Does robot-assisted laparoscopic ileocystoplasty (RALI) reduce peritoneal adhesions compared with open surgery?

OBJECTIVES: To compare perioperative outcomes between open ileocystoplasty and robot-assisted laparoscopic ileocystoplasty (RALI) in a porcine model, as objective data comparing outcomes between these two approaches in children with neurogenic bladder are lacking. We specifically examined differences in postoperative peritoneal adhesion formation between the groups. MATERIALS AND METHODS: In all, 20 pigs were assigned to an open ileocystoplasty or RALI study arm. All the pigs underwent an initial urodynamic study (UDS). In the RALI arm, reconstructive steps were performed intracorporeally using a standard da Vinci(®) system. Postoperatively, variables including first stool, weight gain, and complications were recorded. After 42 days, the pigs underwent a final UDS followed by adhesion assessment. Intraperitoneal adhesions were quantified by a third-party 'blinded' surgeon according to previously described objective scoring systems. RESULTS: Preoperative variables including UDS were similar in both groups. Overall operating time was significantly shorter for open ileocystoplasty than for RALI (149 vs 287 min, P < 0.001, respectively). Postoperatively, all variables including time to first stool, weight gain, and urodynamic parameters were similar amongst the groups. Pigs in the open arm developed significantly more adhesions (P = 0.02) and adhesions with a higher complexity (P = 0.04). CONCLUSIONS: In this porcine model, RALI achieved similar functional outcomes as the open approach, but required longer procedural times. The number and complexity of surgical adhesions among the groups favoured the RALI cohort. This may be of clinical significance in the paediatric spina bifida population, who generally undergo multiple surgical procedures in their lifetime, with increased risk for development of adhesions and subsequent intestinal obstruction.

Short (≤ 1 mm) positive surgical margin and risk of biochemical recurrence after radical prostatectomy.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: It has been suggested that a very short positive margin does not confer additional risk of BCR after radical prostatectomy. This study shows that even very short PSM is associated with increased risk of BCR. OBJECTIVE: To re-evaluate, in a larger cohort with longer follow-up, our previously reported finding that a positive surgical margin (PSM) ≤ 1 mm may not confer an additional risk for biochemical recurrence (BCR) compared with a negative surgical margin (NSM). PATIENTS AND METHODS: Margin status and length were evaluated in 2866 men treated with radical prostatectomy (RP) for clinically localized prostate cancer at our institution from 1994 to 2009. We compared the BCR-free survival probability of men with NSMs, a PSM ≤ 1 mm, and a PSM < 1 mm using the Kaplan-Meier method and a Cox regression model adjusted for preoperative prostate-specific antigen (PSA) level, age, pathological stage and pathological Gleason score (GS). RESULTS: Compared with a NSM, a PSM ≤ 1 mm was associated with 17% lower 3-year BCR-free survival for men with pT3 and GS ≥ 7 tumours and a 6% lower 3-year BCR-free survival for men with pT2 and GS ≤ 6 tumours (log-rank P < 0.001 for all). In the multivariate model, a PSM ≤ 1 mm was associated with a probability of BCR twice as high as that for a NSM (hazard ratio [HR] 2.2), as were a higher PSA level (HR 1.04), higher pathological stage (HR 2.7) and higher pathological GS (HR 3.7 [all P < 0.001]). CONCLUSION: In men with non-organ-confined or high grade prostate cancer, a PSM ≤ 1 mm has a significant adverse impact on BCR rates.

Focal therapy for clinically localized prostate cancer.

The stage migration for newly diagnosed prostate cancer, improvements in prostate imaging, and devices capable of inducing subtotal prostate ablation have allowed for the formal study and evaluation of focal therapy for low-risk prostate cancer. Significant limitations remain: 1) the need for more accurate pre-treatment determination of cancer location, extent, and size, 2) determining appropriate methods of post-treatment surveillance and definitions of clinical progression, 3) the uncertainty whether repeat treatment, by focal or whole-gland therapy, is effective and safe. Clinical trials are ongoing to provide data on the feasibility and reliability of these new therapies, the capability of eradicating cancers, rates of secondary treatment, and impact on urinary and sexual function.

