Is Tumor Budding a New Predictor for Early Cystectomy in pT1 High-Grade Bladder Cancer?

Background & Objectives: We aimed to evaluate the risk of progression in high-grade T1 (HGT1) tumors using tumor budding (TB) and other standard clinical and histological features. TB is defined as an isolated cancer cell or a cluster composed of fewer than 5 cells scattered in the stroma and is usually used as a strong predictor of lymph node metastasis in T1 colorectal cancer. METHODS: This is an observational longitudinal cohort study involving 168 consecutive patients with HGT1 between 2013 and 2016. Cox regression was performed to analyze the relationship between the clinical and histological features and progression. All slides were blindly assessed by 2 genitourinary pathologists. Budding was determined to be positive when the number of buds was equal to or greater than 6. RESULTS: The median age was 75 years; 152 (90.5%) patients were men, and 49 (29.2%) were positive for TB. At a median follow-up time of 35 months, 33 patients (19.6%) showed progression. Progression was observed in 32.7% of the patients positive for TB and in only 14.3% of those who were negative (p = 0.006). TB was significantly associated with the endoscopic tumor pattern (TP) (papillary/solid) and lymphovascular invasion (LVI). Univariate analysis showed that TB, carcinoma in situ (CIS), TP, LVI, sub-staging, and BCG induction predict progression. The multivariate analysis showed that TB (p = 0.032, hazard ratio 2.1), CIS, TP, and lack of BCG induction were significant for progression. CONCLUSIONS: TB is a new and significant pathological variable for predicting progression in HGT1 tumors and can be easily introduced in clinical practice. Its inclusion in the TNM system should be carefully considered, as it may aid early cystectomy decisions.

[Open versus laparoscopic pyeloplasty: review of our series and description of our laparoscopic pyeloplasty procedure]. / Pieloplastia abierta frente a laparoscópica: revisión de nuestra serie y descripción de nuestra técnica de pieloplastia laparoscópica.

INTRODUCTION AND OBJECTIVES: Pyeloplasty has always been the treatment of choice for ureteropelvic junction obstruction at our center, where a laparoscopic approach has been used in the last 4 years to perform this procedure. Results of open pyeloplasty (OP) and laparoscopic pyeloplasty (LP) performed at our center in the past 8 years are compared, and our laparoscopic procedure is described. MATERIALS AND METHODS: Pyeloplasties performed at our center from June 2000 to June 2008 were retrospectively reviewed. Clinical presentation, involved kidney function, operating time, intraoperatory bleeding, presence of kidney stones or crossing vessels, length of hospital stay, possible complications, and results obtained were analyzed in each case. RESULTS: Thirty pyeloplasties were performed, 15 OP and 15 LP (50%). Mean operating time was 167.6 minutes for LP (100-240) and 106 minutes for OP (75-180) (P< .0001). Mean hospital stay was 6.6 days (4-16) for LP and 9.1 days for OP (5-26) (P.05). Intraoperative bleeding was negligible in all patients and no peroperative complications occurred. However, 9 patients (30%) experienced postoperative complications, 5 out of 15 LPs (33.3%) and 4 out of 15 OPs (26.7%) (P.05). Urinary fistula was the most common complication, occurring in 3 of the 30 patients (10%). Procedure was successful in all 15 patients undergoing OP (100%) and in 14 of the 15 patients undergoing LP (93.3%) (P.05). CONCLUSIONS: LP is currently the procedure of choice at our center because of its lower morbidity and similar results to OP, despite the need for a certain laparoscopic skill and a usually longer operating time.

Pieloplastia abierta frente a laparoscópica: revisión de nuestra serie y descripción de nuestra técnica de pieloplastia laparoscópica / Open versus laparoscopic pyeloplasty: review of our series and description of our laparoscopic pyeloplasty procedure

