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To describe our initial experience with a new minimally invasive inguinal and pelvic single-access laparoscopic approach, for performing lymph node dissection (LND) in penile cancer: the Pelvic and Inguinal Single Access (PISA) technique.10 patients with different penile squamous cell carcinoma stages (cN0 and ≥pT1G3 or cN1/cN2) were operated by means of the PISA technique, between 2015-2018. Intraoperative frozen section analysis was carried out routinely and if ≥2 inguinal nodes (pN2) or extracapsular nodal extension (pN3) are detected, ipsilateral pelvic LND was performed sequentially as a single-stage procedure and using the same surgical incisions.30-day PCs, estimated blood loss (EBL), transfusion rate, operative time, time to drainage removal, and length of hospital stay (LOS). Medians and ranges of values for selected variables were reported as descriptive statistics.Inguinal LND was bilateral in all cases, and pelvic LND was required in 40%. Total operative time was 120-170 min and median EBL was 66 (30-100) cc. No blood transfusion was required. No intraoperative complications were noted, and postoperative complications rate was 40% (10% major complications-symptomatic inguinal lymphocele). Median LOS was 5.8 (3-10) days. Median time to inguinal drain removal was 4.7 days. Mean number of lymph nodes removed by inguinal LND: 10.25 (8-14). Limited volume retrospective experience from a referral center with short follow-up. Outcomes reported may not be reproducible by surgeons with less experience and skills.PISA is a novel, minimally invasive single-site surgical approach to one stage bilateral inguinal/pelvic LNDs for penile cancer showing a low rate of major complications.

Resumen Introduccion y objetivos La embolizacion prequirurgica de la arteria renal (EPAR) puede emplearse en grandes masas renales antes de la nefrectomia para simplificar el procedimiento y disminuir el sangrado intraoperatorio. Nuestro objetivo es determinar el papel de la EPAR sobre el sangrado intraoperatorio y las complicaciones postoperatorias en los tumores renales izquierdos con trombo tumoral limitado a la vena renal izquierda (nivel-0). Material y metodos Analisis retrospectivo de 46 pacientes intervenidos de nefrectomia radical izquierda y trombectomia como tratamiento de un carcinoma de celulas renales asociado a trombo tumoral de nivel 0 durante el periodo 1990-2020. La EPAR se limito a aquellos casos en los que el acceso quirurgico a la arteria renal principal se encontraba a priori dificultado en el estudio de imagen prequirurgico (n = 9; 19,6%). El sangrado intraoperatorio se estimo en base a la tasa de transfusion perioperatoria, y las complicaciones postoperatorias se categorizaron segun la clasificacion de Clavien-Dindo. Para el contraste de variables se utilizo el test Chi-cuadrado. Se realizo un analisis multivariable para identificar los predictores de transfusion y complicaciones. Resultados No existieron diferencias significativas en la tasa de complicaciones global (11,1 vs. 32,4%; p = 0,19), complicaciones graves (0 vs. 8,1%; p = 0,51), o tasa de transfusion (11,1 vs. 19%; p = 0,49) entre ambos grupos (EPAR vs. no-EPAR). En el analisis multivariable la EPAR no se comporto como un predictor de complicaciones (OR: 0,11; IC95% 0,01-2,86; p = 0,18) ni de transfusion (OR: 0.46; IC95% 0,02-7,38; p = 0,58). Conclusiones En nuestro estudio sobre carcinomas de celulas renales izquierdos con trombo tumoral de nivel 0 y dificultad de acceso a la arteria renal principal, la EPAR no se asocio a un incremento del sangrado o complicaciones postoperatorias, ni se comporto como un predictor independiente de los mismos. Por tanto, podria emplearse como una maniobra prequirurgica segura para facilitar el manejo vascular en casos seleccionados.

Background Lymph node dissection(LND) remains the gold standard in the staging and treatment of locally advanced penile cancer(PC) 1 . Objective To describe our initial experience with a new minimally invasive inguinal and pelvic single-access laparoscopic approach 2 ,for performing LND in PC, first described in Urology by our group in 2015 3 : the Pelvic and Inguinal Single Access(PISA) technique (Fig. 1). Material Between 2015 and 2018, 10 consecutive patients with different PC stages and indication of inguinal LND (cN0 and ≥pT1G3 or cN1/cN2) 1 were operated by means of the PISA technique (Table 1). Intraoperative frozen section(FS) 4 analysis was carried out routinely and if ≥2 inguinal nodes(pN2) or extracapsular nodal extension(pN3) are detected 1 , 5 , ipsilateral pelvic LND was performed sequentially as a single-stage procedure and using the same surgical incisions. If this condition occurs bilaterally in the inguinal LND, the pelvic LND will be bilateral. The video shows the PISA technique in a step-by-step. Instrumental requirements: 30°laparoscopy optic, monopolar scissors,Ligasure (Covidien Surgical,Minneapolis,MN,USA) vascular sealant, extraction-bag, bipolar forceps and 5-mm endo-clip(Hem-o-lok)are required. Results Intraoperative and postsurgical variables are shown in Table 2. Inguinal LND was bilateral in all cases. Pelvic LND was required in 40% of patients. Total operative time was 120-170 minutes. Median estimated blood loss(EBL) was 66(30-100)cc, but no blood transfusion was required. No intraoperative complications were noted. 40% of patients had postoperative complications (10% major complication- symptomatic inguinal lymphocele). Median lenght of hospital stay(LOS)was 5.8(3-10) days. Median inguinal drain removal was 4.7 days. The pathological analysis outcomes are shown in Table 3. Mean number of lymph nodes removed by inguinal LND was 10.25(8-14). Conclusion PISA technique allow a minimally invasive inguinal and pelvic LND using the same set of incisions and carry it out in the same surgical procedure. PISA technique in PC LND seems to be safe, with a low rate of major complications and preserving oncological efficacy.

Diagnosis and treatment of renal cell carcinoma with venous tumor thrombosis remains a challenge today, requiring multidisciplinary teams, mainly in tumor thrombus levels III-IV. Our objective is to present the various diagnostic techniques used and its controversies. A review of the most relevant related articles between January 2000 and August 2020 has been carried out in PubMed, EMBASE and Scielo. Continuous technological development has allowed progress in its detection, in the approximation of the histological subtype, and in the determination of tumor thrombus level. Regardless of the imaging technique used for its diagnosis (CT, MRI, TEE, ultrasound with contrast), the time elapsed until treatment is vitally important to reduce the risk of complications, some of them fatal, such as pulmonary thromboembolism.

Resumen El diagnostico y tratamiento del carcinoma de celulas renales asociado con trombosis venosa tumoral sigue suponiendo un reto en la actualidad, requiriendo de equipos multidisciplinares, fundamentalmente en niveles del trombo III y IV. Nuestro objetivo es la exposicion de las distintas tecnicas diagnosticas empleadas y de las controversias asociadas. Para ello se ha llevado a cabo una revision de los articulos relacionados mas relevantes entre enero del 2000 y agosto de 2020 en PubMed, EMBASE y Scielo. El continuo desarrollo tecnologico, ha permitido avanzar en su deteccion, en la aproximacion del subtipo histologico y en la determinacion del nivel del trombo tumoral. Independientemente de la tecnica de imagen utilizada para su diagnostico (TC, RMN, ETE, ecografia con contraste), es de vital importancia el tiempo transcurrido hasta su tratamiento con el fin de disminuir el riesgo de complicaciones, algunas de ellas fatales como la tromboembolia pulmonar.

Kidney procurement procedure must be carried out following a standardized technique in order to optimize kidney grafts for their subsequent implantation.Review of the available literature on kidney procurement procedure.Narrative review of the available evidence on deceased donor kidney procurement technique after a search of relevant manuscripts indexed in PubMed, EMBASE and Scielo written in English and Spanish.Deceased donor kidney procurement can be divided into two groups, donation after brain death (DBD) and donation after circulatory death (DCD). Kidney procurement in DBD frequently includes other chest and/or abdominal organs, requiring multidisciplinary surgical coordination. During the harvesting procedure, the renal vascular pedicle must remain intact for subsequent implantation and reduced ischemia time.Adequate execution and perfect knowledge of the technique for surgical removal and anatomy reduces the rate of graft losses associated to inadequate harvesting techniques.

