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Objective: Although an immediate postoperative instillation of chemotherapy (IPOIC) after transurethral resection of bladder tumors (TURBT) is recommended for the prevention of recurrences of non-muscleinvasive bladder cancer (NMIBC), evidence shows there is an important compliance failure worldwide. We believe that an immediate neoadjuvant instillation of chemotherapy (INAIC) can act similarly, reducing the recurrence risk of NMIBC. Here we present the interim analysis of the PRECAVE clinical trial., Material and Methods: Patients with clinically diagnosed NMIBC were randomized to receive an INAIC with mitomycin C before TURBT (Group A) or to a control group with TURBT only (Group B). Primary end point was to compare the efficacy of an INAIC in the early recurrence-free survival (RFS). Secondary end points were: RFS in patients who did not receive adjuvant treatments, toxicity, and feasibility., Results: A total of 124 patients with Ta/T1 G1-G3NMIBC were included in the initial analysis (Group A:64, Group B: 60). Demographics, risk classification, complications, and adjuvant treatments were balanced between groups. Eighty-four patients (Group A: 45, Group B: 39) who completed a one-year follow-up were included in the efficacy analysis and no difference was observed in the RFS between groups (p=0.3). In the subgroup of patients who did not receive adjuvant treatments, we found a significant difference in favor of an INAIC (p=0.009) and an 80% reduction in the risk of early recurrences (Hazard Ratio: 0.20; 95% confidence interval: 0.05-0.81; p=0.0024). No differences were observed in adverse events. Only 4 patients did not receive an INAIC despite being planned., Conclusions: In this interim analysis, although we could not demonstrate a reduction in the RFS of all patients, we did find a significant decrease of recurrences in patients who did not receive adjuvant treatments. The administration of an INAIC seems to be safe and our protocol appears feasible and reproductive.

Introduction: Patients affected by von Hippel-Lindau (VHL) disease experience an increased risk for bilateral, synchronous, and metachronous renal cell carcinoma (RCC). Oncologic and functional outcomes are the main goals in the management of renal masses. We present our protocol for patients with VHL disease-associated RCC alongside functional and oncologic results observed in our series., Material and Methods: We performed a retrospective analysis of our clinical database of patients with VHL disease-associated RCC referred to our department between June 2005 and December 2017. We offer surveillance for lesions <2 cm and active management with radiofrequency ablation (RFA) for lesions 2-3 cm, and nephron-sparing surgery (NSS), RFA or embolization techniques for lesions >3 cm or growth rate >1 cm/year., Results: Our series comprises 14 patients, of whom 13 had undergone at least one invasive procedure for RCC, mean age at first intervention was 27 years (range 18-60). Overall, 30 interventions were performed in 21 kidneys: four radical nephrectomies, 13 RFAs, 12 NSSs, and one embolization. During follow-up (median time: 41 months, range: 6-149), eight patients (57%) presented with new lesions that required treatment, with a mean time between treatments of 32 ±18.5 months. No metastatic progression or need for dialysis was recorded; the success rate for RFA was 85%., Conclusions: Management of VHL kidney disease by NSS is the standard of care with a cut-off at 3 cm, ablative procedures should be offered to lesions ranging 2-3 cm in size. Follow-up should be done strictly in referral centers that can provide all treatment options to renal function and control oncologic progression., Competing Interests: The authors declare no conflicts of interest., (Copyright by Polish Urological Association.)

