Luis Martínez-Piñeiro

The surgical learning curve for laparoscopic radical prostatectomy: a retrospective cohort study

BACKGROUNDnWe previously reported the learning curve for open radical prostatectomy, reporting large decreases in recurrence rates with increasing surgeon experience. Here we aim to characterise the learning curve for laparoscopic radical prostatectomy.nnnMETHODSnWe did a retrospective cohort study of 4702 patients with prostate cancer treated laparoscopically by one of 29 surgeons from seven institutions in Europe and North America between January, 1998, and June, 2007. Multivariable models were used to assess the association between surgeon experience at the time of each patients operation and prostate-cancer recurrence, with adjustment for established predictors.nnnFINDINGSnAfter adjusting for case mix, greater surgeon experience was associated with a lower risk of recurrence (p=0.0053). The 5-year risk of recurrence decreased from 17% to 16% to 9% for a patient treated by a surgeon with 10, 250, and 750 prior laparoscopic procedures, respectively (risk difference between 10 and 750 procedures 8.0%, 95% CI 4.4-12.0). The learning curve for laparoscopic radical prostatectomy was slower than the previously reported learning curve for open surgery (p<0.001). Surgeons with previous experience of open radical prostatectomy had significantly poorer results than those whose first operation was laparoscopic (risk difference 12.3%, 95% CI 8.8-15.7).nnnINTERPRETATIONnIncreasing surgical experience is associated with substantial reductions in cancer recurrence after laparoscopic radical prostatectomy, but improvements in outcome seem to accrue more slowly than for open surgery. Laparoscopic radical prostatectomy seems to involve skills that do not translate well from open radical prostatectomy.nnnFUNDINGnNational Cancer Institute, the Allbritton Fund, and the David J Koch Foundation.

European Association of Urology (@Uroweb) Recommendations on the Appropriate Use of Social Media

Social media use is becoming common in medical practice. Although primarily used in this context to connect physicians, social media allows users share information, to create an online profile, to learn and keep knowledge up to date, to facilitate virtual attendance at medical conferences, and to measure impact within a field. However, shared content should be considered permanent and beyond the control of its author, and typical boundaries, such as the patient-physician interaction, become blurred, putting both parties at risk. The European Association of Urology brought together a committee of stakeholders to create guidance on the good practice and standards of use of social media. These encompass guidance about defining an online profile; managing accounts; protecting the reputations of yourself and your organization; protecting patient confidentiality; and creating honest, responsible content that reflects your standing as a physician and your membership within this profession.

Molecular Staging of Prostatic Cancer with RT-PCR Assay for Prostate-Specific Antigen in Peripheral Blood and Lymph Nodes: Comparison with Standard Histological Staging and Immunohistochemical Assessment of Occult Regional Lymph Node Metastases

BACKGROUNDnAbout 30-40% of men with localized prostate cancer undergoing radical prostatectomy will have cancer recurrence. It is estimated that one third recur locally and two thirds develop distant metastases with or without local recurrence.nnnMETHODSnIn the present study we investigate the detection of prostate-specific antigen (PSA) mRNA in peripheral blood samples (n=200 patients) and pelvic lymph nodes (n=154 patients) by PSA reverse transcriptase polymerase chain reaction (RT-PCR) and compare these results to standard histological and immunohistochemical staging.nnnRESULTSnWe have observed a statistically significant correlation of lymph node PSA RT-PCR with standard pathologic risk factors, such as Gleason score (p=0.011), the presence of Gleason patterns 4 or 5 (p=0.005), lymph node metastasis (p<0.001) and a nearly significant correlation with the pT category (p=0.087). 39.5% (57/145) of the pN0 patients had PSA mRNA detectable in their lymph nodes. Blood PSA RT-PCR showed no correlation with the aforementioned factors and was even inversely correlated with preoperative serum PSA and lymph node status. Immunohistochemistry did not detect unsuspected prostate micrometastases in any pN0 patient.nnnCONCLUSIONSnLymph node PSA RT-PCR correlates with the Gleason score and the presence of Gleason patterns 4 or 5. Further clinical follow-up and correlation of RT-PCR status with overall outcome is required to allow validation of lymph node RT-PCR as a predictor of distant disease recurrence.

