Prostatectomía radical laparoscópica. ¿Sólo en Centros de excelencia? / Laparoscopic radical prostatectomy. Only ar centres of expertise

Objetivos: Presentar la experiencia adquirida en la técnica de la prostatectomía radical laparoscópica en un hospital general con un área de influencia de 200.000 habitantes, analizando los resultados preliminares de nuestra serie. Material y Métodos: Entre diciembre de 2002 y agosto de 2005 se seleccionaron un total de 26 pacientes para prostatectomía radical laparoscópica, 25 vía transperitoneal y 1 extraperitoneal. La edad media fue de 62,3 ± 5,3 años (rango 52-69). El PSA medio fue de 9,16 ± 4,2 ng/ml (rango 5,26-24,3). El estadio clínico preoperatorio fue T1c en 10 (38,4%) T2a en 8 (30,8%) y T2ben 8 (30,8%) pacientes respectivamente. La media preoperatoria del grado de Gleason fue de 6 ± 0,8 (rango 4-7). Tres pacientes tenían bloqueo neoadyuvante en el momento de la cirugía (11,5%). En 2 casos se realizó linfadenectomía bilateral simultánea. No se realizó en ningún caso la técnica de preservación de nervios erectores. Resultados: La cirugía se completó en 20 pacientes. El seguimiento medio ha sido de 12,4 ± 8,6 meses (rango 3-34). No hubo muertes derivadas de la cirugía. En los primeros 10 casos hubo 6 reconversiones. En los 16 restantes 0. El tiempo quirúrgico medio para toda la serie fue de 303,5 ± 95,1 minutos (rango 150-540). En los 14 primeros casos el tiempo quirúrgico medio fue332,14 ± 92,58 y 236,6 ± 66,5 minutos en los últimos 6 casos (p<0.02). El sangrado medio fue de 90,25 ± 46,5 cc (rango 40-250). Complicaciones postoperatorias observamos en 4 pacientes (15,38%). El estadio patológico fue pT2a en 3 (15%), pT2b en10 (50%), pT3a en 3 (15%) y pT3b en 4 (20%) pacientes respectivamente. Márgenes positivos se encontraron en 3 casos (11,5%):1 pT2b (ápex), 1 pT3a y 1 pT3b. La estancia media fue de 4,7 ± 3,1 días (rango 3-18). La sonda vesical se mantuvo de media 12,7± 2,7 días (rango 7-21). Descontados los pacientes que precisaron reconversión, el 85% (17 pacientes) referían continencia (no compresa) a los 3 meses de seguimiento. Conclusiones: La experiencia de nuestro grupo en el manejo de otros procedimientos de cirugía laparoscópica urológica avanzada, ha permitido que la prostatectomía radical laparoscópica sea una técnica factible de realizar en un entorno de baja adscripción poblacional, consiguiendo una rápida curva de aprendizaje y con unos resultados similares a los de la cirugía convencional (AU)

Objectives: To present and evaluate our experience and initial results in radical laparoscopic prostatectomy which we have been using for two and an half years in our General Hospital (covering a total population of 200.000 inhabitants). Material and Methods. Between December 2002 and August 2005, were selected 26 patients for radical laparoscopic prostatectomy (25 transperitoneal and 1 extraperitoneal). Mean age was 62.3 ± 5.3 years (range 52-69). Mean PSA level was 9.16 ± 4.20 ng/mL (range 5.26 to 24.3). Pre-operative classification was T1c in 10 patients (38.4%), T2a in 8 (30.8%) and T2b in 8. Mean Gleason Score was 6 ± 0.8 (range 4-7). Three patients had undergone preoperatively neo-adjuvant hormonal blockage (11.5%). Simultaneous bilateral inguinal lymphadenectomy was performed in two patients. In no case did we consider a nerve sparing approach. Results. The procedure was accomplished in 20 patients. Mean follow-up was 12.4 ± 8.6 months (range 3 - 34). There was no perioperative mortality. Conversion to open surgery was required six times in the ten first cases but not thereafter. Mean operating time for the whole series was 303 ± 95 minutes (range 150-540) but with a distinct difference between the first fourteen and the last six cases: 332 ± 92,58 versus 236.6 ± 66.5 (p<0.02). Mean blood loss was 90.25 ± 46.5 ml. There were early postoperative complications in 4 patients (15.38%). Final pathological staging was: T2a in three patients (15%), T2b (50%) in 10, T3a (15%) in three and T3b (20%) in four. Positive margins were found in three cases (11.5%): T2b, T3a and T3b. Mean hospitalisation time was 4.7 ± 3.1 days. Provided there was no urinary leakage, the urinary catheter was removed at 12.7 ± 2.7 days. Full continence at three months was achieved in 17 of the patients (85%) who had undergone the full laparoscopic procedure. Conclusions: Our previous experience in other major laparoscopic procedures has allowed us to perform radical laparoscopic prostatectomy with a fast learning curve even in a setting of a relatively low population. Initial long term results seem similar to those achieved with conventional surgery (AU)