Androgen deprivation therapy is part of the initial treatment of patients with metastatic prostate cancer. Nevertheless, after an initial response and despite maintaining an effective testosterone suppression, the tumor is able to continue growing.Enzalutamide is an oral second generation pure antiandrogen that acts at various levels in the signal activation cascade of the androgen receptor and has demonstrated being effective in this phase of the disease. In the clinical trials completed, it has demonstrated benefits in overall patient survival in patients with the diagnosis of metastatic castration resistant prostate cancer. Recent studies have also demonstrated benefits in progression free survival in patients with non-metastatic castration resistant prostate cancer. Enzalutamide has an excellent toxicity profile, but we have to avoid it in patients with history of seizure episodes, mainly if they are under anti-epileptic drug therapy. Enzalutamide is rapidly metabolized by the liver, mainly through the CYP2C8 and to a lesser extent by CYP3A4/5 so that its metabolism may be altered when cytochrome isoenzyme inductor or inhibitor drugs are given concomitantly. Moreover, enzalutamide may require dose adjustment for other drugs since it is a potent inductor of CYP3A4 and a moderate inductor of CYP2C9 y el CYP2C19. Even though treatment with enzalutamide has significantly altered the natural history of the disease, in most cases it will progress by development of resistance mechanisms, among which we may emphasize androgen receptor mutations, overexpression, amplification and variants, as well as the intracrine production of androgens. Enzalutamide must be considered as first line therapy in patients with castration resistant prostate cancer.

This article presents a review of the different tests used for the evaluation and follow-up of urethral strictures. Because there is no consensus on how to assess urethral pathology, we reviewed each of the next follow-up tests: questionnaires, uroflowmetry, ultrasound, urethroscopy, urethrogram, CT scan and MRI, outlining their benefits and limitations in the diagnosis and follow-up of urethral stricture. Urethrogram and urethroscopy are the most commonly used tests, as they are those that give us more information on the evaluation of stenosis and for surgery planning. Questionnaires and uroflowmetry play a key role in the follow-up of these patients. Ultrasonography has high sensitivity and specificity for evaluating the spongiofibrosis, however it is not done routinely. The CT/MRI is recommended in the evaluation of pelvic trauma associated with fractures.

Objectives: Testosterone deficit syndrome (TDS)is a clinical and biochemical entity characterized by low testosterone levels and androgenic deprivation clinic, which can cause a decrease in the quality of life. However, today there are doubts about its diagnosis and therapeutic management., Methods: Bibliographic review using the MedLine database and detailed presentation of one clinical case., Results: Testosterone deficit syndrome is associated with metabolic syndrome (visceral obesity, arterial hypertension, diabetes mellitus and dyslipemia). Currently, the performance of TDS screening in all males over the age of 45 years is under discussion. We propose a diagnostic-therapeutic algorithm for the management of TDS and erectile dysfunction., Conclusions: The treatment of erectile dysfunction associated with late start hypogonadism follows the same steps tha other generic cases of erectile dysfunction.

Open radical cystectomy with lymph node dissection remains the gold standard treatment for recurrent, high-grade, non-muscle-invasive and for muscle-invasive bladder cancer. The excellent perioperative and long-term results provided by laparoscopic surgery and the advances in instrumentation design have naturally paved the way for development of laparoscopic radical cystectomy (LRC). In this review, surgical and long-term oncological outcomes of LRC are analysed. The advantages of this technique compared with open surgery are described. The differences between pure laparoscopic technique or laparoscopic cystectomy and extracorporeal urinary diversion have also been analysed.

Radical nephrectomy is the only curative treatment for renal cell cancer. Standard treatment includes ipsilateral adrenalectomy and lymph node dissection. In recent years, development of nephron-sparing surgery and early detection of small renal tumors has led to question this approach. The role of lymphadenectomy and adrenalectomy in surgical treatment of renal cancer is reviewed.

Objective: [corrected] To indirectly address the adequacy of referrals from general practitioners (GP) to specialized care taking into account a previously agreed protocol on ten urological topics., Materials & Methods: The study analyzed all referrals to the Urology department originated in 10 primary care centres (135 GPs involved) throughout a 19-month period. Adequacy of 2841 referrals was checked. The urologist judged the referral as compliant (adequate) or not compliant (inadequate) with the terms of the protocol. Compliance per primary care centres was compared. Also referral adequacy corrected per centre and clinical topic was compared. The relationship between "absolute number of referrals" and "adequate referrals" was tested using a linear regression model., Results: 57.2% of the referrals were inadequate. Overall, no significant differences were detected between primary care centres. Nevertheless significant differences between centres were evident in terms of referrals due to renal colic and female urinary incontinence. 70% (94/135) of the GPs complied with the protocol in, at least, 50% of the cases. A strong association between "absolute number of referrals" and "adequate referrals" was evident (r2=0.86)., Conclusions: Overall compliance with the protocol was modest. While no significant differences between centres were detected in terms of adequacy of referrals certain conditions have to be locally revisited; most of the topics (particularly microhematuria) have to be revisited in every center.