Urinary tract injuries in polytraumatized patients

ZusammenfassungHintergrundIm Rahmen des S3-Leitlinienprojekts der European Association of Urology (EAU) wurde eine Expertengruppe beauftragt, Leitlinien zur Diagnostik und Therapie urogenitaler Verletzungen zu erstellen. Diese Europäischen Leitlinien zum urologischen Trauma selbst wurden prinzipiell von der Deutschen Gesellschaft für Urologie als national gültige Guidelines anerkannt. Sie wurden damit auch Grundlage des Beitrags der Deutschen Gesellschaft für Urologie zu dem S3-Leitlinien-Projekt „Polytrauma“ der Deutschen Gesellschaft für UnfallchirurgieMethodeFür die Leitlinie zur Diagnostik und Therapie urogenitaler Verletzungen wurden alle Voraussetzungen für die Klassifikation als S3-Leitlinie erfüllt. Die Leitlinie selbst wurde entsprechend dem Prinzip „evidenzbasierter Medizin (EBM)“ erarbeitet. Es wurde eine systematische Literaturanalyse von 1966 bis 2004 durchgeführt. Den Artikeln wurde entsprechend ihres Studiendesigns und der inhaltlichen Relevanz ein Evidenzlevel zugeordnet. Die Gewichtung erfolgte nach dem Schema des Centre for Evidence-Based Medicine in Oxford.DiskussionBei Nierentraumata ist die Kreislaufsituation für das diagnostische und therapeutische Procedere bestimmend. Kreislaufstabile Patienten werden mittels CT evaluiert. Hämodynamisch nicht stabilisierbare Patienten werden primär explorativ laparotomiert. Verletzungen des Harnleiters werden je nach Verletzungsgrad durch Schienung oder Rekonstruktion versorgt. Beckenfrakturen sind häufig mit Verletzungen der Blase assoziiert. Diagnostiziert die retrograde Zystographie eine extraperitoneale Blasenruptur, ist die Harnableitung durch Dauerkatheter meist suffizient. Intraperitoneale Läsionen werden operativ versorgt. Blut am Meatus urethrae deutet beim Polytraumatisierten auf eine Urethraläsion; hier sollte der Versuch einer blinden Katheterisierung vermieden werden: die suprapubische Harnableitung mit späterer Diagnostik und Versorgung ist die Therapie der Wahl.AbstractBackgroundWithin the S3 Guideline Project of the European Association of Urology (EAU) an expert committee was set up to develop guidelines for the appropriate management of genitourinary trauma. These European guidelines were accepted in principle as national guidelines by the German Urological Society. Therefore, they also became the basis of the contribution of the German Urological Society to the S3 Guideline Project “Polytrauma” of the German Society for Trauma Surgery.MethodFor the guideline “management of genitourinary trauma” all the requirements for classification as S3 guidelines were fullfilled. The guideline itself was developed in accordance with the principles of “evidence-based medicine”. A systematic analysis of literature published between 1966 and 2004 was carried out. The articles retrieved were assessed in respect of study design and clinical relevance and classified following the scheme of the Centre for Evidence-Based Medicine in Oxford.ConclusionIn suspected renal injuries the hemodynamic situation of the patient is the benchmark for the diagnostic and therapeutic algorithm. The diagnostic gold standard for the assessment of haemodynamically stable patients is CT scanning. Uncontrolled haemodynamic instability is an indication for immediate explorative laparotomy. Partial ureteral tears are managed by stenting; complete tears by immediate surgical repair. Pelvic fractures are often associated with bladder ruptures. Extraperitoneal bladder ruptures, identified by retrograde cystography, are in most cases safely managed by simple catheter drainage. Intraperitoneal ruptures require surgical intervention. Blood at the meatus may suggest a urethral lesion—blind urethral catheterization should not be attempted. Suprapubic cystostomy and delayed urethroplasty are recommended.

