Transumbilical laparoendoscopic single-site ureteral reimplantation.

OBJECTIVE: To analyze the outcomes of umbilical laparoendoscopic single-site (LESS) ureteral reimplantation using a reusable single-port platform. MATERIAL AND METHOD: The casuistic of LESS ureteral reimplantation in 5 patients is presented. The surgical technique using KeyPort system (reusable umbilical single-site platform) is described. Dissection, suctioning and suturing by minilaparoscopy through 3.5mm accessory port in the iliac fossa are performed. Operative and postoperative outcomes are presented. The median follow-up at time of analysis was 11 ± 14 months. RESULTS: The median age of patients was a 49 ± 34 year; male-female ratio was 1:1.15. Left surgery was carried out in all cases. In 4 patients, the etiology was secondary to stenosis (3 iatrogenic and 1 pelvic endometriosis). In the remaining case, the procedure was performed after excision of a symptomatic adult ureterocele. In all cases, bladder catheter and double-J ureteral catheter were inserted for 7 ± 3 and 30 ± 15 days and then removed. No conversion to convectional laparoscopic or open surgery occurred. The surgery time was 145 ± 60 min, and intraoperative bleeding was 100 ± 75 cc. Neither transfusion nor high analgesia was necessary. No postoperative complications, minor or major, have been reported. Hospital stay was 2 ± 0.5 days. In any patient, restenosis or worsening of renal function occurred. CONCLUSIONS: In experimented centers, transumbilical laparoendoscopic single-site ureteroneocystostomy is a safe alternative with comparable results to conventional laparoscopy and an excellent cosmetic result at low cost thanks to device reuse.

Laparoendoscopic single-site retroperitoneal lymph node dissection in non-seminomatous germ cell malignancy.

INTRODUCTION: Umbilical laparoendoscopic single-site (LESS) surgery represents an excellent alternative to laparoscopic or robotic multiport surgery. LESS surgery offers faster recovery, less postoperative pain and optimal cosmetic results. LESS is possible in virtually any urologic surgery. PATIENT AND METHOD: We present a 38-year-old male with BMI 31.2 and with history of stage I nonseminomatous mixed germ cell tumor showing interaortocaval lymph node recurrence without elevation of tumor markers. Patient was undergone to right laparoendoscopic single-site retroperitoneal lymph node dissection (LDRP-LESS) by umbilical approach using a single-site multichannel KeyPort (Richard Wolf GmbH, Knittlingen, Germany). RESULTS: After the placement of the device and triangulation of the clips, we proceeded to operate on posterior parietal peritoneum. The descending colon was mobilized to access the retroperitoneum. Complete retroperitoneal lymph node dissection on the right side from iliac vessels to renal vessels, including the paracaval and interaortocaval space, was performed. The specimen was inserted into a laparoscopic bag and was removed together with multichannel system. Abdominal drainage was not employed. Surgical time was 85 min and estimated bleeding 50 cc. The patient was very satisfied with the cosmetic results and was discharged the following day without needing analgesia. The pathology report revealed metastatic seminoma in 5 of 11 lymph nodes receiving systemic chemotherapy (VP16-CDDPs) for 4 cycles with good tolerance. A year later, the patient was disease-free and had no complications. CONCLUSIONS: Umbilical primary LDRP-LESS, with excellent oncologic and cosmetic results, is feasible in selected cases. This approach could be considered the least invasive surgical option economically advantageous due to the reusable nature of the instruments used.

The best option: Umbilical LESS radical nephrectomy with vaginal extraction.

INTRODUCTION: Umbilical laparoendoscopic single-site (LESS) surgery represents an excellent alternative to laparoscopic or robotic multiport surgery. LESS surgery offers faster recovery, less postoperative pain and optimal cosmetic results. The reusable nature of its instruments also has significant economic advantages. PATIENT AND METHOD: We present a 34-year-old patient with a solid mesorenal lesion measuring 8 cm in the left kidney treated with pure LESS radical nephrectomy assisted by vaginal extraction of the specimen. The umbilical approach using a single-site multichannel KeyPort (Richard Wolf GmbH, Knittlingen, Germany) with DuoRotate curved instruments allows for minimum crushing and fewer spatial conflicts. Its perfect umbilical adaptation provides a hermetic system. The instrument's double rotation provides considerable movement precision. Vaginal extraction avoids damage to the abdominal wall and the need for widening the umbilical incision. RESULTS: After the placement of the device and triangulation of the clips, we proceeded to operate on posterior parietal peritoneum. The descending colon was mobilized to access the retroperitoneum and dissect the renal hilum. Hem-o-lok clips were placed on the artery and vein, which were subsequently sectioned. The specimen was inserted into a laparoscopic bag. Under direct vision, we placed a 15-mm trocar through the bottom of the vaginal posterior fornix to facilitate the extraction of the bag's thread. The incision was widened with the fingers, and the specimen was extracted, closing the vagina from the perineum with visualization from the navel. Abdominal drainage was not employed. The surgical time was 180 min. The patient was discharged the following day without needing analgesia. A year later, the patient was disease-free and had no complications. CONCLUSIONS: Umbilical LESS radical nephrectomy with vaginal extraction is feasible in selected cases. The procedure is oncologically safe, avoids scars and facilitates early recovery. From a practical point of view, this approach greatly simplifies natural orifice transluminal endoscopic surgery (NOTES) and enables a minimally invasive equivalent result.

Utilidad de HistoScanning™ previo a biopsia prostática para el diagnóstico de adenocarcinoma de próstata / Utility of HistoscanningTM prior to prostate biopsy for the diagnosis of prostate adenocarcinoma

