Retrospective study of various conservative treatment options with bacille Calmette-Guérin in bladder urothelial carcinoma T1G3: Maintenance therapy. / Estudio retrospectivo de diferentes opciones de tratamiento conservador con Bacilo de Calmette-Guèrin en el carcinoma urotelial vesical T1G3: terapia de mantenimiento.

OBJECTIVE: To compare various conservative treatment options for high-grade T1 nonmuscle-invasive bladder cancer (NMIBC). Bacille Calmette-Guérin (BCG) is the preferred intravesical treatment for high-grade T1 tumours; however, a number of experts still question the need for maintenance BCG. MATERIAL AND METHODS: We retrospectively analysed data from 1039 patients with primary and recurrent T1G3 NMIBC. All patients underwent complete transurethral resection of the bladder tumour (TURBT), with muscle in the sample and multiple bladder biopsies. The patients were treated with the following: only one initial TURBT (n=108), re-TURBT (n=153), induction with 27mg of BCG (Connaught strain) (n=87), induction with 81mg of BCG (n=489) or induction with 81mg of BCG+maintenance (n=202). The time to first recurrence, progression (to T2 or greater or to metastatic disease) and specific mortality of the disease was assessed using the Kaplan-Meier survival function and were compared using the log-rank test and the Cox multivariate regression model of proportional risks. RESULTS: The mean follow-up was 62±39 months. The risk of recurrence was significantly lower for the patients treated with maintenance therapy of 81mg of BCG than in the other treatment groups (P<.001). The risk of tumour progression was also significantly lower for the patients treated with maintenance BCG than for the patients treated only with one TURBT, re-TURBT and with induction therapy with 27mg of BCG (P=.0003). The specific disease mortality was significantly lower with BCG maintenance (9.4%) than with only one TURBT (27.8%; P=.003). CONCLUSIONS: In the case of T1G3 NMIBC, a complete dose of BCG with maintenance is associated with better recurrence results than are other conservative treatment modalities. The results of progression and survival specific to the disease were also better with induction BCG, with or without maintenance.

Transmural gastric migration of dual-sided PTFE/ePTFEE mesh after laparoscopic surgery for a recurrent hiatal hernia with dysphagia: case report.

Several series have shown that laparoscopic fundoplication is feasible and safe for the treatment of hiatal hernia, although a high recurrence rate of 42% has been published. The use of mesh repair in these hernias has shown fewer recurrences than primary suture with small number of complications reported.Some of these are severe fibrosis within the hiatus, mesh erosion of the intestinal wall, esophageal strictures, mesh migration into the upper gastrointestinal tract and esophageal perforations. We present a case with late erosion and complete transmural gastric migration of the mesh after surgery. In these cases, the patients may require complex surgical intervention.That was not the case in our patient, who did not require further surgery because the mesh migrated completely. It is therefore advisable to use a mesh very selectively for the laparoscopic repair of hiatal hernias, taking into account the surgeon's experience, the anatomy of the hiatus and the symptoms of the patient.

Influence of the true number of Bacillus Calmette-Guérin instillations on the prognosis of non-muscle invasive bladder tumors.

OBJECTIVES: To analyze if the true number of BCG instillations applied in non-muscle invasive bladder tumors has any influence on their prognosis as well as other tumor and clinical characteristics: age, sex, different protocols, BCG dose, whether primary or recurrent, solitary or multiple, tumor size G3 or Cis. PATIENTS AND METHODS: A total of 324 high grade NMIBC (15 TaG3, 184 T1G3, 125 Cis) out of 1491 cases included in the CUETO database were analyzed. Following 6 post transurethral resection (RTU) BCG instillations, the patients were scheduled to receive one instillation every two weeks (3-6 times), for a total of 9-12 instillations. One third of the dose (27 mg) (112 cases) or total dose of 81 mg (212 cases). Mean follow-up was 59.6 months. Statistical Analysis: Kaplan-Meier, Cox-regression (uni-multivariate). RESULTS: A higher level of recurrence (p = 0.032) and progression (P = .013) risk as well as worse Ca-specific survival (P = .005) were obtained if there were fewer than 12 instillations with the Kaplan-Meier and Cox-regression multivariate analysis. A 27 mg (P = .008) dosage and being a female (P < .001) were independent factors for a higher recurrence risk, but not for progression or Ca-specific survival. The remaining characteristics studied were not statistically significant. CONCLUSIONS: In accordance with the results obtained, we can conclude that the number of BCG instillations applied has some influence on the outcome of high grade NMIBC. The optimum number of instillations as well as their time of application must still be determined. A dose of 27 mg and being a female are predictive factors of recurrence.

