Reconstruction Techniques After Partial Nephrectomy: Classic vs. Sutureless Approach-A Narrative Review.

PURPOSE OF REVIEW: The purpose of this review is to update the information about the different types of reconstruction after partial nephrectomy, with special emphasis on the new methods of suture-free hemostasis currently available. RECENT FINDINGS: The aim of renal reconstruction is to avoid bleeding and leakage of the collecting system, but now the renorrhaphy technique used is considered one of the modifiable determinants of renal function after surgery. In an attempt to avoid the loss of renal function implicit in classic reconstruction, new techniques have been described to control hemostasis and urinary leakage, which employ fewer suture layers, different suture materials and designs, and a wide range of commercially available hemostatic materials. Multiple suture characteristics have been studied as a potential factor influencing the renal function observed after partial nephrectomy. Single-plane suture techniques, the use of bearded sutures, and running sutures seem to be associated with less deterioration in postoperative renal function, and deep medullary sutures should be avoided to avoid affecting the arcuate arteries. Sutureless hemostasis systems could prevent the deterioration of renal function and complications derived from suturing, also reducing ischemia time and surgical time without increasing the risk of complications.

Development of an immune-nutritional prognostic index in patients with muscle-infiltrating bladder cancer candidates for radical cystectomy.

INTRODUCTION: Muscle-infiltrating bladder tumor (MIBT) has a recurrence-free survival (RFS) of 50% at 5 years. Although neoadjuvant chemotherapy (NCT) has increased it by 8%, which group of patients benefits the most from this treatment remains unclear. OBJECTIVE: Evaluate the prognostic value of immune-nutritional status in patients with MIBT who are candidates for cystectomy, and to develop a score that allows identifying patients with a worse prognosis (pT3-4 and/or pN0-1). MATERIAL AND METHODS: A retrospective analysis was carried out on 284 patients with MIBT treated with radical cystectomy. Preoperative laboratory tests were analyzed and immune-nutritional indices were calculated. The Kaplan-Meier method was used to calculate the PFS. Cox regression was used for multivariate analysis. RESULTS: Univariate analysis showed a statistically significant relationship with leukocyte/lymphocyte index (p = 0.0001), neutrophil/lymphocyte index (p = 0.02), prognostic nutritional index (p = 0.002), and platelet/lymphocyte ratio (p = 0.002). In multivariate analysis, the leukocyte/lymphocyte ratio (p = 0.002) and PNI (p = 0.04) behaved as independent prognostic factors of decreased RFS. Based on these, a prognostic score was developed to classify patients into 3 prognostic groups. Eighty percent of patients with pT3-4 and/or pN0-1 tumors were in the intermediate-poor prognostic groups. CONCLUSION: The implementation of a precystectomy immune-nutritional score in clinical practice would help in the selection of a group of patients with a more unfavorable pathologic stage and worse PFS. We believe that these patients could benefit more from a NACT.

Elaboración de un índice pronóstico inmunonutricional en pacientes con cáncer de vejiga músculo-infiltrante candidatos a cistectomía radical / Development of an immune-nutritional prognostic index in patients with muscle-infiltrating bladder cancer candidates for radical cystectomy

Introducción El tumor vesical músculo-infiltrante (TVMI) tiene una supervivencia libre de recidiva (SLR) del 50% a los cinco años, la quimioterapia neoadyuvante (QTN) ha aumentado la misma un 8%, pero no está claro qué pacientes se pueden beneficiar en mayor grado de la misma. Objetivo Evaluar el valor pronóstico del estado inmunológico-nutricional en los pacientes con TVMI candidatos a cistectomía, y desarrollar un score que permita identificar precistectomía a los pacientes con peor pronóstico (pT3-4 y/o pN0-1). Material y método Se realizó un análisis retrospectivo de 284 pacientes con TVMI tratados con cistectomía radical. Se revisó la analítica preoperatoria y se calcularon índices inmunonutricionales. El método de Kaplan-Meier se utilizó para el cálculo de la SLR. Para el análisis multivariante se utilizó la regresión de Cox. Resultados Mediante análisis univariante se observó una relación estadísticamente significativa con el índice leucocito/linfocito (p = 0,0001), el índice neutrófilo/linfocito (p = 0,02) el índice pronóstico nutricional (p = 0,002), y el ratio plaqueta/linfocito (p = 0,002). En análisis multivariante, el ratio leucocito/linfocito (p = 0,002) y el IPN (p = 0,04) se comportaron como factores pronósticos independientes de disminución de SLR, y se elaboró con ello un score pronóstico que divide a los pacientes en tres grupos pronósticos. El 80% de los pacientes con tumores pT3-4 y/o pN0-1 se encontraban en los grupos de pronóstico medio-malo. Conclusión La incorporación en la práctica clínica de un score inmunonutricional precistectomía ayudaría a seleccionar a un grupo de pacientes con estadio patológico más desfavorable y peor SLR. Creemos que estos pacientes podrían beneficiarse en mayor medida de una QTN (AU)

Introduction Muscle-infiltrating bladder tumor (MIBT) has a recurrence-free survival (RFS) of 50% at 5 years. Although neoadjuvant chemotherapy (NCT) has increased it by 8%, which group of patients benefits the most from this treatment remains unclear. Objective Evaluate the prognostic value of immune-nutritional status in patients with MIBT who are candidates for cystectomy, and to develop a score that allows identifying patients with a worse prognosis (pT3-4 and/or pN0-1). Material and methods A retrospective analysis was carried out on 284 patients with MIBT treated with radical cystectomy. Preoperative laboratory tests were analyzed and immune-nutritional indices were calculated. The Kaplan–Meier method was used to calculate the PFS. Cox regression was used for multivariate analysis. Results Univariate analysis showed a statistically significant relationship with leukocyte/lymphocyte index (p = 0.0001), neutrophil/lymphocyte index (p = 0.02), prognostic nutritional index (p = 0.002), and platelet/lymphocyte ratio (p = 0.002). In multivariate analysis, the leukocyte/lymphocyte ratio (p = 0.002) and PNI (p = 0.04) behaved as independent prognostic factors of decreased RFS. Based on these, a prognostic score was developed to classify patients into 3 prognostic groups. Eighty percent of patients with pT3-4 and/or pN0-1 tumors were in the intermediate–poor prognostic groups. Conclusion The implementation of a precystectomy immune-nutritional score in clinical practice would help in the selection of a group of patients with a more unfavorable pathologic stage and worse PFS. We believe that these patients could benefit more from a NACT (AU)

Deceased donor kidney procurement: Systematic review of the surgical technique.