Objetivos: HistoScanning™ (HS) es un método de diagnóstico ecográfico del cáncer de próstata. Analizamos la eficacia de la realización de HS previo a las biopsias para el diagnóstico de adenocarcinoma de próstata. Material y métodos: Entre agosto y octubre de 2012 hemos realizado estudio con HS previo a las biopsias en 32 pacientes. En todos los casos se realizaron biopsias transrectales por sextantes (2 tomas en cada sextante) de la zona periférica. En aquellos sextantes en los que hubo áreas sospechosas con HS las biopsias se dirigieron a dichas áreas. Se añadieron biopsias transperineales en aquellas áreas situadas en la zona media-anterior o apical prostática. La edad media fue de 63,7 años (rango: 40-82), con un PSA medio de 8,0 ng/ml (rango: 3,5-36,2) y un volumen prostático medio de 46,6 cc (rango: 18,2-103,2). En 8 casos se trataba de primera biopsia, en 14 de biopsias de repetición y 10 pacientes tenían diagnóstico previo de adenocarcinoma de próstata (8 en programa de vigilancia activa y 2 T1a en RTU de próstata previa). Resultados: En los 32 pacientes se biopsiaron una media de 7,5 zonas (rango: 6-9) con un total de 239 zonas estudiadas. Se identificaron una media de 3,2 zonas con áreas sospechosas (ZS) con HS (rango: 2-5), con un total de 103 ZS. Se encontró adenocarcinoma o PIN en 72 zonas de 25 pacientes (2 PIN, 11 score Gleason 6, 7 score Gleason 7, 3 score Gleason 8 y 2 score Gleason 9). Hubo 35 zonas falsos positivos en 20 pacientes (11 parénquima normal y 9 inflamación crónica). Se produjeron falsos negativos en 5 zonas en 5 pacientes (2 PIN, 2 score Gleason 6 y un score Gleason 7), aunque en los 5 casos se descubrió adenocarcinoma en otras zonas. El HS presentó una sensibilidad del 93,5% con una especificidad del 79,5%. El valor predictivo positivo fue del 67,35% con un valor predictivo negativo del 96,5%. Conclusiones: A pesar de tratarse de una serie seleccionada, con alta tasa de pacientes con adenocarcinoma, la exploración con HS ha presentado una gran sensibilidad y un elevado valor predictivo negativo. Estos datos, aunque deben ser confirmados en series menos seleccionadas, indican que la exploración previa con HS puede ayudar tanto al diagnóstico en las biopsias como en el seguimiento en programas de vigilancia activa (AU)

Objectives: HistoScanning™ (HS) is a method of ecographic diagnosis of prostate cancer. We analyze the effectiveness of the HS realization prior to the biopsys for the prostate adenocarcinoma diagnosis. Material and methods: From August to October 2012 we have carried out a study with HS prior to the biopsys in 32 patients. In all cases sextants transrectalbiopsys have been realized (two cores in each sextant) in the periphery zone. In those sextants in which there were suspicious areas with HS, the biopsys were addressed to those areas. Transperinealbiopsys were added to those zones placed in the half-front or apical prostatic zone. The medium age was 63.7 years (range 40-82) with a medium PSA of 8.0ng/ml (range 3.5-36.2) and a medium prostatic volume of 46.6 cc (range 18.2-103.2). In eight cases it was the first biopsy, in 14 cases they were repetition biopsys and 10 patients had a previous diagnosis of prostate adenocarcinoma (8 in a program of active surveillance and 2 T1a in RTU of previous prostate). Results: In the 32 patients a medium of 7,5 zones were biopsed (range 6-9) with a total of 239 zones studied. There were identified a medium of 3.2 zones with suspictious areas (ZS) with HS (range 2-5) with a total of 103 ZS. In 72 zones of 25 patients it was found adenocarcinoma or PIN (2 PIN, 11 score Gleason 6, 7 score Gleason 7, 3 score Gleason 8 and 2 score Gleason 9). There were 35 positive falses zones in 20 patients (11 normal parenquima and 9 cronic inflammation). Negative falses were produced in 5 zones in 5 patients (2 PIN, 2 score Gleason 6 and 1 score Gleason 7) although in all 5 cases adenocarcinoma was encountered (o discovered) in other zones. The HS presented a sensibility of a 93.5% with a specificity of 79.5%. The positive predictive value was of the 67.35% with a negative predictive value of 96.5%. Conclusions: In spite of being a selected serie, with a high rate of patients with adenocarcinoma, the exploration with HS has presented a great sensibility and a high negative predictive value. These data, although they must be confirmed in less selected series, state that the prior exploration with HS can help as in the diagnostic in the biopsies as in the follow-up of programs of active surveillance (AU)

Utility of Histoscanning™ prior to prostate biopsy for the diagnosis of prostate adenocarcinoma.

OBJECTIVES: HistoScanning™ (HS) is a method of ecographic diagnosis of prostate cancer. We analyze the effectiveness of the HS realization prior to the biopsies for the prostate adenocarcinoma diagnosis. MATERIAL AND METHODS: From August to October 2012 we have carried out a study with HS prior to the biopsies in 32 patients. In all cases sextants transrectal biopsies have been realized (two cores in each sextant) in the periphery zone. In those sextants in which there were suspicious areas with HS, the biopsies were addressed to those areas. Transperineal biopsies were added to those zones placed in the half-front or apical prostatic zone. The medium age was 63.7 years (range 40-82) with a medium PSA of 8.0 ng/ml (range 3.5-36.2) and a medium prostatic volume of 46.6cc (range 18.2-103.2). In eight cases it was the first biopsy, in 14 cases they were repetition biopsies and 10 patients had a previous diagnosis of prostate adenocarcinoma (8 in a program of active surveillance and 2 T1a in RTU of previous prostate). RESULTS: In the 32 patients a medium of 7,5 zones were biopsied (range 6-9) with a total of 239 zones studied. There were identified a medium of 3.2 zones with suspicious areas (ZS) with HS (range 2-5) with a total of 103 ZS. In 72 zones of 25 patients it was found adenocarcinoma or PIN (2 PIN, 11 score Gleason 6, 7 score Gleason 7, 3 score Gleason 8 and 2 score Gleason 9). There were 35 positive false zones in 20 patients (11 normal parenquima and 9 chronic inflammation). Negative falses were produced in 5 zones in 5 patients (2PIN, 2 score Gleason 6 and 1 score Gleason 7) although in all 5 cases adenocarcinoma was encountered (o discovered) in other zones. The HS presented a sensibility of a 93.5% with a specificity of 79.5%. The positive predictive value was of the 67.35% with a negative predictive value of 96.5%. CONCLUSIONS: In spite of being a selected serie, with a high rate of patients with adenocarcinoma, the exploration with HS has presented a great sensibility and a high negative predictive value. These data, although they must be confirmed in less selected series, state that the prior exploration with HS can help as in the diagnostic in the biopsies as in the follow-up of programs of active surveillance.

