Estudio poblacional de casuística y morbimortalidad de la prostatectomía radical en España / Population based study of morbidity and mortality rates associated to radical prostatectomy cases in Spain

Introducción: No existe ningún estudio poblacional que contabilice en número de prostatectomías radicales (PR) realizadas España, ni la morbimortalidad de dicha intervención.Nuestro objetivo es estudiar la morbimortalidad de la PR en España desde el 2011 al 2015 y evaluar la variabilidad geográfica. Material y métodos: Diseñamos un estudio observacional retrospectivo de todos los pacientes intervenidos de PR en España durante cinco años consecutivos (2011-2015) a partir de los datos registrados en el Conjunto Mínimo Básico de Datos (CMBD).Hemos estudiado la distribución del número de casos y la variabilidad intercomunitaria en términos de morbilidad y de estancia hospitalaria, así como el impacto del volumen quirúrgico medio anual por cada centro en dichas variables. Resultados: Entre los años 2011-2015 se han realizado un total de 37.725 PR en 221 hospitales españoles públicos del sistema nacional de salud. La edad media de la serie fue 63,9 ± 3,23 años. El 50% de las PR se han realizado por vía abierta, y un 43,4% se han intervenido en hospitales de < 500 camas. Encontramos una gran variabilidad en la distribución de los casos intervenidos en las distintas Comunidades Autónomas (CCAA Las comunidades que realizan un mayor número de prostatectomías son Andalucía, Cataluña, Galicia y Madrid. La tasa de complicaciones a nivel nacional es de 8,6%, siendo las más frecuentes la hemorragia y necesidad de transfusión (5,3 y 4%, respectivamente). Encontramos importantes diferencias en las tasas de hemorragia y en la estancia hospitalaria entre las distintas CCAA, que se mantienen tras ajustar por las características del paciente y del tipo de hospital. Al estudiar el volumen quirúrgico anual de cada hospital vemos que el impacto en la tasa de hemorragia o transfusión es lineal sin embargo en la estancia a partir de 60 PR/año la estancia se mantiene estable en torno a cinco días. (AU)

Introduction: There is no population-based study that accounts for the number of radical prostatectomies (RP) carried out in Spain, nor regarding the morbidity and mortality of this intervention.Our objective is to study the morbidity and mortality of RP in Spain from 2011 to 2015 and to evaluate the geographic variation. Material and methods: We designed a retrospective observational study of all patients submitted to RP in Spain during five consecutive years (2011-2015). The data was extracted from the «Conjunto Mínimo Básico de Datos» (CMBD).We have evaluated geographic variations in terms of morbidity and hospital stay, and the impact of the mean annual surgical volume for each center on these variables. Results: Between 2011-2015, a total of 37,725 RPs were performed in 221 Spanish public hospitals. The mean age of the series was 63.9 ± 3.23 years. Of all RPs, 50% were performed through an open approach, and 43.4% have been operated on in hospitals with < 500 beds. We observed an important variability in the distribution of the cases operated on in the different regions. The regions that perform more RPs are Andalusia, Catalonia, Galicia, and Madrid. Our study shows a complication rate of 8.6%, with hemorrhage and the need for transfusion being the most frequent (5.3 and 4%, respectively). There are significant differences in bleeding rates and hospital stay among regions, which are maintained after adjusting for patient characteristics and type of hospital. When studying the annual surgical volume of each hospital, we find that the impact on the rate of hemorrhage or transfusion is linear; however, hospital stay remains stable at around 5 days from 60 RPs/year (AU)

Population based study of morbidity and mortality rates associated to radical prostatectomy cases in Spain.

