[Urogenital alterations in hereditary and sporadic neurodegenerative ataxias]. / Alteraciones urogenitales en las ataxias neurodegenerativas hereditarias y esporádicas.

INTRODUCTION: Sporadic and hereditary ataxias (HA) represent a group of clinically and genetically heterogeneous syndromes characterized by spinocerebellar degeneration producing a motoneuron coordination disorder. In these diseases urinary and sexual symptoms are commonly associated to the neurological alterations. OBJECTIVE: To define the prevalence of functional low urinary tract symptoms in an ataxic population and to compare them with the symptomatology control a group of in healthy subjects. PATIENTS AND METHODS: An observational, descriptive, transversal study of 491 subjects recruited from the HA regional associations of Spain was conducted. In addition, a case-control study of prevalent ataxic patients and healthy subjects matched by sex and age was also performed. RESULTS: Among 195 patients included, 138 (70.8 %) had Friedreich ataxia (FA) and 57 (29.2 %) non-Friedreich ataxia (nFA). Global mean age was 32.3 years in FA and 43.7 in nFA patients (p < 0.05). Combined irritative and obstructive symptoms were present in 48.7 %, only irritative in 16.4 % and obstructive in 15 % of patients. Erectile dysfunction in 30.3 % (p < 0.01) and decreased libido in 13.4 % (p < 0.01), were the most common sexual problems. CONCLUSIONS: In HA, urinary symptoms are present in 80 % of patients, with mainly irritative symptoms in 2/3 of them. A complete urodynamic evaluation in symptomatic patients is recommended in order to characterize potential neurogenic vesico-urethral dysfunction. Even though sexual dysfunction may be related to neurological causes, additional etiologic organic factors should be excluded.

Alteraciones urogenitales en las ataxias neurodegenerativas hereditarias y esporádicas / Urogenital alterations in hereditary and sporadic neurodegenerative ataxias

Introducción. Las ataxias hereditarias (AH) y esporádicas comprenden un grupo de síndromes clínica y genéticamente heterogéneos, caracterizados por un trastorno variable de coordinación motora secundario a degeneración espinocerebelosa. Cabe esperar, como en otras enfermedades neurológicas, que junto al cuadro clínico neurológico se asocien síntomas urinarios y sexuales. Objetivo. Conocer la prevalencia de síntomas urinarios y sexuales en una población definida de pacientes atáxicos respecto a un grupo control de sujetos sanos. Pacientes y métodos. Estudio observacional, descriptivo, de corte transversal sobre una muestra de pacientes atáxicos pertenecientes a las asociaciones regionales de AH en España. Los sujetos a estudio fueron evaluados mediante un cuestionario de síntomas. Se trata de un estudio comparativo caso-control sobre una serie de casos prevalentes de sujetos atáxicos y un grupo control de población sana, pareado por sexo y edad. Conceptualmente se investiga la situación clínica referida a abril de 2002, aunque la recogida de información se prolongó durante 6 meses. Resultados. En abril de 2002 estaban asociados en España 491 pacientes atáxicos. Disponemos de datos sobre 195 pacientes, de los que 138 (70,8 %) eran ataxias de Friedreich (AF) y 57 (29,2 %) ataxias no Friedreich (NF). Edad media global de la AF era de 32,3 años frente a los 43,7 años de las NF (p < 0,05). En su evolución presentaron síndrome urinario mixto el 48,7 %, síntomas urinarios irritativos el 16,4 % y síntomas urinarios obstructivos el 14,9 %. Los trastornos sexuales más frecuentes en varones fueron disfunción eréctil (30,3 %) (p < 0,01) y disminución del deseo sexual (13,4 %) (p < 0,01). Conclusiones. En las AH neurodegenerativas pueden presentarse síntomas urinarios leves o moderados en un alto porcentaje de pacientes, predominando los síntomas urinarios irritativos. Recomendamos estudio urodinámico completo en pacientes sintomáticos con objeto de caracterizar la posible disfunción neurógena vesicouretral. Aunque la disfunción sexual puede atribuirse a fenómeno neurológico, existen otros factores orgánicos involucrados en su patogenia, lo que implica un enfoque multidisciplinar

Introduction. Sporadic and hereditary ataxias (HA) represent a group of clineally and genetically heterogeneous syndromes characterized by espinocerebellar degeneration producing a motoneuron coordination disorder. In these diseases urinary and sexual symptoms are commonly associated to the neurological alterations. Objective. To define the prevalence of functional low urinary tract symptoms in an ataxic population and to compare them with the symptomatology control a group of in healthy subjects. Patients and methods. An observational, descriptive, transversal study of 491 subjects recruited from the HA regional associations of Spain was conducted. In addition, a case-control study of prevalent ataxic patients and healthy subjects matched by sex and age was also performed. Results. Among 195 patients included, 138 (70.8 %) had Friedreich ataxia (FA) and 57 (29.2 %) non-Friedreich ataxia (nFA). Global mean age was 32.3 years in FA and 43.7 in nFA patients (p<0.05). Combined irritative and obstructive symptoms were present in 48.7 %, only irritative in 16.4 % and obstructive in 15 % of patients. Erectile dysfunction in 30.3 % (p < 0.01) and decreased libido in 13.4 % (p < 0.01), were the most common sexual problems. Conclusions. In HA, urinary symptoms are present in 80 % of patients, with mainly irritative symptoms in 2/3 of them. A complete urodynamic evaluation in symptomatic patients is recommended in order to characterize potential neurogenic vesico-urethral dysfunction. Even though sexual dysfunction may be related to neurological causes, additional etiologic organic factors should be excluded

[Therapeutic options for patients with localized prostatic carcinoma: our experience with 454 patients]. / Alternativas terapéuticas en el cáncer de próstata localizado. Experiencia sobre 454 pacientes.

