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OBJECTIVE: To expose and remind the supamesocolic approach to the left renal pedicle, in addition to review its main indications.METHODS/RESULTS: We perform a detailed description of the surgical technique showing its indications, the position, the incision and retraction systems employed, detailing the steps followed during dissection.CONCLUSIONS: Adequate vascular control and complete resection of large renal and adrenal masses require an adequate exposition; the knowledge of surgical techniques such as supramesocolic approach to the left renal pedicle is very useful and may ease the course of retroperitoneal operations avoiding complications and giving comfort in a frequently difficult operation.
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OBJECTIVES: Nephron sparing renal surgery is considered the technique of choice for renal tumors smaller than 4 cm. We present our oncological results in a 17-year period.METHODS: Between January 1995 and December 2012, 130 renal tumor surgeries (58 open, 72 laparoscopic) were performed. We analize the pathological results, presence of positive surgical margins, local relapse, distant metastases and death.RESULTS: The most frequent tumor was clear cell carcinoma (73%) in a pT1 stage (87%). Mean tumor size was 3 cm. Positive surgical margin rate was 7%, currently without any tumor recurrence among these cases (follow up 37 months). Cancer specific mortality is 0% and local recurrence rate 3%. Mean follow up is 71 months.CONCLUSIONS: Nephron sparing surgery results are similar to radical nephrectomy in tumors smaller than 4 cm. Positive surgical margins do not seem to have an important repercussion in cancer specific survival.
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OBJECTIVES: To determine diagnostic accuracy of urinary cytology (smear test) in patients with preoperative diagnosis of urothelial bladder carcinoma.METHODS: Clinical records of the patients with urotelial bladder carcinoma at the Instituto Nacional de Cancerología (Bogotá D.C., Colombia) from January 2006 to November 2010 were reviewed. Demographic data, pathological reports of preoperative cytology and definitive surgery, tumor classification and time between sample taking for cytology and final pathology were extracted. Descriptive statistics and graphs for continuous and categorical variables were performed. RESULTS: We included 52 patients, 20 underwent cystectomy and 32 transurethral resection of the bladder tumor (TURB). 41 were male. Mean age was 66.6 ± 10.7 years. 151 smears were obtained before surgery, with a median of 3 smears performed per patient at 2.5 ± 1.8 months before definitive surgery. 107 were negative, 14 low grade positive and 30 high grade positive. The sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio and negative likelihood ratio were 30.7%, 90.9%, 97.7%, 9.34%, 3.37 and 0.76 respectively. When the high-grade cytology was compared with the high-grade definitive report some characteristics increased (Sensitivity 47.4%, Specificity: 97.8%, Positive Likelihood Ratio: 21.8) and also when compared with muscle invasion (Sensitivity: 73.9, Positive Likelihood Ratio: 7.27). CONCLUSION: Preoperative cytology has sensitivity and specificity similar to those described in other clinical settings. Also noteworthy is that one high-grade preoperative cytology has a high positive likelihood ratio for high-grade tumor and invasive tumor (≥T2).
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OBJECTIVES: We intend to analyze the prognostic value of positive surgical margins depending on their number and location in pT2 patients.METHODS: We analyze 448 (34.3%) patients with positive surgical margins from a series of 1,310 T1-T2 patients treated with radical prostatectomy between 1989-2012. Of them 164 are pT2(+). 119 (72.6%) have unifocal affectation (41 (34.5%) unifocal in right lobe; 35 (29.4%) unifocal in left lobe, 40 (33.6%) unifocal in apex, 3 (2.5%) unifocal proximal) and 45 (27.4%) multifocal involvement.RESULTS: Unifocal and multifocal pT2(+) patients have not evidenced significant differences in any of the clinicopathologic variables compared. However the BPFS at 5 and 10 years is significantly worse in the multifocal group, (p<0.000). In the BPFS multivariate study of 164 pT2(+)influential variables are: multifocal involvement (HR: 3.4; 95%IC 1.7-6.9 p<0.000) and PSA (HR: 1.03; 95%IC 1.02-1.05 p<0.000), being PSA >15 ng/ml (HR: 3.7; 95%IC 2.1-6.6 p<0.000) the best cut-off point. Risk groups: Using the independent influence variables, the best model (using Cox models) includes two risk groups: Group 1 (0 variables): They are pT2(+) with unifocal affectation and PSA<15 ng/ml, (63%). Their BPFS are 81±4% and 77±4% (5 and 10 years). Grupo 2 (1-2 variables): They are pT2(+) with multifocal involvement, PSA>15 ng/ml or both of them, (37%). Their BPFS are 46±6% and 26±7% (5 and 10 years). The BPFS differs significantly between the two groups (p<0.000). The Group 1 BPFS is similar to the pT2(-) patients, (p:0.242). The Group 2 BPFS is similar to the pT3(+) patients, (p:0.637). The model explained significantly better the BPFS than any of the individual variables analyzed. CONCLUSIONS: In pT2(+) patients the prognosis is significantly worse in multifocal involvement. In addition two groups of patients can be clearly distinguished from the BPFS point view according to their influential variables. The data suggest that since the prognostic point view the second group is understaged while the first is overstaged.
