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OBJECTIVES: Prostate cancer (PCa) is anandrogen-dependent disease. In some cases, the tumorprogresses despite castration levels of serum testosterone,turning into the lethal phenotype of castration-resistantprostate cancer (CRPC), still driven by androgensand requiring the androgen receptor as a driver andresponsible for progression.Enzalutamide, an androgen receptor inhibitor, isindicated for the treatment of metastatic CRPC,asymptomatic or mildly symptomatic, after failure ofandrogen deprivation. In both clinical trials that led to itsapproval, Enzalutamide was administered with an LHRHanalog, setting the “standard of care” for its use. In thisarticle we evaluate the available evidence and theoryon the use of Enzalutamide as monotherapy.METHODS: Androgen deprivation well-known adverseevents, together with the fact that its clinical benefit ismoderate and the evidence strength is weak, andthe direct negative impact on the common chronicconditions affecting this age-group led to investigationof Enzalutamide without LHRH analogs.RESULTS: There are clinical trials on Enzalutamidemonotherapy for hormone-sensitive prostate cancer withfavourable outcomes, and there are also two ongoingstudies in different advanced PCa scenarios, thePROSPER and EMBARK trials. It would be up to now asafe alternative, with less toxicity and lower costs.CONCLUSION: It is mandatory to validate theseearly results on the use on Enzalutamide monotherapyfor advanced prostate cancer, hormone-sensitive orcastration resistant, metastatic or not, but in the meantime,we wonder, why not?
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OBJECTIVE: To present a predictive tool of success of ESWL adapted to our environment. METHODS: We performed a retrospective, descriptive and analytical study of patients with renal and upper ureteral stones whom underwent ESWL with DUET MAGNA lithotripter between January 2014 and March 2015. We included 114 patients in whom demographics and CT scan characteristics were studied. Multivariate analysis by logistic regression was performed to establish independent predictors of success in ESWL. A ROC curve was used to determine success cut-off values of ESWL in each significant variable. The score was established based on the numbers of variables under the cut-off value in each patient. In every one of these categories, percentage of stone free was determined. Finally, the area under the curve of our ESWL treatment success score was made.RESULTS: Of 114 patients studied, 58 (51%) were stone free. After multivariate study, independent predictors of success with ESWL were tomographic density of lithiasis (UH), body mass index (BMI) and stone diameter (mm). Ideal cut off points of treatment success in each one of the score parameters were: density of lithiasis 900 UH, BMI 27 and lithiasis diameter 11 mm. Percentage of stone free was 31.8% for score 0, 37.1% for score 1, 57.5% for score 2 and 88.3% for score 3. Area under the curve for the score was 0.723 (p< 0.001).CONCLUSIONS: This score could represent a predictive tool in our environment to predict ESWL results. Utilization of this score could limit the use of this therapy only to patients with favorable profile (score2-3) improving in this way cost-effectiveness of this procedure.
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OBJECTIVE: The aim of the present articleis to summarize the results we obtained treating childrenwith urolithiasis over the last 30 years and to perform ananalysis on the basis of the these results and relevant detailsaccording to national and international experience. METHODS: Retrospective and descriptive statisticalanalysis of the 30 year experience in our clinics. Thestudy was performed with a sample size of 178 childrentreated with urolithiasis that underwent 221 procedures.These procedures include ESWL, ureterorenoscopy(URS) and percutaneous nephrolithotomy (PCNL).CONCLUSIONS: We conclude in this study that ESWLin children was the most appropriate procedure for renaland proximal and middle-third ureteral lithiasis. Kidneystones measuring 2 to 3 cm can be treated without additionalprocedures or combined approaches. In contrastcystine stones caused the major problems for fragmentation.Moreover, the use of double J catheters increasedthe need for ESWL when catheter calcification occurredand endoscopic removal was impossible. The benefitsof this method must be individually assessed both for thebenefit of the temporary placement as well as for theexpectation of permanence.We conclude that URS is the best choice for distal-thirdureteral lithiasis and some cases of proximal and middle-third ureteral lithiasis. This enables for simultaneoustreatments, ureteral dilatation and unexpected diagnoses.In particular, rigid ureteroscopy offers adjuvantoptions to ESWL with great therapeutic potential andeasy handling. In consequence, to our good results andcost-benefit balance using ESWL and rigid URS (evencombined), the use of flexible URS for renal lithiasis hasbeen reduced. In general community units like ours, the combinedPCNL has been indicated for particular complex cases,and open or laparoscopic surgery was not necessary inany case.
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This article presents a review of the diffe-rent tests used for the evaluation and follow-up of ure-thral strictures. Because there is no consensus on how to assess urethral pathology, we reviewed each of the next follow-up tests: questionnaires, uroflowmetry, ultra-sound, urethroscopy, urethrogram, CT scan and MRI, outlining their benefits and limitations in the diagnosis and follow-up of urethral stricture. Urethrogram and ure-throscopy are the most commonly used tests, as they are those that give us more information on the evaluation of stenosis and for surgery planning. Questionnaires and uroflowmetry play a key role in the follow-up of these patients. Ultrasonography has high sensitivity and spe-cificity for evaluating the spongiofibrosis, however it is not done routinely. The CT/MRI is recommended in the evaluation of pelvic trauma associated with fractures.