Introducción y objetivos: La pieloplastia ha sido desde siempre el tratamiento de elección en nuestro centro para la estenosis pieloureteral y, desde hace 4 años, hemos optado por el abordaje laparoscópico a la hora de llevar a cabo esta técnica. Queremos comparar el resultado de las pieloplastias abiertas (PA) y laparoscópicas (PL) llevadas a cabo en nuestro centro durante los últimos 8 años, así como describir nuestra técnica de PL. Material y métodos: Revisamos de forma retrospectiva las pieloplastias llevadas a cabo en nuestro centro entre junio de 2000 y junio de 2008, analizando en cada caso el motivo de consulta, la funcionalidad del riñón afectado, el tiempo quirúrgico, el sangrado intraoperatorio, la presencia de litiasis renal o de vaso polar, los días de estancia, las posibles complicaciones y el resultado obtenido. Resultados: Se han practicado un total de 30 pieloplastias, 15 PA y 15 PL (50%). El tiempo quirúrgico fue de media de 167,6 minutos para las PL (100-240) y de 106 min para las PA (75-180) (p < 0,0001). La estancia media en el caso de las PL fue de 6,6 días (4-16) frente a 9,1 días para las PA (5-26) (p > 0,05). El sangrado intraoperatorio fue desdeñable en todos los casos y no hubo complicaciones intraoperatorias, si bien 9 (30%) pacientes presentaron complicaciones postoperatorias: 5 de 15 PL (33,3%) y 4 de 15 PA (26,7%) (p > 0,05). La fístula urinaria fue la complicación más frecuente, presentándose en 3 de los 30 pacientes (10%).El éxito de la intervención se confirmó en los 15 pacientes intervenidos de PA (100%) y en14 de los 15 pacientes intervenidos de PL (93,3%) (p > 0,05).Conclusiones: Por su menor morbilidad y sus resultados equivalentes a la PA, la PL es hoy día la técnica de elección en nuestro centro a pesar de requerir de una cierta habilidad en el manejo de la laparoscopia y de un tiempo quirúrgico habitualmente más largo (AU)

Introduction and objectives: Pyeloplasty has always been the treatment of choice for ureteropelvic junction obstruction at our center, where a laparoscopic approach has been used in the last 4 years to perform this procedure. Results of open pyeloplasty (OP) and laparoscopic pyeloplasty (LP) performed at our center in the past 8 years are compared, and our laparoscopic procedure is described. Materials and methods: Pyeloplasties performed at our center from June 2000 to June 2008were retrospectively reviewed. Clinical presentation, involved kidney function, operating time, intraoperatory bleeding, presence of kidney stones or crossing vessels, length of hospital stay, possible complications, and results obtained were analyzed in each case. Results: Thirty pyeloplasties were performed, 15 OP and 15 LP (50%). Mean operating time was 167.6 minutes for LP (100-240) and 106 minutes for OP (75-180) (P<0.0001). Mean hospitalstay was 6.6 days (4-16) for LP and 9.1 days for OP (5-26) (P>.05). Intraoperative bleeding was negligible in all patients and no peroperative complications occurred. However, 9 patients (30%) experienced postoperative complications, 5 out of 15 LPs (33.3%) and 4 out of 15 Ops (26.7%) (P>0.05). Urinary fistula was the most common complication, occurring in 3 of the30 patients (10%).Procedure was successful in all 15 patients undergoing OP (100%) and in 14 of the 15patients undergoing LP (93.3%) (P>0.05). Conclusions: LP is currently the procedure of choice at our center because of its lower morbidity and similar results to OP, despite the need for a certain laparoscopic skill and ausually longer opertating time (AU)

[Laparoscopic radical cystectomy in clinically localized (T2) bladder tumors]. / Cistectomía radical laparoscópica en los tumores vesicales clínicamente localizados (T2).

OBJECTIVES: Laparoscopic radical cystectomy has been developed after the expansion of laparoscopic radical prostatectomy. This technique makes possible a minimally invasive approach to muscle-invasive bladder cancer with less blood loss and faster postoperative recovery. METHODS: From September 2004 to January 2007, 54 laparoscopic radical cystectomies were performed, 48 of them in stage T2, from which 43 (90%) were male and 5 (10%) female patients. Mean age was 64 years (27-881. Lymphadenectomy was carried out by laparoscopic approach in all cases, with a mean of 13 nodes obtained (4-24). Urinary diversion was done through the incision needed to extract the specimen in all cases but one that was completed completely intracorporeally; constructing a Bricker-type ureteroileostomy in 30 (62%) cases, orthotopic neobladder (Vesica Ileale Padovana) in 17 cases (35%), and cutaneous ureterostomy in 1 case (2%). RESULTS: Mean surgical time for the whole procedure was 287 minutes (180-480), 270 minutes for Bricker-type derivation cases and 316 minutes for neobladder cases. Blood transfusion rate was 25%. Mean ileal paralysis was 5 days (2-10) with a mean hospital stay of 13 days (6-34) for Bricker cases and 16 days (8-30) for neobladder cases. Oncological control, after a mean follow-up of 10,8 months (0,4-30), showed a cancer-specific survival of 90% with a mean survival time of 28 months (95% CI 26-30). Global mean survival was 79% with a mean survival of 26 months (95% CI 23-29). CONCLUSIONS: Laparoscopic radical cystectomy is a feasible technique that offers some advantages. It allows excision with less blood loss and an easier postoperative period. Randomized studies should demonstrate these advantages to confirm this approach as the technique of choice. Urinary diversion performed through the laparotomy incision, necessary to extract the specimen, optimizes derivation results and whole surgical time without reducing the beneficial effects of the laparoscopic exeresis.