Objectives: The surgical procedures for the insertion of tension free vaginal tapes in the treatment of female stress urinary incontinence (SUI) are simple and can be done as outpatient operations. The aim of this study was to perform a budget study comparing TVT in an outpatient basis with transobturator tape (TOT) with hospital admission., Methods: Retrospective analysis of the medical records of 23 patients undergoing surgery for SUI between October 2004 and October 2005. 13 patients were treated by TVT in an outpatient basis (group 1, Department of Urology), 10 patients were treated by TOT with hospital admission (Group 2, Department of Gynaecology). Cost analysis was carried out by the construction of a Marcov model, incorporating the time sequence of the treatment, including adverse events and results. Variables considered for the analysis: number of visits, preoperative tests, operative time, tape cost, hospital stay, unpredicted visits in the first postoperative month at the outpatient clinics or emergency room, and hospital readmissions. Statistical analysis was performed with the G-Stat software. Student's t test was used to compare quantitative variables., Results: 11/13 patients (84.6%) in group 1 completed the day-surgery protocol. Mean surgical time was 61.7 min. (SD 16.2; 35-100) and 61.6 min. (SD 8.3; 50-73) for groups I and 2 respectively. Two cases in group 1 had perioperative complications (15.4%); no patient in group 2 had perioperative complications. Mean hospital stay was 1.3 days for group 1 (SD 0.85; 1-4) and 2.9 days for group 2 (SD 0.31; 2-3). Three patients in group 1 (23%) and 2 in group 2 (20%) presented postoperative complications. Mean cost per process was 4740 EUR for group 1 and 7099 EUR for group 2., Conclusions: SUI correction by tension free tapes as day surgery is a valid option which saves a substantial amount of resources.

We report a case of a patient with a secondary injury of external iliac artery and vein in the L4-L5 laminectomy and discectomy course. An immediately vein suture and ilio-iliac by-pass with Dacron was made. In the postoperative a iatrogenic lumbar ureter section was discovered and treated with renal autotransplantation. We review the options described in the literature in the management of these complex ureteral injuries.

Objective: To analyze the results of the first two years of application of the clinical pathway for transurethral resection (TUR) of bladder tumors at La Paz University Hospital., Methods: We developed a clinical pathway of 4 hospital stays (5 days) for TUR of the bladder that included the following: matrix-verification, treatments prescribed, verification of changes, patient information sheet and patient satisfaction questionnaire. The information for the evaluation of the results were obtained from the pathway records and data on the activities of the Urology services. To assess the results for efficiency in the use of resources, the mean duration of hospital stay of patients in the pathway were compared with that of a control group comprised of 50 randomly selected patients submitted to TUR of the bladder in 1997., Results: From June 1998 to May 2000, 481 of the 494 (97.4%) treated patients entered the clinical pathway., Conclusions: In our experience, the clinical pathway for the urinary bladder is a useful instrument for developing the clinical management of this condition. It reduces the unwanted changes in patient care and hospital stay, carries a low incidence of complications and readmissions, and achieves a high degree of patient satisfaction.

Objective: Inverted papilloma of the urothelium accounts for 2.2% of urothelial neoplasms. Its oncologic significance is unclear; its potential for recurrence and/or progression is not well-known. Our experience from 1976 to 1999 is reviewed., Methods: From 1976 to 1999, 31 patients with urothelial inverted papilloma of the lower urinary tract have been treated in our service: 17 presented previous and/or synchronous association with urothelial carcinoma (group I) and 14 had primary inverted papilloma (group II). The recurrence and progression rates for each group were determined and compared. The overall recurrence and progression rates were also determined. Two patients (one from each group) were lost to follow-up. The remaining 29 patients had a mean follow-up of 51.3 months (range 3-125)., Results: 12 patients (41.4%) showed recurrence in the form of bladder carcinoma; 10 from group I (10/16; 62.3%) and 2 from group II (2/13; 15.4%) (p < 0.05). Mean time to recurrence was 17.9 months (range 3-58). Disease free interval was higher in group II (p < 0.05). Progression to infiltrating tumor was observed in three patients; all three had associated superficial bladder carcinoma (group I). The mean time to progression was 30.7 months (range 18-38). No statistically significant differences were found in the percentage of progression between both groups., Conclusions: Inverted papilloma of the lower urinary tract showed a high incidence of association with urothelial carcinoma and a high recurrence rate, even in primary tumors. Therefore it should be considered a tumor of low grade malignancy that should be followed regularly.