INTRODUCTION: There is no population-based study that accounts for the number of radical prostatectomies (RP) carried out in Spain, nor regarding the morbidity and mortality of this intervention. Our objective is to study the morbidity and mortality of RP in Spain from 2011 to 2015 and to evaluate the geographic variation. MATERIAL AND METHODS: We designed a retrospective observational study of all patients submitted to RP in Spain during five consecutive years (2011-2015). The data was extracted from the «Conjunto Mínimo Básico de Datos¼ (CMBD). We have evaluated geographic variations in terms of morbidity and hospital stay, and the impact of the mean annual surgical volume for each center on these variables. RESULTS: Between 2011-2015, a total of 37,725 RPs were performed in 221 Spanish public hospitals. The mean age of the series was 63.9±3.23 years. Of all RPs, 50% were performed through an open approach, and 43.4% have been operated on in hospitals with <500 beds. We observed an important variability in the distribution of the cases operated on in the different regions. The regions that perform more RPs are Andalusia, Catalonia, Galicia, and Madrid. Our study shows a complication rate of 8.6%, with hemorrhage and the need for transfusion being the most frequent (5.3 and 4%, respectively). There are significant differences in bleeding rates and hospital stay among regions, which are maintained after adjusting for patient characteristics and type of hospital. When studying the annual surgical volume of each hospital, we find that the impact on the rate of hemorrhage or transfusion is linear; however, hospital stay remains stable at around 5 days from 60 RPs/year. CONCLUSIONS: In national terms, morbidity and mortality rates after RP are comparable to those described in the literature. This study reveals a clear dispersion in the hospitals that carry out this intervention, showing clear differences in terms of morbidity and hospital stay between the different regions.

First-degree relationships and genotyping errors deciphered by a high-density SNP array in a Duroc × Iberian pig cross.

BACKGROUND: Two individuals with a first-degree relationship share about 50 percent of their alleles. Parent-offspring relationships cannot be homozygous for alternative alleles (genetic exclusion). METHODS: Applying the concept of genetic exclusion to HD arrays typed in animals for experimental purposes or genomic selection allows estimation of the rate of rejection of first-degree relationships as the rate at which two individuals typed for a large number of Single Nucleotide Polymorphisms (SNPs) do not share at least one allele. An Expectation-Maximization algorithm is applied to estimate parentage. In addition, genotyping errors are estimated in true parent-offspring relationships. Samples from nine candidate Duroc sires and 55 Iberian dams producing 214 Duroc × Iberian barrows were typed for the HD porcine Affymetrix array. RESULTS: We were able to establish paternity and maternity of 75 and 85 piglets, respectively. Rate of rejection in true parent-offspring relationships was estimated as 0.000735. This is a lower bound of the genotyping error since rate of rejection depends on allele frequencies. After accounting for allele frequencies, our estimate of the genotyping error is 0.6%. A total of 7,744 SNPs were rejected in five or more true parent-offspring relationships facilitating identification of "problematic" SNPs with inconsistent inheritance in multiple parent-offspring relationships. CONCLUSIONS: This study shows that animal experiments and routine genotyping in genomic selection allow to establish or to verify first-degree relationships as well as to estimate genotyping errors for each batch of animals or experiment.

Transition from active surveillance to observation in prostate cancer patients older than 75 years. A long follow-up series. / Transición de vigilancia activa a observación en pacientes mayores de 75 años con cáncer de próstata en una serie de largo seguimiento.

INTRODUCTION: The world population is ageing, and life expectancy is increasing. This situation will have a great impact on the management of patients with prostate cancer, especially in those of low risk, susceptible to a conservative management under active surveillance (AS). Regarding these patients' profile, it is necessary to answer the following questions: ¿for how long to continue with the AS scheme?, ¿which tests will be required?, ¿is it possible to carry out a transition to observation with oncological safety? The objective of this work is to analyse those patients with prostatic cancer who have been in AS with 75 years of age or more and assess the safety of the observation in an AS series with a long follow-up. MATERIAL AND METHODS: We analysed our prospective cohort of AS patients between the years 1999 and 2018,including those who had been in follow-up with 75 years or more. They were offered treatment with curative intent when there were progression criteria and transition to observation under the urologist's decision. Some intermediate risk patients were included in the analysis. Comorbidity changes were analysed with the Charlson comorbidity index at entry and exit of AS. The progression and mortality of the patients were studied according to the management they received. RESULTS: From 347 AS patients, 90 patients fulfilled the afore mentioned criteria and 15 (16.7%) were intermediate risk. The median follow-up was 6.4 years and 73 (81.1%) had low comorbidity (Charlson<2).There were 40 (44.4%) patients who left AS, 17 (18.9%) of them went to observationand the rest, 21 (23.3%), received curative treatment. There was a significant difference in comorbidity, measured by the Charlson index, at entry and exit of AS (P<.05) among patients receiving active treatment and the ones submitted to observation.No case of cancer-specific death or progression was observed in the observation group. CONCLUSION: The transition from an active surveillance management to observation of prostate cancer elderly patients, as well as the decision to carry out a treatment with curative intent, seems controversial. In our series, this transition in patients older than 75 years does not increase the oncological risk.

