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Item does not contain fulltext Focal cryoablation is an established minimally invasive technique for the treatment of small renal masses. Because of the lack of robust evidence, it is indicated in selected patients who have relative contraindications to extirpative approaches. With appropriate selection of patients, cryoablation is safe and effective. Main advantages are low risk for complication, minimal invasiveness, and good functional outcomes; oncological outcomes require further studies. The role of the percutaneous approach has been expanding because of its ability to reduce pain and hospitalization, the possibility of performing the procedure under sedation, and the fact that it is potentially more cost effective.

Objective: This study aimed to validate, in a prospective, blinded, international and multicenter cohort, our previously reported four non-invasive tests for bladder cancer (BC) diagnosis based on the gene expression patterns of urine. Methods: Consecutive voided urine samples from BC patients and controls were prospectively collected in five European centres (n=789). Finally, 525 samples were successfully analysed. Gene expression values were quantified using TaqMan Arrays and previously reported diagnostic algorithms were applied to gene expression data. Results from the most accurate gene signature for BC diagnosis were associated with clinical parameters using analysis of variance test. Results: High diagnostic accuracy for the four gene signatures was found in the independent validation set (area under curve [AUC]=Z0.903-0.918), with the signature composed of two genes (GS_D2) having the best performance (sensitivity: 81.48%; specificity: 91.26%; AUC: 0.918). The diagnostic accuracy of GS_D2 was not affected by the number of tumours (p=0.58) but was statistically associated with tumour size (p=0.008). Also, GS_D2 diagnostic accuracy increases with increasing BC tumour risk. We found no differences in the performance of the GS_D2 test among the populations and centres in detecting tumours (p=0.7) and controls (p=0.2). Conclusions: Our GS_D2 test is non-invasive, non-observer dependent and non-labour-intensive, and has demonstrated diagnostic accuracy in an independent, international and multicenter study, equal or superior to the current gold standard (cystoscopy combined with cytology). Additionally, it has higher sensitivity than cytology while maintaining its specificity. Consequently, it meets the requirements for consideration as a molecular test applicable to clinical practice in the management of BC. (C) 2015 Elsevier Ltd. All rights reserved.

Kidney transplantation is the preferred treatment for patients with end-stage renal disease. In order to reduce the morbidity of the open surgery, a robotic-assisted approach has been recently introduced. According to the published literature, the robotic surgery allows the performance of kidney transplantation under optimal operative conditions while maintaining the safety and the functional results of the open approach. We present the case of a mother donating to her daughter affected by end-stage renal disease (ESRD) due to Alport disease (creatinine: 353 umol/l; GFR: 13 ml/min per 1.73 m2). A robotic-assisted kidney transplant (RAKT) was successfully performed. Surgical time was 120 min with 53 min for vascular suture. The estimated blood loss was

INTRODUCTION AND OBJECTIVES: It is unusual to diagnose a urothelial cell carcinoma in the intramural ureter based on the visualization of papillae in the ureteral meatus or as an incidental finding during the transurethral resection of a bladder tumour (TURBT) adjacent to the ureteral meatus. We analyse the incidence of stenosis and upper urinary tract tumours (UTUC) after TURBT/excision of the intramural portion of the distal ureter and/or bladder cancer. METHODS: 112 patients, with a mean age of 69.3 13 years and a mean follow-up of 56 4 months, underwent TUR of the intramuralureter and were diagnosed with non-muscle-invasive bladder cancer (NMIBC) at that location: 58% of cases were concomitant with primary tumours. The TUR specimen of the ureteral meatus was always sent separately for histological analysis. In patients with apparent tumour remaining in the distal ureter, ureterorenoscopy was performed at 3e4 months. A double J catheter was left in patients undergoing extensive resection of the trigone area (32.1%). 22.3% and 75.9% of patients received mitomycin and BCG respectively. RESULTS: Pathological examination revealed Ta in 64%, T1 in 22.3% and CIS in 17%.17 patients (15.2%) developed UTUC, which was located in the distal ureter in 65.4%, and 13 (11.6%) a distal ureteral stenosis. The presence of a ureteral catheter did not influence the outcome (23% vs 33%, p1⁄40.45). In univariate analysis, statistically significant differences were observed between primary and recurrent tumours with respect to the incidence of symptoms (60% vs 26%, p 3 cm were associated with a higher likelihood of development of distal ureteral stenosis and CIS of the intramural portion increased the risk of UTUC. Closer follow-up of should be undertaken since these factors are associated with a higher incidence of upper urinary tract problems.

