¿Está justificada la cistectomía radical en pacientes mayores de 75 años? / Is radical cystectomy justified in patients over 75 years old?

Introducción y objetivos: La cistectomía radical es el tratamiento de elección en el tumor vesical infiltrante. Los objetivos de este trabajo son evaluar las complicaciones intraoperatorias y postoperatorias de la cistectomía radical, así como el intervalo libre de enfermedad y supervivencia cáncer especifica en pacientes con edad superior a 75 años y compararlos con los resultados en pacientes de menor edad. Material y Métodos: Entre agosto de 1980 y octubre de 2004, se realizaron 495 cistectomías radicales. De ellas se excluyeron las cirugías realizadas con intención paliativa. Los pacientes fueron divididos en dos grupos: menores de 75 años (grupo control) y pacientes con edad igual o superior (grupo mayores de 75 años). En todos los casos se realizó cistectomía radical y linfadenectomía pélvica. Resultados: Se evaluaron 402 pacientes, de los cuales 39 fueron pacientes mayores de 75 años (edad media: 76 años) y 363 pacientes control (edad media: 62 años), con una media de seguimiento de 38 y 64 meses respectivamente. Treinta y un pacientes mayores de 75 años (80,4%) y 211 pacientes control (58,2%) tuvieron un tumor no-órgano confinado (pT3-pT4) (p=0,0096). Diez pacientes mayores de 75 años (28,6%) y 111 pacientes control (31,4%) tenían ganglios positivos (p=0,84). No hubo diferencias en la tasa de complicaciones quirúrgicas (p=0.08), reintervención (p=0,58) y mortalidad postoperatoria (p=0,28). Once pacientes mayores de 75 años (28%) y 50 pacientes control (13,8%) tuvieron alguna complicación médica postoperatoria (p=0,03). Catorce pacientes mayores de 75 años (35,9%) y 104 pacientes control (39,4%) murieron debido a su tumor (p=0,73), sin diferencias en la supervivencia cáncer específica ni en el tiempo hasta la progresión. Conclusiones: La cistectomía radical es un tratamiento adecuado en pacientes mayores de 75 años, sin diferencias con la población general en relación a las complicaciones quirúrgicas, intervalo libre de enfermedad y supervivencia cáncer específica. No obstante, es necesario evaluar la comorbilidad preoperatoria dado el aumento de complicaciones médicas postoperatorias (AU)

Introduction and objectives: Radical cystectomy is the standard treatment for invasive bladder cancer. The objectives are to evaluate intraoperative and postoperative complications and to determine overall disease-free interval and overall time to progression in patients over tha age of 75 and to compare these with younger patients. Material and methods: Between august 1980 and october 2004 , 495 patients underwent radical cistectomy. Patients with palliative surgery were excluded. Patients were divided in two groups according to age: control group (<75 years old) and elderly group (>=75 years old). Results: Four hundred and two patients were evaluated: 39 patients (35 male and 5 female) in the elderly group and 363 in the control group (321 males and 42 females). Mean age was 76 (range: 75-82) and 62 (range: 35-74) respectively. Mean followup was 38 months in the elderly group and 64 months in the control group. Thirty one patients (80.4%) in the elderly group and 211 patients (58.2%) in the control had non organ-confined tumour in cystectomy specimen (pT3-pT4) (p=0.0096) and ten patients (28.6%) in the elderly and 111 patients (31.4%) in the control group had positive nodes(p=0.84).There were no differences in postoperative surgical complications (p=0.08), postoperative reoperation rate (p=0.58) and postoperative mortality (p=0.28) in both groups. During postoperative time, 11 patients(28%) in the elderly group and 50 patients (13.8%) in the control had medical complications (p=0.03).Fourteen patients (35.9%) in the elderly group and 104 patients (39.4%) in the control group died due to tumour during follow-up(p=0.73). Kaplan-Meier survival curve revealed no differences between two groups in overall disease-free interval and overall time to progression. Conclusions: Radical cystectomy is a safe and effective treatment in elderly patients with invasive bladder cancer. It is necessary to evaluate co-morbidity in this group because there is an increase in postoperative medical complications. There were no differences between the two groups in overall disease-free interval and overall time to progression (AU)

[Treatment of post radical prostatectomy erectile dysfunction with sildenafil in a non-selected group of patients]. / Tratamiento de la disfunción eréctil tras prostatectomía radical con sildenafilo en un grupo no seleccionado de pacientes.