OBJECTIVES: To evaluate the influence of different therapeutic options on progression-free survival (PFS), overall survival (OS) and specific survival (SS) in a cohort of 454 patients with localized prostatic carcinoma, taking into account different prognostic factors, and to compare our results to those reported in the world literature. MATERIAL AND METHODS: Between 1983 and 2000 we have diagnosed 706 new cases of prostatic carcinoma and 454 were clinically localized tumors. The different therapeutic options employed in our series of patients have been: follow-up (FU) (103 patients); radical prostatectomy (RP) (108 patients); radiotherapy without hormonal blockade (RT) (148 patients); and hormonal blockade (HB) (95 patients). We have determined the PFS, the OS and the SS for each group of patients and compared them in patients with different prognostic factors at the time of diagnosis, including age, PSA levels, Gleason's grading and TNM staging. We have also analysed the influence of the tumor progression on the OS. The mean follow-up time has been 5.6 years (range: 0.1-19.2; median: 5.2). RESULTS: For PFS: the disease progressed in 145 patients (32%) and the PFS at 5 and 10 years has been 77% and 67% for FU; 61% and 50% for RP; 63% and 25% for RT; and 73% and 67% for HB, respectively. The differences between RT and RP were not statistically significant. For the subgroup of patients with PSA levels <10 and Gleason <8 the differences between FU, RP and RT did not reach statistical significance. For OS: 126 patients of our series died (28%) and the OS at 5 and 10 years has been 80% and 61% for FU; 90% and 76% for RP; 85% and 67% for RT; and 64% and 32% for HB, respectively. We have found no significant differences between FU, RP and RT. For SS: 31 patients of our series died of disease (6.8%). The SS at 5 and 10 years has been 100% and 94% for FU; 98% and 98% for RP; 97% and 88% for RT; and 83% and 77% for HB, respectively. We have found no significant differences in the OS between patients with disease progression and without disease progression treated with FU, RP and RT. CONCLUSIONS: Determination of PSA levels has allowed diagnosis of prostatic carcinomas in early stages of disease; however, our results and those reported in the literature cannot define which is the best therapeutic option in these patients. We should offer the patients individualized information both in the phase of early diagnosis and of therapeutic decisions.

Alternativas terapéuticas en el cáncer de próstata localizado. Experiencia sobre 454 pacientes / Therapeutic options for patients uit localized prostatic carcinoma: our experience with 454 patients

OBJETIVOS: Evaluar en una cohorte de 454 pacientes con cáncer de próstata no diseminado tratados con diversas alternativas terapéuticas la supervivencia libre de progresión (SLP), supervivencia global (SG) y supervivencia específica (SE) en función de distintos factores pronósticos y comparar nuestros resultados con la bibliografía. MATERIAL Y MÉTODOS: Entre 1983 y 2000 hemos diagnosticado 706 pacientes de cáncer de próstata, de los que 454 eran clínicamente tumores no diseminados. Los tratamientos utilizados para estos 454 pacientes han sido: observación (OBS) (103 pacientes), prostatectomía radical (PR) (108), radioterapia no asociada a tratamiento hormonal (RT) (148) y bloqueo hormonal (BH) (95). Hemos analizado la SLP, SG y SE en cada grupo y comparativamente en función de distintos factores pronósticos en el momento del diagnóstico: edad, PSA, Gleason y estadio. También analizamos la repercusión de la progresión en la SG. El seguimiento medio ha sido de 5,6 años (0,1-19,2 años; mediana 5,2). RESULTADOS: SLP: han progresado 145 pacientes (32%), a 5 años la SLP para OBS: 77%, PR: 61%, RT: 63%, BH: 73%. A 10 años: 67, 50, 25 y 67%, respectivamente. No diferencias significativas entre PR y RT. En pacientes con PSA <10 y Gleason <8 no diferencias entre OBS, PR y RT. SG: han fallecido 126 pacientes (28%), a 5 años la SG fue: 80, 90, 85 y 64% y a 10 años: 61, 76, 67 y 32%. No diferencias entre OBS, PR y RT. SE: han fallecido por su tumor 31 (6,8%). SE a 5 años: 100, 98, 97 y 83%. A 10 años: 94, 98, 88 y 77%. No diferencias en la SG entre los pacientes en progresión comparados con los pacientes sin progresión tumoral en los tratados con OBS, PR y RT. CONCLUSIONES: La determinación del antígeno PSA ha trasladado el diagnóstico del cáncer de próstata a estadios muy precoces, sin embargo nuestros datos y la revisión de la bibliografía no permiten definir cual es la mejor estrategia terapéutica incluyendo la alternativa observacional. Debemos dar la suficiente información individualizada tanto en la fase de diagnóstico precoz como a la hora de decidir un tratamiento

