S. Esquena

Failure to Maintain a Suppressed Level of Serum Testosterone during Long-Acting Depot Luteinizing Hormone-Releasing Hormone Agonist Therapy in Patients with Advanced Prostate Cancer

Objectives: It was the aim of this study to analyze the failure rates in achieving or maintaining castrate levels of serum testosterone in patients with advanced prostate cancer treated with the 3-month luteinizing hormone-releasing hormone agonist (LH-RH) therapy. Methods:Total serum testosterone was determined in 234 patients with prostate cancer in a cross-sectional study. A subset of 90 patients submitted to radical prostatectomy was used as the control group (group 1), and 144 patients with advanced prostate cancer under androgen suppression therapy were included in the study group (groups 2 and 3). The study group was divided into 93 patients (group 2) treated with 50 mg daily bicalutamide and LH-RH agonist (maximal androgen blockade, MAB) and 51 patients treated with the LH-RH agonist alone (group 3). Median follow-up after androgen suppression was 42 months. The castrate testosterone level was defined below 50 ng/dl. Results: The mean serum testosterone level was 29.1 ng/dl in patients undergoing MAB (group 2) and 29.5 ng/dl in patients treated with the LH-RH agonist (group 3; p > 0.05). In group 1, the mean serum testosterone was 445.2 ng/dl (p < 0.0001). The rate of patients with a serum testosterone level higher than 50 ng/dl was 10.9% in patients undergoing androgen suppression, 10% in patients with MAB treatment and 12.5% in those with LH-RH agonist therapy (p > 0.05). In group 1, 98.9% of the patients had a serum testosterone level higher than 50 ng/dl. Conclusions: A small but clinically significant rate of patients under 3-month LH-RH agonist therapy fail to achieve or maintain castrate testosterone serum levels. This finding supports the need of monitoring testicular response during LH-RH agonist therapy.

Nadir prostate‐specific antigen best predicts the progression to androgen‐independent prostate cancer

The objective of our study was to analyze the value of prostate‐specific antigen (PSA) levels before and after androgen suppression to predict the time to androgen‐independent progression (AIP) in patients with advanced and metastatic prostate cancer. A series of 283 prostate cancer patients under androgen suppression as a single treatment was studied. The disease was locally advanced in 98 patients and metastatic in the remainder 185. AIP was defined after 2 consecutive increases of serum PSA after the nadir value. The mean follow‐up before AIP was 29.2 months (3–198). AIP was detected in 205 patients (72.4%). In 152 patients (74.1%), the event was detected within 24 months, while in 53 patients (25.9%), it was observed beyond 24 months. The multivariate analysis showed that the nadir PSA and the time to reach the nadir PSA were the most significant predictors of the time to AIP. The odds ratio of having a biochemical response greater than 24 months was 20 times higher in patients that achieved an undetectable PSA level of 0.2 ng/mL or less. Moreover in those patients whose nadir PSA reached beyond 12 months after androgen suppression the odds ratio was 18 times higher. These results show that the ability to achieve an undetectable nadir PSA and the time to reach it are the most significant predictors of the time to AIP in patients with locally advanced and metastatic prostate cancer under androgen suppression as a single therapy.

Laparoscopic Kidney Transplantation

We present the details of the first laparoscopic transplantation of a kidney from a living, related donor, performed April 16, 2009. Surgical and functional results were acceptable. Surgical time was 240 min (53 min for vascular suture), with blood loss of 300 cm(3) and a hospital stay of 14 d. Serum creatinine at discharge was 73 mmol/l. Laparoscopic kidney transplantation is a complex technique that requires previous experience in vascular and laparoscopic surgery. As with all novel procedures, technical modifications will be required to formalize its use and detailed comparisons will need to be made with standard procedures.

