International consensus panel for transurethral resection of bladder tumours metrics: assessment of face and content validity.

OBJECTIVE: To develop performance metrics that objectively define a reference approach to a transurethral resection of bladder tumours (TURBT) procedure, seek consensus on the performance metrics from a group of international experts. METHODS: The characterisation of a reference approach to a TURBT procedure was performed by identifying phases and explicitly defined procedure events (i.e., steps, errors, and critical errors). An international panel of experienced urologists (i.e., Delphi panel) was then assembled to scrutinise the metrics using a modified Delphi process. Based on the panel's feedback, the proposed metrics could be edited, supplemented, or deleted. A voting process was conducted to establish the consensus level on the metrics. Consensus was defined as the panel majority (i.e., >80%) agreeing that the metric definitions were accurate and acceptable. The number of metric units before and after the Delphi meeting were presented. RESULTS: A core metrics group (i.e., characterisation group) deconstructed the TURBT procedure. The reference case was identified as an elective TURBT on a male patient, diagnosed after full diagnostic evaluation with three or fewer bladder tumours of ≤3 cm. The characterisation group identified six procedure phases, 60 procedure steps, 43 errors, and 40 critical errors. The metrics were presented to the Delphi panel which included 15 experts from six countries. After the Delphi, six procedure phases, 63 procedure steps, 47 errors, and 41 critical errors were identified. The Delphi panel achieved a 100% consensus. CONCLUSION: Performance metrics to characterise a reference approach to TURBT were developed and an international panel of experts reached 100% consensus on them. This consensus supports their face and content validity. The metrics can now be used for a proficiency-based progression training curriculum for TURBT.

Defining the role of multiparametric MRI in predicting prostate cancer extracapsular extension.

OBJECTIVES: To identify the predictive factors of prostate cancer extracapsular extension (ECE) in an institutional cohort of patients who underwent multiparametric MRI of the prostate prior to radical prostatectomy (RP). PATIENTS AND METHODS: Overall, 126 patients met the selection criteria, and their medical records were retrospectively collected and analysed; 2 experienced radiologists reviewed the imaging studies. Logistic regression analysis was conducted to identify the variables associated to ECE at whole-mount histology of RP specimens; according to the statistically significant variables associated, a predictive model was developed and calibrated with the Hosmer-Lomeshow test. RESULTS: The predictive ability to detect ECE with the generated model was 81.4% by including the length of capsular involvement (LCI) and intraprostatic perineural invasion (IPNI). The predictive accuracy of the model at the ROC curve analysis showed an area under the curve (AUC) of 0.83 [95% CI (0.76-0.90)], p < 0.001. Concordance between radiologists was substantial in all parameters examined (p < 0.001). Limitations include the retrospective design, limited number of cases, and MRI images reassessment according to PI-RADS v2.0. CONCLUSION: The LCI is the most robust MRI factor associated to ECE; in our series, we found a strong predictive accuracy when combined in a model with the IPNI presence. This outcome may prompt a change in the definition of PI-RADS score 5.

Mini Endoscopic Combined Intra-Renal Surgery (MiniECIRS) with endoview puncture in A 12 month boy. A safe but challenging procedure.

INTRODUCTION: Associating minipercutaneous nephrolithotomy and retrograde flexible ureteroscopy (fURS) is called Mini Endoscopic Combined Intra-Renal Surgery (miniECIRS). It's a safe and efficient technique, also in children. MATERIAL AND METHODS: The video describes miniECIRS in a 12 month-old boy with an infectious pelvic left stone (16 mm) and multiple caliceal stones. The UAS used was a 10FR and the percutaneous access was a 14Fr with Clear-Petra® sheath. RESULTS: The operative time was 180 min and blood losses were virtually absent. There were no intra- or post-operative complications and the patient was discharged at the 5th day. After 1 month, double J was removed having a stone free status. CONCLUSIONS: MiniECIRS with endoview puncture is a safe and efficient technique when performed by experienced hands. Therefore, it is an alternative to consider for the treatment of complex lithiasis in the pediatric population.

Robotic kidney transplantation.

Kidney transplantation is the best treatment option for patients with end-stage renal disease owing to improved survival and quality of life compared with dialysis. The surgical approach to kidney transplantation has been somewhat stagnant in the past 50 years, with the open approach being the only available option. In this scenario, evidence of reduced surgery-related morbidity after the introduction of robotics into several surgical fields has induced surgeons to consider robot-assisted kidney transplantation (RAKT) as an alternative approach to these fragile and immunocompromised patients. Since 2014, when the RAKT technique was standardized thanks to the pioneering collaboration between the Vattikuti Urology Institute and the Medanta hospital (Vattikuti Urology Institute-Medanta), several centres worldwide implemented RAKT programmes, providing interesting results regarding the safety and feasibility of this procedure. However, RAKT is still considered an alternative procedure to be offered mainly in the living donor setting, owing to various possible drawbacks such as prolonged rewarming time, demanding learning curve, and difficulties in carrying out this procedure in challenging scenarios (such as patients with obesity, severe atherosclerosis of the iliac vessels, deceased donor setting, or paediatric recipients). Nevertheless, the refinement of robotic platforms through the implementation of novel technologies as well as the encouraging results from multicentre collaborations under the umbrella of the European Association of Urology Robotic Urology Section are currently expanding the boundaries of RAKT, making this surgical procedure a real alternative to the open approach.

Oncologic surveillance intensity after endoscopic treatment of upper tract urothelial carcinoma.