Incidence of surgical wound infection in renal surgery. The effect of antibiotic prophylaxis appropriateness. A prospective cohort study. / Incidencia de infección de herida quirúrgica en cirugía renal. Efecto de la adecuación de la profilaxis antibiótica. Estudio de cohortes prospectivo.

OBJECTIVE: To assess compliance with the antibiotic prophylaxis protocol for patients who underwent renal surgery and its effect on the incidence of surgical wound infection. MATERIAL AND METHODS: We performed a prospective cohort study and assessed the overall compliance and each aspect of the antibiotic prophylaxis (start, administration route, antibiotic of choice, duration and dosage) and reported the compliance rates. The qualitative variables were compared with the chi-squared test, and the quantitative variables were compared with Student's t-test. We studied the effect of antibiotic prophylaxis compliance on the incidence of surgical wound infection in renal surgery, with the relative risk. RESULTS: The study included 266 patients, with an overall compliance rate of 90.6%. The major cause of noncompliance (3.8%) was the start of the prophylaxis, and the incidence rate of surgical wound infections was 3.4%. We found no relationship between antibiotic prophylaxis noncompliance and surgical wound infections (RR=0.26; 95%CI: 0.1-1.2; P>.05). Laparoscopic surgery had a lower incidence of surgical wound infections than open surgery (RR=0.10; 95%CI: 0.01-0.79). CONCLUSIONS: The antibiotic prophylaxis compliance was high. The incidence of surgical site infection was low, and there was no relationship between the incidence of surgical site infection and antibiotic prophylaxis compliance. The incidence of infection was lower in laparoscopic surgery.

Influence of the location and number of metastases in the survival of metastatic prostatic cancer patients. / Influencia de la localización y del número de metástasis en la supervivencia de los pacientes con cáncer de próstata metastásico.

INTRODUCTION: The prognosis of patients diagnosed with metastatic prostate cancer seems to be modulated by factors such as the number and site of metastases. Our objective is to evaluate survival outcomes according to the number and site of metastases in our series of metastatic patients over the last 15 years. MATERIALS AND METHODS: A retrospective analysis was performed on patients diagnosed between 1998 and 2014. We analyzed overall survival and progression-free survival, depending on the number and location of metastases on patients with newly diagnosed metastatic prostate cancer. Other potential prognostic factors were also evaluated: age, clinical stage, PSA at diagnosis, Gleason, PSA nadir, time till PSA nadir and first-line or second-line treatment after progression. RESULTS: We analyzed a series of 162 patients. The mean age was 72.7yr (SD: 8.5). The estimated median overall survival was 3.9 yr (95% CI 2.6-5.2). The overall survival in patients with only lymph node metastases was 7 yr (95% CI 4.1-9.7), 3.9 (95%CI 2.3-5.5) in patients with only bone metastases, 2.5 yr (95% CI 2-2.3) in lymph nodes and bone metastases, and 2.2 yr (95% CI 1.4-3) in patients with visceral metastases (P<.001). In multivariate analysis, the location of metastasesis significantly associated with overall survival and progression-free survival. The number of metastases showed no association with survival. CONCLUSIONS: The site of metastases has a clear impact on both overall survival and progression-free survival. Patients with only lymph node involvement had a better prognosis. The number of metastases showed no significant impact on survival in our series.