OBJECTIVES: To evaluate the influence of different therapeutic options on progression-free survival (PFS), overall survival (OS) and specific survival (SS) in a cohort of 454 patients with localized prostatic carcinoma, taking into account different prognostic factors, and to compare our results to those reported in the world literature. MATERIAL AND METHODS: Between 1983 and 2000 we have diagnosed 706 new cases of prostatic carcinoma and 454 were clinically localized tumors. The different therapeutic options employed in our series of patients have been: follow-up (FU) (103 patients); radical prostatectomy (RP) (108 patients); radiotherapy without hormonal blockade (RT) (148 patients); and hormonal blockade (HB) (95 patients). We have determined the PFS, the OS and the SS for each group of patients and compared them in patients with different prognostic factors at the time of diagnosis, including age, PSA levels, Gleason’s grading and TNM staging. We have also analysed the influence of the tumor progression on the OS. The mean follow-up time has been 5.6 years (range: 0.1-19.2; median: 5.2). RESULTS: For PFS: the disease progressed in 145 patients (32%) and the PFS at 5 and 10 years has been 77% and 67% for FU; 61% and 50% for RP; 63% and 25% for RT; and 73% and 67% for HB, respectively. The differences between RT and RP were not statistically significant. For the subgroup of patients with PSA levels <10 and Gleason <8 the differences between FU, RP and RT did not reach statistical significance. For OS: 126 patients of our series died (28%) and the OS at 5 and 10 years has been 80% and 61% for FU; 90% and 76% for RP; 85% and 67% for RT; and 64% and 32% for HB, respectively. We have found no significant differences between FU, RPand RT. For SS: 31 patients of our series died of disease (6.8%). The SS at 5 and 10 years has been 100% and 94% for FU; 98% and 98% for RP; 97% and 88% for RT; and 83% and 77% for HB, respectively. We have found no significant differences in the OS between patients with disease progression and without disease progression treated with FU, RP and RT. CONCLUSIONS: Determination of PSA levels has allowed diagnosis of prostatic carcinomas in early stages of disease; however, our results and those reported in the literature cannot define which is the best therapeutic option in these patients. We should offer the patients individualized information both in the phase of early diagnosis and of therapeutic decisions

[Treatment approach for vesicogenital fistula. Retrospective analysis of our data]. / Planteamiento terapéutico de las fístulas vesicogenitales. Análisis retrospectivo de nuestra serie.

The vesicogenital fistula are abnormal communications between female genitalia and urinary bladder. We recorded all the vesicogenital fistula diagnosed since 1986, analyzing aetiology, treatment applied, complications and results. Total number of fistula have been 20 (18 vesicovaginal and 2 vesicouterine). The distribution in vesicovaginal fistula was iatrogenic in 15 cases (83%) and tumoral in 3 cases (17%). Vesicouterine fistula were due to cesarean. The initial treatment of the iatrogenic fistula was conservative using foley catheter. Twenty percent of the patients were cured with this treatment (3 cases). Surgical repair was necessary for the other patients, using different surgical approach according to the type of the fistula, intensity and patient age. It was successful in 91% of the patients. The results shows that simple surgical approach generate less morbidity and the early intervention is not less efficient.

[The prostate cancer in the community of Madrid in 2000 I.- Incidence]. / El cáncer de próstata en la Comunidad de Madrid en el año 2000. I--Incidencia.

OBJECTIVE: To know the incidence in the year 2000 of prostate cancer in the Autonomous Community of Madrid and its breakdown by Health Areas. MATERIAL AND METHOD: Study of histologically confirmed prostate cancer case reports and retrospective data acquisition for 2000 in the Autonomous Community of Madrid, both from Public and Private Health Care hospitals. RESULTS: Gross incidence of prostate cancer in the Autonomous Community of Madrid was 100.4 cases per 100,000 males. The incidence adjusted for the Spanish, European and Worldwide population was 120.1, 103.5 and 68.6 cases per 100,000 males, respectively. Mean age at diagnosis was 70 +/- 7.8 (40-94) years, median of 70 years. The age group with higher incidence was 70 to 79 years. CONCLUSIONS: The incidence of prostate cancer in the Autonomous Community of Madrid is lower than that in the US but higher than in most countries or regions in the EU. The different way of using PSA testing in the Health Areas of the Autonomous Community may explain the differences seen in terms of incidence by Area.

[The prostate cancer in the community of Madrid in 2000. II Presentation and diagnosis]. / El cáncer de próstata en la Comunidad de Madrid en el año 2000. II--Presentación y diagnóstico.

OBJECTIVE: To know the presentation form, diagnostic method and clinical stage at the time of diagnosis in subjects with prostate cancer (PC) in the Autonomous Community of Madrid in 2000. MATERIAL AND METHOD: Data from 1745 patients with histologically confirmed prostate cancer obtained from 15 Hospitals participating in the study was analysed. The variables studied were: associated disease, reason for visiting the hospital, digital rectal examination (DRE), PSA, diagnostic method, graded Gleason score, tests performed in the tumoral extension study and tumour staging. The qualitative variables are given in percentages of the overall number and the quantitative variables are expressed as the median, standard deviation, maximum and minimum values and 25%, 50% (median) and 75% percentiles. RESULTS: 67% cases had an associated disease. In most (75%) patients the reason for visiting the hospital was prostatic syndrome. DRE revealed that 42.7% has no tumour. At the time of diagnosis half the patients had PSA levels lower than or equal to 11 ng/ml. Transrectal ultrasound-guided biopsy was used for diagnosis in 93% subjects. The most commonly reported Gleason scores were 6 (31.3%) and 7 (28.7%). In 75% subjects the disease was considered to be clinically limited to the prostate, in 12.5% locally advanced and in 12.5% metastatic. CONCLUSIONS: Most patients came to the hospital because of symptoms not related to PC. Transrectal ultrasound-guided biopsy is confirmed as the choice technique for PC diagnosis. When a comparison is made to historical series in our Autonomous Community a pattern of earlier diagnosis can be seen.