Estado actual de la cirugía transumbilical por puerto único en urología: retos y aplicaciones / Current State of Single-Port Transumbilical Surgery in Urology: Challenges and Applications

Contexto: La cirugía laparoscópica en urología ha supuesto un avance importante, aunque no está exenta de cierta morbilidad asociada al empleo de múltiples trocares y de forma particular a la extracción del espécimen. Con intención de disminuir esta morbilidad y de mejorar la estética se están desarrollado otras técnicas, como la cirugía laparoendoscópica a través de orificios naturales (NOTES) y la cirugía laparoendoscópica a través de puerto único (LESS). Se pretende revisar el estado actual de la cirugía laparoendoscópica por puerto único en urología. Adquisición de evidencia: Se ha llevado a cabo una revisión no sistemática, a través de una búsqueda bibliográfica empleando los términos LESS y urología desde 2007 hasta 2012. Se describen la experiencia actual LESS en urología, sus principales indicaciones y los diferentes dispositivos de puerto único e instrumental disponibles en el mercado. Síntesis de evidencia: La cirugía LESS nace como un paso más en la evolución constante de la cirugía mínimamente invasiva en un intento por mejorar la estética, reducir el traumatismo quirúrgico y disminuir el dolor y las complicaciones postoperatorias asociadas a la laparoscopia convencional con múltiples trocares. Desde la primera descripción en 2007, la experiencia se ha incrementado exponencialmente y la técnica LESS, asistida o no por robot, se está consolidando para un gran espectro de indicaciones urológicas (tanto en cirugía oncológica como reconstructiva), a mucha mayor escala que la técnica NOTES. A pesar de que la mayoría de los datos existentes son no aleatorizados y en escasas ocasiones son comparativos, con el sesgo de selección que ello representa, parece evidente que el beneficio estético y de control analgésico asociado a la cirugía LESS es real y reproducible. Las complicaciones asociadas a la misma son mayores en casos de cirugía oncológica mayor y se deben más a la propia técnica que al abordaje. Conclusiones: Aunque el beneficio real de la cirugía LESS en urología aún no puede cuantificarse oportunamente, la mejora cosmética, el menor dolor y una mayor satisfacción del paciente con su herida resultan evidentes. El entrenamiento apropiado en este tipo de procedimientos en centros de gran volumen y las constantes mejoras técnicas en el desarrollo instrumental por parte de la industria biomédica permiten que la técnica LESS transumbilical en urología haya nacido para quedarse (AU)

Context: Laparoscopic surgery in urology is considered to be an important advance, although it is not exempt from some morbidity associated to the use of multiple trocars and specifically to the extraction of the specimen. In order to decrease this morbidity and improve esthetics, other techniques are being developed, such as natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS). It is aimed to review the current status of laparoendoscopic single site surgery in urology. Acquisition of evidence: A nonsystematic review has been carried out by means of the bibliographic search using the terms LESS and Urology from 2007 to 2012. The current LESS experience in urology is described, and its principal indications and the different single site devices and instruments available on the market are described. Synthesis of evidence: LESS surgery arose as one more step in the constant evolution of minimally invasive surgery in an attempt to improve esthetics, reduce surgical trauma and decrease pain and the post-operative complications associated to the conventional laparoscopy with multiple trocars. Since it was first described in 2007, the experience has been increasing exponentially and the LESS technique, whether assisted or not by robot, is becoming consolidated for a large spectrum of urological indications (both in oncological and reconstructive surgery) on a much greater scale than the NOTES technique. Even though most of the existing data are not randomized and very rarely comparative, with the selection bias that this represents, it seems clear that the esthetic benefit and analgesic control associated to the LESS surgery is real and reproducible. The complications associated to it are greater in cases of major oncology surgery and are due more to the technique itself then to the approach. Conclusions: Although the real benefit of the LESS surgery in urology cannot be appropriately quantified, the cosmetic improvement, less pain and greater patient satisfaction with their wound are clear. Appropriate training in this type of procedures in centers having large volumes and the continuous technical improvements in the instrumental development by the biomedical industry has resulted in the fact that the transumbilical LESS technique in urology has been born to stay (AU)

[Current state of single-port transumbilical surgery in urology: challenges and applications]. / Estado actual de la cirugía transumbilical por puerto único en urología: retos y aplicaciones.

CONTEXT: Laparoscopic surgery in urology is considered to be an important advance, although it is not exempt from some morbidity associated to the use of multiple trocars and specifically to the extraction of the specimen. In order to decrease this morbidity and improve esthetics, other techniques are being developed, such as natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS). It is aimed to review the current status of laparoendoscopic single site surgery in urology. ACQUISITION OF EVIDENCE: A nonsystematic review has been carried out by means of the bibliographic search using the terms LESS and Urology from 2007 to 2012. The current LESS experience in urology is described, and its principal indications and the different single site devices and instruments available on the market are described. SYNTHESIS OF EVIDENCE: LESS surgery arose as one more step in the constant evolution of minimally invasive surgery in an attempt to improve esthetics, reduce surgical trauma and decrease pain and the post-operative complications associated to the conventional laparoscopy with multiple trocars. Since it was first described in 2007, the experience has been increasing exponentially and the LESS technique, whether assisted or not by robot, is becoming consolidated for a large spectrum of urological indications (both in oncological and reconstructive surgery) on a much greater scale than the NOTES technique. Even though most of the existing data are not randomized and very rarely comparative, with the selection bias that this represents, it seems clear that the esthetic benefit and analgesic control associated to the LESS surgery is real and reproducible. The complications associated to it are greater in cases of major oncology surgery and are due more to the technique itself then to the approach. CONCLUSIONS: Although the real benefit of the LESS surgery in urology cannot be appropriately quantified, the cosmetic improvement, less pain and greater patient satisfaction with their wound are clear. Appropriate training in this type of procedures in centers having large volumes and the continuous technical improvements in the instrumental development by the biomedical industry has resulted in the fact that the transumbilical LESS technique in urology has been born to stay.

Pielolitectomía por puerto único umbilical sobre riñón en herradura: una nueva indicación / Umbilical Single-Port Pyelolithectomy on Horseshoe Kidney: a New Indication

Introducción: La cirugía laparoscópica a través de puerto único es una evolución de la cirugía laparoscópica que resulta posible gracias al desarrollo tecnológico reciente de nuevos sistemas de acceso. Se trata de una técnica establecida en el campo de la cirugía mínimamente invasiva, pero sus indicaciones en el campo de la Urología están desarrollándose en la actualidad. Material y métodos: Presentamos la primera pielolitectomía sin incisión, a través de puerto único colocado en el ombligo, realizada en un paciente varón de 47 años (IMC: 38,2) con riñón en herradura portador de una litiasis piélica única de 4cm de diámetro. Se empleó una incisión umbilical de 2,5cm para la introducción del prototipo de puerto único reutilizable de Richard Wolf, sin necesidad de elemento auxiliar adicional alguno. Resultados: Tras colocación de doble-J izquierdo se llevó a cabo liberación del uréter proximal izquierdo y pelvis renal, pielolitectomía y pielorrafia con instrumentos-DuoRotate© (Richard Wolf). Se comprobó estanqueidad de la vía urinaria mediante instilación intravesical de azul de metileno y no se dejó drenaje. El procedimiento duró 280 minutos y el sangrado fue 30cc. El paciente fue dado de alta a las 24 horas sin dolor alguno. Conclusión: La pielolitectomía sin incisión es una opción factible y resolutiva para el tratamiento de la litiasis piélica. En centros con experiencia en cirugía a través de puerto único puede considerarse la opción más beneficiosa estéticamente hablando, sobre todo en casos especiales como el riñón en herradura (AU)

