Using hyperrealistic simulations to improve digital informed consent for endourological procedures.

OBJECTIVES: To show that digital informed consent (DIC) improves the subjective understanding of information and, therefore, informed consent. PATIENTS AND METHODS: A nonblinded randomized controlled trial was performed in 84 patients who had undergone transurethral resection of bladder, transurethral resection of prostate, or ureterorenoscopy between July 2017 and March 2018. The DIC group watched a hyperrealistic simulation on a tablet device before surgery. After surgery and again 30 days later, both groups completed a validated questionnaire that measured subjective understanding, anxiety, and utility of and need for information. RESULTS: The mean ± SD age of the participants was 68.7 ± 11.1 years. Nine of 84 patients (10.7%) did not complete the questionnaire. A total of 42 patients were allocated to the DIC group and 42 to the control group. The mean ± SD score for immediate subjective understanding in the DIC group was 14.5% higher than in the control group (72% ± 17.5% vs 57.5% ± 23.5%, respectively; P = 0.006). There was no statistical difference in anxiety, utility of and need for information relative to delayed subjective understanding. In subgroup analysis, subjective understanding scores were higher, but not significantly so, among patients with low and higher education levels in the DIC group than in the control group (68% ± 18.1% vs 54% ± 22.5% [P = 0.06] and 76% ± 18.3% vs and 66% ± 21.9%, respectively [P = 0.89]). CONCLUSION: Hyperrealistic simulations improved subjective understanding of information and, therefore, informed consent for endourological procedures.

Epidemiology, Diagnosis and Management of Penile Cancer: Results from the Spanish National Registry of Penile Cancer.

INTRODUCTION: Penile cancer (PC) is a rare malignancy with an overall incidence in Europe of 1/100,000 males/year. In Europe, few studies report the epidemiology, risk factors, clinical presentation, and treatment of PC. The aim of this study is to present an updated outlook on the aforementioned factors of PC in Spain. MATERIALS AND METHODS: A multicentric, retrospective, observational epidemiological study was designed, and patients with a new diagnosis of PC in 2015 were included. Patients were anonymously identified from the Register of Specialized Care Activity of the Ministry of Health of Spain. All Spanish hospitals recruiting patients in 2015 were invited to participate in the present study. We have followed a descriptive narration of the observed data. Continuous and categorical data were reported by median (p25th-p75th range) and absolute and relative frequencies, respectively. The incidence map shows differences between Spanish regions. RESULTS: The incidence of PC in Spain in 2015 was 2.55/100,000 males per year. A total of 586 patients were identified, and 228 patients from 61 hospitals were included in the analysis. A total of 54/61 (88.5%) centers reported ≤ 5 new cases. The patients accessed the urologist for visually-assessed penile lesions (60.5%), mainly localized in the glans (63.6%). Local hygiene, smoking habits, sexual habits, HPV exposure, and history of penile lesions were reported in 48.2%, 59.6%, 25%, 13.2%, and 69.7%. HPV-positive lesions were 18.1% (28.6% HPV-16). The majority of PC was squamous carcinoma (95.2%). PC was ≥cT2 in 45.2% (103/228) cases. At final pathology, PC was ≥pT2 in 51% of patients and ≥pN1 in 17% of cases. The most common local treatment was partial penectomy (46.9% cases). A total of 47/55 (85.5%) inguinal lymphadenectomies were open. Patients with ≥pN1 disease were treated with chemotherapy in 12/39 (40.8%) of cases. CONCLUSIONS: PC incidence is relatively high in Spain compared to other European countries. The risk factors for PC are usually misreported. The diagnosis and management of PC are suboptimal, encouraging the identification of referral centers for PC management.

[Management of chylous fistulas, a rare complication after urologic surgery]. / Manejo de las fístulas de quilo, una rara complicación tras cirugía urológica.

OBJECTIVE: To analyze the different treatments for postoperative chylous fistulae. METHODS: A literature review of the main treatments for postoperative chylous fistula, providing our initial experience of two cases of patients with postsurgical chylorrea, with conservative treatment. RESULTS: There is very limited experience in the treatment of chylous ascites. According to the literature reviewed, Octreotide (somatostatin analogue) can be used, to decrease fistula output. Both our cases cases were treated successfully with subcutaneous octreotide, with drain debit decrease in about 3 days. CONCLUSIONS: The use of octreotide appears to be an effective treatment in the management of chylous fistulae, and it is suggested by some authors as first-line treatment in the management of these, thus decreasing the complications that can appear due to chyle loss.