Embolización arterial para el tratamiento del traumatismo del riñón en herradura / Arterial embolization in the treatment of renal trauma of a horseshoe kidney

OBJETIVO: Comunicar un caso de traumatismoen un riñón en herradura que se resolvió de forma conservadora mediante embolizaciónsupra-selectiva.MÉTODOS: Varón de 19 años que consulta a urgencias por macrohematuria junto con dolor abdominal severo despuésde accidente de tráfico. RESULTADOS: La tomografía computerizada con contraste (TC) evidenció un riñón en herradura con una fractura en la zona de unión entre el polo inferior del riñón izquierdo y el istmo, mostrando hemorragia activa y extenso hematomaretroperitoneal con ocupación pélvica. Los cortes retardados mostraron extravasación de contraste compatiblecon un importante urinoma. Se realizó una arteriografía que mostró un doble pedículo para cada riñón y un tronco lumbo-renal distal común que daba ramas accesorias a los polos inferiores de ambos riñones y al istmo, con extravasaciónde contraste compatible con sangrado activo. Se cateterizó selectivamente el tronco lumbo-renal, accediendoa la rama del riñón izquierdo e istmo permitiendo su embolización. Se cateterizó la vía urinaria retrógradamentecon un catéter ureteral recto para facilitar el drenaje del urinoma. Posteriormente, y con buena evolución junto TC de control que mostró ausencia de signos de hemorragiacon completa resolución del urinoma, se retiró el tutor ureteral. A los 3 meses de la embolización, el TC de controldemostró una completa resolución del hematoma. No presentó complicaciones tardías, manteniendo una función renal y una presión arterial completamente normales a los 12 meses de seguimiento.CONCLUSIONES: El riñón en herradura es una malformacióninfrecuente. Este caso clínico es un ejemplo que demuestra que el tratamiento conservador sigue siendo el gold standard en el traumatismo renal, incluso en riñones con anomalías congénitas

OBJECTIVES: To report one case of renal trauma in a patient with horseshoe kidney treated conservatively ;;by superselective embolization. ;;METHODS: We report the case of a 19 year old male presenting at the emergency room with macroscopic ;;hematuria and severe abdominal pain after a motor vehicular accident. ;;RESULTS: IV contrast CT scan showed a horseshoe kidney with a fracture in the area between the lower pole of the left kidney and the isthmus, with active bleeding and a big retroperitoneal hematoma extended to pelvis. ;;Retarded exams showed contrast extravasation compatible with significant urinoma. Renal arteriography was performed, showing a double renal pedicle on each kidney and a common caudal lumbar-renal trunk giving accessory branches to both kidneys’ lower poles and contrast extravasation ;;compatible with active bleeding. The lumbar-renal trunk was selectively catheterized reaching the left kidney and isthmus branches which were embolized. ;;Retrograde catheterization of the urinary tract with a straight ureteral catheter was performed to facilitate drainage of the urinoma. This catheter was subsequently removed after control CT scan showing complete resolution of the urinoma and no bleeding. ;;Control CT scan three months after embolization demonstrated complete resolution of the hematoma. No late complications appeared. Renal function and blood pressure have been completely normal after 12 months of follow-up. ;;CONCLUSIONS: Horseshoe kidney is a rare congenital malformation. This clinical case demonstrates that conservative treatment is a still the gold standard treatment for renal trauma, even in kidneys with congenital anomalies

[Arterial embolization in the treatment of renal trauma of a horseshoe kidney]. / Embolizacion arterial para el tratamiento del traumatismo del riñon en herradura.

OBJECTIVES: To report one case of renal trauma in a patient with horseshoe kidney treated conservatively by superselective embolization. METHODS: We report the case of a 19 year old male presenting at the emergency room with macroscopic hematuria and severe abdominal pain after a motor vehicular accident. RESULTS: IV contrast CT scan showed a horseshoe kidney with a fracture in the area between the lower pole of the left kidney and the isthmus, with active bleeding and a big retroperitoneal hematoma extended to pelvis. Retarded exams showed contrast extravasation compatible with significant urinoma. Renal arteriography was performed, showing a double renal pedicle on each kidney and a common caudal lumbar-renal trunk giving accessory branches to both kidneys' lower poles and contrast extravasation compatible with active bleeding. The lumbar-renal trunk was selectively catheterized reaching the left kidney and isthmus branches which were embolized. Retrograde catheterization of the urinary tract with a straight ureteral catheter was performed to facilitate drainage of the urinoma. This catheter was subsequently removed after control CT scan showing complete resolution of the urinoma and no bleeding. Control CT scan three months after embolization demonstrated complete resolution of the hematoma. No late complications appeared. Renal function and blood pressure have been completely normal after 12 months of follow-up. CONCLUSIONS: Horseshoe kidney is a rare congenital malformation. This clinical case demonstrates that conservative treatment is a still the gold standard treatment for renal trauma, even in kidneys with congenital anomalies.