Resumen Objetivo Analizar la supervivencia de los pacientes con cancer de prostata (CP) con factores pronosticos desfavorables (FPD) tratados con PR y radioterapia de rescate (RTR) tras recidiva bioquimica (RB) y persistencia bioquimica (PB). Material y metodo Analisis retrospectivo de 446 pacientes con al menos uno de los siguientes FPD: score de Gleason ≥ 8, estadio patologico ≥ pT3 y/o margenes quirurgicos positivos (MQ + ). El criterio de RB fue la elevacion del PSA por encima de 0,4 ng/ml. Evaluacion de supervivencia mediante Kaplan-Meier y log-rank. Para identificar factores de riesgo con posible influencia en la respuesta a RTR y la supervivencia causa-especifica (SCE) se uso analisis uni y multivariable (regresion de Cox). Resultados Mediana de seguimiento: 72 (rango 37-122) meses, mediana de tiempo hasta RB: 42 (rango 20-112) meses. El 36,3% presentaron RB. Presentaron respuesta bioquimica a la RTR 121 (74,7%) pacientes. La supervivencia libre de recaida (SLR) despues de la RTR a los 3, 5, 8 y 10 anos fue del 95,7, del 92,3, del 87,9 y del 85%, la SG a los 5, 10 y 15 anos fue del 95,6, del 86,5 y del 73,5%. La SCE a los 5, 10 y 15 anos fue del 99,1, del 98,1 y del 96,6%, respectivamente. Solo el tiempo hasta la RB Conclusiones La PR solo consigue control de la enfermedad a los 10 anos en aproximadamente la mitad de los casos. El tratamiento multimodal secuencial (PR + RTR cuando precise) aumenta este control bioquimico hasta > 87%, lograndose una larga SCE. Los pacientes con un tiempo hasta recidiva > 24 meses respondieron mejor al tratamiento de rescate.

Objective Survival analysis of patients with prostate cancer (PCa) with adverse prognostic factors (APF) treated with radical prostatectomy (RP) and salvage radiotherapy (SRT) after biochemical recurrence (BR) or biochemical persistence (BP). Materials and methods Retrospective analysis of 446 patients with at least one of the following APF: Gleason score ≥8, pathologic stage ≥pT3 and/or positive surgical margins. BR criteria used was PSA level over 0.4 ng/ml. A survival analysis using Kaplan–Meier was performed to compare the different variable categories with log-rank test. In order to identify risk factors for SRT response and cancer specific survival (CSS) we performed univariate and multivariate analyses using Cox regression. Results Mean follow up: 72 (IQR 27–122) months, mean time to BR: 42 (IQR 20–112) months, mean PSA level at BR: 0.56 (IQR 0.42–0.96). BR was present in 36.3% of the patients. Biochemical response to SRT was observed in 121 (75.7%) patients. Recurrence-free survival (RFS) rates after SRT at 3, 5, 8 and 10 years were 95.7%, 92.3%, 87.9%, and 85%; overall survival (OS) rates after 5, 10 and 15 years was 95.6%, 86.5% and 73.5%, respectively. CSS rates at 5, 10 and 15 years were 99.1%, 98.1% and 96.6%. Only time to BR Conclusions In these patients, RP only controls the disease in approximately half of the cases. Multimodal sequential treatment (RP + SRT when needed) increases this control, achieving high CSS rates and biochemical control in over 87% of the patients. Patients with time to recurrence >24 months responded better to rescue treatment.

Introduction Recurrence trends after renal cell cancer (RCC) nephrectomy are not clearly defined. Objective To evaluate recurrence trends according to recurrence risk groups (RRG). Methods Retrospective analysis of 696 patients with RCC treated with nephrectomy between 1990−2010. Three RRG were defined according to the presence of anatomopathological variables (pTpN stage, nuclear grade, tumor necrosis (TN), sarcomatoid differentiation (SD), positive resection margin (RM)): - Low RG (LRG):pT1pNx-0 G1–4, pT2pNx-0 G1–2; no TN, SD and/or RM(+) - Intermediate RG (IRG):pT2pNx-0 G3–4;pT3–4pNx-0 G1–2; LRG with TN. - High RG (HRG):pT3–4pNx-0 G3–4;pT1–4pN+;IRG with TN and/or SD; LRG with SD and/or RM (+). The Kaplan-Meier method has been used to evaluate recurrence-free survival as a function of RRG. The log-rank test was used to evaluate differences between survival curves. Results The median follow-up was 105 (IQR 63–148) months. Of the total series, 177 (25.4%) patients presented recurrence: distant 15.9%, local 4.9% and 4.6% distant and local. The recurrence rate varied according to the RRG with values of 72.9% for HRG, 16.9% for IRG and 10.2% for LRG (P = .0001). Most cases in LRG presented single organ recurrence (72.2%) (P = .006). The LRG experienced recurrence as single metastasis in 50% of cases, compared to 30% and 18.6% in IRG and HRG, respectively (P = .009). The most common sites of recurrence were lung and abdomen. Lung recurrence predominated in the HRG (72.9%) (P = .0001) and abdominal, in the LRG (83.3%) with a tendency to significance (P = .15). Conclusions Recurrence rates (especially bone and lung) increase with higher RG. Single organ recurrences and single metastases are more frequent in LRG.

Resumen Introduccion No estan claramente definidos los patrones de recurrencia tras nefrectomia por cancer renal. Objetivo Evaluar patrones de recidiva en funcion del grupo de riesgo de recurrencia (GRR). Material y metodo Analisis retrospectivo de 696 pacientes con carcinoma de celulas renales tratados con nefrectomia entre 1990-2010. Se definieron tres GRR segun la presencia de variables anatomopatologicas (estadio pTpN, grado nuclear, necrosis tumoral [NT], diferenciacion sarcomatoide [DS], margen de reseccion positivo [MR]): -GR bajo (GRB): pT1pNx-0 G1-4, pT2pNx-0 G1-2; no NT, DS y/o MR (+). -GR intermedio (GRI): pT2pNx-0 G3-4;pT3-4pNx-0 G1-2; GRB con NT. -GR alto (GRA): pT3-4pNx-0 G3-4; pT1-4pN + ; GRI con NT y/o DS; GRB con DS y/o MR (+). Para el contraste de variables cualitativas se utilizo el test de la Chi cuadrado. El metodo de Kaplan-Meier se ha utilizado para evaluar la supervivencia libre de recidiva en funcion de los GRR. Para evaluar diferencias entre las curvas de supervivencia se ha utilizado el test de log-rank. Resultados La mediana de seguimiento fue de 105 (IQR 63-148) meses. Del total de la serie recidivaron 177 (25,4%) pacientes: 15,9% a distancia, 4,9% local y 4,6% a distancia y local. La tasa de recurrencia vario segun el grupo de riesgo con tasas del 72,9% en GRA, 16,9% en GRI y 10,2% en GRB (p = 0,0001). La recurrencia en organo unico fue mayoritaria en el GRB (72,2%) (p = 0,006). El GRB presento recidiva en forma de metastasis unica en el 50% de los casos, frente al 30% y 18,6% en GRI y GRA, respectivamente (p = 0,009). Las localizaciones de recurrencia mas habituales fueron pulmon y abdomen. La localizacion pulmonar predomino en el GRA (72,9%) (p = 0,0001) y la abdominal en el GRB (83,3%) con una tendencia a la significacion (p = 0,15). Conclusiones A medida que aumenta el grupo de riesgo aumentan las recurrencias, sobre todo oseas y pulmonares. En el GRB son mas frecuentes las metastasis unicas y en organo unico.