INTRODUCTION: Kidney procurement procedure must be carried out following a standardized technique in order to optimize kidney grafts for their subsequent implantation. OBJECTIVES: Review of the available literature on kidney procurement procedure. MATERIAL AND METHODS: Narrative review of the available evidence on deceased donor kidney procurement technique after a search of relevant manuscripts indexed in PubMed, EMBASE and Scielo written in English and Spanish. RESULTS: Deceased donor kidney procurement can be divided into two groups, donation after brain death (DBD) and donation after circulatory death (DCD). Kidney procurement in DBD frequently includes other chest and/or abdominal organs, requiring multidisciplinary surgical coordination. During the harvesting procedure, the renal vascular pedicle must remain intact for subsequent implantation and reduced ischemia time. CONCLUSIONS: Adequate execution and perfect knowledge of the technique for surgical removal and anatomy reduces the rate of graft losses associated to inadequate harvesting techniques.

Carcinomatosis peritoneal tras nefrectomía parcial laparoscópica en carcinoma de células renales: nuestra experiencia y revisión de la literatura / Peritoneal carcinomatosis after partial nephrectomy for renal cell carcinoma: Our experience and literature review

Objetivo: La carcinomatosis peritoneal asociada al carcinoma de células renales es una entidad infrecuente, normalmente asociada a grandes masas renales, siendo muy rara su presentación tras la cirugía de tumores renales localizados. Nuestro objetivo es revisar la literatura y analizar los factores implicados en el desarrollo de carcinomatosis peritoneal tras nefrectomía parcial laparoscópica en tumores localizados.Material y métodos: Presentamos nuestra experiencia con 2 casos de carcinomatosis peritoneal tras cirugía parcial laparoscópica. Realizamos revisión de la literatura y analizamos los factores asociados al desarrollo de carcinomatosis peritoneal tras cirugía parcial laparoscópica en carcinoma de células renales.Resultados: Entre 2005-2018 en nuestro servicio fueron sometidos a nefrectomía parcial laparoscópica 225 pacientes por neoplasia renal localizada. Dos pacientes desarrollaron carcinomatosis peritoneal en el seguimiento, uno al año y medio de la cirugía y un segundo caso a los 7 años. Pocos casos de carcinomatosis peritoneal tras cirugías de neoplasia renal han sido descritos en la literatura, estando más frecuentemente asociados a grandes masas renales, con múltiples metástasis al diagnóstico, siendo el pronóstico infausto. Entre los factores implicados en su desarrollo pueden estar la diseminación de células tumorales durante la cirugía, la extensión tumoral directa o la metástasis por vía hematógena.Conclusiones: La carcinomatosis peritoneal tras nefrectomía parcial laparoscópica constituye un evento muy raro, pero que debe ser tenido en cuenta y, dado que es el único factor en el que podemos influir, extremar al máximo las precauciones durante el acto quirúrgico, siguiendo los principios oncológicos. (AU)

Objective: Peritoneal carcinomatosis associated with renal cell carcinoma is an infrequent entity, usually associated with large renal masses, and with a very rare presentation after surgery of localized renal tumors. Our objective is to review the literature and analyze the factors involved in the development of peritoneal carcinomatosis after laparoscopic partial nephrectomy in localized tumors.Material and methods: We present our experience with two cases of peritoneal carcinomatosis after laparoscopic partial nephrectomy. We reviewed the literature and analyzed the factors associated with the development of peritoneal carcinomatosis after laparoscopic partial surgery in renal cell carcinoma.Results: Between 2005-2018, 225 patients underwent laparoscopic partial nephrectomy for localized renal neoplasia in our service. Two patients developed peritoneal carcinomatosis during follow-up, at 1.5 and 7 years after surgery. Few cases of postoperative peritoneal carcinomatosis for renal neoplasia have been described in the literature, being more frequently associated with large renal masses, with multiple metastases at diagnosis, with a poor prognosis. The dissemination of tumor cells during surgery, direct tumor extension or metastasis by hematogenous route, are among the factors involved in the development of this condition.Conclusions: Peritoneal carcinomatosis after laparoscopic partial nephrectomy constitutes a very rare event. However, it should be taken into consideration, and, since it is the only factor we can influence, we must maximize precautions during the surgical act, following oncological principles. (AU)

Peritoneal carcinomatosis after partial nephrectomy for renal cell carcinoma: Our experience and literature review.

OBJECTIVE: Peritoneal carcinomatosis associated with renal cell carcinoma is an infrequent entity, usually associated with large renal masses, and with a very rare presentation after surgery of localized renal tumors. Our objective is to review the literature and analyze the factors involved in the development of peritoneal carcinomatosis after laparoscopic partial nephrectomy in localized tumors. MATERIAL AND METHODS: We present our experience with two cases of peritoneal carcinomatosis after laparoscopic partial nephrectomy. We reviewed the literature and analyzed the factors associated with the development of peritoneal carcinomatosis after laparoscopic partial surgery in renal cell carcinoma. RESULTS: Between 2005-2018, 225 patients underwent laparoscopic partial nephrectomy for localized renal neoplasia in our service. Two patients developed peritoneal carcinomatosis during follow-up, at 1.5 and 7 years after surgery. Few cases of postoperative peritoneal carcinomatosis for renal neoplasia have been described in the literature, being more frequently associated with large renal masses, with multiple metastases at diagnosis, with a poor prognosis. The dissemination of tumor cells during surgery, direct tumor extension or metastasis by hematogenous route, are among the factors involved in the development of this condition. CONCLUSIONS: Peritoneal carcinomatosis after laparoscopic partial nephrectomy constitutes a very rare event. However, it should be taken into consideration, and, since it is the only factor we can influence, we must maximize precautions during the surgical act, following oncological principles.

Influence of double J stent in the complications of ureterovesical anastomosis during kidney transplantation.

