Aplicación de protocolos ERAS (Enhanced Recovery After Surgery) en pacientes cistectomizados: el camino hacia la estandarización. Una revisión sistemática / Implementation of ERAS (Enhanced Recovery After Surgery) protocols for radical cystectomy patients: The pathway to standardization. A systematic review

CONTEXTO: El desarrollo de protocolos ERAS (Enhanced Recovery After Surgery) en pacientes sometidos a cirugía mayor ha aportado beneficios perioperatorios en diversas disciplinas. En urología, su principal aplicación se centra en pacientes sometidos a cistectomía radical. OBJETIVO: Revisión sistemática de la literatura disponible de protocolos ERAS aplicados a pacientes intervenidos de cistectomía radical, tanto a nivel de resultados perioperatorios como en el análisis de su implementación. Adquisición de la evidencia: Se realizó búsqueda bibliográfica en base de datos electrónicas Pubmed, Embase, Cochrane y Scopus, utilizando los términos «Cystectomy», «Enhanced Recovery After Surgery» y «Fast-Track». Se seleccionaron estudios aleatorizados y no aleatorizados que comparasen la implementación de un protocolo ERAS en pacientes sometidos a cistectomía radical frente a un protocolo tradicional. Síntesis de la evidencia: Se identificaron 869 artículos; 25 fueron seleccionados para el análisis final: 22 estudios no aleatorizados y 3 aleatorizados. No se detectaron diferencias en cuanto a características demográficas entre los distintos estudios. Se identificaron diferencias estadísticamente significativas a favor del protocolo ERAS en tiempo de estancia hospitalaria, tasa de complicaciones mayores, tiempo a primera deambulación y recuperación intestinal. En el análisis de protocolos se detectó una alta variabilidad, tanto en número de ítems como en método de implementación. CONCLUSIONES: El carácter multidisciplinar y el número de ítems de los protocolos ERAS conlleva una alta heterogeneidad en su implementación. Se requieren más estudios aleatorizados, estandarización a la hora de reportar y analizar resultados, así como un análisis sistemático de la adherencia posterior para aumentar la comparabilidad entre grupos

CONTEXT: The development of ERAS (Enhanced Recovery After Surgery) protocols in patients undergoing major surgery has brought perioperative benefits in several disciplines. Its main application in urology is focused on patients undergoing radical cystectomy. OBJECTIVE: Systematic review of the available literature on ERAS protocols applied to patients undergoing radical cystectomy in terms of perioperative outcomes as well in the analysis of their implementation. Evidence acquisition: A bibliographic search was conducted in the electronic databases PubMed, Embase, Cochrane and Scopus, using the terms «Cystectomy», «Enhanced Recovery After Surgery» and «Fast-Track». Randomized and non-randomized studies that compared the implementation of an ERAS protocol versus a traditional protocol in patients undergoing radical cystectomy were selected. Evidence synthesis: 869 articles were identified; 25 were selected for final analysis: 22 non-randomized and 3 randomized studies. No differences were observed in terms of demographic characteristics between studies. Statistically significant differences were identified in favor of the ERAS protocol: length of hospital stay, major complication rate, time to first ambulation and return of bowel function. In the analysis of protocols, a high variability was detected in the number of items and in the implementation method. CONCLUSIONS: The multidisciplinary nature and the number of items of the ERAS protocols imply a high heterogeneity in their implementation. Further randomized studies, standardized reporting and analyzing results, as well as a systematic analysis of subsequent adherence are required to increase comparability between groups

Implementation of ERAS (Enhanced Recovery After Surgery) protocols for radical cystectomy patients: The pathway to standardization. A systematic review. / Aplicación de protocolos ERAS (Enhanced Recovery After Surgery) en pacientes cistectomizados: el camino hacia la estandarización. Una revisión sistemática.