EAU policy on live surgery events.

CONTEXTnLive surgery is an important part of surgical education, with an increase in the number of live surgery events (LSEs) at meetings despite controversy about their real educational value, risks to patient safety, and conflicts of interest.nnnOBJECTIVEnTo provide a European Association of Urology (EAU) policy on LSEs to regulate their organisation during urologic meetings.nnnEVIDENCE ACQUISITIONnThe project was carried out in phases: a systematic literature review generating key questions, surveys sent to Live Surgery Panel members, and Internet- and panel-based consensus finding using the Delphi process to agree on and formulate a policy.nnnEVIDENCE SYNTHESISnThe EAU will endorse LSEs, provided that the EAU Code of Conduct for live surgery and all organisational requirements are followed. Outcome data must be submitted to an EAU Web-based registry and complications reported using the revised Martin criteria. Regular audits will take place to evaluate compliance as well as the educational role of live surgery.nnnCONCLUSIONSnThis policy represents the consensus view of an expert panel established to advise the EAU. The EAU recognises the educational role of live surgery and endorses live case demonstration at urologic meetings that are conducted within a clearly defined regulatory framework. The overriding principle is that patient safety must take priority over all other considerations in the conduct of live surgery.nnnPATIENT SUMMARYnControversy exists regarding the true educational value of live surgical demonstrations on patients at surgical meetings. An EAU committee of experts developed a policy on how best to conduct live surgery at urologic meetings. The key principle is to ensure safety for every patient, including a code of conduct and checklist for live surgery, specific rules for how the surgery is organised and performed, and how each patients results are reported to the EAU. For detailed information, please visit www.uroweb.org.

Verletzungen der ableitenden Harnwege bei polytraumatisierten Patienten

ZusammenfassungHintergrundIm Rahmen des S3-Leitlinienprojekts der European Association of Urology (EAU) wurde eine Expertengruppe beauftragt, Leitlinien zur Diagnostik und Therapie urogenitaler Verletzungen zu erstellen. Diese Europäischen Leitlinien zum urologischen Trauma selbst wurden prinzipiell von der Deutschen Gesellschaft für Urologie als national gültige Guidelines anerkannt. Sie wurden damit auch Grundlage des Beitrags der Deutschen Gesellschaft für Urologie zu dem S3-Leitlinien-Projekt „Polytrauma“ der Deutschen Gesellschaft für UnfallchirurgieMethodeFür die Leitlinie zur Diagnostik und Therapie urogenitaler Verletzungen wurden alle Voraussetzungen für die Klassifikation als S3-Leitlinie erfüllt. Die Leitlinie selbst wurde entsprechend dem Prinzip „evidenzbasierter Medizin (EBM)“ erarbeitet. Es wurde eine systematische Literaturanalyse von 1966 bis 2004 durchgeführt. Den Artikeln wurde entsprechend ihres Studiendesigns und der inhaltlichen Relevanz ein Evidenzlevel zugeordnet. Die Gewichtung erfolgte nach dem Schema des Centre for Evidence-Based Medicine in Oxford.DiskussionBei Nierentraumata ist die Kreislaufsituation für das diagnostische und therapeutische Procedere bestimmend. Kreislaufstabile Patienten werden mittels CT evaluiert. Hämodynamisch nicht stabilisierbare Patienten werden primär explorativ laparotomiert. Verletzungen des Harnleiters werden je nach Verletzungsgrad durch Schienung oder Rekonstruktion versorgt. Beckenfrakturen sind häufig mit Verletzungen der Blase assoziiert. Diagnostiziert die retrograde Zystographie eine extraperitoneale Blasenruptur, ist die Harnableitung durch Dauerkatheter meist suffizient. Intraperitoneale Läsionen werden operativ versorgt. Blut am Meatus urethrae deutet beim Polytraumatisierten auf eine Urethraläsion; hier sollte der Versuch einer blinden Katheterisierung vermieden werden: die suprapubische Harnableitung mit späterer Diagnostik und Versorgung ist die Therapie der Wahl.AbstractBackgroundWithin the S3 Guideline Project of the European Association of Urology (EAU) an expert committee was set up to develop guidelines for the appropriate management of genitourinary trauma. These European guidelines were accepted in principle as national guidelines by the German Urological Society. Therefore, they also became the basis of the contribution of the German Urological Society to the S3 Guideline Project “Polytrauma” of the German Society for Trauma Surgery.MethodFor the guideline “management of genitourinary trauma” all the requirements for classification as S3 guidelines were fullfilled. The guideline itself was developed in accordance with the principles of “evidence-based medicine”. A systematic analysis of literature published between 1966 and 2004 was carried out. The articles retrieved were assessed in respect of study design and clinical relevance and classified following the scheme of the Centre for Evidence-Based Medicine in Oxford.ConclusionIn suspected renal injuries the hemodynamic situation of the patient is the benchmark for the diagnostic and therapeutic algorithm. The diagnostic gold standard for the assessment of haemodynamically stable patients is CT scanning. Uncontrolled haemodynamic instability is an indication for immediate explorative laparotomy. Partial ureteral tears are managed by stenting; complete tears by immediate surgical repair. Pelvic fractures are often associated with bladder ruptures. Extraperitoneal bladder ruptures, identified by retrograde cystography, are in most cases safely managed by simple catheter drainage. Intraperitoneal ruptures require surgical intervention. Blood at the meatus may suggest a urethral lesion—blind urethral catheterization should not be attempted. Suprapubic cystostomy and delayed urethroplasty are recommended.