[Laparoscopic radical prostatectomy. Only at centers of expertise]. / Prostatectomía radical laparoscópica. Sólo en centros de excelencia?

OBJECTIVES: To present and evaluate our experience and initial results in radical laparoscopic prostatectomy which we have been using for two and an half years in our General Hospital (covering a total population of 200.000 inhabitants). MATERIAL AND METHODS: Between December 2002 and August 2005, were selected 26 patients for radical laparoscopic prostatectomy (25 transperitoneal and 1 extraperitoneal). Mean age was 62.3 +/- 5.3 years (range 52-69). Mean PSA level was 9.16 +/- 4.20 ng/mL (range 5.26 to 24.3). Pre-operative classification was Tlc in 10 patients (38.4%), T2a in 8 (30.8%) and T2b in 8. Mean Gleason Score was 6 +/- 0.8 (range 4-7). Three patients had undergone preoperatively neo-adjuvant hormonal blockage (11.5%). Simultaneous bilateral inguinal lymphadenectomy was performed in two patients. In no case did we consider a nerve sparing approach. RESULTS: The procedure was accomplished in 20 patients. Mean follow-up was 12.4 +/- 8.6 months (range 3 - 34). There was no perioperative mortality. Conversion to open surgery was required six times in the ten first cases but not thereafter. Mean operating time for the whole series was 303 +/- 95 minutes (range 150-540) but with a distinct difference between the first fourteen and the last six cases: 332 +/- 92.58 versus 236.6 +/- 66.5 (p<0.02). Mean blood loss was 90.25 +/- 46.5 ml. There were early postoperative complications in 4 patients (15.38%). Final pathological staging was: T2a in three patients (15%), T2b (50%) in 10, T3a (15%) in three and T3b (20%) in four. Positive margins were found in three cases (11.5%): T2b, T3a and T3b. Mean hospitalisation time was 4.7 +/- 3.1 days. Provided there was no urinary leakage, the urinary catheter was removed at 12.7 +/- 2.7 days. Full continence at three months was achieved in 17 of the patients (85%) who had undergone the full laparoscopic procedure. CONCLUSIONS: Our previous experience in other major laparoscopic procedures has allowed us to perform radical laparoscopic prostatectomy with a fast learning curve even in a setting of a relatively low population. Initial long term results seem similar to those achieved with conventional surgery.

[Therapeutic approach in adrenal melanoma. Review of the literature]. / Actitud terapéutica en el melanoma suprarrenal. Revisión de la literatura.

OBJECTIVE: To review the treatment strategies for adrenal melanoma and to emphasize the role of curative surgical resection and adjuvant treatment in selected patients with melanoma metastatic to the adrenal gland versus chemotherapy alone in the treatment of patients with advanced malignant melanoma. METHODS: A case of adrenal gland metastasis of a cutaneous melanoma (Clark IV, Breslow 5 mm.) treated by excision one year before that was referred to the Urology Department for Wünderlich syndrome is presented. RESULTS: The analyzed series of programmed adrenalectomy for adrenal metastases from melanoma describe survivals of 26 (3), 36 (9), 59 (3) and 72 (5) months. In our case the patient died at home one month later due to stroke, although concomitant brain metastasis is suspected. Autopsy was not performed. CONCLUSIONS: In the differential diagnosis of an incidentaloma, metastatic disease is likely in a patient with a history of malignant disease. The frequency of malignant melanoma among metastatic adrenal disease varies between 1% and 8.6%; the majority are asymptomatic and incidental findings. We believe that in selected patients with advanced malignant melanoma, with no major coexisting morbidity factors who have isolated melanoma metastatic to the adrenal gland or with limited extra-adrenal sites of disease, curative surgical resection and adjuvant treatment may improve their survival. It must be emphasized that all patients should be followed after surgical resection of the primary tumor because it will facilitate staging of the disease and avoid emergency situations of ruptured friable metastases that make complete resection difficult.