INTRODUCTION: Complications arising from ureterovesical anastomosis in kidney transplantation have an important influence on the success of the procedure. The most serious and frequent complications are fistula and stenosis of the ureterovesical junction. The placement of double J stents in anastomosis is currently recommended to reduce these complications. OBJECTIVE: The aim of the study is to evaluate whether the placement of a DJ stent affects complications of anastomosis. MATERIAL AND METHODS: Retrospective analysis of 697 patients treated with cadaveric donor renal transplant in our center from 1999 to 2018 was performed. Results were compared according to double J stent placement and the surgical technique employed for anastomosis. RESULTS: Transplantation was performed without DJ placement in 51.7% of the patients, compared to 48.3% who were treated with DJ stent placement. The most commonly used technique was Lich-Gregoir. Ureterovesical fistula occurred in 5% of cases, and ureterovesical stenosis in 4.2%. DJ stent behaved as a protective factor for ureterovesical fistula but did not significantly influence the development of stenosis. The Taguchi technique greatly increased the risk of developing both ureterovesical fistula and stenosis. The incidence of stenosis and fistula was significantly higher when the Taguchi technique was combined with no DJ stent placement. CONCLUSION: DJ stent placement acts as a protective factor for ureterovesical stenosis complications. The results of our study seem to agree with current literature.

Influencia del catéter doble J en las complicaciones de la anastomosis vesicoureteral realizada durante el trasplante renal / Influence of double J stent in the complications of ureterovesical anastomosis during kidney transplantation

Introducción: Las complicaciones surgidas de la anastomosis vesicoureteral en el trasplante renal influyen de forma importante en el éxito del trasplante; siendo las más graves y frecuentes la fístula y la estenosis de la unión ureterovesical. Actualmente se recomienda la colocación de catéteres doble J en esta anastomosis para reducir estas complicaciones.Objetivo: El objetivo del estudio es evaluar si la colocación de un CDJ influye en las complicaciones de esta anastomosis.Material y métodosSe ha realizado un análisis retrospectivo de 697 pacientes tratados con trasplante renal de donante cadáver en nuestro centro desde 1999 hasta 2018; y se ha comparado los resultados en función del uso o no de catéter doble J y la técnica quirúrgica realizada en la anastomosis.Resultados: En el 51,7% de los pacientes no se colocó CDJ; frente a un 48,3% en los que sí se colocó. La técnica más utilizada fue Lich-Gregoir. Se produjo fístula ureterovesical en un 5% de casos, y estenosis ureterovesical en un 4,2%. El CDJ se comportó como factor protector de fístula ureterovesical, pero no influyó significativamente en el desarrollo de estenosis. La técnica de Taguchi multiplicó el riesgo de desarrollar tanto fístula como estenosis ureterovesical. La incidencia de estenosis y de fístula fue significativamente mayor al combinar la técnica de Taguchi con la ausencia de catéter.Conclusión: El CDJ actúa como factor protector para las complicaciones de la estenosis ureterovesical. Los resultados de nuestro estudio parecen ir en concordancia con la literatura actual. (AU)

Introduction: Complications arising from ureterovesical anastomosis in kidney transplantation have an important influence on the success of the procedure. The most serious and frequent complications are fistula and stenosis of the ureterovesical junction. The placement of double J stents in anastomosis is currently recommended to reduce these complications.Objective: The aim of the study is to evaluate whether the placement of a DJ stent affects complications of anastomosis.Material and methodsRetrospective analysis of 697 patients treated with cadaveric donor renal transplant in our center from 1999 to 2018 was performed. Results were compared according to double J stent placement and the surgical technique employed for anastomosis.Results: Transplantation was performed without DJ placement in 51.7% of the patients, compared to 48.3% who were treated with DJ stent placement. The most commonly used technique was Lich-Gregoir. Ureterovesical fistula occurred in 5% of cases, and ureterovesical stenosis in 4.2%. DJ stent behaved as a protective factor for ureterovesical fistula but did not significantly influence the development of stenosis. The Taguchi technique greatly increased the risk of developing both ureterovesical fistula and stenosis. The incidence of stenosis and fistula was significantly higher when the Taguchi technique was combined with no DJ stent placement.Conclusion: DJ stent placement acts as a protective factor for ureterovesical stenosis complications. The results of our study seem to agree with current literature. (AU)

Técnica PISA: nueva técnica mínimamente invasiva de acceso único para la linfadenectomía pélvica e inguinal en el cáncer de pene / Pelvic and inguinal single-site approach: PISA technique. New minimally invasive technique for lymph node dissection in penile cancer

Objetivos Describir nuestra experiencia inicial con un novedoso abordaje laparoscópico inguinal y pélvico de acceso único mínimamente invasivo para realizar la disección de los ganglios linfáticos (DGL) en el cáncer de pene: la técnica de acceso único pélvico e inguinal (PISA, por las siglas en inglés de Pelvic and Inguinal Single Access).Material y métodos 10 pacientes en diversos estadios de carcinoma de células escamosas de pene (cN0 y ≥ pT1G3 o cN1/cN2) fueron operados mediante la técnica PISA entre 2015-2018. Se realizaron secciones congeladas intraoperatorias de forma rutinaria y se llevó a cabo secuencialmente la DGL pélvica ipsilateral como procedimiento en un solo acto y utilizando las mismas incisiones quirúrgicas ante la detección de ≥ 2 ganglios inguinales(pN2) o extensión ganglionar extracapsular (pN3). Variables: complicaciones posquirúrgicas a 30 días, pérdida de sangre estimada (PSE), tasa de transfusión, tiempo quirúrgico, tiempo hasta la retirada del drenaje y duración de la estancia hospitalaria (DEH). Las medianas y los rangos de los valores de las variables seleccionadas se presentaron como estadísticas descriptivas.Resultados La DGL inguinal fue bilateral en todos los casos y la DGL pélvica fue necesaria en el 40%. El tiempo quirúrgico total fue de 120-170 minutos y la mediana de PSE fue de 66 (30-100) cc. En ningún caso se requirió transfusión sanguínea. No se observaron complicaciones intraoperatorias y la tasa de complicaciones postoperatorias fue del 40% (10% de complicaciones mayores: linfocele inguinal sintomático). La mediana de la estancia hospitalaria fue de 5,8 (3-10) días. La mediana de tiempo hasta la retirada del drenaje inguinal fue de 4,7 días. Número medio de ganglios linfáticos extirpados mediante DGL inguinal: 10,25(8-14). Experiencia retrospectiva de volumen limitado de un centro de referencia con un seguimiento corto.

