Focal Therapy of Prostate Cancer Index Lesion With Irreversible Electroporation. A Prospective Study With a Median Follow-up of 3 Years.

PURPOSE: Our aim was to assess oncologic, safety, and quality of life-related outcomes of focal therapy with irreversible electroporation in men with localized prostate cancer. MATERIALS AND METHODS: This was a single-center, phase II study. INCLUSION CRITERIA: prostate cancer International Society of Urological Pathology grade 1-2, prostate specific antigen ≤15 ng/ml, ≤cT2b. Patients were selected based on multiparametric magnetic resonance imaging and transperineal systematic and targeted magnetic resonance imaging-ultrasound fusion-guided biopsy. Ablation of index lesions with safety margin was performed. Primary end point was cancer control, defined as the absence of any biopsy-proven tumor. A control transperineal biopsy was planned at 12 months and when suspected based on prostate specific antigen and/or multiparametric magnetic resonance imaging information. Quality of life was assessed using Expanded Prostate Cancer Index Composite Urinary Continence domain, International Index of Erectile Function, and International Prostate Symptom Score. RESULTS: From November 2014 to July 2021, 41 consecutive patients were included with a median follow-up of 36 months. Thirty patients (73%) had International Society of Urological Pathology grade 1 tumors, 10 (24%) grade 2, and 1 (2.4%) grade 3. Recurrence was observed in 16 of 41 (39%) of the whole cohort, and 16 of 33 (48.4%) who underwent biopsy. In-field recurrence was detected in 5 (15%) and out-of-field in 11 (33.3%). Ten of 41 (24.6%) including 3 of 5 (60%) with in-field recurrences had significant tumors (Gleason pattern 4-5; more than 1 core or any >5 mm involved). Median recurrence-free survival was 32 months (95% CI 6.7-57.2). Twenty-six patients (63.4%) were free from salvage treatment. All patients preserved urinary continence. Potency was maintained in 91.8%. CONCLUSIONS: Irreversible electroporation can achieve satisfactory 3-year in-field tumor control with excellent quality of life results in selected patients.

What is the impact of post-radical prostatectomy urinary incontinence on everyday quality of life? Linking Pad usage and International Consultation on Incontinence Questionnaire Short-Form (ICIQ-SF) for a COMBined definition (PICOMB definition).

AIMS: To identify the definition for urinary continence (UC) after radical prostatectomy (RP) which reflects best patients' perception of quality of life (QoL). METHODS: Continence was prospectively assessed in 634 patients, 12 months after RP using the International Consultation on Incontinence Questionnaire Short-Form (ICIQ-SF) and the number of pads employed in a 24-hour period (pad usage). We used the one-way ANOVA technique with posthoc pairwise comparisons according to Scheffé's method (homogeneous subsets) for assessing the degree of QoL deficit related to urinary incontinence (UI). RESULTS: The continence prevalence is 64.4%, 74.1%, 88.3%, and 35.8% using "0 pads," "1 safety pad," "1 pad," and "ICIQ score 0" definitions, respectively. Pad usage is moderately strongly associated with ICIQ 1, 2, and 3 (ρ = 0.744, 0.677, and 0.711, respectively; p < 0.001). Concordance between classical UC definitions is acceptable between "0 pads-ICIQ score 0" (K = 0.466), but poor for "1 safety pad" and "1 pad" (K = 0.326 and 0.137, respectively). Patients with "0 pad usage" have better QoL related to urine leakage than patients with "1 safety pad" or "1 pad" (1.41 vs. 2.44 and 3.11, respectively; p < 0.05). There were no significant differences found regarding QoL between patients with ICIQ score 0 and ICIQ score 2 (1.01 vs. 1.63; p = 0.63). CONCLUSIONS: Pad usage and the ICIQ-SF's answers provide useful information. We propose a combined definition (0 pads and ICIQ score ≤2) as it is the definition with the least impact on daily QoL.

[Benign prostatic hyperplasia management during COVID-19 pandemia.] / Manejo de la hiperplasia benigna de próstata durante la pandemia COVID-19.