BACKGROUND: The optimal oncologic surveillance in patients with upper tract urothelial carcinoma (UTUC) elected for conservative treatment is still a matter of debate. METHODS: Patients elected for endoscopic treatment of UTUC were followed up according to EAU guidelines recommendations after treatment. Bladder cancer recurrence-free survival (BCa-RFS), UTUC recurrence-free survival (UTUC-RFS), radical nephroureterectomy-free survival (RNU-FS), and cancer-specific survival (CSS) were estimated using the Kaplan-Meier method. The crude risks of BCa and UTUC recurrences over time were estimated with the Locally Weighted Scatterplot Smoothing method. RESULTS: Overall, 54 and 55 patients had low- and high-risk diseases, respectively. Median follow-up was 46.9 (IQR: 28.7-68.7) and 36.9 (IQR: 19.8-60.1) months in low and high-risk patients, respectively. In low-risk patients, BCa recurrence risk was more than 20% at 24 months follow-up. At 60 months, time point after which cystoscopy and imaging should be interrupted, the risk of BCa recurrence and UTUC recurrence were 14% and 7%, respectively. In high-risk patients, the risk of BCa and UTUC recurrence at 36 months was approximately 40% and 10%, respectively. Conversely, at 60 months, the risk of bladder recurrence and UTUC recurrence was 28% and 8%, respectively. CONCLUSIONS: For low-risk patients, cystoscopy should be performed semi-annually until 24 months, while upper tract assessment should be obtained up to 60 months, as per current EAU guidelines recommendations. For high-risk patients, upper tract assessment should be intensified to semi-annually up to 36 months, then obtained yearly. Conversely, cystoscopy should be ideally performed semi-annually until 60 months and yearly thereafter.

Perioperative and oncological outcomes of distal ureter management during nephroureterectomy for upper urinary tract urothelial carcinoma: a systematic review and meta-analysis.

INTRODUCTION: The best approach of the bladder cuff (i.e., transvesical, extravesical, endoscopic) during radical nephroureterectomy (RNU) remains an unsolved question. The aim of this review is to compare the oncological and perioperative outcomes among three different approaches of the distal ureter during RNU. EVIDENCE ACQUISITION: A literature search was conducted through June 2022 using PubMed/Medline, Embase, and Web of Science databases. Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed to identify eligible studies. The primary outcome was bladder recurrence-free survival and secondary outcomes included: perioperative outcomes, metastasis-free survival, and cancer-specific survival. EVIDENCE SYNTHESIS: A total of 19 non-randomized studies comprising 6581 patients met our inclusion criteria. The risk of bladder recurrence, metastasis and cancer-related death did not differ significantly between each approach (all P>0.05). In subgroup analysis excluding patients with history of bladder cancer, the risk of bladder recurrence remained similar between each approach (all P>0.05). There was no significant difference in terms of operative time, estimated blood loss, length of hospital stay, and postoperative complications between each approach (all P>0.05). The main limitation is the retrospective design of 18/19 included studies. CONCLUSIONS: The present systematic review and meta-analysis highlights the lack of high-level evidence on distal ureter management during RNU. On the basis of the available data, the present review supports the equivalence of different techniques of bladder cuff excision during RNU. The extravesical approach seems non-inferior to the transvesical approach in terms of oncological and perioperative outcomes.

Reduced Dose Intravesical Bacillus Calmette-Guérin: Why It Might Not Matter.

When it comes to the treatment of patients with non-muscle-invasive bladder cancer (NMIBC) with intravesical bacillus Calmette-Guérin (BCG), two questions must be considered: 1) what dose to give, and 2) for how long? The issue of optimal dose and duration has been the subject of several randomized trials and is especially pertinent in the context of a global BCG shortage. Despite this, there appears to be uncertainty as to whether BCG dose or duration may be compromised in the event of shortage. As such, we wish to summarize the available evidence as an aid to the practicing urologist.

Robot-assisted radical cystectomy and ileal conduit with Hugo™ RAS system: feasibility, setting and perioperative outcomes

ABSTRACT Introduction: Robotic approach has shown its feasibility and safety with respect to open approach for radical cystectomy (1). The performances of Hugo™ RAS system (Medtronic, Minneapolis, USA) have been demonstrated in several clinical scenarios (2-5). We report the feasibility and surgical settings of the first series of robot-assisted radical cystectomy (RARC) with intracorporeal ileal-conduit performed with Hugo™ RAS system. Methods: Two patients were submitted to RARC with ileal conduit at our institution. The trocar placement scheme and the operating room setting with docking angles of the four arms were already described (6). A 12-mm and a 5-mm trocar for the assistant were placed. In both cases, an ileal-conduit with a Wallace type-1 uretero-enteric derivation was performed intra-corporeally. Results: The first patient was a 71-year-old male with a very-high risk non-muscle invasive bladder cancer(BC), and the second patient was a 64-year-old male with a diagnosis of T2 high-grade BC. Operative times were 360 and 420 minutes with a docking time of 12 and 9 minutes, respectively. No intraoperative complications occurred. The estimated blood loss was 200ml and 400ml, respectively. The second patient developed an ileus on postoperative day 4 (Clavien-Dindo grade 2). No positive surgical margins were recorded. No recurrence nor progression occurred during follow-up. Conclusion: RARC with intracorporeal ileal conduit urinary diversion is feasible with Hugo™ RAS system. We provided insight into the surgical setting using this novel robotic platform to help new adopters to face this challenging procedure. These findings may help a wider distribution of robotic programs for BC treatment.