[Quality of life in patients with prostate cancer: validation of an instrument for clinical practice]. / Calidad de vida en pacientes con cáncer de próstata: la validación de un instrumento para la práctica clínica.

OBJECTIVES: Currently there are instruments to evaluate the different features of the impact on quality of life in those patients with prostate cancer undergoing any type of treatment, but most of them have 50 or more questions and they are difficult to apply in clinical practice. An English validation of a shortened version of the EPIC (Expanded Prostate Cancer Composite), the most used instrument to measure the quality of life in patients with prostate cancer, has been published recently. This version called EPIC-CP (Expanded Prostate Cancer Composite-Clinical Practice) consists of 16 questions arranged in a page, for easy and rapid clinical application. The objective of this work is to validate a Spanish version of the EPIC-CP. METHOD: An inversa-directa Spanish translation of the original version was performed. The EPIC-CP and EQ5D questionnaires were applied to 46 patients eligible to be subjected to different treatments - open prostatectomy (OP), Robotic Prostatectomy (RP), brachytherapy (Br) or conformational radiotherapy (CR) - and 82 patients already treated (9 OP, 13 RP, 7 Br, 4 CR). For reliability evaluation, the Cronbach's alpha was used to test the internal consistency for each domain of the EPIC-CP. Treated and untreated patients' scores were compared with the Wilcoxon range sum test to assess the sensitivity to change. RESULTS: Cronbach's alpha was elevated in all the EPIC-CP domains (near or greater than 0.7), indicating a high internal consistency. There was no significant difference in age and educational level between treated and untreated patients. We found significant differences between treated and untreated patients in the total EPIC CP score, in the domains of urinary incontinence, bowel function, sexual function and hormonal function. CONCLUSION: The Spanish version of the EPIC-CP is reliable and valid, so it is a useful tool to measure the quality of life in patients with prostate cancer, as well as the impact of different treatments.

Traumatic testicular dislocation.

INTRODUCTION: Traumatic testicular dislocation is a rare entity. It occurs after a direct blunt scrotal trauma causing the testicle to migrate outside the scrotum, most frequently to the superficial inguinal region. MATERIALS AND METHODS: A review of the diagnostic database of our two institutions was performed searching for complex genital trauma between 1990 and 2012. RESULTS: Seven cases of traumatic testicular dislocation were identified (four on the left side; one on the right side and two bilateral) for a total of nine testicles. Six were motorcycle accidents, and the other case suffered a pelvic crush injury. All victims had significant associated injuries, one case had an open dislocation and two were killed by the accident. The testicle was located at the inguinal region in four cases at the suprapubic area in four, and the other was an open dislocation. Diagnosis was suspected with the physical examination and confirmed by Doppler ultrasound; however, in one case, the diagnosis was missed during several weeks. In one case, the testicle was reduced into the scrotum immediately at the emergency department. Two cases were operated shortly after admission, performing testicular reduction into the scrotum and standard orchidopexy. Two other cases underwent delayed intervention, and both needed release of peri-testicular adhesions. Two cases (both bilateral) died at the accident site and were diagnosed by autopsy. In all surviving cases, it was possible to obtain a satisfactory orchidopexy with gonadal preservation. CONCLUSIONS: Traumatic testicular dislocation is rare and diagnosis can be elusive. It should be suspected in motorcycle and high-energy accidents around the groin area and depends on a careful physical examination. With proper management, prognosis is excellent.

Management of the ventriculo-peritoneal shunt in pediatric patients during robot-assisted laparoscopic urologic procedures.