Diagnosis challenge of atypical spindle cells neoplasm of the spermatic cord. / Reto diagnóstico de neoplasia de células fusiformes atípicas del cordón espermático.

OBJECTIVE: To report an unusual case of softtissue neoplasm and to review the literature on this type of tumour. METHODS: We report an accidentally found tumour closely related to the spermatic cord that was diagnosed in a 70 year-old man when he was being operated on for an inguinal hernia repair. RESULTS: After thorough analysis by experienced pathologists it was not possible to determine the nature of the tumour that was removed at surgery. CONCLUSIONS: Soft tissues neoplasms of the spermatic cord may occur in an unusual way and they may be a real challenge to diagnose.

Diagnostic yield and complications of extended lymphadenectomy versus limited lymphadenectomy combined with radical prostatectomy.

BACKGROUND: Lymphadenectomy for prostate cancer (PC) is the most reliable procedure for detecting lymphatic metastases. The optimal extension of this procedure is still a topic of debate. OBJECTIVE: To analyse the diagnostic performance and complications of extended lymphadenectomy (ELD) and limited lymphadenectomy (LLD) in a series of patients with high-risk PC who underwent radical prostatectomy (RP). MATERIAL AND METHODS: A retrospective study was conducted on patients with high d'Amico risk who underwent RP with lymphadenectomy between 1999 and 2014. A comparative analysis was performed of the diagnostic capacity of lymphatic metastases of ELD and LLD and of postoperative complications at 90 days. RESULTS: Ninety-three patients were analysed, 20 (21.5%) and 73 (78.5%) of whom underwent ELD and LLD, respectively. The mean age of the series was 65.26 years (SD, 5.51). The median follow-up was 1.51 (0.61-2.29) years in the ELD group and 5.94 (3.61-9.10) in the LLD group. The median number of nodes obtained was 13 (9-23) in the ELD group compared with 5 (2-8) in the LLD group (p <.001). The percentages of patients with positive nodes in the ELD and LLD groups were 35% and 5.47%, respectively (p <.001). The overall complication rate at 90 days was 35.5% (33 patients). In the ELD group, 12 patients (60%) had complications, compared with 21 patients (28.8%) in the LLD group (p=.016), with no significant differences in severity according to the Clavien scale (p=.73). CONCLUSIONS: In our series, the detection of metastatic nodes was significantly greater with ELD. ELD increases the number of complications, with no differences compared with LLD in severity according to the modified Clavien scale.

Cohort study comparing prostate photovaporisation with XPS 180W and HPS 120W laser.

INTRODUCTION AND OBJECTIVE: Prostate photovaporisation with Greenlight laser for the surgical treatment of benign prostate hyperplasia has rapidly evolve to the new XPS 180W. We have previously demonstrated the safety and efficacy of the HPS 120W. The aim of this study was to assess the functional and safety results, with a year of follow-up, of photovaporisation using the XPS 180W laser compared with its predecessor. MATERIAL AND METHODS: A cohort study was conducted with a series of 191 consecutive patients who underwent photovaporisation between 1/2008 and 5/2013. The inclusion criteria were an international prostate symptom score (IPSS) >15 after medical failure, a prostate volume <80 cm(3) and a maximum flow <15 mL/s. We assessed preoperative and intraoperative variables (energy used, laser time and total surgical time), complications, catheter hours, length of stay and functional results (maximum flow, IPSS, prostate-specific antigen and prostate volume) at 3, 6 and 12 months. We analysed the homogeneity in preoperative characteristics of the 2 groups through univariate analysis techniques. The postoperative functional results were assessed through an analysis of variance of repeated measures with mixed models. RESULTS: A total of 109 (57.1%) procedures were performed using HPS 120W, and 82 (42.9%) were performed using XPS. There were no differences between the preoperative characteristics. We observed significant differences both in the surgical time and effective laser time in favour of the XPS system. This advantage was 11% (48 ± 15.7 vs. 53.8 ± 16.2, p<.05) and 9% (32.8 ± 11.7 vs. 36 ± 11.6, p<.05), respectively. There were no statistically significant differences in the rest of the analysed parameters. CONCLUSION: The technical improvements in the XPS 180W system help reduce surgical time, maintaining the safety and efficacy profile offered by the HPS 120W system, with completely superimposable results at 1 year of follow-up.