[Prostate cancer in the Community of Madrid in the year 2000. III. Study of tumor extent]. / El cáncer de próstata en la Comunidad de Madrid en el año 2000. III--Estudio de extensión tumoral.

OBJECTIVE: To identify a potential relationship between two variables, risk of metastasis and use of imaging techniques, in an extension study in prostate cancer patients diagnosed in the Autonomous Community of Madrid in 2000. MATERIAL AND METHODS: 1,127 patients with available data on the tumour extension study were analysed. Performance and non performance of bone scans and CTs were correlated to risk variables for developing metastasis as described in the literature (PSA, Gleason and stage) and to therapy administered. RESULTS: The proportion of patients with risk variables for metastasis when bone scans were performed was between 7% to 14% greater than in patients with no variables. No differences were seen for CTs based on risk variables. With matching risk variables, more imaging techniques were used in patients receiving radiotherapy that in those managed with prostatectomy. CONCLUSION: Based on current recommendations imaging techniques were used in excess in the extension study in patients with no risk variables for metastasis. Conduct of a further study in the Autonomous Community seems advisable to confirm the likelihood of implementing such recommendations considering our prevalence of metastatic disease.

[Prostate cancer in the Community of Madrid in the year 2000. IV. Treatment]. / El cáncer de próstata en la Comunidad de Madrid en el año 2000. IV Tratamiento.

OBJECTIVE: To know the therapeutic options used in patients diagnosed with prostate cancer in the Autonomous Community of Madrid in 2000. MATERIAL AND METHODS: The study was conducted on 1,745 patients referred by hospitals taking part in the study. Data on treatment used was available for 1,104 (63%) patients. Treatment modality was correlated to clinical stage and patient age. RESULTS: Most frequent choice was hormone therapy (35%) followed by radical prostatectomy (34%) and radiotherapy (25%). Prostatectomy was most commonly used in patients with localised (42.3%) disease while hormone therapy was preferred for locally advanced (45.6%) or disseminated (94%) disease. There are significant differences in therapeutic indications between the various Health areas participating in the survey. Median age of patients with localised and locally advanced disease was lower in patients managed with prostatectomy (65 and 64 years, respectively) than in those managed with radiotherapy (70 and 69 years, respectively). CONCLUSION: The therapeutic modality indicated by urologists in the Madrid Autonomous Community for managing patients with prostate cancer generally meets with literature recommendations.

Planteamiento terapéutico de las fístulas vesicogenitales. Análisis retrospectivode nuestra serie / Treatment approach for vesicogenital fistula. Restrospective analysis of our data

Las fístulas vesicogenitales son comunicaciones anómalas de la vejiga urinaria con cualquier parte del aparato genital femenino. En el presente trabajo analizamos nuestra serie de fístulas vesicogenitales diagnosticadas y tratadas desde 1986, analizando las causas etiológicas, tratamientos aplicados, complicaciones y resultados de los mismos.El número total de fístulas han sido 20 (18 vesicovaginales y 2 vesicouterinas). De las fístulas vesicovaginales 15 (83 por ciento) eran yatrógenas y 3 (17 por ciento) neoplásicas. Las fístulas vesicouterinas aparecieron tras sendas cesáreas.El tratamiento inicial de las fístulas yatrógenas fue conservador con sondaje vesical, produciéndose su resolución en el 20 por ciento de las mismas (3 casos). En el resto de las pacientes se realizó tratamiento quirúrgico por vía abdominal con distintas técnicas según el tipo de fístula, intensidad y edad de la paciente, resultando satisfactorio en el 91 por ciento de los casos. La utilización de técnicas sencillas que generan menor morbilidad así como la actuación precoz no implica un peor resultado en las fístulas yatrógenas simples. (AU)

El cáncer de próstata en la Comunidad de Madrid en el año 2000. IV Tratamiento / Prostate cancer in the autonomous community of Madrid in 2000. IV.- Management

Clásicamente ha existido gran controversia entre el psoriasis pustuloso generalizado del embarazo y el impetigo herpetiforme. Presentamos el caso de una mujer de 34 años que en su segunda gestación desarrolla un cuadro compatible con psoriasis pustuloso generalizado del embarazo. Comentamos su evolución, características diferenciales y las diferentes opciones terapéuticas disponibles OBJETIVO: Conocer el tratamiento aplicado en los pacientes con cáncer de próstata diagnosticados en la Comunidad de Madrid en el año 2000. MATERIAL Y MÉTODO: El estudio se realizó sobre los 1.745 pacientes remitidos por los Hospitales participantes en el estudio. En 1.104 (63 por ciento) de los casos existían datos sobre el tratamiento aplicado. Se comparó la modalidad de tratamiento con el estadio clínico y la edad de los pacientes. RESULTADOS: El tratamiento más utilizado fue la hormonoterapia (35 por ciento) seguido de la prostatectomía radical (34 por ciento) y la radioterapia (25 por ciento). En los pacientes con enfermedad localizada la prostatectomía fue el tratamiento más utilizado (42,3 por ciento) y la hormonoterapia cuando la enfermedad estaba localmente avanzada (45,6 por ciento) o diseminada (94 por ciento). Existen diferencias importantes en la indicación terapéutica entre las distintas Áreas Sanitarias participantes. La mediana de edad de los pacientes con enfermedad localizada y localmente avanzada fue más baja en los tratados con prostatectomía (65 y 64 años respectivamente) que los tratados mediante radioterapia (70 y 69 años respectivamente). CONCLUSIONES: El tratamiento indicado por los Urólogos de la Comunidad de Madrid en los pacientes con cáncer de próstata cumple, en líneas generales, las recomendaciones de la literatura (AU)

