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OBJECTIVES: To review the features of nonmetastatic castration resistant prostate cancer (nmCRPC) and analyze the available therapeutic options. METHODS: A literature search was performed using MEDLINE/Pubmed and EMBASE databases.RESULTS: Non metastatic CRPC occurs when a properly castrated patient presents a PSA increase without radiological distant metastases. Up to now, the new therapies available for treatment of castration resistant prostate cancer (CRPC) have been tested and approved to be used in patients with distant metastases. Therefore there is a lack of proved effective therapies that have been traditionally covered with second line hormonal maneuvers.A major limitation of studies evaluating hormonal maneuvers is that they had as primary end point PSA decline assesment, generally equal or greater than 50%, on the basis that a response entailed a greater survival. However, and admitting that there is a relationship between PSA progression and survival, nowadays in a clinical trial changes in PSA are not accepted as surrogate for survival. For this reason there are no studies that directly show that second-line hormonal maneuvers prolong survival. Despite the absence of alternatives, some patients especially those worried about PSA progression, can benefit from these maneuvers.CONCLUSIONS: Second-line hormonal maneuvers can be an alternative in the absence of effective therapies, as long as they are well tolerated in well informed patients who refused observation or clinical trial inclusion.
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OBJECTIVE: To define, based on PSA value, Gleason score (GS), clinical stage and age, those patients diagnosed with asymptomatic prostate cancer whose cases warrant further study of bone metastasis (BMet).METHODS.- From January 2006 to May 2010, we evaluated 263 patients diagnosed with prostate cancer who were chosen for further study of bone scintigraphy following the consensus protocol accepted by the Ministry of Health of Andalusia (Integrated Andalusian Process Prostate Cancer- BPH). All selected studies met the criteria defined in the test indications: PSA >10 or Gleason score (GS) ≥7 or positive biopsy of seminal vesicles, all without symptoms of bone pain. A multivariate analysis of potential predictive factors for positive bone scintigraphy was performed and cutoffs were determined by calculating the following diagnostic rates: sensitivity, specificity and positive and negative predictive values with their respective confidence intervals at 95% certainty.RESULTS- BMet were detected in 29 cases (11%). The average age of the patients with a positive bone scan was 65.5 and 68.4 years in those with a negative result (p=0.03). Multivariate analysis showed that GS OR: 2.08 [95% CI (1.34 – 3.18)] (p<0.001) and PSA level 21-200 ng/ml OR: 3.68 [95% CI (1.13-1.02)] (p<0.05) were independent predictive variables for positive bone scan. The cutoffs were estimated by ROC curve analysis, resulting in a cutoff of 16.18 ng/ml for PSA value and 7 for GS (larger area under the curve: 0.864 with a sensitivity of 94.5% and specificity of 47%). CONCLUSIONS.- In the group of patients defined in our study, diagnosed with asymptomatic prostate cancer, the assessment of BMet using a bone scan should be carried out with a PSA level ≥ 16.18 ng/ ml and GS ≥7 as reference points.
