J.M. Fernández Gómez

Predictive Factors for Impaired Renal Function following Nephroureterectomy in Upper Urinary Tract Urothelial Cell Carcinoma

Objectives: Despite the uncertain value of adjuvant chemotherapy after radical nephroureterectomy (RNU) it is clear that impaired renal function represents a contraindication to its administration. The objective of this study was to identify possible predictive clinical factors for impaired renal function following RNU in patients with upper urinary tract urothelial cell carcinoma (UUT-UCC). Patients and Methods: A retrospective analysis was conducted of 546 patients who underwent RNU between 1992 and 2008 at our institution. Data of interest for this study included estimated glomerular filtration rate (eGFR), age, pathological stage and preoperative hydronephrosis (HN). The predictive value of HN, age and pathological stage for impaired renal function after RNU was calculated by multivariate linear regression analysis. Results: In total, 138 patients met the criteria for inclusion, including 108 men (78%). Mean age at surgery was 67 ± 10 years. There was a significant correlation (p < 0.001) between pre- and postoperative eGFR (decrease of 21% after NU). Preoperative HN was present in 51 patients (37%). On linear regression analysis, preoperative eGFR ≤60 ml/min (p = 0.012; OR = 4.60) and HN (p = 0.027; OR = 10.34) were confirmed to be predictive factors for a postoperative eGFR ≤60 ml/min. When postoperative eGFR ≤45 ml/min was used as the criterion for impaired renal function, predictive factors proved to be preoperative eGFR ≤45 ml/min (p < 0.0001; OR = 18.53), HN (p = 0.038; OR = 0.380) and age ≥70 years (p < 0.0001; OR = 0.169). Conclusions: Preoperative HN, older age and preoperative eGFR <60 ml/min were proven to be predictive factors for impaired renal function after RNU. In these settings, neoadjuvant chemotherapy may be considered.

Significance of Collagenase 3 (Matrix Metalloproteinase 13) in Invasive Bladder Cancer: Correlation with Pathological Parameters

Purpose: To determine if collagenase 3 expression is associated with stage progression and prognosis of bladder cancer. Patients and Methods: Immunohistochemical staining for collagenase 3 was carried out on serial sections from specimens of 42 patients (32 males and 10 females) who underwent radical cystectomy for bladder cancer (median follow-up, 67.2 ± 5.99 months). Results: Immunohistochemical expression of collagenase 3 was detected in 13 (31%) patients. Pathological stage was pT2 in 12 (28.57%) patients, pT3a in 7 (16.6%), pT3b in 21 (50%) and pT4 in 2 (4.76%). Four tumours (9.52%) were grade II and 38 (90.47%) were grade III. Stage and tumours >3 cm in size were associated with bladder cancer progression-free survival and overall survival. We did not find any statistical differences with collagenase 3 expression related with stage and size. Conclusions: Immunohistochemical expression of matrix metalloproteinase 13 in invasive bladder cancer is not useful as marker for transformation and invasion. These findings should be evaluated in large multicentre prospective trials.

Etiología neurógena en pacientes con disfunción eréctil.

OBJETIVOS La disfuncion erectil (DE) es una alteracion cuya prevalencia es elevada y aumenta con la edad. Se estima que en Espana afecta al 18,9% de los varones de 25 a 70 anos. En la mayor parte de los casos es de origen multifactorial y en su patogenia se admite la influencia de enfermedades sistemicas, farmacos de diferentes tipos, factores psicogenos, patologias cardiovasculares, endocrinopatias y alteraciones neurologicas. La disfuncion erectil de causa neurologica puede tener su origen a nivel del Sistema Nervioso Central o Periferico. Entre las posibles causas de disfuncion erectil neurogena de origen central estarian tumores, accidentes cerebrovasculares, encefalitis, Enfermedad de Parkinson, Esclerosis Multiple y otras enfermedades desmielinizantes, demencias, degeneracion olivopontocerebelosa y epilepsia. Las mielopatias de cualquier etiologia, pueden ser dependiendo de su localizacion o extension, causas de disfuncion erectil.A nivel periferico pueden ser causa de DE las alteraciones de las vias sensitivas que constituyen el brazo aferente del reflejo espinal de la ereccion y las de las vias eferentes vegetativas o somaticas que median en la vasodilatacion arterial, la relajacion del musculo liso cavernoso o la contraccion de la musculatura estriada del suelo de la pelvis. La finalidad de este trabajo es revisar detalladamente las causas mas relevantes de DE de origen neurogeno, sus mecanismos etiopatogenicos y los abordajes terapeuticos que en la actualidad se consideran mas adecuados para cada caso particular. CONCLUSIONES La correcta aproximacion diagnostica al paciente con DE pasa por identificar, en la medida de lo posible, los factores etiopatogenicos implicados su origen. En este sentido, la deteccion e identificacion, de la posible presencia del factor de riesgo neurogeno, contibuira a un mejor entendimiento de sus mecanismos fisiopatologicos y con ello a una aproximacion diagnostica, pronostica y terapeutica mas adecuada especialmete en aquellos pacientes refractarios a la terapia de primera linea.