[The figure of the head of service (Chairman): what profile should have?]. / La figura del Jefe de Servicio: qué perfil debe de tener?

Great social-health care changes in the short term have been predicted that will seriously affect the departmental structure and care hierarchy of future hospital, universitary, public or private. The Spanish Association of Urology (AEU) wondered whether in these circumstances, in which the welfare and economic management of the hospital so-called "industrial" will dominate over other traditional aspects of the scientific hierarchy, social welfare and teaching of head Urology of service, will change his image, goals, functions, and ultimately its authority. Likewise which must be the attributes of this new generation of department heads. To this end the AEU call a roundtable requesting opinions and comments which are reflected in the enclosed text.

La figura del Jefe de Servicio: ¿qué perfil debe de tener? / The figure of the head of service (chairman): what profile should have?

Se prevén grandes cambios socio sanitarios a corto plazo que afectarán seriamente la estructura departamental y jerarquía asistencial del hospital futuro, universitario público o privado. La Asociación Española de Urología se pregunta si en estas circunstancias, en la que la gestión asistencial y economicista del hospital así llamado 'industrial' dominará sobre otros aspectos tradicionales de la jerarquía científica, asistencial y docente del jefe de servicio, modificará su imagen, objetivos, funciones, y en definitiva su autoridad. Así mismo cuales han de ser los atributos de esta nueva generación de jefes de servicio. Para ello la A.E.U. convocó una mesa redonda solicitando opiniones y comentarios que se recogen en el texto adjunto (AU)

Great social-health care changes in the short term have been predicted that will seriously affect the departmental structure and care hierarchy of future hospital, universitary, public or private. The Spanish Association of Urology (AEU) wondered whether in these circumstances, in which the welfare and economic management of the hospital so-called 'industrial' will dominate over other traditional aspects of the scientific hierarchy, social welfare and teaching of head Urology of service, will change his image, goals, functions, and ultimately its authority. Likewise which must be the attributes of this new generation of department heads. To this end the AEU call a roundtable requesting opinions and comments which are reflected in the enclosed text (AU)

Cirugía uretral / Urethral surgery

A propósito del 25 aniversario de Actas Urológicas Españolas se efectúa una exhaustiva actualización de la cirugía uretral en toda su extensión. La dilatada experiencia personal del autor preside esta revisión que se extiende tanto las anomalías congénitas como la complejidad inherente a los procedimientos quirúrgicos y elección técnica de las uretroplastias. (AU)

Long-term follow-up of a randomized prospective trial comparing a standard 81 mg dose of intravesical bacille Calmette-Guérin with a reduced dose of 27 mg in superficial bladder cancer.