Objective: The purpose of the present study was to evaluate the length of telomeres in patients with bladder cancer using a quantitative flow cytometry (flow-FISH) technique. Methods: Bladder washing samples from 51 patients with bladder cancer were obtained immediately before transurethral resection. The average length of telomere repeats was measured by flow-FISH, as previously reported. Results were expressed in molecular equivalents of soluble fluorochrome (MESF) units. Results: Bladder washing specimens provided adequate cell numbers for flow-FISH in 49 cases. The TEL means were 1014.71, 2343.36, 5567 and 18267.57 for Ta, T1, T2 and T3/4 tumors, respectively. Regarding grade it was obtained a mean MESF value of 1379.46, 3391.29 and 15925.11 for G1, G2 and G3, respectively. ANOVA demonstrated statistically significant differences in stage ( p : 0.014) and tumor grades ( p : 0.012). In relation to ploidy, we found a mean MESF value of 2701.37 and 16085.44 MESF units for diploid and aneuploid cells, respectively. Significant difference ( p : 0.003) was observed between both groups. Conclusion: To date, this is the first report wherein telomere length was measured using flow-FISH method in exfoliated cells in urine from patients with bladder cancer. Further investigations are required to demonstrate whether flow-FISH technique might be considered as a tumor marker of bladder cancer.

Metastatic renal cell carcinoma can be clinically diverse in terms of the pattern of metastatic disease and response to treatment. We studied the impact of metastasis and location on cancer specific survival.The records of 2,017 patients with renal cell cancer and tumor thrombus who underwent radical nephrectomy and tumor thrombectomy from 1971 to 2012 at 22 centers in the United States and Europe were analyzed. Number and location of synchronous metastases were compared with respect to patient cancer specific survival. Multivariable Cox regression models were used to quantify the impact of covariates.Lymph node metastasis (155) or distant metastasis (725) was present in 880 (44%) patients. Of the patients with distant disease 385 (53%) had an isolated metastasis. The 5-year cancer specific survival was 51.3% (95% CI 48.6-53.9) for the entire group. On univariable analysis patients with isolated lymph node metastasis had a significantly worse cancer specific survival than those with a solitary distant metastasis. The location of distant metastasis did not have any significant effect on cancer specific survival. On multivariable analysis the presence of lymph node metastasis, isolated distant metastasis and multiple distant metastases were independently associated with cancer specific survival. Moreover higher tumor thrombus level, papillary histology and the use of postoperative systemic therapy were independently associated with worse cancer specific survival.In our multi-institutional series of patients with renal cell cancer who underwent radical nephrectomy and tumor thrombectomy, almost half of the patients had synchronous lymph node or distant organ metastasis. Survival was superior in patients with solitary distant metastasis compared to isolated lymph node disease.

The impact of cardiopulmonary bypass in level III-IV tumor thrombectomy on surgical and oncologic outcomes is unknown. We determine the impact of cardiopulmonary bypass on overall and cancer specific survival, as well as surgical complication rates and immediate outcomes in patients undergoing nephrectomy and level III-IV tumor thrombectomy with or without cardiopulmonary bypass.We retrospectively analyzed 362 patients with renal cell cancer and with level III or IV tumor thrombus from 1992 to 2012 at 22 U.S. and European centers. Cox proportional hazards models were used to compare overall and cancer specific survival between patients with and without cardiopulmonary bypass. Perioperative mortality and complication rates were assessed using logistic regression analyses.Median overall survival was 24.6 months in noncardiopulmonary bypass cases and 26.6 months in cardiopulmonary bypass cases. Overall survival and cancer specific survival did not differ significantly in both groups on univariate analysis or when adjusting for known risk factors. On multivariate analysis no significant differences were seen in hospital length of stay, Clavien 1-4 complication rate, intraoperative or 30-day mortality and cancer specific survival. Limitations include the retrospective nature of the study.In our multi-institutional analysis the use of cardiopulmonary bypass did not significantly impact cancer specific survival or overall survival in patients undergoing nephrectomy and level III or IV tumor thrombectomy. Neither approach was independently associated with increased mortality on multivariate analysis. Greater surgical complications were not independently associated with the use of cardiopulmonary bypass.

Patients with end-stage renal disease (ESRD) have an increased risk of developing renal cell carcinoma (RCC). This retrospective study compared clinical and pathological outcomes of RCC occurring in native kidneys of patients with ESRD (whether they underwent kidney transplantation or not) with those of renal tumors diagnosed in the general population. The study included a total of 533 patients with RCC. The ESRD cohort included 92 patients with RCC in native kidneys. Of these, 58 and 34 cases were identified before (pre-Tx group) and after kidney transplantation (post-Tx group), respectively. The control group was composed of 441 RCCs diagnosed in the general population. Variables were compared by chi-square and Student's t tests. Cancer-specific survival was assessed by Kaplan-Meier and Cox methods. The ESRD groups had smaller (P = 0.001), lower-grade, and lower-stage tumors than the non-ESRD group (P = 0.001). The papillary RCC rate was higher in the ESRD groups (P = 0.01). Ten-year cancer-specific survivals were 94.5, 87.9, and 74.6 % in pre-Tx, post-Tx, and non-ESRD patients, respectively (P = 0.003). Mean follow-up was 90.2 months. At multivariate analysis, tumor size (HR = 1.10), pathological stage (HR = 1.46), presence of nodal (HR = 2.22) and visceral metastases (HR = 3.49), and Fuhrman grade (HR = 1.48) were independent adverse prognostic factors for cancer-specific survival. Native kidney RCCs arising in ESRD patients are lower stage and lower grade as compared to RCCs diagnosed in the general population, and these tumors exhibit favorable clinical and outcome features.