Resumen Introduccion y objetivos Las Guidelines de la AEU de 2017, consideran el acceso laparoscopico o asistido por robot como procedimientos en investigacion. La curva de aprendizaje se define por el numero minimo de casos que es necesario realizar para reproducir la tecnica considerada como estandar. El objetivo de este estudio es analizar en el mismo servicio, la implantacion de un programa de cistectomia laparoscopica (CRL), comparandolo con un programa consolidado y estandarizado de cistectomia abierta (CRA). Material y metodo Analisis de cohortes retrospectivo de dos grupos de cistectomias: CRL (n = 196) (2006-2016) frente a CRA (n = 96) (2003-2005). Comparacion de la evolucion en el tiempo de los siguientes parametros: tiempo quirurgico, las necesidad de transfusion, el estado de los margenes quirurgicos de reseccion, las complicaciones postoperatorias, la duracion de la estancia hospitalaria y las recidivas. Se han definido 3 periodos de tiempo para CRL: implantacion (2006-09) (CRLI), desarrollo (2010-14) (CRL-D) y consolidacion (2015-16) (CRL-C); comparandose cada uno de ellos con el grupo control (CRA). Para el contraste de variables cualitativas se ha utilizado el test de la Chi cuadrado y para las variables numericas el test de Anova. Resultados La CRL, en comparacion con la CRA, presento un mayor tiempo quirurgico en las fases de CRL-I y CRL-D, observando una tendencia de menores tiempos operatorios que la CRA en el periodo de consolidacion. La CRL presenta ademas menor trasfusion intraoperatoria en los 3 periodos y postoperatoria en CRL-D y CRL-C, menos complicaciones totales en CRL-D y CRL-C, menos complicaciones graves (Clavien≥3) en las 3 fases; asi como una disminucion de la mortalidad y estancia hospitalaria desde la fase de CRL-I, consolidandose esta disminucion en los otros dos periodos de estudio. No hemos observado diferencias significativas entre CRA y CRL en cuanto a margenes quirurgicos y recurrencias ni en el total de la serie ni en la comparacion entre los distintos periodos, lo que avala la seguridad de la CRL, desde su inicio. Conclusiones La CRL frente a CRA mejora desde su implantacion el porcentaje de transfusiones, de complicaciones y la estancia hospitalaria, con seguridad oncologica, a expensas de un mayor tiempo quirurgico en las fases de implantacion y desarrollo. Sin embargo, en nuestra serie observamos una tendencia de menores tiempos quirurgicos que la CRA en el periodo de consolidacion. En nuestro servicio el abordaje laparoscopico se ha validado en el tratamiento de la cistectomia radical.

Resumen Introduccion No existe consenso sobre el seguimiento tras nefrectomia por cancer renal(CCR), siendo necesario establecer grupos de riesgo de recurrencia(GRR). Objetivo Clasificar en GRR los CCR. Material y metodo Analisis retrospectivo de 696 pacientes con cancer renal intervenidos entre 1990-2010; 568 (81,6%) pacientes con nefrectomia radical y 128 (18,4%) con nefrectomia parcial. Se clasificaron las variables patologicas como variables de 1.er nivel: estadio pTpN y grado de Fuhrman y variables patologicas de 2.° nivel (VP2N): diferenciacion sarcomatoide (DS), necrosis tumoral (NT), infiltracion microvascular y margenes de reseccion(MR). Realizamos un analisis multivariante (regresion de Cox) para identificar las variables de 1.er nivel relacionadas con la recurrencia. Clasificamos a los pacientes en 3 GRR segun las variables de primer nivel: bajo (GRB) 50%. Tras ello realizamos un analisis univariante y multivariante con las VP2N para cada GRR. Con estos datos se reclasificaron los pacientes en GRR+. Para la comparacion de los GRR con los GRR+ se utilizaron curvas ROC. Resultados La mediana de seguimiento fue de 105 (IQR 63-148) meses. Recidivaron 177 (25,4%) pacientes: 111 (62,7%) con recidiva a distancia, 34 (19,2%) recidiva local y 32 (18%) a distancia y local. Se comportaron como factores predictores independientes de recurrencia el grado de Fuhrman (HR = 2,75; p = 0,0001) y el estadio pTpN (HR = 2,19; p = 0,0001). Se agruparon los pacientes en GRR (ABC = 0,76; p = 0,0001): - GRB (pT1pNx-0 G1-4; pT2pNx-0 G1-2): 456 (65,5%) pacientes. - GRI (pT2pNx-0 G3-4; pT3-4pNx-0 G1-2): 110 (15,8%) pacientes. - GRA (pT3-4pNx-0 G3-4; pT1-4pN+): 130 (18,6%) pacientes. Tras el analisis multivariable con las VP2N, los GRR se reclasificaron (GRR+) (ABC = 0,84; p = 0,0001): -GRB+: GRB sin NT,DS y/o MR(+). -GRI+: GRI; GRB con NT. -GRA+: GRA; GRB con DS y/o MR(+); GRI con NT y/o DS. Conclusiones La adicion de las variables patologicas de segundo nivel a la clasificacion, segun las variables de primer nivel, mejora la capacidad de discriminacion de la clasificacion en GRR.

Introduction and objectives The AEU Guidelines of 2017 consider laparoscopic and robot-assisted approaches as investigational procedures. The surgical learning curve is defined as the minimum number of cases that a surgeon has to perform in order to reproduce a technique considered as standard. The aim of this study is to analyze, within our department, the implementation of a laparoscopic radical cystectomy (LRC) program compared with a well consolidated and standardized open radical cystectomy (ORC) program. Material and methods Retrospective cohort analysis of two cystectomy groups: LRC (n = 196) (20062016) vs ORC (n = 96) (2003–2005). Comparison of the evolution over time of the following parameters: operative time, blood transfusion rates, resection margins, postoperative complications, hospital stay and recurrence. Three time periods have been defined for LRC: implementation (2006–09) (LRC-I), development (2010–14) (LRC-D) and consolidation (2015–16) (LRC-C); comparing each of them with the control group (ORC). The chi-square test was used for the comparison of the qualitative variables and the Anova test for the numerical ones. Results When compared to ORC, LRC presented longer operative times in LRC-I and LRC-D periods. We observed a trend toward shorter operative time than ORC in the consolidation period (LRC-C). LRC also presented lower intraoperative transfusion rates in all periods and lower postoperative rates in CRL-D and CRL-C. Overall complications in LRC-D and LRC-C were lower in LRC, having fewer major complications (Clavien ≥ 3) in the 3 periods. A decrease in mortality and hospital stay after the LRC-I phase was also observed. These results were consolidated during the two last periods of the study. We have not observed significant differences between ORC and LRC when comparing surgical margins and recurrence rates, neither in the total series, nor in the comparison between the different periods. These results endorse the oncologic safety of LRC from the beginning of the implementation process. Conclusions When compared to ORC, LRC improves perioperative transfusion rates, complications and hospital stay from its implementation period, maintaining oncological safety. On the contrary, longer operative times during implementation and development were observed. However, in our series, we observed a trend toward shorter operative times than ORC approach in the consolidation period. We have validated the laparoscopic approach for radical cystectomy in our service.

Introduction There is no consensus on the follow-up protocol after nephrectomy for renal cell carcinoma (RCC), and the identification of recurrence risk groups (RRG) is required. Objective Establish recurrence risk groups (RRG). Material and methods A retrospective analysis of 696 patients with renal cancer submitted to surgery between 1990 and 2010; 568 (81.6%) patients treated with radical nephrectomy and 128 (18.4%) treated with partial nephrectomy. Pathological variables were classified as: 1st-level variables (1LPV): pTpN stage and Fuhrman grade (FG); and 2nd level pathological variables (2LPV): sarcomatoid differentiation (SD), tumor necrosis (TN), microvascular invasion (MVI) and positive surgical margins (PSM). Univariate and multivariate analysis have been performed using Cox regression to determine 1LPV related to recurrence. Based on 1LPV, we classified patients into three RRG: Low (LRG) 50%. We performed univariate and multivariate analysis with the 2LPVs for each RRG. With these data, patients were reclassified as RRG +. ROC curves were used for comparison of RRG and RRG+. Results The median follow-up was 105 months (range 63–148). There were 177 (25.4%) patients with recurrence: 111 (15.9%) distant, 34 (4.9%) local and 32 (4.6%) distant and local. In the multivariable analysis, Fuhrman grade HR = 2,75; p = 0,0001 and pTpN stage HR = 2,19;p = 0,0001 behaved as independent predictive variables of recurrence. Patients were grouped as RRG AUC = 0,76; p = 0,0001: - LRG (pT1pNx-0 G1-4; pT2pNx-0 G 1-2 ): 456 (65.5%) patients. - IRG (pT2pNx-0 G 3-4 ; pT 3-4 pNx-0 G 1-2 ): 110 (15.8%) patients. - HRG (pT 3-4 pNx-0 G 3-4 ; pT1-4pN+): 130 (18.6%) patients. After multivariate analysis with 2LPV, RRG were reclassified RRG+ AUC = 0,84, p = 0,0001: -LRG+ (LRG without TN, SD and/or PSM(+)) -IRG+ (IRG; LRG with TN) -HRG+ (HRG; LRG with SD and/or PSM(+); IRG with TN and/or SD) Conclusion The inclusion of 2LPV to the classification according to VP1N improves the discriminating capacity of RRG classification.