Laparoscopic transperitoneal radical prostatectomy in renal transplant recipients: a review of the literature.

To report our experience with laparoscopic radical prostatectomy (LRP) for the treatment of localized prostate carcinoma in two renal transplant recipients and a review of the literature.

Cirugía conservadora de parénquima en neoformaciones renales

Resumen Objetivos Analizar retrospectivamente una serie de 60 intervenciones ahorradoras de parenquima en pacientes con masas renales. Material Y Metodos Se han revisado los protocolos clinicos de 59 pacientes operados conservadoramente entre Enero de 1978 y Diciembre de 1997; 40 eran varones, la edad media era de 54 anos (rango 17-77); 10 (17%) tenian tumores bilaterales sincronicos, 15 (25%) eran monorrenos y 2 tenian insuficiencia renal; en 25 pacientes (26 operaciones) la indicacion de cirugia ahorradora fue obligada, mientras que en 34 fue electiva, por tener un rinon contralateral sano. Treinta (50%) de las masas renales habian sido descubiertas incidentalmente. En total se realizaron enucleaciones en 49 rinones y nefrectomias parciales en 11. Resultados El estudio histopatologico de los tumores extirpados revelo 43 (71,6%) carcinomas de celulas renales (ccr), 2 (3,4%) carcinomas uroteliales, 6 (10,2%) oncocitomas, 7 (11,6%) angiomiolipomas y 2 (3,4%) nefromas quisticos multiloculares. entre los ccr, 8 median ??3 cm, 22 median entre 3,1-5 cm, 10 entre 5,1-8 cm y 3 mas de 8 cm; estaban bien encapsulados 31 (72,1%) y solo en 2 (4,6%) casos habia infiltracion del parenquima vecino. siete (16,2%) eran pt1, 34 (79%) eran pt2 y 2 (4,6%) eran pt3, 39 (90,7%) eran g1 o g2 y solo 4 (9,3%) eran g3. Hubo 2 (3,3%) muertes perioperatorias, ambas en el grupo de cirugia obligada; 3 (6,8%) de los pacientes con tumores malignos progresaron y murieron, todos del grupo de cirugia obligada con ccr. otros 3 de este grupo desarrollaron recidivas locales, pero fueron rescatados con nueva cirugia (conservadora en 1); 2 de ellos tenian ccr esporadicos, pero el tercero padecia un von hippel-lindau. Ninguno de los 34 pacientes operados electivamente progreso, ni tuvo recidiva local y todos viven libres de enfermedad; solo sobreviven 14 (56%) de los 25 operados por necesidad, si bien 6 murieron por causas ajenas al tumor. La supervivencia cancer especifica a los 58,3 meses de seguimiento (rango 5-187 meses) es del 86,8% para toda la serie, del 100% para los casos operados electivamente y del 68,7% para los operados de necesidad. Han presentado complicaciones 19 (31,6%) de las operaciones, de las cuales 14 eran obligadas; dos de ellas fueron mortales (hemorragia y sepsis). Tres pacientes hicieron fracasos renales agudos, pero no precisaron dialisis y actualmente hay 4 (6,7%) pacientes con pobre funcion renal, de los cuales 1 precisa dialisis. Conclusion La cirugia ahorradora de parenquima proporciona un control excelente de los carcinomas renales; en los casos operados electivamente, la supervivencia cancer especifica del 100% justifica continuar indicando la cirugia conservadora en pacientes con masas renales bien delimitadas, aunque tengan el rinon contralateral sano.