Tecnica alternativa para prevenir la estimulación del nervio obturador durante la RTU vesical de neoformaciones en cara lateral

AN ALTERNATIVE TECHNIQUE TO PREVENT OF OBTURATOR NERVE STIMULATION DURING LATERAL BLADDER TUMOURS TRANSURETHRAL RESECTION Objetives: We presents an alternative to prevent the obturator nerve stimulation during TUBR. Material and Method: We revise 400 bladder tumours corresponding to 218 patients, 46,8% of them localized in lateral bladder wall. An alternative technique is used for that blockade. Results: There have been no adductor contractions in more than 95% of TUBR. Conclusions: The alternative technique may reduce the stimulation of the obturador nerve and the risk of bladder perforation.

ACTINOMICOSIS URACAL: A PROPÓSITO DE UN CASO

The report a new case of infected urachal cyst. The embriologic origin of the urachus, its anomalies, clinical features, diagnosis and treatment are discused with the case of a 51 years old man who presented an hypogastric mass with the diagnosin of urachal actynomicosis.

Características clínico-patológicas del carcinoma de células renales detectado incidentalmente mediante estudios radiológicos

Resumen Objetivos Evaluar el motivo de diagnostico del carcinoma renal y su variacion a lo largo de los anos en los Servicios de Radiodiagnostico 1 y Urologia 1 del Hospital Universitario Central de Asturias (HUCA), comparando los periodos 1970-1995 y 1996-2005 y determinar si el hallazgo incidental puede explicar de forma independiente el pronostico de estos tumores o es dependiente de sus caracteristicas clinico-patologicas. Material y metodos Se llevo a cabo una revision exhaustiva de las historias clinicas, de manera retrospectiva, de 373 carcinomas de celulas renales sometidos a reseccion quirurgica entre los anos 1970 y 2005, recogiendose unos datos segun un protocolo establecido. Resultados De los 373 tumores de nuestra serie, 146 (39,1%) fueron diagnosticados segun nuestros criterios de forma incidental, mientras que 227 (60,9%) lo fueron por presentar clinica sospechosa de presencia de un tumor. Cuando realizamos el recuento distribuyendo estos pacientes en dos grupos, por un lado los diagnosticados entre los anos 1970-1995, y por otro lado los diagnosticados entre 1996-2005, observamos un incremento significativo en el numero de tumores diagnosticados de forma incidental en el segundo periodo. Encontramos como factores independientes en la supervivencia cancer especifica la presencia de metastasis, la invasion microvascular de la pieza quirurgica y el tratamiento de la recidiva (quirurgico vs otros), mientras que los factores independientes de la recidiva resultaron ser el grado nuclear, la presencia de adenopatias y el estadio T3, por tanto la presencia de clinica no fue un factor independiente de recidiva ni de supervivencia cancer especifico. Conclusiones Clasicamente el carcinoma de celulas renales se diagnosticaba cuando presentaba sintomas locales (la hematuria y el dolor lumbar, eran los mas frecuentes), sintomas derivados de las metastasis o por la expresion de un sindrome paraneoplasico. Desde la generalizacion de la ecografia y la tomografia computerizada (TC) en el estudio de la patologia abdominal ha aumentado de forma espectacular el descubrimiento de adenocarcinomas renales asintomaticos. Cabe destacar, en nuestro estudio, que a pesar de que los pacientes diagnosticados con tumores incidentales presentaron un mayor tiempo libre de enfermedad y de supervivencia sin embargo, la presencia de clinica no fue un factor independiente ni de recidiva ni de supervivencia cancer especifico.

