Surgical treatment of renal-cell carcinoma in elderly people. / Tratamiento quirúrgico del carcinoma de células renales en personas de edad avanzada.

OBJECTIVE: To describe the oncological characteristics and evolution of patients 65 years or older who underwent surgery for renal-cell carcinoma (RCC). METHODS: We reviewed our prospectively maintained database of patients with RCC treated surgically. Those ≥ 65 years old were selected. We analyzed clinical and pathological characteristics as well as oncological and functional outcomes. Overall survival (OS) was estimated with the Kaplan-Meier method. Multivariate Cox-proportional hazards model was used to determine predictors of OS. RESULTS: A total of 156 elderly patients with mean age 72.0±5.5 years (range 65-92) and median follow-up of 33 months were included. Surgical approach was open radical nephrectomy in 114 (73.5%), laparoscopic radical nephrectomy in 13 (8.4%), open partial nephrectomy in 23 (14.2%) and laparoscopic partial nephrectomy in 6 (3.9%). Pathological stage was: Stage I, 71 (45.5%); Stage II, 27 (17.3%); Stage III, 48 (30.8%); and Stage IV, 10 (6.4%). Lastly, 51 (32.6%) patients died, 22 (43.1%) from cancer. The 5-year OS according to pathological stage was 77.6%, 71.9%, 45.1% and 11.7% for stage I, II, III and IV, respectively (P<.001). On multivariate analysis, pathological stage independently predicted OS (HR 1.96, 95% CI [1.36-2.84], P=.0003). CONCLUSIONS: The surgical management of RCC appears to be safe in properly selected patients 65 years or older. Pathological stage predicts survival in this population.

Historia natural de la piuria y microhematuria después de la cirugía de próstata / Natural History of Pyuria and Microhematuria After Prostate Surgery

Objetivo: Las alteraciones del examen general de orina (EGO) son comunes después de la cirugía prostática. Sin embargo, el tiempo de normalización no ha sido establecido. La presencia de estas alteraciones puede propiciar abordajes diagnósticos innecesarios. El objetivo de este estudio es determinar el tiempo de normalización para ambos parámetros. Material y métodos: Estudiamos pacientes sometidos a cirugía prostática sin complicaciones infecciosas durante su seguimiento. Incluimos pacientes sometidos a resección transuretral de próstata (RTUP) con energía monopolar y bipolar y a prostatectomía abierta (PA). Se utilizaron curvas de Kaplan-Meier para determinar el tiempo de persistencia. Se utilizó ANOVA para comparar los 3 grupos de acuerdo a la cirugía. Analizamos el impacto del uso preoperatorio de inhibidores de la 5-alfa reductasa y correlacionamos el peso del tejido resecado con la persistencia de ambos parámetros. Resultados: Analizamos 85 pacientes: 44 sometidos a RTUP monopolar, 27 a RTUP bipolar y 14 a PA. El tiempo de persistencia de piuria fue significativamente mayor que el de microhematuria, con una mediana de 274 vs 176 días. Estos resultados no se vieron afectados por el tipo de energía utilizada, ni por el uso de inhibidores de la 5-alfa reductasa. Encontramos una correlación entre el peso del tejido resecado y la persistencia de piuria posterior a cirugía endoscópica: 23 g (fue el mejor punto de corte). Conclusiones: La piuria persiste más que la microhematuria independientemente del tipo de cirugía. Existe una correlación entre el tejido resecado y la persistencia de piuria. La presencia de estas alteraciones después de la cirugía prostática no siempre es un hallazgo patológico (AU)