El cáncer de próstata en la Comunidad de Madrid en el año 2000.III.- Estudio de extensión tumoral / Prostate cancer in the autonomous community of Madrid in 2000. III.- Tumour extension study

OBJETIVO: Conocer si existe relación entre las variables de riesgo de metástasis y la utilización de las pruebas de imagen en el estudio de extensión de los pacientes con cáncer de próstata diagnosticados en la Comunidad de Madrid en el año 2000. MATERIAL Y MÉTODO: Se analizaron 1.127 pacientes en los que se conocían los datos sobre el estudio de extensión tumoral. Se relacionó la realización o no de gammagrafía ósea y tomografía computarizada con las variables de riesgo de presentar metástasis descritas en la literatura (PSA, Gleason y estadio) y con el tratamiento aplicado. RESULTADOS: El porcentaje de pacientes con variables de riesgo de metástasis en los que se realizó gammagrafía ósea fue superior entre un 7 por ciento y 14 por ciento que los que no las presentaban. No existió diferencias en la realización de tomografía computarizada en función de las variables de riesgo. En los pacientes tratados con radioterapia se realizaron más pruebas de imagen en igualdad de variables de riesgo que en los tratados mediante prostatectomía. CONCLUSIÓN: Según las recomendaciones de la literatura se utilizaron un excesivo número de pruebas de imagen en el estudio de extensión en los pacientes sin variables de riesgo de metástasis. Sería conveniente la realización de un estudio a nivel de nuestra Comunidad para comprobar si con nuestra prevalencia de enfermedad metastásica es posible aplicar dichas recomendaciones (AU)

El cáncer de próstata en la Comunidad del Madrid en el año 2000, I - Incidencia / The prostate cancer in the Community of Madrid in 2000. I - Incidence

OBJETIVO: Conocer la incidencia del cáncer de próstata en la Comunidad de Madrid y en sus distintas Áreas Sanitarias en el año 2000.MATERIAL Y MÉTODO: Estudio de casos incidentes con confirmación histológica de cáncer de próstata y con recogida de datos retrospectiva en la Comunidad de Madrid durante el año 2000, tanto en la Sanidad Pública como en la Privada. RESULTADOS: La incidencia bruta del cáncer de próstata en la Comunidad de Madrid fue de 100,4 casos por 100.000 hombres. La incidencia ajustada a la población española, europea y mundial fue de 120,1, 103,5 y 68,6 casos por 100.000 hombres respectivamente. La edad media al diagnóstico fue de 70 ñ 7,8 (40-94) años con una mediana de 70 años. El tramo etario con una incidencia más elevada se situó entre los 70 y los 79 años. CONCLUSIONES: La incidencia del cáncer de próstata en la Comunidad de Madrid es más baja que en USA, pero más elevada que en la inmensa mayoría de los países o regiones de Europa. El diferente uso del PSA en las distintas Áreas Sanitarias de la Comunidad podría justificar las diferencias observadas en la incidencia por Área (AU)

El cáncer de próstata en la Comunidad de Madrid en el año 2000. II - Presentación y diagnóstico / The prostate cancer in the Community of Madrid in 2000. II - Presentation and diagnosis

OBJETIVO: Conocer la forma de presentación, el método diagnóstico utilizado y el estadio clínico en el momento del diagnóstico de los sujetos diagnosticados de cáncer de próstata en la Comunidad de Madrid en el año 2000.MATERIAL Y MÉTODOS: Se analizaron los datos de los 1.745 pacientes con diagnóstico histológico de cáncer de próstata remitidos por los 15 Hospitales que colaboraron en el estudio. Las variables analizadas fueron: patología asociada, motivo de consulta, tacto rectal, PSA, método de diagnóstico, score de Gleson agrupándose en grados de diferenciación, pruebas realizadas en el estudio de extensión tumoral y clasificación tumoral. Las variables cualitativas se expresaron en porcentajes del total de las mismas. Las variables cuantitativas se expresaron mediante la media, la desviación típica, los valores máximo y mínimo y los percentiles 25 por ciento, 50 por ciento (mediana) y 75 por ciento. RESULTADOS: El 67 por ciento presentaron patología asociada. La mayoría (75 por ciento) de los pacientes consultó por síndrome prostático. El 42,7 por ciento presentaban al tacto rectal una glándula no sospechosa de tumor. La mitad de los pacientes en el momento del diagnóstico presentaron un PSA igual o menor a 11 ng/ml. El 93 por ciento de los sujetos fueron diagnosticados mediante biopsia transrectal ecodirigida. Los score más frecuentemente informados fueron el 6 (31,3 por ciento) y el 7 (28,7 por ciento). El 75 por ciento se consideraron clínicamente como enfermedad localizada a la próstata, el 12,5 por ciento como enfermedad localmente avanzada y el otro 12,5 por ciento como enfermedad metastásica. CONCLUSIONES: La mayoría de los pacientes consultaron por síntomas no relacionados con el CP. La biopsia transrectal ecodirigida se confirma como la técnica de elección para el diagnóstico del CP. Al comparar con series históricas de nuestra Comunidad se observa una anticipación diagnóstica (AU)