[Differential diagnosis of epididymal leiomyoma. Report of a new case]. / Diagnósticos diferenciales del leiomioma de epidídimo. Aportación de un nuevo caso.

OBJECTIVE: A case of epididymal leiomyoma is presented. This lesion is uncommon and sometimes misdiagnosed. The literature is briefly reviewed. METHODS/RESULTS: A 29-year-old patient presented with a tumor in the tail of the right epididymis that was initially diagnosed as scrotal hematoma or complex cyst in the tail of the epididymis. RESULTS/CONCLUSIONS: Ultrasound has an important role in distinguishing testicular from epididymal tumors. However, if the diagnosis is unclear, surgical resection and subsequent anatomopathological analysis must be performed.

[Primary neuroectodermal tumor (PNET) of the kidney: 26 cases. Current status of its diagnosis and treatment]. / Tumor neuroectodérmico primitivo renal (PNET): 26 casos. Estado actual de su diagnóstico y tratamiento.

OBJECTIVE: To report a case of primitive neuroectodermal tumor (PNET) of the kidney and review the literature and the 25 cases previously reported as PNET. METHODS: A 39-year-old man who consulted for nephric colic is described. Ultrasound evaluation disclosed a mass arising from the left kidney. The clinical, radiological and pathologic features, treatment and differential diagnosis of small cell tumors are discussed, as well as the important role of immunohistochemical techniques (positive staining with O13 or 12E7 antibodies) and cytogenetic analysis [a characteristic chromosomal translocation t(11;22) (q24;q12) or variant translocation, such as t(21;22) (q22;q12), may be detected by fluorescence in situ hybridization (FISH) or polymerase chain reaction-reverse transcriptase (PCR-RT)]. RESULTS: Survival of our patient was 20 months. Only three of the 25 previously reported cases had a longer survival: 60, 48 and 24 months. Mean survival was 10 months. 95.24% of the cases were positive for NSE. Immunostaining (CD99) was performed in 16 patients and was found to be positive in all cases. Cytogenetic and molecular analyses were performed in 11 cases; PCR-RT was negative in two, as well as in the case described herein. CONCLUSIONS: PNET is a highly aggressive neoplasm that tends to recur locally and to metastasize. Despite the poor response to standard therapy combining surgical resection, postoperative irradiation and chemotherapy, the results might change due to current research on genetic therapy based on creating antisense oligonucleotides against the EWS-FLI 1 fusion gene.

[Stromal tumor of the rectum and leiomyosarcoma of the prostate as a cause of urinary syndrome attributable to BPH]. / Tumor estromal de recto y leiomiosarcoma de próstata como causa de síndrome miccional atribuible a HBP.

OBJECTIVE: To discuss the classifications of patients with lower urinary tract symptoms ascribed to BPH, in order to define the indication for treatment for patients with similar features but of a different etiology. The literature is also reviewed. METHODS/RESULTS: Two patients, aged 62 and 63 years, diagnosed as having BPH were found to have a gastrointestinal stromal tumor (GIST) and a leiomyosarcoma of the prostate, respectively. The first patient had undergone retropubic resection. Frozen section analysis revealed a GIST. The second patient had undergone TURP twice. A perineal biopsy at the last medical examination showed a leiomyosarcoma of the prostate. This patient finally underwent pelvic tumorectomy. The international classification of BPH is discussed: PQSF (P: prostatic weight determined by transrectal US or DRE; Q: quality of life assessment; S: international prostate symptom score (IPSS); F: maximum urinary flow rate by uroflowmetry--Qmax). CONCLUSIONS: The classifications are practical, but should be improved. In our view, details useful in orienting the diagnosis could be lost by oversimplification.