INTRODUCTION: Infection or malfunction of ventriculo-peritoneal (VP) shunts is a severe complication during laparoscopic surgery involving the gastrointestinal or urinary tract. It has been recently suggested to externalize the shunt or convert into a ventriculo-atrial shunt to prevent this complication with laparoscopic approach. Herein, we present a novel technique for management of the VP shunt during robot-assisted laparoscopic (RAL) urologic procedures. MATERIALS AND METHODS: After port placement and diagnostic peritoneoscopy, an Endopouch bag (Ethicon Endo-Surgery) was inserted into the peritoneal cavity and the distal end of the shunt was placed into the pouch. The Endopouch suture was synched around the shunt and the pouch was placed in the subhepatic space during the surgery. The intraperitoneal pressure was maintained at 12 mm Hg during the entire procedure. Metronidazole, gentamicin, and vancomycin were administered as prophylaxis. Following the completion of the surgery and profuse irrigation of the peritoneal cavity, the shunt was repositioned within the peritoneum. We evaluated perioperative shunt-related complications. RESULTS: We used this technique in four patients with VP shunt undergoing RAL cystoplasty and appendicovesicostomy and/or colonic enema channel formation. The average age of the patient at surgery was 10.8 (7-14) years. One patient was converted to open because of failure to progress due to multiple adhesions and the shunt was externalized temporarily. At a mean follow-up of 13 (3-20) months, no shunt-related complications were seen. CONCLUSIONS: In our preliminary experience, the use of an intracorporeal Endopouch bag with controlled pneumoperitoneal pressure to protect the VP shunt may be an effective alternative to prevent complications related to it during RAL urologic surgery involving the gastrointestinal or urinary tract. Further studies will be needed to confirm our results.

Impact of prostate weight on probability of positive surgical margins in patients with low-risk prostate cancer after robotic-assisted laparoscopic radical prostatectomy.

OBJECTIVE: To evaluate the impact of prostate weight (PW) on probability of positive surgical margin (PSM) in patients undergoing robotic-assisted radical prostatectomy (RARP) for low-risk prostate cancer. METHODS: The cohort consisted of 690 men with low-risk prostate cancer (clinical stage T1c, prostate-specific antigen <10 ng/mL, biopsy Gleason score ≤6) who underwent RARP with bilateral nerve-sparing at our institution by 1 of 2 surgeons from 2003 to 2009. PW was obtained from the pathologic specimen. The association between probability of PSM and PW was assessed with univariate and multivariate logistic regression analysis. RESULTS: A PSM was identified in 105 patients (15.2%). Patients with PSM had significant higher prostate-specific antigen (P = .04), smaller prostates (P = .0001), higher Gleason score (P = .004), and higher pathologic stage (P < .0001). After logistic regression, we found a significant inverse relation between PSM and PW (OR 0.97%; 95% confidence interval [CI] 0.96, 0.99; P = .0003) in univariate analysis. This remained significant in the multivariate model (OR 0.98%; 95% CI 0.96, 0.99; P = .006) adjusting for age, body mass index, surgeon experience, pathologic Gleason score, and pathologic stage. In this multivariate model, the predicted probability of PSM for 25-, 50-, 100-, and 150-g prostates were 22% (95% CI 16%, 30%), 13% (95% CI 11%, 16%), 5% (95% CI 1%, 8%), and 1% (95% CI 0%, 3%), respectively. CONCLUSIONS: Lower PW is independently associated with higher probability of PSM in low-risk patients undergoing RARP with bilateral nerve-sparing.

Robotic technologies in surgical oncology training and practice.

