[Clinical and analytical parameters that might indicate a second biopsy in patient with high PSA and previously negative biopsy]. / Parámetros clínicos y analíticos que indicarían la realización de una segunda biopsia en pacientes con PSAelevado y biopsia previa negativa.

OBJECTIVES: To determine what clinical, analytic and ultrasound parameters, are more effective to predict the result of a second biopsy in patient with high PSA and a first prostate biopsy negative. MATERIAL AND METHODS: It was carried out a longitudinal study in a series of 435 cases with negative prostate biopsy. In 59 of these cases it was practiced a second biopsy due to a permanent or sudden high PSA levels with or without a suspicious digital rectal examination. Of the 31 cases with a negative second biopsy, in 4 cases it was carried out a third biopsy. The biopsy was made in all the occasions by transrectal ultrasound guided sextant biopsy. It were also valued the ultrasound characteristic of the prostate, the prostate volume and the proportion of free PSA. RESULTS: It was demonstrated statistically significant differences among the patients with a second biopsy negative and positive regarding: the age, proportion of free PSA, abnormal digital rectal examination and presence of hipoechogenic areas in the prostate. The multivariate analysis demonstrated that the only significant parameters were the proportion of free PSA and the existence of an abnormal digital rectal examination. Based on the data of multivariate analysis, we settled down for the patients with normal digital rectal examination a cut-off point of 0.23 of proportion of free PSA as indication for the realization of a second biopsy, and of 0.59 for the patients with abnormal digital rectal examination. This protocol applied to our series would avoid the realization of a second biopsy in 8 patients, and a third biopsy in 1 patient, diagnosing all the cases of prostate cancer. CONCLUSIONS: The digital rectal examination associated with the proportion of free PSA constitutes a reliable parameter to indicate the realization of a second prostate biopsy in patient with high PSA and previous negative biopsy.

Parametros clínicos y analíticos que indicarían la realización de una segunda biopsia en pacientes con PSA elevado y biopsia previa negativa / Clinical and analytical parameters indicating the need of a second biopsy in patients with high PSA and earlier negative biopsy

OBJETIVOS: Determinar que parámetros clínicos, analíticos y ecográfícos resultan más eficaces para predecir el resultado de una segunda biopsia en pacientes con PSA elevado, y una primera biopsia prostática negativa.MATERIAL Y MÉTODOS: Se realizó un estudio longitudinal en una serie de 435 casos con biopsia negativa. En 59 de estos casos se practicó una SEGUNDA biopsia por mantenerse o aparecer un PSA elevado con o sin tacto rectal sospechoso. De los 31 casos en que esta segunda biopsia fue negativa, en 4 casos se realizó una tercera biopsia. La biopsia se efectuó en todas las ocasiones mediante control ecográfico, se valoraron además las características ecográficas de la próstata, el volumen prostático y la proporción de PSA libre.RESULTADOS: Se demostraron diferencias estadísticamente significativas entre los pacientes con una segunda biopsia negativa y positiva respecto a: la edad, proporción de PSA libre, tacto rectal anormal y presencia de áreas hipoecogénicas en la próstata. El análisis multivariante demostró que los únicos parámetros significativos fueron la proporción de PSA libre y la existencia de un tacto rectal anormal. Basándose en los datos del análisis multivariante se estableció para los pacientes con tacto rectal normal un punto de corte de 0,23 de proporción de PSA libre como indicación para la realización de una segunda biopsia, y de 0,59 para los pacientes con tacto rectal anormal. Este protocolo aplicado a nuestra serie evitaría la realización de una segunda biopsia en 8 pacientes, y de la tercera biopsia en 1 paciente, diagnosticando todos los casos de cáncer prostático.CONCLUSIONES: El tacto rectal combinado con la proporción de PSA libre constituye un parámetro fiable para indicar la realización de una segunda biopsia prostática en pacientes con PSA elevado y biopsia previa negativa (AU)

[Diagnostic algorithm based on a multivariate model to reduce the percentage of negative prostatic biopsies in patients with changed PSA or suspicious rectal palpation]. / Algoritmo diagnóstico basado en un modelo multivariante para reducir el porcentaje de biopsias prostáticas negativas en pacientes con PSA alterado o tacto rectal sospechoso.