OBJECTIVES: The pandemic caused by the new SARS / Cov-2 Coronavirus represents an unprecedented scenario in modern medicine that affects many aspects of daily healthcare. Lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH) has a high prevalence and is related to high consumption of health resources. For this reason, we performed a revision of the management of LUTS and HBP during and after COVID-19 pandemic. MATERIAL AND METHODS: A group of experts in benign prostatic hyperplasia from different regions of Spain were selected to design a strategy to reorganize the management of benign prostatic hyperplasia and lower urinary tract symptoms during the pandemic. A comprehensive review of the literature was undertaken and a set of recommendations are generated. RESULTS: Recommendations for the management of LUTS-BPH during and after the SARS/CoV2 coronavirus pandemic outbreak consist of promoting telemedicine and developing joint protocols with Primary Care Attention .Clear diagnostic and treatment criteria and referral criteria must be established. Referral of patients for risk complications such as kidney failure, recurrent hematuria and obstructive uropathy are a priority. Surgeries due to BPH are generally potentially delayed until phases I and II of the pandemic, in which the percentage of hospitalized patients with COVID-19 does not exceed 25%, and it is necessary to determine COVID19 negativity. The surgical technique that associates the least complications and the shortest stay should be selected. CONCLUSIONS: The diagnosis and prescription of treatment for BPH during the COVID-19 pandemic should be based on telemedicine and joint protocols for primary care attention and urology. Elective surgical treatment can be delayed until we are in phases I or II, individualizing the surgical and anaesthetic technique of choice to minimize risks.

OBJETIVOS: La pandemia causada por el nuevo Coronavirus SARS/Cov-2 supone un escenario sin precedentes en la medicina moderna que afecta de manera indirecta en numerosos aspectos de nuestra actividad diaria como sanitarios. La hiperplasia benigna de próstata (HBP) es una patología con una elevada prevalencia y consumo de recursos sanitarios. Por ello, es necesaria una revisión en el manejo de la misma con el fin de adecuarlo a las necesidades impuestas por los acontecimientos recientes.MATERIAL Y MÉTODOS: Un grupo de expertos en hiperplasia benigna de próstata de distintas comunidades autónomas de España fueron contactados para diseñar una estrategia para reorganizar el manejo de la hiperplasia benigna de próstata y los síntomas del tracto urinario inferior durante la pandemia. Se realiza una revisión narrativa de la literatura publicada y se generan una serie de recomendaciones de manejo. RESULTADOS: Entre las recomendaciones para el manejo de HBP en tiempos de pandemia por coronavirus SARS/CoV2 se incluyen la promoción de teleconsulta y la realización de protocolos conjuntos con Atención Primaria estableciendo criterios de diagnóstico, tratamiento y derivación claros y homogéneos. Deben priorizarse las derivaciones pacientes complicaciones de riesgo tales como insuficiencia renal, hematuria recidivante y uropatía obstructiva. Desde el punto de vista quirúrgico, se trata generalmente de cirugías potencialmente demorables hasta fases I y II de la pandemia, donde el porcentaje de pacientes hospitalizados con Covid-19 no supera el 25%, siendo preciso determinar negatividad de COVID19. Debe seleccionarse la técnica quirúrgica que asocie una menor tasa de complicaciones así como una estancia más baja. CONCLUSIONES: El diagnóstico y el inicio del tratamiento médico de la HBP durante la pandemia debe basarse en la instauración de la telemedicina y protocolos conjuntos con atención primaria y urología. El tratamiento quirúrgico electivo se puede demorar hasta encontrarnos en fases I o II, individualizando la técnica quirúrgica y anestésica de elección para minimizar riesgos.

[Prognostic factors and response predictors in castration resistant prostate cancer.] / Factores pronósticos y predictores de respuesta en cáncer de próstata resistente a la castración.

Prostate cancer is a health problem in many Countries worldwide. Understanding the essential function of androgens in the prostate physiology led to the development of hormonal blockade as a therapeutic option in advanced disease, with limited response with time and development of resistance. In this stage, where castration resistant prostate cancer (CRPC) is defined, it is associated with poor prognosis because survival varies between 18 and 24 months. Even with castration levels, tumors are dependent on the functional androgen receptor (AR). In this paper, we analyze pretreatment clinical parameters such as prognostic or progression-predictive biomarkers, castration resistance mechanisms, the development of new technologies for the use of the so called liquid biopsies from biological ayufluids and the identification of circulating tumor cells as CRPC response and progression biomarkers. Currently ongoing clinical trials are partially oriented to the search of new prognostic and predictive biomarkers, that will enable to open up precision medicine and so to improve oncological patient's quality of life with it.

[Immunotherapy in castration resistant prostate cancer.] / Inmunoterapia en cáncer de próstata resistente a la castración.