Objectives To describe our initial experience with a new minimally invasive inguinal and pelvic single-access laparoscopic approach, for performing lymph node dissection (LND) in penile cancer: the Pelvic and Inguinal Single Access (PISA) technique.Material and Methods 10 patients with different penile squamous cell carcinoma stages (cN0 and ≥pT1G3 or cN1/cN2) were operated by means of the PISA technique, between 2015-2018. Intraoperative frozen section analysis was carried out routinely and if ≥2 inguinal nodes (pN2) or extracapsular nodal extension (pN3) are detected, ipsilateral pelvic LND was performed sequentially as a single-stage procedure and using the same surgical incisions. Variables: 30-day postoperative complicactions, estimated blood loss (EBL), transfusion rate, operative time, time to drainage removal, and length of hospital stay (LOS). Medians and ranges of values for selected variables were reported as descriptive statistics.ResultsInguinal LND was bilateral in all cases, and pelvic LND was required in 40%. Total operative time was 120-170minutes and median EBL was 66 (30-100) cc. No blood transfusion was required. No intraoperative complications were noted, and postoperative complications rate was 40% (10% major complications- symptomatic inguinal lymphocele). Median LOS was 5.8 (3-10) days. Median time to inguinal drain removal was 4.7 days. Mean number of lymph nodes removed by inguinal LND: 10.25(8-14). Limited volume retrospective experience from a referral center with short follow-up. Outcomes reported may not be reproducible by surgeons with less experience and skills.Conclusions PISA is a novel, minimally invasive single-site surgical approach to one stage bilateral inguinal/pelvic LNDs for penile cancer showing a low rate of major complications

Pelvic and inguinal single-site approach: PISA technique. New minimally invasive technique for lymph node dissection in penile cancer.

OBJECTIVES: To describe our initial experience with a new minimally invasive inguinal and pelvic single-access laparoscopic approach, for performing lymph node dissection (LND) in penile cancer: the Pelvic and Inguinal Single Access (PISA) technique. MATERIAL AND METHODS: 10 patients with different penile squamous cell carcinoma stages (cN0 and ≥pT1G3 or cN1/cN2) were operated by means of the PISA technique, between 2015-2018. Intraoperative frozen section analysis was carried out routinely and if ≥2 inguinal nodes (pN2) or extracapsular nodal extension (pN3) are detected, ipsilateral pelvic LND was performed sequentially as a single-stage procedure and using the same surgical incisions. VARIABLES: 30-day PCs, estimated blood loss (EBL), transfusion rate, operative time, time to drainage removal, and length of hospital stay (LOS). Medians and ranges of values for selected variables were reported as descriptive statistics. RESULTS: Inguinal LND was bilateral in all cases, and pelvic LND was required in 40%. Total operative time was 120-170 min and median EBL was 66 (30-100) cc. No blood transfusion was required. No intraoperative complications were noted, and postoperative complications rate was 40% (10% major complications-symptomatic inguinal lymphocele). Median LOS was 5.8 (3-10) days. Median time to inguinal drain removal was 4.7 days. Mean number of lymph nodes removed by inguinal LND: 10.25 (8-14). Limited volume retrospective experience from a referral center with short follow-up. Outcomes reported may not be reproducible by surgeons with less experience and skills. CONCLUSIONS: PISA is a novel, minimally invasive single-site surgical approach to one stage bilateral inguinal/pelvic LNDs for penile cancer showing a low rate of major complications.

Evolución de la función renal en pacientes con cáncer renal cT1 después de nefrectomía parcial y radical laparoscópica. Factores predictores de deterioro de función renal / Evolution of renal function in patients with cT1 renal tumors after laparoscopic partial and radical nephrectomy. Predictive factors for renal function impairment

Introducción y objetivos Analizar la evolución de la función renal tras nefrectomía parcial (NP) y radical (NR) laparoscópica e identificar factores predictores de deterioro de función renal.Material y método Estudio retrospectivo de pacientes birrenos con filtrado glomerular (FG) > 60 mL/min/1,73 m2 y tumor renal único cT1 tratados en nuestro centro entre los años 2005 y 2018.Resultados 372 pacientes cumplieron los criterios de inclusión para el estudio. 156 (41,9%) fueron tratados mediante NR y 216 (58,1%) mediante NP. Al alta hubo una diferencia de 26,75 mL/min/1,73 m2 de FG entre NR y NP. La edad > 60 años, las complicaciones postoperatorias (OR 2,97, p = 0,005) y NR (OR 10,03, p = 0,0001) fueron factores predictores de FG<60 mL/min/1,73 m2 al alta. Únicamente la NR (OR 7,69, p = 0,0001) se comportó como factor pronóstico independiente de FG<45 mL/min/1,73 m2 al alta. La mediana de seguimiento de la serie fue de 57 (IQR 28 - 100) meses. Al final del seguimiento, nueve (6%) pacientes tratados con NR desarrollaron enfermedad renal crónica (ERC) grave y tres (2%) insuficiencia renal terminal (IRT). Edad > 70 años, diabetes mellitus (DM) (HR 2,12, p = 0,001), hipertensión arterial (HTA) (HR 1,73, p = 0,01) y NR (HR 2,88, p = 0,0001) se comportaron como factores predictores independientes de FG<60 mL/min/1,73 m2. Para un FG<45 mL/min/1,73 m2 fueron edad > 70 años, DM (HR 1,99 IC 95% 1,04 a 3,83, p = 0,04) y NR (HR 5,88 IC 95% 2,57 a 13,45, p = 0,0001).Conclusiones La NR es un factor de riesgo a corto y largo plazo de ERC, aunque con baja probabilidad de ERC grave o IRT en pacientes con FG > 60 mL/min/1,73 m2 preoperatoria. La edad, DM e HTA contribuyen al empeoramiento de la función renal durante el seguimiento (AU)

