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Radical prostatectomy is currently the mainstay of treatment for localized prostate cancer. Although there is evidence that the evolution in surgical technique with the introduction of laparoscopic and robot-assisted radical prostatectomy has resulted in an improvement of functional outcomes, a significant percentage of patients are still bothered by post-prostatectomy incontinence. However, the majority of patients will find improvement in their continence status from conservative measures and a small cohort will require more invasive therapeutic options. Conservative treatment includes pelvic floor muscle training with or without biofeedback techniques and pharmacotherapy. There is evidence that immediate initiation of physiotherapy after surgery will help in early restoration of continence, while additional benefit can be provided from pharmacotherapy mainly from duloxetine. The present review aims to provide an update on the epidemiology of post-prostatectomy incontinence, identify risk factors for incontinence after surgery and suggest current trends for conservative treatment.
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OBJECTIVES: We performed a study on the notes made by doctor Antonio Alfaro to the book by Bichat and Desault “Treaty of urinary tract diseases”.RESULTS: Such notes are altogether more extensive than the work they accompany. In them we see the knowledge about the treatment of urinary tract diseases in the beginning of the XIX century had a great level and, at least, similar to that of other European countries. The notes are accompanied by multiple references to surgeons of various times, and publications of that time. All them conform a real Urology text with its own personality.CONCLUSIONS: Dr. Antonio Alfaro must be among the Spanish urological medical literature authors of the 19th Century
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OBJECTIVES: To identify risk factors for progression in patients with invasive bladder carcinoma who were pT0/pT1/pTa after cystectomy.METHODS: We analyzed the clinical records of 97 post-cystectomy pT0/pT1/pTa patients for the following variables: hydronephrosis, carcinoma in situ (CIS), lymphovascular invasion, history of non-muscular invasive disease, residual tumor in the specimen and lymphatic invasion (pN). pN+ patients were excluded from definitive analysis. The quantitative and qualitative variables were analyzed using standard statistics. The chi-square test was used to analyze associations between categorical variables. Univariate Cox proportional hazard regression analysis (enter method) was performed. The Kaplan-Meier method was used to evaluate survival and the log-rank test to assess differences between groups. Statistical significance was set at p<0.05. The analysis was performed using SPSS version 15.0.RESULTS: The study sample included 97 cases. The specimen was staged at T2 in 97% of patients after transurethral resection (TUR); After cystectomy, the specimen was staged as pT0 (R0) in 44.3% and pT1/Ta (R1) in 55.7%. Median follow-up was 47 months. Lymph node metastasis were detected in 5.2% of patients (pN+) and had a negative impact on survival (p=0.02). Overall survival was 59.8% and cancer-specific survival 76.6%. Univariate analysis showed a relationship between tumor progression and the presence of CIS (p<0.001), lymphovascular invasion (p=0.049), and hydronephrosis (p<0.001). In the multivariate analysis, only the presence of CIS in the transurtethral resection was associated with reduced cancer-specific survival (HR 100.5; 95% CI, 10.8 to 933.1; p<0.001).CONCLUSIONS: Although the prognosis of stage pT0/pT1/pTa carcinoma in the cystectomy specimen is excellent, some patients experience progression. The presence of CIS in the transurethral resection was an independent predictor of recurrence in these cases.
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OBJECTIVES: We intend to assess the prognostic influence of surgical margins on the biochemical progression free survival (BPFS) in patients classified as pT2 after radical prostatectomy.METHODS: We analyze a series of 1,132 T1-T2 patients with prostate cancer treated with radical prostatectomy between 1989-2009. PT3b, pT4 and patients with lymph node involvement were excluded from the series.The clinicopathologic variables and the BPFS of pT2(+), pT2(-) and pT3 patients are compared. The influential clinicopathologic variables in the BPFS are identified in the pT2(+) group and risk groups are designed.RESULTS: Of 1,051 patients evaluated finally: 598 (59,6%) were pT2(-); 163 (15,5%) pT2(+);80 (7,6%) pT3a(-) and 210 (20%) pT3(+).Clinical characteristics of pT2(+). It is homogeneous with the pT2(-) group and significantly better than pT3(+) group in all the clinicopathologic variables evaluated.5 and 10 year BPFS of the pT2(+) (68±3% and 57±5%) is significantly worse than pT2(-) (87±1% and 79±2%), similar to pT3a(-) (75±5% and 64±7%) and better than pT3(+) (44±3% and 36±3%).BPFS pT2(+) influential factors: Univariate study: Pathological Gleason score 7-10 (HR:2.1; 95% IC: 1.1-4.1), (p=0.02); MRI that indicates T3 (HR:3.2; 95%IC: 1.4-7.3), (p=0.04); PSA>15 ng/ml (HR:4; 95%IC: 2-8.2), (p<0.0001) and high risk D’Amico group (HR:3.3; 95%IC: 1.3-8.5), (p=0.01) are influential variables. A risk model with the involved variables can be designed. Each variable present is a point. Two groups are designed:Group 1 (0-1 variable); Group 2 (2-3 variables). 5 and 10 year BPFS for Group 1 are 71±5% and 69±5%, and are 37±12% and 22±11% for Group 2.(p <0.0001).CONCLUSIONS: Surgical margins in pT2 patients have independent influence in the BPFS. The group is heterogeneous and it can be divided into two risk groups accordingly to the BPFS influential variables: a larger group (86% pT2(+)) with worse prognosis than pT2(-), and a smaller group (remaining 14%) with similar prognosis to pT3 (+).It is likely that pT2(+) patients are a mixture of understaged patients with others with iatrogenic margins or false margins due to poor assessment of the surgical specimen.