OBJECTIVES: To determine the efficacy of a three-fold reduced dose (RD, 27 mg) of intravesical bacille Calmette-Guérin (BCG) against the standard dose (81 mg) in patients with superficial bladder cancer, assessing recurrence, progression and differences in toxicity. PATIENTS AND METHODS: Five hundred patients with superficial bladder cancer (Ta, T1, Tis) were enrolled and randomly assigned to be treated after transurethral resection of all visible lesions with intravesical BCG Connaught strain (weekly x six and thereafter fortnightly x six) either with the standard or RD instillation. RESULTS: All but one of the 500 patients were evaluable for efficacy and toxicity (252 in the standard arm and 247 in the RD arm). The median follow-up was 69 months (maximum 104); 71 (28%) patients in the standard arm and 76 (31%) in the RD arm developed recurrences; the median time to recurrence has not yet been attained, but at 5 years the mean (sd) percentage of recurrence-free patients was 70.5 (3.12) and 70.4 (3.1) for the standard and RD arms, respectively. In patients presenting with multifocal tumours, the standard dose was more effective against recurrences than the RD (P=0.0151). In those with G3 and high-risk tumours overall, the superiority of the standard dose was marginal (P=0.060 and P=0.082). Twenty-nine (11.5%) tumours in the standard arm and 33 (13.3%) in the RD arm progressed to invasive disease; the median time to progression has not yet been attained, but the percentage of progression-free patients at 5 years was 88.8 (2.23) and 86.9 (2.31) for the standard and RD arms, respectively. The standard dose was more effective than the RD against progression only in patients with multifocal disease (P=0.048). Twelve (4.8%) cystectomies were performed in the standard and 15 (6.1%) in the RD arm. Currently, 106 (21.2%) patients have died, but only 38 (7.6%) from bladder cancer, i.e. 20 (7.9%) in the standard and 18 (7.5%) in RD arm. Overall the disease-specific death rate was lower for those patients who completed the scheduled treatment. The cause-specific survival at 5 years did not differ between the arms (P=0.76) but there was a trend toward better cause-specific survival for patients with multifocal tumours in the standard arm. Toxicity differed between the arms, significantly more patients having no toxicity in the RD arm, and fewer having delayed instillations or withdrawing. However, severe systemic toxicity occurred even in patients treated with the RD, in a similar proportion to those receiving the standard dose. CONCLUSION: Overall, the RD gave similar results for recurrence and progression but with significantly less toxicity. However, patients with multifocal tumours fared better with the standard dose and there was a trend towards better recurrence rates in patients with high-risk tumours. We recommend continuing to use the standard dose for high-risk tumours, while we consider the reduced dose safe and effective for intermediate-risk lesions and for maintenance schedules.

[Urethral surgery]. / Cirugía uretral.

A propos of the 25 anniversairy of Actas Urologicas Españolas it carry out a comprehensive up to date of the extended urethral surgery. The wide personal experience of the author rules through this revision ranging over the whole field of congenital abnormalities as well as the inherent complexity of surgical procedures and technical selection of for urethroplasty.

[Conservative parenchymal surgery in kidney neoplasms]. / Cirugía conservadora de parénquima en neoformaciones renales.

OBJECTIVES: To analyze retrospectively a series of 60 nephron sparing surgeries (NSS) in patients presenting with renal masses. MATERIAL AND METHODS: The clinical histories of 59 patients undergoing NSS between january 1978 and december 1997 were reviewed. 40 were males, the mean age 54.4 years (range 17-77 years). 10 (17%) had bilateral synchronous tumors, 15 (25%) had a solitary kidney and 3 a renal insufficiency. In 25 patients NSS was obligatory, while in 34 it was elective. 30 (50%) of the renal masses had been diagnosed incidentally. Overall, 49 kidneys underwent an enucleation and 11 a partial nephrectomy. RESULTS: The histopathological exam revealed 43 (71.6%) renal cell carcinomas (RCC), 2 (3.4%) urothelial carcinomas, 6 (10.2%) oncocytomas, 7 (11.6%) angiomyolipomas and 2 (3.4%) multilocular cystic nephromas. Among the RCC, 8 had < or = 3 cm, 22 between 3.1-5 cm, 10 between 5.1-8 cm and 3 more than 8 cm. 31 (72.1%) were well encapsulated and only 2 (4.6%) invaded the nearby parenchyma. 7 (16.2%) were pT1, 34 (79%) pT2 and 2 (4.6%) pT3. 39 (90.3%) were G1 or G2, and only 4 (9.3%) were G3. Two patients (3.3%) died perioperatively, both from the obligatory group. 3 (6.8%) of the patients with malignant tumors progressed and died, all with CCR and from the obligatory surgery group. Another 3 patients of this group developed local recurrences, but were rescued with iterative surgery (conservative in 1); 2 of these patients had sporadic CCR, another a von Hippel Lindau disease. None of the 34 patients who underwent elective NSS progressed, nor recurred locally and all are alive and disease free; only 14 (56%) of the 25 patients operated on by necessity survived, although 6 of them died of causes not related with the kidney tumor. The cancer specific survival at 58.3 months of follow-up (range 5-187 months) is 86.8% for the whole series, 100% for the elective NSS group and 68.7% for the obligatory NSS group. 19 (31.6%) patients developed complications, 14 among the obligatory group; two died (hemorrhage and sepsis). 3 patients presented acute renal failure, but none required dialysis; presently 4 (6.7%) patients have poor renal function and 1 requires dialysis. CONCLUSION: NSS affords good control of renal carcinoma; in the cases operated on electively, the 100% cause specific survival yielded by NSS supports the use of conservative surgery in patients with well delimited tumors and normal contralateral kidney.