We review the role of immunotherapy in castration resistant prostate cancer. Two immunotherapeutic strategies have been applied, isolated or in combination, either with each other or with other agents with demonstrated efficacy in this scenario that would play a role as immunomodulators: vaccines or monoclonal antibodies aimed to block immune response checkpoint inhibitors. Although CRPC presents, a priori, characteristics suggesting that immunotherapy may play a relevant role as a therapeutic strategy, its clinical application has demonstrated a limited and heterogeneous activity, in terms of proportion of responders and response intensity. Generally, the objective response rate is very low, although, in patients who have response it is possible to detect a clear, long-lasting benefit. Only the autologous vaccine Sipuleucel T has demonstrated an overall survival increase in patients with good prognosis criteria. In these treatments, it is characteristic that no progression free survival increase is visible due to its action mechanism. PSA evolution may not be considered a surrogate variable of radiological response or clinical benefit in this environment either. It is necessary to identify what patient's or tumor's characteristics are able to maximize the response. An important limitation is the absence of response predictive biomarkers that serve for patient preselection. As a general rule, the best responses with isolated immunotherapeutic treatments have been observed in patients with low tumor load, which may suggest that their optimal application could be in earlier phases of the disease (high risk localized, biochemical failure, etc) Combination strategy, without doubt the one with best future, is based on additional treatments increasing cell lysis with the subsequent antigen exposure and/ or producing an immunomodulatory effect that can surmount tumor induced immunologic tolerance. The results obtained suggest that immunotherapy may be more effective in combined therapy with other active therapies (abiraterone, enzalutamide, Radium 223, docetaxel) in a fight to achieve disease chronification.

El cáncer de próstata metastásico resistente a la castración en perspectiva 2018 / Metastatic castration resistant prostate cancer: 2018 perspective

No disponible

Inmunoterapia en cáncer de próstata resistente a la castración / Immunotherapy in castration resistant prostate cancer

Revisamos el papel de la inmunoterapia en el cáncer de próstata resistente a castración. Se han aplicado dos estrategias inmunoterápicas, de forma aislada o en combinación, bien entre ellas o bien con otros agentes de eficacia demostrada en este escenario y que ejercerían un papel inmunomodulador: vacunas o anticuerpos monoclonales destinados al bloqueo de puntos de control inhibidores de la respuesta inmune. Aunque a priori el CPRC presenta características que sugieren que la inmunoterapia podría jugar un papel relevante como estrategia terapéutica, su aplicación clínica ha demostrado una actividad limitada y heterogénea, en cuanto a la proporción de respondedores e intensidad de respuesta. En términos generales, la tasa de respuestas objetivas es muy baja, aunque, en los pacientes que responden, es posible detectar un beneficio claro y duradero. Sólo la vacuna autóloga Sipuleucel T ha demostrado un aumento de la supervivencia global en pacientes con criterios de buen pronóstico. Es característico en estos tratamientos que no se observe un incremento en la supervivencia libre de progresión debido a su propio mecanismo de acción. Tampoco la evolución del PSA puede considerarse una variante subrogada de respuesta radiológica o beneficio clínico en este entorno. Se hace necesario identificar qué características de los pacientes o del tumor son capaces de maximizar la respuesta. Una limitación importante es la ausencia de biomarcadores predictores de respuesta que sirvan para la preselección de pacientes. Como norma general, las mejores respuestas con tratamientos inmunoterápicos aislados se han observado en pacientes con baja carga tumoral, lo cual puede sugerir que su aplicación óptima podría ser en fases más precoces de la enfermedad (localizado de alto riesgo, fracaso bioquímico, etc.). La estrategia de combinación, sin lugar a dudas la de más futuro, se fundamenta en que los tratamientos adicionales incrementan la lisis celular con la consiguiente exposición antigénica y/o ejercen un efecto inmunomodulador capaz de vencer la tolerancia inmunológica inducida por el tumor. Los resultados obtenidos sugieren que la inmunoterapia puede ser más efectiva en modo tratamiento combinado con otros tratamientos activos (abiraterona, enzalutamida, Radio 223, docetaxel) en la lucha por lograr cronificar la enfermedad