OBJECTIVES: To determine what tests have a better diagnosis utility in patient with suspected prostate cancer due to PSA equal or greater than 4 ng/ml or abnormal digital rectal examination in order to reduce the number of negative prostate biopsies. MATERIAL AND METHODS: We carried out a ultrasound-guided sextant transrectal biopsy in a series of 400 patient with prostate-specific antigen (PSA) levels equal or greater than 4 ng/ml or abnormal digital rectal examination. All patients had also transrectal rectal ultrasonography to value the echographic prostatic characteristics and the prostatic volume, and a free PSA determination. RESULTS: The free/total PSA ratio (PSAl) and the PSA density (DPSA) were the most powerful predictors of prostate cancer, both with a 66% sensitivity and a 70% specificity (at a 0.15 cutoff), followed by the total PSA (PSAt), the digital rectal examination and the hypoechogenic prostatic nodules. We constructed a logistic multivariate model with these data. The outcome variable of logistic model was the probability of having prostate cancer. The significant predictive variables of the model were the PSAl, the DPSA, the digital rectal examination and the presence and extension of hypoechogenic prostatic. This model had a 81% sensitivity and 79% specificity at a 0.24 probability cutoff. We considered a 0.1 probability cutoff to reduce the number of false negative. With this strategy the sensitivity was 94% and the specificity 54%. If we had applied this model to the patient of our series then, we would be able to avoid prostate biopsy in 164 cases (the 41% of the patient), leaving only 7 cases without diagnosis of prostate cancer. CONCLUSIONS: The most effective combination parameters were the digital rectal examination, PSAl, presence and extension of prostatic hypoechogenic zones and DPSA. This combination allows us to diminish the percentage of negative prostate biopsy in patient with prostate-specific antigen (PSA) levels equal or greater than 4 ng/ml or abnormal digital rectal examination without significantly descending the number of detected prostate cancers.

Algoritmo diagnóstico basado en un modelo multivariante para reducir el porcentaje de biopsias prostáticas negativas en pacientes con psa alterado o tacto rectal sospechoso / Multivariate analysis based diagnosis algorithm for reducing the negative prostatic biopsies percentage in patients with elevated PSA level or abnormal digital rectal examination

OBJETIVOS: Determinar que pruebas tienen un mejor rendimiento diagnóstico en pacientes con sospecha de cáncer de próstata por PSA superior o igual a 4 ng/ml, o tacto rectal anormal, con el fin de disminuir el número de biopsias prostáticas negativas. MATERIAL Y MÉTODOS: Se realizó una biopsia transrectal ecodirigida en sextantes a una serie de 400 pacientes con PSA total superior o igual a 4 ng/ml, o tacto rectal sospechoso. En estos pacientes se valoró además las características ecográficas de la próstata, el volumen prostático y el PSA libre. RESULTADOS: Los parámetros de mayor rendimiento diagnóstico fueron la proporción de PSA libre (PSAl) y la densidad de PSA (DPSA), ambos con una sensibilidad del 66 por ciento y una especificidad del 70 por ciento (tomando como punto de corte óptimo un valor de 0,15), seguido del PSA total (PSAt), el tacto rectal y la presencia de zonas prostáticas hipoecoicas. Con estos datos se construyó un modelo logístico multivariante, siendo la variable resultado la probabilidad de presentar cáncer de próstata. Las variables predictivas significativas del modelo fueron el PSAl, la DPSA, el tacto rectal y la presencia y extensión de las zonas prostáticas hipoecoicas. Este modelo presentó una sensibilidad del 81 por ciento y una especificidad del 79 por ciento, tomando como punto de corte óptimo una probabilidad de padecer cáncer de próstata de 0,24. Con el fin de reducir el número de falsos negativos, se consideró como punto de corte del modelo una probabilidad del 0,1. Con este valor la sensibilidad fue del 94 por ciento y la especificidad del 54 por ciento. Si se hubiera aplicado este modelo al grupo de pacientes de nuestra serie se hubiera evitado la biop-sia en 164 casos (el 41 por ciento de los pacientes), dejándose sin diagnosticar únicamente 7 casos. CONCLUSIONES: La combinación de tacto rectal, PSAl, presencia y extensión de zonas hipoecoicas prostáticas y DPSA, permiten disminuir el porcentaje de biopsias en pacientes con PSAt superior o igual a 4 ng/ml, tacto rectal anormal, sin descender apreciablemente el número de cánceres de próstata detectados (AU)

[Multivariate analysis of graft survival prognostic factors in renal transplantation]. / Análisis multivariado de los factores pronósticos en la supervivencia del injerto en el trasplante renal.