Resumen Introduccion La cirugia minimamente invasiva en la cistectomia no ha tenido el mismo desarrollo que en otras cirugias urologicas, entre otros motivos por la falta de estudios publicados que definan las ventajas de este abordaje frente a la cirugia abierta. Objetivos El principal objetivo de este estudio es establecer el papel de la cirugia minimamente invasiva, laparoscopia, en la cistectomia radical frente a la cirugia abierta en un analisis de complicaciones perioperatorias. Material y metodo Analisis de cohortes retrospectivo de complicaciones perioperatorias de 2 series homogeneas de cistectomias: laparoscopica (n = 196) frente a abierta (n = 197). Identificacion mediante analisis multivariante de factores independientes predictores de complicaciones perioperatorias. Resultados En el analisis comparativo entre el abordaje laparoscopico y el abierto observamos una menor tasas de trasfusion perioperatoria (p 3; p Conclusiones En nuestro estudio identificamos el abordaje laparoscopico como protector de complicaciones en la cistectomia radical. El abordaje abierto casi triplica el riesgo de tener complicaciones.

Introduction Minimally invasive surgery regarding cystectomy has not had the same development as other urological surgeries. This could be due to the lack of published studies defining the advantages of this approach versus open surgery. Objectives The main objective of this study is to establish the role of minimally invasive surgery, laparoscopic radical cystectomy, versus open surgery by analyzing their perioperative complications. Material and method Retrospective cohort analysis of perioperative complications of 2 homogeneous series of cystectomies: laparoscopic (n = 196) versus open (n = 197). Identification of independent predictors of perioperative complications by multivariate analysis. Results In the comparative analysis between laparoscopic cystectomies and open cystectomies we observed a lower rate of perioperative blood transfusion (p 3; p Conclusions We have identified the laparoscopic approach as a complication shield for radical cystectomy. The open approach almost triples the risk of complications.

Resumen Introduccion El objetivo es comparar el rendimiento de la secuencia resonancia magnetica (RM) y biopsia transrectal «cognitiva» (BTRCog) frente a la biopsia transrectal clasica (BTRCl) en pacientes con al menos una biopsia de prostata (BP) negativa. Material y metodo Analisis retrospectivo de 205 pacientes con al menos una BP negativa. A 144 (70,2%) pacientes se les realizo antes de la biopsia una RM y a 61 (29,8%) no. Los nodulos se clasificaron segun la clasificacion PI-RADS v2 agrupando pZa, pZpl y pZpm como zona periferica (ZP), Tza, Tzp y CZ como zona transicional (ZT) y areas AS como zona anterior (ZA). A los pacientes con RM se les realizo BTRCog. A los pacientes sin RM se les realizo una BTRCl de la ZP y de la ZT. Comparacion de variables cualitativas con test de la chi2 y de cuantitativas con t de Student. Analisis multivariante (regresion logistica) para identificar variables predictoras. Resultados La mediana de edad fue 68 (IQR 62-72%) anos, de PSA 8,3 (IQR 6,2-11,7) ng/ml y del numero de biopsias previas fue 1 (IQR 1-2). En 169 (82,4%) el tacto rectal (TR) fue normal, mientras que en 36 (17,6%) sospechoso (cT2a-b en 34 y cT2c en 2). La mediana del volumen prostatico (VP) fue de 48 (IQR 38-65) cc. Existio diferencia en el PSAD (p = 0,03) entre ambos grupos. En la ETR se identifico nodulo hipoecoico en 8 (13,1%) pacientes con BTRCl y en 62(43,1%) (p = 0,0001) con BTRCog. La mediana de cilindros extraidos en BTRCl fue 10 (IQR 10-10) y en el grupo BTRCog fue 11 (IQR 9-13) (p = 0,75). Se diagnostico cancer en 74 (36,1%) pacientes. En BTRCl 10 (16,4%) y en BTRCog 64 (44,4%) (p = 0,0001). Los tumores diagnosticados fueron clasificados: ISUP-1: 34 (45,9%), ISUP-2: 21 (28,4%), ISUP-3: 9 (12,2%), ISUP-4: 7 (9,5%), ISUP-5: 3 (4,1%). No existieron diferencias (p = 0,89). La mediana de cilindros afectados en BTRCl fue 1 (IQR 1-5) frente a 2 (IQR 1-4) en el grupo BTRCog (p = 0,93). Variables predictoras independientes de cancer: edad (OR = 12,05, p = 0,049). TR sospechoso (OR = 2,64, p = 0,04), nodulo hipoecoico en ecografia (OR = 2,20, p = 0,03) y la secuencia RM + BTRCog (OR = 3,49, p = 0,003). Conclusiones La secuencia RMNmp + BTRCog en pacientes con al menos una BP previa negativa multiplica casi por 3,5 (OR = 3,49) la probabilidad de diagnosticar un cancer frente a la BTRCl.

Introduction In patients with high-risk localized prostate cancer (HRPCa), multimodal treatment plays a fundamental role. Objective To compare relapse-free survival (RFS) in patients with HRPCa, treated primarily with radiotherapy (RT) + hormone therapy (HT) versus radical prostatectomy (RP) and salvage RT (sRT) ± HT when biochemical recurrence (BCR) appears. Material and methods Retrospective analysis of 226 patients with HRPCa (1996–2008), treated primarily with RT + HT (n = 137) or RP (n = 89). The Kaplan–Meier method has been used to evaluate survival and the log-rank test has been used to evaluate the contrast between the different categories of the variables. Multivariate analysis has been performed using Cox regression to determine variables with an impact on RFS with statistical significance (p Results The median follow-up of the series was 111 (IQR 85–137.5) months. After RT + HT, 32 (23.4%) patients relapsed, and after RP 41 (46.1%) cases, (p = 0.0001). When comparing the primary treatments, the RFS at 5 and 10 years was higher after RT + HT versus RP in monotherapy (p = 0.001). The primary treatment with RT + HT reduced the risk of BCR when compared to the RP (HR = 0.41, p = 0.002). The estimation of the RFS at 5 and 10 years after RP + sRT ± HT was 89.7 and 87.1%, while after primary RT + HT was 91.6 and 71.1%, respectively (p = 0.01). The only factor that behaved as an independent predictor of RFS was the multimodal treatment with RP + sRT ± HT when BCR showed up (HR = 2.39, p = 0.01). Conclusion In HRPCa, multimodal treatment with RP + sRT ± HT if BCR, significantly improves RFS with respect to treatment with RT + HT.