We review the role of immunotherapy in castration resistant prostate cancer. Two immunotherapeutic strategies have been applied, isolated or in combination, either with each other or with other agents with demonstrated efficacy in this scenario that would play a role as immunomodulators: vaccines or monoclonal antibodies aimed to block immune response checkpoint inhibitors. Although CRPC presents, a priori, characteristics suggesting that immunotherapy may play a relevant role as a therapeutic strategy, its clinical application has demonstrated a limited and heterogeneous activity, in terms of proportion of responders and response intensity. Generally, the objective response rate is very low, although, in patients who have response it is possible to detect a clear, long-lasting benefit. Only the autologous vaccine Sipuleucel T has demonstrated an overall survival increase in patients with good prognosis criteria. In these treatments, it is characteristic that no progression free survival increase is visible due to its action mechanism. PSA evolution may not be considered a surrogate variable of radiological response or clinical benefit in this environment either. It is necessary to identify what patient`s or tumor's characteristics are able to maximize the response. An important limitation is the absence of response predictive biomarkers that serve for patient preselection. As a general rule, the best responses with isolated immunotherapeutic treatments have been observed in patients with low tumor load, which may suggest that their optimal application could be in earlier phases of the disease (high risk localized, biochemical failure, etc) Combination strategy, without doubt the one with best future, is based on additional treatments increasing cell lysis with the subsequent antigen exposure and/ or producing an immunomodulatory effect that can surmount tumor induced immunologic tolerance. The results obtained suggest that immunotherapy may be more effective in combined therapy with other active therapies (abiraterone, enzalutamide, Radium 223, docetaxel) in a fight to achieve disease chronification

Factores pronósticos y predictores de respuesta en cáncer de próstata resistente a la castración / Prognostic factors and response predictors in castration resistant prostate cancer

El cáncer de próstata es un problema de salud en muchos países a nivel mundial. La comprensión de la función esencial que los andrógenos tienen en la fisiología de la próstata condujo al desarrollo del bloqueo hormonal como opción de tratamiento en la enfermedad avanzada, con respuesta limitada en el tiempo y desarrollo de resistencia. Es en esta etapa donde se define el cáncer de próstata resistente a la castración (CPRC) y se asocia con mal pronóstico ya que la supervivencia oscila entre 18 y 24 meses a partir de ese momento. Aún con niveles de castración, los tumores son dependientes del receptor androgénico (RA) funcional. En el presente trabajo analizamos los parámetros clínicos pre-tratamiento como biomarcadores pronósticos o predictivos de progresión, los mecanismos de resistencia a la castración, el desarrollo de nuevas tecnologías para el uso de las denominadas biopsias líquidas a partir de fluidos biológicos y la identificación de células tumorales circulantes como biomarcadores de respuesta y progresión en CPRC. Los ensayos clínicos actualmente en marcha están en parte orientados hacia la búsqueda de nuevos biomarcadores pronósticos y predictivos, lo que permitirá abrir las puertas a la medicina de precisión y con ello mejorar la calidad de vida del paciente oncológico

Prostate cancer is a health problem in many Countries worldwide. Understanding the essential function of androgens in the prostate physiology led to the development of hormonal blockade as a therapeutic option in advanced disease, with limited response with time and development of resistance. In this stage, where castration resistant prostate cancer (CRPC) is defined, it is associated with poor prognosis because survival varies between 18 and 24 months. Even with castration levels, tumors are dependent on the functional androgen receptor (AR). In this paper, we analyze pretreatment clinical parameters such as prognostic or progression-predictive biomarkers, castration resistance mechanisms, the development of new technologies for the use of the so called liquid biopsies from biological ayufluids and the identification of circulating tumor cells as CRPC response and progression biomarkers. Currently ongoing clinical trials are partially oriented to the search of new prognostic and predictive biomarkers, that will enable to open up precision medicine and so to improve oncological patient's quality of life with it

[Maximal androgen deprivation with abiraterone acetate in hormone sensitive prostate cancer.] / Supresión androgénica máxima con acetato de abiraterona en cáncer de próstata hormonosensible.

