Comparación entre abordajes quirúrgicos de prostatectomía radical en nuestra serie, más allá de los resultados oncológicos y funcionales / Comparison of surgical approaches to radical prostatectomy in our series beyond oncological and functional outcomes

Objetivos Evaluar los resultados de la prostatectomía radical asistida por robot (PRAR), y compararlos con los de la cirugía abierta (PRA) y laparoscópica (PRL). El interés no solo radica en los resultados oncológicos y funcionales de la serie, sino en la evaluación de la calidad de vida (QoL), la recuperación postoperatoria y la satisfacción personal de los pacientes con la intervención (PR), fundamentalmente. Métodos Se realizaron 685 PR en nuestro centro entre 2011-2018 (17,8% PRA, 22,2% PRL y 60% PRAR). Los pacientes fueron evaluados prospectivamente mediante seguimiento hasta abril de 2020, y con la realización un cuestionario múltiple a los 12 meses post-PR, que incluía ICIQ-SF, SHIM, IPSS, IQL y preguntas sobre el dolor, la recuperación postoperatoria y la satisfacción del paciente (SP). También se recogieron datos basales y postoperatorios relacionados con el paciente y el tratamiento, y se realizaron regresiones logísticas binomiales para las comparaciones 1 vs. 1 (PRA vs. PRAR y PRL vs. PRAR). Resultados Los pacientes tratados con PRAR tienen en general menos comorbilidades, menos agresividad tumoral, un requerimiento de mayor tiempo operatorio y un número mayor de márgenes quirúrgicos positivos que los pacientes tratados con PRA y PRL. Sin embargo, la PRAR supera a la PRA en: días de estancia hospitalaria (OR: 0,86; IC 95%: 0,80-0,94), disminución de hemoglobina (OR: 0,38; IC 95%: 0,30-0,47), tasas de transfusión (OR: 0,18; IC 95%: 0,09-0,34), complicaciones tempranas (p=0,001), IQL (OR: 0,82; IC 95%: 0,69-0,98), función eréctil (OR: 0,41; IC 95%: 0,21-0,79), manejo del dolor (OR: 0,82; IC 95%: 0,75-0,89), recuperación postoperatoria (p<0,001) y elección de un abordaje diferente (OR: 5,55; IC 95%: 3,14-9,80). La PRAR es superior a la PRL en: continencia urinaria (OR: 0,55; IC 95%: 0,37-0,82), IPSS (OR: 0,96; IC 95%: 0,93-0,98) (AU)

Objectives To evaluate the outcomes of robot-assisted radical prostatectomy (RARP) compared to those of open (ORP) and laparoscopic (LRP) surgery. The interest lies fundamentally in the quality-of-life (QoL) evaluation, postoperative recovery, and personal satisfaction of patients with the intervention (PS) beyond oncological and functional outcomes. Methods Six hundred eighty-five RPs were performed in our center between 2011-2018 (17.8% ORP, 22.2% LRP and 60% RARP). Patients were prospectively assessed through follow-up until April 2020 and a multiple questionnaire at 12-months post-RP that included ICIQ-SF, SHIM, IPSS, IQL and questions about pain, postoperative recovery and PS. Also baseline and postoperative patient- and treatment-related data were collected, and binomial logistic regressions were performed for the 1 vs. 1 comparisons (ORP vs. RARP and LRP vs. RARP). Results RARP patients have overall fewer comorbidities, less tumor aggressiveness, more operative time requirements and more positive surgical margins than ORP and LRP patients. Nevertheless, RARP outperforms ORP in: hospital say (days) (OR: 0.86; 95% CI: 0.80-0.94), hemoglobin loss (OR: 0.38; 95% CI: 0.30-0.47), transfusion rate (OR: 0.18; 95% CI: 0.09-0.34), early complications (P=.001), IQL (OR: 0,82; 95% CI: 0.69-0.98), erectile function (OR: 0.41; 95% CI: 0.21-0.79), pain control (OR: 0.82; 95% CI: 0.75-0.89), postoperative recovery (P<.001) and choice of a different approach (OR: 5.55; 95% CI: 3.14-9.80). RARP is superior to LRP in: urinary continence (OR: 0.55; 95% CI: 0.37-0.82), IPSS (OR: 0.96; 95% CI: 0.93-0.98), IQL (OR: 0.76; 95% CI: 0.66-0.88), erectile function (OR: 0.52; 95% CI: 0.29-0.93), postoperative recovery (P=.02 and .004), PS (P=.005; 0.002; and .03) and choice of a different approach (OR: 7.79; 95% CI: 4.63-13.13) (AU)