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OBJECTIVES: To perform a systematicbibliographic review of the literature assessing the qualityof life and complications of robotic prostatectomy (RP)versus low-dose rate brachytherapy (LDR-BT) in patientswith localized prostate cancer (PCa).METHODS: A systematic search was conducted inPubMed, EMBASE and Cochrane, Centre for Reviews andDissemination, Emergency Care Research Institute, Webof Knowledge, Technology Evaluation Center, ClinicalEvidence, Uptodate, Hayes and Drug EffectivenessReview Project. Systematic reviews and prospectivestudies comparing RP to LDR-BT in men with localized PCawere included. The primary outcome was quality of lifeand the secondary endpoint complications rate.RESULTS: Three systematic reviews and four prospectivestudies were included. RP showed better results thanLDR-BT for SF-12-physical domain (p <0.01) and fasterrecovery to pre-operative scores. LDR-BT improvedscores for UCLAPCI questionnaire-urinary and sexualdomains compared to RP during the first three years offollow-up (p <0.001). First postoperative year urinaryincontinence rate was favorable for LDR-BT (88.0%vs 84.5%, p <0.001). No differences for intestinalfunction scores for the first three post-intervention years(p = 0.02) were found. Major complications of LDR-BTwere gastrointestinal and genitourinary toxicity, althoughpooled weighted events rate of the studies was notanalyzed.CONCLUSIONS: LDR-BT improves quality of life in termsof urinary and sexual function in patients with localizedPCa vs RP during the first three years post-intervention
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Low-intensity extracorporeal shock wave therapy (LIESWT) of the penis has recently emerged as a promising modality in the treatment of ED.OBJECTIVES: The objective of this paper is to assess the effectiveness and safety of LIESWT on patients with ED who have failed to respond to PDE5i treatment.METHODS: Open label, prospective, longitudinal observational study. The study involved an uncontrolled population of 25 patients. The treatment consisted in applying 20,000 shock waves during a period of four weeks. In each session the patient received 5000 shock waves of 0.09 mJ/mm2: 1800 were applied on the penis (900 on each corpus cavernosum), and 3200 were applied on the perineum (1600 on each crus). During the active treatment and follow-up phases, all patients remained on their regular high on demand or once-a-day dose PDE5i schedules.Main Outcome Measures: Effectiveness was assessed by IIEF-6, SEP2, SEP3 and GAQ. Patients were considered to be responders whenever they improved on all three erection assessment parameters and respond positively to the GAQ at three months post-treatment. Adverse events were recorded. Statistical variables were applied and findings were considered to be statistically significant whenever the P value was<0.05.RESULTS: Eighty percent (median age 63) of the patients (20/25) completed the study. Five patients were lost to follow-up and were excluded from the analysis.Sixty percent (60%) of the patients responded to the treatment, improved the 3 efficacy evaluating parameters and responded positively to the GAQ. The increase in mean IIEF-6 score was of 9 points after the third posttreatment month. There were no patients reporting treatment-related adverse events. CONCLUSIONS: LIESWT for men with ED and that are PDE5i non-responders was safe and effective and restoring PDE5i response in more than 50% of patients. A large-scale multicenter study is required to determine the benefits of this treatment for ED
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OBJECTIVES: To analyse the improvement in both symptoms (IPSS questionnaire) and uroflowmetry parameters (Qmax) after treatment with different alphablockers in patients with LUTS and BPH. The efficacy of alpha-blocker treatment on urodynamic parameters was also analysed in some patients.METHODS: An epidemiological, retrospective, multicentre, and observational study. Twenty-five (24) Spanish healthcare centres recruited 443 patients with LUTS and BPH, and no other concurrent urological disease, they were on treatment with alpha-blockers. The study variables (demographic, physical examination, IPSS, and urodynamic) were collected retrospectively at start of the study (at least 12 weeks after the start of treatment). Two-tailed statistical tests were performed with a 5% significance level using a SAS statistical software package version 9.0.RESULTS: The IPSS score improved after 12 weeks of treatment (p< 0.0001). The quality of life perception significantly improved (p< 0.0001). The voiding volume and Qmax increased (p<0.0001) and the post-void residual urine decreased (p<0.0001) after treatment both in patients with moderate and severe symptoms. Other than filling pressure and involuntary contraction amplitude (p> 0.05), all cystomanometry parameters improved(p< 0.05). There were statistically significant differences (p< 0.05) in the pressure flow study values, except for the detrusor contractility rate.CONCLUSION: Alpha-blocker drug treatment of LUTS in patients with BPH leads to a significant improvement in symptoms and bladder voiding urodynamic parameters.