Efecto terapéutico de Mitomicina C en el postoperatorio inmediato de pacientes con tumores vesicales no músculo invasores de bajo riesgo

INTRODUCTION: Approximately 70-85% of transitional bladder cell carcinomas are non-muscle-invasive. After an initial surgery, around 60-90% will have a recurrence, being the highest risk period the first two years. Urothelium instability could be the main reason for recurrence in mid grade tumours, reason why a single dose of a chemotherapy after transurethral resection of the bladder (TURB) might be insufficient. That is why a deferred therapy in occasions associated with maintenance is recommended. PATIENTS AND METHODS: A prospective, controlled and randomized study was performed. We included non-muscle-invasive mid risk bladder tumours. All patients had initially a TURB performed and were randomized to receive a single dose of mitomycin C (MMC), in the immediate postoperative period. RESULTS: A total of 105 patients were included. Mean follow-up was 22, 70 +/- 8, 15 months. MMC was administered to 53 patients. Of these 66, 0% had no recurrence and 34.0% had a non-muscle-invasive recurrence. Of the 52 patients in the non MMC group, 53.8% had no recurrence and 44.2% had a non-muscle-invasive recurrence and only 1 patient had a muscle-invasive progression. We did not find significantly differences in time to recurrence in mid risk tumours when using immediate postoperative single dose of MMC or deferred therapy. There was only one case of myelosuppression. DISCUSSION: In mid risk non-muscle-invasive tumors, some studies suggest that early intravesical instillation of chemotherapy reduces the risk of recurrence after TURB. We could not show significantly differences when comparing postoperatorive MMC versus traditional deferred instillations.

Linfoma renal primario en paciente con Gammapatía monoclonal IgM

Resumen Son infrecuentes los casos de linfoma renal primario, ya que la afectacion renal por un proceso linfoproliferativo es, por lo general, secundaria a una enfermedad sistemica. Presentamos el caso de un paciente varon de 77 anos que acude por hallazgo ecografico incidental de una masa en su rinon izquierdo. Despues de realizar estudios (TC), se practica nefrectomia cuyo resultado anatomopatologico fue de linfoma no-hodking B primario renal. Asimismo el paciente presentaba una gammapatia monoclonal IgM asociada, por lo que preciso tratamiento quimioterapico sistemico. Realizamos una revision bibliografica centrandonos en los criterios diagnosticos y terapeuticos actuales.

Masas sólidas pelvianas de etiología incierta. Caso clínico.

Resumen Presentamos el caso de un varon de 73 anos con una gran masa endovesical infiltrante de estructuras vecinas en los estudios radiologicos y uropatia obstructiva secundaria. Se detalla la bateria diagnostica realizada que concluye con el diagnostico de H.B.P. masiva A proposito del caso, comentamos las posibles causas de masas pelvianas solidas (endo y retrovesicales) y los mecanismos diagnosticos disponibles, haciendo hincapie en la importancia capital de un estudio anatomopatologico

Opciones terapéuticas y factores predictivos de recurrencia y mortalidad cáncer-específica en pacientes con tumor vesical después de trasplante renal: análisis multiinstitucional

OBJECTIVES Bladder cancer (BC) in the transplanted population can represent a challenge owing to the immunosuppressed state of patients and the higher rate of comorbidities. The objective was to analyze the treatment of BC after renal transplant (RT), focusing on the mode of presentation, diagnosis, treatment options and predictive factors for recurrence. MATERIAL AND METHODS We conducted an observational prospective study with a retrospective analysis of 88 patients with BC after RT at 10 European centers. Clinical and oncologic data were collected, and indications and results of adjuvant treatment reviewed. The Kaplan-Meier method and uni- and multivariate Cox regression analyses were performed. RESULTS A total of 10,000 RTs were performed. Diagnosis of BC occurred at a median of 73 months after RT. Median follow-up was 126 months. Seventy-one patients (81.6%) had non-muscle invasive bladder cancer, of whom 29 (40.8%) received adjuvant treatment; of these, six (20.6%) received bacillus Calmette-Guérin and 20 (68.9%) mitomycin C. At univariate analysis, patients who received bacillus Calmette-Guérin had a significantly lower recurrence rate (P=.043). At multivariate analysis, a switch from immunosuppression to mTOR inhibitors significantly reduced the risk of recurrence (HR 0.24, 95% CI: 0.053-0.997, P=.049) while presence of multiple tumors increased it (HR 6.31, 95% CI: 1.78-22.3, P=.004). Globally, 26 patients (29.88%) underwent cystectomy. No major complications were recorded. Overall mortality (OM) was 32.2% (28 patients); the cancer-specific mortality was 13.8%. CONCLUSIONS Adjuvant bacillus Calmette-Guérin significantly reduces the risk of recurrence, as does switch to mTOR inhibitors. Multiple tumors increase the risk.