Outcomes following surgical management of adrenocortical carcinoma: a single-center experience / Resultados después del manejo quirúrgico del carcinoma adrenocortical: una experiencia de un solo centro

Objetive: Adrenocortical carcinoma(ACC) is a rare and heterogeneous disease, with challenging management and poor prognosis. Surgery withcurative intent is the preferred treatment option for localized disease, with a reported 5-year survival rate of55% for complete resections. However, owing to thehigh risk of recurrence there is a need for adjuvant therapies, such as mitotane, an adrenolytic drug, or irradiation, while in advanced disease the standard of careis a combined chemotherapy scheme. The aim of thisstudy was to report our experience in the surgical management and outcomes of ACC patients. Material and methods: A retrospective observational study was performed in a cohort of ACC patientswho had undergone surgical resection (open or laparoscopic approach) and were followed up at our tertiary hospital. Patients with localized or locally advanced disease were included in the analysis. All medical records,including clinical, surgical, pathologic, and follow-updata, were collected and analyzed. Results: A total of 19 ACC patients were managedat our center between August 1990 and August 2013.The median age at diagnosis was 50.5 years (range19–72), and most patients were males. Abdominalpain was the most common clinical presentation (n=9,47.4%). Abdominal contrast-enhanced computed tomography (CT) was performed in all cases. Only 3 tu-mors (15.8%) were functional and most were stage II atdiagnosis (n=9, 47.4%). No patient presented metastasis. Of the 19 patients, 18 (94.7%) underwent surgerywith curative intent, while one (5.3%) received adjuvantradiotherapy (ART). The open approach was used in17 patients (89.5%), while the remaining 2 (10.5%)underwent laparoscopy. Postoperative complicationsoccurred in 8 patients (42.1%); none were of grade IVor V. Median follow-up was 66 months (range 3–312).The majority of patients (n=15, 78.9%) were diseasefree with surgery alone. None received adjuvant mitotane therapy...(AU)

Objetivo: El carcinoma adrenocorticales una enfermedad heterogénea y rara que conllevaun manejo complicado y cuyo pronóstico es malo. Anteuna enefermedad localizada el manejo quirúrgico es deelección, observando una tasa de supervivencia a los 5años del 55% en resecciones completas. Sin embargo,debido a la alta tasa de recurrencias, se requiere complementar el manejo con una terapia adyuvante comoes el caso del mitotane, un agente adrenolítico, o laradioterapia. En casos de enfermedad avanzada la terapia de elección incluye una pauta de quimioterapiacombinada. El objetivo del presente estudio es reportarnuestra experiencia en el manejo quirúrgico y resultadosobtenidos de los pacientes con diagnóstico de carcinoma adrenocortical. Materiales y métodos: Se realizó un estudio observacional de una cohorte de pacientes diagnosticados de carconinoma adrenocortical que requirieronun manejo quirúrgico (abierto o laparoscópico) y querealizaron su seguimiento en nuestro hospital terciario.Se incluyó a pacientes con enfermedad localizada ylocalmente avanzada en el análisis. Todos los dados clínicos, quirúrgicos, patológicos y de seguimiento fueronrecolectados para el análisis. Resultados: Entre agosto del 1990 y agosto del2013 un total de 19 pacientes diagnosticados decarcinoma adrenocortical fueron tratados en nuestrocentro. La mediana de edad al diagnóstico fue 50,5años (rango 19-72), siendo la mayoría hombres. Elsíntoma inicial mas frecuente fue el dolor abdominal(n=9, 47,4%). Una tomografía computarizada con contraste fue realizada en todos los casos. Sólo 3 tumores(15,8%) eran funcionales y la mayoría correspondíaa un estadio II al diagnóstico (n=9, 47,4%). Ningúnpaciente presentaba metástasis. De los 19 pacientes,18 (94,7%) requirieron cirugía con intención curativa,mientras que a uno (5,3%) se le realizó radioterapiaadyuvante...(AU)

Inmunoterapia con BCG: pasado, presente y futuro / BCG Immunotherapy, past, present and future

Desde su introducción hace más de 40 años, el tratamiento adyuvante con BCG (Bacilo Calmette-Guérin) para el tumor vesical no-músculo invasivo (TVNMI) sigue siendo el tratamiento de elección en el grupo de alto riesgo, y una de las inmunoterapias para el cáncer de mayor éxito. Sin embargo, hasta el 20% de los pacientes progresarán a enfermedad músculo-invasiva después del tratamiento con BCG. Por otra parte, nos encontramos ante una escasez de suministro de BCG a nivel mundial. A pesar de su extenso uso clínico, no existe una clara certeza del mecanismo de acción de la BCG, y todavía persiste controversia en cuanto a las dosis y cepas más eficaces, así como su utilidad en tratamientos combinados con otros fármacos y con dispositivos que podrían facilitan su acción en la vejiga. En este artículo se revisa históricamente el impacto que ha tenido la BCG en el tratamiento del TVNMI, las directrices actuales en cuanto a dosis, cepas y tratamientos de combinación, y el futuro que acontecerá con los resultados de los ensayos clínicos sobre inmunoterapia sistémica, inmunomoduladores, vacunas y terapia génica en el TVNMI

Since its introduction more than 40 years ago, adjuvant treatment with BCG (Bacillus Calmette-Guérin) for non-muscle invasive bladder cancer (NMIBC) continues to be the treatment recommended in the highrisk group, and one of the most successful immunotherapies for cancer treatment. However, up to 20% of patients will progress to muscle-invasive disease after BCG treatment. On the other hand, we are facing a shortage of BCG supply worldwide. Despite its extensive clinical use, there is no clear certainty of the mechanism of action of BCG, and controversy persists regarding to the most effective dose and strains, as well as their usefulness in combined treatments with other drugs and with devices that could facilitate their action on the bladder. This article historically reviews the impact that has had BCG in the treatment of NMIBC, the current guidelines in terms of doses, strains and treatments combination, and the future that will happen with the results of the ongoing clinical trials with systemic immunotherapy, vaccines and gene therapy

Situación actual de los tumores del tracto urinario superior en el contexto de la pandemia por Covid-19 / Current status for urpper tract transitional cell carcinoma during COVID-19 pandemia