Changes in Gleason score grading on serial follow-up biopsies in prostate cancer patients undergoing active surveillance.

INTRODUCTION: Active surveillance for prostate cancer has grown systematically in the recent years with more robust mid-term outcomes. However, changes in Gleason score during serial biopsies are not detailed in many of these reports. OBJECTIVES: To evaluate changes in Gleason score on follow-up biopsies in low-risk prostate cancer in patients undergoing AS program in our center. MATERIAL AND METHODS: Series of patients diagnosed of prostate cancer between 2004 and 2013 have been analyzed. The inclusion criteria were: PSA ≤ 10 ng/ml + Gleason ≤ 6 + T1c/T2a + ≤ 2 positive cores, and no more than 50% of affected core. The pathology of each of the biopsies was analyzed. RESULTS: We studied a series of 175 patients undergoing AS. Mean follow-up was 3.96 years (SD 2.4). Follow-up biopsies with Gleason scores ≥ 7 were: 5.72% in the first biopsy, 7.39% and 7.41% in subsequent biopsies. By contrast, in 42.03% of cases did not show evident tumor involvement in the first biopsy, 40.74% and 51.85% in the second and third biopsies respectively. Median stay in the AS program was: 90.99 months (95% CI: 53.53-128.46) in patients with first positive biopsy vs. 96.66 months (95% CI: 63.19-130.13) in those without evidence of tumor. CONCLUSIONS: In our series the pathological data of the first 3 biopsies remain stable in terms of the positive biopsy rate, Gleason score, or indication of active treatment proportions. Those patients who do not show evidence of malignancy in the first follow-up biopsy are less likely to need active treatment than the other patients in the series.

Optimization of an early discharge program after laparoscopic radical prostatectomy.

OBJECTIVE: To assess the safety of hospital discharge 24 hours after laparoscopic radical prostatectomy and to identify possible factors associated with longer hospital stays. MATERIAL AND METHODS: Retrospective study of patients diagnosed with localized prostate cancer underwent to laparoscopic radical prostatectomy consecutively between May of 2007 and December of 2010. Those patients who met the following requirements were discharged in less than 24 hours: absence of complications, drainage debit minor than 50 cc, normal oral tolerance, no significant bladder haematuria and good functional recovery. Logistic regression analysis was conducted in order to assess the possible associated variables with longer hospital stays. RESULTS: A total of 266 patients were analysed. The follow-up median was 34 months. Eighty patients (30.1%) were discharged in less than 24 hours. Average stay (SD) of all series was 2.9 days (3.08). Solely HTA, neurovascular bundles sparing and the development of lymphadenectomy were statistically significant between both groups in univariate analysis (discharge<24 hours vs. discharge>24 hours). In multivariate analysis, only HTA (OR=1.98 [CI 95%:1.13-3.47], P=.016) and lymphadenectomy performance (OR=2.56 [CI 95%:1.18-5.56] P=.017) were independent predictive variables of hospital stays longer than 24 hours. CONCLUSIONS: Early hospital discharge of patients underwent to LRP is feasible and safe. In our series, the lymphadenectomy performance and the HTA were associated factors to longer hospital stay.

Oncological outcomes in patients potentially eligible for active surveillance who underwent radical prostatectomy.

