Prospective follow-up study of artificial urinary sphincter placement preserving the bulbospongiosus muscle.

AIMS: Artificial urinary sphincter (AUS) AMS-800® is an effective treatment for male stress urinary incontinence. The aim of the study was to assess the long-term effectiveness and complications of artificial urinary sphincter placement preserving the bulbospongiosus muscle. METHODS: From April 2004 to March 2014, all consecutive male patients with urinary incontinence who underwent an AUS prosthesis insertion were prospectively evaluated. Surgical technique consisted of a perineal incision for cuff placement around the bulbous urethra preserving the bulbospongiosus muscle. Cure rate was defined as no pad use. RESULTS: A total of 82 consecutive patients (median age 68 years, range: 54-78) were prospectively evaluated (median follow-up 46 months, range: 12-135). Bulbospongiosus muscles were preserved intact in all cases with no intraoperative complications. Postoperative complications were reported in 14 patients (1 urethral erosion). The overall cure rate (dry rate) was 76.8% and the median ICIQ-UI score improved from 18 (range: 8-21) to 4 (range: 0-17) (P < 0.001). Artificial urinary sphincter survival rate was 95.5% (95%CI 89.4-100%) at 24 months and 62.6% (95%CI 45.5-79.6%) at 60 months. The mechanical failure rate was 6.3% (median 46.1 months, range: 22.2-100.9) and urethral atrophy and/or inadequate compression rate was 9.5% (median 58.6 months, range: 39-101.4 months). CONCLUSIONS: Our study suggests that placement of AUS preserving the bulbospongiosus muscle is technically easy and efficient, reports excellent continence rates and lower urethral erosion rates, and could delay the onset of urethral atrophy compared to other surgical procedures used for sphincter placement.

Indocyanine Green Guided Pelvic Lymph Node Dissection: An Efficient Technique to Classify the Lymph Node Status of Patients with Prostate Cancer Who Underwent Radical Prostatectomy.

PURPOSE: We evaluated the effectiveness of indocyanine green guided pelvic lymph node dissection for the optimal staging of prostate cancer and analyzed whether the technique could replace extended pelvic lymph node dissection. MATERIALS AND METHODS: A solution of 25 mg indocyanine green in 5 ml sterile water was transperineally injected. Pelvic lymph node dissection was started with the indocyanine green stained nodes followed by extended pelvic lymph node dissection. Primary outcome measures were sensitivity, specificity, predictive value and likelihood ratio of a negative test of indocyanine green guided pelvic lymph node dissection. RESULTS: A total of 84 patients with a median age of 63.55 years and a median prostate specific antigen of 8.48 ng/ml were included in the study. Of these patients 60.7% had intermediate risk disease and 25% had high or very high risk disease. A median of 7 indocyanine green stained nodes per patient was detected (range 2 to 18) with a median of 22 nodes excised during extended pelvic lymph node dissection. Lymph node metastasis was identified in 25 patients, 23 of whom had disease properly classified by indocyanine green guided pelvic lymph node dissection. The most frequent location of indocyanine green stained nodes was the proximal internal iliac artery followed by the fossa of Marcille. The negative predictive value was 96.7% and the likelihood ratio of a negative test was 8%. Overall 1,856 nodes were removed and 603 were stained indocyanine green. Pathological examination revealed 82 metastatic nodes, of which 60% were indocyanine green stained. The negative predictive value was 97.4% but the likelihood ratio of a negative test was 58.5%. CONCLUSIONS: Indocyanine green guided pelvic lymph node dissection correctly staged 97% of cases. However, according to our data it cannot replace extended pelvic lymph node dissection. Nevertheless, its high negative predictive value could allow us to avoid extended pelvic lymph node dissection if we had an accurate intraoperative lymph fluorescent analysis.

[Spontaneous enterocutaneous and rectovaginal fistula: potential complications during therapy with anti-angiogenic drugs in renal cancer]. / Fistula rectovaginal y enterocutánea espontáneas: potenciales complicaciones durante la terapia con fármacos antiangiogénicos en cancer renal.