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OBJECTIVE: We investigated the characteristics of patients who underwent Double-J catheter (D-J) implantation, the risk factors for prolonged urine leakage (PUL), and prediction of patients who require medical treatment.METHODS: The data of 535 adult patients who underwent PNL due to kidney stone disease between January 2005 and December 2011 in our clinic were analyzed retrospectively. Patients were divided into 2 groups: Group 1 (n=77) (14.39%) included patients with Double-J catheter due to prolonged (> 24 h) urinary leakage and Group 2 (n=458) (85.61%) patients without urinary leakage.RESULTS: The mean stone burden was 951.94 ± 539.09 mm2 in Group 1, and 676.35 ± 296.65 mm2 in Group 2 (p< 0.05). DJ catheter was implanted in 11.33% of the patients with stone burden below 1000 mm2 versus in 51.21% of the patients with stone burden above 1000 mm2. In Group 1, the number of patients with two or more accesses performed was 18.18%, whereas in Group 2 it was 8.5% (p < 0.05). Among all patients, DJ implantation was performed in 13.07 % of patients with a single access versus 26.41% of patients with two or more accesses. Also, DJ catheter was implanted in 41.46% of patients with residual stones versus 12.14% of stone-free patients. Three patients with stone burden above 1000 mm2, two or more accesses, and residual stone, all of them required DJ implantation.CONCLUSION: DJ implantation due to PUL had approximately 5-fold increase stone burden above 1000 mm2, 2-fold increase in patients undergoing two or more access and 3-fold increase in patients with residual stones. Therefore, we think that the D-J implantation is highly advisable in case of a stone load above 1000 mm2, two or more accesses, and in patients with residual stones.
Case Report
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OBJECTIVE: To report two cases of urachal adenocarcinoma and to review the published literature.METHODS / RESULTS: We present a review of our urachal carcinoma cases from a third level hospital between 1990-2011 in an area of 520.000 inhabitants. Both cases were middle aged men, consulting for repeated urine infections, and abdominal mass with hematuria and mucous discharge through the urethra. They were treated initially with partial cystectomy and adjuvant treatment with chemotherapy in one case, and chemo and radiotherapy in the other. The first case died in 3 years and the other is still alive after 4 years of follow up.CONCLUSIONS: Urachal adenocarcinomas of the bladder are rare tumors the natural history of which has not changed during the last years. Open partial cystectomy with en bloc resection of the bladder dome, urachus and the umbilicus is the standard treatment in localized stages, although minimal invasive techniques appear to have the same oncological outcomes. Pelvic lymphadenectomy is advised. Most of the patients are diagnosed at an advanced local or metastatic stage. There is a need to improve diagnostic techniques for early treatment and to find new chemotherapy protocols @ that can help to improve these patients` survival.
Case Report
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OBJECTIVE: To analyze the different treatments for postoperative chylous fistulae.METHODS: A literature review of the main treatments for postoperative chylous fistula, providing our initial experience of two cases of patients with postsurgical chylorrea, with conservative treatment.RESULTS: There is very limited experience in the treatment of chylous ascites. According to the literature reviewed, Octreotide (somatostatin analogue) can be used, to decrease fistula output. Both our cases cases were treated successfully with subcutaneous octreotide, with drain debit decrease in about 3 days.CONCLUSIONS: The use of octreotide appears to be an effective treatment in the management of chylous fistulae, and it is suggested by some authors as first-line treatment in the management of these, thus decreasing the complications that can appear due to chyle loss.
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We present two cases of enterovaginal and enterocutaneous fistulae associated to treatment with pazopanib, which is an angiogenesis inhibitor for the treatment of metastatic renal cancer. The times from drug administration and the first appearance of a fistula were 6 and 16 months, respectively. None of the cases had a history of surgery or radiotherapy in the area where the complication was observed.Enterovaginal and enterocutaneous fistula represent less than 1% of all published complications caused by the use of antiangiogenic drugs. However, they must be taken into account as the reported mortality rate is close to 30%.Given its low incidence, we believe that sharing this data is a great way to help specialists who have to treat these patients to take the necessary precautions and decide on an adequate approach.