Introduction and objectives To analyze the evolution of kidney function after laparoscopic partial nephrectomy (PN) and radical nephrectomy (RN) and to identify predictive factors for deterioration in kidney function.Material and method Retrospective study of patients with two kidneys, glomerular filtration rate (GFR) > 60 mL/min/1.73 m2, and single renal tumor cT1, treated in our center between 2005 and 2018.Results A total of 372 patients met the inclusion criteria for the study; 156 (41.9%) were treated by RN and 216 (58.1%) by PN. There was a difference of 26.75 mL/min/1.73 m2 in GFR between RN and PN at discharge. Age > 60 years, postoperative complications (OR 2.97, p = 0.005) and RN (OR 10.03, p = 0.0001) were predictors of GFR<60 mL/min/1.73 m2 at discharge. Only RN (OR 7.69, p = 0.0001) behaved as an independent prognostic factor for GFR<45 mL/min/1.73m2 at discharge. The median follow-up of the series was 57 (IQR 28-100) months. At the end of the follow-up period, nine (6%) patients treated with RN developed severe chronic kidney disease (CKD) and three (2%) developed end stage renal disease (ESRD). Age > 70 years, diabetes mellitus (DM) (HR 2.12, p = 0.001), arterial hypertension (AHT) (HR 1.73, p = 0.01) and RN (HR 2.88, p = 0.0001) behaved as independent predictors of GFR<60 mL/min/1.73 m2. The independent predictors for GFR< 45 mL/min/1.73m2 were age >70 years, DM (HR 1.99 CI 95% 1.04-3.83, p = 0.04) and RN (HR 5.88 CI 95% 2.57-13.45, p = 0.0001).Conclusions RN is a short- and long-term risk factor for CKD, although with a low probability of severe CKD or ESRD in patients with preoperative GFR > 60 mL/min/1.73 m2. Age, DM and AHT contribute to worsening renal function during follow-up (AU)

Evolution of renal function in patients with cT1 renal tumors after laparoscopic partial and radical nephrectomy. Predictive factors for renal function impairment.

INTRODUCTION AND OBJECTIVES: To analyze the evolution of kidney function after laparoscopic partial nephrectomy (PN) and radical nephrectomy (RN) and to identify predictive factors for renal function impairment. MATERIALS AND METHOD: Retrospective study of patients with two kidneys, glomerular filtration rate (GFR) > 60 mL/min/1.73 m2 and single renal tumor cT1, treated in our center between 2005 and 2018. RESULTS: A total of 372 patients met the inclusion criteria for the study; 156 (41.9%) were treated with RN and 216 (58.1%) with PN. There was a difference of 26.75 mL/min/1.73 m2 in GFR between RN and PN at discharge. Age >60 years, postoperative complications (OR 2.97, p = 0.005) and RN (OR 10.03, p = 0.0001) were predictors of GFR <60 mL/min/1.73 m2 at discharge. Only RN (OR 7.69, p = 0.0001) behaved as an independent prognostic factor for GFR <45 mL/min/1.73 m2 at discharge. The median follow-up of the series was 57 (IQR 28-100) months. At the end of the follow-up period, nine (6%) patients treated with RN developed severe chronic kidney disease (CKD) and three (2%) developed end stage renal disease (ESRD). Age >70 years, diabetes mellitus (DM) (HR 2.12, p = 0.001), arterial hypertension (AHT) (HR 1.73, p = 0.01) and RN (HR 2.88, p = 0.0001) behaved as independent predictors of GFR <60 mL/min/1.73 m2. The independent predictors for GFR <45 mL/min/1.73 m2 were age >70 years, DM (HR 1.99 CI 95% 1.04-3.83, p = 0.04) and RN (HR 5.88 CI 95% 2.57-13.45, p = 0.0001). CONCLUSIONS: RN is a short- and long-term risk factor for CKD although with a low probability of severe CKD or ESRD in patients with preoperative GFR >60 mL/min/1.73 m2. Age, DM and AHT contribute to worsening renal function during follow-up.

Manejo quirúrgico de tumores en riñón en herradura. Revisión de la literatura y análisis de 2 casos / Surgical management of horseshoe kidney tumors. Literature review and analysis of two cases

Introducción: El riñón en herradura es una anomalía congénita poco frecuente en la población general que combina ectopia renal, malrotación y alteraciones en la vascularización. El tumor que más frecuentemente se desarrolla en estos casos es el carcinoma de células renales (50%).Una de sus características a destacar es la gran variabilidad en su anatomía, sobre todo a nivel vascular.Material y métodosPresentamos 2 casos de pacientes con diagnóstico de tumor renal en riñones en herradura, ambos tratados con nefrectomía parcial laparoscópica, llevados a cabo en nuestro servicio; y realizamos una revisión de la literatura actual.DiscusiónLas indicaciones de tratamiento quirúrgico en tumores en esta enfermedad son las mismas que en los riñones anatómicamente normales. Tradicionalmente, el tratamiento ha sido la cirugía abierta, siendo la heminefrectomía la cirugía de elección. En la actualidad se tiende a defender la cirugía conservadora de nefronas, y el abordaje laparoscópico ha adquirido más importancia progresivamente.ConclusiónEs fundamental realizar un estudio de imagen minucioso para una correcta planificación quirúrgica. (AU)

Introduction: The horseshoe kidney is a rare congenital anomaly in the general population that combines renal ectopia, malrotation and abnormal vascular supply. The most frequently developed tumor in this case is renal cell carcinoma (50%).One of its main characteristics is great anatomical variation, especially in terms of vascular structures.Material and methodsWe present two cases of patients with diagnosis of renal tumor in horseshoe kidneys, both treated with laparoscopic partial nephrectomy in our department. Additionally, we have carried a review of the current literature.DiscussionIndications for surgical treatment in this pathology are the same as in kidneys with normal anatomy. Traditionally, treatment has been open surgery, with heminephrectomy as surgery of choice. The current trend is to advocate nephron-sparing surgery, and the laparoscopic approach has been progressively gaining importance.ConclusionA thorough imaging study is essential for proper surgical planning. (AU)

Evolution of renal function in patients with CT1 renal tumors after laparoscopic partial and radical nephrectomy. Predictive factors for renal function impairment. / Evolución de la función renal en pacientes con cáncer renal cT1 después de nefrectomía parcial y radical laparoscópica. Factores predictores de deterioro de función renal.