Comparison of surgical approaches to radical prostatectomy in our series beyond oncological and functional outcomes.

OBJECTIVES: To evaluate the outcomes of robot-assisted radical prostatectomy (RARP) compared to those of open (ORP) and laparoscopic (LRP) surgery. The interest lies fundamentally in the quality-of-life (QoL) evaluation, postoperative recovery, and personal satisfaction of patients with the intervention (PS) beyond oncological and functional outcomes. METHODS: Six hundred eighty-five RPs were performed in our center between 2011-2018 (17,8% ORP, 22,2% LRP and 60% RARP). Patients were prospectively assessed through follow-up until April 2020 and a multiple questionnaire at 12-months post-RP that included ICIQ-SF, SHIM, IPSS, IQL and questions about pain, postoperative recovery and PS. Also baseline and postoperative patient- and treatment-related data were collected, and binomial logistic regressions were performed for the 1 vs.1 comparisons (ORP vs. RARP and LRP vs. RARP). RESULTS: RARP patients have overall fewer comorbidities, less tumor aggressiveness, more operative time requirements and more positive surgical margins than ORP and LRP patients. Nevertheless, RARP outperforms ORP in: hospital stay (days) (OR 0,86; 95% CI: 0,80-0,94), hemoglobin loss (OR 0,38; 95% CI: 0,30-0,47), transfusion rate (OR 0,18; 95% CI: 0,09-0,34), early complications (p = 0,001), IQL (OR 0,82; 95% CI: 0,69-0,98), erectile function (OR 0,41; 95% CI: 0,21-0,79), pain control (OR 0,82; 95% CI: 0,75-0,89), postoperative recovery (p < 0,001) and choice of a different approach (OR 5,55; 95% CI: 3,14-9,80). RARP is superior to LRP in: urinary continence (OR 0,55; 95% CI: 0,37-0,82), IPSS (OR 0,96; 95% CI: 0,93-0,98), IQL (OR 0,76; 95% CI: 0,66-0,88), erectile function (OR 0,52; 95% CI: 0,29-0,93), postoperative recovery (p = 0,02 and 0,004), PS (p = 0,005; 0,002; and 0,03) and choice of a different approach (OR 7,79; 95% CI: 4,63-13,13). CONCLUSIONS: The findings of our study globally endorse a positive effectiveness of RARP over ORP and/or LRP, both on functional issues, postoperative recovery, QoL and PS. Oncologic results should still be improved.

Results of adrenalectomy in lung cancer metastases. / Resultados de la adrenalectomía en la metástasis del cáncer de pulmón.

BACKGROUND: The aim of this study was to report our centre's experience over the past 15 years with patients with lung carcinoma and adrenal metastases treated sequentially with lung resection and adrenalectomy. PATIENTS AND METHODS: We analysed a retrospective series of 19 patients who underwent adrenalectomy for lung carcinoma metastasis. All patients were operated on at the same centre, between October 2000 and October 2015. We performed a descriptive analysis and an overall survival and disease-free survival analysis. RESULTS: The study included 13 men and 6 women. The most common primary lung tumour was adenocarcinoma, 87.5% of which were G3. In 7 patients, the adrenal metastasis was detected synchronously, and in 12 patients it was detected metachronously. The median size of the metastasis was 63mm. Twenty-one percent of the cases presented local recurrence, and 79% presented distant metastasis. The median DFS was 21.5 months, while the DFS at 5 years was calculated at 58.33%. The median overall survival was 37.3 months, while survival at 5 years was calculated at 42.86%. None of the prognostic factors evaluated were statistically significant. CONCLUSIONS: Adrenalectomy in cases of isolated lung carcinoma metastasis can offer increased overall survival. Age and the degree of differentiation of the primary lung carcinoma are the factors that most influence poorer survival.