It was estimated that in 2012, 57% of the incidence and 65% of cancer deaths have occurred in developing countries, and in the future, the incidence of cancer-related mortality is even expected to rise significantly in these countries. Despite this alarming data, there are still significant disparities in access to cancer care and cancer control between developing nations and higher income countries. There are several hurdles for cancer patients in developing countries which impair adequate treatment, including very little access to programs of cancer prevention and screening measures, early diagnosis and adequate surgical and medical tumor treatment. In this review article, we provide a short assessment and breakdown of the main barriers for proper cancer treatment admission and provide a perspective on potential approached and solutions to enhance cancer research and care in developing countries.

(P 1⁄4 0.180) or when adjusting for thrombus level, age, sex, T stage, N stage, presence of metastasis, and time under surgery (P 1⁄4 0.734). Median cancer-specific survival was 29.1 months (95% CI [21.2, 48.3]) in non-CPB patients and 39.4 months in CPB patients (95% CI [29.3, 80.0]). Cancer-specific survival did not differ significantly based on CPB, either in the univariate analysis (P 1⁄4 0.704) or in the multivariate analysis (P 1⁄4 0.888). In univariate analysis, length of stay (LOS) was estimated to be 26% higher in CPB patients (P 1⁄4 0.002) and the complication rate was marginally lower in CPB patients (P 1⁄4 0.053). However, in multivariable analysis, no significant difference was seen in hospital LOS (P 1⁄4 0.439) or complication rate with the use of CPB (P 1⁄4 0.457). CONCLUSIONS: In our multi-institutional analysis, the use of cardiopulmonary by-pass did not significantly impact cancer specific survival or overall survival in patients undergoing nephrectomy and level III or IV tumor thrombectomy. Higher surgical complications or longer hospital stay were not independently associated with the used of CPB.

Renal cell carcinoma (RCC) extension into the renal vein or the inferior vena cava occurs in 4%-10% of all kidney cancer cases. This entity shows a wide range of different clinical and surgical scenarios, making natural history and oncological outcomes variable and poorly characterized. Infrequency and variability make it necessary to share the experience from different institutions to properly analyze surgical outcomes in this setting. The International Renal Cell Carcinoma-Venous Tumor Thrombus Consortium was created to answer the questions generated by competing results from different retrospective studies in RCC with venous extension on current controversial topics. The aim of this article is to summarize the experience gained from the analysis of the world's largest cohort of patients in this unique setting to date.

INTRODUCTION AND OBJECTIVES: Patients with end-stage renal disease (ESRD) have an increased risk of developing renal cell carcinoma (RCC) in their native kidneys. Although recent studies have shown that most RCCs arising in kidney graft are low-grade, low stage tumors with favourable prognosis, little is known on RCC in native kidneys. The aim of this study was to compare clinical and pathological outcomes of RCC in native kidneys preand post kidney transplantation. METHODS: This was a retrospective study including data from 2 European transplant centers. Information about age, sex, tumour size and staging (T1a vs T1b), grading, histological subtype and outcome were recorded. Qualitative and quantitative variables were compared by using chi-square and t-Student tests. Cancer-specific survival was assessed by Kaplan-Meier method. RESULTS: The study included 92 patients with RCC arising in native kidneys in a total of 2690 recipients. Of these, 58 and 34 cases were diagnosed before and after kidney transplantation (Tx) respectively. The mean age at diagnosis was 58 (range:37-66) and 55 (range: 31-80) in the pre-Tx and post-Tx group respectively (p 0.6). Post-Tx group tumors were smaller (2.9 / 1.4 vs 4.2 / 1.9; p 0.001) and lower stage (p 0.02). Histologic subtype and Furhman grade were not significantly different between the 2 groups. Estimated 5-year and 10-year cancer-specific survival rates were 97 and 87% (p 0.1), and 94% and 87% for pre-Tx and post-Tx group respectively (p 0.4). CONCLUSIONS: This is the first study comparing RCC in native kidneys preand postrenal transplantation. RCCs arising in kidneys of patients after renal transplantation are smaller and lower stage compared to those diagnosed before transplantation. These features may be related to differences in the surveillance strategies between transplanted and not transplanted patients.