OBJECTIVE: The aim of this paper is to identify the variables that could be of interest in the outcome of a series of cadaveric kidney transplantation performed at the University Hospital, Navarra School of Medicine, by means of multifactorial and multivariate statistical analyses. METHOD: We analyzed 307 cadaveric kidney transplantation performed since 1976 at the University Hospital, School of Medicine, University of Navarra. Two series are included: the historical and the actual. The former did not include cyclosporine A in the immunosuppressor protocol. RESULTS: The first step was to compare survival in both series. The cyclosporine A series had a better survival, which was statistically significant (p < 0.0001). The prognostic factors in both series were also analyzed. The influence of the different variables were studied in the survival distribution. The worse prognostic variables of the historical group on allograft survival were donor's age (particularly between 20 and 50 years old), delayed graft function, serum creatinine level greater than 2.5 mg/dl at the first month following transplantation, general surgical complications, and vascular and other complications. In the actual group, the allografts with the worst survival were in those that received 4-10 pre-transplant blood transfusions, those with more that 2 HLA-DR mismatches, the hyperimmunized receptors with a level of pre-formed cytotoxic antibodies greater than 50%, those who rejected the allograft in the initial post-transplant period, those with a serum creatinine level greater than 2.5 mg/dl and those who presented surgical complications in general and urinary and vascular complications in particular. CONCLUSIONS: The multivariate analysis reveals that the prognostic factors of the historical group were delayed graft function, surgical complications, HLA A+B mismatches and the donor's age. In the actual group, the factors were receptor's age, surgical complications, large ischemia time, peak reactive antibody and number of rejections.

[Multivariate analysis of the impact of surgical complications in renal transplant]. / Análisis multivariado del impacto de las complicaciones quirúrgicas en el trasplante renal.

We analyzed 307 cadaver kidney transplantations performed since 1976 at the University Hospital of the University of Navarra. Two series, the historical and the current one, are presented. In the former, cyclosporine A was not included in the immunosuppressor protocol. The surgical complications were evaluated in both series and their influence on the survival of the allograft. The current series showed a significant decrease in surgical complications. Allograft survival in the historical series was influenced by surgical complications in general, and vascular and other complications in particular. The current series was influenced by surgical complications in general, and urinary and vascular complications in particular. The multivariate analysis showed that surgical complications were one of the most important prognostic factor in both series.

[Advanced germinal tumors of the testicle: clinical experience with cisplatin, bleomycin and vinblastine (PVB) or etoposide (BEP)]. / Tumores germinales avanzados de testículo: experiencia clínica con cisplatino, bleomicina y vinblastina (PVB) o etoposido (BEP).

Thirty previously untreated patients with advanced germ cell testicular tumours received PVB or BEP. Four patients with bulky disease underwent debulking surgery before initiating chemotherapy and two between cycles of treatment. Twenty-seven (90%) complete responses, two (6.7%) partial responses and one (3.3%) no changes were observed. Both partial remissions were rendered disease-free with surgical removal of residual disease. Four patients presented tumour progression with PVB or BEP, three of whom developed a non-germ cell malignancy within the germ cell tumour. One toxic death and three patients with radiological evidence of reversible interstitial pneumonitis attributed to bleomycin were observed. With a median follow-up time of 38.5 months, range 2.5 to 130 months, 83.3% of the patients are alive and free of disease. Actuarial overall survival is 85.6%. This study confirms once again the high percentage of curability of this disease.

[Pure squamous carcinoma of the ureter. Review of a case]. / Carcinoma escamoso puro de uréter. Revisión de un caso.

We report a case of squamous cell carcinoma of the ureter with periureteral infiltration. Three years following radical surgery, no evidence of tumor progression has been observed. Only 1% to 1.6% of urothelial tumors of the upper urinary tract are purely squamous cell tumors. This tumor type carries a poor prognosis. Currently, the best results can be achieved by early diagnosis and radical surgery.

[Tumor thrombosis in inferior vena cava: diagnostic imaging and therapeutic approximation]. / Trombosis tumoral en vena cava inferior (TTVCI): diagnóstico por imagen y aproximación terapéutica.

