Characteristics and Surgical Outcomes in Very Elderly Patients (≥75 years) with Renal Cell Carcinoma: Data from the Latin American Renal Cancer Group

Background: The incidence of renal cell carcinoma (RCC) is increasing globally due to an aging population and widespread use of imaging studies. Objective: The aim of this study was to describe the characteristics and perioperative outcomes of RCC surgery in very elderly patients (VEP), ≥75 years of age. Methods: This is a retrospective comparative study of 3656 patients who underwent the treatment for RCC from 1990 to 2015 in 28 centers from eight Latin American countries. We compared baseline characteristics as well as clinical and perioperative outcomes according to age groups (<75 vs.≥ 75 years). Surgical complications were classified with the Clavien-Dindo score. We performed logistic regression analysis to identify factors associated with perioperative complications. Results: There were 410 VEP patients (11.2%). On bivariate analysis, VEP had a lower body mass index (p < 0.01) and higher ASA score (ASA >2 in 26.3% vs. 12.4%, p < 0.01). There was no difference in performance status and clinical stage between the study groups. There were no differences in surgical margins, estimated blood loss (EBL), complication, and mortality rates (1.3% vs. 0.4%, p = 0.17). On multivariate regression analysis, age ≥75 years (odds ratio [OR] 2.33, p < 0.01), EBL ≥ 500 cc (OR 3.34, p < 0.01), and > pT2 stage (OR 1.63, p = 0.04) were independently associated with perioperative complications. Conclusions: Surgical resection of RCC was safe and successful in VEP. Age ≥75 years was independently associated with 30-day perioperative complications. However, the vast majority were low-grade complications. Age alone should not guide decision-making in these patients, and treatment must be tailored according to performance status and severity of comorbidities. (REV INVEST CLIN. 2020;72(5):308-15)

Voiding symptoms obtained by open versus directed anamnesis as predictors of voiding dysfunction in women

ABSTRACT Objectives To determine the differences between voiding symptoms obtained by open anamnesis (VS-Open) versus voiding symptoms obtained by directed anamnesis (VS-Directed) to predict voiding dysfunction in women. Materials and Methods Retrospective study of women with prior anti-incontinence surgery evaluated during 5 years. In a standardized clinical history taking, each patient was asked to answer question number five of the UDI-6 questionnaire ("Do you experience any difficulty emptying your bladder?"). If the answer was positive, the following voiding symptoms spontaneously described by the patient were documented: slow urine stream, straining to void, intermittent stream and feeling of incomplete bladder emptying, which were considered VS-Open. If the answer to this question was negative or if the patient had not reported the four voiding symptoms, she was asked in a directed manner about the presence of each o Ninety-one women are analyzed. Eighteen patients presented voiding dysfunction (19.8%), There was a statistical association between voiding dysfunction and the presence of any VS-Open (p = 0.037) and straining to void obtained by open anamnesis (p = 0.013). Sensitivity, specificity, PPV, NPV, positive likelihood ratio and negative likelihood ratio, respectively, were 44.4% and 27.8%, 80.8% and 94.5%, 36.3% and 55.6%, 85.5% and 84.1%, 2.324 and 5.129, and 0.686 and 0.764. There was no statistical association between voiding dysfunction and VS-Directed. Conclusions VS-Open may predict better voiding dysfunction than VS-Directed in women.

OAB score: A clinical model that predicts the probability of presenting overactive detrusor in the urodynamic study

ABSTRACT Purpose To create a predictive model of involuntary detrusor contraction (IDC) to improve the diagnostic accuracy of overactive detrusor (OAD), associating overactive bladder (OAB) symptoms with other clinical parameters in the female population. Materials and Methods A total of 727 women were studied retrospectively. In all of them, urodynamic study was conducted for urogynecological causes. Demographics information, personal history, symptoms, physical exam, a 3-day frequency/volume chart and urinary culture, were collected in all patients and they subsequently underwent uroflowmetry and urodynamic studies. A logistic regression model was performed in order to determine independent predictors of presence of IDC. Odd ratio (OR) estimation was used to assign a score to each one of the significant variables (p≤0.05) in the logistic regression model. We performed a ROC curve in order to determine the predictive ability of the score in relation to the presence of OAD. Results presence of OAD was evident in 210 women (29%). In the logistic regression analysis, independent predictors of OAD were urgency, urgency incontinence, nocturia, absence of SUI symptoms, diabetes mellitus, reduction of vaginal trophism and bladder capacity below 150 mL. The probability of IDC diagnosis increases as the score raises (Score 0: 4% until Score ≥10: 88%). Sensitivity was 71% and specificity 72%. The area under the curve of OAB score was 0.784 (p>0.001). Conclusions OAB score is a clinical tool that shows higher diagnostic accuracy than OAB symptoms alone to predict overactive detrusor.