and 2009 archived at our institution. A total of 330 patients with initially diagnosed NMIBC were identified. The use of antihypertensive drugs at TUR-BT was reviewed focusing on the use of RAS inhibitors and other agents (calcium-channel blockers, ƒA-blockers, and diuretics). We retrospectively investigated the clinical outcomes following TUR-BT in patients who did or did not administer RAS inhibitors. The median follow-up period was 4.1 years. RESULTS: A total of 128 patients (38.8%) experienced subsequent tumor recurrence during follow-up. One hundred sixteen patients (35.2%) received medications for hypertension at TUR-BT. Fifty-one patients (15.5%) had received ACEI or ARB administration. Multivariate analysis demonstrated that tumor multiplicity, the absence of BCG instillation, and no ACEI or ARB administration (P 0.010 HR 2.26) were independent risk factors for subsequent tumor recurrence. The 5-year recurrence-free survival rate was 78.4% in patients administered ACEIs or ARBs, and 53.3% in their counterparts (p 0.011). CONCLUSIONS: The absence of RAS inhibitor administration was an independent risk factor for subsequent tumor recurrence in patients with initially diagnosed NMIBC. Our data supports further investigation of the RAS inhibitors as a potential therapy to decrease tumor recurrence in NMIBC.

Juan I. Martinez-Salamanca*, Madrid, Spain; Giacomo Novara, Padua, Italy; Roberto Bertini, Milan, Italy; Joaquin Carballido, Madrid, Spain; Thomas Chromecki, Graz, Austria; Gaetano Ciancio, Miami, FL; Sia Daneshmand, Los Angeles, CA; Christopher Evans, Davis, CA; Paolo Gontero, Turin, Italy; Javier Gonzalez, Madrid, Spain; Axel Haferkamp, Frankfurt, Germany; Markus Hohenfellner, Heidelberg, Germany; William C. Huang, New York, NY; Theresa Koppie, Portland, OR; Adam Lorentz, Atlanta, GA; Claudio Martinez-Ballesteros, Madrid, Spain; Viraj Master, Atlanta, GA; Rayan Matloob, Milan, Italy; James McKiernan, Carrie Mlynarczyk, New York, NY; Francesco Montorsi, Milan, Italy; Hao Nguyen, Davis, CA; Sascha Pahernik, Heidelberg, Germany; Joan Palou, Barcelona, Spain; Raj Pruthi, Chapel Hill, NC; Krishna Ramaswamy, New York, NY; Oscar Rodriguez-Faba, Barcelona, Spain; Paul Russo, New York, Spain; Martin Spahn, Wuzburg, Germany; Shahrokh Shariat, New York, NY; Carlo Terrone, Novara, Italy; Derya Tilki, Davis, CA; Daniel Vergho, Wuzburg, Germany; Alex Volpe, Novara, Italy; Eric Wallen, Chapel Hill, NC; Evangelos Xylinas, New York, NY; Richard Zigeuner, Graz, Germany; John A. Libertino, Burlington, Macedonia

Background The indication and timing of nephrectomy in patients with autosomal dominant polycystic kidney disease (ADPKD) remain controversial, especially in patients who are candidates to renal transplantation (RT). The main surgical options such as unilateral vs. bilateral nephrectomy, nephrectomy before vs. after RT, or simultaneous nephrectomy and transplantation, are herein discussed. Objective Evidence acquisition of the best surgical management available for ADPKD in the context of kidney transplantation. Acquisition of evidence Systematic literature review in PubMed from 1978 to 2013 was conducted. Articles selected included: randomized controlled trials and cohort studies. Furthermore, well designed ADPKD reviews were considered for this study. Synthesis of evidence Laparoscopic nephrectomy in ADPKD is a safe procedure with an acceptable complication rate. Unilateral nephrectomy has advantages over the bilateral one regarding the perioperative complication rate. Although the timing of nephrectomy is controversial, it seems that simultaneous nephrectomy and renal transplantation neither increase surgical morbidity nor affect graft survival. Conclusions Simultaneous nephrectomy and RT appear to be an acceptable alternative to conventional two-stage procedure without any increased morbidity, in the context of ADPKD. Furthermore, laparoscopic nephrectomy performed in experienced centers is a safe alternative to conventional approach.

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Objectives: Evaluate the rate of residual tumor, understaging and perioperative complications in patients with high grade non-muscle-invasive bladder cancer who underwent second transurethral resection (re-TUR). Material and methods: A retrospective review of 47 patients with high grade non-muscle-invasive bladder cancer who underwent second TUR from January 2007 to December 2009 at our institution. We evaluated the rate of residual tumor and understaging detected by re-TUR, complications, and the cost of the surgery. Results: Twenty-two patients underwent second TUR because of the absence of muscle in the initial resection specimen (cTx). We observed residual disease in 8/47 patients (17%) and understaging in 2 cases (4.2%), the only 2 patients understaged muscularis propria was not present in the sample of initial TUR. The other 20 cTx (90%) were cT0 in the re-TUR. We did not identify any case of cT1 understaged in the re-TUR (>= cT2). Six patients (12.6%) reported complications related with the second TUR (one urethral stricture, two patients required reintervention because of bleeding, one febrile urinary infection and two bladder perforations). Conclusions: Our findings show that the absence of muscle in the initial resection specimen is the only risk factor for understaging. Therefore, we consider re-TUR is mandatory in these cases. On the other hand, when complete TUR has been performed and the muscularis propria is present and tumor free (cTa-T1), we consider systematic re-TUR is not necessary and only indicated in selected patients, even more if we consider that re-TUR is not exempt from complications. (C) 2011 AEU. Published by Elsevier Espana, S.L. All rights reserved.