Review of our experience in the diagnosis and treatment of 44 patients with inferior vena cava tumoral thrombosis (IVCTT), associated or not to other neoplastic processes: 34 hypernephroma, 2 cava leiomyosarcoma, 1 paratesticular rhabdomyosarcoma and 1 biphasic synovial sarcoma. Twenty-five patients with hypernephroma and tumor thrombi in the ipsilateral renal vein only were excluded from the analysis since this fact did not change the usual therapeutic approach. In the 19 remaining patients, concomitantly to the primary tumour exeresis a thrombectomy was performed, using cavotomy with proximal and distal clamping in 11 patients and cardiopulmonary by-pass, deep hypothermia and cardiocirculatory arrest in 8 patients. The paper analyzes the radiological investigations performed in order to reach a IVCTT diagnosis, and reviews the related literature.

[Vascular complications in 237 recipients of renal transplant from cadaver]. / Complicaciones vasculares en 237 receptores de trasplante renal de cadáver.

Between July 1976 and June 1990, 244 transplantations were performed. Of the 237 patients monitored, 13 (5.4%) had vascular complications: 10 (77%) renal artery stenosis, 1 (7.7%) primitive iliac artery stenosis, 1(7.7%) renal artery thrombosis, 1 (7.7%) renal vein thrombosis. Six patients underwent surgery (Angioplasty was performed in three patients, re-anastomosis to the common iliac artery in one, by-pass of saphenous vein in another one, while in the last one it was tried a release of the vascular pediculus). Management with drugs was possible in one case. At present, 11 of the 13 patients are still alive and three of the grafts remain functional after a mean follow-up time of 83 months. According to a univariate study, the influential factors in the development of vascular complications are, the identity of Locus A, the type of extraction in Locus B, the length of cold ischaemia, the type of vascular anastomosis and the number of previous rejections. The factors with maximal influence in the development of complications are the type of vascular suture (with or without patch) and the number of previous rejections (according to a study of log regression models). The study demonstrates the significant influence vascular complications have on the graft's durability (p = 0.005).

[Infiltrating bladder carcinoma with metastatic lymph node involvement: radical treatment and survival]. / Carcinoma vesical infiltrante con afectación ganglionar metastásica: tratamiento radical y supervivencia.

Presentation of the results obtained from the study of 64 patients with T2-4 stage vesical carcinoma, treated with radical cystectomy, local lymphadenectomy, with and without complementary radiotherapy, with and without neoadjuvant chemotherapy. The univariate study of 19/64 patients with microscopic nodular disease revealed a significant relationship with the pathological stage but not with the clinical stage. The multivariate study demonstrated that the most relevant prognostic factors are a decrease in tumoral stage (P) and the presence of vascular and/or lymphatic involvement in the TUR-biopsy. The analysis of survival confirms the poor prognosis of patients with metastatic nodular involvement, in spite of the association of pelvic radiotherapy or neoadjuvant chemotherapy to the treatment.

[Tumors of the upper urothelium and cyclophosphamide: presentation of a case and review of the literature]. / Tumores de urotelio superior y ciclofosfamida: presentación de un caso y revisión de la literatura.

We report a case of upper urothelial tumor in a patient who had previously received prolonged cyclophosphamide therapy for Waldeström's macroglobulinemia. Although bladder tumors in cyclophosphamide-treated patients are relatively frequent, upper urothelial tumors are rare. Only 5 cases of this latter tumor type have been reported as of 1987. The literature on this disease entity is reviewed. Patients who have received prolonged therapy with cyclophosphamide or similar drugs must be followed very closely.

[Paratesticular rhabdomyosarcoma with intracaval neoplastic involvement: presentation of a case and review of the literature]. / Rabdomiosarcoma paratesticular con afectación tumoral intracava: presentación de un caso y revisión de la literatura.

One case of paratesticular embryonal rhabdomyosarcoma (RMS), affected during its evolution by a tumoral thrombus in the inferior vena cava. This unusual association forced the use of a cardiopulmonary by-pass, profound hypothermia and circulatory arrest, in order to carry out complete exeresis of the damage. Also, revision of the literature emphasizing that today's therapeutical approach for RMS should essentially be multidisciplinary.

[Hyperammonemia and transient blindness after transurethral resection of the prostate. Review of a case]. / Hiperamonemia y ceguera transitoria post resección transuretral de próstata. Revisión de un caso.

We report a case of hyperammonemia and transient blindness following transurethral prostatic resectin. Glicine and ammonia metabolism are reviewed. Water intoxication may not account for these symptoms.

[Uretero-iliac fistula: presentation of a case and review of the literature]. / Fístula uretero-ilíaca: presentación de un caso y revisión de la literatura.