Resumen Introduccion En pacientes con cancer de prostata localizado de alto riesgo (CPAR) el tratamiento multimodal juega un papel fundamental. Objetivo Comparar la supervivencia libre de recidiva (SLR) en pacientes con CPAR tratados de forma primaria con radioterapia (RT) + hormonoterapia (HT) frente a prostatectomia radical (PR) rescatados con RT de rescate (RTR) con o sin HT tras recidiva bioquimica (RB). Material y metodos Analisis retrospectivo de 226 pacientes con CPAR (1996-2008), tratados de forma primaria con RT + HT (n = 137) o PR (n = 89). Utilizamos el metodo de Kaplan-Meier para evaluar la supervivencia y el test de log-rank para evaluar las diferencias entre las distintas categorias de las variables. Se realiza analisis multivariante mediante regresion de Cox para determinar variables con impacto en la SLR con significacion estadistica (p Resultados La mediana de seguimiento de la serie fue de 111 (RIC 85-137,5) meses. Tras RT + HT recidivaron 32 (23,4%) pacientes, y 41 (46,1%) tras PR (p = 0,0001). Al comparar los tratamientos primarios, la SLR a los 5 y 10 anos fue mayor tras RT + HT frente a PR en monoterapia (p = 0,001). El tratamiento primario con RT + HT redujo a mas de la mitad el riesgo de RB al compararse con la PR (HR = 0,41, p = 0,002). La estimacion de la SLR a los 5 y 10 anos despues de PR + RTR ± HT fue de 89,7 y 87,1%, mientras que tras RT + HT primaria fue de 91,6 y 71,1%, respectivamente (p = 0,01). El unico factor que se comporto como predictor independiente de SLR fue el tratamiento multimodal mediante PR + RTR ± HT cuando se presento la RB (HR = 2,39, p = 0,01). Conclusion En CPAR el tratamiento multimodal con PR + RTR ± HT si RB mejora significativamente la SLR con respecto al tratamiento con RT + HT.

Resumen Introduccion y objetivos No existe evidencia de alto nivel sobre que tratamiento primario proporciona una ventaja de supervivencia global (SG) y supervivencia cancer especifica(SCE) en cancer de prostata localizado de alto riesgo (CPAR). Nuestro objetivo es analizar las diferencias en supervivencia, asi como sus factores predictores, en este grupo de pacientes segun su tratamiento primario (prostatectomia radical [PR] o radioterapia y bloqueo androgenico [RT + HT]). Material y metodos Estudio retrospectivo de 286 pacientes con CPAR diagnosticados entre 1996-2008, tratados mediante PR (n = 145) o RT + HT (n = 141). La supervivencia se evaluo con el metodo de Kaplan-Meier. La existencia de diferencias significativas entre las distintas variables se analizo mediante el test de log-rank. Para la identificacion de factores de riesgo se utilizo un analisis uni y multivariante mediante regresion de Cox. Resultados La mediana de seguimiento fue de 117,5 (IQR 87-158) meses. La SG fue mayor (p = 0,04) en los pacientes con PR, mientras que no existieron diferencias (p = 0,44) en la SCE entre ambos grupos. El tipo de tratamiento primario no se relaciono con la SG ni SCE. La edad (p = 0,002), la aparicion durante el seguimiento de un segundo tumor (p = 0,0001) y el estadio cT3a (p = 0,009) se comportaron como variables predictoras independientes de SG. Ninguna de las variables se comporto como variable predictora independiente de SCE, aunque la recidiva bioquimica tras tratamiento de rescate (p = 0,058) y la aparicion de un segundo tumor durante el seguimiento presentaron una tendencia importante a la significacion estadistica, reduciendo este ultimo la mortalidad cancer especifica (hazard ratio 0,16, intervalo de confianza del 95% 0,02-1,18, p = 0,07). Conclusiones El tratamiento primario no se relaciono con la SG ni SCE en pacientes con CPAR.

Introduction and aim The main aim of the study was to establish the oncological safety of the laparoscopic approach to radical cystectomy for high-risk, non-organ-confined urothelial tumours. Material and methods A retrospective cohort study of 216 stage pT3-4 cystectomies operated between 2003 and 2016; using an open approach (ORC, n = 108), and using a laparoscopic approach (LRC, n = 108). Results Both groups have similar pathological features except, in G3 TUR, there were more lyphadenectomies and greater pN+, and more adjuvant chemotherapies using the LRC. The median follow-up of the series was 15 (IQR: 8–10.5) months. Sixty-eight point one percent of the series relapsed, with no differences between either group (p = 0.11). The estimated differences for cancer-specific survival was greater in the LRC group (p = 0.03), as was overall survival (p = 0.009). There were no differences between either group in estimated recurrence-free survival (p = 0.26). The type of surgical approach (p = 0.03), pTpN stage (p = 0.0001), and administration of adjuvant chemotherapy (p = 0.003) were related to cancer-specific mortality (CSM) in the univariate analysis. Only the pTpN stage (p = 0.0001), and not giving adjuvant chemotherapy (p = 0.003) behaved as independent predictive factors of CSM. Conclusion The type of surgical approach to cystectomy (ORC vs. LRC) did not influence CSM. Lymph node involvement and not giving adjuvant chemotherapy were identified as predictive factors of CSM. Our study supports the oncological safety of the laparascopic approach for cystectomy in patients with locally advanced muscle-invasive bladder tumours.

Introduction and objectives There is no high-level evidence as to which primary treatment provides an overall survival (OS) or cancer-specific survival (CSS) advantage in high-risk localised prostate cancer (HRLPC). Our aim was to analyse the differences in survival and predictive factors in this group of patients, according to their primary treatment (radical prostatectomy (RP) or radiotherapy and androgen blockade (RT + HT)). Material and methods A retrospective study of 286 HRLPC patients diagnosed between 1996 and 2008, treated by RP (n = 145) or RT + HT (n = 141). Survival was assessed using the Kaplan–Meier method. Significant differences between the different variables were analysed using the log-rank test. A uni and multivariate Cox regression analysis was performed to identify risk factors. Results The median follow-up was 117.5 (IQR 87–158) months. The OS was longer (p = 0.04) in the RP patients, while there were no differences (p = 0.44) in CSS between either group. The type of primary treatment was not related to OS or CSS. Age (p = 0.002), the onset during follow-up of a 2nd tumour (p = 0.0001), and stage cT3a (p = 0.009) behaved as independent predictive variables of OS. None of the variables behaved as an independent predictive variable of CSS, although biochemical recurrence after rescue treatment (p = 0.058), and the onset of a 2nd tumour during follow-up showed a significant trend to statistical significance, the latter reducing specific cancer mortality (HR .16, 95%CI 0.02–1.18, p = 0.07). Conclusions Primary treatment did not relate to OS or CSS in patients with HRPC.

espanolIntroduccion y objetivo Una de las caracteristicas inherentes a los tumores renales es la capacidad de extenderse al interior del sistema venoso como trombos tumorales. El objetivo de este estudio es evaluar en los pacientes con cancer renal en un estadio pT3apN0cM0 si la existencia de afectacion tumoral venosa influye en la recidiva tumoral. Materiales y metodos Analisis retrospectivo de pacientes con cancer renal en estadio pT3apN0cM0 tratados con nefrectomia radical entre 1990-2015. Analisis univariante y multivariante mediante regresion de Cox para identificar variables predictoras y variables predictoras independientes relacionadas con la recidiva. Resultados Se analizaron los resultados de 153 pacientes. La mediana de seguimiento fue de 82 (IQR 36-117) meses. La supervivencia libre de recidiva a los 5 anos fue del 58,9% con una mediana de 97 (IC95% 49,9-144,1) meses. Recidivaron 77 (50,3%) pacientes. En 70 (90,9%) casos las metastasis fueron a distancia, en 17 (14,2%) de estos pacientes se objetivo recurrencia local en el lecho de nefrectomia sincronica. En el analisis multivariable se identificaron como variables predictoras independientes de recidiva tumoral la necrosis tumoral (p=0,0001) y la invasion microvascular (p=0,001). Conclusiones La existencia de extension tumoral venosa no se ha relacionado, en nuestra serie y tras la realizacion del analisis multivariable, con la recidiva. La necrosis tumoral y la infiltracion microvascular si se comportaron como factores predictores independientes de recidiva tumoral. EnglishIntroduction and objective One of the inherent features of kidney tumours is the capacity to spread inside the venous system as tumour thrombi. The aim of this study was to assess in patients with stage pT3apN0cM0 kidney cancer whether venous tumour involvement influenced tumour recurrence. Materials and methods A retrospective analysis of patients with stage pT3apN0cM0 kidney cancer treated with radical nephrectomy between 1990-2015. Univariate and multivariate Cox regression analysis to identify predictive variables and independent predictive variables relating to recurrence. Results The results of 153 patients were studied. The median follow-up was 82 (IQR 36-117) months. Recurrence-free survival at 5 years was 58.9% with a median of 97 (95% CI 49.9-144.1) months. Seventy-seven (50.3%) patients recurred. Seventy cases 70 (90.9%) had distant metastases, 17 (14.2%) of these patients had local recurrence in the bed of nephrectomy. Tumour necrosis (p=.0001), and microvascular invasion (p=.001) were identified as independent predictors of tumour recurrence in the multivariable analysis. Conclusions In our series, after multivariable analysis, venous tumour extension was not related to recurrence. Tumour necrosis and microvascular infiltration did behave as independent predictive factors of tumour recurrence.