Impacto de la rehabilitación del piso pelviano en la calidad de vida de mujeres con incontinencia urinaria / Impact of Pelvic Floor Rehabilitation on the Quality of Life of Women with Urinary Incontinence

Objetivos: Evaluar el impacto en la calidad de vida de mujeres con diversos tipos de incontinencia urinaria, en quienes se realizó un programa de entrenamiento de la musculatura del piso pelviano (EMPP). Materiales y métodos: Se llevó a cabo un estudio retrospectivo, descriptivo y analítico que evaluó a mujeres con incontinencia urinaria derivadas al Centro Urológico Profesor Bengió para realizar rehabilitación del piso pelviano entre enero de 2014 y diciembre de 2015. Todas las pacientes recibieron EMPP como primera línea de tratamiento. La calidad de vida fue evaluada mediante cuestionarios validados, entre los que se realizó UDI-6 (Urogenital Distress Index), IIQ-7 (Incontinence Impact Questionnaire) versión corta e IQoL (Incontinence Quality of Life). Las variables continuas fueron comparadas a través de pruebas pareadas de T test y las categóricas por el método de chi cuadrado (X2 ). Las puntuaciones fueron evaluadas previo y posterior al EMPP. Se definió una p<0,05 como estadísticamente significativa. Resultados: La población en estudio se remitió a 82 pacientes. La mejoría subjetiva expresada por las pacientes en una escala de 0-10 fue de 6,33 (desvío estándar [DE]=2,42) con una mediana de 7. En la población general existe una declinación en el cuestionario UDI-6 (-2,6; p<0,0001), IIQ-7 (-2,4; p=0,0001) y un aumento en IQoL (11,35; p<0,0001). En los diferentes tipos de incontinencia urinaria (esfuerzo, urgencia y mixta) también se observó una mejoría individual en todos los cuestionarios en cada tipo de incontinencia urinaria, excepto en el cuestionario IQoL (p=0,34) en pacientes con incontinencia de orina de esfuerzo. Conclusiones: El EMPP representa una terapia no invasiva efectiva en el tratamiento de diversas formas de incontinencia de orina, produciendo un impacto favorable en la calidad de vida de mujeres que padecen esta patología.(AU)

Objectives: To assess the impact on the quality of life in women with different types of urinary incontinence, who was a training of the musculature of the pelvic floor muscle (TMPP) program. Materials and methods: Was a retrospective, descriptive and analytical study evaluated women with urinary incontinence derived for rehabilitation of pelvic floor between January 2014 and December 2015. All patients received TMPP as first line treatment. Quality of life was evaluated performing validated questionnaires, which was carried out: UDI-6 (Urogenital Distress Index), IIQ-7 (Incontinence Impact Questionnaire) short version and IQoL (Incontinence Quality of Life). Continuous variables were compared through the categorical and paired T test tests by chi square (X2 ) method. Scores were assessed pre and post the TMPP. Defined a p<0.05 as statistically significant. Results: The study population was referred to 82 patients. Subjective improvement expressed by patients on a scale of 0-10 was 6.33 (standard deviation [SD]=2.42) with a median of 7. In the general population, there is a decline in the UDI-6 questionnaire (-2.6; p<0.0001), IIQ-7 (-2.4; p=0.0001) and an increase in the IQoL (11.35; p<0.0001). In the different types of urinary incontinence (stress, urgency and mixed) also find an individual improvement in all the questionnaires in each type of urinary incontinence, except in questionnaire IQoL (p=0.34) in patients who are stress urinary incontinence. Conclusions: The TMPP represents a therapy effective non-invasive in the treatment of various forms of urinary incontinence producing a positive impact on the quality of life of women living with this disease.(AU)

¿Existen diferencias clínicas, patológicas y evolutivas del cáncer renal en relación con la edad? / Are there Clinical, Pathological and Evolutionary Differences in Renal Cancer Related to Age?