We report a case of right common iliac artery fistula to the left ureter in a patient affected by an invasive bladder tumour treated with radical surgery, radiotherapy and neo-adjuvant chemotherapy. At the time of manifestation, our patient had indwelling catheters and presented an urinary tract infection. Diagnosis was established during autopsy. We feel that the cause of this complication is multifactorial.

[Neoadjuvant immunotherapy in non-metastatic renal adenocarcinoma]. / Inmunoterapia con fines neoadyuvantes en el adenocarcinoma renal no metastásico.

Prognostic factors were studied in 91 patients with diagnosed renal adenocarcinoma in stages pT1-4/N0-3/V0-2/M0. All patients had been treated with radical surgery, extended nephrectomy with or without cardiopulmonary by-pass and extracorporeal circulation in those cases with suprahepatic tumoral thrombosis. The tumoral features which have a significant incidence on the patient's survival rate are the degree of cellular anaplasia, GI 72% vs GII 42% vs GIII 22% (p less than 0.0001); pathological stage, pT1-2 86% vs pT3 30% (p = 0.0000), perirenal fat invasion, pT1-2 86% vs pT3a 61% (p = 0.01); renal vein or cava vein invasion, V0 72% vs V1-2 30% (p less than 0.01) and gangliar affection. N0 69% vs N1-3 11% (p = 0.0000). Development of systemic disease is significantly high in pT3 stages (p = 0.0001), mainly in pT3a (p = 0.01), N1-3 (p less than 0.05) and/or V1-2 (p = 0.01). There is premature development of metastasis conditioning death before the second year o study in 90% of patients. In our opinion, patients with renal adenocarcinoma in stages pT3a/N0/M0, pT3b/N0/M0 and pT2-4/N1-3/M0 present a high potential risk of developing metastatic disease following radical surgery. These patients, as well as those with high degree tumours and presumably minimum residual disease, are candidates for supplementary therapy with lymphokine immunotherapy (rIL-2,FNT, alpha or gamma IF, etc) with or without adoptive cellular immunotherapy (LAK or TIL) following radical surgery, and extended nephrectomy plus tumoral thrombectomy, if required, with or without cardiopulmonary bypass.

[Tumor of the upper urothelium: radical treatment and prognostic factors]. / Tumores de urotelio superior: tratamiento radical y factores pronósticos.

The paper presents the results obtained from a study of 28 patients with high urothelial tumour, treated with radical surgery (total nephroureterectomy). Multivariable study of survival rates (Cox models) indicates that cellular differentiation is the most significant prognostic factor. Single variable study indicates that tumour stage has some significance mainly due to the large relationship to the degree of cellular anaplasty.

[Extracorporeal shockwave lithotripsy (ESWL) for the treatment of bladder lithiasis. A new therapeutic option]. / Litotricia extracorpórea por ondas de choque (L.E.O.C.) en el tratamiento de la litiasis vesical. Una nueva opción terapéutica.

A case is presented on the use of extracorporeal lithotrity by shock waves to treat vesical lithiasis, using the desk module of a Lithostar-PlusR (Siemens) lithotripter. This is an effective method without morbidity an adequate for ambulatory use, specially valuable in patients where the use of more invasive methods, or surgery can be contraindicated or when the patient refuses such methods.

[Cardiopulmonary by-pass with cardiac arrest and deep hypothermia for the surgical treatment of tumor thrombi in the vena cava caused by kidney carcinoma]. / By-pass cardiopulmonar con parada cardiocirculatoria e hipotermia profunda en el tratamiento quirúrgico de trombos tumorales en vena cava por carcinoma renal.

The by-pass technique with controlled cardiac arrest and hypothermia is probably the best method for an extirpation of intracava tumoral thrombi in renal tumours. The technique is easy to perform, represents a great help in the extirpation of thrombi regardless their size and location, and avoids massive bleeding.

[Stage Ta/T2 bladder tumors: prognostic and clinical course factors]. / Tumores vesicales estadío Ta/T2: factores pronóstico y progresión.

One hundred and twenty-three patients with a Ta/T2 stage vesical tumour were studied in order to identify the histological aspects associated to a tumoral behaviour particularly aggressive. The multivariate study demonstrates that those patients with a infiltrating tumour (T1-T2) or diffused urothelial dysplasia, have specially high possibilities to progress with regard to the degree of cell anaplasia (p less than 0.05); very close follow-up is needed in those patients. Likewise, patients presenting disseminated dysplastic lesions and with a history of previous urothelial tumours, progress to a new tumour stage with a significantly higher frequency (p less than 0.01); in those cases, radical surgery is the choice treatment.