OBJECTIVE: To evaluate erectile disfunction (ED) after radical prostatectomy in a non selected group of patients and their response to sildenafil. METHODS: We included our patients who were operated on between 1998 and 2001. The patients filled in a modification of IIEF (mIIEF) before the RP operation. We tried sildenafil with doses of 100 mg in 3 different periods: 3-6, 12 and 18-24 months after the RP operation. In the event of a complete response they filled in the mIIEF again. RESULTS: The mean age of the patients was 62.8 years old and the mean observation period was 31.7 months. Only 111 (62%) of the total number of patients operated on wanted treatment and only 90 took sildenafil in the proposed protocol; 27 (30%), 18 (20%) and 45 (50%) patients had a complete response, a partial response or no response to the sildenafil respectively. The mIIEF showed 6.5+/-5.7 points less than the mIIEF pre-treatment. In the univariate analysis, the preservation of bundles, the presence of a previous partial response and the presence of the previous tumescence were significantly related to the complete response; however, only tumescence kept its value in the multivariate study. CONCLUSIONS: Urologists must involve themselves in the early rehabilitation of the erectile function even in those patients where preservation of the NVB was not possible. One must always try to preserve, uni or bilaterally, whenever the patient desires preservation of EF. The response to sildenafil is better after the first year and in patients who have previous tumescence.

Tratamiento de la disfunción eréctil tras prostatectomía radical con sildenafilo en un grupo no seleccionado de pacientes / Treatment of post radical prostatectomy erectile dysfunction with sildenafil in a non-selected group of patients

FUNDAMENTO: Conocer la disfunción eréctil (DE) tras prostatectomía radical en un grupo no seleccionado de pacientes y su respuesta al sildenafilo. MÉTODOS: Incluimos a nuestros pacientes operados entre 1998 y 2001. Los pacientes rellenaron una modificación del IIEF (mIIEF) antes de la PR. Probamos sildenafilo a dosis de 100 mg en 3 periodos diferentes: 3-6, 12 y 18-24 meses tras la PR. En caso de respuesta completa volvieron a rellenar el mIIEF. RESULTADOS: La edad media fue de 62,8 años y el seguimiento medio de 31,7 meses. Sólo 111 (62%) del total de pacientes operados quisieron tratamiento y tan solo 90 tomaron sildenafilo en el régimen propuesto; 27 (30%), 18 (20%) y 45 (50%) tuvieron una respuesta completa, parcial o no tuvieron respuesta al sildenafilo respectivamente. El periodo más frecuente de respuesta completa fue entre los 18-24 meses. El mIIEF mostró 6,5±5,7 puntos menos respecto al mIIEF pre tratamiento. En el análisis univariado, la preservación de bandeletas (BNV), la presencia de respuesta parcial previa y la presencia de tumescencia previa se relacionaron significativamente con la respuesta completa; sin embargo, solo la tumescencia mantuvo su valor en el estudio multivariado. CONCLUSIONES: El urólogo debe implicarse en la rehabilitación precoz de la FE incluso en los pacientes en los que no se ha podido realizar preservación de las BNV. Esta se debe intentar uni o bilateralmente siempre que el paciente desee preservar FE. La respuesta al sildenafilo es mejor a partir del primer año y mejor en aquellos que presentan tumescencia previa

OBJECTIVE: To evaluate erectile disfunction (ED) after radical prostatectomy in a non selected group of patients and their response to sildenafil. METHODS: We included our patients who were operated on between 1998 and 2001. The patients filled in a modification of IIEF (mIIEF) before the RP operation. We tried sildenafil with doses of 100 mg in 3 different periods: 3-6, 12 and 18-24 months after the RP operation. In the event of a complete response they filled in the mIIEF again. RESULTS: The mean age of the patients was 62.8 years old and the mean observation period was 31.7 months. Only 111 (62%) of the total number of patients operated on wanted treatment and only 90 took sildenafil in the proposed protocol; 27 (30%), 18 (20%) and 45 (50%) patients had a complete response, a partial response or no response to the sildenafil respectively. The mIIEF showed 6.5±5.7 points less than the mIIEF pre-treatment. In the univariate analysis, the preservation of bundles, the presence of a previous partial response and the presence of the previous tumescence were significantly related to the complete response; however, only tumescence kept its value in the multivariate study. CONCLUSIONS: Urologists must involve themselves in the early rehabilitation of the erectile function even in those patients where preservation of the NVB was not possible. One must always try to preserve, uni or bilaterally, whenever the patient desires preservation of EF. The response to sildenafil is better after the first year and in patients who have previous tumescence

