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OBJETIVO: Pretendemos analizar en los pacientes pT2 con márgenes afectados el valor pronóstico real de los márgenes en función de su número y localización.MÉTODOS: Analizamos 448 (34,3%) pacientes con márgenes afectados de una serie de 1.310 pacientes T1-T2 tratados mediante prostatectomía radical entre 1.989-2.012. De ellos 164 son pT2(+), 119 (72,6%) tienen afectación unifocal 41 (34,5%) unifocal en lóbulo derecho; 35 (29,4%) unifocal en lóbulo izquierdo, 40 (33,6%) unifocal en ápex, 3 (2,5%) unifocal proximal y 45 (27,4%) afectación multifocal.RESULTADOS: Los pT2(+) unifocales y multifocales no evidencian diferencias significativas en ninguna de las variables clínico-patológicas comparadas. Sin embargo la Supervivencia Libre de Progresión Bioquímica (SLPB) a 5 y 10 años es significativamente peor en el grupo multifocal, (p<0,000). En el estudio multivariado son influyentes en la SLPB de los 164 pT2(+): afectación multifocal (HR: 3,4; IC 95% 1,7-6,9 p<0,000) y PSA (HR: 1,03; IC 95% 1,02-1,05 p<0,000) siendo el mejor punto de corte, PSA >15 ng/ml (HR: 3,7; IC 95% 2,1-6,6 p<0,000). Grupos de Riesgo: Utilizando las variables de influencia independiente el mejor modelo utilizando los modelos de Cox incluye dos grupos de riesgo: Grupo 1 (0 variables presentes): Son pT2(+) con afectación unifocal y PSA<15 ng/ml, (63%). Su SLPB es 81±4% y 77±4% (5 y 10 años). Grupo 2 (1-2 variables presentes): Son pT2(+) con afectación multifocal, PSA>15 ng/ml o ambas, (37% restante). Su SLPB es 46±6% y 26±7% (5 y 10 años). La SLPB es significativamente diferente entre ambos grupos (p<0,000). La SLPB del Grupo 1 es similar a la de los pacientes pT2 márgenes (-), (p=0,242). La SLPB del Grupo 2 es similar a la de los pT3 márgenes (+), (p=0,637). El modelo explica significativamente mejor la SLPB que cualquiera de las variables analizadas individualmente (estudio multivariado, modelo de Cox).CONCLUSIONES: En los pT2(+) el pronóstico es significativamente peor cuando la afectación es multifocal. Además pueden diferenciarse claramente dos grupos de pacientes desde el punto de vista de la SLPB según sus variables influyentes. Los datos sugieren que desde el punto de vista del pronóstico el segundo grupo está infraestadiado mientras que el primero está sobreestadiado.
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OBJECTIVES: Currently there are instruments to evaluate the different features of the impact on quality of life in those patients with prostate cancer undergoing any type of treatment, but most of them have 50 or more questions and they are difficult to apply in clinical practice. An English validation of a shortened version of the EPIC (Expanded Prostate Cancer Composite), the most used instrument to measure the quality of life in patients with prostate cancer, has been published recently. This version called EPIC-CP (Expanded Prostate Cancer Composite-Clinical Practice) consists of 16 questions arranged in a page, for easy and rapid clinical application. The objective of this work is to validate a Spanish version of the EPIC-CP.METHOD: An inversa-directa Spanish translation of the original version was performed. The EPIC-CP and EQ5D questionnaires were applied to 46 patients eligible to be subjected to different treatments - open prostatectomy (OP), Robotic Prostatectomy (RP), brachytherapy (Br) or conformational radiotherapy (CR) - and 82 patients already treated (9 OP, 13 RP, 7 Br, 4 CR). For reliability evaluation, the Cronbach´s alpha was used to test the internal consistency for each domain of the EPIC-CP. Treated and untreated patients´ scores were compared with the Wilcoxon range sum test to assess the sensitivity to change.RESULTS: Cronbach´s alpha was elevated in all the EPIC-CP domains (near or greater than 0.7), indicating a high internal consistency. There was no significant difference in age and educational level between treated and untreated patients. We found significant differences between treated and untreated patients in the total EPIC CP score, in the domains of urinary incontinence, bowel function, sexual function and hormonal function.CONCLUSION: The Spanish version of the EPIC-CP is reliable and valid, so it is a useful tool to measure the quality of life in patients with prostate cancer, as well as the impact of different treatments.