Fístula arterioileal: experiencia en un hospital terciario y revisión de la literatura / Arterial-ileal fistula: experience from a tertiary referral center and literature review

Introducción y objetivo: la fístula entre la arteria ilíaca y el conducto ileal (Bricker) es una patología con un elevado riesgo vital. El objetivo de este artículo es dar a conocer esta entidad, describir su presentación, sus métodos diagnósticos y su tratamiento basados en los casos en un hospital terciario y en la revisión de la literatura. Material y métodos: presentamos los casos de fístulas arterioileales ocurridos en nuestro centro entre 2016 y 2020. Se realizó una exhaustiva revisión de la literatura publicada hasta la fecha mediante la búsqueda en PubMed de artículos publicados entre 1971 y 2020, incluyendo las palabras claves “arterial ileal conduit fistula” y seleccionando únicamente los artículos en español e inglés. Resultados: se identificaron 4 casos en nuestro centro. Se reconocieron en la búsqueda bibliográfica 13 artículos que describían 16 casos de fístulas arterioileales. La mayoría compartía factores comunes de riesgo y el abordaje quirúrgico fue mayoritariamente la cirugía abierta. El abordaje adecuado parece ser la combinación de cirugía abierta y endovascular, efectiva en 3 de nuestros 4 casos. Conclusión: la fístula entre la arteria ilíaca y el conducto ileal es una complicación infrecuente y grave, con una mortalidad en torno al 44 %. Resulta difícil de diagnosticar, salvo que exista alta sospecha clínica, con pocos casos descritos en la literatura. Es fundamental tener en cuenta la historia clínica previa del paciente. (AU)

Introduction and objective: the presence of a fistula between the iliac artery and the ileal conduit is a live-threatening condition that must be known and, therefore, suspected after a massive bleeding through the ileal conduit. The objective of this article is to present the arterial-ileal fistula, describe its presentation, diagnostic methods, and treatments, based on the cases presented in a tertiary referral center and literature review. Material and methods: all cases of arterial-ileal fistulas collected at our center from 2016 through 2020 are presented here. A comprehensive literature review published to date was also conducted based on a search for articles published from 1971 through 2020 on the PubMed database with the keywords “arterial ileal conduit fistula”, including studies only published in English and Spanish languages. Results: a total of 4 cases were identified in our center. A total of 13 articles describing 16 cases of arterial-ileal fistula were identified from the medical literature, most of them with some risk factors in common. The approach followed was mainly open surgery. The proper treatment seems to be a combination between open surgery and endovascular approaches, which turned out to be effective in 3 of our 4 cases. Conclusion: a fistula between the artery and the ileal conduit is a rare but serious complication, with a 44% mortality rate. It is difficult to diagnose unless there is clinical suspicion involved, with only a few cases reported in the medical literature. We should consider the patient’s pathological history to identify this entity. (AU)

Manejo de las fístulas de quilo, una rara complicación tras cirugía urológica / Management of chylous fistulas, a rare complication after urologic surgery

OBJETIVO: Analizar los diferentes tratamientos para la fístula de quilo postoperatorias. MÉTODOS: Realizamos una revisión bibliográfica de los principales tratamientos para la fístula de quilo postoperatorias, aportando nuestra experiencia inicial de dos casos de pacientes con quilorrea postquirúrgica, con tratamiento conservador. RESULTADO: Existe muy poca experiencia del tratamiento de la ascitis quilosa, puede utilizarse, según la literatura revisada, el octreótide (análogo de la somatostatina), aportamos fueron tratados exitosamente con octreótide subcutáneo, disminuyendo el débito del drenaje en 3 días aproximadamente. CONCLUSIONES: El uso del octreótide aparece como un tratamiento efectivo en el manejo de las fístulas quilosas, y sugerido por algunos autores como tratamiento de primera línea en el manejo de estas, disminuyendo así las complicaciones que la pérdida de quilo puede conllevar