Introduction and objective One of the inherent features of kidney tumours is the capacity to spread inside the venous system as tumour thrombi. The aim of this study was to assess in patients with stage pT3apN0cM0 kidney cancer whether venous tumour involvement influenced tumour recurrence. Materials and methods A retrospective analysis of patients with stage pT3apN0cM0 kidney cancer treated with radical nephrectomy between 1990 and 2015. Univariate and multivariate Cox regression analysis to identify predictive variables and independent predictive variables relating to recurrence. Results The results of 153 patients were studied. The median follow-up was 82 (IQR 36–117) months. Recurrence-free survival at 5 years was 58.9% with a median of 97 (95% CI 49.9–144.1) months. Seventy-seven (50.3%) patients recurred. Seventy cases 70 (90.9%) had distant metastases, 17 (14.2%) of these patients had local recurrence in the bed of nephrectomy. Tumour necrosis (p = 0.0001), and microvascular invasion (p = 0.001) were identified as independent predictors of tumour recurrence in the multivariable analysis. Conclusions In our series, after multivariable analysis, venous tumour extension was not related to recurrence. Tumour necrosis and microvascular infiltration did behave as independent predictive factors of tumour recurrence.

Resumen Introduccion Evaluacion de la efectividad de la biopsia cognitiva (BC) en los pacientes con sospecha clinica de cancer de prostata (caP) y al menos una biopsia negativa (BTR). Material y metodo Analisis retrospectivo de 144 pacientes con al menos una BTR y una resonancia magnetica nuclear (RMN) previa. Los nodulos de la RMN se clasificaron segun la clasificacion PI-RADS v2 agrupando pZa, pZpl y pZpm como zona periferica (ZP), Tza, Tzp y CZ como zona transicional (ZT) y areas AS como zona anterior (ZA). Se indico biopsia en nodulos ≥ PI-RADS 3. Se llevo a cabo analisis uni y multivariante (regresion logistica) tratando de identificar variables relacionadas con tumor en biopsia de PI-RADS 3. Resultados La mediana de edad fue de 67 (IQR: 62-72) anos, la de PSA 8,2 (IQR: 6,2-12) ng/ml. Se identifico nodulo en la RMN en la ZP en 97 (67,4%) casos, en la ZT en 29 (20,1%) casos y en ZA en 41 (28,5%) casos. Se diagnostico caP en la biopsia en 64 (44%) pacientes. En PI-RADS 3 se obtuvo un 17,5% (7/40) de cancer, PI-RADS 4 un 47,3% (35/73) y en los PI-RADS 5 un 73,3% (22/29) (p = 0,0001). Analisis multivariable con variables que pudieran influir en el resultado de la biopsia en pacientes con PI-RADS 3: ninguno (edad, PSA, numero de biopsias previas, tacto rectal, PSAD, volumen prostatico ni numero de cilindros extraidos) se comporto como factor predictor independiente de tumor. Conclusiones El rendimiento diagnostico de la BC en pacientes con al menos una biopsia previa negativa fue del 44% incrementandose segun el grado de PI-RADS, siendo en PI-RADS 3 bajo. No se identifico ninguna variable clinica predictora de caP en pacientes con PI-RADS 3.

Introduction Evaluation of the effectiveness of cognitive biopsy (CB) in patients with clinical suspicion of prostate cancer (PC), and at least one negative biopsy (TRB). Material and method Retrospective study of 144 patients with at least one previous TRB and magnetic resonance imaging (MRI). The MRI nodules were classified based on PI-RADS v2 grouping pZa, pZpl and pZpm as the peripheral zone (PZ), Tza, Tzp and CZ as the transitional zone (TZ), and the AS zones as the anterior zone (AZ). A biopsy was indicated for nodules ≥PI-RADS 3. Uni and multivariate analysis was undertaken (logistic regression) to identify variables relating to a PI-RADS 3 tumour on biopsy. Results The median age was 67 (IQR: 62–72) years, the median PSA was 8.2 (IQR: 6.2–12) ng/ml. A nodule was identified on MRI in the PZ in 97 (67.4%) cases, in the TZ in 29 (20.1%), and in the AZ in 41 (28.5%). PC was diagnosed on biopsy in 64 (44%) patients. The cancer rate in the PI-RADS 3 lesions was 17.5% (7/40), in the PI-RADS 4 47.3% (35/73), and in the PI-RADS 5 lesions it was 73.3% (22/29) (p = 0.0001). Multivariable analysis with variables that could influence the biopsy result in patients with PI-RADS 3: none (age, PSA, number of previous biopsies, rectal examination, PSAD, prostate volume or number of extracted cylinders) behaved as an independent tumour predictor. Conclusions The diagnostic performance of CB in patients with at least one previous negative biopsy was 44%, increasing according to the PI-RADS grade, and low in PI-RADS 3. No clinical variable predictive of cancer was found in patients with PI-RADS 3.

Introduction and objectives The onset of second primary tumours should be considered in high-risk prostate cancer patients in the natural course of the disease. Our aim was to evaluate the influence of primary treatment with curative intent for these patients on the development of second primary tumours. Material and methods A retrospective study of 286 patients diagnosed between 1996 and 2008, treated by radical prostatectomy (n = 145) or radiotherapy and androgen blockade (n = 141). The homogeneity of both series was analyzed using the Chi-squared test for the qualitative variables, and the Student's t-test for the quantitative variables. A multivariate Cox regression analysis was performed to assess whether the type of primary treatment influenced the development of second tumours. Results The median age was 66 years, and the median follow-up was 117.5 months. At the end of follow-up, 60 patients (21%) had developed a second primary tumour. In the prostatectomy group it was located in the pelvis in 13 (9%) cases, and those treated with radiotherapy and hormonotherapy in 8 (5.7%) cases (p = 0.29). The most common organ sites were: colo-rectal in 17 (28.3%) patients, the lung in 11 (18.3%), and the bladder in 6 (10%) patients. In the multivariable analysis, the risk of a second tumour doubled for those treated with radiotherapy and hormonotherapy (HR = 2.41, 95% CI: 1.31–4.34, p = 0.005) compared to the patients treated by prostatectomy. Age and rescue radiotherapy did not behave as independent predictive factors. Conclusions The onset of a second primary tumour was related with the primary treatment given; thus the risk for those treated with radiotherapy and androgen deprivation therapy more than doubled.

Resumen Introduccion y objetivos La aparicion de segundos tumores primarios en pacientes con cancer de prostata de alto riesgo debe tenerse en cuenta en la evolucion natural de la enfermedad. Nuestro objetivo es evaluar la influencia del tratamiento primario con intencion curativa de dichos pacientes en el desarrollo de segundos tumores primarios. Material y metodos Estudio retrospectivo de 286 pacientes diagnosticados entre 1996 y 2008, tratados mediante prostatectomia radical (n = 145) o radioterapia y bloqueo androgenico (n = 141). La homogeneidad de ambas series fue analizada con el test de la Chi-cuadrado para las variables cualitativas y la t de Student para las cuantitativas. Se realizo un analisis multivariante mediante regresion de Cox, para evaluar si el tipo de tratamiento primario influia en el desarrollo de segundos tumores. Resultados La mediana de edad fue de 66 anos, y la mediana de seguimiento de 117,5 meses. Al final del seguimiento, 60 pacientes (21%) habian desarrollado un segundo tumor primario. En el grupo de prostatectomia se localizo en la pelvis en 13 (9%) casos y en 8 (5,7%) casos en los tratados con radioterapia y hormonoterapia (p = 0,29). Las localizaciones mas frecuentes por organos fueron: colorrectal en 17 (28,3%) pacientes, pulmon en 11 (18,3%) y vejiga en 6 (10%) pacientes. En el analisis multivariable, los tratados con radioterapia y hormonoterapia duplicaban el riesgo de segundo tumor (HR = 2,41, IC95%: 1,31-4,34; p = 0,005) con respecto a los pacientes tratados con prostatectomia. La edad y la radioterapia de rescate no se comportaron como factores predictores independientes. Conclusiones La aparicion de un segundo tumor primario se relaciono con el tratamiento primario administrado; asi, los tratados con radioterapia y privacion androgenica multiplicaron por mas de 2 su riesgo.