Laparoscopy has become the standard of care for kidney recovery during live donor nephrectomy (LDN) because of the well-documented better outcomes of minimally invasive surgery compared with the open approach [1-4]. Especially in the donor population, the cosmetic results are of great importance; therefore, an effort to reduce the incision size should be attempted while maintaining the safe general principles of surgery. We present our initial experience with the use of 3-mm instruments for laparoscopic LDN. (C) 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Purpose: Describe morbidity and survival in patients older than 80 years with muscle invasive bladder cancer (MIBC) treated with radical cystectomy (RC) or transurethral resection (TUR) in our institution. Materials and Methods: We reviewed our database of all patients older than 80 years treated with RC and TUR for MIBC between 1993 and 2005 in our institution. Twenty-seven patients were submitted to RC, with mean age of 82 years and mean follow-up of 16.4 months. RC was carried out following diagnosis of previous MIBC in 14 cases (51.9%). The American Society of Anesthesiology (ASA) score was III or IV in 23 patients (85.1%). Seventy-two patients with a mean age of 84 years and mean follow-up of 33 months, diagnosed with MIBC, were managed by means of TUR. The ASA score was III-IV in 64 (88.8%) patients. Results: Pathological stage of the RC specimen was pT3 in 18 cases (66.7%). Mean hospital stay was 16 days. Early complications were assessed in 8 patients (29.6%), with an overall survival (OS) of 42.94%, and cancer-specific survival (CSS) of 60.54%. In patients submitted to TUR, clinical stage was T2 in 36 cases (50%). The mean hospital stay was 7 days, with a readmission rate (RR) of 87.5%. OS and CSS was less than 20%. Conclusions: RC in octogenarian patients is a safe procedure, with complication and survival rates comparable to RC series in general population. Transurethral resection (TUR) for patients with MIBC within this age range is a much less morbid procedure, but disease specific survival is lower.

OBJECTIVE To review the results of parastomal hernia repair with a simplified technique of translocation of the stoma with no need for a midline incision. METHODS A total of 405 radical cystectomies with creation of an ileal conduit were reviewed at our institution. The primary goal of the review was to determine the incidence of parastomal hernias in a large series of cystectomies and their management at our institution. Surgical correction of parastomal hernia was indicated in case of pain, discomfort, risk of bowel obstruction, and/or distortion of the abdominal wall. The simplified technique includes an elliptical incision around the stoma and dissection of the hernia's sac down to the level of the fascia. The sac is incised and the peritoneum is entered. The ileal conduit is thereafter mobilized to guarantee sufficient length. This is crucial to be able to transpose the conduit 5-10 cm superiorly and to obtain a tension-free ileostomy. RESULTS Sixty-three patients (16%) presented during the follow-up after ileal conduit a palpable defect or bulge adjacent to the stoma. The review highlighted 19 patients (4.69%) who developed a parastomal hernia and underwent surgical repair. Four cases (21%) recurred at a median follow-up of 55 months. Recurrence was not found to be related to gender, age, body mass index, protein level, radiotherapy, adjuvant chemotherapy, or previous abdominal surgery on univariate analysis. Postoperative complications included one wound infection (5.2%) and one stomal necrosis (5.2%). CONCLUSIONS The technique herein proposed simplifies the management of parastomal hernia repair by avoiding a midline incision, which implies a reduction in surgical trauma with acceptable recurrence and postoperative complication rate. UROLOGY 77: 1491-1494, 2011. (C) 2011 Elsevier Inc.

Purpose: We evaluated new pre-cystectomy predictive factors for outcomes in patients with no evidence of residual tumor at cystectomy (pT0). Materials and Methods: A total of 1,114 patients underwent radical cystectomy at our institution between August 1978 and June 2002, of whom 141 (12.66%) had stage pT0. We analyzed overall and disease specific survival in relation to pre-cystectomy predictive factors, such as clinical stage, grade, size, previous nonmuscle invasive disease, number of previous recurrences, associated carcinoma in situ and lymphovascular invasion in the transurethral resection. Other factors analyzed were lymph node (N+) at cystectomy and induction chemotherapy. Results: Clinical stage was cTa in 10 patients, cT1 in 34, cT2 in 55, cT3 in 30 and cTis in 12. At a median followup of 42.5 months overall survival was 62.53% and disease specific survival was 79.14%. Metastatic disease developed in 17 cases (12.1%). Univariate analysis revealed worse disease specific survival in patients in whom muscle invasive tumor developed after nonmuscle invasive disease (p < 0.05), and in those who presented with 5 or more previous recurrences (p < 0.05), lymphovascular invasion in the transurethral resection (p < 0.05) and N+ at cystectomy (p < 0.05). Multivariate analysis confirmed a statistically significant association between disease specific survival and 5 or more previous recurrences (HR 1.5, 95% CI 1.07-2.10, p = 0.018), muscle invasive tumor after nonmuscle invasive disease (HR 4.4, 95% CI 1.20-16.5, p = 0.026) and lymphovascular invasion in the transurethral resection (HR 1.7, 95% CI 1.12-2.30, p = 0.04). Conclusions: Although clinical outcomes in patients with stage pT0 disease are often excellent, metastatic disease develops in a percentage of them. Muscle invasive tumor after primary nonmuscle invasive disease, 5 or more previous recurrences and lymphovascular invasion in the transurethral resection predict poor survival.