OBJECTIVES: The treatment of metastatic prostate cancer has remained unchanged for more than 70 years, based on androgen deprivation therapy (ADT). In 2015, following the CHAARTED and STAMPEDE trials, it was established that the addition of 6 cycles of docetaxel to ADT was associated with significantly increased survival. In June 2017, the LATITUDE trial and the G arm of the STAMPEDE trial showed that the addition of Abiraterone with Prednisone (5 mg/day) to ADT was also associated with a significant increase in survival in metastatic patients. The present study analyzes these two trials. RESULTS: LATITUDE demonstrated a 38% reduction in the risk of death (HR=0.62, 95% CI, 0.61-0.76) in almost all sub-groups. Risk reduction for radiological progression was 53% (HR=0.47, 95% CI 0.39-0.55). Secondary objectives such as prostate specific antigen progression, time to chemotherapy or a new skeletal event are also significantly delayed. STAMPEDE also showed that the combination of Abiraterone and Prednisone is associated with a 37% increase in survival (HR=0.63, 95% CI, 0.52- 0.76, p<0.001) in metastatic patients, but not in nonmetastatic patients. Progression-free survival was greatly improved in this arm (HR=0.29, 95% CI 0.25-0.34, p<0.001). The side effects reported show the known pattern of mineral corticosteroid excess with increased blood pressure, hypokalemia, and of liver enzymes elevation. CONCLUSIONS: The indirect comparison of docetaxel and abiraterone studies confirms that both populations and results are comparable. Two comparative indirect metanalysis (>6000 patients) gave marginal superiority to abiraterone. In favor of abiraterone we have that it is an oral, comfortable medication with a good tolerance profile and side effects that are easy to manage, useful in patients who are old and fragile, in whom chemotherapy may not be indicated; the downsides are prolonged exposure to the drug and its current price. Future trials, currently in progress, will determine the ideal patient profile, or a potential association of both therapies.

Efficacy and safety of a hexanic extract of Serenoa repens (Permixon® ) for the treatment of lower urinary tract symptoms associated with benign prostatic hyperplasia (LUTS/BPH): systematic review and meta-analysis of randomised controlled trials and observational studies.

OBJECTIVES: To comprehensively evaluate the efficacy and safety of the hexanic extract of Serenoa repens (HESr, Permixon® ; Pierre Fabre Médicament, Castres, France), at a dose of 320 mg daily, as monotherapy for the treatment of lower urinary tract symptoms associated with benign prostatic hyperplasia (LUTS/BPH). MATERIALS AND METHODS: We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) and prospective observational studies in patients with LUTS/BPH identified through searches in Medline, Web of Knowledge (Institute for Scientific Information), Scopus, the Cochrane Library, and bibliographic references up to March 2017. Articles studying S. repens extracts other than Permixon were excluded. Data were collected on International Prostate Symptom Score (IPSS), maximum urinary flow rate (Qmax ), nocturia, quality of life, prostate volume, sexual function, and adverse drug reactions (ADRs). Data obtained from RCTs and observational studies were analysed jointly and separately using a random effects model. A sub-group analysis was performed of studies that included patients on longer-term treatment (≥1 year). RESULTS: Data from 27 studies (15 RCTs and 12 observational studies) were included for meta-analysis (total N = 5 800). Compared with placebo, the HESr was associated with 0.64 (95% confidence interval [CI] -0.98 to -0.31) fewer voids/night (P < 0.001) and an additional mean increase in Qmax of 2.75 mL/s (95% CI 0.57 to 4.93; P = 0.01). When compared with α-blockers, the HESr showed similar improvements on IPSS (weighted mean difference [WMD] 0.57, 95% CI -0.27 to 1.42; P = 0.18) and a comparable increase in Qmax to tamsulosin (WMD -0.02, 95% CI -0.71 to 0.66; P = 0.95). Efficacy assessed using the IPSS was similar after 6 months of treatment between the HESr and 5α-reductase inhibitors (5ARIs). Analysis of all available published data for the HESr showed a mean improvement in IPSS from baseline of -5.73 points (95% CI -6.91 to -4.54; P < 0.001). HESr did not negatively affect sexual function and no clinically relevant effect was observed on prostate-specific antigen. Prostate volume decreased slightly. Similar efficacy results were seen in patients treated for ≥1 year (n = 447). The HESr had a favourable safety profile, with gastrointestinal disorders being the most frequent ADR (mean incidence of 3.8%). CONCLUSION: The present meta-analysis, which includes all available RCTs and observational studies, shows that the HESr (Permixon) reduced nocturia and improved Qmax compared with placebo and had a similar efficacy to tamsulosin and short-term 5-ARI in relieving LUTS. HESr (Permixon) appears to be an efficacious and well-tolerated therapeutic option for the long-term medical treatment of LUTS/BPH.