Objetivos: Evaluar las características clínicas, patológicas y evolutivas en diferentes grupos etarios con cáncer renal. Materiales y métodos: Se llevó a cabo un análisis retrospectivo, descriptivo y analítico de 269 pacientes con carcinoma de células renales. Los pacientes fueron divididos en tres grupos de acuerdo con la edad al momento del diagnóstico: <50 años, entre 50 y 65 años y >65 años. En cada grupo se evaluaron características clínicas (edad, sexo, presencia de manifestaciones clínicas), patológicas (diámetro tumoral, tipo histológico, estadío patológico [TNM 2009], grado histológico, presencia de necrosis coagulativa, invasión microvascular, presencia de elementos sarcomatoides, compromiso de la grasa periférica, compromiso vascular macroscópico de vena renal o cava inferior e invasión ganglionar) y presencia de metástasis a distancia al diagnóstico. El análisis univariado de las variables categóricas fue realizado por el método de chi cuadrado o test de Fischer según correspondiera; las variables continuas fueron calculadas según el test de Student. Los puntos principales del trabajo, la sobrevida libre de metástasis y la sobrevida cáncer-específica fueron evaluados mediante el método de Kaplan-Meier y las diferencias entre los grupos fueron evaluadas por el Log-Rank test. Resultados: De los 269 pacientes estudiados, 40 (14,88%) corresponden a <50 años, 136 (50,55%) corresponden a pacientes entre 50 y 65 años y 93 (34,57%) corresponden a pacientes >65 años de edad. No existieron diferencias significativas al evaluar variables clínicas. Los pacientes <50 años presentaron mayor número de nefrectomías parciales (p=0,04), menor grado histológico (p=0,05), necrosis coagulativa (p=0,002), infiltración de la grasa periférica (p=0,02) y compromiso ganglionar (p=0,05). La sobrevida libre de metástasis a 5 años en pacientes <50 años fue del 95%; en los grupos entre 50-65 años y >65 años fue del 70% y el 71%, respectivamente, con diferencias significativas (Log-Rank test=0,004). De la misma manera, al comparar la sobrevida cáncerespecífica a 5 años entre los grupos se pudo evidenciar que las diferencias también fueron significativas a favor de pacientes <50 años (<50 años del 98%, 50-65 años del 79% y >65 años del 83%; Log-Rank test=0,02). Conclusiones: En nuestra serie, los pacientes >50 años de edad se asociaron a características patológicas y evolutivas desfavorables al ser comparados con pacientes de menor edad. Sin embargo, creemos que el seguimiento no debiera limitarse exclusivamente a la edad, sino que debiera incluir el resultado de todas las variables pronósticas de malignidad en cáncer renal (AU)

Objectives: To evaluate clinical, pathological and evolutionary characteristics in different age groups with renal cancer. Materials and methods: A retrospective, descriptive and analytics analysis of 269 patients with renal cell cancer was made. Patients were divided in three groups according to age at the moment of diagnosis: <50 years old, between 50 y 65 years old and >65 years old. In each group clinical (age, sex, presence of clinical manifestations), pathological (tumor diameter, histological type, pathological stage (TNM2009), histological grade, presence of coagulative necrosis, microvascular invasion, presence of sarcomatoid elements, peripheral fat compromise, renal vein or inferior cava vein macroscopic vascular compromise, and nodes invasion) characteristics and presence of distance metastasis at diagnosis were evaluated. Univariated analysis of categorical variables was made by Chi square or Fischer test just as correspond; continuous variables were calculated by Student test. Main points, metastasis free and cancer-specific survival, were evaluated by Kaplan-Meier method and differences between groups by the Log-Rank test. Results: Of 269 patients studied, 40 (14.88%) were <50 years old group, 136 (50.55%) between 50 and 65 years old group and 93 (34.57%) >65 years old group. There are no significative differences when we evaluate clinical variables. Patients in <50 years old group had higher number of nephron-sparing surgery (p=0.04), lower histological grade (p=0.05), coagulative necrosis (p=0.002), peripheral fat invasion (p=0.02) and node invasion (p=0.05). Metastasis free survival at 5 years in this group was 95%; in 50-65 years old group and >65 years old group was 70% and 71%, respectively, with significant differences (Log-Rank test=0.004). Likewise, when we compared cancer-specific survival at 5 years between groups, we demonstrate that differences are significant in favor of patients younger than 50 years old (<50 years old 98%, 50-65 years old 79% and >65 years old 83%; Log-Rank test=0.02). Conclusions: In our series, age >50 years old is associated with unfavorable pathological and evolutionary characteristics to be compared with younger patients. However, we believe that the follow-up should not be limited only to the age but should include the results of all prognostic variables of malignancy in kidney cancer. (AU)