INTRODUCCIÓN: Los primeros casos de la enfermedad por coronavirus (Coronavirus Disease 19, también denominada COVID-19) aparecieron en China en diciembre de 2019, desde donde se extendieron al resto del mundo. La rápida aparición de casos y el alto volumen de pacientes que han requerido hospitalización han provocado la demora de un gran número de intervenciones quirúrgicas, incluidas las cirugías oncológicas. Todo ello está suponiendo un reto para los servicios de urología de todo el mundo, y obliga a una redistribución de sus recursos. Los pacientes con tumores del tracto urotelial superior (TUS), en muchos casos de mal pronóstico, se pueden ver potencialmente afectadospor esta situación. MATERIAL Y MÉTODOS: Se realizó una búsqueda no sistemática en web y en PubMed utilizando las palabras clave "Upper tract urothelial tumours", "COVID-19", "nephroureterectomy". Se realizó una revisión narrativa de la literatura incluyendo solo artículos y documentos escritos en lengua española e inglesa. Se remitió el documento a varios autores nacionales expertos en patología del urotelio superior, con el fin de unificar criterios y experiencias para llegar a un rápido consenso sobre la importancia relativa de las distintas actividades, problemas y soluciones. EVIDENCIA CIENTÍFICA: Diversos estudios tratan de determinar el impacto que presenta el retraso en la realización de la nefroureterectomía como tratamiento curativo, siendo el punto de corte de 3 meses en la mayoría de ellos. Tres de ellos concluyen que dicha demora implica una disminución de la supervivencia global y cáncer específica, mientras que el retraso de la nefroureterectomía radical debido a la realización de ureterorrenoscopia (URS) como tratamiento conservador en tumores de bajo grado no parece tener impacto en la supervivencia. CONCLUSIONES: El retraso en el tratamiento de los tumores del TUS a 3 meses supone una disminución de la supervivencia global y cáncer específica. Por ello, el tratamiento de esta patología no debería demorarse, en la medida en que los recursos hospitalarios y la alerta sanitaria por COVID-19 lo permita

INTRODUCTION: First cases of COVID-19 were reported in China on December 2019 and rapidly spread globally. The explosive increase in number of cases requiring hospitalization has led to a delay in a big number of surgical interventions, including oncologic surgeries. Collateral effects of this increase means a challenge for urologists, who have been forced to redistribute their resources. Due to its poor pronostic, patients suffering from by upper tract urinary tumours will be negatively affected by this pandemic. METHODS: A non sistematic review was performed using literature published until May 23, 2020, using "Upper tract urothelial tumours", "COVID-19" and "nephroureterectomy". as keywords. The resulting manuscript was critically revised by national authors in order to establish common criteria about treatment and follow up. EVIDENCE SYNTHESIS: Four studies were identified that assessed the impact of delaying radical nephrouretrectomy as curative treatment. These studies showed that surgery delays decrease overall survival and cancer specific survival rates in high-risk groups. On the other hand, delaying radical nephrouretrectomy due to ureteroscopy did not affect survival in cohorts of patients with predominately low-grade disease. CONCLUSIONS: A delay in curative treatment of upper tract urothelial tumours for more than three months results in adverse outcomes as overal survival and cancer specific survival. Hence, it is important to prioritize the timely care of this group of patients as far as COVID-19 pandemic allows it

Embarazo de alto riesgo en pacientes con complejo extrofia-epispadias: características uro-ginecológicas y manejo / High risk pregnancy in patients with extrophy-epispadia complex: Uro-gynecological characteristics and management

OBJETIVO: El complejo extrofia-epispadias (CEE) abarca desde las epispadias distales hasta la extrofia de cloaca, con serias repercusiones en la calidad de vida de los pacientes; sin embargo, la cirugía reconstructiva ofrece la oportunidad de llegar a la edad adulta y plantearse la maternidad. El objetivo de este trabajo es valorar las características uro-ginecológicas y los riesgos que presentan las gestantes con CEE. MATERIALES Y MÉTODO: Estudio retrospectivo de 50 pacientes diagnosticadas de CEE y tratadas en un centro de referencia para esta patología, nacidas entre 1968 y 2000. Se revisaron sus historias clínicas y se recogieron todos los datos demográficos, patológicos y ginecológicos. RESULTADOS: 37 pacientes cumplían los criterios de inclusión y de estas 8 lograron 17 embarazos (90% espontáneos y 10% mediante FIV). 10 fueron exitosos (50% a término) y 7 fueron abortos, 87,5% de los cuales fueron en el primer trimestre. La infección urinaria (ITU) fue la complicación más frecuente (41,6%) y la más severa fue la oclusión intestinal. Ninguna de las pacientes presentó deterioro de la función renal durante la gestación o dilatación del tracto urinario superior (TUS) patológica. 62,5% de las pacientes presentaron prolapsos genitales posteriores a los embarazos, 80% de los cuales fueron grado III y IV. 87,5% se encontraban secas en el seguimiento posterior a sus embarazos. CONCLUSIÓN: El embarazo en el CEE es de alto riesgo y es crucial que el seguimiento sea llevado a cabo por un equipo multidisciplinar especializado e integrado para minimizar las complicaciones