Manejo de la masa suprarrenal: lo que el urólogo debe saber / Management of adrenal mass: What urologist should know

El incidentaloma suprarrenal es una entidad en aumento en la práctica clínica habitual debido al gran número de exploraciones radiológicas que se realizan. No existen guías clínicas publicadas sobre el manejo del incidentaloma suprarrenal apoyadas por ninguna sociedad científica. Toda masa suprarrenal debe ser estudiada para descartar malignidad o hipersecreción hormonal. Creemos que la patología suprarrenal quirúrgica debe ser manejada por el urólogo, por ser la especialidad que mayor relación tiene con en el retroperitoneo alto. El objetivo de esta revisión es desarrollar los aspectos fundamentales que el urólogo debe saber en el manejo de las masas suprarrenales. Conjuntamente con el servicio de endocrinología de nuestro hospital describimos los principales estudios a realizar ante el diagnóstico de una masa suprarrenal y el esquema terapéutico vigente en nuestro centro (AU)

Adrenal incidentaloma's prevalence is rising because of the big volume of radiologic explorations that we daily do. No comprehensive guidelines have been published by professional societies to guide the evaluation of patients with adrenal incidentalomas. All adrenal masses should be inspected for malignancy or hypersecreting disorders. In our point of view, adrenal surgery should be performed by the urologist, because it's the medical speciality which knows the best this anatomical region. The objective of this review is to present the main points that the urologist may know in the management of adrenal masses. Together with the department of Endocrinology of our hospital, we describe the main studies to perform in front of adrenal mass diagnosis and the current therapeutical diagram utilized in our center (AU)

[Management of adrenal mass: What urologists should know]. / Manejo de la masa suprarrenal: lo que el urólogo debe saber.

Adrenal incidentaloma's prevalence is rising because of the big volume of radiologic explorations that we daily do. No comprehensive guidelines have been published by professional societies to guide the evaluation of patients with adrenal incidentalomas. All adrenal masses should be inspected for malignancy or hypersecreting disorders. In our point of view, adrenal surgery should be performed by the urologist, because it's the medical speciality which knows the best this anatomical region. The objective of this review is to present the main points that the urologist may know in the management of adrenal masses. Together with the department of Endocrinology of our hospital, we describe the main studies to perform in front of adrenal mass diagnosis and the current therapeutical diagram utilized in our center.

[Surgical experience and results in transperitoneal laparoscopic adrenalectomy]. / Experiencia y resultados en la suprarrenalectomía laparoscópica transperitoneal.

INTRODUCTION: Laparoscopic adrenalectomy is currently the gold standard in surgical management of adrenal pathology. OBJECTIVES: To analyze our results after 12 years of experience in this surgery and to compare with the main published series. MATERIAL AND METHODS: we describe retrospectively 100 adrenalectomies performed between 1997-2009. Analyzed variables: age, size, side, preoperative diagnosis, operative time, blood loss, reconversion, hospital stay and histopathologic report. We utilized Fisher test and chi square test to compare categoric data. We utilized t-Student test to compare means from independent groups with normal distribution. We considered statistical significance when p<0.05. RESULTS: Mean age was 53.1 years (+/-14.4). Mean size was 3,7 cm (+/-2.2). In 51% of cases it was the left side. Mean follow-up was 15 months (+/-11.9). Preoperative diagnosis was: functional mass (44%), pheocromocytome (17%), incedentaloma>4 cm (20%), metastasis (10%) and adrenal carcinoma (5%). Mean operative time was 145.1 min (+/-55.6). Mean hematocrite loss was 6.26 points (+/-3.3). Reconversion rate was 9.6%. 2 cases of prolonged postoperative ileus. 2 patients required transfusion. 1 patient death because of an descompensation of liver cirrhosis. 80% of complications were on right side. Mean hospital stay was 6 days (+/-5.6). In last 30 procedures we realized statistical differences with first group, in terms of operative time (119.1 min vs 171.2 min) and hospital stay (4.1 days vs 6.1) (p<0.05). CONCLUSIONS: Transperitoneal laparoscopic adrenalectomy is a surgical feasible and safe procedure in urological groups with previous laparoscopic experience. Our results are similar with the published series and confirm the efficacy, security and reproducibility of this technique.

