G. Andrés

A DNA hypermethylation profile reveals new potential biomarkers for prostate cancer diagnosis and prognosis.

DNA hypermethylation has emerged as a novel molecular biomarker for the evaluation of prostate cancer diagnosis and prognosis. Defining the specific gene hypermethylation profile for prostate cancer could involve groups of genes that specifically discriminate patients with indolent and aggressive tumors.

Puesta en marcha de un programa de entrenamiento para laparoscopia urológica por puerto único

OBJECTIVES To describe the onset of a single port laparoendoscopic program to carry out oncology surgery in a Urology Service. We present the initial experience in the laboratory and in the Animal Facility with rigid precurved instruments and KeyPort reusable access element (Richard Wolf). MATERIAL AND METHODS Two surgeons experienced in laparoscopic surgery and with the help of four assistants performed a training program based on predetermined tasks performed in simulation boxes (pelvitrainer) and porcine model following the requirements of the Regional Community of Madrid to handle experimental animals. RESULTS The participants in this program were initially divided into pairs made up of an experienced surgery and assistant for the predetermined multiple tasks in simulator box in order to become familiarized with the instruments. After, 20 animal sessions were conducted in which the following were performed: (retroperitoneal or pelvic) lymph node dissections (n = 20), nephrectomies (n = 40), cystorrhaphy with suture (n = 20) and uterine-vesical anastomosis (n = 20). Times needed to perform the exercises and the principal errors perceived during the performance of each one of the tasks were recorded. The tasks, of growing complexity, were performed with the instruments described in increasingly less time and with less difficulty. An accessory trocar of 3.5 mm was required to perform the in vivo sutures. CONCLUSIONS The KeyPort approach has potential application in different urological applications. Standardized training allows the acquirement of skills and makes the successful implementation possible of a laparoendoscopic surgery program in humans.

Estudio comparativo entre cirugía retrógrada intrarrenal y micro-nefrolitotomía percutánea en el tratamiento de la litiasis renal de tamaño intermedio

OBJECTIVE Retrograde intrarenal surgery (RIRS) has proven efficacy with minimal morbidity in the treatment of intermediate-sized kidney stones. The aim of this study was to examine the feasibility of micropercutaneous nephrolithotomy (microperc) for this indication and evaluate its results compared with those of RIRS. MATERIAL AND METHODS From September to December 2013, we performed a comparative prospective study between RIRS and microperc, with 20 consecutive patients with intermediate-sized (1-3cm) kidney stones. We employed a flexible dual-channel ureteroscope (Cobra, Richard Wolf GmbH) and a Microperc 4.85/8 Fr (with the patient supine) with flexible fiberoptics (0.9mm, 120° and 10,000 pixels) (PolyDiagnost GmbH). The study variables were demographic data, stone characteristics, percentage of stone elimination, complications (Clavien-Dindo), surgical time, hospital stay and need for auxiliary procedures. RESULTS The patients underwent RIRS (n=12) or microperc (n=8). There were no differences in the demographics or stone characteristics between the 2 groups. The percentage of stone elimination with RIRS and microperc was 91.7% and 87.5% (P=1), respectively. One of the patients who underwent RIRS (8.3%) experienced postoperative fever; one of the patients who underwent microperc (12.5%) experienced postoperative colic pain (both cases were classified as Clavien I). The operative times were similar: 120min (111.2-148.7) and 120 (88.7-167.5) min for RIRS and microperc (P=.8), respectively. None of the patients required a blood transfusion. The hospital stays were also equivalent: 1 day (1-2) and 1.5 days (1-3.5) for RIRS and microperc (P=.33), respectively. Two patients treated with microperc (25%) required auxiliary procedures (simultaneous RIRS and flexible nephroscopy after percutaneous trajectory dilation to treat, in both cases, a significant fragment that had migrated to an inaccessible calyx), and 1 patient in the RIRS group (8.3%) required percutaneous nephrolithotomy due to unfavorable infundibular-calyceal anatomy (P=.54). CONCLUSIONS Microperc is a minimally invasive method that is emerging as an effective and safe treatment for intermediate-sized kidney stones. Studies are needed to better evaluate its cost-effectiveness, the need for complementary treatments and its possible complementarity with RIRS when working with patients in the supine position.