[Usefulness of serum markers in renal cell carcinoma]. / Utilidad de marcadores séricos del carcinoma renal.

OBJECTIVES: To select a group of useful serum markers in renal cell carcinoma (RCC) with investigational purpose in future. MATERIAL AND METHODS: Periodic determination in serum of 21 RCC patients of the following markers: EGR, RPC, hemogram and leucocyte differential count (LDC), standard biochemist parameters, beta-2 microglobuline, CEA, CA 12.5, CA 50, CA 15.3, ferritin, interleukin-6, serum interleukin-2 receptor, TNF-alpha and TPSA. RESULTS: Different elements within the LDC had relations with the presence of symptoms/signs, tumour size, pathological stage and disease progression. There was a significant increase of beta-2 microglobuline and sIL-2 receptor when disease progressed, as well as a similar statistical trend with RPC and alkaline phosphatases. Beta-2 microglobuline and sIL-2 receptor also decreased after treatment of the disease progression. CONCLUSIONS: We will keep analysing hemogram, LDC and standard byochemics, RPC, ferritin, beta-2 microglobuline and sIL-2 receptor only with investigational purposes, obviating the determination of the rest of the tested markers.

Utilidad de marcadores séricos del carcinoma renal / Usefulness of seum markers in renal cell carcinoma

FUNDAMENTO: Seleccionar un grupo de marcadores tumorales útiles en el carcinoma renal (CR) para su ulterior estudio y desarrollo. MÉTODOS: Determinación seriada en suero de 21 pacientes con CR de los siguientes marcadores: VSG, PCR, hemograma y recuento diferencial leucocitario (RDL), bioquímica estándar, ß2-microglobulina, CEA, CA 12.5, CA 50, CA 15.3, ferritina, interleukina-6, receptor de la interleukina-2, factor de necrosis tumoral a y antígeno tisular polipeptídico. RESULTADOS: Diferentes elementos dentro del RDL tuvieron relación con la presencia de clínica, con el tamaño, estadio patológico y la progresión tumoral. Se observa un incremento estadísticamente significativo de los valores de la ß-2 microglobulina y del RIL-2 en el momento de la progresión, así como un aumento con tendencia a la significación de los valores de la PCR y las fosfatasas alcalinas. La ß-2 microglobulina y el RIL-2 decrecen significativamente al tratar la progresión. CONCLUSIONES: Seguiremos determinando el hemograma, RDL y bioquímica estándar, la PCR, la ferritina, la ß-2 microglobulina, y el RIL-2 exclusivamente con el objeto de delimitar su utilidad en el seguimiento de los pacientes con CR, desestimando la determinación del resto de marcadores testados (AU)

OBJECTIVES: To select a group of useful serum markers in renal cell carcinoma (RCC) with investigational purpose in future. MATERIAL AND METHODS: Periodic determination in serum of 21 RCC patients of the following markers: EGR, RPC, hemogram and leucocyte differential count (LDC), standard biochemist parameters, ß-2 microglobuline, CEA, CA 12.5, CA 50, CA 15.3, ferritin, interleukin-6, serum interleukin-2 receptor, TNF- a and TPSA. RESULTS: Different elements within the LDC had relations with the presence of symptoms/signs, tumour size, pathological stage and disease progression. There was a significant increase of ß-2 microglobuline and sIL-2 receptor when disease progressed, as well as a similar statistical trend with RPC and alkaline phosphatases. ß-2 microglobuline and sIL-2 receptor also decreased after treatment of the disease progression. CONCLUSIONS: We will keep analysing hemogram, LDC and standard byochemics, RPC, ferritin, ß-2 microglobuline and sIL-2 receptor only with investigational purposes, obviating the determination of the rest of the tested markers (AU)

[Surgical treatment of urinary bladder cancer. Indications, technics, and general results]. / Tratamiento quirúrgico del cáncer de la vejiga urinaria. Indicaciones, técnicas y resultados generales.