Determination of the percentage of free prostate-specific antigen helps to avoid unnecessary biopsies in men with normal rectal examinations and total prostate-specific antigen of 4-10 ng/ml.

OBJECTIVE: To assess the usefulness of measuring the percentage of free prostate-specific antigen (PSA) in serum to reduce the number of prostate biopsies in men with serum PSA levels between 4 and 10 ng/ml and benign prostate examinations. MATERIALS AND METHODS: The percentage of free PSA (Immulite((R))) in serum was analyzed prospectively in 180 men with benign digital rectal examinations and total PSA serum levels of between 4 and 10 ng/ml. All patients underwent ultrasound-guided sextant prostatic biopsies. Sensitivity, specificity and positive and negative predictive values were calculated as well as the percent of patients in which biopsies could have been avoided for various cutoff values of the percentage of free PSA as an indicator for biopsy. Influence of age in the determination of cut points was evaluated. RESULTS: Cancer was detected in 22.2% (40/180) of the patients. Mean percentage of free PSA was 13.4% in patients with cancer and 18.9% in patients with benign prostatic hyperplasia (p = 0.001). Using a percentage of free PSA cutoff of 22% or less as a criterion for performing prostatic biopsy would have detected 95% of cancers, avoided 25% of benign biopsies and yielded a positive predictive value of 29% in patients who underwent biopsy. Mean percent of free PSA values increased as mean subject age increased, influencing the calculation of cut points, sensitivity and specificity. Leaving the cut point constant across all age groups will oblige older patients to undergo an increased number of unnecessary biopsies, although allowing for higher sensitivity in younger men. CONCLUSIONS: Measurement of the percentage of free serum PSA improves specificity of prostate cancer detection in patients with elevated total serum PSA levels and benign prostate examinations. Subject age seemed to influence the determination of optimal cut points.

[Bladder leiomyoma during pregnancy]. / Leiomioma vesical durante el embarazo.

OBJECTIVE: To describe an additional case of rapidly growing leiomyoma of the bladder in a pregnant woman. METHODS: A case of leiomyoma of the bladder in a woman at 8 months of pregnancy is presented. Transurethral resection was performed, but the tumor recurred a few weeks later. The tumor was resected by partial cystectomy after delivery. CONCLUSIONS: Leiomyoma of the bladder is an uncommon benign lesion that is successfully managed by surgical resection. The rapid recurrence of the tumor in our patient can be ascribed to the hormonal changes during pregnancy.

[Substitution urethroplasties with free graft buccal mucosa]. / Uretroplastias de sustitución con injerto libre de mucosa bucal.

OBJECTIVE: To present our experience with free graft buccal mucosa substitution urethroplasties. METHODS: Between June, 1992 and December, 1997, we performed 18 urethroplasties with buccal mucosa in 17 patients (double urethroplasty in the same stage in one): 8 for the repair of urethral strictures, 9 for the repair of hypospadias cripples and one for epispadias repair, in an exstrophic boy. Only 3 patients had not undergone previous reconstructive operations. The mean age was 26.2 years (range 10-69). In 8 cases we harvested the graft from the inner cheek and in another 8 cases from the inner lower lip; in two cases we combined mucosa from the cheek and from the lip. In 14 patients we managed to preserve the urethral roof and the buccal mucosa was grafted as an onlay patch; 4 patients underwent full circumference tube replacement. The median follow-up of the series was 17.8 months, ranging from 1 month to 5.5 years. RESULTS: In 15 out of 18 repairs (83.3%) the final outcome was satisfactory, while in three cases the graft failed and reoperation was necessary. In 10 of the 15 successful urethroplasties the end result was excellent: first intention healing no complications or sequelae; in the other 5, although the end result was good, fistulae requiring surgery for closure developed in 2 and meatal stenosis requiring autodilations in three patients. The best results were obtained in strictures of the bulbar urethra secondary to trauma with 100% success rate. In hypospadias the success rate was 77.7%. Onlay patch grafts never failed, with 10 out of 14 excellent results. Three out of 4 tubed grafts failed. CONCLUSIONS: At short and medium term, the free grafts of buccal mucosa yield results comparable to those of other epitheliums in use for urethral repair, thus increasing the choice of techniques at our disposal for one-stage repairs. We consider that it is best suited for long strictures of the bulbar urethra.