Hallazgos patológicos y evolución en prostatectomía radical de pacientes candidatos para vigilancia activa / Pathological findings and follow-up of radical prostatectomy patients candidates for active surveillance

El APE ha derivado en el diagnóstico de CaP en etapas más tempranas de la enfermedad. Por otra parte, existen evidencias de que muchos pacientes son sobretratados. La vigilancia activa tiene como premisa reducir el sobre tratamiento y la morbilidad relacionada con el tratamiento primario. El objetivo de este estudio fue evaluar las características patológicas desfavorables en pacientes sometidos a PR que fueron estratificados pre-operatoriamente de bajo riesgo según 10 modalidades para definir pacientes posibles de seguimiento activo. Realizamos un estudio retrospectivo y analítico de 230 pacientes con diagnóstico de CAP y tratados con PR, realizadas entre 1999 y 2011 en el Centro Urológico Profesor Bengió. Se evaluaron las características clínicas en 10 protocolos de seguimiento activo. Las variables anatomopatológicas evaluadas en la pieza de PR fueron el estadio patológico, SG de la pieza operatoria, la extensión extraprostática (EEP), invasión de vesículas seminales y compromiso de ganglios linfíticos regionales. El informe histopatológico fue realizado por un único uropatólogo (VB).En cada uno de los protocolos se evalúa el índice de recurrencia bioquímica. La población del estudio fue 198 pacientes. La media de edad fue 63 años. La media de APE 12,4/ml. Predominaron los estadíos clínicos T1c (48 por ciento) y T2 (48 por ciento). El índice de concordancia entre el SG de la biopsia y la PR en la serie se observó en 128 pacientes (64,6 por ciento). La extensión extraprostática, invasión de vesículas seminales e invasión ganglionar fue encontrada en 44 (22,2 por ciento), 38 (19,2 por ciento) y 3 (1,5 por ciento) pacientes respectivamente. La presencia de elementos patológicos desfavorables en pacientes candidatos a seguimiento activo oscila entre 12 por ciento y el 32 porciento. En nuestra serie de pacientes tratados con prostatectomía radical, los esquemas de vigilancia activa más estrictos, basados en APE <10ng/ml,...

The PSA has resulted in the diagnosis of prostate cancer in earlier stages of the disease. Moreover, there is evidence that many patients are over-treated. Active surveillance tries to prevent overtreatment and reduce the morbidity associated with primary treatment. The aim of this study was to evaluate the adverse pathologic features in patients who underwent RP and were stratified preoperatively as potential candidate for active surveillance through 10 different protocols. A retrospective study of 230 patients diagnosed with CAP treated with PR, conducted between 1999 and 2011 in the Urological Center Professor Bengio. Clinical characteristics were evaluated in 10 active surveillance protocols. Pathologic variables evaluated in RP specimens were pathological stage, surgical specimen SG, extraprostatic extension (EEP), seminal vesicle invasion and regional lymph nodes. The histopathological report was done by a single uropathologist (VB). In each of the protocols biochemical recurrence rate was evaluated. The study population was 198 patients. The average age was 63. The mean PSA 12.4 / ml. Predominant clinical stages T1c (48 percent) and T2 (48 percent). The concordance rate between the SG biopsy and RP in the series was observed in 128 patients (64.6 percent). Extraprostatic extension, seminal vesicle invasion and lymph node involvement was found in 44 (22.2 percent), 38 (19.2 percent) and 3 (1.5 percent) patients, respectively. The presence of unfavorable pathological elements in candidates for active surveillance patients ranges from 12 percent to 32 percent. In our series of patients treated with radical prostatectomy, stricter schemes of active surveillance based on PSA <10ng/ml, clinical stage T1c-T2a, biopsy Gleason score ¡Ü 6 and minimally invasive biopsy (<2 cylinders and <50 percent involvement) show better agreement with favorable histopathology findings in radical prostatectomy and correspond with greater biochemical recurrence-free survival...