We present two cases of enterovaginal and enterocutaneous fistulae associated to treatment with pazopanib, which is an angiogenesis inhibitor for the treatment of metastatic renal cancer. The times from drug administration and the first appearance of a fistula were 6 and 16 months, respectively. None of the cases had a history of surgery or radiotherapy in the area where the complication was observed. Enterovaginal and enterocutaneous fistula represent less than 1% of all published complications caused by the use of antiangiogenic drugs. However, they must be taken into account as the reported mortality rate is close to 30%. Given its low incidence, we believe that sharing this data is a great way to help specialists who have to treat these patients to take the necessary precautions and decide on an adequate approach.

AdVance/AdVance XP transobturator male slings: preoperative degree of incontinence as predictor of surgical outcome.

OBJECTIVE: To evaluate the efficacy of the AdVance transobturator male sling in the treatment of male stress urinary incontinence and to identify the preoperative predictors of a successful outcome. MATERIALS AND METHODS: All patients were considered for sling placement 1 year after radical prostatectomy or transurethral resection of the prostate. The degree of incontinence was assessed using the 24-hour pad weight test. A preoperative urodynamic assessment and cystoscopy were performed in all cases. Patients without sphincter contractions during the "repositioning test" were excluded. Since September 2010, we have implanted the AdVance XP transobturator sling. Cure was defined as no pad use. RESULTS: From February 2008 to June 2011, 61 patients underwent transobturator sling (34 AdVance and 27 AdVance XP) insertion. In 26 cases, the sling was anchored with bioabsorbable sutures, and in 35 cases, it was not fixed. Of the 61 patients, 7 had a history of anastomotic stricture and 3 of radiotherapy. Preoperatively, median 24-hour pad weight was 200 g (range 25-1848). Finally, 26 patients had detrusor overactivity or low bladder compliance. The median follow-up was 26 months (range 12-53). The overall cure rate was 80% (49 of 61). Deterioration of continence was observed during follow-up in 2 patients. The preoperative variables (age, body mass index, 24-hour pad weight, International Consultation on Incontinence Questionnaire-Short Form, adverse urodynamics, sling fixation, AdVance XP) and their association with the surgical outcome were analyzed. The preoperative 24-hour pad weight correlated inversely with the outcome (odds ratio 0.996), with a 0.4% decrease in cure rate for each 1-g increase in the preoperative 24-hour pad weight. The complications included perineal hematoma in 2, acute urinary retention in 9, perineal numbness in 5, and de novo storage symptoms (urgency) in 5 patients. CONCLUSION: The results of our study have shown that the AdVance and AdVance XP male slings are safe and efficient in patients with mild postprostatectomy stress incontinence. The severity of incontinence was the only predictor of a successful outcome.

Importance of previous transurethral resection of the prostate before eerpe.short-term functional outcomes in a single surgeon series.

OBJECTIVES: Laparoscopic Radical Prostatectomy (LRP) is technically a very demanding procedure and potentially even more challenging in patients with previous transurethral resection (TURP). This study evaluates the impact of previous TURP on the short-term functional outcome of patients undergoing extraperitoneal LRP. METHODS: Retrospective analysis of a prospectively collected database, comprising a single-surgeon cohort of 155 consecutive LRP cases, 19 of which had previous history of TURP. Demographics, clinical and functional outcomes were evaluated and compared among patients with and without previous TURP. Multivariate analysis was performed to identify potential variables independently associated with continence outcomes. Incontinence was defined as the need of more than 1 pad/day. Potency was defined as the ability for sexual intercourse with or without the use of phosphodiesterase inhibitors. RESULTS: Demographic and clinical variables were comparable among the two study groups. Neurovascular bundle preservation was possible in 26% and 37% of patients with and without previous TURP, respectively. No major complications were recorded and the incidence of minor complications was comparable. Overall continence rate at 3 months was 82,58%, for the entire cohort. Subset analysis demonstrated a 3-month continence rate of 73.7% vs. 83.8% (p>0.05) in patients with and without TURP, respectively. Multivariate analysis demonstrated age, BMI and ASA were variables independently associated with continence outcomes. In the cohort of patients with previous TURP, 2 out of 7 undergoing preservation recovered erections, with a mean follow up of 15.5 months, comparable to the 30% achieved in patients without TURP and nerve sparing procedure. CONCLUSIONS: Laparoscopic Radical Prostatectomy in patients with previous TURP is feasible, with complication rates and short-term functional outcomes comparable to those in patients without previous resection.