Introduction: Laparoscopic surgery through a single port is an evolution of laparoscopic surgery, possible after recent technological development of new access systems. It is an established minimally invasive technique, although its indications in the field of Urology are currently under development. Material and methods: We present the first case of incision-less pyelolithectomy, performed through a single-port placed in the umbilicus, performed in a 47 years-old male patient(38.2 BMI) with solitary 4 cm diameter lithiasis in a horseshoe kidney. An umbilical 2.5 cm incision was used for the introduction of a prototype of the reusable Richard Wolf single-port system, without any ancillary elements. Results: After placement of left double-J stent proximal left ureter and renal pelvis, pyelolithectomy and pyelorraphy were performed with Duo Rotate-Instruments© (Richard Wolf). Water-tightness was demostrated with methylene blue intravesical instillation and no drain was placed. The procedure lasted for 280 min and bleeding was 30 cc. The patient was discharged 24 hours later without pain. Conclusion: Incision-less pyelolithectomy is a feasible and resolutive option to treat pelviclithiasis. It can be considered the most beneficial option in aesthetical terms in experienced centers, especially in peculiar cases like horseshoe kidney (AU)

[Umbilical single-port pyelolithectomy on horseshoe kidney: a new indication]. / Pielolitectomía por puerto único umbilical sobre riñón en herradura: una nueva indicación.

INTRODUCTION: Laparoscopic surgery through a single port is an evolution of laparoscopic surgery, possible after recent technological development of new access systems. It is an established minimally invasive technique, although its indications in the field of Urology are currently under development. MATERIAL AND METHODS: We present the first case of incision-less pyelolithectomy, performed through a single-port placed in the umbilicus, performed in a 47 years-old male patient (38.2 BMI) with solitary 4 cm diameter lithiasis in a horseshoe kidney. An umbilical 2.5 cm incision was used for the introduction of a prototype of the reusable Richard Wolf single-port system, without any ancillary elements. RESULTS: After placement of left double-J stent proximal left ureter and renal pelvis, pyelolithectomy and pyelorraphy were performed with DuoRotate-Instruments© (Richard Wolf). Water-tightness was demostrated with methylene blue intravesical instillation and no drain was placed. The procedure lasted for 280 min and bleeding was 30 cc. The patient was discharged 24 hours later without pain. CONCLUSION: Incision-less pyelolithectomy is a feasible and resolutive option to treat pelvic lithiasis. It can be considered the most beneficial option in aesthetical terms in experienced centers, especially in peculiar cases like horseshoe kidney.

Nefrectomía parcial laparoscópica / Laparoscopic Partial Nephrectomy

Objetivo: Analizar el resultado quirúrgico y oncológico de una experiencia prospectiva con nefrectomía parcial laparoscópica. Se describe la técnica quirúrgica y los resultados oncológicos conseguidos a medio plazo. Material y métodos: Fueron intervenidos 60 pacientes mediante esta técnica entre junio de 2005 y junio de 2009. La edad media de los pacientes fue 58,9 (38-77 años), siendo 40 (66,7%) varones y 20 (33,3%) mujeres. El IMC medio fue 26,8 (18-40). La lateralidad fue 28 (46,7%) tumores derechos y 32 (53,3%) izquierdos, localizándose en el polo superior en 14 (23,3%) pacientes, en la zona media en 13 (21,7%), en el polo inferior en 22 (36,7%) y en la zona hiliar en 11 (18,3%). En 23 (38,3%) casos el tumor se localizó en la valva anterior, en 24 (40%) en la valva posterior, en 10 (16,7%) en el borde externo y en 3 (5%) en el borde interno. El tamaño medio tumoral en la TAC fue 3,3 (1-6,4) cm y en la pieza quirúrgica 3,1 (1,2-7) cm. Resultados: El tiempo medio quirúrgico fue 107,17 (50-185) minutos, con un tiempo de isquemia caliente de 33 (0-70) minutos. En 56 casos (93,3%) había una sola arteria y en 4 (6,7%) dos. Se realizó clampaje sólo de la arteria en 15 pacientes (25%), de la arteria y la vena en 44 (73,3%) y no se realizó clampaje en uno (1,7%). Se realizó reparación de la vía urinaria en 32 pacientes (53,3%), dejándose catéter ureteral en todos ellos. Precisaron transfusión el 20% de los pacientes (12). Se produjeron complicaciones intraoperatorias en 5 pacientes (8,7%). Estas fueron: una lesión esplénica que requirió esplenectomía (1,7%), un desgarro de la vena cava que se suturó laparoscópicamente (1,7%) y tres casos de sangrado por mal funcionamiento del «bulldog» (5%). Se produjeron complicaciones postquirúrgicas en 11 pacientes (18,7%) y estas fueron: un hematoma de pared que requirió reintervención (1,7%), una fístula urinaria que terminó en atrofia renal y posterior nefrectomía (1,7%), tres hematomas intracavitarios que se resolvieron de manera conservadora (5%), una fístula arteriovenosa que precisó embolización selectiva (1,7%), un urinoma que se solucionó con drenaje percutáneo (1,7%) y tres casos de fiebre postoperatoria (5%). Hubo márgenes positivos en un paciente (1,7%). En 49 casos (81,7%) la histología fue carcinoma renal, en 8 (13,3%) oncocitoma, en dos (3,3%) angiomiolipoma y en uno (1,7%) metástasis. La estancia media fue 5 (3-29) días. El seguimiento medio fue de 31 (12-61) meses. Se produjo una recidiva local a los 16 meses (tumor primario hiliar de 2,5 cm) y una metástasis en la suprarrenal ipsilateral a los 34 meses (tumor primario de 5,6 cm en el polo inferior izquierdo). Conclusiones: En esta serie de nefrectomía parcial laparoscópica se demuestra la baja tasa de complicaciones, los buenos resultados oncológicos y la baja tasa de recidiva a corto plazo. Se precisa mayor número de pacientes y seguimiento para afianzar los resultados oncológicos y funcionales de esta técnica quirúrgica (AU)