OBJECTIVE: The exstrophy-epispadias complex (EEC) ranges from distal epispadias to cloacal exstrophy, with serious repercussions on the quality of life of patients. However, reconstructive surgery offers the opportunity to reach adulthood and consider motherhood. The objective of this work is to assess the uro-gynecological characteristics and the risks that pregnant women have with EEC. MATERIALS AND METHOD: Retrospective study of 50 patients diagnosed with EEC and treated in a reference center for this pathology, born between 1968 and 2000. Their medical records were reviewed and all demographic, pathological and gynecological data were collected. RESULTS: 37 patients have the inclusion criteria and of these 8 achieved 17 pregnancies (90% spontaneous and 10% through IVF). 10 were successful (50% at term) and 7 were abortions, 87.5% of which were in the first trimester. Urinary tract infection (UTI) was the most frequent complication (41.6%) and the most severe was intestinal occlusion. None of the patients presented renal function impairment during the gestation or dilation of the pathological upper urinary tract (UUT). 62.5% of the patients presented genital prolapses after pregnancies, 80% of which were grade III and IV. 87.5% were dry in the follow-up after their pregnancies. CONCLUSION: Pregnancy in the EEC patients is high risk and it is crucial that the follow-up is carried out by a specialized and integrated multidisciplinary team to minimize complications

Situación de la cirugía laparoscópica y robótica urológica durante la pandemia COVID-19 / Robotic and laparosocpic urological surgery during COVID-19 pandemia

OBJETIVO: La pandemia provocada por el nuevo coronavirus SARS-CoV-2 ha tenido una elevada repercusión sobre la cirugía mínimamente invasiva (CMI). Ha surgido una importante controversia sobre la realización de CMI durante la pandemia COVID-19. Es prioritario, establecer un consenso sobre la organización y realización con seguridad de la CMI durante la pandemia. MATERIAL Y MÉTODOS: Se realizó una búsqueda web y en PubMed con los términos: "SARS-CoV-2", "COVID19", "COVID19 Urology", "COVID19 Surgery", "COVID19 transmission", "SARS-CoV-2 transmission", "COVID19 and minimally invasive surgery", "SARSCoV-2 and CO2 insuflation". Se realizó una revisión narrativa de la literatura y una síntesis de la evidencia disponible. Se ha utilizado una técnica de grupo nominal modificada, circulando un primer borrador a todos los autores y aprobándose la versión definitiva el día 26 de Mayo de 2020. RESULTADOS: No existe evidencia sobre una mayor exposición a SARS-CoV-2 en CMI respecto a cirugía abierta. La CMI se asocia a una menor estancia hospitalaria por lo que cambiar, sin justificación, la indicaciónde CMI puede retrotraer recursos que podrían ser utilizados para la pandemia COVID-19. Se debe priorizar la CMI según los recursos disponibles y la intensidad de la pandemia en cada momento. Se recomienda realizar despistaje de SARS-CoV-2 mediante cuestionario clínico-epidemiológico y PCR nasofaríngea 72 horas antes de la CMI electiva, para minimizar las complicaciones postoperatorias, evitar la transmisión cruzada entre pacientes y la posible exposición de los profesionales sanitarios. Se recomienda establecer medidas de organización en quirófano, de protección personal, técnica quirúrgica y manejo del CO2 y aerosoles generados para reducir la exposición y riesgos del personal sanitario. CONCLUSIONES: La CMI realizada con las medidasd e seguridad adecuadas para el paciente y profesionales, puede contribuir durante la desescalada a una menor utilización de recursos sanitarios y por tanto, no debe limitarse su utilización o cambiar sus indicaciones

OBJECTIVE: SARS-CoV-2 pandemic has high repercussion on urologic minimally invasive surgery (MIS). Controversy about safety of MIS procedures during COVID-19 pandemic has been published. Nowadays, our priority should be create agreement in order to restart and organize MIS with safety conditions for patients and healthcare workers. METHODS: Pubmed and web search was conducted with following terms: "SARS-CoV-2", "COVID19"; "COVID19 Urology", COVID19 Surgery", "COVID19 transmission", "SARS-CoV-2 transmission", "COVID19 and minimally invasive surgery" "SARS-CoV-2 and CO2 insuflation". A narrative review of available literature and scientific evidence summary was done. A modify nominal group technique was used to achieve an expert consensus. First draft was circulated amongst authors. Definitive document was approved in May 26th. RESULTS: Non evidence supports higher risk of SARSCoV-2 healthcare workers infection with MIS compared to open surgery. MIS is associated with shorter hospital stay than open surgery. Modify MIS indications to open surgery, with no scientific evidence, could spend valuable resources in detriment to COVID-19 patients. MIS indications should be prioritized attending to available resources and pandemic intensity. SARS-CoV-2 screening 72 hours prior to surgery by clinical and epidemiological questionnaire and nasopharyngeal PCR is recommended, in order to prevent nosocomial transmission, professional infections and to minimize postoperative complications. Intraoperative steps should be established to reduce professional exposure to surgical aerosols, including: surgical room reorganization, adequate personal protective equipment, surgical technique optimization and management of CO2 and surgical smoke

Robotic radical cystectomy / Cistectomía radical robótica

Objectives: Radical cystectomy (RC) is one of the most complex and morbid surgical procedures in Urology. Several retrospective and prospective studies have demonstrated that robotic-assisted RC (RARC) represents a minimally invasive alternative to open surgery, showing non-inferiority in mid-term oncological outcomes. Moreover, important advantages related with perioperative complications have also been published. The aim of this article is to describe RARC surgical steps and to review the most relevant ndings in the eld of RARC, focusing on its strengths and weaknesses when compared with open RC. Methods: We performed a detailed step-by-step description of the RARC surgical technique, paying particular attention to its specific surgical details and adding our tips and tricks for an outstanding performance. We also conducted a review of the most relevant articles in literature in terms of oncological, pathological and perioperative results. All these findings have been compared with the classical open radical cystectomy (ORC) technique Results: None of the studies published have demonstrated RARC to have worse oncological outcomes (PSM, RFS, CSS, OS) compared to ORC. RARC shows a decrease in blood loss and transfusion rates. No dif- ferences have been observed in complications rate, length of hospital stay, quality of life, and time to bowel movement between both approaches. The two disad- vantages of RARC compared to ORC are a longer oper- ative time and increased cost. Operating time can be re- duced with surgeons gaining experience and technique standardization. The cost disparities and operative time between ORC and RARC at high-volume academic cen- ters are less pronounced than in the general medical community. ConclusionS: RARC is a technically feasible and safe approach, with oncological, pathological and perioperative results, at least, equivalent to ORC