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Adjuvant intravesical bacillus Calmette-Guérin (BCG) therapy is the standard conservativeadjuvant treatment and the most effective regimen forpatients with high-risk non-muscle-invasive bladdercancer (NMIBC). The term “BCG failure” is generallyused to refer to recurrence or progression following BCGtherapy, as experienced by many patients. However, theterm has been defined inconsistently, and several studieshave indicated that patients with a particular pattern ofBCG failure have a worse prognosis. There are manydifferent treatment options for patients who experienceBCG failure.OBJECTIVE: To summarize the different currentdefinitions of BCG failure and the present treatmentoptions available for patients with high-risk NMIBC whoexperience BCG failure.EVIDENCE SYNTHESIS: Overall, the failure rate inresponse to BCG is about 40-50%. Most guidelinesrecommend that patients failing BCG should be offeredradical cystectomy (RC). The significant potential forprogression specific to high-risk NMIBC leads someclinicians to argue that immediate RC should beconsidered the preferred first-line treatment in high-riskpatients, bearing in mind that it achieves a long-termsurvival rate in excess of 90% with ongoing improvementsin morbidity. While other salvage intravesical treatmentshave to be considered oncologically inferior to RC,several therapies are now available if the patient is unfitto undergo RC or if bladder preservation is the objective,and some agents have shown promise in the context ofBCG failure.CONCLUSIONS: The definition, prediction, andtreatment of BCG failure remain topics of debate. Patientswith BCG failure need carefully selected, individualizedtherapy in experienced hands. Stratification of patientswith BCG failure into groups can identify those with abetter or worse prognosis. RC should be the selectedoption if a patient experiences BCG failure, but severalpromising intravesical salvage options are availablefor those cases in which the patient is unfit for surgeryor bladder preservation is preferred. Currently dataare still inadequate to allow formulation of definitiverecommendations, and larger and higher quality studiesof salvage intravesical therapies are urgently required.
Case Report
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OBJECTIVE: The aim of this brief report was to present and evaluate workflow of preparation of lowcost individual silicone replicas of kidneys for laparoscopic training and surgical simulation of difficult nephron sparing surgeries.METHODS: The work flow consists of four steps: 1.Image segmentation; 2.Casting mould designing; 3.Manufacturing of casting mould; 4.Silicone replica casting. To evaluate the cost and time required to execute the presented method, authors prepared 5 silicone models for 5 consecutive patients undergoing laparoscopic kidney tumorectomy due to renal cell cancer.RESULTS: Average times of image segmentation, casting mould design, casting mould printing and pouring of silicon replicas were 94 min, 22 min, 14 h and 30 min, respectively. Average costs of casting mould printing and casting of silicon replica were 14.4$ and 7.4$ respectively.CONCLUSION: The presented technique is simple to perform and beyond basic 3D printer it does not require any other expensive equipment. The final silicone model reproduces shape and elasticity of the living organ and has similar mechanical strength. These properties of silicone replica in combination with the presented technique can be used to prepare other artificial organs, ready for a simulation of treatment.
Case Report
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OBJECTIVE: We describe the characterization of a new isolated in Spain of Klebsiella pneumoniae ST258 producing KPC-3, carbapenems non-susceptible, recovered from a sample of urine from a patient with urinary tract infection and no history of carbapenems exposure.METHODS: After the isolation, identification of K. pneumoniae was performed by biochemical tests and mass spectrometry. The carbapenems susceptibility testing was performed by microdilution and E-test in cation-adjusted Mueller-Hinton. The study was completed by Rapidec® Carba NP. In order to determine the genetic basis of resistance to carbapenems we used Xpert® Carba-R for carbapenemase type and subtype was subsequently analyzed by amplification by PCR and sequencing. RESULT: We demonstrated by MLST that the strain belonged to the clone of high-risk ST258. CONCLUSIONS: This is the first characterization, in our media, of a clinical isolated of K. pneumoniae ST258 producing KPC-3 and no history of carbapenems exposure.
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OBJECTIVSE: To describe the completeresponses in our patients with metastatic renal cancertreated with tyrosine kinase inhibitors.MATERIAL AND METHODS: Between June 2007 andDecember 2014 we treated in our department 43 patientswith metastatic renal cancer with antiangiogenic drugs.RESULTS: 9.3% (4/43) of the patients treated withantiangiogenic drugs obtained complete responseaccording to RECIST 1.1 criteria. In 3 of the 4 patients,complete response was obtained during the first-linetreatment with sunitinib at doses of 50 mgr/day in a 4/2scheme and the remaining patient obtained it with secondline axitinib at doses of 10 mgr/day.CONCLUSIONS: Tyrosine kinase inhibitors can inducecomplete responses in patients with metastatic renal cancer.Discontinuation of treatment with tyrosine kinase inhibitorsafter a complete response may be an option.