Objetives: To analyze the surgical and oncologic outcome of prospective experience with laparoscopic partial nephrectomy. We describe the surgical technique and mid term oncological results achieved. Material and methods: 60 patients were operated with this technique between June 2005 and June 2009. The mean age of patients was 58.9 [38-77] years, being 40 (66.7%) males and 20 (33.3%) women. The average BMI was 26.8 [18-40]. Laterality was 28 (46.7%) tumors rights and 32 (53.3%) left, being located in the upper pole in 14 (23.3%) patients, in the middle third in 13 (21.7%) in the lower pole in 22 (36.7%) and hiliar region in 11 (18.3%). In 23 cases (38.3%) tumors were located in the anterior valve, in 24 (40%) in posterior valve, in 10 (16.7%) at the outer edge and 3 (5%) at the inner edge. The average size tumor on CT was 3.3 [1-6.4] cm and in the surgical specimen 3.1 [1.2-7] cm. Results: The mean operative time was 107.17 [50-185] min, with a warm ischemia time of 33 [0-70] min. In 56 cases (93.3%) had a single artery and 4 (6.7%) cases had 2 arteries. The artery was clamped alone in 15 patients (25%), artery and vein in 44 (73.3%) and no clamping was performed in 1 (1.7%). We repaired the urinary tract in 32 patients (53.3%), leaving ureteral catheter in all patients. 20% of patients (12) required transfusion. Intraoperative complications occurred in 5 patients (8.7%). These were: 1 splenic injury requiring splenectomy (1.7%), 1 tear in the vena cava, sutured laparoscopically (1.7%) and 3 cases of bleeding due to bulldog malfunction (5%). Postoperative complications occurred in 11 patients (18.7%) and these were: 1 wall hematoma that required reoperation (1.7%), 1 urinary fistula ending in renal atrophy and subsequent nephrectomy (1.7%), 3 intracavitary hematomas hich resolved conservatively (5%), 1 arteriovenous fistula that needed embolization (1.7%), 1 urinoma that was resolved with percutaneous drainage (1.7%) and 3 cases of postoperative fever (5%). Margins were positive in 1 patient (1.7%). In 49 cases (81.7%) histology was renal cell carcinoma, in 8 (13.3%) oncocytoma, in 2 (3.3%) angiomyolipoma and 1 (1.7%) metastasis. The average stay was 5 [3-29] days. Median follow up was 31 [12-61] months. There was a local recurrence at 16 months (hiliar primary tumor 2.5 cm) and an ipsilateral adrenal metastasis at 34 months (primary tumor 5.6 cm in left lower pole). Conclusions: In this series of laparoscopic partial nephrectomy low rate of complications, good oncologic results and low recurrence rate in the short term are shown. More patients and further monitoring is required to strengthen the functional and oncological outcomes of this surgical technique (AU)

[Laparoscopic partial nephrectomy]. / Nefrectomía parcial laparoscópica.

OBJECTIVES: To analyze the surgical and oncologic outcome of prospective experience with laparoscopic partial nephrectomy. We describe the surgical technique and mid term oncological results achieved. MATERIAL AND METHODS: 60 patients were operated with this technique between June 2005 and June 2009. The mean age of patients was 58.9 [38-77] years, being 40 (66.7%) males and 20 (33.3%) women. The average BMI was 26.8 [18-40]. Laterality was 28 (46.7%) tumors rights and 32 (53.3%) left, being located in the upper pole in 14 (23.3%) patients, in the middle third in 13 (21.7%) in the lower pole in 22 (36.7%) and hiliar region in 11 (18.3%). In 23 cases (38.3%) tumors were located in the anterior valve, in 24 (40%) in posterior valve, in 10 (16.7%) at the outer edge and 3 (5%) at the inner edge. The average size tumor on CT was 3.3 [1-6.4] cm and in the surgical specimen 3.1 [1.2-7] cm. RESULTS: The mean operative time was 107.17 [50-185] min, with a warm ischemia time of 33 [0-70] min. In 56 cases (93.3%) had a single artery and 4 (6.7%) cases had 2 arteries. The artery was clamped alone in 15 patients (25%), artery and vein in 44 (73.3%) and no clamping was performed in 1 (1.7%). We repaired the urinary tract in 32 patients (53.3%), leaving ureteral catheter in all patients. 20% of patients (12) required transfusion. Intraoperative complications occurred in 5 patients (8.7%). These were: 1 splenic injury requiring splenectomy (1.7%), 1 tear in the vena cava, sutured laparoscopically (1.7%) and 3 cases of bleeding due to bulldog malfunction (5%). Postoperative complications occurred in 11 patients (18.7%) and these were: 1 wall hematoma that required reoperation (1.7%), 1 urinary fistula ending in renal atrophy and subsequent nephrectomy (1.7%), 3 intracavitary hematomas hich resolved conservatively (5%), 1 arteriovenous fistula that needed embolization (1.7%), 1 urinoma that was resolved with percutaneous drainage (1.7%) and 3 cases of postoperative fever (5%). Margins were positive in 1 patient (1.7%). In 49 cases (81.7%) histology was renal cell carcinoma, in 8 (13.3%) oncocytoma, in 2 (3.3%) angiomyolipoma and 1 (1.7%) metastasis. The average stay was 5 [3-29] days. Median follow up was 31 [12-61] months. There was a local recurrence at 16 months (hiliar primary tumor 2.5 cm) and an ipsilateral adrenal metastasis at 34 months (primary tumor 5.6 cm in left lower pole). CONCLUSIONS: In this series of laparoscopic partial nephrectomy low rate of complications, good oncologic results and low recurrence rate in the short term are shown. More patients and further monitoring is required to strengthen the functional and oncological outcomes of this surgical technique.

[Laparoscopic radical cystectomy and orthotopic urinary diversion in the male patient: technique]. / Técnica de cistectomía radical laparoscópica y derivación urinaria ortotópica en el varón.

Radical cystectomy with extended pelvic lymphadenectomy remains the treatment of choice for muscle invasive bladder cancer and non-metastatic chorion-invasive high grade tumors resistant to treatment with intravesical chemotherapy. During the last decade the procedure has been refined and we have acquired the skills necessary to perform it using the laparoscopic approach. In this way, the oncologic and functional outcomes obtained can be compared to those of its open counterpart. This article describes in detail the technique of radical cystoprostatectomy and urinary diversion in the male patient conducted by our group in an attempt to improve the knowledge and spread of this always difficult procedure.

