Pelvic exenteration for gynecologic malignancies: Postoperative complications and oncologic outcomes. / Exenteración pélvica para neoplasias ginecológicas: Complicaciones postoperatorias y resultados oncológicos.

INTRODUCTION AND OBJECTIVE: To evaluate complications, morbidity and oncologic outcomes of pelvic exenteration as treatment for gynecologic malignancies. MATERIALS AND METHODS: Between 2008 and 2015, a total of 35 patients underwent pelvic exenteration, due to recurrence of gynecological cancer. Surgical outcomes, early and late postoperative complications, and recurrence/survival outcomes were assessed. RESULTS: Mean patient age was 53.8 years. Anterior exenteration was done in 20 patients, while 15 were total exenterations. Ileal conduit was done in 24 patients, while 8 received a neobladder and 3 a cutaneous ureterostomy. Postoperative complications were divided in 2groups, early (<30 days) and late complications (>30 days). A total of 25 patients (71.4%) had one or more early complications; 16 (45.7%) had fever due to a urinary tract infection, pyelonephritis or intra-abdominal collection; 2 (5.7%) developed a vesicovaginal fistula; 4 (11.4%) a rectovaginal fistula; 3 (8.5%) acute kidney failure and one (2.85%) uronephrosis. Regarding to late complications, 8patients (22.8%) had fever. Six (17%) presented with uronephrosis, and 5 (14.2%) with ureteral-pouch stricture. Five patients (14.2%) had acute renal insufficiency, 3 (8,6%) rectovaginal fistula and one (2.85%) urinary fistula. Mean follow up time was 20.3 month (2-60). A total of 22patients (62.8%) were free of disease. Another 13 (37.1%) patients relapsed. Only 4 (11.4%) patients died after pelvic exenteration due to underlying disease. CONCLUSION: Pelvic exenteration has a high rate of complications and morbidity, but can be the last curative opportunity in patients with recurrent or persistent gynecologic malignancies. This procedure should be performed by multidisciplinary, experienced teams in a tertiary medical center.

The role of radical prostatectomy as an initial approach for the treatment of high-risk prostate cancer. / Papel de la prostatectomía radical como abordaje inicial en el tratamiento del cáncer de próstata de alto riesgo.

CONTEXT: The treatment of high-risk prostate cancer requires a multimodal approach to improve control of the disease. There is still no consensus as to the initial strategy of choice. The aim of this study is to review the results of radical prostatectomy as first step in management of patients with high-risk disease. ACQUISITION OF EVIDENCE: A search was conducted on PubMed of English and Spanish texts. We included those studies that reported the results of radical prostatectomy in patients with high-risk prostate cancer, as well as those that compared radical prostatectomy with other treatment alternatives. The last search was conducted in November 2015. SYNTHESIS OF THE EVIDENCE: The advantages of radical prostatectomy include a better pathological analysis, more accurate staging, better local control of the disease and better follow-up and adjuvant therapy strategies. When compared with external radiation therapy plus hormonal blockade, the patients who underwent prostatectomy had greater chances of healing and longer cancer-specific survival. The patients who most benefit from this approach are younger, have fewer comorbidities and no evidence of organ metastases. CONCLUSIONS: The available scientific evidence to date is not without bias and confounders; however, they appear to favour radical prostatectomy as the initial approach of choice for high-risk prostate cancer.

[Management of malignant ureteral obstruction.] / Manejo de la obstrucción ureteral maligna.

OBJECTIVE: To describe the different therapeutic alternatives in malignant ureteral obstruction (MUO), and to analyze short and long-term results. METHODS: We conducted a bibliographic search about MUO in Spanish and English languages in PubMed and Google Scholar. We examined the most relevant reviews, original manuscripts and their respective citations. Last search was on April 2016. RESULTS: Polymeric double J stent is the cheapest and most accessible internal urinary diversion, but has also the shortest duration. Early and late failure rates were 0-35% and 14-49% respectively. Mean time to late failure was 3-12 months. Percutaneous nephrostomy is the safest alternative in terms of failure rates, though it has frequent complications such as tube dislodgement, and may have a negative effect on quality of life. The only metallic double J stent with enough bibliographic background is the Resonance® stent. Early failure was 0-15% and late failure 4-41%, with a mean time to late failure of 2.6-13 months. Regarding metallic stents, Memokath 051® has obtained the best results, with 0-5% early failure rates, 19-49% late failures and mean time to late failure of 7-11 months. In patients with polymeric double J stent failure, patients benefited from tandem double J stents, metallic double J catheters or metallic stents, avoiding the need of a percutaneous nephrostomy. The evidence level was low in all cases. CONCLUSIONS: Results in MUO are very heterogeneous and have a low evidence level. Factors that influence results include stent characteristics, status and prognosis of the obstructive condition and probably patient and physician's preferences. Polymeric double J stents seem to have higher early and late failure rates than metallic double J catheters and metallic stents. Even though, the difference is not clearly evident. Prospective, multicenter, multidisciplinary trials are necessary to elucidate convenience and adequate selection of each type of stent.