Experiencia y resultados en la suprarrenalectomía laparoscópica transperitoneal / Surgical experience and results in transperitoneal laparoscopic adrenalectomy

Introducción: La suprarrenalectomía laparoscópica es actualmente el gold estándar en el manejo quirúrgico de la patología suprarrenal. Objetivos: Analizar nuestros resultados tras 12 años de experiencia en esta cirugía y compararlos con las principales series publicadas. Material y métodos: Estudio descriptivo y retrospectivo. Análisis de 100 suprarrenalectomías realizadas entre junio de 1997 y junio de 2009. Se describen las siguientes variables: edad, tamaño, lateralidad, diagnóstico preoperatorio, tiempo quirúrgico, pérdida sanguínea, reconversión, complicaciones, estancia media y resultado anatomopatológico. Se utilizaron el test de Fisher y el test de chi cuadrado para comparar datos categóricos. Se utilizó el test t de Student para comparar medias de grupos independientes con distribución normal. Se consideró la significación estadística cuando p<0,05. Resultados: La edad media fue de 53,1 años (±14,4). El tamaño medio fue de 3,7cm (±2,2). En el 51% de los casos fue izquierda. La media de seguimiento fue de 15 meses (±11,9). El diagnóstico preoperatorio fue masa funcionante (44%), feocromocitoma (17%), incidentaloma mayor de 4cm (20%), metástasis (10%) y carcinoma suprarrenal (5%). El tiempo quirúrgico medio fue de 145,1 min (±55,6). El descenso medio de hematocrito fue de 6,26 puntos (±3,3). La tasa de reconversión fue del 9,6%. Hubo 2 casos de íleo postoperatorio prolongado. Dos pacientes requirieron transfusión. Uno murió en el postoperatorio por descompensación de cirrosis hepática asociada. El 80% de las complicaciones fueron en el lado derecho. La estancia media hospitalaria fue de 6 días (±5,6). En el grupo de los 30 últimos procedimientos se obtuvieron diferencias significativas en cuanto al tiempo quirúrgico (119,1 vs. 171,2min) y a la estancia media hospitalaria (4,1 vs. 6,1 días, p<0,05). Conclusiones: La suprarrenalectomía laparoscópica transperitoneal es una cirugía factible y segura en grupos con experiencia laparoscópica previa. Nuestros resultados se asemejan a las series publicadas en cuanto a la eficacia y a la morbilidad de la técnica (AU)

Introduction: Laparoscopic adrenalectomy is currently the gold standard in surgical management of adrenal pathology. Objectives: To analyze our results after 12 years of experience in this surgery and to compare with the main published series. Material & methods: we describe retrospectively 100 adrenalectomies performed between 1997–2009. Analized variables: age, size, side, preoperative diagnosis, operative time, blood loss, reconversion, hospital stay and histopathologic report. We utilized Fisher test and chi square test to compare categoric data. We utilized t-Student test to compare means from independents groups with normal distribution. We considered statistical significance when p<0.05. Results: mean age was 53,1 years (±14,4). Mean size was 3,7cm (±2,2). In 51% of cases it was the left side. Mean follow-up was 15 months (±11,9). Preoperative diagnosis was: functional mass (44%), pheocromocytome (17%), incedentaloma >4cm (20%), metastasis (10%) and adrenal carcinoma (5%). Mean operative time was 145,1min (±55,6). Mean hematocrite loss was 6,26 points (±3,3). Reconversion rate was 9,6%. 2 cases of prolonged postoperative ileus. 2 patients required transfusion. 1 patient death because of an descompensation of liver cirrhosis. 80% of complications were on right side. Mean hospital stay was 6 days (±5,6). In last 30 procedures we realized statistical differences with first group, in terms of operative time (119,1min vs 171,2min) and hospital stay (4,1 days vs 6,1) (p<0,05). Conclusions: Transperitoneal laparoscopic adrenalectomy is a surgical feasible and safe procedure in urological groups with previous laparoscopic experience. Our results are similar with the published series and confirm the efficacy, security and reproducibility of this technique (AU)