Objetivo: La cistectomía radical (CR) es uno de los procedimientos quirúrgicos más complejos y con mayor morbilidad. Varios estudios retrospectivos y prospectivos han demostrado que la CR asistida por robot (CRAR) representa una alternativa mínimamente invasiva a la cirugía abierta, mostrando no inferioridad en los resultados oncológicos a medio plazo. Además, se han publicado importantes ventajas en relación con las complicaciones peroperatorias. El objetivo de este artículo es describir los pasos quirúrgicos de la CRAR y revisarlos hallazgos más relevantes en el campo de la CRAR, focalizando en sus fortalezas y debilidades cuando se comparan con la CR abierta. Métodos: Realizamos una descripción paso a paso, detallada, de la técnica quirúrgica de CRAR, poniendo particular atención a sus detalles quirúrgicos específicos y añadiendo nuestros trucos y consejos para una ejecución excelente. También realizamos una revisión de los artículos más relevantes de la literatura en términos de resultados oncológicos, patológicos y peroperatorios. Todos estos hallazgos se han comparado con los de la técnica clásica de cistectomía radical abierta (CRA). Resultados: Ninguno de los estudios publicados ha demostrado que la CRAR tenga peores resultados oncológicos (márgenes quirúrgicos positivos, supervivencia libre de recurrencia, cáncer específica y global) en comparación con la CRA. La CRAR muestra un descenso del sangrado y las tasas de transfusión. No se han observado diferencias entre ambos abordajes en las tasas de complicaciones, estancias hospitalarias, calidad de vida y el tiempo hasta la deposición. Dos desventajas de la CRAR en comparación con la CRA son el tiempo operatorio más largo y el aumento del coste. El tiempo operatorio puede reducirse con el aumento de la experiencia de los cirujanos y la estandarización de la técnica. Las disparidades en los costes y la duración de la cirugía son menos pronunciadas en centros académicos de gran volumen que en los de la comunidad médica general. Conclusiones: La CRAR es un abordaje técnicamentefactible y seguro, con resultados oncológicos, patológicosy peroperatorios, al menos, equivalentes a los dela CRA

Crioterapia renal guiada por ecografía para el tratamiento de masas renales de pequeño tamaño: revisión sistemática / Ultrasound-guided cryotherapy of small renal masses: Systematic review

Objetivo: La crioterapia renal (CR) es una opción terapéutica alternativa a la nefrectomía parcial en pacientes de edad avanzada y/o comorbilidades. La técnica puede realizarse guiada por ecografía, TC y RM. Aunque la TC es la técnica más utilizada, no existen estudios comparativos. El objetivo de este estudio fue revisar el estado actual de la ecografía como guía para la planificación y ejecución de la CR. Métodos: Se llevó a cabo una revisión sistemática de la literatura en la base de datos Pubmed/Medline siguiendo las normas PRISMA. Se utilizaron 42 artículos que cumplieron los criterios de inclusión para la síntesis de la evidencia. Resultados: La ecografía permite la monitorización dinámica y en tiempo real de todo el procedimiento permitiendo guiar la toma de biopsia, colocación de las criosondas, formación de la criobola, así como la identificación temprana de complicaciones. La tasa de éxito y recurrencias encontradas en la CR Percutánea (CRP) fue de 97,04% y 1,81%, respectivamente, con un 9,35 % de complicaciones. La ecografía en CR Laparoscópica (CRL) ha mostrado reducir el tiempo empleado en la localización de la masa renal e igualmente disminuye la necesidad de grandes disecciones. La ecografía con contraste durante el seguimiento muestra una concordancia con la TC o RMN de 72-96% y no se han descrito complicaciones asociadas a su ejecución. Conclusión: La CR guiada por ecografía es una técnica factible cuya principal ventaja se basa en la monitorización a tiempo real durante el procedimiento. La CRP presenta tasa de complicaciones y resultados oncológicos aceptables. Mediante la CRL se puede realizar una localización rápida de la masa renal y reduce las disecciones extensas. Durante el seguimiento, el uso de la ecografía con contraste es una alternativa segura que ha mostrado tener buen grado de concordancia con respecto a la TC y la RMN

Objective: Renal cryotherapy (RC) is an alternative therapeutic option to partial nephrectomy in elderly patients and/or patients with comorbidities. The technique can be guided by ultrasound, CT and MRI. Although CT is the most used technique, there are no comparative studies. The objective of this study was to review the current status of ultrasound as a guide for the planning and execution of RC. Methods: A systematic review of the literature was carried out in the Pubmed/Medline database following the PRISMA guidelines. We used 42 articles that met the inclusion criteria for the synthesis of the evidence. Results: Ultrasound allows dynamic and real-time monitoring of the entire procedure to guide the biopsy, placement of the cryoprobes, cryoball formation, and early identification of complications. The success rate and recurrences found in the percutaneous renal cryotherapy (PRC) were 97.04% and 1.81%, respectively, with 9.35% complications. The ultrasound during laparoscopic renal cryotherapy (LRC) has been shown to reduce the time spent in localizing the renal mass and also decreases the need for large dissections. On the other hand, contrast-enhanced ultrasound during follow-up shows a concordance with the CT or MRI of 72-96% and no complications have been described associated with its execution. Conclusion: Renal cryotherapy guided by ultrasound is a feasible technique, its main advantage is based on real-time monitoring during the procedure. The PRC presents an acceptable rate of complications and excellent oncological results. The LRC allows a rapid localization of the renal mass and reduces extensive dissections. During follow-up, the use of contrast ultrasound is a safe alternative that has been shown to have a good degree of agreement with respect to CT and MRI