CONTEXT: The development of ERAS (Enhanced Recovery After Surgery) protocols in patients undergoing major surgery has brought perioperative benefits in several disciplines. Its main application in urology is focused on patients undergoing radical cystectomy. OBJECTIVE: Systematic review of the available literature on ERAS protocols applied to patients undergoing radical cystectomy in terms of perioperative outcomes as well in the analysis of their implementation. EVIDENCE ACQUISITION: A bibliographic search was conducted in the electronic databases PubMed, Embase, Cochrane and Scopus, using the terms «Cystectomy¼, «Enhanced Recovery After Surgery¼ and «Fast-Track¼. Randomized and non-randomized studies that compared the implementation of an ERAS protocol versus a traditional protocol in patients undergoing radical cystectomy were selected. EVIDENCE SYNTHESIS: 869 articles were identified; 25 were selected for final analysis: 22 non-randomized and 3 randomized studies. No differences were observed in terms of demographic characteristics between studies. Statistically significant differences were identified in favor of the ERAS protocol: length of hospital stay, major complication rate, time to first ambulation and return of bowel function. In the analysis of protocols, a high variability was detected in the number of items and in the implementation method. CONCLUSIONS: The multidisciplinary nature and the number of items of the ERAS protocols imply a high heterogeneity in their implementation. Further randomized studies, standardized reporting and analyzing results, as well as a systematic analysis of subsequent adherence are required to increase comparability between groups.

Valoración objetiva de la continencia urinaria precoz mediante el análisis y la visualización de variables intraoperatorias de prostatectomías radicales robóticas con un editor de vídeos / Objective assessment of early urinary continence by analysis and visualisation of intraoperative variables of radical robotic prostatectomies with a video editor

Introducción: La IU tras PR es uno de los factores con mayor impacto en la calidad de vida de los pacientes y en el gasto sanitario asociado. La definición de IU es muy variable en la literatura. De igual modo, son múltiples los factores predictores estudiados que influyen en la recuperación de la continencia posquirúrgica, siendo los más importantes los factores intraoperatorios. Material y métodos: Estudio retrospectivo y observacional, desde septiembre del 2008 hasta marzo del 2015. Se realiza el análisis de factores intraoperatorios mediante la visualización, con un editor de vídeos, de 148 pacientes tratados mediante prostatectomía radical asistida por robot, junto con otros factores perioperatorios asociados a la continencia y descritos en la literatura. Valoramos la continencia mediante cuestionarios ICQ, pérdidas urinarias contabilizadas con absorbentes y entrevista clínica en el primer, el tercer y el sexto mes, y al año de la cirugía. Definimos continencia como el no uso de absorbente o uno como protección social o ICQ ≤ 7. Analizamos mediante regresión logística binaria y lineal qué relación tienen las variables intraoperatorias y perioperatorias sobre la continencia urinaria medidas el primer, el tercer y el sexto mes, y al año de la cirugía, y sobre la estabilidad de la continencia. Resultados: En nuestro estudio el 72,9% de los pacientes conseguían estar continentes al año de la cirugía, con un tiempo medio de estabilización de la misma a los 4,3 meses. En nuestro análisis de regresión logística binaria de las variables intraoperatorias, no hemos encontrado una relación significativa con la variable continencia, analizadas durante el primer año. En el análisis de regresión logística lineal hemos encontrado que las suturas libres de tensión tienen un efecto directo positivo (p ≤ 0,05) sobre el tiempo de estabilidad de la continencia, al igual que las pérdidas urinarias medidas en el primer mes de la cirugía. Conclusión: En conclusión, en nuestro estudio encontramos que aquellas suturas libre de tensión pueden ayudar a la estabilidad precoz de la continencia. No hemos encontrado otros predictores intraoperatorios que influyan en la continencia urinaria. Las pérdidas urinarias medidas en el primer mes se relacionan con la recuperación precoz de la continencia

Introduction: UI after RP is a factor that has a major impact on patients' quality of life and the associated healthcare costs. The definition of UI is very variable in the literature. Similarly, a great many predictors have been studied that affect recovery of continence after surgery, the most important of which are intraoperative. Material and methods: a retrospective and observational study performed between September 2008 and March 2015. We studied intraoperative factors through visualisation using a video editor of 148 patients who underwent robot-assisted radical prostatectomy, together with other perioperative factors associated with continence, and described in the literature. We assessed continence through ICQ questionnaires, urinary loss calculated by pad count, and clinical interview in the first, third, sixth month and at one year after surgery. We defined continence as not having to use a pad or using a pad for protection socially, or an ICQ ≤ 7. We used binary and lineal logistic regression analysis to study the relationship between the intraoperative and perioperative variables on urinary continence measured at the first, third, sixth month and one year after the operation, and on continence stability. Results: In our study, 72.9% of the patients were continent at one year after surgery with a mean continence stabilisation time at 4.3 months. In our lineal logistic regression analyses we found no significant relationship with the continence variable analysed during the first year. In the lineal logistic regression analysis we found that tension-free sutures had a direct positive effect (P≤.05) on the stability time of continence, as well as the urinary losses measured in the first month after surgery. Conclusion: In conclusion, we found in our study that the tension-free sutures were able to help towards early stability of continence. We found no other intraoperative predictors that influenced urinary continence. The urinary losses measured in the first month related to early recovery of continence

Objective assessment of early urinary continence by analysis and visualisation of intraoperative variables of radical robotic prostatectomies with a video editor. / Valoración objetiva de la continencia urinaria precoz mediante el análisis y la visualización de variables intraoperatorias de prostatectomías radicales robóticas con un editor de vídeos.

