Role of 3.0 T multiparametric MRI in local staging in prostate cancer and clinical implications for radiation oncology.

PURPOSE: To evaluate the accuracy of preoperative 3T multiparametric magnetic resonance imaging (3TmMRI) for local staging of prostate cancer and its influence on the decision to change the clinical target volume (CTV), total dose and hormonal therapy when treating prostate cancer patients with radiotherapy. METHODS: From 2009 to 2013, 150 patients, who had confirmed prostate cancer and underwent a 3TmMRI before treatment with radical prostatectomy or radical radiation therapy, were included. Radiation therapy treatment (CTV, total dose and hormonal therapy) was initially determined on the basis of the clinical information, and radiation therapy plan was reevaluated after 3TmMRI review. The value of preoperative 3TmMRI in local staging and in the decision of radiotherapy treatment according to NCCN risk classification was analyzed. RESULTS: 3TmMRI performed correct, over- and under staging in 78.7 % (37/47), 6.3 % (3/47), 14.8 % patients (7/47), respectively. 3TmMRI identified 6 cT2a, 7 cT2b, 28 cT2c, 3 cT3a, 3 cT3b tumors. At final pathology, 5 tumors were classified as pT2a, 5 as pT2b, 30 as pT2c, 4 as pT3a, 3 as pT3b. After reviewing the MRI reports, the initial radiotherapy and hormonal therapy plan was changed in 33.9 % patients (35/103). CONCLUSIONS: In our group of patients, 3TmMRI has been a reliable technique providing an optimal staging for prostate cancer. Its routine use could induce important changes in radiation therapy treatments in a significant number of such patients. However, more additional studies are needed to clarify this issue.

[Primary testicular lymphoma. Report of a new case and review of the literature]. / Linfoma testicular primario. Aportación de un nuevo caso y revisión de la literatura.

Primary testicular lymphoma is an uncommon testicular tumour that accounts for no more than 9% of all testicular tumours in those series with higher incidence; testicular lymphoma as haematopoietic tumours are also rare accounting for just 1% of all lymphomas; but due to their highly malignant histopathology they may become highly aggressive tumours. Patient age at presentation is over 60 years old which makes it the most frequent tumour for this age group. There is no standard protocol to treat this malignancy due to lack of extensive series. We contribute one case and make a literature review discussing the current therapeutic trends for this disease.

Linfoma testicular primario. Aportación de un nuevo caso y revisión de la literatura / Primary testicular lymphoma. Contribution of one case and literature review

El linfoma testicular primario es un tumor testicular infrecuente, suponiendo no más del 9 por ciento de los tumores testiculares en las series con mayor incidencia; a su vez el linfoma testicular como tumor hematopoyético es infrecuente, con una incidencia del 1 por ciento de los linfomas, pero debido a su histopatología en la mayoría de los casos de alta malignidad, les hace ser de los tumores testiculares más agresivos. La edad de aparición es por encima de los 60 años, convirtiéndose en el tumor más frecuente para este grupo de edad. La falta de series amplias, hace que no exista un protocolo establecido para el tratamiento de esta patología. Presentamos un nuevo caso, realizando revisión de la bibliografía presentando las tendencias terapéuticas actuales para este tipo de patología (AU)

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[Treatment of complex fistula and urinary stenosis in renal transplantation]. / Tratamiento de la fístula y la estenosis urinaria complejas en el trasplante renal.

OBJECTIVES: Urological complications in renal transplantation occasionally denote the failure of a technique intended to provide the patient on hemodialysis a significant improvement of quality of life. Our experience in the management of these complicated cases which could not be resolved by conventional measures is described. METHODS: Since the transplantation program began, our department has performed 530 renal transplants. There have been 40 fistulae (7.5%) and 23 stenoses (4.3%) of graft urinary tract. All the foregoing complications had been treated by endourological procedures (nephrostomy or ureteral stent) and/or simple ureteral reinsertion. There were 5 unresolved or recurrent fistulae (0.9%) and 2 stenoses (0.4%) that were repaired using the recipient's ipsilateral urinary tract (6 pyeloureterostomies and 1 pyelopyelostomy). RESULTS: Good results were achieved in all of the cases with adequate urinary tract function. CONCLUSIONS: Urological complications following renal transplantation can be successfully treated by surgical correction (pyeloureterostomy or pyelopyelostomy).