Experiencia inicial en el diagnóstico y tratamiento del tumor vesical superficial con Hexvix® / Initial experience in the diagnosis and treatment of superficial bladder tumors with Hexvix®

Objetivo: El actual standar en el diagnóstico y seguimiento del tumor vesical es la cistoscopia con luz blanca. Recientes estudios sugieren que la cistoscopia con fluorescencia a través de derivados de las porfirinas puede mejorar la detección de lesiones vesicales. Hemos analizado los resultados en el diagnóstico y tratamiento de lesiones vesicales utilizando la cistoscopia de fluorescencia con hexaminolevulinato (Hexvix®) en nuestro centro. Métodos: Entre septiembre 2006 y septiembre 2007, a 39 pacientes consecutivos con sospecha ó confirmación de tumor vesical se les administró una instilación endovesical de Hexvix® una hora antes de la cirugía. Se realizó en primer lugar una cistoscopia con luz blanca (CLB) y posteriormente con luz azul (CLA). Se resecaron todas las lesiones papilares y las sospechosas para análisis histológico. La edad media fue de 70.1 años (50-86). 30 hombres (76.9%) y 9 mujeres (23.1%). Las características de los tumores fueron: 18% tumores primarios, 51% recurrencias y 30% controles cistoscópicos. 24 pacientes habían recibido con anterioridad algún tratamiento (9 mitomicina C y 15 BCG). 7 pacientes demostraron citologías urinarias positivas previas. Resultados: Todas las lesiones papilares visualizadas con luz blanca se confirmaron con luz azul (18 pacientes). De éstos, 17 tuvieron biopsias positivas (6 pTaG1, 9 pT1G1-3, 1 pT2, 1 CIS). En 15 pacientes (38.4%) se objetivó al menos 1 lesión más solo visualizada con la luz azul. En este grupo, 8 pacientes (20.5%) tuvieron un diagnóstico histológico positivo (3 pTaG1, 2 pT1G3, 3 CIS). En 5 de estos casos (13%) el manejo terapéutico posterior cambió al introducir la luz azul (BCG vs MMC). Todos los casos de CIS (4) fueron diagnosticados mediante luz azul. En el postoperatorio no se demostraron efectos secundarios (locales ó sistémicos) debidos a la administración de Hexvix® Conclusiones: Nuestros resultados sugieren un incremento en el diagnóstico de lesiones tumorales vesicales, papilares y planas, con el uso de la cistoscopia bajo fluorescencia. Esto ha determinado un cambio de actitud terapéutica relevante en un 13% de los pacientes. Obviamente, se necesita mayor experiencia para consolidar estos resultados y un seguimiento a largo plazo para valorar el impacto a nivel de recurrencia y progresión tumoral (AU)