The modern-day surgeon is frequently exposed to new technologies and instrumentation. Robotic surgery (RS) has evolved as a minimally invasive technique aimed to improve clinical outcomes. RS has the potential to alleviate the inherent limitations of laparoscopic surgery such as two dimensional imaging, limited instrument movement and intrinsic human tremor. Since the first reported robot-assisted surgical procedure performed in 1985, the technology has dramatically evolved and currently multiple surgical specialties have incorporated RS into their daily clinical armamentarium. With this exponential growth, it should not come as a surprise the ever growing requirement for surgeons trained in RS as well as the interest from residents to receive robotic exposure during their training. For this reason, the establishment of set criteria for adequate and standardized training and credentialing of surgical residents, fellows and those trained surgeons wishing to perform RS has become a priority. In this rapidly evolving field, we herein review the past, present and future of robotic technologies and its penetration into different surgical specialties.

Nefrectomía radical derecha con resección de trombo tumoral en vena cava inferior nivel III / Right radical nephrectomy with inferior vena cava tumor thrombus level III

INTRODUCCIÓN: El CCR presenta una tendencia conocida a propagarse mediante la formación de trombo tumoral a la vena renal o vena cava inferior (4-10 por ciento ) El nivel que alcanza dicho tumor, está en directa relación con la sobrevida estimada a 5 años. MATERIALES Y MÉTODOS: Se presenta un caso de un paciente de sexo masculino de 58 años de edad, con antecedentes de Dm2 No IR y Tabaquismo crónico, el cual consulto por cuadro de 10 meses de evolución caracterizado por hematuria macroscópica. Dentro de la analítica sanguínea, destacaba paciente anémico, con hemoglobina de 8 g/dL y creatinemia de 1.1mg/mL. Se solicita URO-TAC, evidenciándose tumor renal derecho, de 18 cms en su eje largo, asociado a trombo en vena cava inferior, que se alojaba hasta el diafragma (Nivel III), no observándose metástasis a distancia o adenopatías de aspecto patológico. RESULTADOS: Se propone nefrectomía radical abierta por vía anterior, posteriormente se aísla y controla VCI, la cual se abre en su eje longitudinal. Se realiza trombectomia convencional con cierre primario, verificando hermeticidad del vaso. El tiempo operatorio total fue de 260 minutos, con un sangrado estimado de 1600ml. Se requirió transfusión de 3U de GR intraoperatorios sin incidentes reportados. El manejo post-operatorio inmediato fue en unidad de cuidados intensivos por 24 hrs, con un tiempo hospitalario total de 5 días. El paciente evoluciona favorablemente, sin complicaciones, destacando dentro de los exámenes de control, creatinina de 1.3 mg/dL. A la fecha, no hay evidencia de enfermedad residual clínica, o radiológica. CONCLUSIÓN: La nefrectomía radical convencional con trombo en vena cava inferior (nivel III) es el estándar de tratamiento para pacientes cáncer renal localmente avanzado en condiciones para afrontar la cirugía

INTRODUCTION: CCR presents a known trend to spread by means of a tumor thrombus in renal vein or inferior vena cava (4-10 pertcent ) The level reached by such tumor has a direct relation with the 5-year survival rate. MATERIALS AND METHODS: A 58-year old male patient presented with a history of Dm2 No IR and chronic tabaquism who enquired about 10-month symptoms, characterized by macroscopic hematuria. Amongst the blood analytics, an anemic patient stood out, whose hemoglobin level is 8 g/dL and 1.1mg/mL creatinemia. URO-TAC is requested which shows right kidney tumor, of 18 centimeters on its longer axis, associated to thrombus in the inferior vena cava, extended to the diaphragm (Level III), without presence of distant metastasis or adenopathies with pathological aspect. RESULTS: Anterior open radical nephrectomy is suggested, posteriorly isolated and VCI controlled, which is performed on its longitudinal axis. Conventional thrombectomy with primary closing and verification of vessel hermetism are performed. Operative time was 260 minutes. Estimated blood loss was 1600ml. 3U of GR intraoperative transfusion was required and no incidents were reported. Postoperative management took place in intensive care unit for 24 hours and the patient was discharged 5 days after surgery. The patient evolves favorably, without complications, presenting a 1.3 mg/dL creatinine level. To date, there is no evidence of clinical residual or radiological illness. CONCLUSION: Radical nephrectomy with inferior vena cava thrombus (level III) is the standard treatment for kidney cancer patient presenting local progression in a condition to withstand surgery.