Objective: To evaluate a bladder preservation strategy in patients with either muscle-invasive bladder cancer (MIBC) or development of MIBC cancer due to progression of non-muscle-invasive bladder cancer (NMIBC). Methods: Between October 1982 and March 1998, 48 patients (mean age 61 years, range 45–75) with MIBC (T2a–b and T3a) were treated using transurethral resection followed by three cycles of systemic chemotherapy. 42 patients (87.5%) had primary MIBC and 6 (12.5%) had MIBC subsequent to NMIBC. After chemotherapy, 39 patients (81.25%) achieved complete remission and 4 (8.3%) partial remission. Results: With a median follow-up of 98.5 months (13–246), the overall survival of the 48 patients was 62.6%. The cancer-specific survival (CSS) of the 39 patients with complete remission was 80.8%. Among the 39 patients with complete remission, 19 had invasive recurrence during follow-up with a CSS of 53.2%; by comparison, among patients with preserved bladders, CSS was 72.1% (p = 0.046). Predictive factors analysed were age, sex, tumour size >3 cm, grade, associated carcinoma in situ (CIS), number of tumours and number of previous recurrences. In multivariate analysis only tumour size and CIS were significant predictive factors for progression after preservation. Of the 6 patients with MIBC after NMIBC, 3 (50%) had no remission and underwent cystectomy and 15 patients (38.6%) had NMIBC recurrences during follow-up. CIS and high-grade tumours were treated with bacillus Calmette-Guérin. A bladder preservation rate of 81% and a CSS rate of 89% were obtained in the group with NMIBC recurrences. Conclusions: Conservative management of MIBC cancer is a feasible alternative to cystectomy in selected cases. Patients with MIBC after progression of primary NMIBC are not good candidates for a bladder preservation approach. NMIBC recurrences after bladder preservation in patients with MIBC respond to transurethral resection and bacillus Calmette-Guérin instillations.

Resumen Introduccion La cirugia laparoscopica robotizada da Vinci, ha demostrado en la prostatectomia radical, optimos resultados funcionales y oncologicos con menor curva de aprendizaje, mayor comodidad y vision para el cirujano, y correcta preservacion de las bandeletas neurovasculares. Esto ha dado lugar a que iniciar la experiencia con cistectomia radical robotica (CRR), fuera de nuestro pais. Objetivos Revisar nuestra experiencia inicial en CRR, valorando los resultados quirurgicos y funcionales obtenidos, y complicaciones inmediatas y a corto plazo. Pacientes y metodo Entre diciembre del 2007 y enero del 2009 hemos realizado nueve cistoprostatectomias radicales roboticas y en siete de los nueve casos con linfadenectomia (LDN) robotica. En 5 pacientes por tumor musculo-invasivo y 4 por no musculoinvasivo de alto riesgo. La mediana de edad fue 57 anos (rango 34-81). La derivacion urinaria se realizo extracorporeamente, en 3 casos un conducto ileal, en los 6 restantes una neovejiga tipo Studer, en 3 de estos 6 casos la anastomosis uretro-neovejiga se realizo intracorporeamente. Resultados El tiempo medio total de cirugia fue 300 minutos (rango 280-420) en el conducto ileal y 360 (rango 330-540) en el Studer. Ningun caso requirio conversion ni transfusion sanguinea. La mediana de ganglios extraidos mediante LDN robotica fue 10 (rango 6-18). La AP de la pieza revelo 3 pT0, 2 CIS, 3 pT3, 1 pT4b (margenes positivos). Con mediana de seguimiento de 7 meses no se ha observado ningun implante peritoneal y unicamente una estenosis ureteral. Se inicio dieta oral en 5 casos a las 48 horas. De los 6 pacientes con funcion sexual conservada preoperatoria y seguimiento > 3 meses, 2 tenian ereccion completa al mes, 2 a los 3 y 6 meses, y los 2 restantes presentan ereccion completa con inhib de la 5PDE a los 3 y 9 meses. Todos los pacientes con neovejiga presentan correcta continencia diurna. La estancia media hospitalaria fue de 8,5 dias (rango 7-19). Conclusiones La cistectomia radical mas linfadenectomia robotica, con reconstruccion extracorporea de la derivacion urinaria ofrece buenos resultados quirurgicos y funcionales tempranos. La preservacion cuidadosa de las bandeletas neurovasculares en esta cirugia radical pelvica permite obtener excelentes resultados en la funcion sexual y miccional.