Objectives: White light cystoscopy is the current standard for the diagnosis of bladder cancer and monitorization for recurrence. Recent studies suggest that porphyrin based fluorescence cystoscopy may improve endoscopic detection of bladder tumors. We aimed to evaluate the improvement that hexaminolevulinate fluorescence cystoscopy could lead in bladder cancer detection and treatment at one single centre. Methods: Between September 2006 and September 2007 a total of 39 patients with known or suspected bladder cancer underwent bladder instillation with 50 ml 8 mM hexaminolevulinate (HAL) for 1 hour. The bladder was inspected using white light cystoscopy (WLC), followed by blue light (fluorescence) cystoscopy (BLC). Papillary and suspicious lesions were resected for histological examination. Mean age was 70.1 years (50-86). Thirty patients were male (76.9%) and 9 female (23.1%). The tumor characteristics were: 18% primary tumors, 51% recurrences and 30% control cystoscopies. 24 patients had previously received some treatment (9 MMC and 15 BCG). Only 7 patients had previous positive urine cytology. Results: All papillary lesions visualized with WLC were confirmed by BLC (18 patients). From these, 17 have positive biopsies (6 pTaG1, 9 pT1G1-3, 1 pT2, 1 CIS). In 15 patients (38.4%) we found at least 1 lesion more with BLC. In this group 8 cases (20.5%) had positive histological diagnosis (3 pTaG1, 2 pT1G3, 3 CIS). In five patients (13%) post-TUR therapeutic management has changed by using BLC (BCG vs MMC). All four patients with CIS were diagnosed by BLC. There was no evidence of local or systemic side effects due to HAL in the postoperative time. Conclusions: Our results suggest there is an improvement in the diagnosis of papillary and flat lesions in bladder cancer by using HAL fluorescence cystoscopy. This has changed the management in the postoperative period (MMC vs BCG) in 13% of the patients. Obviously, we need more patients to assess our data and long term follow-up to analyze the impact in terms of tumor recurrence and progression (AU)

[Brachyterapy in localized prostate cancer]. / Braquiterapia en el cáncer de próstata localizado.

INTRODUCTION AND OBJECTIVES: Considering the high frequency of localized prostate cancer in stages, at the moment there are minimally invasive techniques that compete with the classic surgery. One of them is the Low Dose Rate (LDR) Brachytherapy with permanent implants of 1125 seeds. The objective of the present study is to expose our experience from the year 1998, when we made the first treatment, until today. The results and the morbidity of the patients over a 7 and a half years period are analyzed. MATERIAL AND METHODS: A total of 800 patients were treated with LDR brachytherapy, with average age of 68 years and range between 48 and 83 years. In all patients the 1125 seeds were used with Rapid-Strand and peripheral load by means of intraoperative planning. RESULTS: The urinary rate of complications was of 3% of AUR, and 0.2% of urinary incontinence. The morbidity on the digestive apparatus was of a 12% intermittent bleeding, 2% of proctitis, and a 0.3% of rectal fistulas.

Braquiterapia en el cáncer de próstata localizado / Brachytherapy in the localized prostate cancer

Introducción y objetivos: Teniendo en cuenta la alta frecuencia del cáncer de próstata en estadios localizados, existen actualmente técnicas mínimamente invasivas que compiten con la cirugía clásica. Una de ellas es la Braquiterapia de Baja Tasa de Dosis con implantes permanentes de semillas de Yodo-125. El objetivo del presente trabajo es exponer nuestra experiencia desde el año 1998 en que realizamos el primer tratamiento hasta el día de hoy. Se analizan los resultados y la morbilidad de los pacientes con un seguimiento de 7 años y medio. Material y Métodos: Un total de 800 pacientes fueron tratados con Baja Tasa de Dosis, con edad media de 68 años y rango entre 48 y 83 años. En todos los pacientes las semillas de I125 fueron utilizadas con Rapid-Strand, con técnica de carga periférica y mediante planificación intraoperatoria. Resultados: La tasa de complicaciones urinarias fueron del 3% de RAO, y del 0,2% de incontinencia urinaria. La morbilidad sobre el aparato digestivo fue de un 12% de sangrados intermitentes, 2% de proctitis, y un 0,3% de fístulas rectales

Introduction and objectives: Considering the high frequency of localized prostate cancer in stages, at the moment there are minimally invasive techniques that compete with the classic surgery. One of them is the Low Dose Rate (LDR) Brachytherapy with permanent implants of I125 seeds. The objective of the present study is to expose our experience from the year 1998, when we made the first treatment, until today. The results and the morbidity of the patients over a 7 and a half years period are analyzed. Material and methods: A total of 800 patients were treated with LDR brachytherapy, with average age of 68 years and range between 48 and 83 years. In all patients the I125 seeds were used with Rapid-Strand and peripheral load by means of intraoperative planning. Results: The urinary rate of complications was of 3% of AUR, and 0.2% of urinary incontinence. The morbidity on the digestive apparatus was of a 12% intermittent bleeding, 2% of proctitis, and a 0.3% of rectal fistulas