Exenteración pélvica para neoplasias ginecológicas: Complicaciones postoperatorias y resultados oncológicos / Pelvic exenteration for gynecologic malignancies: Postoperative complications and oncologic outcomes

Introducción y objetivo: Evaluar las complicaciones, morbilidad y resultados oncológicos de la exenteración pelviana como tratamiento para los tumores ginecológicos. Materiales y métodos: Entre enero de 2008 y diciembre de 2015, 35 pacientes fueron tratadas mediante exenteración pelviana debido a recurrencia de cáncer de origen ginecológico. Se evaluaron resultados quirúrgicos, complicaciones postoperatorias tempranas y tardías, recurrencia y sobrevida. Resultados: La edad media de las pacientes fue de 53,8 años. Se realizó exenteración anterior en 20 pacientes, mientras que en 15 se realizó exenteración total. En 24 pacientes se realizó derivación urinaria de tipo Bricker, neovejiga ileal en 8 y ureterostomía cutánea en 3. Las complicaciones postoperatorias se dividieron en 2 grupos: tempranas (<30 días) y tardías (>30 días). Un total de 25 pacientes (71,4%) tuvieron una o más complicaciones tempranas; 16 (45,7%) tuvieron fiebre debido a infección urinaria, pielonefritis o colección intraabdominal; 2 (5,7%) evolucionaron con fístula vesicovaginal; 4 (11,4%) con fístula recto vaginal; 3 (8,5%) con insuficiencia renal aguda y uno (2,85%) con uronefrosis. Con respecto a las complicaciones tardías, 8 pacientes (22,8%) tuvieron fiebre. Seis (17%) se presentaron con uronefrosis y 5 (14,2%) con estenosis uretero-pouch. Cinco pacientes (14,2%) tuvieron insuficiencia renal aguda, 3 (8,6%) fístula recto vaginal y una (2,85%) fístula urinaria. El tiempo de seguimiento medio fue de 20,3 meses (rango 2-60). En total, 22 pacientes (62,8%) permanecieron libres de enfermedad. Otras 13 pacientes (37%) recayeron y 4 pacientes (11,4%) murieron luego de la exenteración pelviana debido a la enfermedad de base. No hubo muertes relacionadas a la cirugía. Conclusión: La exenteración pelviana tiene una alta tasa de complicaciones, pero puede ser la última oportunidad curativa en pacientes con tumores ginecológicos. Este procedimiento debería llevarse a cabo por equipos multidisciplinarios, con experiencia, en centros médicos de alta complejidad

Introduction and objective: To evaluate complications, morbidity and oncologic outcomes of pelvic exenteration as treatment for gynecologic malignancies. Materials and methods: Between 2008 and 2015, a total of 35 patients underwent pelvic exenteration, due to recurrence of gynecological cancer. Surgical outcomes, early and late postoperative complications, and recurrence/survival outcomes were assessed. Results: Mean patient age was 53.8 years. Anterior exenteration was done in 20 patients, while 15 were total exenterations. Ileal conduit was done in 24 patients, while 8 received a neobladder and 3 a cutaneous ureterostomy. Postoperative complications were divided in 2 groups, early (< 30 days) and late complications (> 30 days). A total of 25 patients (71.4%) had one or more early complications; 16 (45.7%) had fever due to a urinary tract infection, pyelonephritis or intra-abdominal collection; 2 (5.7%) developed a vesicovaginal fistula; 4 (11.4%) a rectovaginal fistula; 3 (8.5%) acute kidney failure and one (2.85%) uronephrosis. Regarding to late complications, 8 patients (22.8%) had fever. Six (17%) presented with uronephrosis, and 5 (14.2%) with ureteral-pouch stricture. Five patients (14.2%) had acute renal insufficiency, 3 (8,6%) rectovaginal fistula and one (2.85%) urinary fistula. Mean follow up time was 20.3 month (2-60). A total of 22 patients (62.8%) were free of disease. Another 13 (37.1%) patients relapsed. Only 4 (11.4%) patients died after pelvic exenteration due to underlying disease. Conclusion: Pelvic exenteration has a high rate of complications and morbidity, but can be the last curative opportunity in patients with recurrent or persistent gynecologic malignancies. This procedure should be performed by multidisciplinary, experienced teams in a tertiary medical center