Evolución y pronóstico a medio y largo plazo de los tumores vesicales superficiales / Outcome and medium and long-term prognosis of superficial transitional cell carcinoma of the bladder

OBJETIVOS: Evaluar la evolución de 551 pacientes con carcinomas transicionales vesicales. Mediante el análisis log-rank de las curvas de Kaplan-Meier y análisis multivariante con regresión de Cox, analizamos factores pronósticos en base a la supervivencia libre de enfermedad (SLE), supervivencia libre de progresión a infiltrantes (SLP) y supervivencia específica (SE), con el fin de agrupar a los pacientes en base a sus factores de riesgo reales. MATERIAL Y MÉTODOS: Desde 1983 hasta 1998 se han controlado en nuestro centro 551 pacientes con tumores vesicales superficiales. En este grupo se incluyen 15 pacientes diagnosticados con anterioridad a 1983 en otros centros. Los historiales clínicos están actualizados al periodo 19982000 salvo en 21 pacientes (3,8 por ciento) perdidos para seguimiento. El seguimiento medio ha sido de 6,2 años (mediana 5,3). Han fallecido 111 pacientes (20 por ciento) en una media de 4,5 años (mediana 3,4). Siguen vivos 440 pacientes con un seguimiento medio de 6,6 años (rango 2-24 años, mediana 5,7).RESULTADOS: Hombres han sido 459 (83 por ciento) con una edad media de 64 años, mujeres 92 (17 por ciento) con una edad media de 70. En 347 pacientes había un solo tumor (63 por ciento). Tumores Ta: 79 (14 por ciento), T1: 431 (78 por ciento), Tis: 41(7 por ciento). G1: 406 (74 por ciento), G2: 96 (17 por ciento), G3: 33 (6 por ciento) y Tis primario: 16 (3 por ciento).Han recidivado 253 pacientes (46 por ciento) en una media de 2,2 años. SLE a 5 años: 55 por ciento, a 10 años: 44 por ciento, a 15 años: 38 por ciento. En análisis multivariante han tenido significación estadística desfavorable para la SLE: los tumores múltiples con un riesgo relativo (RR) de 1,4 (IC: 1,19-1,69); la edad avanza-da en variable continua y el sexo femenino (RR: 1,2; IC: 0,98-1,52).Han progresado a infiltrantes 40 pacientes (7,3 por ciento) en una media de 3,3 años. SLP a 5 años: 93 por ciento, a 10 años: 91 por ciento, a 15 años: 90 por ciento. Factores des-favorables en multivariante para SLP: tumores G3 (RR: 5,1; IC: 2,7-9,6); el grupo de riesgo integrado por: tumores Ta-T1G3 o Tis o T1G2 múltiples (RR: 4,6; IC: 2,6-7,9); y la edad mayor de 70 años (RR: 2,14; IC: 1,2-3,7).Han fallecido por su tumor: 31 pacientes (5,6 por ciento) en una media de 4,6 años. SE a 5 años: 95 por ciento, a 10 años: 93 por ciento, a 15 años: 91 por ciento. Factores significativos en multivariante para SE: el mismo grupo de riesgo significativo en SLP (RR: 5; IC: 2,7-9) y los pacientes con edad superior a 70 años (RR: 4,56; IC: 2,2-8,8).CONCLUSIONES: La capacidad de recidiva es muy elevada en todos los pacientes siendo el riesgo mayor cuando existen tumores múltiples. La posibilidad de progresión es baja pero existe incluso en los pacientes con tumores muy poco agresivos. El grupo de riesgo más elevado es el integrado por los pacientes con tumores Ta-T1G3 o Tis o T1G2 múltiples (AU)

[Clinical course and mid- and long-term prognosis of superficial bladder tumors]. / Evolución y pronóstico a medio y largo plazo de los tumores vesicales superficiales.