Técnica de cistectomía radical laparoscópica y derivación urinaria ortotópica en el varón / No disponible

La cistectomía radical asociada a linfadenectomía pélvica ampliada, continúa siendo el tratamiento quirúrgico de elección para el carcinoma de vejiga músculo infiltrante no metastático y para los tumores con infiltración del corion de alto grado resistentes al tratamiento con quimioterapia endovesical. Durante la última década se ha conseguido depurar el procedimiento, y se han adquirido las destrezas necesarias para realizar este procedimiento mediante abordaje laparoscópico. De este modo han conseguido obtenerse resultados oncológicos y funcionales superponibles a su homónimo abierto. El presente artículo describe detalladamente la técnica de cistoprostatectomía radical y derivación urinaria en el paciente varón llevada a cabo por nuestro grupo en un intento por mejorar el conocimiento y la difusión de este siempre difícil procedimiento(AU)

Radical cystectomy with extended pelvic lymphadenectomy remains the treatment of choice for muscle invasive bladder cancer and non-metastatic cho-rion-invasive high grade tumors resistant to treatment with intravesical chemotherapy. During the last decade the procedure has been refined and we have acquired the skills necessary to perform it using the laparoscopic approach. In this way, the oncologic and functional outcomes obtained can be compared to those of its open counterpart. This article descri-bes in detail the technique of radical cystoprostatectomy and urinary diversion in the male patient conducted by our group in an attempt to improve the knowledge and spread of this always difficult procedure(AU)

[Treatment of distal ureteral stricture by laparoscopic ureterovesical reimplantation]. / Tratamiento de la estenosis de uréter distal mediante reimplantación urétero-vesical laparoscópica.

INTRODUCTION: to analyse the results achieved to treat iliac or pelvic ureteric stricture using laparoscopic reimplantation of the ureter in a psoic bladder. MATERIAL AND METHOD: in a four-year period, we performed laparoscopic ureteral reimplantation in a psoic bladder in 6 patients (right/left 1:1; male/female 1:2; mean age 59.2 years, range 47-87). In 4 cases the lesion was iatrogenic and in 2 cases idiopathic. Ureteral resection with bladder cuff and cystorraphy followed by ipsilateral lymph node dissection was performed in idiopathic cases or those with history of previous urothelial tumour (4 cases in total) before ureteral reimplantation. Bladder was extensively mobilized and fixed to minor psoas tendon before performing ureteroneocystostomy. Mixed intra and extravesical technique with submucosal tunnel (Politano) was used in a case and in the remaining 5 cases extravesical technique with submucosal tunnel (Goodwin) was used. Mean follow-up was 26 months (range 18-34). RESULTS: there was no need to convert to open surgery. Time of surgery was 230 minutes in the case treated with Politano ureteroneocystostomy and 120 (range 75-150) in those treated purely extravesically. The mean hospital stay was 3.2 days (range 2-5). There were no intra or postoperative complications. Histologic assessment always revealed ureteral fibrosis and in 2 cases accompanying granulomatous inflammation and dysplasia. No patient suffered re-stricture or impairment in renal function during follow-up. CONCLUSIONS: laparoscopic ureteral reimplantation is an effective and safe minimally invasive technique to treat benign distal stricture of the ureter. Simplicity of extravesical reimplantation has an advantage over its intravesical counterpart.

Tratamiento de la estenosis de uréter distal mediante reimplantación urétero-vesical laparoscópica / Treatment of distal ureteral stricture by laparoscopic ureterovesical reimplantation

Introducción: analizar los resultados obtenidos para tratar la estenosis de uréter iliaco-pelviano sin tumor activo mediante reimplantación laparoscópica en vejiga psoica. Material y método: en un período de 4 años hemos practicado reimplantación ureteral laparoscópica en vejiga psoica a 6 pacientes (derecho/izquierdo 1:1; hombre/mujer 1:2; edad media 59,2 años, rango 47-85). En 4 casos la etiología fue iatrogénica y en 2 idiopática. En los pacientes con causa idiopática o antecedentes de tumor urotelial (4 casos en total) se realizó resección ureteral laparoscópica con rodete vesical, cistorrafia y linfadenectomía ipsilateral antes de la reimplantación. Se movilizó ampliamente la vejiga y se fijó al tendón del psoas. La reimplantación se realizó mediante técnica mixta intra-extravesical con túnel submucoso (Politano) en un caso, y mediante técnica extravesical con túnel submucoso (Goodwin) en el resto. El seguimiento medio fue 26 meses (rango 18-34). Resultados: no hubo reconversión a cirugía abierta y la duración fue 230 minutos en el caso de la reimplantación tipo Politano y 120 minutos (rango 75-150) para la reimplantación extravesical. La estancia postoperatoria fue 3,2 días (rango 2-5). No se produjeron complicaciones intra o postoperatorias. El estudio histológico mostró en todos los casos fibrosis ureteral sin signos de malignidad y ausencia de metástasis ganglionares. Ningún paciente ha presentado reestenosis ni deterioro de la función renal durante el seguimiento. Conclusiones: en casos seleccionados la reimplantación ureteral laparoscópica es una técnica mínimamente invasiva, eficaz y segura para el tratamiento de las estenosis ureterales distales sin tumor activo. Por su simplicidad de ejecución es preferible la reimplantación extravesical (AU)

Introduction: to analyse the results achieved to treat iliac or pelvic ureteric stricture using laparoscopic reimplantation of the ureter in a psoic bladder. Material and method: in a four-year period, we performed laparoscopic ureteral reimplantation in a psoic bladder in 6 patients (right/left 1:1; male/female 1:2; mean age 59.2 years, range 47-87). In 4 cases the lesion was iatrogenic and in 2 cases idiopathic. Ureteral resection with bladder cuff and cystorraphy followed by ipsilateral lymph node dissection was performed in idiopathic cases or those with history of previous urothelial tumour (4 cases in total) before ureteral reimplantation. Bladder was extensively mobilized and fixed to minor psoas tendon before performing ureteroneocystostomy. Mixed intra and extravesical technique with submucosal tunnel (Politano) was used in a case and in the remaining 5 cases extravesical technique with submucosal tunnel (Goodwin) was used. Mean follow-up was 26 months (range 18-34). Results: there was no need to convert to open surgery. Time of surgery was 230minutes in the case treated with Politano ureteroneocystostomy and 120 (range 75-150) in those treated purely extravesically. The mean hospital stay was 3.2 days (range 2-5). There were no intra or postoperative complications. Histologic assessment always revealed ureteral fibrosis and in 2 cases accompanying granulomatous inflammation and dysplasia. No patient suffered re-stricture or impairment in renal function during follow-up. Conclusions: laparoscopic ureteral reimplantation is an effective and safe minimally invasive technique to treat benign distal stricture of the ureter. Simplicity of extravesical reimplantation has an advantage over its intravesical counterpart (AU)

Adenomectomía extraperitoneal laparoscópica: descripción técnica quirúrgica y resultados preliminares / Laparoscopic extraperitoneal adenomectomy: surgical technique and preliminar results