Supresión androgénica máxima con acetato de abiraterona en cáncer de próstata hormonosensible / Maximal androgen deprivation with abiraterone acetate in hormone sensitive prostate cancer

OBJETIVO: El tratamiento del cáncer de próstata (CP) metastático ha permanecido inalterado durante más de 70 años fundamentado en la deprivación androgénica (DA). En 2015, a raíz de los estudios CHAARTED y STAMPEDE se estableció que la adición de 6 ciclos de docetaxel a la DA se asociaba significativamente con incremento de la supervivencia. En junio de 2017 los estudios LATITUDE y el brazo G del STAMPEDE demuestran que la adición de Abiraterona junto con Prednisona (5 mg/día) a DA se asocia también a un incremento significativo de supervivencia en los pacientes metastáticos. El presente trabajo analiza estos dos estudios. RESULTADOS: LATITUDE demostró una reducción relativa del riesgo de muerte del 38% (HR=0,62, 95% IC, 0,61-0,76) patente en la práctica totalidad de subgrupos. La reducción del riesgo relativo de progresión radiológica fue del 53 % (HR=0,47,IC 95% 0,39-0,55). Los objetivos secundarios como progresión de PSA, tiempo a quimioterapia o a nuevo evento esquelético también son significativamente retrasados. STAMPEDE también demuestra que la combinación con Abiraterona+prednisolona se asocia a un incremento relativo de SV del 37% (HR=0,63;95% IC, 0,52-0,76; p < 0,001) en pacientes M1, no así en los M0. La supervivencia libre de progresión fue muy mejorada en este brazo (HR=0,29;95% IC 0,25-0,34, p < 0,001). Los efectos secundarios referidos muestran el patrón conocido de exceso mineralcorticoide con incremento de HTA, hipokaliemia y elevación de enzimas hepáticas. CONCLUSIONES: La comparación indirecta de los trabajos de docetaxel y abiraterona confirma que tanto poblaciones, como resultados, son superponibles. Dos meta-análisis indirectos comparativos (>6000 pacientes) otorgan beneficio marginal a abiraterona. A favor de Abiraterona juega el ser una medicación oral, cómoda, con buen perfil de tolerancia y efectos secundarios de fácil manejo, útil en pacientes con frecuencia añosos y frágiles en los que la QT pudiera no estar indicada, aún a costa de una exposición al fármaco es más prolongada y de su actual precio. Futuros ensayos, en curso, determinará el perfil de pacientes idóneo, su posicionamiento en el tiempo o una potencial asociación de ambos

OBJECTIVES: Prostate cancer is linked to bone disease by two different entities. On one hand, androgen deprivation therapy (ADT) usually causes osteoporosis, on the other a great number of patients with advanced prostate cancer will present bone bicametastases, that condition not only their vital prognosis but also an important quality of life deterioration. METHODS: We performed a bibliographic review on both the physiology and therapy of osteoporosis secondary to ADT and bone metastasis in prostatic neoplasias. RESULTS: Osteoporosis: Long term ADT is associated with osteopenia/osteoporosis in 80% of the patients, with a 5-20% incidence of osteoporotic fractures. We should monitor bone mineral density before starting ADT therapy and during treatment. Treatment is based on risk factors reduction, regular physical exercise, calcium and vitamin D supplements, and drugs such as biphosphonates or denosumab. Bone metastasis: Currently, both zolendronic acid and denosumab have approval for the prevention of skeletal events in patients with castration resistant prostate cancer (CPRC). Although the last one seems to be more effective, it is associated with a higher risk of hypocalcemia and jaw osteonecrosis so that the choice of drug must be individualized in every patient. The duration of treatment is not clear. Currently, the indication for the use of this drugs in earlier phases of advanced disease is not approved. CONCLUSIONS: Comprehensive management of the patient with advanced prostate cancer should include the study and treatment of osteoporosis and bone metastases. Currently, very effective therapies are available for both entities

Tumor paratesticular atípico. Mesotelioma papilar bien diferenciado / Paratesticular atypical tumor. Well differentiated papillary mesothelioma

Los tumores paratesticulares son poco frecuentes: suponen menos del 5% de las neoplasias intraescrotales. El mesotelioma testicular es un tumor raro paratesticular de la línea de células no germinales. Presentamos el caso de un varón de 69 años de edad que consulta por tumoración testicular derecha y al que, tras exploraciones complementarias, se realiza orquiectomía radical con resultado anatomopatológico de mesotelioma de túnica albugínea (AU)

Paratesticular tumors are rare, less than 5% of intrascrotal neoplasms. Testicular mesothelioma is a rare paratesticular not germ cell tumor. We report the case of a 69 year-old man after attending Urology consultation due to the appearance of a right testicular tumor. He is diagnosed of mesothelioma of tunica albuginea after surgical treatment by radical right orchiectomy (AU)

Cáncer de próstata de bajo riesgo e intermedio: opciones de tratamiento / Low and intermediate risk prostate cancer: Treatment options