["Ex-situ" reconstructive surgery of the renal arteries]. / Cirugía reconstructiva "ex-situ" de arterias renales.

The paper sums up our experience with kidneys which have undergone "bench" extracorporeal arterial surgery. The reasons making this procedure necessary were: renal graft from corpse donor presenting multiple arteries or arterial lesions (12 cases); orthoptic kidneys with stenotic lesions or arterial aneurism (5 cases); transplanted grafts which developed renal artery stenosis (2 cases). Incidence of arterial thrombosis and ureteral fistula was significantly higher in the first group than in grafts where no "bench" surgery had been performed. Medium- and long-term actuarial survival, however, showed no difference. In the second and third groups, extracorporeal arterial reconstructive surgery is a technique with a high risk for the loss of the involved renal unit.

[Endourologic treatment of uretero-ileal stenosis]. / Tratamiento endourológico de las estenosis ureteroileales.

OBJECTIVES: Ureterointestinal stricture represents a serious problem whose management has traditionally been by open surgery. Endourological treatment is an alternative that is generally free from the complications of open surgery, but with a lower success rate. The efficacy of endourological treatment is analyzed in 14 cases of ureteroileal stricture (12 patients) and the different treatment options are discussed. METHODS: Ureteroileal stricture was managed endourologically in 9 of 13 cases (69%) by dilatation (6 cases), incision+dilatation (2 cases) and stenting (1 case). RESULTS: Of the 6 cases submitted to dilatation, 3 recurred at 6 months, 2 remained patent at 18 and 24 months, respectively, and 1 was lost to follow up because the patient underwent reimplantation (40% success rate). The two cases submitted to incision are patent at 18 and 19 months, respectively. CONCLUSIONS: The overall success rate for endourological treatment of ureteroileal stricture is 28% (4/14 cases) at 19 months mean follow up.

[Intraluminal invagination technic for the incision of ureterointestinal stenosis]. / Técnica de invaginación endoluminal para la sección de las estenosis ureterointestinales.

OBJECTIVE: This paper describes the endoscopic incision of uretero-ileal anastomotic strictures by a combined approach (percutaneous antegrade and endoscopic retrograde) using the intraluminal invagination technique over a balloon dilatation catheter. METHODS: The different steps of the surgical procedure of incision of the stenotic segment of different techniques of ureteroileal diversion (Bricker, Camey, ureterosigmoidostomy) are described in detail. Endoscopic images and those from the image intensifier are shown. RESULTS: Of the 6 cases described herein, incision was achieved in 5 and in 1 case stenting of the stenotic segment could not be achieved. CONCLUSIONS: Intraluminal invagination of the stenotic segment considerably facilitates endoscopic incision.

[Vascular complications in renal transplantation]. / Complicaciones vasculares en el trasplante renal.

Between the years 1979 and 1992 we a total of 479 renal transplants (RT) were performed. In 62 patients (12.9%) there were some clinically significant vascular complications. These have consisted of: 10 cases of arterial thrombosis (2%); 10 cases of venous thrombosis (2%); 5 cases of arterial and venous thrombosis (1%); 31 cases of arterial stenosis (6.5%); and 6 cases of acute haemorrhage originated at the vascular anastomosis level (1.2%). In all those cases with arterial or venous thrombosis, or both, it was necessary to perform transplantation. The arterial stenosis cases were treated with antihypertensive agents in 13 patients; with endoluminal percutaneous angioplasty (EPA) in other 13 patients and with surgery in 5. Both arterial stenosis and complications from their treatment resulted in 5 transplantations. In all cases with early post-surgical haemorrhage originated at the vascular anastomosis level, a surgical review and suture of bleeding site was performed. A total of 31 grafts (6.5%) were lost as a result of vascular complications.

[Abnormalities of the inferior vena cava: the retrocaval ureter]. / Malformaciones de la vena cava inferior: el uréter retrocavo.