Los efectos de resveratrol y otros polifenoles del vino sobre la proliferación, apoptosis y expresión de receptor androgénico en células LNCaP

PURPOSE To address the effect of resveratrol and other red wine polyphenols on cell proliferation, apoptosis and androgen receptor (AR) expression in human prostate cancer LNCaP cells. MATERIALS AND METHODS LNCaP cells (5 × 102) were cultured in microtiter plate modules and treated with gallic acid, tannic acid and quercetin (1, 5 and 10 μM), rutin and morin (25, 50 and 75 μM) and resveratrol (5, 10 and 25 μM). To address the extent of proliferation at 24, 48, 72 and 96 hours, a colorimetric immunoassay method was used. An activity caspase 3/7 detection assay was used to disclose apoptosis at 24, 48 and 72 hours. AR mARN levels were determined by real time RT-PCR. RESULTS All polyphenols studied significantly inhibited (P<.05) cell proliferation compared to control. However, there were moderate differences between them. Resveratrol was the strongest inhibitor at different times and doses. Also, caspase-3 and caspase-7 activity was significantly higher (P<.05) than control in the presence of all the compounds, but the earlier response was achieved by resveratrol. Resveratrol, quercetin and morin were the only nutrients that significantly inhibited AR mRNA expression. Again resveratrol produced the highest inhibition (90-250 times less than control), followed by morin (67-100 times) and quercetin (55-91 times). CONCLUSIONS All polyphenols studied showed important antiproliferative effects and induced apoptosis when added to LNCaP cells culture. We confirm that resveratrol, morin and quercetin may achieve such effect through reduced expression of AR. The synergistic effects of these compounds and their potential to prevent progression of hormone-dependent prostate cancer merit further study.

El estudio de la metilación del ADN en el cáncer urológico: presente y futuro

OBJECTIVES We have synthesized the principal advances in the field of the study of epigenetics and specifically DNA methylation regarding the diagnosis of urological neoplasms. ACQUISITION OF EVIDENCE Review of the literature (PubMed, MEDLINE and Cochrane) on the study of DNA methylation in urological neoplasms (prostate cancer, bladder cancer, renal cancer and testicular cancer), considering all the studies published up to January 2013. SYNTHESIS OF EVIDENCE It was possible to determine the state of methylation of many genes in our tumor samples. When these were compared with healthy tissue samples, it was possible to define the specific aberrant methylation patterns for each type of tumor. The study and definition of specific abnormal methylation patterns of each type of tumor is a tool having potential utility for diagnosis, evaluation, prediction of prognosis and treatment of the different forms of genitourinary cancer. The analysis of gene methylation in urine after micturition or post-prostatic massage urine, semen, in the wash plasma or fluid from prostatic biopsies may allow early detection of bladder, prostate, renal and testicular cancer. In each one of the neoplasms, an epigenetic signature that may be detected in the DNA has been identified, obtained from very scarce or not at all invasive specimens, with potential in the diagnosis and evaluation of prognosis. Validation of these studies will confirm the accuracy, effectiveness and reproducibility of the results available up to now. Criteria have still not been developed that determine if a gene panel provides sufficient information in the health care practice to guide an unequivocal diagnosis or therapeutic conduct. More studies are needed to compare sensitivity, specificity, positive and negative predictive value of the test in each case. Multicenter studies analyzing the real reproducibility of these results in a clinical setting also do not exist. CONCLUSIONS The study of aberrant DNA methylation in biological specimens of patients has an enormous potential for the early diagnosis and screening of genitourinary neoplasms. A larger number of studies is needed to be able to define the series of genes that would mean unequivocal signatures of malignancy. This methodology also has potential when defining prognostic groups and potential of response to different therapies.

Two-Port Approach Compared to Standard Laparoscopic Radical Cystectomy

BACKGROUND AND OBJECTIVES Two-port laparoscopic radical cystectomy (LRC) using a multichannel platform through the umbilicus and one additional 10-mm in the right iliac fossa has been recently described. We compare the perioperative and early results of this technique with a cohort of patients simultaneously treated in our institution with four-port LRC and a 7 to 10 cm midline incision. MATERIALS AND METHODS A matched-pair study comparing perioperative outcomes, postoperative visual analog pain scale (VAPS), and morbidity of two-port (n=30) and four-port (n=30) LRC. Preoperative and perioperative data analyzed and compared included demographics, type of urinary diversion, operative time, blood loss, transfusion requirements, decrease in serum hemoglobin, operative complications, analgesic needs, length of stay, number of nodes removed, and other pathologic information. Complications in the first 3 months were evaluated according to the Clavien-Dindo classification. RESULTS There was no significant difference between the two groups regarding patient age, gender, body-mass index, American Society of Anesthesiologists (ASA) score, Charlson comorbidity index, tumor stage, percent of positive nodes, positive margin rate, number of nodes retrieved, proportion of neobladders, secondary carcinoma in situ, incidental prostate cancer, or need of systemic chemotherapy. Median operative time was 20 minutes higher in the two-port procedure, but this difference was not statistically significant (p=0.2). Estimated blood loss and differential hemoglobin change were lower in the two-port technique (each p=0.03), but no difference was detected regarding the intraoperative or postoperative transfusion rate. Length of hospital stay was also equivalent. Differences were not observed either in the number or severity of complications. VAPS at days 2, 3, and 5 was significantly lower for two-port LRC (p<0.01). CONCLUSIONS Two-port LRC performed through an umbilical platform and an accessory 10-mm port seems technically equivalent to standard four-port LRC. Perioperative outcomes regarding hospital stay and complications are tantamount. Diminished blood loss and, especially, less postoperative pain favor the reduced-port approach in this complex urologic minimally invasive procedure.