Pase de guardia: información relevante y toma de decisiones en clínica médica. Estudio prospectivo / Handoffs: relevant information and decision making in internal medicine. A prospective study

Introducción. El pase de guardia es una actividad médica en la que se transfiere información y responsabilidad entre profesionales en situaciones de discontinuidad o transiciones en el cuidado de los pacientes. Los pases de guardia son fuente de errores médicos, a pesar de lo cual la programación formal en la competencia específica está ausente en los currículos de las residencias médicas. En este sentido, implementamos el proyecto educativo ‘Pase de guardia oral y escrito en la residencia de clínica médica’. Materiales y métodos. Definimos el constructo ‘información relevante’ a partir de cinco ítems, uno sistémico y cuatro cognitivos. Se analizó la prevalencia de los déficits de información relevante y su repercusión sobre la práctica clínica. Resultados. En 230 protocolos de guardia, la prevalencia de déficits de información relevante fue del 31,3% (n = 72) y afectó tanto al ítem sistémico (11%) como a los ítems con contenidos sustantivos (20%). Con información relevante, las conductas activas fueron del 34,6%, y las pasivas, del 65,4%; con déficits de información relevante, las activas fueron del13,9%, y las pasivas, del 86,1%. Estas diferencias fueron significativas (p < 0,001).Conclusiones. Los déficits de información relevante tienen alta prevalencia en los pases de guardia y favorecen los errores por omisión. La mayor parte de los errores médicos reconocen fallos en habilidades cognitivas propias del razonamiento clínico de médicos en formación (errores cognitivos), por lo que se hace necesario incorporar el pase de guardia oral y supervisado al currículo de la residencia de medicina interna (AU)

Introduction. Handoffs are medical activity which transfers information and responsibility among professionals in situations of discontinuity or transitions in patient care. Handoffs are source of medical errors and adverse events, which despite the formal programming of specific competencies are absent in the curricula of medical residencies. In this sense, we implemented the educational project ‘Oral and written handoffs in internal medicine residency program’. Materials and methods. We defined the parameter relevant information with a systemic item and four other cognitive items; we assess the prevalence of relevant information deficits and the effects on the clinical practice in a prospective study. Results. In 230 protocols the prevalence of relevant information deficits was 31.3% (n = 72) and affected both, systemic item (11%) as the cognitive items (20%). With relevant information, active behaviors were 34.6% and passive 65.4%;with relevant information deficits, the active behaviors were 13.9% and 86.1% passive respectively, this difference was significant (p < 0.001).Conclusions. We conclude that relevant information deficit is highly prevalent in the handoffs and results in errors of omission. The majority of medical errors recognize flaws in their own cognitive skills (cognitive errors) of clinical reasoning of physicians in training, so it is necessary to incorporate the oral and supervised handoffs at the residency curriculum (AU)

Calidad de vida en pacientes con cáncer de próstata: Validación de un instrumento para la práctica clínica / Quality of life in patients with prostate cancer: validation of an instrument for clinical practice