INTRODUCTION: UI after RP is a factor that has a major impact on patients' quality of life and the associated healthcare costs. The definition of UI is very variable in the literature. Similarly, a great many predictors have been studied that affect recovery of continence after surgery, the most important of which are intraoperative. MATERIAL AND METHODS: a retrospective and observational study performed between September 2008 and March 2015. We studied intraoperative factors through visualisation using a video editor of 148 patients who underwent robot-assisted radical prostatectomy, together with other perioperative factors associated with continence, and described in the literature. We assessed continence through ICQ questionnaires, urinary loss calculated by pad count, and clinical interview in the first, third, sixth month and at one year after surgery. We defined continence as not having to use a pad or using a pad for protection socially, or an ICQ ≤ 7. We used binary and lineal logistic regression analysis to study the relationship between the intraoperative and perioperative variables on urinary continence measured at the first, third, sixth month and one year after the operation, and on continence stability. RESULTS: In our study, 72.9% of the patients were continent at one year after surgery with a mean continence stabilisation time at 4.3 months. In our lineal logistic regression analyses we found no significant relationship with the continence variable analysed during the first year. In the lineal logistic regression analysis we found that tension-free sutures had a direct positive effect (P≤.05) on the stability time of continence, as well as the urinary losses measured in the first month after surgery. CONCLUSION: In conclusion, we found in our study that the tension-free sutures were able to help towards early stability of continence. We found no other intraoperative predictors that influenced urinary continence. The urinary losses measured in the first month related to early recovery of continence.

Valor preventivo adyuvante del arándano rojo americano (proantocianidinas 120 mg) en las infecciones del tracto urinario tras la colocación de catéter ureteral / American cranberry (proanthocyanidin 120mg): Its value for the prevention of urinary tracts infections after ureteral catheter placement

Introducción: La infección del tracto urinario (ITU) representa una de las complicaciones más frecuentes tras los procedimientos sobre la vía urinaria, sobre todo si se requiere la colocación de un catéter. El tratamiento con arándano rojo se ha relacionado con una disminución del riesgo de ITU, pero hasta ahora no se ha realizado ningún estudio que valore si este efecto preventivo se produce en pacientes portadores de un catéter ureteral a nivel de la vía urinaria, que es el objetivo de este estudio. Material y métodos: Se trata de un ensayo prospectivo en el que se se comparó la tasa de ITU (urocultivo positivo) en 31 pacientes portadores de catéter doble J (JJ) y profilaxis con arándano rojo (120 mg) como adyuvante al tratamiento profiláctico habitual, con la tasa de ITU de 31 pacientes portadores de JJ que solo recibieron profilaxis habitual. Resultados: La caracterización de los pacientes no encontró diferencias significativas entre los 2 grupos. En el análisis de los factores de riesgo y la aparición de ITU, únicamente las variables tratamiento con arándano y tiempo de permanencia del JJ mostraron diferencias significativas. El tiempo de permanencia del catéter fue mayor en aquellos pacientes con ITU, 35,9 respecto a 28,5 días (p = 0,03), y el grupo tratado con arándano mostró un porcentaje de ITU menor que aquellos que no recibieron arándano, 12,9 y 38,7%, respectivamente (p = 0,04). Conclusiones. Podemos concluir que el arándano (120 mg) tiene un efecto adyuvante en la prevención de la ITU en pacientes portadores de JJ tras la cirugía