Los pacientes con cáncer de próstata de bajo riesgo e intermedio constituyen el grupo más frecuentemente diagnosticado en la actualidad. En aquellos con una esperanza de vida inferior a 10 años es muy probable que cualquier tratamiento sea innecesario por lo que la observación debe ser la aproximación más apropiada. En los pacientes en los que esté indicada alguna forma de terapia activa es necesario llevar a cabo un balance entre los riesgos de morir o desarrollar metástasis por la enfermedad y los efectos adversos de los tratamientos radicales comúnmente aceptados, como la prostatectomía radical y la radioterapia externa o intersticial. La significativa incidencia de morbilidad asociada, fundamentalmente disfunción eréctil e incontinencia urinaria, de alto impacto en la calidad de vida, exige esta aproximación en el ámbito de decisiones compartidas con los pacientes. El riesgo de sobretratamiento en este grupo de pacientes ha dado lugar a la introducción de abordajes más conservadores como el seguimiento activo y la terapia focal. El primero, trata de demorar los tratamientos radicales en tanto no existan criterios de agresividad suficiente por parte del tumor o el paciente los solicite. El segundo, que está llamado a ocupar un lugar entre el seguimiento activo y los tratamientos radicales, consiste en llevar a cabo una ablación parcial de la próstata para evitar los efectos adversos de los tratamientos radicales, tratando de lograr un control oncológico lo más similar posible al obtenido con estos

Patients with low and intermediate risk prostate cancer are the most frequently diagnosed group currently. In those with a life expectancy inferior to 10 years it is highly likely that treatment is not necessary so that observation must be the most appropriate approach. In patients in whom active therapy, in any of its forms, is indicated, it is necessary to balance between risk of dying or developing metastases from the disease and adverse effects of commonly accepted radical treatments, such as radical prostatectomy and external beam or interstitial radiotherapy. The significant incidence of associated morbidity, mainly erectile dysfunction and urinary incontinence, with high impact on quality of life, demands this approach in the field of decisions shared with patients. The risk of overtreatment in this group of patients has generated the introduction of more conservative approaches such as active surveillance and focal therapy. The first one tries to differ radical treatments as far as there are not enough aggressiveness criteria on the tumor or the patient requests them. The second, called to have a place between active surveillance and radical treatments, involves the performance of a partial ablation of the prostate to avoid the adverse effects of radical treatments, trying to achieve the closest oncological control to the radical options. We perform a review of the therapeutic options and their results in this type of patients

La importancia de exploración física en la incontinencia urinaria: Urocolpos / The importance of physical examination in urinary incontinence: Urocolpos

No disponible

Outpatient holmium laser treatment for recurrent low-grade superficial bladder cancer under local anesthesia.

BACKGROUND: The aim of this paper is to analyze the results of a prospective study conducted on a cohort of patients undergoing outpatient holmium laser fulguration. The "gold standard" treatment of superficial bladder cancer is transurethral resection, although in recent years improvements in laser technology and endoscopy equipment have allowed further therapeutic alternatives. METHODS: This is a descriptive study of a cohort of 37 patients with low-risk recurrent superficial bladder cancer undergoing holmium laser fulguration after bladder instillation of local anesthesia. The study included patients with a history of low-risk primary superficial bladder cancer with papillary tumor recurrence, tumor size ≤10 mm, fewer than 5 tumors, absence of carcinoma in situ, negative cytology, no coagulation disorders and no local anesthesia allergies. Demographic variables, previous history of transurethral resection, safety and oncological results after fulguration were analyzed using the SPSS software. Statistical analyses include calculating mean and frequency, and Kaplan-Meier curve for recurrence. RESULTS: Mean age of the patients was 69.2 years with 86.5% being male. The number of tumors was 1.5±0.8 and the overall average size of 5.5±2.7 mm. The mean duration of the endoscopic procedure was 12±4.3 minutes. Hundred percent of patients had scores on the Visual Analogue Scale ≤3. There was only one case of hematuria, who required hospitalization. After a median follow-up period of 13 months, there was a 35.1% recurrence rate with one case of tumor progression. CONCLUSIONS: Holmium laser treatment of recurrent low-risk superficial bladder tumor is a safe and effective alternative, but long-term clinical trials are necessary to increase the current scientific evidence base.