OBJETIVO: Actualmente existen instrumentos para evaluar los distintos aspectos en el impacto sobre la calidad de vida en aquellos pacientes portadores de cáncer de próstata que son sometidos a algún tipo de tratamiento, pero la mayoría son de 50 o más preguntas y de difícil aplicación en la práctica clínica. Recientemente se ha publicado la validación en inglés de una versión acortada del instrumento más utilizado para medir la calidad de vida en pacientes con cáncer de próstata: EPIC (Expanded Prostate Cancer Composite). Esta versión denominada EPIC-CP (Expanded Prostata Cancer Composite-Clinical Practice) consiste en 16 preguntas dispuestas en una página, de fácil y rápida aplicación clínica. El objetivo primario de este trabajo fue desarrollar y validar el cuestionario EPIC-CP en español como instrumento de evaluación de calidad de vida en pacientes con cáncer de próstata (CaP). Un objetivo secundario fue la observación de las diferencias de los aspectos que impactan en la calidad de vida entre los pacientes tratados y los candidatos a tratamiento. MÉTODOS: Se realizó una traducción inversa-directa al español de la versión original de la encuesta. Se aplicaron 128 cuestionarios de calidad de vida EPIC-CP y EQ5D (cuestionario de salud del EuroQuol Group Association) a 46 (40%) pacientes candidatos a ser sometidos a diferentes tratamientos - Prostatectomía abierta (PA), Prostatectomía robótica (PR), Braquiterapia (Br) o Radioterapia Conformacional (RC)- y a 82 (64%) pacientes ya tratados (9 PA, 13 PR, 7 Br y 4 RC). Para evaluar la confiabilidad se evaluó la consistencia interna a través del Coeficiente Alfa de Cronbach para cada categoría de la EPIC-CP. Para valorar la sensibilidad al cambio se compararon las puntuaciones en pacientes tratados y no tratados con el test de Suma de Rangos de Wilcoxon. RESULTADOS: En todos los dominios de la EPIC-CP, se obtuvo un consistencia interna elevada (alfa de Cronbach 0,66-0,9). No se encontraron diferencias significativas en la edad ni en el nivel educacional entre pacientes tratados y no tratados. Se encontraron diferencias significativas en la puntuación total de la EPIC CP entre pacientes tratados y no tratados en los dominios incontinencia urinaria (p = 0,0002), función intestinal (p = 0,04), sexual (p < 0,0001) y función hormonal (p = 0,002). CONCLUSIÓN: La versión en del EPIC-CP es confiable y válida, por lo que resulta una herramienta útil para medir la calidad de vida en pacientes con CaP, así como el impacto de distintos tratamientos en ella

OBJECTIVES: Currently there are instruments to evaluate the different features of the impact on quality of life in those patients with prostate cancer undergoing any type of treatment, but most of them have 50 or more questions and they are difficult to apply in clinical practice. An English validation of a shortened version of the EPIC (Expanded Prostate Cancer Composite), the most used instrument to measure the quality of life in patients with prostate cancer, has been published recently. This version called EPIC-CP (Expanded Prostate Cancer Composite-Clinical Practice) consists of 16 questions arranged in a page, for easy and rapid clinical application. The objective of this work is to validate a Spanish version of the EPIC-CP. METHOD: An inversa-directa Spanish translation of the original version was performed. The EPIC-CP and EQ5D questionnaires were applied to 46 patients eligible to be subjected to different treatments - open prostatectomy (OP), Robotic Prostatectomy (RP), brachytherapy (Br) or conformational radiotherapy (CR) - and 82 patients already treated (9 OP, 13 RP, 7 Br, 4 CR). For reliability evaluation, the Cronbach's alpha was used to test the internal consistency for each domain of the EPIC-CP. Treated and untreated patients' scores were compared with the Wilcoxon range sum test to assess the sensitivity to change. RESULTS: Cronbach's alpha was elevated in all the EPIC-CP domains (near or greater than 0.7), indicating a high internal consistency. There was no significant difference in age and educational level between treated and untreated patients. We found significant differences between treated and untreated patients in the total EPIC CP score, in the domains of urinary incontinence, bowel function, sexual function and hormonal function. CONCLUSIÓN: The Spanish version of the EPIC-CP is reliable and valid, so it is a useful tool to measure the quality of life in patients with prostate cancer, as well as the impact of different treatments

Tratamiento focal para el cáncer de próstata clinícamente localizado / Focal therapy for clinically localized prostate cancer