OBJECTIVE: To analyze the different treatments for postoperative chylous fistulae. METHODS: A literature review of the main treatments for postoperative chylous fistula, providing our initial experience of two cases of patients with postsurgical chylorrea, with conservative treatment. RESULTS: There is very limited experience in the treatment of chylous ascites. According to the literature reviewed, Octreotide (somatostatin analogue) can be used, to decrease fistula output. Both our cases cases were treated successfully with subcutaneous octreotide, with drain debit decrease in about 3 days. CONCLUSIONS: The use of octreotide appears to be an effective treatment in the management of chylous fistulae, and it is suggested by some authors as first-line treatment in the management of these, thus decreasing the complications that can appear due to chyle loss

Extravasación urinaria renal espontánea / Spontaneous renal urinary extravasation

La extravasación espontánea de orina, descrita por Albarrán y publicada por Sole se consideraba como un hallazgo radiológico poco frecuente y la definió en 198 como la salida de orina fuera del tracto urinario en ausencia de trauma, de intervención quirúrgica previa o reciente y tampoco sin antecedente de instrumentación urológica o de urografía excretora practicada con compresión externa. Se presenta a un paciente de 28 años, sin antecedentes de interés, que acudió con cuadro astenia de 1 mes de evolución, asociado a dolor en fosa lumbar izquierda. Que fue estudiado mediante ecografía y tomografía computarizada (TC). Las exploraciones radiológicas identificaron múltiples litiasis en uréter proximal y distal izquierdo. Voluminosa colección de baja densidad rodeando al riñón izquierdo, limitada por la fascia pararrenal sugestiva de urinoma, identificando solución de continuidad en cáliz superior, que se comunica con el urinoma. El tratamiento inicial del paciente fue la colocación de Nefrostomía percutánea de urgencia, para realizar posteriormente, ureteroscopia con ascensión de las litiasis y extracción de estas mediante pielolitotomía abierta. Conclusión: El conocimiento de la clínica y de los hallazgos radiológicos de la extravasación urinaria espontánea por litiasis ureteral en las distintas pruebas de imágenes son cruciales para el manejo de los pacientes afectados por esta infrecuente complicación...

Spontaneous extravasation of urine, described by Albarran and published by Sole was considered a rare radiological finding in 198 and defined as the flow of urine out of the urinary tract in the absence of trauma, previous surgery or recent nor no history of urological instrumentation or excretory urography performed with external compression. We report a patient of 28 years, with no history of interest came with asthenia of 1 month’s duration, associated with pain in left lumbar fossa. That was studied by ultrasound and computed tomography (CT). The radiological identified multiple stones in proximal and distal left ureter. Collection bulky low density surrounding the left kidney limited by suggesting pararenal urinoma fascia, identifying continuity solution upper calyx, which communicates with the urinoma. The patient’s initial treatment was percutaneous nephrostomy placement of urgency for later ascension of the stones with ureteroscopy and removal of these by open pyelolithotomy. The knowledge of the clinical and radiological findings of spontaneous urinary extravasation with ureteral stones in various imaging tests are crucial for the management of patients affected by this rare complication...

Valor actual de la biopsia de vesículas seminales en pacientes con cáncer de próstata e influencia de la prostatecmía radical en pacientes con infiltración seminal / Current value of seminal vesicle biopsy in patients with prostate cancer and influence of radical prostatectomy in patients with seminal vesicle invasion