Tratamiento de la estenosis de uretra bulbar larga con afectación membranosa mediante uretroplastia con injerto de mucosa bucal

INTRODUCTION Urethroplasty with oral mucosa grafting is the most popular technique for treating nontraumatic bulbar urethral strictures; however, cases involving the membranous portion are usually treated using progressive perineal anastomotic urethroplasty. We assessed the feasibility of performing dorsal (or ventral) graft urethroplasty on bulbar urethral strictures with mainly membranous involvement using a modified Barbagli technique. MATERIAL AND METHODS This was a prospective study of 14 patients with bulbomembranous urethral strictures who underwent dilation urethroplasty with oral mucosa graft between 2005 and 2013, performed using a modified technique Barbagli, with proximal anchoring of the graft and securing of the graft to the tunica cavernosa in 12 cases (85.7%) and ventrally in 2 (14.3%). The minimum follow-up time was 1 year. We evaluated the subjective (patient satisfaction) and objective (maximum flow [Qmax] and postvoid residual volume [PVRV], preoperative and postoperative) results and complications. Failure was defined as the need for any postoperative instrumentation. RESULTS A total of 14 patients (median age, 64+13 years) underwent surgery. The main antecedent of note was transurethral resection of the prostate in 9 cases (64.3%). The median length of the stenosis was 45+26.5mm. Prior to surgery, 50% of the patients had been subjected to dilatations and 4% to endoscopic urethrotomy. The mean surgical time and hospital stay were was 177+76min and 1.5+1 day, respectively. The preoperative Qmax and PVRV values were 4.5+4.45mL/sec and 212.5+130 cc, respectively. The postoperative values were 15.15+7.2mL/sec and 6+21.5cc, respectively (P<.01 for both comparisons). Surgery was successful in 13 cases (92.9%). None of the patients had major complications. There were minor complications in 1 (7.1%) patient, but reintervention was no required. CONCLUSION The repair of long bulbar urethral strictures with membranous involvement using urethroplasty with free oral mucosa grafts represents a viable alternative for patients with nontraumatic etiology and little fibrosis. The dilation of the urethral lumen achieves good results with minimum failure rates and little probability of complications. For many of these patients, the length of the stricture is too long to perform the tension-free anastomosis technique.

El papel de la metaloproteinasa de la matriz MMP-9 y del inhibidor tisular de metaloproteinasa TIMP-2 como marcadores séricos de cáncer vesical

INTRODUCTION The diagnosis and molecular staging of bladder cancer based on the detection of gelatinases mRNA (MMP-2 and MMP-9) in peripheral blood circulating and mononuclear cells have shown promising results. We analyze if the determination of the corresponding protein synthesis products makes it possible to diagnose and characterize patients with bladder cancer. MATERIAL AND METHOD Quantification of the serum levels of MMP-2, MMP-9 and TIMP-2 in a series of 42 individuals (31 patients with bladder cancer in different stages and 11 healthy controls) using the ELISA technique was carried out. The determinations were compared between cases and controls (Mann-Whitney U) and between different groups of tumors (Mann-Whitney U or Kruskal-Wallis), according to the clinical-pathological characteristics (age, gender, T category, M category or grade). Diagnostic yield of these markers was evaluated by analysis of the ROC curves. RESULTS There is a correlation between the determinations of MMP-2 and TIMP-2 (R=.699; P>.0001) and MMP-9 and TIMP-2 (R=.305; P=.049). Patients with bladder cancer have higher levels of MMP-9 (p<0.0001) and TIMP-2 (P=.047) than the controls. Furthermore, the MMP-9/TIMP-2 ratio is also superior in cancer patients (P<.001). Differences were not detected between cancer and controls regarding age (P=.64) or gender (P=.64). Differences were also not detected regarding MMP-2 (P=.35) or MMP-2/TIMP-2 rate (P=.45). Within the cancer patient population, the MMP-2 and MMP-9 values differ according to T category (P=.022 and P=.038, respectively) and those of the TIMP-2 according to M category (P=.036). ROC curve analysis showed that both MMP-9 and the MMP-9/TIMP-2 ratio discriminate patients with cancer and controls, with equivalent diagnostic accuracy (ABC 0.953) and cut offs of 3.93 ng/mL (S 90%; Sp 81%) and 0.053 ng/mL (S 96%; Sp 84%), respectively. CONCLUSIONS The results obtained suggest that both serum MMP-9 and TIMP-2 would have an application in the prediction of the development and progression of bladder cancer, and a potential utility as clinical markers of the disease. Multicenter, prospective studies that confirm their preliminary results are necessary.