Objective: Urinalysis alterations are common after prostatic surgery. However, time to normalization has not been established. Presence of pyuria and microhematuria can lead to unnecessary diagnostic procedures. The objective of this study is to determine the time to normalization for both parameters. Materials and methods: We reviewed medical records of patients who underwent prostatic surgery without infectious complications during follow-up. We included patients who underwent transurethral resection of the prostate (TURP) with either monopolar or bipolar energy, or open prostatectomy (OP). Kaplan–Meier curves were used to determine the time of persistence of both parameters. ANOVA was used to compare the 3 groups according to the type of surgery. We analyzed the impact of preoperative use of 5-α-reductase inhibitors, and searched for a correlation between the weight of resected tissue and persistence of both parameters. Results: 85 patients were analyzed: 44 underwent monopolar TURP, 27 bipolar TURP, and 14 OP. Persistence of pyuria was significantly longer than microhematuria with a median of 274 days vs. 176 days. Neither the use of monopolar or bipolar energy, nor the use of preoperative 5α-reductase inhibitors affected the persistence time. We found a positive correlation between the resected tissue weight and the persistence of leukocyturia after endoscopic surgery: 23 g was the best cut-off point. Conclusions: Pyuria persists longer than microhematuria regardless of the type of surgery. There is a correlation between the resected tissue weight and the persistence of this feature. The presence of pyuria and microhematuria after prostatic surgery is not always a pathological finding (AU)

Exactitud de la urotomografía computarizada para detectar tumores vesicales en pacientes con hematuria microscópica / Performance of Computed Tomographic Urography for the Detection of Bladder Tumors in Patients With Microscopic Hematuria

Objetivo: Evaluar la sensibilidad, especificidad, valores predictivos y exactitud de la tomografía computarizada en la detección de tumores vesicales en pacientes con hematuria microscópica. Material y métodos: Analizamos retrospectivamente los casos de hematuria microscópica evaluados con tomografía computarizada y cistoscopia de enero de 2006 a diciembre de 2009. Ambos estudios se consideraron como positivos en caso de identificarse una lesión sospechosa de neoplasia. El desempeño de la tomografía computarizada fue determinado mediante los resultados de la cistoscopia y los hallazgos histológicos. Resultados: Ciento doce pacientes fueron analizados. En 7 de ellos se identificó un tumor vesical por cistoscopia. La tomografía computarizada solo diagnosticó correctamente 2 casos y falló en 5. Un caso más fue considerado erróneamente como positivo en la tomografía computarizada. Esto resulta en una sensibilidad del 29%, especificidad del 99%, valor predictivo positivo del 67%, valor predictivo negativo del 95% y exactitud del 95%. Conclusiones: Aunque la tomografía computarizada tiene una especificidad alta en la evaluación de pacientes con hematuria microscópica, su sensibilidad es limitada. Por tal motivo la cistoscopia debe seguir siendo el estándar en estos casos (AU)

Objective: Our objective was to evaluate the sensitivity, specificity, predictive value, and accuracy of computed tomographic urography for the detection of bladder tumors in patients with microscopic hematuria. Material and methods: Patients with microscopic hematuria initially evaluated with computed tomography and cystoscopy from January 2006 to December 2009 were evaluated. Computed tomography detecting a bladder lesion suspicious of malignancy was considered positive. Cystoscopy was classified as positive when a lesion requiring biopsy or resection was found. Performance characteristics of computed tomography were determined by comparing with cystoscopic and pathological findings. Results: A total of 112 patients were eligible for analysis. Seven tumors were found on cystoscopy; of these, 2 were correctly diagnosed by computed tomography and 5 were missed. An additional case was considered erroneously positive. The results are a sensitivity of 29%, specificity of 99%, positive predictive value of 67%, negative predictive value of 95%, and accuracy of 95%. Conclusions: Although computed tomography has a high specificity its sensitivity is limited. For this reason conventional cystoscopy should be considered the standard for bladder evaluation of patients with microscopic hematuria (AU)

Natural history of pyuria and microhematuria after prostate surgery.