OBJECTIVE: To analyze the results and indications of the three surgical techniques commonly utilized alone or as part of other treatments for infiltrating bladder tumors. METHODS: Our series of patients with infiltrating bladder tumors are analyzed and the literature reviewed. RESULTS: Transurethral resection (TUR) is essential for tumor staging and is controversial as a therapeutic approach. However, using stringent selection criteria and careful follow-up, retrospective studies have reported survival rates of 82-83%, which are similar to those of radical cystectomy in similar cases, but with bladder preservation rates of 67%-75%. However, only 19-21% of patients can benefit from this surgical technique and the selection criteria are relatively subjective. Partial cystectomy achieves a considerable survival rate of 40-80%, but very stringent selection criteria must be met, which are partly similar to those of the previously mentioned technique, therefore it is not an alternative to TUR since it is a more aggressive surgical procedure. It could be an alternative to radical cystectomy in the more advanced stages of the disease, but although it may be technically biologically feasible, there is a high risk of local and cicatricial recurrence and difficulty in the early detection of recurrence caused by the anatomical disturbance in the bladder wall. For all the foregoing, partial cystectomy is utilized only for very specific cases of urachal carcinoma, as a palliative approach instead of cystectomy, or for areas that are not accessible to TUR. However, although it has specific indications, it has been demonstrated to be effective in the evaluation of the response to chemotherapy and systematically utilized in bladder preservation programs. CONCLUSIONS: Radical cystectomy continues to be the standard treatment for infiltrating bladder tumors with overall 5-year survival rates in recent series ranging from 56%-72%, and is related with the pathological stage and particularly nodal involvement. The morbidity has dropped and the operative mortality rate is about 2%. Quality of life has also improved with the new techniques of urinary diversion, especially orthotopic diversion.

[Adrenal gland incidentaloma in the oncologic patient: is its histologic study obligatory?]. / Incidentalomas suprarrenales en el paciente oncólogico: es obligado suestudio histólogico?

OBJECTIVES: To analyze the need for histological study in suprarenal incidentalomas in the specific status of the oncological patient. MATERIAL AND METHODS: 21 patients with tumoral suprarenal masses, 12 diagnosed in the initial study and 9 during the follow-up RESULTS: 16 masses were benign in nature and 5 were metastatic. Neither the location nor the staging of the initial tumour, the time of diagnosis, or the hormonal study were of any use to separate the primitive tumour from the metastasis. All metastasis were equal to or greater than 5 cm in size. Radiological study only confirmed the nature of the tumour in a few cases. Percutaneous biopsy was resolutive in 4/8 cases (50%). Suprarenalectomy was performed in 15 occasions, associated in 10 to surgical treatment of the primary therapy with not added morbidity. CONCLUSION: When incidentaloma is detected in tumoral patients at the time of diagnosis, it requires an histological study which in 1 out of 3 cases will modify the therapeutic attitude in the presence of metastasis. If the incidentaloma is detected during follow-up, it may be monitored in terms of evolution as we would only be delaying a palliative treatment.

[Bladder carcinosarcoma. Report of 2 cases]. / Carcinosarcoma vesical. A propósito de dos casos.

Two additional cases of this rare bladder tumor are described. The immunohistochemical analyses confirmed the histological diagnosis of this aggressive tumor type. The choice of treatment for the tumor and its metastasis is influenced by its rarity.

[Results of a randomized, double blind prospective study of intravesical chemoprophylaxis with 2 drugs: adriamycin and mitomycin; and 2 ways of initiating the instillations: early and late. Effect on recurrence and progression]. / Resultados de un estudio de quimioprofilaxis intravesical, prospectivo, doble aleatorio, entre dos drogas: la adriamicina y el mitomicin; y dos modos de iniciar las instilaciones: precoz y tardío. Efecto sobre la recidiva y la progresión.