La opción óptima: nefrectomía radical LESS umbilical con extracción vaginal

INTRODUCTION Umbilical laparoendoscopic single-site (LESS) surgery represents an excellent alternative to laparoscopic or robotic multiport surgery. LESS surgery offers faster recovery, less postoperative pain and optimal cosmetic results. The reusable nature of its instruments also has significant economic advantages. PATIENT AND METHOD We present a 34-year-old patient with a solid mesorenal lesion measuring 8 cm in the left kidney treated with pure LESS radical nephrectomy assisted by vaginal extraction of the specimen. The umbilical approach using a single-site multichannel KeyPort (Richard Wolf GmbH, Knittlingen, Germany) with DuoRotate curved instruments allows for minimum crushing and fewer spatial conflicts. Its perfect umbilical adaptation provides a hermetic system. The instruments double rotation provides considerable movement precision. Vaginal extraction avoids damage to the abdominal wall and the need for widening the umbilical incision. RESULTS After the placement of the device and triangulation of the clips, we proceeded to operate on posterior parietal peritoneum. The descending colon was mobilized to access the retroperitoneum and dissect the renal hilum. Hem-o-lok clips were placed on the artery and vein, which were subsequently sectioned. The specimen was inserted into a laparoscopic bag. Under direct vision, we placed a 15-mm trocar through the bottom of the vaginal posterior fornix to facilitate the extraction of the bags thread. The incision was widened with the fingers, and the specimen was extracted, closing the vagina from the perineum with visualization from the navel. Abdominal drainage was not employed. The surgical time was 180 min. The patient was discharged the following day without needing analgesia. A year later, the patient was disease-free and had no complications. CONCLUSIONS Umbilical LESS radical nephrectomy with vaginal extraction is feasible in selected cases. The procedure is oncologically safe, avoids scars and facilitates early recovery. From a practical point of view, this approach greatly simplifies natural orifice transluminal endoscopic surgery (NOTES) and enables a minimally invasive equivalent result.

Anatomía de la próstata en ratones motheaten viable (mev) con mutaciones en el gen de la proteína tirosina fosfatasa SHP-1

OBJECTIVE To study prostate and seminal vesicle anatomy in viable motheaten (mev) with mutations in PTPN6 gene leading to a severe reduction in the activity of protein tyrosine phosphatase SHP-1. Homozygous mev mice exhibit multiple anomalies that include immunodeficiencies, increased proliferation of macrophage, neutrophil, and erythrocyte progenitors, decreased bone density and sterility. MATERIAL AND METHOD We analyzed macro- and microscopic anatomy of the seminal vesicle and prostate macro- and microscopic anatomy of 5 mev/mev and 8 wt/wt adult 7 week old mice. Computerized morphometric analysis was performed to measure the relative changes appearing in the epithelial volume of the different prostatic lobes. RESULTS All mice studied revealed normal genital organs (penis, testis, epididymis, vas deferens) and bladder. The seminal vesicle was absent in all mev/mev individuals analyzed, being normal and very noticeable in wt/wt mice. The different glands that compose the prostatic complex (anterior, ventral and dorso-lateral prostate) were atrophied in mev/mev mice: anterior prostate 0.4 times, ventral 0.19 times, dorsal 0.35 times and lateral 0.28 times those of the respective regions in wt/wt mice. Microscopically, mev/mev mice revealed scarce and large prostatic ducts, acini severely atrophic with empty lumen and scarce loose epithelial component forming tufts and infoldings, and hyperplastic changes in fibromuscular stroma. CONCLUSIONS The prostate of mev/mev mice exhibits signs of aberrant differentiation and the resulting phenotype may be related to the loss of function of SHP-1. Prostatic anomalies in these mice affect, together with defects in sperm maduration, for their sterility. These data suggest SHP-1 plays an important role in prostate epithelial morphogenesis.