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OBJECTIVES: Surgical manipulation of cancer has been shown to increase blood borne cancer cell dissemination and increase the risk of metastasis. We present the effect of prostate biopsy on prostate cell dissemination and the phenotypic characteristics of these cells.METHODS: 50 men undergoing initial prostate biopsy for suspicion of prostate cancer were studied. Blood samples were taken immediately before, and 1 and 24 hours after biopsy for circulating prostate cells (CPC) determination and phenotypic characterization. CPCs were detected and counted using standard immunocytochemistry using anti-PSA and then characterized using anti-P504S and anti-matrix metalloproteinase-2 (MMP-2).RESULTS: 14 (28%) men had cancer detected on biopsy. 13/14 had P504S (+) and MMP-2 (+) cells detected prior to biopsy. One hour after biopsy there was a mixture of P504S (+) and P504S (-) cells detected, as well as MMP-2 (+) and MMP-2 (-) cells detected. 24 hours after biopsy the same 13/14 men remained positive, although the number of CPCs increased 1 hour after biopsy and then the numbers decreased to prebiopsy levels after 24 hours. In cancer negative men, P504S (-) and MMP-2 (-) cells were detected, some of these cells persisted 24 hours after biopsy.CONCLUSIONS: Prostate biopsy causes dissemination of prostate cells into the circulation, both malignant and benign; the majority of them are cleared within 24 hours. There was no conversion of negative to positive result in men with cancer, this suggests that the inherent capacity of malignant CPCs to disseminate is more important than the effect of dissemination caused by prostate biopsy.
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OBJECTIVES: To study the relationshipbetween cost-effectiveness and budgetary impact theapplication of a neoadjuvant chemo-hyperthermiatreatment on 15 patients with NMI multi-recurrentbladder cancer and/or whose risk of recurrence andprogression is medium-high, compared with the standardneoadjuvant BCG treatment, has had on the HospitalComarcal de Monforte de Lemos (Lugo).METHODS: A model was designed from an SNSperspective with a temporary horizon of three yearsto compare the costs of applying neoadjuvant chemo-hyperthermia on the patients of the clinical test (8instillations weekly of 80 mg Mitomycin C recirculatingat 43° C for an hour prior to carrying out a transurethralresection of the bladder tumor) with the costs of treating15 patients with the same risk profile with the standardadjuvant treatment of BCG (control group). The effectiveavailable costs corresponding to drugs, disposables andthose relative to TURBT, cold biopsy and tumor relapsewere included. The costs of diagnostic tests and follow-up were discarded from the model because they did notvary between groups.RESULTS: The model built with effective and publishedcost data establishes a favourable difference in favourof the neoadjuvant treatment with chemo hyperthermiain terms of 3 year costs with a minimum global savingsof 10,300€ and 687€ per patient, together with animprovement in the effectiveness of the treatment. Thesevalues could reach a minimum savings of 25,960€ and1,731€ per patient, if a change in protocol is made afterthe neoadjuvant treatment, which uses the cold biopsyto check the results. Of the 15 patients pre-treated withchemo-hyperthermia, 11 high-risk and 4 medium-risk, 9have responded completely (absence of residual tumor)and 6 partially (shrinking of the tumor). The number ofexpected relapses has been reduced from 8 to 2 andprogression from 3 to 0.CONCLUSIONS: The neoadjuvant treatment with chemohyperthermia constitutes a cost-effective therapeuticstrategy
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OBJECTIVES: The aim of our study was to correlate the results obtained by 3T Magnetic Resonance Spectroscopic Imaging (MRSI3T) with those obtained by histological examination of samples of the trans-perineal ultrasound-guided prostate biopsy (TPUS-B). METHODS 34 patients were enrolled in the study. All patients had a clinical suspicion of cancer due to increased PSA and/or positive digital rectal examination. Patients were subjected to an MRSI 3T examination and subsequently to TPUS-B.RESULTS Of the 22 (22/34) patients who presented abnormalities MRSI at 3T, 9 had a histological diagnosis of Prostate adenocarcinoma. Of the remaining 13 patients, 6 were found to be histologically positive for Benign Prostatic Hypertrophy and 7 Chronic Interstitial Inflammation or High Grade Prostatic Intraepithelial Neoplasia. 