Endomicroscopía láser confocal en el tratamiento del tumor urotelial del tracto urinario superior / Confocal laser endomicroscopy for the treatment of upper urinary tract transitional cellcarcinoma

Objetivos: La endomicroscopía láser confocal (CLE) es una técnica óptica que permite la caracterización citológica en vivo de un tejido. Estudios previos en lesiones del tracto digestivo y respiratorio han mostrado una alta concordancia entre el resultado en vivo y el resultado histopatológico. Recientemente, se ha propuesto el uso de la CLE en el estudio del tracto urinario superior (TUS) durante la ureteroscopia, ya que permite obtener información a tiempo real del grado tumoral y complementa la información de las biopsias ureteroscópicas, que dadas sus limitaciones, pueden infraestimar el grado y el estadío de la lesión hasta en un 43% de los casos. Métodos: Se llevó a cabo una revisión de la literatura en la base de datos Pubmed/Medline siguiendo las normas Prisma. Se utilizaron 21 artículos que cumplieron los criterios de inclusión para la síntesis de la evidencia. Resultados: La sensibilidad y especificidad descrita, alcanza el 79%/78% y 67%/79% para tumores de bajo y alto grado respectivamente, con una concordancia sustancial entre observadores cirujano/anatomopatólogo; K=0,64). No se han reportado complicaciones asociadas a la utilización de la fluoresceína ni sondas de CLE. Conclusiones: La CLE representa una herramienta útil y segura, capaz de proporcionar información citológica de tumores del TUS en tiempo real que permitela identificación del grado tumoral con sustancial grado de acuerdo entre la tipificación en vivo y su análisis histopatológico final. Por este motivo, actualmente, la CLE es considerada como una herramienta en el manejo conservador del carcinoma del TUS en las guidelines de la European Association of Urology (EAU)

Objectives: Confocal lasser endomicroscopy (CLE) is an optical technique that enables in vivo cytological characterization of a tissue. Previous studies have shown it useful in the evaluation of urinary and respiratory tracts for a better characterization of mucosal lesions, showing a high concordance between in vivo and final histopathological results. Recently, the use of CLE has been proposed for the study of transitional cell carcinoma of the upper urinary tract (UUT) during ureteroscopy, because it enables real time information about tumor grade and supplements the information of ureteroscopic biopsies, which may understimate the grade and stage of the lesion up to 43% of the cases due to its limitiations. Methods: We performed a systematic review of the literature in the Pubmed/Medline database following the PRISMA standard. We selected 20 articles that complied with the inclusion criteria for evidence synthesis. Results: Equipment miniaturization has enabled CLE as part of the diagnostic options in upper urinary tract tumors. This technique performs in vivo cytological characterization of the evaluated tissue, accomplishing differentiation between tumor and normal tissue, as well as tumor grade identification. Its communicated sensitivity and specificity reach 79%/78% respectively for low grade tumors and 67%/79% for high grade, with a substantial inter observer concordance (surgeon/pathologist;k=0.64). No complications have been communicated in the literature with the use of fluorescein or confocal laser microscopy probes in patients undergoing this technique. CONCLUSIONS: CLE represents a useful and safe tool, capable of providing cytological real time information of UUT tumors that enables tumor grade identification with substantial concordance between in vivo tumor typifying and the final histopathological analysis. For this, CLE is currently considered a tool for conservative management of UUT transitional cell carcinoma in the European Association of Urology (EAU) guidelines

Tratamiento quirúrgico de la enfermedad local en cáncer de próstata metastásico / Surgical treatment of local disease in metastatic prostate cancer

OBJETIVO: El cáncer de próstata metastásico es una enfermedad muy heterogénea con varias opciones de tratamiento. En algunos casos de enfermedad oligometastásica el tratamiento local del tumor primario acompañado de terapia dirigida de las metástasis parece que puede mejorar los resultados oncológicos. Los objetivos de este estudio son definir y entender el cáncer de próstata oligometastásico, ver la utilidad y justificación de la cirugía citorreductora en este escenario y revisar todos los estudios que se han publicado sobre prostatectomía radical en pacientes con cáncer de próstata metastásico inicial. MÉTODOS: Se realizó una búsqueda bibliográfica en Pubmed usando las palabras clave: cáncer de próstata, metastásico, oligometastásico, tratamiento local, prostatectomía radical y cirugía citorreductora. Se incluyeron todos los trabajos publicados hasta la fecha de prostatectomía radical en paciente metastásico inicial. Además, se revisaron artículos publicados en revistas de distintas especialidades médicas y ciencias básicas que trataban sobre cirugía citorreductora y biología de la enfermedad oligometastásica. RESULTADOS: El cáncer de próstata oligometastásico se reconoce como un estadio clínico intermedio entre la enfermedad local y la diseminada que parece beneficiarse de un tratamiento local del tumor primario y dirigido de las metástasis. En este escenario, los distintos estudios retrospectivos han demostrado que la prostatectomía radical disminuye la tasa de complicaciones locales y mejora los resultados oncológicos sin aumentar la morbilidad. Actualmente, no existe consenso en definir el número, la localización y las técnicas de imagen a emplear para poder considerar un paciente oligometastásico. Por todo ello, resulta difícil la comparación de los resultados entre los distintos estudios y la identificación del subgrupo de pacientes que se pueden beneficiar de este tratamiento local. CONCLUSIONES: A falta de estudios prospectivos aleatorizados, la prostatectomía radical parece ser una opción válida para el tratamiento del tumor primario en algunos pacientes con cáncer de próstata oligometastásico