Objective: To review the current status of superficial bladder cancer treatment with several immune response modifiers., Methods: A review of the advances in the treatment of superficial bladder cancer with BCG, interferon, interleukin-2, bropirimine and keyhole-limpet hemocyanin was performed., Results: Treatment with BCG has been demonstrated to be superior to intravesical chemotherapy and other immune response modifiers in the trials reviewed. BCG therapy, however, carries a higher toxicity. Several trials have demonstrated that in low and medium risk patients, it is better to administer low BCG doses to reduce the toxicity. Furthermore, the trials confirm the utility of maintenance schedules with BCG., Conclusion: The Calmette-Guérin Bacillus is the most effective adjuvant treatment in superficial bladder cancer, especially in the high risk patients. The other immune response modifiers are an alternative to this treatment.

Objective: To analyze the results achieved with vacuum devices in the treatment of erectile dysfunction., Methods: A telephone survey was conducted on 150 patients undergoing treatment with a vacuum device. Of these, 89 responded; 79 of which were considered valid for the study. The duration and frequency of use, side effects and degree of patient and partner satisfaction were analyzed. Mean follow-up was 59.5 months., Results: There were 14 dropouts early in the course of treatment. The remaining 65 patients used the device for a mean duration of 34.6 months, 3.7 times monthly. 63.3% of the patients achieved erection in more than half of the attempts. The most frequent side effects were pain (27 patients) and ecchymosis (7 patients). Forty-eight patients discontinued treatment at 10.8 months' mean follow-up. The most common causes for discontinuing treatment were lack of efficacy, refusal of the partner and pain., Conclusions: Treatment of erectile dysfunction with the vacuum constriction device should be utilized as an alternative to intracavernosal drug-induced erection therapy when oral therapy fails or is contraindicated. A male with a stable partner and impotence arising from venous leakage or mild cavernous artery insufficiency is the ideal candidate.

Objective: To describe the clinical care path for retropubic radical prostatectomy of the La Paz teaching hospital and the results achieved after the first 6 months., Methods: We have developed a clinical care path for radical prostatectomy with a hospital stay of 6 days. Thirty-one patients submitted to retropubic radical prostatectomy from June to November 1998 were included in the program. The mean length of total, preoperative and postoperative stay were analyzed and compared with those of 31 patients who had undergone radical prostatectomy before the program was developed. Readmissions, adverse effects and patient satisfaction were also analyzed., Results: Of the 31 patients included in the clinical care path, 22 (71%) had a stay equal to or less than the program's length of stay. The mean total, pre and postoperative stay for the group of patients included in the clinical care path were 6.0 days (SD = 1.1), 1 day (SD = 0.0) and 4.9 days (SD = 1.1), respectively. The length of stay was significantly longer before the program was developed [mean total 10.2 days (SD = 4.9), mean preoperative 2.6 days (SD = 2.6) and mean postoperative 7.6 days (SD = 3.6)] (p < 0.001). Twenty-four patients (77.4%) completed the questionnaire on patient satisfaction, which was highly positive, the overall patient satisfaction rate being higher than the 90% standard. There were no readmissions or significant events ascribable to the program., Conclusions: In our experience, the clinical care path for radical prostatectomy is a useful tool to reduce the unwanted variability. Its design is based on the best possible evidence, therefore the scientific and technical quality, patient satisfaction and efficiency are enhanced. In our view, our results are attainable and feasible in any health care setting.