OBJECTIVES: To evaluate the outcome of 551 patients with superficial transitional cell carcinomas of the bladder. To determine prognostic factors in these patients by means of the log-rank analysis of the Kaplan-Meier curves and a multivariate analysis with Cox regression model for the disease free survival (DFS), time to progression to infiltrating lesions (TTP) and overall survival (OS). MATERIAL AND METHODS: Between 1983 and 1998 we have seen 551 patients with superficial transitional cell carcinomas of the bladder in our Hospital. Fifteen patients included in this series had been diagnosed in other hospitals before 1983. The clinical records were actualized between 1998 and 2000 and only 21 patients were lost to follow-up (3.8%). The mean follow-up time was 6.2 years (median time: 5.3). One hundred and eleven patients (20%) died with a mean of 4.5 years (median time 3.4). Four hundred and forty patients were still alive on completion of the study with a mean follow-up time of 6.6 years (range 2-24 years; median 5.7). RESULTS: Four hundred and fifty-nine patients were men (83%) with a mean age of 64 years and 92 were women (17%) with a mean age of 70 years. In 347 patients there was only one tumour (63%). The tumours were stage Ta in 79 cases (14%). T1 in 431 (78%) and Tis in 41 (7%). The histological grade was G1 in 406 cases (74%), G2 in 96 (17%) and G3 in 33 (6%). There were recurrences in 253 patients (46%) with a mean time of 2.2 years. The DFS was 55% at 5 years, 44% at 10 years and 38% at 15 years. The multivariate analysis has shown a negative prognostic influence on DFS of the presence of multiple tumours (RR 1.4 CI 1.19-1.69), increasing age (analysed as a continuous variable) and the sex (being worse for females; RR 1.2 CI 0.98-1.52). In 40 patients (7.3%) the tumour became infiltrative in a mean of 3.3 years. The TTP was 93% at 5 years, 91% at 10 years and 90% at 15 years. The negative prognosticators in the multivariate analysis were G3 tumour (RR: 5.1 CI 2.7-9.6), the group of tumours Ta-T1G3 or multiple T1G2 or Tis (RR 4.6 CI 2.6-7.9) and the age > 70 years (RR 2.14 CI 1.2-3.7). Thirty-one patients (5.6%) died of the tumour in a mean time of 4.6 years. The OS was 95% at 5 years, 93% at 10 years and 91% at 15 years. Significant prognosticators in the multivariate analysis for OS were the group of risk tumours Ta-T1G3 and multiple Tis or T1G2 (RR 5 CI 2.7-9) and age > 70 years (RR 4.56 CI 2.2-8.8). CONCLUSIONS: The recurrence rate is very high in all the patients, but the risk is highest when the tumours are multiple. The risk of progression is low, but still exits even in patients with tumours of low malignant potential. The highest risk is associated with Ta-T1G3 of Tis or multiple T1G2.

[Progression and prognosis of in situ carcinoma of the bladder treated with BCG]. / Evolución y pronóstico del carcinoma in situ vesical tratado con BCG.

OBJECTIVES: In situ carcinoma (isT) of the bladder is a poor prognostic tumour with a natural progressive evolution. Treatment with BCG achieves a significant improvement in survival. This paper analyses our experience in the management of isT patients with endovesical BCG. MATERIAL AND METHODS: Between 1983 and 1997 the Urology Unit in the Móstoles Hospital saw 636 patients with transitional carcinoma of the bladder. Of these, 498 (78%) were surface tumours, and 138 (22%) were infiltrant. isT: 80 patients (13%), 14 of which were primary (17%), 37 associated to a surface tumour (46%), and 29 to infiltrant tumours (36%). All surface tumours: isT was present in 51 patients (10%) 44 of which were managed with 2 courses of BCG Connaught (81 mg), for 6 weeks each followed by vesical reassessment. Quarterly follow-up was conducted during a 2-year period. Patients not managed with BCG were treated with radical cystectomy. An analysis was made of patients without complete response to BCG, as well as actuarial analysis of disease-free survival (DFS), survival until progression (SUP) and specific survival (SS). All possible prognostic factors are analyzed: sex, focal isT (a single focus) or diffuse isT (more than one focus). Primary or secondary isT and association to G1, G2 or G3 tumours. RESULTS: In all 44 patients managed with BCG: males 37 (84%), females 7 (16%), primary 14 (32%), focal 22 (50%), diffuse 22 (50%). Six patients died (5 because of the tumour). Mean follow-up of living patients: 3.7 years (0.5-7.5 years). After the 2 BCG courses, 36 (82%) showed complete response. Thirteen patients (30%) had no complete response during follow-up, and 11 (85%) continued to progression. In total 7 patients underwent cystectomy. Of 5 patients directly cystectomized due to persistence of isT or T1G3 tumour at monitoring after BCG, 2 (40%) had infiltrant tumour and one (20%) nodular metastasis. Three patients with persistent isT or T1G3 after BCG were not initially cystectomized: two that were treated with other endovesical therapies because of their age progressed, and the third one underwent a third BCG course and required cystectomy due to tumour persistency. 5-year DFS: 56%, being diffuse isT vs. focal isT (p = 0.0206) was an unfavourable prognostic factor. 5-year SUP: 63%, no significant prognostic factor. 5-year SS: 79%, being a female was an unfavourable prognostic factor (p = 0.0201). CONCLUSIONS: Based on our results and the analysis of the literature we recommend treatment with 2 BCG courses of all isTs of the bladder that present some of the following factors: Diffuse cancer associated to T1G3, involvement of prostatic urethra or overexpression of p53 over 20%. In the rest of vesical tumours, one BCG course followed by a second one if lack of response to the first. After failure of both BCG courses, cystectomy must be performed in both groups.

[Fibroepithelial polyps of the upper urinary tract: their diagnostic evaluation and treatment in pediatrics]. / Polipos fibroepiteliales del tracto urinario superior: evaluación diagnóstica y tratamiento en pediatría.