We report three cases of retrocaval ureter with a clear indication for surgery: one patient with severe hydronephrosis and two cases with mild dilatation of the renal pelvis, calyces and upper ureter, both complicated by renal stones. The initial diagnosis was based on the ultrasound and the intravenous urogram findings, and was confirmed by a retrograde pyelogram in combination with cavography and CT. All patients were submitted to surgery (1 nephrectomy and 2 uretero-ureteric anastomosis). Renal stone was resolved at the same time in one case, and by ESWL after surgery in the other.

[Diagnostic yield of Echo-Doppler in dysfunction of the grafted kidney]. / Rentabilidad diagnóstica del eco-Doppler en la disfunción del injerto renal.

The study's goal is to analyze the usefulness of Eco-Doppler in the knowledge of renal graft hemodynamics and the description of its dysfunction. 234 examinations were performed in 110 patients. Acceleration, mean rate (MR), maximum systolic rate (MXSR) and minimal diastolic rate (MNDR), as well as resistance index (RI) and pulsatility index (PI) were determined in the external iliac, renal, segmentary, interlobular and arcuate arteries. RI and PI, as well as MXSR and the acceleration are higher in the extra-parenchymatous versus the intra-parenchymatous beds. Peak MR and MNDR values are reached in the renal artery. Termino-lateral to external iliac arterial anastomosis conditions higher MXSRs in the renal artery as opposed to termino-terminal to hypogastric artery (p < 0.05). In the arcuate artery, RI > 0.8 is reached in 51.6% of acute tubular necrosis (ATN), 46.9% of acute rejections (CR), 46.3% of chronic rejection (AR), 21% of grafts with cyclosporin-induced nephrotoxicity (NFX) and 12.5% of normal functioning kidneys isolated chance analysis with Eco-Doppler does not distinguish between AR and ATN. A dysfunctional graft with an RR in the arcuate artery of nearly 9.7 suggests NFX, but AR with interstitial predominance cannot be ruled out.

[Surgical complications in 479 renal transplantations]. / Complicaciones quirúrgicas en 479 trasplantes renales.

Exposition of results obtained from the review of the surgical complications found in a series of 479 renal transplantations performed between 1978 and 1992 in our centre, although some of them lack clinical relevance. There was fluid accumulation in 69 patients, distributed between 31 perirenal haematoma. 17 lymphocele, 13 urinoma, 5 perirenal abscesses and 3 mixed. 27.7% required no action. Frequency of renal rupture was 18 cases, 9 due to acute rejection and 9 to vascular thrombosis. Incidence of urinary obstruction was 4.8% with 5.8% of urinary fistula. With regard to the surgical wound, 9 infections, 7 haematomas, 1 eventration and 1 necrotizing fasciitis were observed. Vascular complications consisted in 10 arterial thrombosis, 10 venous thrombosis, 5 mixed thrombosis and 31 arterial stenosis. Treatment instituted for the various cases, its evolution, and an statistical study of risk factors are illustrated.

[Laparoscopic transplantectomy of renal graft. Experimental model]. / Trasplantectomía laparoscópica del injerto renal. Modelo experimental.

Renal transplant nephrectomy carries a high morbidity and mortality. Conceptually, graft removal by laparoscopy is a logical less invasive alternative. We have developed an experimental model for renal autotransplantation in the pig, with laparoscopic graft removal eight weeks following autotransplantation. Although the clinical indication for laparoscopic nephrectomy of a failed graft will provoke controversy, a nonfunctioning renal graft with intolerance and no rupture or infection late post-transplantation theoretically could be the indication for this procedure.

[Treatment of recurrent bladder surface tumors with laser Nd:Yag: a single-year experience]. / Tratamiento de los tumores vesicales superficiales recidivantes con laser Nd:Yag: un año de experiencia.

Management of surface vesical tumours using laser photocoagulation has proven to be a safe and effective method. The technique can be performed under anaesthetic sedation and in the outpatient clinic environment thus allowing a considerable cost saving and the reduction of hospital's waiting lists. Throughout 1990, 47 patients with relapsing vesical tumours were treated in 55 sessions. Most cases were performed on ambulatory patients with a low complications rate and an estimated saving of 18,326,400 pesetas as compared to transurethral resection.

[Extracorporeal arterial reconstructive surgery in complex vasculo-renal pathology]. / Cirugía reconstructiva arterial extracorpórea en patología vásculo-renal compleja.