Relevancia de la resección transuretral de próstata en los resultados funcionales de la prostatectomía radical laparoscópica / Importance of previous transurethral resection of the prostate before eerpe. short-term functional outcomes in a single surgeon series

OBJETIVO: La dificultad del tratamiento quirúrgico del Cáncer de próstata (caP) se acentúa en los pacientes con antecedentes de resección transuretral de próstata (RTU). En este estudio valoraremos la influencia de la RTU en los resultados funcionales a corto plazo de la prostatectomía radical laparoscópica extraperitoneal. MÉTODO: Revisión retrospectiva de una base de datos de cumplimentación prospectiva de una serie de pacientes intervenidos por un solo cirujano de manera consecutiva. Se compararon las características demográficas, clínicas y patológicas de los pacientes con y sin RTU previa, para posteriormente realizar un estudio multivariante mediante regresión logística para comprobar qué variables se asociaban de manera independiente y significativa a la incontinencia según el criterio (>1 compresa/día). Se consideró potentes a aquellos pacientes capaces de penetrar con o sin la ayuda de inhibidores de la 5 fosfodiesterasa. Se dispuso de la evaluación funcional de 155 pacientes, 19 de los cuales tenían antecedentes de RTU previa. RESULTADOS: Los subgrupos no diferían en las variables relevantes para el estudio. La conservación de haces neurovasculares se realizó en un 37% de los pacientes sin RTU previa y en un 26% del grupo contrario. No se objetivaron complicaciones mayores, la frecuencia de complicaciones menores no difería. La tasa de continencia de la serie global, evaluada en los 3 primeros meses, era del 82,58%. En el subgrupo de pacientes sin antecedentes de RTU previa era del 83,8% mientras que en el subgrupo de pacientes con RTU previa era del 73,7%, p>0,05. En el análisis multivariante, se asociaron de manera independiente y significativa a la continencia la edad, el IMC y el ASA. Tampoco se observaron diferencias significativas en la proporción de pacientes que recuperaron la erección en uno y otro grupo (28 vs 30%). CONCLUSIONES: Los resultados funcionales a corto plazo son aceptables y comparables a los de los pacientes sin resección previa (AU)

OBJECTIVES: Laparoscopic Radical Prostatectomy (LRP) is technically a very demanding procedure and potentially even more challenging in patients with previous trans-urethral resection (TURP). This study evaluates the impact of previous TURP on the short-term functional outcome of patients undergoing extraperitoneal LRP. METHODS: Retrospective analysis of a prospectively collected database, comprising a single-surgeon cohort of 155 consecutive LRP cases, 19 of which had previous history of TURP. Demographics, clinical and functional outcomes were evaluated and compared among patients with and without previous TURP. Multivariate analysis was performed to identify potential variables independently associated with continence outcomes. Incontinence was defined as the need of more than 1 pad/day. Potency was defined as the ability for sexual intercourse with or without the use of phosphodiesterase inhibitors. RESULTS: Demographic and clinical variables were comparable among the two study groups. Neurovascular bundle preservation was possible in 26% and 37% of patients with and without previous TURP, respectively. No major complications were recorded and the incidence of minor complications was comparable. Overall continence rate at 3 months was 82,58%, for the entire cohort. Subset analysis demonstrated a 3-month continence rate of 73.7% vs. 83.8% (p>0.05) in patients with and without TURP, respectively. Multivariate analysis demonstrated age, BMI and ASA were variables independently associated with continence outcomes. In the cohort of patients with previous TURP, 2 out of 7 undergoing preservation recovered erections, with a mean follow up of 15.5 months, comparable to the 30% achieved in patients without TURP and nerve sparing procedure. CONCLUSIONS: Laparoscopic Radical Prostatectomy in patients with previous TURP is feasible, with complication rates and short-term functional outcomes comparable to those in patients without previous resection (AU)