OBJECTIVE: To establish the diagnostic criteria, analyze the histological patterns of benign and malignant ureteral and renal pelvic polyps in pediatric patients and discuss the best treatment option based on the final diagnosis. METHODS/RESULTS: The literature is reviewed with special reference to the diagnostic and therapeutic aspects of fibroepithelial polyps of the upper urinary tract in pediatric patients. An additional case with benign cytological and radiological findings is described. The patient underwent partial pyeloureteral resection. Histological analysis of the surgical specimen confirmed a fibroepithelial polyp. CONCLUSIONS: We emphasize the importance of adequate preoperative evaluation, precise identification of the base of the lesion for a correct choice of the surgical approach, and the advantages of complete segmental resection and reanastomosis over simple excision of the polyp.

[Urothelial carcinoma of the upper urinary tract. Survival and prognostic factors]. / Carcinomas uroteliales del tracto urinario superior. Supervivencia y factores pronósticos.

OBJECTIVE: To analyze the survival and the main prognostic factors in patients with transitional cell carcinoma of the upper urinary tract. METHODS: From 1983 to 1996, we treated 50 patients with transitional cell carcinoma of the upper urinary tract. Treatment was basically conservative except in those cases whose tumor stage or grade required a radical approach. Grading and staging were performed according to the 1992 TNM classification. Eighteen patients had died at one year mean follow-up., At the time the study was completed (June, 1997), 32 patients were alive with a mean follow-up of 4.9 years. Disease-free survival, overall and specific survival were analyzed according to sex, age, association with bladder tumors, localization, type of treatment, tumor size, number, histological grade and stage. RESULTS: The male-to-female ratio was 5:1. Patient mean age was 65.7 years. Association with bladder tumors was observed in 50%. Treatment was conservative in 40% and radical in 60%. The five- and ten-year disease-free survival rates were 69%, overall survival 61% and specific survival 71%. The univariate analysis showed the following to be unfavorable prognostic factors for survival: renal vs ureteral tumors, radical vs conservative treatment, high grade and stage tumors. The association of carcinoma in situ with other tumors of the upper urinary tract was also found to be an unfavorable factor for disease-free survival. The multivariate analysis associated T4 and G3 tumors with poor prognosis. CONCLUSIONS: Transitional cell carcinoma of the upper urinary tract was associated with bladder tumors in 50% of the cases. Low grade stage tumors demonstrated a high survival rate, therefore conservative treatment should be the first approach. High grade/ stage tumors were found to be unfavorable prognostic factors for survival.

[Evolution and prognostic factors of adenocarcinomas of the prostate metastasizing at diagnosis]. / Evolución y factores pronósticos de los adenocarcinomas de próstata metastásicos al diagnóstico.

OBJECTIVES: In 30-40% patients, prostate adenocarcinoma is diagnosed already in the metastatic phase, a percentage that will depend on the number of patients with localized cancer that we are unable to detect. Hormonal suppression is the most widely accepted therapeutical option, although there are doubts on the value of rescue treatment after the hormone-refractive stage. This paper analyses those parameters as well as the main prognostic factors in a series of 135 patients with metastatic prostate cancer at diagnosis. MATERIAL AND METHODS: Between 1983 and 1996, 414 patients were diagnosed with prostate adenocarcinoma in the Urology Unit. Móstoles Hospital, 135 of which (32.6%) were metastatic at the time of diagnosis and were managed as follows: 113 (84%) were treated with maximum androgenic blockade (MAB). 13 (9.6%) with orchiectomy and antiandrogens, 5 (3.7%) with various treatments, and only 4 received symptomatic treatment. Of those treated with MAB, 97 (72%) continued treatment after the hormone-refractive stage and 16 (12%) were given stramustine phosphate instead of the antiandrogen. Response monitoring was done basically by means of serial PSA determination. The parameters analyzed included survival and the following potential prognostic factors: age, performance status, metastatic bone pain, tumour diagnosis based on number of metastasis, prior PSA level, Gleason, local stage, M1 type at diagnosis based on the 1992 TNM classification, and response to the various treatment applied. RESULTS: Mean age: 72 years. Over an average of 25 (0-127) months, 80 (59%) patients have died; mean follow-up of patients alive at end of study: 24 months (3-111). Lost to follow-up: 6 patients (4.4%). Up to 1991, the proportion of patients with metastasis was 48%; since 1992, 24%. Percentage of patients diagnosed due to clinical manifestations of the metastasis (25 patients) over these two periods increased, mean age decreased and the proportion of patients with highly aggressive tumours increased. Mean overall survival, 26 months: influential prognostic factors: diagnosis due to metastasis and Gleason greater than 7; very poor prognosis for those receiving no hormonal therapy, with no differences between drug versus surgical treatment. Tumour-dependent mean survival, 32 months; influential prognostic factors: performance status, metastatic bone pain, diagnosis due to metastasis and Gleason greater than 7; very poor prognosis for those receiving no hormonal therapy. Progression-free interval, 19 months; influential prognostic factors: metastatic bone pain, PSA higher or lower than 90. Gleason greater than 7 and local stage: no differences between treatments. Mean survival after progression, 6 months; influential prognostic factors: diagnosis due to metastasis, M1b versus M1c patients: increased survival in patients rescued with stramustine phosphate. CONCLUSIONS: The proportion of prostate adenocarcinomas with metastasis at diagnosis shows a trend to decrease, although the percentage of patients who are diagnosed by the sings and symptoms of their metastasis is increasing. These patients should be treated with pharmacological or surgical hormone-suppression. Rescue treatment with stramustine phosphate prolongs survival. Influential prognostic factors: Gleason greater than 7, metastatic bone pain, tumour extent and previous PSA.