Objetivos: Analizamos los resultados preliminares de la adenomectomía laparoscópica y su descripción técnica, para el tratamiento de la HBP, en glándulas con un tamaño superior a 60cc. Material y métodos: Entre enero y abril de 2009 hemos realizado 10 adenomectomías laparoscópicas. Realizamos un estudio retrospectivo y descriptivo y analizamos los resultados obtenidos en el postoperatorio inmediato. El análisis estadístico descriptivo se realizó con el programa SPSS versión 17. Se describe paso a paso la técnica quirúrgica utilizada. Resultados: No hubo conversión a cirugía abierta en ninguno de los casos, tampoco hubo complicaciones peri-postoperatorias de carácter grave. Ningún paciente requirió transfusión sanguínea. La mediana de la duración de la cirugía fue de 112,5min (80–135). La mediana de estancia hospitalaria fue de 3,5 días (2–5) y el tiempo con sonda vesical de 7 días (3–21). El peso medio del tejido enucleado fue de 62 gramos (40–93). El Qmax postoperatorio fue de 18,8ml/seg y la puntuación media del cuestionario IPSS de 5. Conclusiones: La adenomectomía laparoscópica es una técnica con baja morbilidad y reproducible en centros con experiencia laparoscópica. Serán necesarios estudios prospectivos comparativos con cirugía abierta, para elegir la mejor técnica para nuestros pacientes (AU)

Objective: We analyze the laparascopic adenomectomy preliminar results and describe the surgical technique, for benign prostatic hyperplasia (BPH), for glands greater than 60cc. Materials and methods: From January to April 2009 we have performed 10 laparoscopic adenomectomies. We performed a descriptive and retrospective study and early postoperative results were analyzed. Descriptive statistical analyses were performed using IPSS 17.0. The surgical technique is described step by step. Results: Conversion to open surgery was not required, and none of the patients had serious peri-operative and post-operative complications. None of the ten patients required blood transfusions. Median operating time was 112,5min (80–135). Median hospital stay was 3,5 days (2–5) and median catheterization period was 7 days (3–21). The median prostate enucleated weight was 62gr. (40–93). The median postoperative Qmax was 18,8ml/seg and the median score of IPSS was 5. Conclusions: Laparoscopic adenomectomy is a low rate morbidity technique and reproducible in centers with laparoscopic skills. Prospective and comparative studies with open surgery will be necessaries to choose the best technique for our patients (AU)

[Laparoscopic extraperitoneal adenomectomy: surgical technique and preliminary results]. / Adenomectomía extraperitoneal laparoscópica: descripción técnica quirúrgica y resultados preliminares.

OBJECTIVE: We analyze the laparascopic adenomectomy preliminary results and describe the surgical technique, for benign prostatic hyperplasia (BPH), for glands greater than 60cc. MATERIALS AND METHODS: From January to April 2009 we have performed 10 laparoscopic adenomectomies. We performed a descriptive and retrospective study and early postoperative results were analyzed. Descriptive statistical analyses were performed using IPSS 17.0. The surgical technique is described step by step. RESULTS: Conversion to open surgery was not required, and none of the patients had serious peri-operative and post-operative complications. None of the ten patients required blood transfusions. Median operating time was 112,5min (80-135). Median hospital stay was 3,5 days (2-5) and median catheterization period was 7 days (3-21). The median prostate enucleated weight was 62gr. (40-93). The median postoperative Qmax was 18,8ml/seg and the median score of IPSS was 5. CONCLUSIONS: Laparoscopic adenomectomy is a low rate morbidity technique and reproducible in centers with laparoscopic skills. Prospective and comparative studies with open surgery will be necessary to choose the best technique for our patients.

Resultados iniciales con bioglue en la prevención de fístulas urinarias en cirugía renal conservadora laparoscópica / Preventing urinary fistulas in laparoscopic renal conservative parenchima surgery with purified bovine serum albumin and glutaraldehyde (Bioglue(R)). Initial outcomes

Introducción: La aparición de una fístula urinaria constituye una complicación de la cirugía renal conservadora de parénquima (CRCP), sobre todo en tumores de localización central o hiliar y en aquellos mayores de 4 cm de diámetro. Presentamos nuestra experiencia inicial en su prevención utilizando Bio Glue tras la realización de CRCP laparoscópica en las que se produce apertura de la vía urinaria. Pacientes y métodos: Entre septiembre de 2005 y febrero de 2006 se han realizado 5 CRC laparoscópicas en las que ha sido necesario proceder a la apertura de la vía urinaria. En todos los casos se realizó cateterismo ureteral previo. Mediante abordaje laparoscópico transperitoneal se realizó clampaje arterial selectivo, tumorectomía o heminefrectomía, sutura de la vía urinaria comprobando estanqueidad, aproximación de los bordes de la incisión renal y recubrimiento de la misma con adhesivo tisular compuesto por glutaraldehido y albúmina (BioGlue). El seguimiento medio fue de 8,2 meses (rango 6-12 meses). Resultados: La duración media de la cirugía fue de 138 minutos (rango 105-180), con un tiempo medio de isquemia de 45 minutos (rango 35-60). El catéter ureteral se retiró en todos los casos entre las 24 y 48 horas postoperatorias. La estancia media fue de 3,8 días (rango 3-5). Como complicaciones se produjo un defecto del clampaje arterial por el torniquete de Rummel que requirió transfusión intraoperatoria y una fístula arterio-calicial al décimo día postoperatorio que requirió reingreso y embolización selectiva. No se produjeron fístulas urinarias ni urinomas. En la TAC al mes de la cirugía se apreció en un caso una fístula urinaria contenida por el Bio-glue. Dicha fístula había desaparecido en el control a los 3 meses de la cirugía. Conclusiones: En la CRCP laparoscópica de masas que interesen la vía renal, la realización de un cateterismo ureteral previo, la sutura de la vía por separado junto con la aplicación de Bio Glue permite reducir la posibilidad de una fístula urinaria (AU)

Introduction: Urinary fistulas remain an important conservative renal parenchyma surgery (CRPS) complication, especially in central or hiliar tumours and bigger than 4 cm. Herein we present our initial experience preventing fistulae with bioglue(R) (Criolife Inc GA, USA) on laparoscopic CRPS in which urinary tract was opened. Patients and methods: We performed 5 laparoscopic CRPS between September 2005 and February 2006 in which urinary tract was necessarily opened. Previous uretheral catheter, transperitoneal approach, selective arterial control, tumorectomy or heminephrectomy, suturing urinary tract and renal parenchyma and bioglue(R) administration was performed. Results: Median follow up time was 8.2 months (6-12 months). Median surgery time was 138 minutes (105-180 minutes) with a median ischemia time of 45 minutes (35-60). Uretheral catheter was removed before second post-op day in all cases. Average discharged day was 3.8 (3-5 days). One patient required intraoperative transfusion due to breaking Rummel tourniquet and one arterio- calyceal fistula on tenth day pos-op that required selective embolization remained the worst complication. Neither urinary fistulas nor urinomas were reported. Conclusions: Uretheral cathetesim, suturing urinary tract and parenchyma in an independent fashion and applying some kind of surgical adhesive such as bioglue(R) seems to reduce the urinary fistulae risk in laparoscopic CRPS (AU)

[Prevalence and clinical meaning of focal and incidental prostate cancers]. / Prevalencia y significado clínico de los cánceres de próstata focales e incidentales.