OBJECTIVES To evaluate the risk factors for disease progression in the frequent subgroup of Stage T1G2 (World Health Organization 1973) bladder tumors using an analysis of a large cohort of patients with Stage T1G2 disease. METHODS A cohort of 616 patients with Stage T1G2 were treated with transurethral resection and random bladder biopsies. The mean follow-up was 4.2 years. Univariate and multivariate analyses were done using Cox regression analysis. The independent variables were multiplicity, association with carcinoma in situ (CIS), tumor size, tumor recurrence at 3 or 6 months, tumor grade, and association with CIS at first recurrence. The dependent variable was progression to Muscle-invasive disease. RESULTS Progression to muscle-invasive disease was identified in 28 of the 616 patients (4.5%). On multivariate analysis, when considering recurrence at 3 months, this factor was the principal prognostic factor, with a relative risk of 4.0 (95% confidence interval 1.2-13.3), followed by the presence of high-grade disease or CIS at first recurrence (relative risk 2.8, 95% confidence interval 1.3-5.8) and CIS associated with the primary tumor (relative risk 1.8, 95% confidence interval 1.1-2.9). When considering recurrence at 6 months, more prognostic factors were involved for progression, including as multiple tumors, CIS associated with the primary tumor, recurrence at 6 months, and the presence of high-grade disease or CIS at the first recurrence. CONCLUSIONS In primary urothelial T1G2 bladder cancer, recurrence at 3 months was the main prognostic factor related to progression. Additional factors were the association of CIS with the primary tumor and the presence of high-grade disease and/or CIS at first recurrence. UROLOGY 73: 1313-1317, 2009. (C) 2009 Elsevier Inc.

Resumen Objetivo La crioterapia renal se ha descrito como una tecnica minimamente invasiva que constituye una alternativa para pacientes seleccionados con tumores renales de pequeno tamano. Presentamos nuestra experiencia preliminar con este procedimiento. Material y metodos Dieciocho pacientes (21 tumores) con un tamano medio de 2,2 cm (1-4) en TC prequirurgico se trataron mediante crioterapia renal con doble ciclo de congelacion. Catorce (64%) varones y 4 (18%) mujeres con una edad media de 68 anos (32-84). Todos los pacientes habian tenido cirugias previas: 3 por tumor renal en el rinon que recibio el tratamiento o en el contralateral. El abordaje fue laparoscopico transperitoneal en todos los pacientes. Resultados La media de tiempo operatorio fue de 196 min (120-420) y ningun paciente recibio transfusion intra o postoperatoria. No presentaron complicaciones 14 (64%) pacientes, y hubo un absceso perirrenal en 1 caso, laceracion esplenica (1), lesion ureteral (1) y lesion de la arteria polar (1). Se realizo biopsia peroperatoria en 5 (22,7%) casos, que resulto positiva para carcinoma renal en 2 casos y material insuficiente en 3. La estancia media fue de 6 dias (2-16). Los valores de creatinina preoperatorios fueron de 106 mg/% (48-230) y a los 6 meses de 123 mg/% (52-270). En todos los pacientes se realizo una tomografia computariza al mes y a los 6 meses de la cirugia; en 2 de ellos habia una zona hipercaptante residual. Con un tiempo medio de seguimiento de 46 meses (6-116), 16 (88,8%) pacientes se encuentran libres de enfermedad. En 2 (11%) casos aparecio enfermedad metastasica en el contexto de un enfermedad previa tumoral en el mismo rinon o en el contralateral, que requirio tratamiento con antiangiogenicos. Conclusiones Se trata de la serie mas amplia en nuestro pais, en casos complejos y con un buen seguimiento. Los resultados son prometedores y permiten considerar la crioterapia del tumor renal dentro de las tecnicas minimamente invasivas de cirugia conservadora renal.

Objectives We evaluated incidence, diagnosis, risk factors, and outcome of urethral recurrences (URs) following radical cystectomy in men with bladder urothelial carcinoma (UC). Methods Between 1978 and 2003, a total of 729 male patients underwent radical cystectomy for UC. We determined UR presentation mode and diagnosis. UR was analysed by multivariate analyses according to clinical and pathological risk factors . We evaluated the relative influence of bladder versus urethral pathology on overall survival. Results A total of 34 URs (4.6%) were identified. Previous history of non–muscle-invasive bladder cancer (NMIBC) ( p =0.005), NMIBC pathological subgroup (pTis, pTa, pT1) ( p =0.038) and prostate tumor involvement ( p =0.0001) in cystectomy specimens were independent predictors of UR. URs developed in 5 (2.2%) of 219 cases with orthotopic diversion and in 29 (5.6%) of 510 with cutaneous diversion ( p =0.073). The difference could be explained by patient selection. Cutaneous diversion group had more patients at risk of UR: more cases with prostate tumor involvement ( p =0.026) and with a history of NMIBC ( p =0.009). Neither bladder nor urethral pathology showed any superiority as a predictor of overall survival. Conclusions Previous history of NMIBC, and also NMIBC and prostate tumor involvement in cystectomy specimen were predictors of UR. The lower incidence of UR in patients with orthotopic diversion could be a result of patient selection. Bladder tumor, UR, and even an upper urinary tract tumor could have been the cause of death in these patients.