Postprostatectomy established stress urinary incontinence treated with duloxetine.

OBJECTIVES: To evaluate the efficacy of duloxetine to treat stress urinary incontinence, 1 of the most frequent complications after radical prostatectomy. Conservative measures and surgery are well-established treatments. However, drug treatment could be an intermediate option. METHODS: All patients had >1 year of follow-up after radical prostatectomy to avoid interfering with the natural recovery period (established stress urinary incontinence). Continence was measured by the average daily use of pads and the International Consultation on Incontinence Questionnaire-short form. In Spain, it is necessary to proceed with off-label use formality, and all patients were informed and agreed. The initial dose of duloxetine was 30 mg once daily and was increased to 60 mg/d. Drug treatment was maintained for 9 months. RESULTS: From June 2006 to July 2007, 68 patients were included. The median age was 68 years (range 52-79). The median duration of duloxetine treatment was 5.56 months (range 1-18). A statistically significant decrease in the International Consultation on Incontinence Questionnaire-Urinary Incontinence-short form (from 13 to 9; P < .001) and the average number of pads/d (from 2 to 1; P < .001) was observed between the initial and 3-month visit. At the end of the follow-up period, 74% and 57% of the patients had a reduced International Consultation on Incontinence Questionnaire-Urinary Incontinence-short form score and a decrease in the number of pads used daily, respectively. Of the 68 patients, 32 (47%) presented with some side effects and 17 patients stopped the treatment because of adverse effects (25%). CONCLUSIONS: Our results suggest that duloxetine is a possible alternative treatment of postprostatectomy established stress urinary incontinence. The continence improvement results were mild and conditioned in part by the frequency of the side effects. Provided that duloxetine does not preclude later continence surgery and the benefits are observed at the first visit, we believe it can be a treatment option for selected patients.

High-intensity focused ultrasound in small renal masses.

High-intensity focused ultrasound (HIFU) competes with radiofrequency and cryotherapy for the treatment of small renal masses as a third option among ablative approaches. As an emerging technique, its possible percutaneous or laparoscopic application, low discomfort to the patient and the absence of complications make this technology attractive for the management of small renal masses. This manuscript will focus on the principles, basic research and clinical applications of HIFU in small renal masses, reviewing the present literature. Therapeutic results are controversial and from an clinical view, HIFU must be considered a technique under investigation at present time. Further research is needed to settle its real indications in the management of small renal masses; maybe technical improvements will certainly facilitate its use in the management of small renal masses in the near future.

Metodología diagnóstica ante la recidiva bioquímica después de prostatectomía radical / Diagnostic methodology for the biochemical recurrence of prostate cancer after radical prostatectomy

El cáncer de próstata es uno de los principalesproblemas de salud de la población masculina. La prostatectomía radical ha demostrado una excelente tasa de curación a largo plazo. No obstante, de forma global, un 25% de los pacientes intervenidos experimentaránuna elevación del PSA durante los 15 años de seguimiento. En general, el valor de PSA asociado con un mayor riesgo de progresión clínica y por lo tanto,merecedor de ser establecido como punto de corte para una recidiva bioquímica es de 0.4 ng/ml. Una vez detectada la recidiva bioquímica, el dato clínico más importante será determinar si la recidiva clínica se va a producir a nivel local o sistémico, ya que ello determinaráel tratamiento a realizar. Los principales parámetrosque ayudan a diferenciar entre una y otra son los siguientes: intervalo de tiempo hasta el incremento del PSA, la velocidad del PSA, el tiempo de doblaje del PSA (PSADT), el estadio patológico y el Gleason de la pieza quirúrgica. Las posibilidades de tratamiento ante el fracaso bioquímico de una PTR están sometidas todavía a debate. No obstante, actualmente se consideraque los pacientes con una recidiva bioquímica sin evidencia radiológica de metástasis a distancia son candidatos ideales para el tratamiento local con radioterapia