OBJECTIVES: To calculate the proportion of focal and incidental prostate cancers (PCa) in our setting, to study their relationship with the findings in radical prostatectomy (RP) specimens, and to establish their clinical relevance in terms of progression and survival. MATERIAL AND METHODS: We selected patients with focal cancer, defined as a maximum extent of 3 mm in one or two adjacent prostate biopsy cores (transrectal ultrasound guided, sextant). In addition we included a group of patients with incidental T1a cancers (diagnosed after prostatectomy, nonpalpable, with less than 5% tumor in specimen). The proportion of those cancers over the total of tumors diagnosed in our health area was calculated. Also, clinical characteristics of such cancers were recorded (age, PSA, Gleason grade and score), and also therapy given. In cases that underwent RP, pathological findings were also recorded. Finally, survival analysis (Kaplan-Meier) was carried out to describe the natural history of these patients in terms of time to progression and time to death from PCa. RESULTS: From 819 patients diagnosed of PCa, 46 (5.6%) presented with focal cancer and 23 (2.8%) with stage T1a tumors. None of the patients with incidental cancer (T1a) underwent RP opposed to 17 of 46 focal T1c cancers (37%). Although none of these cases showed extracapsular extension, seminal vesicle invasion, or lymph node invasion, relevant disease (stage pT2b or higher) was found in 15 cases (88.2%) and pathological Gleason score > 7 in 2 cases (2.9%). With a mean follow-up time of 37.6 months (standard error 4.26), the probability of being free from any progression was, for T1a cancers at 2 and 5 years, of 75.4% and 57.1% respectively, and 94.4% and 94.4% respectively for T1c cases. No PCa deaths were recorded in the presented cases during the mentioned follow-up period. CONCLUSION: In our experience, the finding of microscopic or focal cancers in sextant prostate biopsy is related to a high proportion of clinically relevant tumors in RP specimens (88%). We think that expectant management of patients with such findings in prostate biopsy should be questioned.

Prevalencia y significado clínico de los cánceres de próstata focales e incidentales / Prevalence and clinical meaning of focal and incidental prostate cancers

Objetivos: Calcular la proporción de cánceres de próstata (CaP) focales e incidentales en nuestro ámbito, investigar su relación con los hallazgos en la pieza de prostatectomía radical (PR), así como establecer su relevancia clínica en términos de progresión y supervivencia. Material y Métodos: Hemos seleccionado los pacientes con cáncer focal, definiendo éste como un máximo de 3 mm en uno o dos cilindros adyacentes en la biopsia prostática (dirigidas mediante ecografía transrectal, de modo randomizado sextante). Adicionalmente, hemos incluido un grupo de pacientes con cáncer incidental T1a (diagnosticados tras prostatectomía, no palpables, con tumor en menos del 5% del tejido obtenido). Se ha calculado la proporción de estos cánceres en nuestra área sanitaria sobre el total de tumores detectados, y registrando las características clínicas de dichos tumores (edad, PSA, grado y score de Gleason), así como el tratamiento efectuado. En los casos sometidos a PR, se han analizado los parámetros patológicos de la pieza. Por último, se ha realizado un análisis de supervivencia (Kaplan-Meier) para describir la evolución de estos pacientes en cuanto al tiempo hasta la progresión de la enfermedad y al fallecimiento por CaP. Resultados: De 819 pacientes con CaP, 46 (5,6%) presentaron cáncer focal y 23 (2,8%) tumores estadio T1a. Ninguno de los pacientes con tumor incidental (T1a) fue sometido a PR frente a 17 de los 46 cánceres focales T1c (37%). Aunque ninguno de los casos mostró enfermedad extracapsular, invasión de vesículas seminales, o invasión ganglionar, se detectó enfermedad relevante (estadio pT2b o superior) en 15 casos (88,2%) y un score de Gleason patológico >7 en 2 casos (2,9%). Con una media de seguimiento de 37,6 meses (error estándar 4,26), la probabilidad de permanecer libre de cualquier tipo de progresión para los T1a a los 2 y 5 años fue de 75,4% y 57,1% respectivamente, siendo de 94,4% y 94,4% respectivamente para los T1c. No se registraron fallecimientos por CaP en esta serie durante el seguimiento mencionado. Conclusión: En nuestra experiencia, el hallazgo de cáncer microscópico o focal en la biopsia randomizada sextante se corresponde una elevada proporción de tumores clínicamente relevantes en la pieza de PR (88%). Creemos que la actitud expectante ante dichos hallazgos en la biopsia prostática debe ser sometida a crítica

Objectives: To calculate the proportion of focal and incidental prostate cancers (PCa) in our setting, to study their relationship with the findings in radical prostatectomy (RP) specimens, and to establish their clinical relevance in terms of progression and survival. Material and methods: We selected patients with focal cancer, defined as a maximum extent of 3 mm in one or two adjacent prostate biopsy cores (transrectal ultrasound guided, sextant). In addition we included a group of patients with incidental T1a cancers (diagnosed after prostatectomy, nonpalpable, with less than 5% tumor in specimen). The proportion of those cancers over the total of tumors diagnosed in our health area was calculated. Also, clinical characteristics of such cancers were recorded (age, PSA, Gleason grade and score), and also therapy given. In cases that underwent RP, pathological findings were also recorded. Finally, survival analysis (Kaplan-Meier) was carried out to describe the natural history of these patients in terms of time to progression and time to death from PCa. Results: From 819 patients diagnosed of PCa, 46 (5.6%) presented with focal cancer and 23 (2.8%) with stage T1a tumors. None of the patients with incidental cancer (T1a) underwent RP opposed to 17 of 46 focal T1c cancers (37%). Although none of these cases showed extracapsular extension, seminal vesicle invasion, or lymph node invasion, relevant disease (stage pT2b or higher) was found in 15 cases (88.2%) and pathological Gleason score >7 in 2 cases (2.9%). With a mean follow-up time of 37.6 months (standard error 4.26), the probability of being free from any progression was, for T1a cancers at 2 and 5 years, of 75.4% and 57.1% respectively, and 94.4% and 94.4% respectively for T1c cases. No PCa deaths were recorded in the presented cases during the mentioned follow-up period. Conclusion: In our experience, the finding of microscopic or focal cancers in sextant prostate biopsy is related to a high proportion of clinically relevant tumors in RP specimens (88%). We think that expectant management of patients with such findings in prostate biopsy should be questioned