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OBJECTIVES: To identify post-prostatectomy prognostic factors for biochemical recurrence (BR).METHODS: We retrospectively analyze a series of patients with clinically localized prostate cancer who were treated with radical prostatectomy (RP) as monotherapy between 1996 and 2007, pN0-pNx, with a minimum of 12 months of follow-up. BR is considered to be persistence or elevation in PSA after RP greater than 0.4 ng/ml on the subsequent determination. Analyzed variables were Gleason Score, pathological stage, surgical margin involvement, capsular involvement, and perineural involvementWe performed univariate and multivariate analysis using the chi squared test and proportional Cox risk model in order to determine the variables associated with BR. RESULTS: We included 693 patients. Mean age was 63.5 years with a mean follow-up of 88.5 months. Mean PSA was 9.2 ng/ml. BR was observed in 218 patients, 43 due to biochemical persistence. More common pathological findings were Gleason score 7 (47.1%), and pathological stage pT2c (60.1%). Mean time to BR was 35.5 months with 91.2% occurring in the first 8 years.On multivariate analysis, Gleason score ≥ 7(4+3), pathological stage pT3b and positive surgical margin were independent predictors of BR. CONCLUSIONS: Gleason Score ≥ 7(4+3), positive surgical margins and pathological stage pT3 are independent prognostic factors associated with BR-free survival.
Case Report
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OBJECTIVE: We present a case of cutaneous metastasis caused by a bladder tumor.METHODS: 68 year old male, diagnosed with an ISUP high grade urothelial carcinoma, affecting the whole bladder wall, including the perivesicular fat and macroscopic metastasis in the left ilio-obturator chain (T3N2MO), who presents painless induration on the dorsal surface of the glans penis with non-exudative ulcerated areas, evolving over several months. Given the negative serology result, the lesion was biopsied for anatomopathological study.RESULTS: The histopathological study of the lesion corresponded to a cutaneous metastasis from high grade urothelial carcinoma.CONCLUSION: Approximately 370 cases of penile metastasis have been described and the primary tumor is located in the bladder in 30-35% of them. Presentation of these lesions is very heterogeneous and requires anatomopathological study of the lesion for definitive diagnosis.
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OBJECTIVE: To report a complication of a staghorn stone in a non-functioning right kidney.METHODS: We present a 47 year old female with right lumbar pain and history of recurrent urinary tract infection (UTI). After an acute pyelonephritis episode, a right staghorn stone was diagnosed in a non-functioning right kidney.RESULTS: During right nephrectomy, we found a renocolic fistula not observed in the imaging studies before surgery. We performed a simple closure of the colon wall after resection of the fistula.CONCLUSION: Asymptomatic renocolic fistula is a rare complication of an acute pyelonephritis secondary to a staghorn stone.
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OBJECTIVE: To describe a case of paraurethral leiomyoma and to review the literature.METHODS: The usual preoperative diagnostic procedures and clinical manifestations are discussed.RESULTS: The mass was resected and, 6 years later, the patient remains asymptomatic and with no recurrence.CONCLUSIONS: Urethral or paraurethral leiomyomas are benign tumors that arise from the urethral or vaginal smooth muscle. Radiological findings (particularly magnetic resonance imaging) may suggest the origin of the tumor before surgery; however, the final diagnosis is determined by histology.
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OBJECTIVE: To describe a case of staged conservative treatment of a synchronic bilateral renal tumor, a real surgical challenge.METHODS: 46-year old obese female who consulted for fever; bilateral solid masses >70 mm were detected and surgical treatment was offered.RESULTS: Staged conservative treatment consisting in selective embolization of both lesions and subsequent surgery was performed. Right partial nephrectomy with ipsilateral adrenalectomy was done first, and 90 days later left partial nephrectomy. Pathology revealed, clear cell carcinomas with negative surgical margins in both cases in addition to a right adrenal adenoma. After 48 months of follow up, the patient remains free of local or systemic disease with normal renal function.CONCLUSIONS: The objective for these patients is a complete resection of the tumors and preservation of as much renal tissue as possible. Conservative surgery has proven to be an effective therapy to achieve both goals in cases of bilateral synchronic renal tumors.
Case Report
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Case Report
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