The results of a double blind prospective study comparing the chemoprophylactic effects of adriamycin and mitomycin C and two modes of instillation (early: 6 hours following transurethral resection; late: 7-14 days later) for superficial carcinoma of the bladder are presented herein. Since the minimum follow up is over 5 years, the effects on tumor progression and mortality achieved by each of the 4 arms of the protocol were also evaluated. Concerning tumor recurrence, early instillation of mitomycin and overall early instillation therapy achieved significantly better results (p < 0.01). No differences, however, were observed relative to tumor progression or mortality.

[Mitoxantrone (MTX) versus mitomycin C (MMC) in the ablative treatment of Ta, T1 superficial bladder tumors. Phase III, randomized prospective study]. / Mitoxantrone (MXT) "versus" mitomycin C (MMC) en el tratamiento ablativo de los tumores vesicales superficiales Ta, T1. Estudio prospectivo y al azar, en fase III.

A prospective randomized study was conducted to determine the ablation capacity of mitoxantrone in Ta-T1 superficial bladder tumors versus mitomycin C, a drug whose intravesical ablation properties are well-known. Fifty-seven patients comprised the study. The tumor was not completely resected when the patient underwent TUR. This residual tumor was used as control. The patients were treated with either 20 mg Mitoxantrone or 40 mg mitomycin C weekly for 8 weeks and two other instillations every 15 days in 50 ml saline solution. Response to therapy was evaluated between the 4th and 8th week and classified as complete response (CR), defined as no gross and microscopic evidence of residual tumor, or no response (NR) or therapeutic failure. CR was observed in 77.7% of the patients treated with mitomycin C and in 50% in those that had been treated with Mitoxantrone. Treatment was discontinued because of side effects in 15% of the patients treated with mitomycin C and in 63.4% of those who received Mitoxantrone. We can conclude from the results of the present study that Mitoxantrone is a useful agent for ablation therapy of superficial bladder tumors, although the high incidence of severe side effects warrants its limited use and at high dilutions.

[Tumor embolization to the lymphatic vessel structures of the bladder wall (L+). Its effect on the course of bladder tumors]. / La embolización tumoral de las estructuras vásculo-linfáticas de la pared vesical (L+). Su influencia en la evolución de los tumores vesicales.

A retrospective study was conducted in patients with bladder tumors equal to or higher than stage T1 to determine the influence on survival of tumor cell invasion of the microscopic lymphatic vessels of the bladder wall. Sixty-two patients were studied (34 recurrent and 28 primary tumors). Evidence of microscopic lymphatic invasion was disclosed following TUR (48 cases) and cystectomy (14 cases). Overall and with a mean follow up of 27 months, 25% of the patients are alive and tumor free, 51.6% had died from the tumor (90% less than 3 years following diagnosis). Forty-five percent had lymph node metastasis and 56.6% node and organ metastases. For a time interval of over 6 months between the diagnosis of L + and definitive treatment, there was an 80% mortality versus 43% when treatment was concurrent with diagnosis. Finally, survival was much better in patients submitted to radical surgery. We can conclude from the present study that evidence of tumor invasion of the lymphatic vessels must be routinely sought by the pathologist in order to identify those patients with a high probability of tumor dissemination.

[Locoregional treatment of carcinoma of the penis]. / El tratamiento locorregional del carcinoma de pene.

Locoregional treatment of penile carcinoma continues to be a controversy between those who advocate early treatment of lymph nodes and those who advocate delaying treatment. The present study reviews 81 cases of penile carcinoma and describes our approach to treatment of the lymph nodes. A study undertaken to compare the different treatment modalities revealed that at 71 months mean follow-up 64% of the patients submitted to inguinal lymphadenectomy were alive and disease free versus 33% of those submitted to radiotherapy. Statistical analyses comparing the survival rates revealed that the likelihood of survival at 5 years was 100% for those patients submitted to prophylactic lymphadenectomy versus 51% for those submitted to therapeutic lymphadenectomy. We can conclude that since nodal metastasis represents a worse prognosis in these patients, it is advisable to perform prophylactic or therapeutic lymphadenectomy early and, furthermore, regional treatment by radiotherapy appears to be of little use.