Prostate cancer is one of the main health problems of the male population. Radical prostatectomy has demonstrated to have an excellent long-term cure rate. Nevertheless, globally, a 25% of the operated patients will suffer a PSA increase over 15 years offollow-up. Generally, the PSA value associated with a higher risk of clinical progression, that may be established as the cut point for biochemical recurrence is 0.4 ng/ml. Once biochemical recurrence is diagnosed, the most important clinical data is to determine if clinical recurrence is going to be local or systemic, because it will determine treatment. Main parameters helping to differentiate between one and another are: time interval to PSA increase, PSA velocity, PSA doubling time (PSADT),pathologic stage and specimen’s Gleason’s score. The possibilities of treatment of biochemical failure after radical prostatectomy are under debate. Nevertheless, it is currently considered that patients with biochemical recurrence without radiological evidence of distantmetastases are ideal candidates for local treatment with radiotherapy

Tratamiento quirúrgico del tumor germinal de testículo estadio I / Surgical treatment of stage I testicular germ cell tumors

OBJETIVO: En este capítulo se intenta sintetizar y actualizar el papel que la cirugía tiene en la actualidad en el tratamiento de los tumores germinales testiculares estadío I.MÉTODO: Revisión bibliográfica de la literatura publicada del tema. Se analizan la técnica de la orquiectomía, los argumentos a favor de la linfadenectomía retroperitoneal y la evolución de esta técnica, y por último los factores pronósticos que pueden ayudar a determinar qué línea terapéutica adoptar en el estadío I RESULTADOS/CONCLUSIONES: El manejo de los tumores germinales testiculares se debe centralizar en centros especializados que puedan ofertar todas las líneas terapéuticas posibles con las máximas garantías de aplicabilidad para que el paciente escoja ante la exposición objetiva de las ventajas e inconvenientes de cada modalidad terapéutica. La linfadenectomía retroperitoneal con preservación de la inervación simpática preserva la eyaculación y su tasa de curabilidad es similar a la de las otras opciones terapéuticas, tiene una morbilidad mínima y ofrece las ventajas de simplificar el seguimiento, disminuir la ansiedad del paciente y del ahorro económico a largo plazo (AU)

Biología molecular en el cáncer de testículo / Molecular biology in testicular cancer

OBJETIVO: En este capítulo se sintetiza y actualiza desde la investigación básica en Biología Molecular el estado actual del conocimiento de la patogenia de los tumores germinales de testículo y el valor de los distintos marcadores genético-moleculares para el manejo de estos tumores MÉTODOS: Revisión de la bibliografía publicada sobre el tema. Se analizan los conocimientos epidemiológicos relacionados con la patogenia de estos tumores, sus cambios citogenéticos y sus cambios a nivel molecular que pudieran servir como factor pronóstico en el protocolo de actuación frente a los mismos CONCLUSIONES: El efecto estrogénico prenatal complementado con el hipergonadotrofismo puberal pueden ser los responsables de la patogenia de los tumores germinales de testículo. Las alteraciones citogenéticas del cromosoma 12, si bien típicas del fenotipo de estos tumores, no parecen servir como factor pronóstico. En cambio, los factores de proliferación celular, preferentemente el Ki-67 ofrecen resultados prometedores como factor pronóstico, pero aún se han de considerar en investigación (AU)