OBJECTIVE: To determine whether there are differences in the oncological outcomes after radical prostatectomy (adverse pathology and biochemical recurrence) based on clinical selection criteria used in two active surveillance (AS) protocols. MATERIAL AND METHODS: 442 patients diagnosed with localized prostate cancer (CP) underwent radical prostatectomy at our institution between August 2003 and December 2009. We selected patients with low-risk CP, which could have been included in an AS program. Patients were divided into two groups: group i, those who met the most strict surveillance criteria described by Epstein (PSAD<.15; T1/T2a;<2 positive core, Gleason≤6,<50% involvement of the core) and group ii, those meeting the more open criteria described by Klotz (PSA≤10 or<15 at age 70, Gleason≤6 or<7 [3+4] in over 70 years). We compared both groups to determine differences in pathological stage, positive surgical margins and biochemical recurrence after radical prostatectomy. RESULTS: Of the 442 patients 48% (213 patients) had low-risk PC, and become potential candidates for an AS program. Of the patients operated on 17% (76 patients) met the criteria for AS as of Epstein's and 48% (213 patients) according to Klotz. Comparing patients in both groups there were no statistically significant differences in the presence of pT3 (7.9% vs 10.8%) P=.55, positive margins (22.4% vs. 28.3%) P=.41, nor in biochemical recurrence at 3 years (5.3% vs 5.6%) P=.86. CONCLUSIONS: In our series of patients theoretically candidates for inclusion in a program of active surveillance, we found no differences in the percentage of patients with pathological stage pT3, positive margins and biochemical recurrence according to clinical inclusion criteria currently used.

Active surveillance in low-risk prostate cancer. Patient acceptance and results.

OBJECTIVES: To evaluate the acceptance of active monitoring by patients treated in our healthcare community and to report the clinical results of an active surveillance program in patients with low-risk prostate cancer. MATERIAL AND METHODS: Prospective study of patients enrolled in an active surveillance programme at our centre between 2004 and 2012. The inclusion criteria were PSA <10 ng/ml, Gleason score ≤6, clinical stage T1c/T2a, ≤2 positive cores, and no more than 50% of the core being affected. Curative treatment was proposed when faced with pathological progression over the course of the monitoring. RESULTS: In 2011, only 17% of the total number of potential candidate patients rejected their inclusion in a surveillance programme and were treated actively. We analysed a series of 144 patients included in our active surveillance protocol. The mean follow-up time was 3.22 years (SD 2.08). A total of 110 patients (76.3%) remained under active monitoring, with an estimated median treatment-free survival after diagnosis of 6.9 years (95% CI: 6.2-7.6). The percentage of patients who remained free of treatment at 2 and 5 years was 96.3% (95% CI: 92.8%-99.8%) and 70.9% (95% CI: 59.3%-85.5%), respectively. Thirty four patients (23.6%) required curative treatment. The mean time to treatment was 4.6 years (SD 2.3). CONCLUSIONS: Active surveillance of highly selected patients with low-risk prostate cancer is a valid alternative therapy that is accepted by patients in our community.

External validation and applicability of the EORTC risk tables for non-muscle-invasive bladder cancer.

PURPOSE: To perform an external validation of the EORTC risk tables and to evaluate their applicability in the patients of our institution by comparing the actual risk of recurrence and progression in our series to those obtained through the application of the EORTC tables. METHODS: Retrospective study, based on a prospective cohort of 417 patients in follow-up with primary TaT1 bladder tumors, operated on in our center between 1998 and 2008 and collected in our database. Risk scores were assigned depending on the tumor characteristics to divide our series into four risk groups according to these ratings. An analysis of survival was carried out to calculate the probability of recurrence by the method of Kaplan-Meier. RESULTS: A total of 417 patients with a median follow-up of 59 months were studied. The overall recurrence and progression rates of our series were 25.95% (21.97-30.49) and 4.86% (3.16-7.43) at 1 year and 53.46% (48.06-59.05) and 8.43% (5.95-11.86) at 5 years, respectively. When we compare our rates of recurrence and progression by groups with the corresponding values from Sylvester's publication, an overlapping of the confidence intervals between both populations is detected. CONCLUSIONS: In terms of the applicability of the EORTC risk tables in our patients' population, we conclude that these tables predict accurately the clinical course of patients with NMIBC. Due to the sample size of our study, we can only validate the recurrence model of the EORTC tables.