OBJECTIVES: Metastatic prostate cancer is a very heterogeneous disease with several treatment options. In some cases of oligometastatic disease, local treatment of the primary tumor complemented by metastasis directed therapy seems to improve oncological results. The objectives of this study are to define and understand oligometastatic prostate cancer, to showthe usefulness and rationale of cytoreductive surgery in this scenario and to review all published studies about radical prostatectomy in patients with initially metastatic prostate cancer. METHODS: We performed a Pubmed bibliographic search using the keywords: prostate cancer, metastatic, oligometastatic, local treatment, radical prostatectomy, and cytoreductive surgery. We included all published works on radical prostatectomy in initially metastatic patient. Furthermore, we reviewed published articles about cytoreductive surgery and biology of the oligometastatic disease in journals of different medical specialties. RESULTS: Oligometastatic prostate cancer is recognized as an intermediate clinical stage between local and disseminated disease that seems to benefit from local treatment of the primary tumor plus metastasis directed treatment. In this scenario, different retrospective studies have demonstrated that radical prostatectomy diminishes local complication rate and improves oncological results without increasing morbidity. Currently, there is no consensus definition about the number, location, and imaging techniques to employ to consider a patient oligometastatic. Thus, it is difficult to compare the results of the different studies and identification of a subgroup of patients that could benefit from this local treatment. CONCLUSIONS: In absence of prospective randomized data, radical prostatectomy seems to be useful for local treatment of the primary tumor in a selected group of patients with oligometastatic prostate cancer

Manejo laparoscópico de la estenosis uretero-ileal con seguimiento a largo plazo / Laparoscopic management of ureteroileal stenosis: Long term follow up

OBJETIVO: El objetivo de este artículo es la descripción de la técnica laparoscópica para el tratamiento de las estenosis uretero-ileales tras la cistectomía radical y analizar nuestra serie a largo plazo. MÉTODOS: Se realizó una revisión retrospectiva de los pacientes tratados laparoscópicamente de EUI tras cistectomía radical desde el Enero de 2011 (año en el que se implementó la técnica) hasta Marzo de 2017. Se tomaron los datos perioperatorios y se clasificaron según la graduación Clavien-Dindo. Asimismo, se describió la técnica quirúrgica y se realizó una búsqueda en la literatura del tema. RESULTADOS: Diez pacientes con EUI fueron tratados laparoscópicamente realizando un total de 11 cirugías. La pérdida sanguínea intraoperatoria media fue de 180 ml. No hubo conversión a cirugía abierta. La estancia hospitalaria media fue 10 días (4-23). Las complicaciones postoperatorias tempranas fueron Clavien-Dindo I y II e incluyen dos fugas limitadas de la anastomosis, una linforrea, un íleo paralítico y un descenso accidental de catéter ureteral. La media de seguimiento de los pacientes fue 56 meses (rango 12-179). Hasta el momento no se observaron complicaciones tardías. CONCLUSIONES: El tratamiento laparoscópico de las EUI es seguro, factible y eficaz según nuestra experiencia con seguimiento de casi 5 años

OBJECTIVE: To describe the laparoscopic approach for uretero-ileal anastomosis strictures and to analyse our long term series. METHODS: A retrospective review was performed evaluating our series of patients with benign uretero-ileal anastomosis strictures treated laparoscopically from 2011 to 2017. Demographics and perioperative data were obtained and analyzed. Complications were described with the Clavien-Dindo classification. The surgical technique was described and a literature review was performed. RESULTS: Eleven procedures were performed in ten patients. Mean blood loss was 180 ml. All the operations were performed laparoscopically without conversion. Mean hospital stay was 10 days (4-23). Early complications were Clavien-Dindo I y II: Two cases of limited anastomosis leakage, one lymphorrea, one paralitic ileum and one accidental descent of the ureteral catheter. Mean follow-up was 56 months (12-179) No late complications have been described. CONCLUSION: Based on our series with 5 year follow up, the laparoscopic approach for uretero-ileal anastomosis strictures is feasible and safe

Invasive bladder cancer in the eighties: transurethral resection or cystectomy?

PURPOSE: Describe morbidity and survival in patients older than 80 years with muscle invasive bladder cancer (MIBC) treated with radical cystectomy (RC) or transurethral resection (TUR) in our institution. MATERIALS AND METHODS: We reviewed our database of all patients older than 80 years treated with RC and TUR for MIBC between 1993 and 2005 in our institution. Twenty-seven patients were submitted to RC, with mean age of 82 years and mean follow-up of 16.4 months. RC was carried out following diagnosis of previous MIBC in 14 cases (51.9 percent). The American Society of Anesthesiology (ASA) score was III or IV in 23 patients (85.1 percent). Seventy-two patients with a mean age of 84 years and mean follow-up of 33 months, diagnosed with MIBC, were managed by means of TUR. The ASA score was III-IV in 64 (88.8 percent) patients. RESULTS: Pathological stage of the RC specimen was pT3 in 18 cases (66.7 percent). Mean hospital stay was 16 days. Early complications were assessed in 8 patients (29.6 percent), with an overall survival (OS) of 42.94 percent, and cancer-specific survival (CSS) of 60.54 percent. In patients submitted to TUR, clinical stage was T2 in 36 cases (50 percent). The mean hospital stay was 7 days, with a readmission rate (RR) of 87.5 percent. OS and CSS was less than 20 percent. CONCLUSIONS: RC in octogenarian patients is a safe procedure, with complication and survival rates comparable to RC series in general population. Transurethral resection (TUR) for patients with MIBC within this age range is a much less morbid procedure, but disease specific survival is lower.