 54,2 g (SD 27,2) (p=0,001). Total estimated prostate volume underestimated prostatectomy specimen weight by 29%. In order to adequate the estimated volume to the specimen weight, we calculated the formula: estimated prostate weight=0,95 x prostatic measured volume + 17,657 (p=0,005). Group B: mean TZ measured volume was 62,8 cc. (SD 23,3), mean adenomectomy specimen weight was 79,9 g (SD 45,9) (p=0,001). TZ estimated volume underestimated adenomectomy specimen weight by 21%. In order to adequate the estimated volume to the specimen weight, we calculated the formula: estimated TZ weight=1,67 x TZ measured volume - 24,768 (p=0,04). Conclusions: We found significative differences between TRUS measured volumes and real weight of surgical specimen. These differences could be corrected by simple formulas that allow to minimize the observed underestimations

Validez diagnóstica del tacto rectal en la era del antígeno específico de la próstata / Validity of digital rectal examination of prostate specific antigen

Objetivo. Determinar la posible correlación entre los valores del antígeno específico de la próstata (PSA) y los hallazgos del tacto rectal en pacientes con cáncer prostático y enfermedad prostática benigna. Diseño. Estudio de evaluación de pruebas diagnósticas de tipo retrospectivo, longitudinal, con carácter observacional. Emplazamiento. Hospital Gregorio Marañón, Madrid. Participantes. Se incluyó a 706 pacientes con PSA en el rango de 4,1-20 ng/ml estudiados por sospecha de cáncer prostático localizado mediante tacto rectal y ecografía transrectal, en los que se realizaron biopsias prostáticas aleatorizadas. Mediciones principales. Se estudiaron como variables predictoras el PSA total, el cociente PSA libre/total y el tacto rectal categorizado como normal o sospechoso de cáncer. La variable desenlace fue el diagnóstico de cáncer prostático obtenido mediante biopsia. Resultados. Con una detección de cáncer del 28,2%, no se encontraron diferencias estadísticamente significativas en los valores medios de PSA o PSA libre/total entre los pacientes sin/con tacto rectal sospechoso. El análisis mediante curvas ROC (con un intervalo de confianza del 95%) entre ambos grupos de pacientes encontró para el PSA en el valor de 4,8 ng/ml una misma sensibilidad del 95%, con una especificidad similar, del 6 y el 10%, respectivamente. Conclusiones. En el rango de PSA 4,1-20 ng/ml, los hallazgos del tacto rectal aparecieron como una variable sin relación con la elevación del PSA ni con el cociente PSA libre/total y, por tanto, no son indicativos de un menor o mayor volumen tumoral productor de PSA. La realización de esta exploración podría ser considerada como opcional

Objective. To determine the presence of a possible correlation between prostate specific antigen (PSA) and the findings from digital rectal examination (DRE) in patients with prostate cancer or benign prostatic hyperplasia. Design. Retrospective, longitudinal, and observational study of diagnostic tests. Setting. Gregorio Marañón Hospital, Madrid, Spain. Participants. It included 706 patients with a PSA in the range 4.1-20 ng/mL, studied owing to suspected prostate cancer localised using DRE and transrectal ultrasound, in whom randomised prostate biopsies were performed. Main measurements. Total PSA and free/total PSA ratio and DRE normal or suspicious were studied as main variables. The outcome variable was the diagnosis of prostatic cancer by biopsy. Results. With a detection of cancer of 28.2%, there were no statistically significant differences in the PSA or free/total PSA ratio mean values between patients with or without suspicious DRE. The analysis using ROC curves (with a 95% confidence interval) between both groups of patients found the same sensitivity of 95% with a similar specificity of 6% and 10%, respectively, for a PSA of 4.8 ng/mL. Conclusions. In the PSA range of 4.1-20 ng/mL, the findings of DRE appeared as a variable unrelated to the increase in PSA or the free/total PSA ratio and, therefore are not indicative of a lesser or greater volume of a tumour producing PSA. The performing of this examination could be considered as optional