OBJECTIVE: Urinalysis alterations are common after prostatic surgery. However, time to normalization has not been established. Presence of pyuria and microhematuria can lead to unnecessary diagnostic procedures. The objective of this study is to determine the time to normalization for both parameters. MATERIAL AND METHODS: We reviewed medical records of patients who underwent prostatic surgery without infectious complications during follow-up. We included patients who underwent transurethral resection of the prostate (TURP) with either monopolar or bipolar energy, or open prostatectomy (OP). Kaplan-Meier curves were used to determine the time of persistence of both parameters. ANOVA was used to compare the 3 groups according to the type of surgery. We analyzed the impact of preoperative use of 5-α-reductase inhibitors, and searched for a correlation between the weight of resected tissue and persistence of both parameters. RESULTS: 85 patients were analyzed: 44 underwent monopolar TURP, 27 bipolar TURP, and 14 OP. Persistence of pyuria was significantly longer than microhematuria with a median of 274 days vs. 176 days. Neither the use of monopolar or bipolar energy, nor the use of preoperative 5α-reductase inhibitors affected the persistence time. We found a positive correlation between the resected tissue weight and the persistence of leukocyturia after endoscopic surgery: 23 g was the best cut-off point. CONCLUSIONS: Pyuria persists longer than microhematuria regardless of the type of surgery. There is a correlation between the resected tissue weight and the persistence of pyuria. The presence of pyuria and microhematuria after prostatic surgery is not always a pathological finding.

Factores pronósticos en pielonefritis enfisematosa / Prognostic Factors in Emphysematous Pyelonephritis

Objetivos: Analizar nuestra experiencia con 18 casos de pielonefritis enfisematosa (PE) en un centro de tercer nivel. Material y métodos: De 262 pacientes hospitalizados por pielonefritis aguda, 18 mostraron hallazgos radiológicos de PE. Utilizamos la clasificación de Wan y Huang. Analizamos las características clínicas, radiológicas y terapéuticas de los pacientes. Buscamos factores pronósticos de mortalidad. Resultados: De 2005 a 2010 17 mujeres y un hombre recibieron tratamiento por PE. La media de edad fue de 52,4 años. El 72% de los pacientes padecían hipertensión y el 66% diabetes tipo 2. Los hallazgos clínicos más comunes fueron: taquicardia (11), fiebre (11) y dolor en flanco (9). Doce pacientes presentaron sepsis grave y 2 choque séptico. El 61% de los pacientes tuvo insuficiencia renal aguda a su ingreso. Nueve sujetos recibieron manejo conservador; se colocó catéter doble J a 5 pacientes y drenaje percutáneo a 3. Solo realizamos una nefrectomía después de un manejo conservador no exitoso. La mortalidad fue del 11%. Las alteraciones en el estado de conciencia (p=0,0001), disfunción orgánica múltiple (p=0.0004), hiperglucemia (p=0,003) y leucocitosis (> 20.000 K) (p=0,01) fueron más comunes en aquellos pacientes que no sobrevivieron. No hubo diferencias en mortalidad entre los pacientes tratados de forma conservadora (solo manejo médico) y aquellos que recibieron tratamiento invasivo. Conclusiones: La PE debe sospecharse en pacientes con múltiples comorbilidades que se presentan con sepsis grave. La alteración en el estado de alerta, la disfunción orgánica múltiple, la hiperglucemia y la leucocitosis son factores de mal pronóstico. El tratamiento invasivo debe utilizarse de forma juiciosa, y el tratamiento conservador puede ser una estrategia segura en casos seleccionados (AU)