Introduction: Urinary tract infection (UTI) is among the most frequent complications after urinary tract surgical procedures, mainly when catheter placement is necessary. Although the use of American cranberry has been related with a reduced risk of UTI, there is no study reporting the value of its prevention effect against catheter-associated urinary tract infections. Material and methods: A prospective trial comparing UTI rate (positive urine culture) among 31 patients with double J catheter (JJ) and adding American cranberry (120 mg) in routine prophylactic therapy, and 31 patients with JJ catheter only receiving routine prophylactic therapy. Results: Regarding general characteristics of the populations no significant difference among groups have been found. Only significant differences have been observed when the variables “cranberry treatment” and “dwell time of JJ catheter” were related. “Dwell time of JJ catheter” was higher in patients with UTI (35.9 compared 28.5 days [P = .03]). UTI percentage was lower in cranberry supplemented patient group (12.9 compared to 38.7% [P = .04]). Conclusions: We can conclude that American cranberry (120 mg) has an adjuvant effect in the prevention of UTI in patients with JJ catheter after surgery

Tendencia en los tratamientos invasivos en la litiasis urinaria en un hospital de tercer nivel / Invasive treatment trends in urinary calculi in a third level hospital

Objetivo: En el siguiente trabajo se revisa la evolución de los diferentes tratamientos invasivos de la litiasis que se ha producido en nuestro hospital en los últimos 15 años. Material y método: Se han extraído de la base de datos de nuestro hospital los pacientes intervenidos de litotricia extracorpórea por ondas de choque (LEOC), de cirugía endoscópica y de cirugía abierta y se ha analizado cómo ha evolucionado la incidencia de estos tratamientos en los últimos 15 años. Así mismo se ha estudiado el número de publicaciones en PubMed que hacen referencia a los tratamientos invasivos de la litiasis. Resultados: Desde enero de 1998 hasta diciembre de 2012 se han tratado instrumentalmente de litiasis un total de 10.947 pacientes, 9.695 pacientes (90,4%) de LEOC y 1.034 pacientes de cirugía (9,6%), endoscópica o abierta. La incidencia de tratamientos con litotricia ha tenido su máximo en 2006, presentando posteriormente una disminución progresiva. La incidencia de la cirugía endoscópica ha aumentado progresivamente hasta 2009 para luego mantenerse. Vemos cómo en los últimos años existe un aumento claro de los artículos que tratan de cirugía endoscópica, disminuyendo los trabajos de LEOC. Conclusiones: La LEOC sigue siendo en nuestro medio el tratamiento invasivo para la litiasis más empleado. En los últimos años ha habido una disminución de los tratamientos de LEOC y un aumento de los tratamientos endoscópicos, presentando la cirugía abierta una clara tendencia a la baja

Objective: In the following study, we observe the progress of various invasive calculi treatments that have taken place in our hospital in the last 15 years. Material and method: We extracted data from our hospital database on patients who underwent extracorporeal shock wave lithotripsy (ESWL), endoscopic surgery and open surgery. We analyzed how the incidence of these treatments has evolved over the last 15 years. We also studied the number of publications in PubMed that reference invasive calculi treatments. Results: From January 1998 to December 2012, a total of 10,947 patients were treated instrumentally for lithiasis, 9,695 of whom (90.4%) underwent ESWL and 1,034 of whom underwent endoscopic or open surgery (9.6%). The incidence of lithotripsy treatments reached its maximum in 2006, with a progressive reduction thereafter. The incidence of endoscopic surgery increased progressively until 2009 and then leveled off. We can see how in recent years there has been a clear increase in the number of studies that have covered endoscopic surgery, with a decreasing number covering ESWL. Conclusions: In our community, ESWL remains the most widely used invasive treatment for calculi. In recent years, there has been a reduction in the number of ESWL treatments and an increase in the number of endoscopic treatments, with open surgery showing a clearly decreasing trend

Prevalence of pain and relative diagnostic performance of screening tools for neuropathic pain in cancer patients: A cross-sectional study.

BACKGROUND: Neuropathic pain can be overlooked in cancer patients. The advent of screening tools can help in recognizing it. However, little is known about their relative diagnostic performance and factors that affect it. This study evaluated the prevalence of neuropathic pain using several diagnostic strategies in cancer patients undergoing chemotherapy. METHODS: Patients attending the Oncology Unit of the investigators' site to continue their chemotherapy schedule were systematically screened for this cross-sectional study. Before starting chemotherapy drugs, pain specialists made a clinical diagnosis of neuropathic pain (either disease related, treatment related or comorbid) and medical oncologists administered three validated screening tools. Their relative diagnostic performance and the impact of some pain features on it were analysed using multivariate statistical methods. RESULTS: From a total of 358 patients, 194 (54.2%) suffered from pain and 73 (20.4%) had a clinical diagnosis of pure neuropathic or mixed pain. Among the screening tools, the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) was more specific (93.4%), although less sensitive (68.1%) than the Douleur Neuropathique in 4 Questions (DN4) (sensitivity: 87.5%, specificity: 88.4%). Interestingly, the specificities of these two instruments did not differ in patients with mild pain, while the DN4 remained to be more sensitive than the LANSS regardless of pain severity. CONCLUSIONS: Neuropathic pain is common in cancer patients undergoing chemotherapy. The DN4 might be of great help for the early detection of patients at risk because of incipient chemotherapy-related neuropathies and the LANSS to rule out neuropathic pain in patients with complex pain conditions.