INTRODUCTION AND OBJECTIVES: To analyze the evolution of kidney function after laparoscopic partial nephrectomy (PN) and radical nephrectomy (RN) and to identify predictive factors for deterioration in kidney function. MATERIALS AND METHOD: Retrospective study of patients with two kidneys, glomerular filtration rate (GFR) > 60 mL/min/1.73 m2, and single renal tumor cT1, treated in our center between 2005 and 2018. RESULTS: A total of 372 patients met the inclusion criteria for the study; 156 (41.9%) were treated by RN and 216 (58.1%) by PN. There was a difference of 26.75 mL/min/1.73 m2 in GFR between RN and PN at discharge. Age > 60 years, postoperative complications (OR 2.97, p = 0.005) and RN (OR 10.03, p = 0.0001) were predictors of GFR < 60 mL/min/1.73 m2 at discharge. Only RN (OR 7.69, p = 0.0001) behaved as an independent prognostic factor for GFR < 45 mL/min/1.73m2 at discharge. The median follow-up of the series was 57 (IQR 28-100) months. At the end of the follow-up period, nine (6%) patients treated with RN developed severe chronic kidney disease (CKD) and three (2%) developed end stage renal disease (ESRD). Age > 70 years, diabetes mellitus (DM) (HR 2.12, p = 0.001), arterial hypertension (AHT) (HR 1.73, p = 0.01) and RN (HR 2.88, p = 0.0001) behaved as independent predictors of GFR < 60 mL/min/1.73 m2. The independent predictors for GFR< 45 mL/min/1.73m2 were age >70 years, DM (HR 1.99 CI 95% 1.04-3.83, p = 0.04) and RN (HR 5.88 CI 95% 2.57-13.45, p = 0.0001). CONCLUSIONS: RN is a short- and long-term risk factor for CKD, although with a low probability of severe CKD or ESRD in patients with preoperative GFR > 60 mL/min/1.73 m2. Age, DM and AHT contribute to worsening renal function during follow-up.

Surgical management of horseshoe kidney tumors. Literature review and analysis of two cases.

INTRODUCTION: The horseshoe kidney is a rare congenital anomaly in the general population that combines renal ectopia, malrotation and abnormal vascular supply. The most frequently developed tumor in this case is renal cell carcinoma (50%). One of its main characteristics is great anatomical variation, especially in terms of vascular structures. MATERIAL AND METHODS: We present two cases of patients with diagnosis of renal tumor in horseshoe kidneys, both treated with laparoscopic partial nephrectomy in our department. Additionally, we have carried a review of the current literature. DISCUSSION: Indications for surgical treatment in this pathology are the same as in kidneys with normal anatomy. Traditionally, treatment has been open surgery, with heminephrectomy as surgery of choice. The current trend is to advocate nephron-sparing surgery, and the laparoscopic approach has been progressively gaining importance. CONCLUSION: A thorough imaging study is essential for proper surgical planning.

Comparación entre prostatectomía laparoscópica y abierta: análisis de la evolución oncológica / Comparison between laparoscopic and open prostatectomy: Oncological progression analysis

INTRODUCCIÓN: Existe muy poca literatura española que compare resultados oncológicos tras prostatectomía radical (PR) según la vía de abordaje y la metodología es inadecuada. OBJETIVO: Comparar los resultados oncológicos en cuanto a márgenes quirúrgicos (MQ) y recidiva bioquímica (RB) entre PR abierta (PRA) y laparoscópica (PRL). MATERIAL Y MÉTODOS: Comparación de 2 cohortes (307 con PRA y 194 con PRL) entre 2007 y 2015. El estado de los MQ se clasificaron como positivos o negativos y la RB como la elevación del PSA después de la PR > 0,4 ng/ml. Para el contraste de variables cualitativas se utilizó el test Chi-cuadrado y ANOVA para las cuantitativas. Para evaluar los factores predictores de los MQ se ha realizado un análisis multivariante mediante regresión logística. Para evaluar los factores predictores de RB se ha realizado un análisis multivariable mediante regresión de Cox. RESULTADOS: El 43,5% de pacientes tuvieron un Gleason 7 (3 + 4) en la pieza quirúrgica y un 31,7% MQ positivos siendo el estadio patológico más frecuente pT2c en el 61,9%. No existieron diferencias significativas entre ambos grupos, excepto la afectación extracapsular (p = 0,001), más frecuente en la PRL. La mediana de seguimiento fue de 49 meses, evidenciando RB en el 23% de pacientes, sin diferencias significativas entre cohortes. En el análisis multivariable solo el grupo de riesgo D'Amico se comportó como factor predictor independiente de MQ positivos y el score de Gleason y los MQ positivos como factores predictores independientes de RB. CONCLUSIÓN: La vía de abordaje no influyó en el estado de MQ ni en la RB

INTRODUCTION: There are very few Spanish studies that compare oncological outcomes following radical prostatectomy (RP) based on surgical approach, and their methodology is not appropriate. OBJECTIVE: To compare oncological outcomes in terms of surgical margins (SM) and biochemical recurrence (BR) between open radical prostatectomy (ORP) and laparoscopic radical prostatectomy (LRP). MATERIAL AND METHODS: Comparison of two cohorts (307 with ORP and 194 with LRP) between 2007-2015. Surgical margin status was defined as positive or negative, and BR as a PSA rise of > 0.4 ng/ml after surgery. To compare the qualitative variables, we employed the Chi-squared test, and ANOVA was used for quantitative variables. We performed a multivariate analysis using logistic regression to evaluate the predictive factors of SM, and a multivariate analysis using Cox regression to evaluate the predictive factors of BR. RESULTS: Gleason 7 (3 + 4) was determined in the surgical specimens of 43.5% of patients, and 31.7% had positive SM. The most frequent pathological stage was pT2c, on the 61.9% of the cases. No significant differences were found between both groups, except for extracapsular extension (p = 0.001), more frequent in LRP. The median follow-up was 49 months. BR was seen in the 23% of patients, without significant differences between groups. In the multivariable analysis, only the D'Amico risk group behaved as an independent predictive factor of positive SM, and Gleason score and positive SM acted as independent predictive factors of BR. CONCLUSION: The surgical approach did not influence SM status or BR

Comparison between laparoscopic and open prostatectomy: Oncological progression analysis. / Comparación entre prostatectomía laparoscópica y abierta: análisis de la evolución oncológica.