Fulguración con láser de la recidiva de tumores vesicales superficiales bajo anestesia local: diseño de procesos / Laser fulguration of superficial bladder tumor recurrence under local anesthesia. design process

Introduction: The process design is one of the most interesting tools to ensure the quality of health care before the start of an activity. Although the gold standard treatment of superficial bladder tumors remains transurethral resection (TUR), the onset of laser energy source with better endourological systems allows us to adopt alternative therapies. The aim of this pilot study is to describe the design and protocol in 37 patients with a novel process consisting of outpatient treatment under local anesthesia of bladder tumors with holmium laser. Material and Methods: Pilot study includes 37 patients between January 2012 and December 2013, for the development of a process of holmium laser bladder fulguration without anesthetic infiltration in outpatient study. It analyzes and studies the procedure tolerance, development of immediate complications, visual analog scale (VAS) of pain, patient satisfaction, hospital stays avoided, problems during the application process and development. Results: The mean age of the patients was 69.2 +/- 10.3 years, 100 percent of patients prefer this procedure instead conventional transurethral resection and VAS rating presenting ≤ 3. There were no important complications. Only one patient was admitted at hospital due to hematuria resolved without surgical treatment. Conclusions: The development and implementation of fulguration of superficial papillary bladder tumors with holmium laser process is simple, well tolerated, ambulatory and without complications, with no need of hospital stay.

Introducción: El diseño de procesos es una de las herramientas de mayor interés para asegurar la calidad de la asistencia sanitaria antes del comienzo de una determinada actividad. Aunque el gold standard del tratamiento de los tumores vesicales superficiales sigue siendo la resección transuretral (RTU), la aparición de la fuente de energía láser con mejores medios endourológicos nos permite adoptar otras alternativas terapéuticas. El objetivo de este estudio piloto es describir el diseño y protocolo en 37 pacientes de un proceso novedoso consistente en el tratamiento en régimen ambulatorio y bajo anestesia local intravesical de los tumores de vejiga con láser de holmium. Material y Métodos: Estudio piloto que incluye 37 pacientes entre enero de 2012 y diciembre de 2013, para la elaboración de un proceso de fulguración vesical con láser de holmium sin infiltración anestésica en régimen ambulatorio. Se analiza y estudia tolerancia al procedimiento, desarrollo de complicaciones inmediatas, escala visual analógica (EVA) del dolor, satisfacción del paciente, estancias hospitalarias evitadas, problemas durante la aplicación del proceso y desarrollo del mismo. Resultados: La edad media de los pacientes fue 69,2 +/- 10,3 años, presentando puntuación EVA ≤ 3. No existieron complicaciones importantes. Hubo un ingreso por hematuria tardía que se resolvió de forma conservadora. Conclusiones: La elaboración y aplicación del proceso de fulguración de tumores vesicales papilares superficiales con láser holmium es una técnica sencilla, con buena tolerancia, ambulatoria y sin complicaciones de interés, con eliminación de estancias hospitalarias.

[Endoscopic urethrotomy: indications and limitations]. / Uretrotomía endoscópica: indicaciones y limitaciones.

Endoscopic urethrotomy is a simple, reproducible, highly widespread technique that enables an appropriate management of patients with urethral stenosis, if the indication is well established. Determinants of success of this procedure are stenosis length, site, number, degree of spongiofibrosis and previous treatments. The best results would be obtained in single, short bulbar stenoses with limited spongiofibrosis, in which it may be the first choice. Its main limitation is the fact that the procedure itself is a controlled intentional trauma the result of which depends on multiple variables, including the technique employed.

Uretrotomía endoscópica: indicaciones y limitaciones / Endoscopic urethrotomy: Indications and limitations

La uretrotomía endoscópica es una técnica sencilla, reproducible y altamente difundida que permite un manejo apropiado de pacientes con estenosis de uretra, si está bien indicada. Los determinantes del éxito de este procedimiento son la longitud de la estenosis, la localización, el número, el grado de espongiofibrosis y los tratamientos previos. Sus mejores resultados se obtendrían en las estenosis únicas bulbares, cortas, con escasa espongiofibrosis donde podría ser de primera elección. Su principal limitación radica en el hecho de tratarse en si misma de un traumatismo intencional controlado cuyo resultado depende de múltiples variables, incluida la técnica empleada

Endoscopic urethrotomy is a simple, reproducible, highly widespread technique that enables an appropriate management of patients with urethral stenosis, if the indication is well established. Determinants of success of this procedure are stenosis length, site, number, degree of spongiofibrosis and previous treatments. The best results would be obtained in single, short bulbar stenoses with limited spongiofibrosis, in which it may be the first choice. Its main limitation is the fact that the procedure itself is a controlled intentional trauma the result of which depends on multiple variables, including the technique employed