Tratamiento actual de la litiasis en malformaciones congénitas renoureterales / Current treatment of calculi in congenital renouretral malformations

OBJETIVO: Evaluar el tratamiento de la litiasis urinaria en malformaciones renoureterales. MÉTODOS: Entre abril de 1988 y diciembre de 2000 hemos tratado a 158 pacientes con malformaciones renoureterales (36 riñones en herradura, 32 divertículos caliciales, 2 megacaliosis, 2 ectopia renal cruzada, 3 poliquistosis, 7 hidrocáliz, 24 duplicidades ureterales completas, 18 duplicidades ureterales incompletas, 22 ureterocele, 2 megaureteres segmentarios. RESULTADOS: Las malformaciones renoureterales diagnosticadas en nuestra unidad de litiasis han sido de 158 de todos los pacientes tratados (19.000 pacientes entre 1988 y diciembre 2000).Rinón en Herradura: 54 por ciento de pacientes libres de litiasis con LEOC; 2 pacientes se solucionaron con nefrolitotomía percutánea y otros 2 pacientes se solucionaron con cirugía clásica. Divertículo calicial: 40 por ciento de pacientes libres de litiasis con LEOC. Cirugía clásica en 3 pacientes. Resto de malformaciones renales: 62 por ciento de pacientes libres de litiasis con LEOC. Malformaciones ureterales: duplicidades y megaureter: 82 por ciento de pacientes libres de litiasis con LEOC. Ureterocele: dado el mal resultado de la LEOC optamos por la meatotomía endoscópica transuretral. CONCLUSIONES: Estos resultados sugieren que la LEOC monoterapia puede considerarse como primera elección ante una litiasis de pequeño tamaño alojada en un riñón malformado, si bien consideramos mandatario en este grupo de pacientes realizar una valoración individual de la via urinaria y tamaño de la litiasis a tratar para elegir la mejor opción terapéutica. En las malformaciones ureterales pueden aplicarse los mismos criterios que se utilizan en una vía normal excepto en los ureteroceles que optamos por la cirugía endoscópica y extracción de la litiasis (AU)

Tratamiento de la estenosis uretral mediante prótesis termoexpandible "Memotherm®". Nuestra experiencia / Treatment of urethral strictures with the Memotherm® heat-expansible stent : Our experience

OBJETIVO: Presentar nuestra experiencia en el tratamiento de la estenosis recidivante de uretra masculina mediante el uso de la prótesis endouretral termoexpandible Memotherm®. MÉTODOS: Presentamos 4 pacientes afectos de estenosis uretral tratados con esta técnica en el período comprendido entre diciembre de 1995 y marzo de 1999. A estos pacientes les fueron realizadas sucesivas uretrotomías, dilataciones uretrales periódicas y, en los de etiología post-traumática, cirugía abierta practicándose uretroplastia y reanastomosis uretral. En todos los casos estudiados el resultado fue el de una estenosis uretral multirrecidivante, rebelde a los tratamientos practicados por lo que se optó por la colocación de una prótesis endouretral Memotherm®. RESULTADOS: Todos los pacientes presentaron una buena evolución postoperatoria con micciones cómodas y chorro miccional amplio y de buena proyección. El control se ha realizado a nivel ambulatorio mediante micciometría semestral y a todos ellos se les practica control endoscópico anual con el objeto de despistar el crecimiento mucoso uretral hipertrófico y/o la calcificación endoluminal. Todas las prótesis se encuentran completamente englobadas en la pared uretral tras 12 meses de su colocación. Como efectos secundarios sólo hemos encontrado discreto goteo postmiccional limitado a los primeros meses post-implantación de la prótesis y un caso transitorio de hemospermia. CONCLUSIONES: La prótesis endouretral termoexpandible es un tratamiento válido para casos seleccionados de estenosis uretral recidivante. Si bien podría ser un paso a utilizar antes de practicar una uretroplastia, a menudo de técnica compleja y de resultados inciertos, por el momento puede ser una solución muy válida, al menos como segunda opción ante el fracaso de la misma (AU)