Objectives: The purpose of this study is to analyze our experience with 18 cases of Emphysematous pyelonephritis (EPN) in a tertiary care center and describe our treatment strategy. Material and methods: Of 262 patients admitted with acute pyelonephritis, 18 had CT findings of EPN. The Wan and Huang classifications were used. We assessed the clinical, radiological, and therapeutic characteristics of these patients and investigated potential prognostic factors of mortality. Results: Between 2005 and 2010, 17 women and 1 man with EPN were treated. Mean age was 52.4 years. Diabetes was found in 66% and hypertension in 72%. The most common clinical findings were tachycardia (11), fever (11) and flank pain (9); 66% (12) presented with severe sepsis and 2 had septic shock. Acute renal injury developed in 61%. Nine patients were treated exclusively with conservative management; 5 had double J stenting, 3 had CT-guided PCD and 1 required nephrectomy after unsuccessful medical management. Mortality was 11%. Altered consciousness (P=0.0001), multiple organ failure (P=.0004), hyperglycemia (P=0.003) and elevated leukocyte count (> 20000 K) (P=0.01) were more frequent among patients dying from EPN. No difference in mortality was found between patients managed conservatively and those undergoing invasive therapy. Conclusions: Although rare, EPN should be suspected in patients with multiple comorbidities presenting with severe sepsis. Altered consciousness, multiple organ failure, hyperglycemia and elevated leukocyte count are poor prognosis indicators. Invasive management should be used judiciously and medical treatment can be a safe strategy in selected cases (AU)

Performance of computed tomographic urography for the detection of bladder tumors in patients with microscopic hematuria.

OBJECTIVE: Our objective was to evaluate the sensitivity, specificity, predictive value, and accuracy of computed tomographic urography for the detection of bladder tumors in patients with microscopic hematuria. MATERIAL AND METHODS: Patients with microscopic hematuria initially evaluated with computed tomography and cystoscopy from January 2006 to December 2009 were evaluated. Computed tomography detecting a bladder lesion suspicious of malignancy was considered positive. Cystoscopy was classified as positive when a lesion requiring biopsy or resection was found. Performance characteristics of computed tomography were determined by comparing with cystoscopic and pathological findings. RESULTS: A total of 112 patients were eligible for analysis. Seven tumors were found on cystoscopy; of these, 2 were correctly diagnosed by computed tomography and 5 were missed. An additional case was considered erroneously positive. The results are a sensitivity of 29%, specificity of 99%, positive predictive value of 67%, negative predictive value of 95%, and accuracy of 95%. CONCLUSIONS: Although computed tomography has a high specificity its sensitivity is limited. For this reason conventional cystoscopy should be considered the standard for bladder evaluation of patients with microscopic hematuria.

[Prognostic factors in emphysematous pyelonephritis]. / Factores pronósticos en pielonefritis enfisematosa.

OBJECTIVES: The purpose of this study is to analyze our experience with 18 cases of Emphysematous pyelonephritis (EPN) in a tertiary care center and describe our treatment strategy. MATERIAL AND METHODS: Of 262 patients admitted with acute pyelonephritis, 18 had CT findings of EPN. The Wan and Huang classifications were used. We assessed the clinical, radiological, and therapeutic characteristics of these patients and investigated potential prognostic factors of mortality. RESULTS: Between 2005 and 2010, 17 women and 1 man with EPN were treated. Mean age was 52.4 years. Diabetes was found in 66% and hypertension in 72%. The most common clinical findings were tachycardia (11), fever (11) and flank pain (9); 66% (12) presented with severe sepsis and 2 had septic shock. Acute renal injury developed in 61%. Nine patients were treated exclusively with conservative management; 5 had double J stenting, 3 had CT-guided PCD and 1 required nephrectomy after unsuccessful medical management. Mortality was 11%. Altered consciousness (P=.0001), multiple organ failure (P=.0004), hyperglycemia (P=.003) and elevated leukocyte count (> 20000 K) (P=.01) were more frequent among patients dying from EPN. No difference in mortality was found between patients managed conservatively and those undergoing invasive therapy. CONCLUSIONS: Although rare, EPN should be suspected in patients with multiple comorbidities presenting with severe sepsis. Altered consciousness, multiple organ failure, hyperglycemia and elevated leukocyte count are poor prognosis indicators. Invasive management should be used judiciously and medical treatment can be a safe strategy in selected cases.