Surgical repair of anterior hypospadias with fish-mouth meatus and intact prepuce based on anatomical characteristics.

Purpose: A variant form of anterior hypospadias, called a megameatus and intact prepuce (MIP), is thought to be less amenable to conventional distal hypospadias repair. The feasibility of using the standard technique with a parameatal-based foreskin flap is described herein. Materials and Methods: Nine children with the MIP variant underwent repair. A foreskin flap for urethroplasty was harvested from either the ventral (Mathiew) or unilateral site. The glans was split along with the cleft glanular groove to create the glans wings. The flap was laid on the urethral plate to form a neourethra, and glanulomeatoplasty was completed by approximation of the glans wings. Sleeve reapproximation of the penile foreskin was performed for uncircumcised skin closure. Results: The functional and cosmetic results of the procedure were excellent in 8 cases including 1 with temporary postoperative edema of redundant foreskin. The last case underwent excision of the ventral excess foreskin for cosmetic reasons. Conclusions: Although the etiology of the MIP variant remains obscure, the urethral plate distal to the meatus is uniformly pliable and healthy in this variant. Furthermore, the ventral portion just proximal to the meatus is well developed and not atretic so that the parameatal ventral foreskin is safely harvested for onlay urethroplasty.

NKG2D is a Key Receptor for Recognition of Bladder Cancer Cells by IL-2-Activated NK Cells and BCG Promotes NK Cell Activation

Intravesical instillation of bacillus Calmette–Guérin (BCG) is used to treat superficial bladder cancer, either papillary tumors (after transurethral resection) or high-grade flat carcinomas (carcinoma in situ), reducing recurrence in about 70% of patients. Initially, BCG was proposed to work through an inflammatory response, mediated by phagocytic uptake of mycobacterial antigens and cytokine release. More recently, other immune effectors such as monocytes, natural killer (NK), and NKT cells have been suggested to play a role in this immune response. Here, we provide a comprehensive study of multiple bladder cancer cell lines as putative targets for immune cells and evaluated their recognition by NK cells in the presence and absence of BCG. We describe that different bladder cancer cells can express multiple activating and inhibitory ligands for NK cells. Recognition of bladder cancer cells depended mainly on NKG2D, with a contribution from NKp46. Surprisingly, exposure to BCG did not affect the immune phenotype of bladder cells nor increased NK cell recognition of purified IL-2-activated cell lines. However, NK cells were activated efficiently when BCG was included in mixed lymphocyte cultures, suggesting that NK activation after mycobacteria treatment requires the collaboration of various immune cells. We also analyzed the percentage of NK cells in peripheral blood of a cohort of bladder cancer patients treated with BCG. The total numbers of NK cells did not vary during treatment, indicating that a more detailed study of NK cell activation in the tumor site will be required to evaluate the response in each patient.