La migración del estadío en los tumores de próstata recién diagnosticados, la mejora de las imágenes de la próstata, y los dispositivos capaces de inducir la ablación subtotal de próstata han permitido el estudio formal y la evaluación de la terapia focal para el tumor de próstata de bajo riesgo. Siguen existiendo limitaciones importantes: 1) la necesidad de mayor precisión pre-tratamiento de la ubicación del tumor, extensión y tamaño, 2) determinar métodos apropiados de vigilancia post-tratamiento y definiciones de progresión clínica, 3) la incertidumbre acerca de si la repetición del tratamiento, mediante terapia focal o de toda la glándula es eficaz y seguro. Están en curso ensayos clínicos para proporcionar datos sobre la viabilidad y fiabilidad de estas nuevas terapias, la capacidad de erradicación del tumor, las tasas de tratamiento secundario, y el impacto en la función urinaria y sexual(AU)

The stage migration for newly diagnosed prostate cancer, improvements in prostate imaging, and devices capable of inducing subtotal prostate ablation have allowed for the formal study and evaluation of focal therapy for low-risk prostate cancer. Significant limitations remain: 1) the need for more accurate pre-treatment determination of cancer location, extent, and size, 2) determining appropriate methods of post-treatment surveillance and definitions of clinical progression, 3) the uncertainty whether repeat treatment, by focal or whole-gland therapy, is effective and safe. Clinical trials are ongoing to provide data on the feasibility and reliability of these new therapies, the capability of eradicating cancers, rates of secondary treatment, and impact on urinary and sexual function(AU)

Prostatectomía radical retropúbica: experiencia Hospital Padre Hurtado / Radical retropubic prostatectomy: Hospital Padre Hurtado’s experience

Introducción: A través del siguiente reporte damos a conocer nuestra experiencia en el tratamiento quirúrgico del cáncer de próstata. Material y métodos: Se revisó retrospectivamente la ficha clínica de 60 pacientes sometidos durante6 años (2003-2008) a una prostatectomía radical retropúbica (PRR) con o silinfadenectomía ileo obturatriz. Analizamos los resultados desde una perspectiva demográfica, clínica, bioquímica, quirúrgica y patológica. Resultados: El periodo de seguimiento promedio fue de 2,5 años (0,5-5,5). La edad promedio al someterse a la intervención fue de 64,6 años (52-78). El antígeno prostático específico (APE) promedio preoperatorio fue de 10,72 ng/ml (2,5-56,8) con el 57,9 por ciento detectados con APE <10 ng/ml. El estadio preoperatorio fue T1c en 72,5 por ciento, T2 en el 23,5 por ciento y T3 en el 4 por ciento. El tiempo operatorio promedio fue de 197 minutos (120-330). Hubo necesidad de transfusión sanguínea posoperatoria en el 30 por ciento de los operados. En 2 pacientes (3,3 por ciento) hubo lesión de recto. Un paciente tuvo TEP recuperado. No hubo mortalidad perioperatoria. El promedio de días de hospitalización fue de 7 días (4-48) y el promedio de días de sonda de 17 días (7-30). Se comparó el Gleason de la biopsia transrectal con el de la pieza operatoria. La biopsia transrectal subestimó en el 42 porciento de los casos, sobreestimó en el 11,3 por ciento de los casos y en el resto se mantuvo (46,7 por ciento). Hubo 21 por ciento de márgenes quirúrgicos positivos. El estadio TNM fue de 55 por ciento pT2, 45 por ciento pT3 y 5 por ciento pN1. A los 6 meses de seguimiento 82 por ciento de los pacientes había negativizado sus antígenos. En 18,3 por ciento se agregó radioterapia a la cirugía. La sobrevida global libre de enfermedad al momento de hacer el corte en el estudio fue de 73 por ciento. Conclusiones: Presentamos nuestra experiencia en prostatectomía radical. Nuestros resultados oncológicos son comparables a lo reportado...