Prospective comparative study with intracavernous sodium nitroprusside and prostaglandin E1 in patients with erectile dysfunction.

PURPOSE: To compare the effectiveness of intracavernous administration of sodium nitroprusside and prostaglandin E1 to induce penile erection in men with erectile dysfunction. MATERIAL AND METHODS: 100 patients with erectile dysfunction entered the study prospectively. As part of the diagnostic workup, each patient received an intracavernous injection of 20 microg prostaglandin E1 and a second injection of 600 microg sodium nitroprusside 1-7 days later. A tourniquet was placed at the base of the penis before each injection. The data recorded included time required to initiate tumescence, local and systemic side effects, objective and subjective quality of erections, duration of tumescence and patient satisfaction by means of a personal questionnaire. RESULTS: Prostaglandin E1 induced better overall responses than sodium nitroprusside, the difference being almost significant (p = 0.055). The overall duration of erections was also significantly longer with prostaglandin E1 (mean 81.3 min) than with sodium nitroprusside (mean 65.4 min; p < 0.04). 67% of the patients considered the erections induced with prostaglandin E1 to be of better quality than those with sodium nitroprusside, and only 11% stated that sodium nitroprusside was superior. Side effects were minimal with both drugs, the most frequent side effect being systemic hypotension, which was induced by sodium nitroprusside in 7% of the patients. CONCLUSIONS: The moderate risk of systemic hypotension and the lower potency of sodium nitroprusside to induce erections compared to prostaglandin E1 rules out sodium nitroprusside as a routine alternative intracavernous drug in men with erectile dysfunction at the doses employed. Sodium nitroprusside, however, could be used in patients who have intolerance or penile pain with intracavernous prostaglandin E1.

Topographical anatomy of the penile arteries.

OBJECTIVE: To determine the relationship of the penile arteries to anatomical landmarks and thus ease their identification, so avoiding injury during surgery. MATERIALS AND METHODS: The penile arteries in 12 formalin-preserved adult male cadavers were dissected and the distances measured between the cavernosal arteries and both the endopelvic fascia and distal attachment of the crura to the ischial bones. The distance between the origins of both bulbar and cavernosal arteries, their length and the length of the cavernosal bodies and crural attachments were also measured. RESULTS: Several anatomical variations, e.g. accessory pudendal arteries, multiple cavernosal and bulbar arteries, irrigation of cavernosal bodies by contralateral branches, anastomosis of cavernosal arteries with accessory pudendal branches, dorsal artery or bulbar artery as main branches of accessory pudendal arteries, were observed in 13 of the 24 specimens. The mean distances between the anterior attachment of the crura to the ischial rami and the site on the tunica albuginea where the cavernosal arteries penetrated the cavernosal bodies were 1.26 cm on the right and 0.69 cm on the left. The corresponding measurements between the cavernosal arteries and the endopelvic fascia were 5.68 cm (right) and 4.85 cm (left). The mean extracavernosal lengths of the right and left cavernosal arteries were 2.47 and 2.2 cm, respectively. CONCLUSIONS: Multiple anatomical variations of the arterial penile anatomy occur frequently. Surgery at the penile hilum may easily damage the cavernosal arteries, which lie medially to the dorsal nerves and arteries of the penis, have an extracavernosal length of about 2.3 cm and perforate the tunica albuginea about 1 cm distally to the anterior attachment of the crura to the ischial ramus.

[Review of complications of urinary diversions performed during a 6-year period in the era of orthotopic neobladders]. / Revisión de las complicaciones de las derivaciones urinarias realizadas en un periodo de 6 años en la era de las neovejigas ortotópicas.