12 (12/34) patients found to have no peripheral alterations in their prostate on 3T MRSI, none were positive for ADK or inflammation on histology. The sensitivity, specificity, positive predictive value and negative predictive value were 100%, 48%, 40% and 100% respectively.DISCUSSION In this study, we correlated the values obtained from 3T MRSI with the results of histologically examined prostate biopsies. Our work shows that 72.8% of the voxels in which there was a change in ratio of Cit/(Cho + Cr), corresponded to areas of prostate tissue disease. Of these, 73.2% were positive for ADK and 26.8% for CII or HG PIN. In literature, it is noted that PCa can be distinguished from areas of benign tissue, in the peripheral zone, on the basis of the values of the ratio Cit/(Cho + Cr) (17), although some benign conditions, such as prostatitis or PINHG, can alter these values (18-19).CONCLUSIONS In conclusion, the use of MRSI 3T before performing prostate biopsies may represent a valid aid for the urologist in the diagnosis of PCa, allowing them to avoid unnecessary prostate biopsies that may be negative. Furthermore, it would also be possible to reduce the total number of biopsies, thus decreasing patient exposure to the unnecessary risks associated with biopsy.
Case Report
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OBJECTIVE: Vesico-vaginal reflux (VVR) is defined as the reflux of urine into the vaginal vault during voiding, occasionally seen in pre- adolescent girls. The typical history consists in post voiding leaks in the daytime, that correspond to the progressive urine discharge from the vagina, after it has been filled up during micturition. We intend to show two cases presenting with significant urocolpos.METHODS: Description of two clinical cases observed in the pediatric urology office.RESULTS: Clinical case 1.- A 10-year-old girl presented with the complaint of diurnal incontinence (in the immediate post-voiding minutes). The early voiding phase in the cystourethrogram (VCUG) demonstrated progressive gross distension of the vagina (urocolpos) due to retrograde filling as the bladder emptied. The girl was managed with behavioural modifications, and was dry afterwards. Clinical case 2.- A 9-year-old girl presented with history of incomplete voiding. In infancy, she had right-sided vesicoureteral reflux (VUR) and was endoscopically treated at the age of 2. VCUG showed VVR, and no VUR. She was then successfully treated with behavioural modifications. Clinical case 3.- A 10-year-old girl complained of diurnal urinary incontinence, described as post voiding leaks. Again, a VCUG showed VVR and a small urocolpos. After re-education of voiding habits, leaks disappeared, but recurred 6 months afterwards, when she acknowledged no adherence to the therapy.DISCUSSION: Between 12 to 15% of girls referred to Urological clinics because of urine incontinence present VVR. In the absence of a clear anatomical obstruction, reflux happens as the urine flow encounters a natural obstacle in the labia majora usually in girls that close their legs as they void. Instructions on proper voiding form a key element in the management of VVR, and if not enough, the behavioural modification consists on a reverse position during voiding.
Case Report
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OBJECTIVE: Calciphylaxis is a potentially lethal syndrome reported mainly in patients with ESRD on hemodialysis. Etiopathogenesis remains unclear and there is much controversy regarding optimal diagnostic and therapeutic approach. Penile necrosis as a disease presentation is extremely rare. We report two clinical cases treated in our center and perform an evidence review.METHODS: Clinical data was obtained from both patients and an evidence review was performed on PubMed under the criteria “penile necrosis” and “Calciphylaxis”.RESULTS: Both patients underwent partial penectomy due to severe penile necrosis. After surgery both patients received treatment with sodium thiosulfate (STS) 20mg in every hemodialysis session. Both patients showed stabilization of necrotic lesions.DISCUSSION: The same way that biopsying the ischemic lesions produced by Calciphylaxis is discussed and even misadvised, the role of aggressive surgery as first line therapy might be uncertain specially with the raising of new specific drugs such as sodium thiosulfate (STS) that have shown efficacy stopping disease progression.