INTRODUCTION: There are very few Spanish studies that compare oncological outcomes following radical prostatectomy (RP) based on surgical approach, and their methodology is not appropriate. OBJECTIVE: To compare oncological outcomes in terms of surgical margins (SM) and biochemical recurrence (BR) between open radical prostatectomy (ORP) and laparoscopic radical prostatectomy (LRP). MATERIAL AND METHODS: Comparison of two cohorts (307 with ORP and 194 with LRP) between 2007-2015. Surgical margin status was defined as positive or negative, and BR as a PSA rise of >0.4 ng/ml after surgery. To compare the qualitative variables, we employed the Chi-squared test, and ANOVA was used for quantitative variables. We performed a multivariate analysis using logistic regression to evaluate the predictive factors of SM, and a multivariate analysis using Cox regression to evaluate the predictive factors of BR. RESULTS: Gleason 7 (3+4) was determined in the surgical specimens of 43.5% of patients, and 31.7% had positive SM. The most frequent pathological stage was pT2c, on the 61.9% of the cases. No significant differences were found between both groups, except for extracapsular extension (p=0.001), more frequent in LRP. The median follow-up was 49 months. BR was seen in the 23% of patients, without significant differences between groups. In the multivariable analysis, only the D'Amico risk group behaved as an independent predictive factor of positive SM, and Gleason score and positive SM acted as independent predictive factors of BR. CONCLUSION: The surgical approach did not influence SM status or BR.

Análisis de supervivencia de los pacientes con cáncer de próstata con factores patológicos desfavorables tratados con prostatectomía radical y radioterapia de rescate tras la recidiva y persistencia bioquímica / Survival analysis of patients with prostate cancer and unfavorable risk factors treated with radical prostatectomy and salvage radiotherapy after biochemical recurrence and persistence

OBJETIVO: Analizar la supervivencia de los pacientes con cáncer de próstata (CP) con factores pronósticos desfavorables (FPD) tratados con PR y radioterapia de rescate (RTR) tras recidiva bioquímica (RB) y persistencia bioquímica (PB). MATERIAL Y MÉTODO: Análisis retrospectivo de 446 pacientes con al menos uno de los siguientes FPD: score de Gleason ≥ 8, estadio patológico ≥ pT3 y/o márgenes quirúrgicos positivos (MQ+). El criterio de RB fue la elevación del PSA por encima de 0,4 ng/ml. Evaluación de supervivencia mediante Kaplan-Meier y log-rank. Para identificar factores de riesgo con posible influencia en la respuesta a RTR y la supervivencia causa-específica (SCE) se usó análisis uni y multivariable (regresión de Cox). RESULTADOS: Mediana de seguimiento: 72 (rango 37-122) meses, mediana de tiempo hasta RB: 42 (rango 20-112) meses. El 36,3% presentaron RB. Presentaron respuesta bioquímica a la RTR 121 (74,7%) pacientes. La supervivencia libre de recaída (SLR) después de la RTR a los 3, 5, 8 y 10 años fue del 95,7, del 92,3, del 87,9 y del 85%, la SG a los 5, 10 y 15 años fue del 95,6, del 86,5 y del 73,5%. La SCE a los 5, 10 y 15 años fue del 99,1, del 98,1 y del 96,6%, respectivamente. Solo el tiempo hasta la RB < 24 meses (HR = 2,55, p = 0,01) se comportó como un factor predictor independiente de SLR después de RTR. CONCLUSIONES: La PR solo consigue control de la enfermedad a los 10años en aproximadamente la mitad de los casos. El tratamiento multimodal secuencial (PR + RTR cuando precise) aumenta este control bioquímico hasta > 87%, lográndose una larga SCE. Los pacientes con un tiempo hasta recidiva > 24 meses respondieron mejor al tratamiento de rescate

OBJECTIVE: Survival analysis of patients with prostate cancer (PCa) with adverse prognostic factors (APF) treated with radical prostatectomy (RP) and salvage radiotherapy (SRT) after biochemical recurrence (BR) or biochemical persistence (BP). MATERIALS AND METHODS: Retrospective analysis of 446 patients with at least one of the following APF: Gleason score ≥ 8, pathologic stage ≥ pT3 and/or positive surgical margins. BR criteria used was PSA level over 0.4 ng/ml. A survival analysis using Kaplan-Meier was performed to compare the different variable categories with log-rank test. In order to identify risk factors for SRT response and cancer specific survival (CSS) we performed univariate and multivariate analyses using Cox regression. RESULTS: Mean follow up: 72 (IQR 27-122) months, mean time to BR: 42 (IQR 20-112) months, mean PSA level at BR: 0.56 (IQR 0.42-0.96). BR was present in 36.3% of the patients. Biochemical response to SRT was observed in 121 (75.7%) patients. Recurrence-free survival (RFS) rates after SRT at 3, 5, 8 and 10 years were 95.7%, 92.3%, 87.9%, and 85%; overall survival (OS) rates after 5, 10 and 15 years was 95.6%, 86.5% and 73.5%, respectively. CSS rates at 5, 10 and 15 years were 99.1%, 98.1% and 96.6%. Only time to BR < 24 months (HR = 2.55, P = .01) was identified as an independent risk factor for RFS after SRT. CONCLUSIONS: In these patients, RP only controls the disease in approximately half of the cases. Multimodal sequential treatment (RP+SRT when needed) increases this control, achieving high CSS rates and biochemical control in over 87% of the patients. Patients with time to recurrence > 24 months responded better to rescue treatment

Comparación entre prostatectomía laparoscópica y abierta: análisis de la continencia urinaria poscirugía / Comparison between laparoscopic and open prostatectomy: Postoperative urinary continence analysis

INTRODUCCIÓN: Pocos son los estudios que comparan la prostatectomía radical abierta (PRA) con la prostatectomía radical laparoscópica (PRL) y sus resultados funcionales, como la continencia urinaria (CU), que es uno de los objetivos prioritarios tras el control oncológico. OBJETIVOS: Comparar la CU postoperatoria en los pacientes con adenocarcinoma de próstata localizado intervenidos mediante PRA frente a PRL. MATERIAL Y MÉTODOS: Comparación de dos cohortes (312 con PRA y 206 con PRL) entre los años 2007 y 2015. El estado de CU se recogió a los 3, 6, 12, 18 y 24meses. Para el manejo estadístico hemos agrupado la continencia en: a)CU, pacientes que no precisaron absorbentes, y b)incontinencia urinaria (IU), pacientes que precisaron absorbentes. Para el contraste de variables cualitativas se ha utilizado el test de la chi cuadrado para las variables cualitativas y ANOVA para las cuantitativas. Análisis multivariable mediante regresión logística para la variable dependiente IU. La significación estadística se consideró cuando existió una p < 0,05. RESULTADOS: En el 51,7% se realizó conservación neurovascular. A los 24meses de la cirugía, el 72,4% presentaban CU, de los cuales el 87,8% con PRA frente al 78,1% con PRL (p = 0,004). El 22,7% presentaron recidiva bioquímica (RB), siendo el 83% tratados con radioterapia de rescate (RTR). Los pacientes con RTR presentaron mayor porcentaje de IU frente a los que no la recibieron (p = 0,036). Se objetivó mayor porcentaje de estenosis de la anastomosis en PRA (p = 0,03). CONCLUSIONES: La PRL, la no preservación de los fascículos neurovasculares y la RTR se relacionaron directamente con la CU postoperatoria