OBJECTIVE: To compare the morbidity of different types of permanent urinary diversion. METHODS: We reviewed the postoperative and longterm complications observed in 85 patients who underwent permanent urinary diversion from December, 1986 to January, 1993: cutaneous ureterostomy (16 pts.), transintestinal incontinent cutaneous ureterostomy (41 pts.), orthotopic neobladder (27 pts.). All patients underwent radical cystectomy for bladder carcinoma. The surgical technique utilized for the construction of the orthotopic neobladders were as follows: Camey 1 (4 cases), Camey II (6 cases), Mainz (2 cases), Hautman (6 cases), detubularized sigmoid (6 cases). We also reviewed and used for comparison 18 augmentation cystoplasties that underwent simple subtotal cystectomy. Augmentation cystoplasty was performed with the sigmoid (n = 8), ileon (n = 5) and ileocecal segment (n = 4). RESULTS: The incidence of postoperative complications was similar for all types of urinary diversion (64.3% for cutaneous ureterostomy, 61% for transintestinal intermittent cutaneous ureterostomy, 59.3% for orthotopic neobladder), although patients with orthotopic neobladders required surgery more frequently (7.1% for cutaneous ureterostomy, 22% for transintestinal cutaneous ureterostomy, 41% for orthotopic neobladder). The incidence of postoperative complications was much lower in patients who underwent augmentation cystoplasty (complications 17.7%; none required surgery). The percentage of longterm complications was 71.4% for cutaneous ureterostomy, 74.2% for cutaneous transintestinal ureterostomy, 86.9% for orthotopic neobladders and 100% for augmentation cystoplasties. The patients who required surgery were 14.3%, 19.3%, 26% and 47%, respectively. Twelve out of 24 patients in whom metalic staples were employed for the construction of the neobladders and cystoplasties developed bladder stones; 78.3% of the patients with orthotopic neobladders showed perfect daytime continence, 65.2% night-time incontinence and 21.7% stress incontinence. The figures for augmentation cystoplasties were 94.1%, 5.9% and 5.9%; 4.3% of patients with orthotopic neobladders and 29.4% of patients with augmentation cystoplasties required self intermittent catheterization. Patients with larger neobladders showed best continence rates. Fifty-three ureters were reimplanted in the orthotopic neobladders of augmentation cystoplasties with the Le Duc technique; 17% developed ureteral stenosis and 15.1% vesicoureteral reflux. CONCLUSION: Patients who undergo permanent urinary diversion have a far from negligible number of postoperative and long-term complications. Orthotopic intestinal neobladders have a slightly higher rate of serious complications than incontinent cutaneous diversions.

[Prognostic value of lymphatic metastasis in bladder cancer]. / Valor pronóstico de las metástasis ganglionares en el cáncer vesical.

OBJECTIVE: The presence of lymph node metastasis in bladder cancer is considered to be a sign of poor prognosis. The present study was performed to analyze the influence of the number of positive lymph nodes on survival and the therapeutic value of lymphadenectomy in pN+patients. METHODS: From January, 1983 to January, 1993, 160 patients aged 39 to 77 years (mean 61.8) underwent radical cystectomy and pelvic lymphadenectomy for carcinoma of the bladder. The records of 122 patients were available for review. The UICC 1978 classification system was used. RESULTS: Cancer-specific mortality was 22.8% (16/70) for pNo patients, 44.4% (4/9) for pN1 patients and 88.9% (16/18) for pN2-4 patients. We obtained the following cancer-specific mortality by stratifying according to T category: 5.4% (2/37) for pNoT1-T3a, 42.4% (14/33) for pNoT3b-T4, 0% (0/2) for pNIT1-T3a, 57.1% (4/7) for pNIT3b-T4 and 88.9% (16/18) for pN2-4T3b-T4. CONCLUSION: The presence of only 1 positive regional lymph node (pN1) appears to worsen patient survival, particularly when the primary tumor is T3b or worse. In these cases cancer-specific mortality after patient discharge increased from 42% for the pNo patients to 57% for the pN1 patients (p > 0.05). Radical cystectomy was highly effective and curative in 95% of T1-T3apNo-1 patients (37/39). The presence of multiple positive lymph nodes carries a very poor prognosis, with 89% of the patients dying at a mean of 12 months.