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OBJECTIVES: To identify the postprostatectomy prognostic factors of biochemical recurrence (BCR) and develop a predictive model for BCR based on predictive pathological variables after radical prostatectomy (RP). METHODS: We retrospectively analysed patients with clinically localised prostate cancer treated with RP as monotherapy with a minimum follow up period of 12 months. We considered BCR to be the persistence or elevation of PSA levels after RP of > 0,4 ng/ml, and rising in the following determination.We performed uni- and multivariate analysis, using the logistic regression test to determine the variables associated with BCR. We developed a mathematical model to estimate BCR, based on the variables identified, with a logistic function equation and then designed an Excel spreadsheet to apply it. Calibration and discrimination were performed by way of a Hosmer-Lemeshow test and an ROC curve.RESULTS: 693 patients were included. Average age was 63.5 years and average follow up was 88.5 months. BCR was observed in 218 patients. The average time to BCR was 35.5 months, and 90% of the cases occurred in the first 7 years. In the multivariate analysis, the PSA, Gleason Score (GS) ≥ 7(4+3), pathological stage pT3b and affectation of the surgical margin (PSM) were identified as independent prognostic pathological variables related to BCR (p<0,001). The above four variables were included into the equation of the model.Specificity and sensitivity were 90.6% and 50.2%. Its predictive capacity was 80.5% (CI 95% 76,80 – 84.3). CONCLUSIONS: PSA, GS ≥ 7(4+3), pathological stagepT3b and PSM were found to be the independent prognostic pathological variables related to BCR-free survival. The predictive model developed permits BCR risk estimation with a reliability of 80.5%.
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INTRODUCTION: The choice of ideal treatment for a given lithiasis is a crucial factor for its success, minimizing the number of interventions and complications. Previous determination of stone composition and its fragility is desirable, to predict its behavior during extracorporeal shock wave lithotripsy and for evaluation of its appropriateness, or to set the indication for other techniques.OBJETIVES: To determine the role of densitometry in the prediction of composition and fragility of urinary lithiasis undergoing SWL.METHODS: Experimental prospective, blinded, in vitro study using 193 urinary calculi of known composition: monohydrated calcium oxalate, mixed calcium oxalate, uric acid, and calcium carbonate, obtained from spontaneous passage or surgery. Densitometry and SWL were performed on them.We compare the mineral composition of the stone and mineral density of each composition group to check if they are characteristic of each type and correlate these parameters with the energy dose required to fragment them down to a given fragment size.RESULTS: Only 53 out of 193 stones showed valuable data. Calcium carbonate was the composition showing grater mineral content and density (1,24 gr and 0,47 gr/cm2), followed by mixed oxalate (0,51/0,26) and uric acid ((0,52/ 0,15), finishing with the monohydrate calcium oxalate group (0,32/0,05). Only the comparison between calcium carbonate and monohydrated calcium oxalate showed statistically significant results (p< 0,05). Correlation coefficients between mineral content (0,347) and density (0,424) and the energy used for stone fragmentation to a given fragment size were statistically significant (p< 0,05)CONCLUSIONS: In our study, the use of densitometry to determine stone composition and lithiasic fragility did not show conclusive results due to the limited number of calculi tested. Nevertheless, there are signs that, with a different study design , more practically useful results could be achieved.
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OBJECTIVES: Local recurrence after a correct surgical technique and absence of distant metastasis is a rare occurrence after radical nephrectomy. Surgical resection remains the standard management for this pathological setting. Nevertheless controversy persists over surgical approach and adjuvant treatments. METHODS: We report on perioperative outcomes of a small multi-institutional series of patients with fully laparoscopic management of isolated renal fossa recurrence following open radical nephrectomy.RESULTS: All patients underwent full laparoscopic surgery. Mean operative time was 140 minutes (range 75 to 240 minutes). Only one patient had a Clavien Grade IIIa complication. Mean hospital stay was 3 days (range 2 to 4 days). Out of the six patients, 5 had a mean follow-up of 20 months (range 9 to 32 months). Only one of these patients evolved with distant metastasis after surgery.CONCLUSIONS: Laparoscopic resection of local recurrence after open radical nephrectomy is a challenging but reproducible technique. There is still no consensus or an operative protocol for this clinical setting. However, as long as surgery is kept within the possibilities, a laparoscopic approach should be sought.
Case Report
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Topiramate is an approved drug to treatseizures, but its indications have been extended to otherdiseases of the nervous system and as an adjuvant tochronic pain.We present four cases of topiramate-induced nephrolithiasisfrom 2006-2012 in women whose treatment wasprescribed for pain control and as a mood stabilizer atdoses of 250-300 mg/day. In two cases, the lithiasis wascaused by calcium phosphate (apatite) and in the othertwo cases by oxalate and calcium phosphate. The mostcommon metabolic alteration was an alkaline pH, followedby hypocitraturia. The drug was discontinued in twopatients; it was reduced in one and was maintained in thefourth. An increase in fluid and potassium citrate intake wasprescribed. In patients starting treatment with topiramate, anadequate control and prevention of nephrolithiasis shouldbe performed due to the risk of mixed tubular acidosis andhypocitraturia
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