INTRODUCTION: There are very few articles comparing open radical prostatectomy (ORP) vs. laparoscopic radical prostatectomy (LRP) and their functional results or urinary continence (UC), which is one of the most important objectives to pursue after oncological results. OBJECTIVES: To compare postoperative UC in patients with localized prostatic adenocarcinoma treated with OPR or LRP. MATERIAL AND METHODS: Comparison between two patient cohorts (312 for ORP and 206 for LRP) between 2007-2015. The UC was evaluated at 3, 6, 12, 18 and 24months. Continence was defined and classified as follows: a)UC, no need of pads, and b)urinary incontinence (UI), use of pads. To compare the qualitative variables, we employed the chi-squared test and ANOVA for quantitative variables. We performed a multivariate analysis using logistic regression with dependent qualitative variable UI. Statistical significance when P<.05. RESULTS: Nerve-sparing was performed in 51.7% cases. At 24months after surgery, 72.4% patients had UC, of which 87.7% were from the ORP group and 78.1% in the LRP group (P=.004). 22,7% of patients experienced biochemical recurrence (BR), with 83% treated with salvage radiotherapy (SRT), presenting greater UI percentage (P=.036). ORP patients showed a higher percentage of anastomosis stricture (P=.03). CONCLUSIONS: LRP, non-nerve sparing, and SRT were directly related to postoperative UI

Evaluación de los patrones de recurrencia por grupos de riesgo tras nefrectomía por cáncer renal / Analysis of recurrence trends according to risk groups after renal cancer nephrectomy

INTRODUCCIÓN: No están claramente definidos los patrones de recurrencia tras nefrectomía por cáncer renal. OBJETIVO: Evaluar patrones de recidiva en función del grupo de riesgo de recurrencia (GRR). MATERIAL Y MÉTODO: Análisis retrospectivo de 696 pacientes con carcinoma de células renales tratados con nefrectomía entre 1990-2010. Se definieron tres GRR según la presencia de variables anatomopatológicas (estadio pTpN, grado nuclear, necrosis tumoral [NT], diferenciación sarcomatoide [DS], margen de resección positivo [MR]): -GR bajo (GRB): pT1pNx-0 G1-4, pT2pNx-0 G1-2; no NT, DS y/o MR (+). -GR intermedio (GRI): pT2pNx-0 G3-4;pT3-4pNx-0 G1-2; GRB con NT. -GR alto (GRA): pT3-4pNx-0 G3-4; pT1-4pN+; GRI con NT y/o DS; GRB con DS y/o MR (+). Para el contraste de variables cualitativas se utilizó el test de la Chi cuadrado. El método de Kaplan-Meier se ha utilizado para evaluar la supervivencia libre de recidiva en función de los GRR. Para evaluar diferencias entre las curvas de supervivencia se ha utilizado el test de log-rank. RESULTADOS: La mediana de seguimiento fue de 105 (IQR 63-148) meses. Del total de la serie recidivaron 177 (25,4%) pacientes: 15,9% a distancia, 4,9% local y 4,6% a distancia y local. La tasa de recurrencia varió según el grupo de riesgo con tasas del 72,9% en GRA, 16,9% en GRI y 10,2% en GRB (p = 0,0001). La recurrencia en órgano único fue mayoritaria en el GRB (72,2%) (p = 0,006). El GRB presentó recidiva en forma de metástasis única en el 50% de los casos, frente al 30% y 18,6% en GRI y GRA, respectivamente (p = 0,009). Las localizaciones de recurrencia más habituales fueron pulmón y abdomen. La localización pulmonar predominó en el GRA (72,9%) (p = 0,0001) y la abdominal en el GRB (83,3%) con una tendencia a la significación (p = 0,15). CONCLUSIONES: A medida que aumenta el grupo de riesgo aumentan las recurrencias, sobre todo óseas y pulmonares. En el GRB son más frecuentes las metástasis únicas y en órgano único

INTRODUCTION: Recurrence trends after renal cell cancer nephrectomy are not clearly defined. OBJECTIVE: To evaluate recurrence trends according to recurrence risk groups (RRG). MATERIAL AND METHOD: Retrospective analysis of 696 patients with renal cell cancer treated with nephrectomy between 1990-2010. Three RRG were defined according to the presence of anatomopathological variables (pTpN stage, nuclear grade, tumor necrosis [TN], sarcomatoid differentiation [SD], positive resection margin [RM]): -Low RG (LRG): pT1pNx-0 G1-4, pT2pNx-0 G1-2; no TN, SD and/or RM (+). -Intermediate RG (IRG): pT2pNx-0 G3-4; pT3-4pNx-0 G1-2; LRG with TN. -High RG (HRG): pT3-4pNx-0 G3-4; pT1-4pN+; IRG with TN and/or SD; LRG with SD and/or RM (+). The Kaplan-Meier method has been used to evaluate recurrence-free survival as a function of RRG. The log-rank test was used to evaluate differences between survival curves. RESULTS: The median follow-up was 105 (IQR 63-148) months. Of the total series, 177 (25.4%) patients presented recurrence: distant 15.9%, local 4.9% and 4.6% distant and local. The recurrence rate varied according to the RRG with values of 72.9% for HRG, 16.9% for IRG and 10.2% for LRG (p=.0001). Most cases in LRG presented single organ recurrence (72.2%) (p=.006). The LRG experienced recurrence as single metastasis in 50% of cases, compared to 30% and 18.6% in IRG and HRG, respectively (p=.009). The most common sites of recurrence were lung and abdomen. Lung recurrence predominated in the HRG (72.9%) (p=.0001) and abdominal, in the LRG (83.3%) with a tendency to significance (p=.15). CONCLUSIONS: Recurrence rates (especially bone and lung) increase with higher RG. Single organ recurrences and single metastases are more frequent in LRG