Introduction and objectives Preoperative renal artery embolization (PRAE) for large renal masses may be performed prior to nephrectomy in order to simplify the procedure and reduce intraoperative bleeding. The objective of this work is to determine the role of PRAE on intraoperative bleeding and postoperative complications in left renal tumors with tumor thrombus limited to the left renal vein (level 0). Material and methods Retrospective analysis to evaluate 46 patients who underwent left radical nephrectomy and thrombectomy for the treatment of renal cell carcinoma with level 0 tumor thrombus during the period 1990–2020. PRAE was limited to those cases in which surgical access to the main renal artery was presumed a priori difficult in the preoperative imaging study (n = 9; 19.6%). Intraoperative bleeding was estimated based on the perioperative transfusion rate, and postoperative complications were categorized according to the Clavien–Dindo classification. The Chi-squared test was used for comparisons. A multivariate analysis was performed to identify predictors of transfusion and complications. Results There were no significant differences in the overall complication rate (11.1% vs. 32.4%, p = 0.19), major complication rate (0% vs. 8.1%, p = 0.51), or transfusion rate (11.1% vs. 19%, p = 0.49) between both groups (PRAE vs. non-PRAE). In the multivariate analysis, PRAE did not behave as a predictor of complications (OR: 0.11, 95%CI 0.01–2.86; p = 0.18) nor transfusion (OR: 0.46, 95%CI 0.02–7.38; p = 0.58). Conclusions In our study on left RCC with level 0 tumor thrombus and difficult access to the main renal artery, PRAE was not associated with increased bleeding or postoperative complications, and it did not behave as an independent predictor of these variables. Therefore, it could be used as a preoperative maneuver to facilitate vascular management in selected cases.

Diagnosis and treatment of renal cell carcinoma with venous tumor thrombosis remains a challenge today, requiring multidisciplinary teams, mainly in tumor thrombus levels III-IV. Our objective is to present the various diagnostic techniques used and its controversies. A review of the most relevant related articles between January 2000 and August 2020 has been carried out in PubMed, EMBASE and Scielo. Continuous technological development has allowed progress in its detection, in the approximation of the histological subtype, and in the determination of tumor thrombus level. Regardless of the imaging technique used for its diagnosis (CT, MRI, TEE, ultrasound with contrast), the time elapsed until treatment is vitally important to reduce the risk of complications, some of them fatal, such as pulmonary thromboembolism.

Infection of the artery at or around the anastomotic site is an ominous complication commonly presenting as a leak and/or local dissolution of the arterial wall.Narrative review based on relevant PubMed, EMBASE, and Scielo indexed English or Spanish-written articles for the period January 2000-December 2019. A pooled analysis regarding etiology was performed. Based on the results obtained with this approach, a diagnostic/therapeutic algorithm is suggested in order to optimize its clinical management.Arterial pseudoaneurysms are pseudocapsuled contained hematomas generated as the result of an arterial leaking. They are infrequent (1% of cases), mostly related with infection (contamination of preservation fluid or sepsis) and located at the arterial anastomotic site in renal transplantation recipients. Although they are frequently diagnosed in symptomatic patients days/weeks after transplantation, they may remain unnoticed for long periods being diagnosed incidentally. Color coded-Doppler ultrasound confirms the clinical suspicion. Angio CT-scan and angiography are used for surgical planning or endovascular treatment, respectively. The etiological diagnosis is made on a basis of excised tissue culture. The decision-making process regarding the treatment approach, mostly relies on clinical presentation and anatomical location. Therapeutic options include ultrasound-guided percutaneous thrombin injection, endovascular treatment, and surgery.Mycotic pseudoaneurysms in renal transplantation recipients may pose a significant challenge in cases of spontaneous rupture, given the risk for massive bleeding and death. Adequate management requires accurate diagnosis. Early endovascular stenting remains the treatment of choice in hemodynamically unstable patients. Percutaneous injection and vascular reconstruction present variable success rates in preserving graft function.

Background and objective Surgery on renal tumors with venous tumor thrombus presents a high complication rate and non-negligible perioperative mortality. Our objective was to analyze the postoperative complications, their relationship with the level of the tumor thrombus and its potential predisposing factors. Materials and methods A retrospective analysis was conducted in 101 patients with renal and venous tumor thrombus operated on between 1988 and 2017. Two patients were excluded because of intraoperative pulmonary thromboembolism and exitus (2%). The postsurgical complications were classified according to Clavien–Dindo classification system. To compare the qualitative variables, we employed the chi-squared test. We performed a multivariate analysis using binary logistic regression to identify the independent predictors. Results Some type of postsurgical complication occurred in 34 (34.3%) patients, 11 (11.1%) of which were severe (Clavien III–V). There were significant differences in the total complications (p = 0.003) and severe complications (Clavien ≥ III; p = 0.03) depending on the level of the tumor thrombus.

Resumen Introduccion y objetivo La cirugia de los tumores renales con trombosis venosa esta gravada con un porcentaje elevado de complicaciones y con una mortalidad perioperatoria no despreciable. Nuestro objetivo es analizar las complicaciones postoperatorias, su relacion con el nivel del trombo y sus posibles factores favorecedores. Materiales y metodos Analisis retrospectivo de 101 pacientes con tumores renales con trombosis venosa intervenidos entre 1988 y 2017. Se descartaron 2 pacientes por TEP intraoperatorio y exitus (2%). Las complicaciones posquirurgicas se clasificaron segun Clavien-Dindo. Para el contraste de variables cualitativas se ha utilizado el test de la Chi cuadrado. Se realizo un analisis multivariante mediante regresion logistica binaria para identificar las variables predictoras independientes. Resultados En 34 (34,3%) pacientes se produjo algun tipo de complicacion posquirurgica, siendo en 11 (11,1%) graves (Clavien III-IV). Existen diferencias significativas en las complicaciones totales (p = 0,003) y las graves (Clavien ≥ III) (p = 0,03) segun el nivel del trombo tumoral.

Acute thrombophlebitis of spermatic vein is an unusual pathology involving, in most of the cases, the left side, and whose etiology remains uncertain. Most of them are found during a a differential diagnosis in acute testicular pain. We introduce the case of a 29 years old male with abusive cocaine consumption, admitted to hospital due to severe testicular pain. Doppler-ultrasound examination was undertaken, showing right spermatic vein flux alteration. Conservative management was decided and anticoagulant and non-esteroidal anti-inflammatory drugs were started. Eco-doppler is the most specific and sensible technique for diagnosis of these cases, while TC can always confirm etiologic diagnosis. Treatment was initially conservative based on anticoagulation. Hematological study is necessary in order to determine coagulation alterations.

Context Bladder cancer is the cause of more than 150,000 deaths per year. The overall rate of survival is approximately 45%, with a 10-year recurrence-free rate of 50–59%, with no changes in the last decade. Objective Due to a lack of agreement on the follow-up of cystectomy or on a uniform treatment when faced with the various types of recurrence, we have analyzed the most recent literature in an attempt to unify the criteria for the diagnosis and treatment of bladder cancer. Acquisition of evidence Review of Spanish and English publications in the medical literature in the last 10 years, highlighting the most significant series in terms of the number of patients, follow-up time, as well as the existing meta-analyses. Synthesis of the evidence Recurrence after cystectomy can occur in the urinary apparatus (upper urinary tract or distal urethra) and local (cystectomy bed) and/or distant metastases. Despite strict control, more than 60% of the relapses are discovered based on symptoms and not by the routine follow-up test. Locoregional and distant relapses are more common the more advanced the stage at the time of cystectomy, going from 11–21% in pT2N0 to 52–72% when there is lymphocytic N+ involvement. Recurrence in the urethra and/or upper urinary track has other prognostic factors such as multiplicity, the presence of Cis and involvement of prostatic stroma. There are various treatments for tumor relapses. Increasingly, the patient's comorbidity is considered when deciding on the therapeutic strategy. Treatments are typically multimodal and include surgery, radiotherapy and chemotherapy. Conclusion The follow-up of patients who undergo cystectomy should be individualized, taking into account the prognostic factors of recurrence and the patient's comorbidity, assuming that in some cases, multimodal treatment is indicated.