Herein we describe a case of a 23-year-old male patient with severe hypertension that was refractory to medication, a hypoplastic left kidney and complex renovascular disease. Patient evaluation revealed stenosis of the right renal artery and saccular aneurysms of its three branches. Treatment with converting enzymes was discarded due to the risk of azotemia and the complex vascular disease advised against percutaneous transluminal angioplasty. He was therefore submitted to ex situ vascular repair (bench surgery) using the hypogastric artery with its three branches and autotransplantation in the right iliac fossa. The foregoing procedure achieved excellent results. The arterial pressure and overall renal function returned to normal 15 days postoperatively. In our view extracorporeal surgery is the procedure of choice in patients with complex renovascular disease involving the small branches of the renal artery.

Control of massive hematuria in idiopathic hemorrhagic cystitis after administration of conjugated estrogen.

A renal transplant patient with severe hemorrhagic cystitis of idiopathic etiology was treated initially with intravenous administration of conjugated estrogen (1 mg./kg.), followed on day 2 and thereafter with 5 mg. per day orally for 3 weeks. Hematuria decreased in intensity within 10 hours and disappeared within 48 hours. Hematuria did not recur by 6 months after completion of oral doses of conjugated estrogen. Complications or other side effects were not observed. In our experience conjugated estrogen controls hematuria in patients with idiopathic hemorrhagic cystitis and this form of treatment must be considered in this condition.

[Infiltrating transitional carcinoma of the bladder (4). Our approach to stage pT2 and critique of other risk factors. Multifactorial analysis]. / Carcinoma transicional infiltrante de vejiga. (4a parte). Nuestra actitud frente al estadio pT2 y crítica de otros factores de riesgo. Análisis multifactorial.

From the analysis of our experience with pT2 and pT3a tumours it could be deduced that the former have better prognosis. The papillary appearance, invasion in a wide front and extent, whether with good or moderate differentiation, in T2 are signs of good prognosis, as well as the non-existence of unilateral dilation or an effaced kidney. Considering the good evolution obtained with radical cystectomy only, these patients should be recruited for study in order to see whether evolution with bladder preservation is similar. Patients with pT2 tumours should not be included in protocols to evaluate the efficacy of adjuvant therapies used with surgery. The evolution is not equivalent to that expected in tumours of deeper invasion.

[Transrectal echography: diagnostic accuracy in the local staging of cancer of the prostate]. / Ecografía transrectal: seguridad diagnóstica en el estadiaje local del cáncer de próstata.

Herein we report on the results afforded by transrectal ultrasound relative to local staging of tumor in 18 patients who had undergone radical surgery for prostatic cancer. The diagnostic accuracy for prostatic capsule involvement was 83.3% and 100% when there was seminal vesicle invasion.

[Interventional echography]. / Ecografía intervencionista.

We describe the different interventional ultrasonographic techniques available in our unit and report the results achieved in 254 puncture-aspiration of abdominal and retroperitoneal masses, 158 ultrasonically-guided nephrostomies, 36 percutaneous drainage of purulent or serous collections, 114 biopsies of orthotopic kidneys and 129 renal grafts. We analyze the techniques' safety as well as their complications.

[New applications of the Doppler effect in urology]. / Nuevas aplicaciones del efecto Doppler en urología.

Ultrasound is currently the noninvasive imaging technique most commonly utilized in the clinical setting. It can be used in two ways: to obtain morphological data and to obtain dynamic information via the Doppler effect.

[Transvaginal echography in urology]. / Ecografía transvaginal en urología.

Performing a morphologic study of the pelvic cavity is of special interest to the urologist since anatomic structures considered very important to our specialist field are located in this area. This type of evaluation has been difficult to carry out with precision; however, ultrasound offers the possibility of exploring this anatomic region via intracavitary techniques that provide precise information. Transrectal and transurethral sonography are imaging techniques that the urologist usually recurs to. These permit us to study the structures in the pelvic region with precision. Although transvaginal ultrasonography has been utilized in gynecology for some time; its urological application had not been described until 1988. To date, three previous studies have referred to its application in urology. The present article describes the procedure and its possibilities.