OBJETIVO: Comprobar si la prostatectomíaradical puede influir favorablemente en la supervivenciacáncer-específica (SCE), tiempo libre de hormonorresistenciay tiempo libre de metástasis (TLM) y calidad de vida (CV), en pacientes con adenocarcinomade próstata e invasión de vesículas seminales, así como, realizar una actualización de nuestro pensamientosobre la biopsia de vesículas seminales.MÉTODOS: Se incluyeron 114 pacientes En 46 se diagnosticó invasión de vesículas seminales tras la realizaciónde prostatectomía radical (PRVS) de intención curativa y en 68 casos, la invasión fue diagnosticada mediante la biopsia de las mismas (BxVS) no practicándosela prostatectomía radical. Se compararon la SCE, tiempo hasta la hormonorresistencia desde el inicio del tratamiento hormonal (THR), TLM y CV medida en necesidadesde atención hospitalaria en ambos grupos. La mediana del tiempo de seguimiento fue de 52,6 meses.RESULTADOS: No hubo diferencias estadísticamente signi- ficativas entre ambos grupos en SCE, THR, TLM y CV. La SCE a 3 y 5 años fue del 100% y 80.77% para el grupo PRVS y del 92.03% y 77,46% para el grupo BxVS. El THR a 3 y 5 años fue del 90.6% y 58.7% para el grupo PRVS y del 74,4% y 56,2% para el grupo BxVS. En la regresión de Cox se mostraron predictores independientes de SCE el grado primario y suma de Gleason y de THR el estadio clínico.CONCLUSIONES: La prostatectomía radical como monoterapiano influye de forma estadísticamente significativaen el tiempo de seguimiento realizado, en la SCE, THR, TLM y CV de los pacientes con cáncer de próstata e invasión de vesículas seminales asociada a otros factoresde mal pronóstico (Gleason y PSA desfavorables). El valor de la biopsia de vesículas seminales permaneceen el estudio de nuevos tratamientos multimodales, como pueden ser la quimioterapia en combinación con la cirugía, y esta pendiente de definir en la planificaciónde la radioterapia y la criocirugía

OBJECTIVES: To evaluate if radicalprostatectomy may positively influence cancer-specific survival (CSS), hormone-resistance-free time, metastasis-free time, and quality of life(QoL) of patients with prostate adenocarcinoma and seminal vesicle invasion, and also to update our thoughts about seminal vesicle biopsy.METHODS: 114 patients were included. Forty-six cases were diagnosed of seminal vesicle invasion after radical prostatectomy; 68 cases were diagnosed of seminal vesicle invasion after biopsy, not undergoing then surgery. Cancer specific survival, time to hormone resistance from the start of hormonal treatment, metastasis free time and QoL, measured as need for hospital care, were compared between groups. Median follow-up time was 52.6 mos.RESULTS: There were not statistically significant differences between groups in CSS, time to hormone resistance, metastasis free time and QoL. Three and five-year cancer specific survival were 100% and 80.77% for the radical prostatectomy group and 74.4% and 56.2% for the biopsy group. Primary grade and Gleason Score were independent predictors for CSS in the Cox regression test; clinical stage was independent predictor for time to hormone resistance.CONCLUSIONS: Radical prostatectomy as monotherapy does not show a statistically significant influence onfollow-up time, CSS, time to hormone resistance, metastasis free time or QoL in patients with prostate cancer and seminal vesicle invasion associated with other bad prognostic factors (unfavourable Gleason and PSA). The value of seminal vesicle biopsy remains for the study of new multimodal treatments, such as chemotherapy + surgery, and it is to be defined in the planning of radio and cryosurgery

Vigencia actual de los nomogramas en la estadificación del cáncer de próstata / Current validity of nomograms for prostate cancer staging

OBJETIVO: En este trabajo se presenta una revisión del concepto de “nomograma” aplicado al cáncer de próstata y específicamente como medio de estadificación.MÉTODOS/RESULTADOS: Para ello se describen los parámetros indispensables para evaluar este tipo de modelos predictivos, a saber: Calibración, Discriminacióny Utilidad Clínica. Estos requisitos son analizados sobre un caso práctico real en nuestro medio asistencial comparando las “Tablas de Partin” y el “Nomograma del Hospital Universitario Miguel Servet”, demostrando su correcta calibración, discriminación y utilidad clínica previa selección de adecuados puntos de corte.CONCLUSIÓN: La aplicación del modelo predictivo a nuestra práctica asistencial ha logrado una infraestadificaciónclínica tras prostatectomía radical del 17,3%

OBJETIVE: This paper presents a review of the concept of “nomogram” applied to prostate cancer, and specifically as a staging tool.METHODS/RESULTS: We describe the essentialparameters for the evaluation of such type of predictive models: Calibration, discrimination and clinical usefulness. Such requisites are analyzed using a real clinical case in our clinical setting, comparing the “Partin`s tables” and the “Miguel Servet University Hospital´s nomogram”. We demonstrate its correct calibration, discrimination and clinical usefulness after previous selection of proper cut points.CONCLUSION: The application of the predictivemodel to our clinical practice has achieved a clinical understaging of 17.3% after radical prostatectomy