[Is radical cystectomy indicated for the treatment of patients with bladder carcinoma N+ M0?]. / Está indicada la cistectomía radical (CTR) en el tratamiento de los pacientes con carcinoma vesical (CV) N+ M0?

UNLABELLED: The following parameters were analyzed in 55 patients with N + M0 bladder carcinoma: 1. Extent of lymph node involvement: A significant difference was observed for those with N1 whose 5 year survival rate is 46%, whereas those with N3, N4 did not survive at two years. 2. TREATMENT: 29 patients underwent cystectomy and 26 did not. Of these 26 patients, 14 received polychemotherapy and 11 received only symptomatic treatment. Survivorship was significantly better for those who underwent cystectomy than those who received polychemotherapy, and it was better for this latter patient group than for those who received symptomatic treatment. 3. Finally, we studied the possible effect of changing the chemotherapeutic regimen on patient survival. Although patients treated with CMV or M-VAC have only a short follow-up, patient survival appears to be enhanced.

[Verrucous carcinoma of the penis. Report of 8 cases]. / El carcinoma verrucoso de pene. A propósito de 8 casos.

This paper presents a retrospective study of the incidence and evolution of Penis Verruciform Carcinoma, covering a series of 101 cases of primitive penis carcinomas. Incidence reaches 7.9% of all cases. Analysis of tumour evolution is made and compared with Epidermoid Carcinoma. The findings are that there is neither loco-regional nor distant gangliar dissemination and that no patient dies due to this tumour as apposed to 38% deaths in epidermoid cases. Similarly, the survival likelihood at 5 years is 100% for verruciform carcinomas against 54% for epidermoid ones. All the above confirms the benignancy of Penis Verruciform Carcinoma, which makes it recommendable for conservative therapy, whenever volume and location would allow it. Thus, performance of lymphadenectomies is not generally justified since there is no tumoral dissemination, and adoption of an expectant attitude in presence of inguinal ganglia should be advisable.

[Reliability of computerized axial tomography (CAT), for the evaluation of lymph node involvement in patients with infiltrating bladder tumor]. / Fiabilidad de la tomografía axial computerizada (TAC), para la valoración de la afectación de las cadenas ganglionares linfáticas en enfermos portadores de un tumor vesical infiltrante (TVI).

The present study was undertaken to determine the reliability of CAT scanning in the preoperative evaluation to detect or discard pelvic lymph node involvement in patients with infiltrating bladder tumor. We compared the radiologic findings with the results of histopathologic examination of the lymph nodes following lymphadenectomy or biopsy of nodes with gross evidence of tumor spread. A comparative study performed in 84 patients revealed a sensitivity rate of 36.3%, a specificity of 87.2%, and an accuracy rate of 66.2% for CAT scanning and, although radiologic evaluation afforded good results, pelvic lymphadenectomy continues to be the method of choice for correct staging of infiltrating bladder tumors.

[Incidence of vesico-ureteral reflux after endoscopic surgery of superficial tumors of the bladder. A prospective study]. / Incidencia del reflujo vésico-ureteral tras la cirugía endoscópica de los tumores vesicales superficiales. Estudio prospectivo.

The present retrospective study was undertaken to determine the true incidence of vesicoureteric reflux after transurethral resection (TUR) of superficial bladder tumors. The possible role of tumor size, number, site, etc., relative to the appearance of reflux were analyzed, and the principal pathogenic factors involved in iatrogenic vesicoureteric reflux were determined. The incidence of reflux was studied using pre and postoperative ureterocystograms. The study revealed the presence of vesicoureteric reflux long after TUR in 20.6% of the patients.

[Epidermoid carcinoma of the bladder. An uncommon tumor]. / El carcinoma epidermoide de vejiga. Un tumor poco común.

A review of 921 bladder tumors revealed epidermoid carcinoma accounted for 29 (3.1% of total). The present study was undertaken to determine the most important features of transitional cell carcinoma; e.e. its being highly prevalent in women, the high incidence of infiltrating tumors at the time of diagnosis, and its apparently scant potential to spread. Similarly, we studied the scant response achieved by radiotherapy and emphasize that the best results are achieved by radical surgery combined with preoperative radiotherapy.