American cranberry (proanthocyanidin 120 mg): its value for the prevention of urinary tracts infections after ureteral catheter placement.

INTRODUCTION: Urinary tract infection (UTI) is among the most frequent complications after urinary tract surgical procedures, mainly when catheter placement is necessary. Although the use of American cranberry has been related with a reduced risk of UTI, there is no study reporting the value of its prevention effect against catheter-associated urinary tract infections. MATERIAL AND METHODS: A prospective trial comparing UTI rate (positive urine culture) among 31 patients with double J catheter (JJ) and adding American cranberry (120 mg) in routine prophylactic therapy, and 31 patients with JJ catheter only receiving routine prophylactic therapy. RESULTS: Regarding general characteristics of the populations no significant difference among groups have been found. Only significant differences have been observed when the variables "cranberry treatment" and "dwell time of JJ catheter" were related. "Dwell time of JJ catheter" was higher in patients with UTI (35.9 compared 28.5 days [P=.03]). UTI percentage was lower in cranberry supplemented patient group (12.9 compared to 38.7% [P=.04]). CONCLUSIONS: We can conclude that American cranberry (120 mg) has an adjuvant effect in the prevention of UTI in patients with JJ catheter after surgery.

Invasive treatment trends in urinary calculi in a third level hospital.

OBJECTIVE: In the following study, we observe the progress of various invasive calculi treatments that have taken place in our hospital in the last 15 years. MATERIAL AND METHOD: We extracted data from our hospital database on patients who underwent extracorporeal shock wave lithotripsy (ESWL), endoscopic surgery and open surgery. We analyzed how the incidence of these treatments has evolved over the last 15 years. We also studied the number of publications in PubMed that reference invasive calculi treatments. RESULTS: From January 1998 to December 2012, a total of 10,947 patients were treated instrumentally for lithiasis, 9,695 of whom (90.4%) underwent ESWL and 1,034 of whom underwent endoscopic or open surgery (9.6%). The incidence of lithotripsy treatments reached its maximum in 2006, with a progressive reduction thereafter. The incidence of endoscopic surgery increased progressively until 2009 and then leveled off. We can see how in recent years there has been a clear increase in the number of studies that have covered endoscopic surgery, with a decreasing number covering ESWL. CONCLUSIONS: In our community, ESWL remains the most widely used invasive treatment for calculi. In recent years, there has been a reduction in the number of ESWL treatments and an increase in the number of endoscopic treatments, with open surgery showing a clearly decreasing trend.

[Extramedullary plasmacytoma and hypercalcemia]. / Plasmocitoma extramedular e hipercalcemia.

Extramedullary plasmocytoma (EMP) is an infrequent entity characterized by the proliferation of malignant plasma cells which are generally found on the mucosa of the upper respiratory tract. A case of EMP located in the right maxillary sinus is referred. Peculiarities of the same were resistance to radiotherapy with local relapse and severe hyperkalemia. Despite deliberate searching, disease dissemination could not be demonstrated.

[Oropharyngeal pemphigus vulgaris]. / Penfigo vulgar orofaringeo.

Etiologic and pathogenic as well the Pemphigus vulgaris is an autoimmune disease, being its symptomatology polysystemic. Accordingly, under the diagnostic viewpoint, must be considered as a multidisciplinary illness. Either the evolutive course, the differential diagnosis or the treatment emphasizes the importance of the attendance of these patients ambulatory or hospitalized. An exclusively ENT case of pemphigus vulgaris seen by the AA. compelled them to a perusal of the bibliography of the subject, in order to update the problems of diagnosis and treatment of the disease.

[Keratosis obturans]. / Keratosis obturans.

The Keratosis obturans is a disease localized in the EAC. It is an important pathology because its physiopathology differs from other analogous diseases of the same site, and has a clinical and pathological aspect uniform and peculiar, in spite of its evolutive course. The AA. review the bibliography and report their experience with the aim to define and classify this disorder.