Evolution of body condition-dependent dispersal in metapopulations.

Body condition-dependent dispersal strategies are common in nature. Although it is obvious that environmental constraints may induce a positive relationship between body condition and dispersal, it is not clear whether positive body conditional dispersal strategies may evolve as a strategy in metapopulations. We have developed an individual-based simulation model to investigate how body condition-dispersal reaction norms evolve in metapopulations that are characterized by different levels of environmental stochasticity and dispersal mortality. In the model, body condition is related to fecundity and determined either by environmental conditions during juvenile development (adult dispersal) or by those experienced by the mother (natal dispersal). Evolutionarily stable reaction norms strongly depend on metapopulation conditions: positive body condition dependency of dispersal evolved in metapopulation conditions with low levels of dispersal mortality and high levels of environmental stochasticity. Negative body condition-dependent dispersal evolved in metapopulations with high dispersal mortality and low environmental stochasticity. The latter strategy is responsible for higher dispersal rates under kin competition when dispersal decisions are based on body condition reached at the adult life stage. The evolution of both positive and negative body condition-dependent dispersal strategies is consequently likely in metapopulations and depends on the prevalent environmental conditions.

Safety of active surveillance program for recurrent nonmuscle-invasive bladder carcinoma.

OBJECTIVES: To report our experience with a select group of patients with low-risk tumors included in an observation and monitoring program after the diagnosis of recurrence. METHODS: We performed a prospective cohort study in patients diagnosed with recurrent, nonmuscle-invasive bladder cancer maintained under an active surveillance protocol. The inclusion criteria were papillary tumors with negative cytology findings, previous nonmuscle-invasive tumor (Stage pTa, pT1a), grade 1-2, size <1 cm, and number of tumors <5. No symptomatic patients or those with carcinoma in situ or grade 3 tumors were included. A retrospective analysis of a control group of patients with clinical characteristics similar to those of the patients on active surveillance, but who underwent transurethral resection immediately after the recurrence was diagnosed was also performed. RESULTS: The data from 64 patients (70 observation events) were analyzed. The mean patient age was 66.7 years. The median follow-up was 38.6 months. The median time patients remained in observation was 10.3 months. The tumor histologic features before observation were Stage pTa in 77.1%, Stage pT1a in 22.9%, grade 1 in 67.1%, and grade 2 in 23%. After 10.3 months, 93.5% of the patients had not progressed in stage and 83.8% had not progressed in grade. None of the patients experienced progression to muscle-invasive disease. A comparison between the rates of progression in the study and control groups showed no statistically significant difference. CONCLUSIONS: Patients with recurrent, small (<1 cm), nonmuscle-invasive bladder tumors can be safely offered monitoring under an active surveillance protocol, with a minimal risk of progression in either grade or stage, thus reducing the amount of surgical intervention they might undergo throughout their life.

In vitro assessment of the cytotoxic and mutagenic potential of perfluorooctanoic acid.

Perfluorooctanoic acid (PFOA) is a perfluorinated compound ubiquitously detected in the environment, including wildlife and humans. Despite the available information, research on the cytotoxicity of PFOA in non-tumoral mammalian cells is relatively limited. In this work, two in vitro toxicity systems were employed to provide further insight into the cytotoxic and mutagenic potential of PFOA. The cytotoxicity of the chemical towards Vero cells was assessed using biochemical and morphological parameters, while mutagenicity was evaluated according to Ames test. High doses of PFOA cause oxidative stress in Vero cells, that was closely linked to cell cycle arrest at the G1 phase and induction of apoptosis. Our results corroborate previous findings in human tumoral cells and suggest that the mode of action of this perfluorinated compound is not a peculiarity among mammalian cell types. On the other hand, the compound was not mutagenic in the Ames test, using four strains of Salmonella typhimurium in the presence or absence of rat S9 metabolic activation system.

[Use of ureterocalicostomy in child]. / Uso de la ureterocalicostomía en la edad pediátrica.