Resumen Contexto El cancer de vejiga es la causa de mas de 150.000 muertes/ano. La tasa de supervivencia global es de aproximadamente un 45% con un periodo libre de recurrencia a diez anos del 50-59%, sin cambios en la ultima decada. Objetivo Al no existir un acuerdo en el seguimiento tras cistectomia ni un tratamiento uniforme ante los distintos tipos de recidiva, analizamos la literatura mas reciente para intentar unificar criterios en su diagnostico y tratamiento. Adquisicion de evidencia Revision de las publicaciones en castellano e ingles de la literatura medica en los ultimos diez anos, destacando las series mas importantes en numero de pacientes, tiempo de seguimiento, asi como los metanaalisis existentes. Sintesis de la evidencia La recurrencia tras cistectomia puede producirse en el aparato urinario (tracto urinario superior o uretra distal), local (lecho de la cistectomia) y/o metastasis a distancia. A pesar de un control estricto, mas del 60% de las recidivas se descubren en base a la sintomatologia y no en las pruebas rutinarias de seguimiento. Las recidivas locorregionales y a distancia son mas frecuentes cuanto mas avanzado es el estadio en el momento de la cistectomia, pasando del 11-21% en pT2N0 al 52-72% cuando existe afectacion linfatica N+. La recidiva a nivel uretral y/o en el aparato urinario superior tiene otros factores pronosticos como la multiplicidad, presencia de Cis, afectacion del estroma prostatico, etc. Los tratamientos de las recidivas tumorales son diversos y, cada vez mas, se considera la comorbilidad del paciente a la hora de decidir la estrategia terapeutica. Habitualmente los tratamientos son multimodales, incluyendo cirugia, radio y quimioterapia. Conclusion El seguimiento de los pacientes sometidos a cistectomia debe ser personalizado teniendo en cuenta los factores pronosticos de recurrencia y la comorbilidad del paciente, asumiendo que, en algunos de ellos, estara indicado el tratamiento multimodal.

Recurrence trends after renal cell cancer nephrectomy are not clearly defined.To evaluate recurrence trends according to recurrence risk groups (RRG).Retrospective analysis of 696 patients with renal cell cancer treated with nephrectomy between 1990-2010. Three RRG were defined according to the presence of anatomopathological variables (pTpN stage, nuclear grade, tumor necrosis [TN], sarcomatoid differentiation [SD], positive resection margin [RM]): -Low RG (LRG): pT1pNx-0 G1-4, pT2pNx-0 G1-2; no TN, SD and/or RM (+). -Intermediate RG (IRG): pT2pNx-0 G3-4; pT3-4pNx-0 G1-2; LRG with TN. -High RG (HRG): pT3-4pNx-0 G3-4; pT1-4pN+; IRG with TN and/or SD; LRG with SD and/or RM (+). The Kaplan-Meier method has been used to evaluate recurrence-free survival as a function of RRG. The log-rank test was used to evaluate differences between survival curves.The median follow-up was 105 (IQR 63-148) months. Of the total series, 177 (25.4%) patients presented recurrence: distant 15.9%, local 4.9% and 4.6% distant and local. The recurrence rate varied according to the RRG with values of 72.9% for HRG, 16.9% for IRG and 10.2% for LRG (p=.0001). Most cases in LRG presented single organ recurrence (72.2%) (p=.006). The LRG experienced recurrence as single metastasis in 50% of cases, compared to 30% and 18.6% in IRG and HRG, respectively (p=.009). The most common sites of recurrence were lung and abdomen. Lung recurrence predominated in the HRG (72.9%) (p=.0001) and abdominal, in the LRG (83.3%) with a tendency to significance (p=.15).Recurrence rates (especially bone and lung) increase with higher RG. Single organ recurrences and single metastases are more frequent in LRG.

There is no consensus on the follow-up protocol after nephrectomy for renal cell carcinoma (RCC), and the identification of recurrence risk groups (RRG) is required.Establish recurrence risk groups (RRG).A retrospective analysis of 696 patients with renal cancer submitted to surgery between 1990-2010; 568 (81.6%) patients treated with radical nephrectomy and 128 (18.4%) treated with partial nephrectomy. Pathological variables were classified as: 1st-level variables (1LPV): pTpN stage and Fuhrman grade (FG); and 2nd level pathological variables (2LPV): sarcomatoid differentiation (SD), tumor necrosis (TN), microvascular invasion (MVI) and positive surgical margins (PSM). Univariate and multivariate analysis have been performed using Cox regression to determine 1LPV related to recurrence. Based on 1LPV, we classified patients into three RRG: Low (LRG)25%; Intermediate (IRG) 26-50% and High (HRG)50%. We performed univariate and multivariate analysis with the 2LPVs for each RRG. With these data, patients were reclassified as RRG+. ROC curves were used for comparison of RRG and RRG+.The median follow-up was 105 months (range 63 to 148). There were 177 (25.4%) patients with recurrence: 111 (15.9%) distant, 34 (4.9%) local and 32 (4.6%) distant and local. In the multivariable analysis, Fuhrman grade (HR=2,75; P=.0001) and pTpN stage (HR=2,19; P=.0001) behaved as independent predictive variables of recurrence. Patients were grouped as RRG (AUC=0,76; p=0,0001): - LRG (pT1pNx-0 G1-4; pT2pNx-0 G1-2): 456 (65,5%) patients. - IRG (pT2pNx-0 G3-4; pT3-4pNx-0 G1-2): 110 (15,8%) patients. - HRG (pT3-4pNx-0 G3-4; pT1-4pN+): 130 (18,6%) patients. After multivariate analysis with 2LPV, RRG were reclassified (RRG+) (AUC=.84, P=.0001): -LRG+(LRG without TN, SD and/or PSM(+)). -IRG+(IRG; LRG with TN) -HRG+(HRG; LRG with SD and/or PSM(+); IRG with TN and/or SD) CONCLUSIONS: The inclusion of 2LPV to the classification according to VP1N improves the discriminating capacity of RRG classification.

Evaluation of the effectiveness of cognitive biopsy (CB) in patients with clinical suspicion of prostate cancer (PC), and at least one negative biopsy (TRB).Retrospective study of 144 patients with at least one previous TRB and magnetic resonance imaging (MRI). The MRI nodules were classified based on PI-RADS v2 grouping pZa, pZpl and pZpm as the peripheral zone(PZ), Tza, Tzp and CZ as the transitional zone (TZ), and the AS zones as the anterior zone (AZ). A biopsy was indicated for nodules ≥PI-RADS 3. Uni and multivariate analysis was undertaken (logistic regression) to identify variables relating to a PI-RADS 3 tumour on biopsy.The median age was 67 (IQR: 62-72) years, the median PSA was 8.2 (IQR: 6.2-12) ng/ml. A nodule was identified on MRI in the PZ in 97 (67.4%) cases, in the TZ in 29 (20.1%), and in the AZ in 41 (28.5%). PC was diagnosed on biopsy in 64 (44%) patients. The cancer rate in the PI-RADS 3 lesions was 17.5% (7/40), in the PI-RADS 4 47.3% (35/73), and in the PI-RADS 5 lesions it was 73.3% (22/29) (p=.0001). Multivariable analysis with variables that could influence the biopsy result in patients with PI-RADS 3: None (age, PSA, number of previous biopsies, rectal examination, PSAD, prostate volume or number of extracted cylinders) behaved as an independent tumour predictor.The diagnostic performance of CB in patients with at least one previous negative biopsy was 44%, increasing according to the PI-RADS grade, and low in PI-RADS 3. No clinical variable predictive of cancer was found in patients with PI-RADS 3.