Introduction: Through this report we expose our experience with the surgical management of prostate cancer. Materials and methods: Retrospective review of 60 patient charts that were submitted to radical retropubic prostatectomy (RRP) with or without ileo-obturatory lymphadenectomy during a 6-year period (2003-2008). Results are analyzed from a demographic, clinic, biochemical, surgical and pathological perspective. Results: follow-up period was 2,5 years (0,5-5,5). Mean age at surgery was 64,6 (52-78). Mean preoperative PSA was 10,72 ng/dl with 57,9 percent of the patients detected with a PSA <10ng/dl. 72,5 percent of the patients had a T1c preoperative staging, 23,5 percent a T2 and 4 percent a T3. Mean surgical time was 197min (120-330). 30 percent of the patients needed a postoperative transfusion. In 2 patients (3,3 percent) there was a rectal lesion. One patient presented a pulmonally embolism and there was no mortality. Mean admission time was 7 days (4-48) and mean duration of catheterization was 17 days (7-30). We compared Gleason score between preoperative biopsy and definitive pathology: trans-rectal biopsy underestimated the Gleason score in 42 percent of the cases, overestimated 11,3 percent and did not change in46,7 percent. We had 21 percent of positive borders. TNM was pT2 55 percent, pT3 45 percent and pN1 5 percent. At a 6 month follow-up 82 percent of the patients had undetectable PSA. Radiotherapy was used in 18,3 percent of the patients. Global disease free survival at the closing of the study was 73 percent. Conclusion: We present our experience with retropubic radical prostatectomy. We show oncological results that are similar to those reported in national literature. A longer follow-up is necessary to confirm them.

Mioplastia del detrusor mediante autotrasplante microquirúrgico del músculo Latissimus dorsi para el tratamiento de la acontractilidad vesical: comunicación preliminar / Detrusor myoplasty through microsurgical autotrasplant of the latissium dorsi muscle for vesical acontractility: preliminary communication

La acontractilidad vesical es un trastorno invalidante cuyo único manejo práctico actual es el auto cateterismo crónico. En fecha reciente se ha descrito el auto trasplante libre del músculo Latissimus Dorsi a la pelvis para envolver la vejiga de modo que su contracción voluntaria sea capaz de vaciar la orina. Material y Métodos: Se presenta un caso portador de acontractilidad vesical secundaria a lesión traumática del cono medular que se manejó con auto cateterismo por varios años: fue estudiado con ecotomografía, cistoscopia y urodinamia. Además, fisiatría lo evaluó con electromiografía y aplicó un programa de focalización neuromuscular del recto abdominal. Se realizó cirugía a dos equipos: el equipo de urología diseca la vejiga en toda su circunferencia hasta el nivel de los uréteres, quedando sostenida sólo por el trígono y la uretra. Luego se cubre el detrusor con una malla de vicryl a la cual se fijará el músculo auto trasplantado. Por su parte, el equipo de cirugía plástica procura el músculo Latissimus Dorsi del brazo no dominante, cuidando especialmente el pedículo (arteria, vena y nervio). Además se preparan los vasos epigástricos inferiores y el 12_ nervio intercostal (que inerva el músculo recto anterior del abdomen). A continuación se transfiere el músculo a la pelvis, revascularizandolo con técnica microquirúrgica y empleando el 12_ nervio intercostal de modo que el paciente "aprende" a orinar mediante contracción del recto abdominal. Finalmente se envuelve la vejiga con el músculo trasplantado en forma espiral, de modo que al contraerse comprima la vejiga y la vacíe. Luego de un período de 3 a 4 meses de reinervación el paciente inicia esfuerzos miccionales por contracción de la musculatura abdominal anterior, sin Valsalva y con controles del residuo. Resultados: El paciente fue operado en septiembre de 2003 y luego de 4 meses de reinervación recuperó micción espontánea, guiada por deseo miccional útil, a buen flujo y bajo residuo; esta contine...