Score de Gleason 7 en la prostatectomía radical: ¿es lo mismo 3+4 que 4+3? / Gleason Score of 7 on radical prostatectomy: Is it the same 3+4 and 4+3?

El score de Gleason (SG) es un importante predictor de resultados en cáncer de próstata. El SG 7 es un grupo heterogéneo que presenta en las diversas series un riesgo de muerte cáncer específico del 29 por ciento-41 por ciento. La diferenciación de los casos en que el patrón dominante sea 3(3+4) y los casos en donde el patrón dominante sea 4 (4+3) podría representar un factor pronóstico significativo. Objetivos: Evaluar las diferencias clínicas, patológicas y evolutivas de pacientes con prostatectomía radical con score de Gleason 3+4 y 4+3.Materiales y métodos: Se consideraron 73 pacientes con score de Gleason 7 en el espécimen de prostatectomía radical entre 1999 y 2009. Se evaluaron variables clínicas (antígeno prostático específico (APE), estadio clínico y score de Gleason de la biopsia) y patológicas (estadio patológico, Gleason, márgenes quirúrgicos, invasión de vesículas seminales, compromiso ganglionar). Como punto de corte se utilizó la recurrencia bioquímica y la mortalidad cáncer específica. Se consideró fallo bioquímico a la elevación de APE por encima de 0,2 ng/ml con dos ascensos sucesivos. Resultados: En los 73 pacientes, 48 (65,8 por ciento) y 25 (34,2 por ciento) tuvieron score de Gleason 3+4 y 4+3 respectivamente en la pieza operatoria. Esto contrasta con el Gleason de la biopsia previa que sub graduó 54 por ciento para el grupo 3+4 y 32por ciento para el grupo 4+3. Los valores de APE correlacionaron el score de Gleason, siendo el promedio del marcador de 14,4 ng/ml para el grupo 3+4 y 17,7 ng/ml para el grupo 4+3. El grupo de patrón predominante 4 se asoció a mayor estadio patológico, no notándose diferencias significativas en lo referente a márgenes quirúrgicos positivos. La sobre vida libre de recurrencia bioquímica a los 5 años fue de 54,2por ciento en el grupo con patrón predominante 3, con una media al fallo de APE de 14 meses...

The Gleason score (GS) is an important predictor of outcome in prostate cancer. The SG 7 is a heterogeneous group in several series presents a specific cancer death risk of 29 percent-41 percent. The differentiation of cases in which the dominant pattern is 3 (3 +4) and cases where the dominant pattern is 4 (4 +3) could be a significant prognostic factor Objectives: Evaluate the different clinical, pathological and outcome of patients who underwent to radical prostatectomy whit a Gleason score 3+4 and 4+3.Materials and methods: We considered 73 patients with Gleason Score 7 in the specimen of radical prostatectomy between 1999 and 2009. Clinical variables were evaluated (prostate specific antigen (PSA), clinical stage and Gleason score of the biopsy) and pathological (pathological stage, Gleason score, surgical margins, seminal vesicle invasion, lymph node invasion). We used biochemical recurrence and cancer-specific mortality as our end point. Biochemical failure was a PSA rise above0.2 ng/ml with two successive determinations. Results: In the 73 patients, 48 (65.8 percent) and 25 (34.2 percent) had Gleason score 3 +4 and 4 +3, respectively, in the specimen. This contrasts with the previous biopsy Gleason which undergraduate 54 percent for group3+4 and 32 percent for the 4 +3. PSA values correlated the Gleason score, where the average score of 14.4 ng/ml for group 3 +4 and 17.7 ng/ml for group 4 +3. The predominant pattern group 4 was associated with higher pathological stage, no significant differences being noted in terms of positive surgical margins. The biochemical recurrence-free survival at 5 years was 54.2 percent in the group with the predominant pattern 3, with a mean to PSA failure of 14 months. In group 4, the predominant pattern of biochemical recurrence-free survival at 5 years was 16 percent, with a mean to recurrence of 5.8 percent months...