Objetivo: El objetivo de nuestro estudio, fue valorar la tolerancia por parte del paciente a una biopsia de próstata transrectal ecodirigida usando como método anestésico un gel con 2 gramos de lidocaina intrarectal, así como valorar las complicaciones de esta prueba. Método: Durante 4 meses consecutivos se realizaron 148 biopsias de próstata ecodirigidas usando 2 gramos de lidocaina intrarectal. Se usó el mismo transductor ecográfico transrectal en todos los pacientes, usándose también el mismo mecanismo de aguja para la obtención de los cilindros. Las biopsias fueron realizadas por 7 urólogos diferentes obteniéndose en cada biopsia entre 6 y 12 cilindros. A todos los pacientes se les entregó tras la prueba un cuestionario para valorar la tolerancia a este método. Así mismo, el médico que realizó las biopsias rellenaba un cuestionario a cerca del paciente en el que valoraba la tolerancia del paciente y las complicaciones tras la prueba. Resultados: Se recogieron los datos de tolerancia en 147 casos, existiendo dolor intenso o insoportable globalmente en 25 casos (16,9 %) y nada molesto en 45 pacientes (30,4 %). Se evidenció una asociación significativa entre el resultado del cuestionario del paciente y la percepción del médico que realizó la prueba. Sólo en 10 casos el tacto rectal fue doloroso, en 13 el paso del transductor y en 15 los movimientos del mismo en el recto. Prácticamente todos los cilindros que resultaron dolorosos o insoportables en la toma de muestras fueron los recogidos de la zona del ápex. Se encontró una asociación significativa (p=0,005) entre el número de cilindros y el dolor durante la obtención de los mismos, siendo mayor de lo esperado el dolor cuando se realizaron biopsias por encima de las sextantes. Sólo 14 pacientes no realizarían nuevamente la misma prueba o requerirían otro tipo de anestesia y el 89,9 % (133), volverían a realizarla en las mismas condiciones. Conclusiones: En nuestra experiencia la biopsia prostática ecodirigida es generalmente bien tolerada empleando únicamente un gel anestésico intrarectal. No obstante, el número de punciones durante la biopsia ha sido el factor asociado al dolor de la prueba y al incrementarse aquel debería plantearse el empleo de algún tipo adicional de anestesia.

Objetivo: La sífilis es una enfermedad sistémica que cursa en estadios clínicos sucesivos. La afectación del sistema nervioso central y de la médula espinal en fases tardías puede provocar disfunción vesical. Presentamos un caso de neurosífilis con hiperreflexia asociada. Método: Varón de 51 años diagnosticado de neurosífilis que consultó por trastornos miccionales objetivando en el estudio urodinámico un detrusor hiperactivo de causa neurogénica. Conclusiones: En el diagnóstico diferencial de vejiga neurógena en pacientes que presentan síntomas psiquiátricos y neurológicos debería ser considerada la neurosífilis. El diagnóstico etiológico es por examen del líquido cefalorraquídeo y el diagnóstico de su disfunción vesical mediante estudio urodinámico.

Objetivo: Añadir a la literatura un caso clínico poco frecuente de tumor fibroso solitario pararrenal, analizando las características anatomo-patológicas del mismo así como su pronóstico mediante una revisión bibliográfica de la literatura al respecto. Métodos/Resultados: Presentamos el caso clínico de un varón de 36 años que consultó por dolor cólico en fosa renal derecha, siendo diagnosticado de masa sólida en polo inferior riñón derecho, motivo por el que fue sometido a una nefrectomía radical derecha. El estudio histológico de la pieza evidenció la presencia de un tumor fibroso solitario pararrenal. Conclusiones: El tumor fibroso solitario es una neoplasia muy poco frecuente siendo su localización pararrenal aún menos frecuente, siendo una tumoración de comportamiento benigno en hasta un 90 % de casos. En su diagnóstico resulta clave el estudio inmunohistoquímico.

OBJETIVO: Describir el primer caso de regresión espontánea de trombosis de vena renal y cava inferior en un paciente con carcinoma de células renales. MÉTODO/RESULTADO: Se describe el caso de una mujer diagnosticada de masa renal con trombosis de venas renal y cava. En los estudios de extensión previos a la nefrectomía radical se constata la regresión de dicho trombo que se confirma posteriormente tras la nefrectomía. CONCLUSIÓN: La regresión espontánea de metástasis de carcinoma de células renales se estima menor al 1%. Este es el primer caso descrito en la literatura que afecta a una trombosis tumoral de venas renal y cava inferior.