INTRODUCTION: There are many clinical situations in wich it may be difficult to perform appropriately an anastomosis between the renal pelvis and the proximal portion of the uretersafely. Preservation of the organ depens upon the availability of surgical resources. In fact, that principle becomes particularipy significant when dealing with children. OBJECTIVES: To describe different clinical and surgical situations in wich the successful performance of ureterocalicostomy has enable us to maintain three renal units with function from child patients and without complications. METHOD AND PATIENTS: Three children aged 8, 4 and 1 year were submitted to surgery because of pyelocaliceal lithiasis in the first case and secundary ureteropelvic stenosis in the remaning two cases. RESULTS: With a median follow-up of 12 months, all three renal units were preserved and, according to the isotopic study, functionality was improved in the two cases of ureteropelvic obstruction and the normal preoperative function was preserved in the first case. No complications occurred either during the immediate postoperative period or up to the date of this review. CONCLUSION: Ureterocalicostomy should be considered a suitable alternative in different clinical situations in wich the ureteropelvic continuity could be compromised, or in cases of indundibulopelvic stenosis.

Prevention of vesicoureteral reflux at the time of complete primary repair of the exstrophy-epispadias complex.

INTRODUCTION: With Mitchell's technique it is possible to perform bladder closure, reconstruction of epispadias and the bladder neck in one single procedure in an exstrophy patient. However the most common postoperative complication is pyelonephritis secondary to vesicouretral reflux. Reflux is closely linked to bladder exstrophy due to an abnormal anatomic development of the distal ureteral segment and to a pathologic bladder disposition. This problem is normally solved in subsequent surgical procedures. TECHNICAL CONSIDERATIONS: We decided to apply the technique described by Gil-Vernet as a first step of a bladder exstrophy repair following the Mitchell's technique. This ureteral advancement by means of trigonoplasty is a simple surgical procedure for vesicouretral reflux that preserves the intrinsic and extrinsic periureteral musculature. It is quite a short procedure that has yielded rates of success over 90%. CONCLUSIONS: The realization of this antireflux technique together with the primary closure could avoid later surgical correction in patients whose have had multiple operations.

[Treatment of bladder instability (non-neurogenic hyperactive bladder) in children, with tolterodine]. / Tratamiento de la inestabilidad vesical (vejiga hiperactiva no neurógena) en niños, con Tolterodina.

INTRODUCTION: Overactive bladder (OB) is one of the no-neurogenic voiding dysfunctions whose prevalence has been precisely defined among the general population but not so among the paediatric population. Its clinical manifestations are various, and its association with other pathologies like enuresis, vesico-ureteral reflux (VUR) and recurrent infections is particularly significant in children. OB is basically managed with anticholinergic drugs. The efficacy of oxybutynin chloride has been sufficiently proved; however its dosage and side effects, although scarce in children, usually cause treatment discontinuation. OBJECTIVES: Tolterodine has been successfully used as an alternative therapy of OB in adults, however its use has not been sufficiently evaluated in children. Our objective is to determine tolterodine's efficacy and tolerability in the paediatric population suffering from OB. MATERIAL AND METHODS: A retrospective study of 72 children who were diagnosed no-neurogenic OB and who received no previous treatment. A concomitant urological pathology diagnostic protocol was applied to all cases, as well as a urodynamic test (UDT) and a neurological examination. Post-treatment UDT was performed to one group of patients. RESULTS: The mean age was 10.9 years and the children were assessed between 4 and 31 months after treatment initiation. Healing was proved through cistomanometry in 67% of the cases, there was improvement in 14% and 19% of the patients showed no changes in the UDT. Following the criteria of the International Children's Continence Society (ICCS) applied to those children with no post-treatment UDT, 51% were healed, 27% improved and 22% experienced no changes. None of the patients had to discontinue the treatment due to side effects. CONCLUSIONS: Tolterodine's tolerability and efficacy are good within the paediatric population, which turns it into an alternative to the traditional anticholinergics for the treatment of OB.