Prostatectomía radical robótica: revisión de nuestra curva de aprendizaje

Resumen Prostatectomia radical robotica: revision de nuestra curva de aprendizaje Objetivo Presentamos los primeros casos de nuestra serie de prostatectomia radical robotica con Da Vinci (PRRdaV), que corresponden a la curva de aprendizaje (CA) del cirujano que se ha iniciado en la tecnica. Metodos Se revisan los 20 primeros pacientes sometidos a PRRdaV y realizados por un cirujano experto, sin entrenamiento laparoscopico previo, pero con amplia experiencia en prostatectomia radical retropubica y perineal (HV). Se analiza: tiempo operatorio, perdidas hematicas, tasa de conversion, complicaciones intra y postoperatorias, estancia hospitalaria y dias de sonda vesical. Tambien: las tasas y la localizacion de los margenes positivos, asi como los resultados funcionales con un seguimiento medio de 10 meses. Resultados La media de tiempo operatorio fue de 140 minutos (100-211) y la perdida hematica media de 180 mL (80- 360), no requiriendo transfusion sanguinea en ningun caso. No se presentaron complicaciones intraoperatorias, y tampoco ninguna reconversion. Como acontecimientos postoperatorios solo destaca una retencion aguda urinaria tras retirada de sonda vesical. La estancia hospitalaria media fue 3,35 dias (3-5). Se obtuvieron 6 casos con margenes quirurgicos positivos (30%). La localizacion mas frecuente fue postero-lateral. Dieciocho de los 20 pacientes (90%) son completamente continentes de forma precoz, 2 (10%) requirieron utilizar una compresa de seguridad durante los 6 primeros meses por incontinencia leve de esfuerzo que se resolvio espontaneamente. De los 20 casos, 2 de ellos (10%) presentaban disfuncion erectil preoperatoria; de los 18 restantes, 12 (66.6%) conservaban potencia en el momento de la revision y 6 (33.4%) presentaron disfuncion erectil postoperatoria. Conclusiones La prostatectomia radical mediante cirugia robotica se ha demostrado claramente ventajosa (excelente maniobrabilidad para una tecnica minimamente invasiva, postura mas comoda y anatomica, vision tridimensional y corta curva de aprendizaje). Una amplia experiencia quirurgica previa en cirugia abierta y/o laparoscopica, acortan de forma significativa esta curva de aprendizaje de la PRRdaV.

The Percentage of Free Prostatic-Specific Antigen Is Also Useful in Men with Normal Digital Rectal Examination and Serum Prostatic-Specific Antigen between 10.1 and 20 ng/ml

OBJECTIVE The percentage of free prostatic-specific antigen (PSA) has been introduced as a tool to avoid unnecessary biopsies in men with normal digital rectal examination (DRE) and serum PSA between 4.1 and 10 ng/ml. In this series we also analyze its utility in men with normal DRE and serum PSA between 10.1 and 20 ng/ml. MATERIALS AND METHODS A series of 1149 consecutive men with normal DRE and serum PSA between 4.1 and 20 ng/ml submitted for the first ultrasound guided sextant biopsy is analyzed. In 921 (80.2%) the serum PSA was from 4.1 to 10 ng/ml and in 228 (19.8%) from 10.1 to 20 ng/ml. Total and free serum PSA determinations were done by the inmunoradiometric assays Tandem and Tandem free PSA (Hybritech Inc.). RESULTS The overall detection rate of prostate cancer was 27.9%. In the group of men which serum PSA ranged from 4.1 to 10 ng/ml the rate of detection was 25.4% and 37.7% when it was between 10.1 and 20 ng/ml. Using 25% or less of percent free PSA as a criterion for performing prostatic biopsy it would have detected 95.3% and 95.4% of the prostate cancers, respectively. The rate of unnecessary avoided biopsies would be 17.5% when serum PSA ranged from 4.1 to 10 ng/ml and 17.6% between 10.1 and 20 ng/ml. CONCLUSIONS This prospective study demonstrates that the percentage of free PSA seems to have similar utility when serum PSA levels are between 4.1 and 10 ng/ml and between 10.1 and 20 ng/ml, at the time of the first prostatic biopsy indication.

Cólico renal: Revisión de la literatura y evidencia científica

RENAL COLIC: REVISION OF LITERATURE AND SCIENTIFIC EVIDENCE In recent years diagnosis and treatment of acute renal colic have changed thanks to the introduction of new radiological procedures that allow with high reliability to establish obstructive cause and a better treatment. In the other hand, there are multiple clinical studies that show the most effective treatments for acute crisis. The aim of this revision is to update the diagnostic and therapeutic aspects of renal colic which were modified recently, and allowed to break some classic concepts without scientific evidence.

Increase of bone alkaline phosphatase after androgen deprivation therapy in patients with prostate cancer

OBJECTIVES To evaluate the behavior of bone alkaline phosphatase (BAP) after androgen deprivation therapy in patients with prostate cancer. METHODS BAP was determined in the serum of 35 patients with nonmetastatic prostate cancer before maximal androgen blockade. During 5 years of follow-up, BAP was determined annually. A subset of 36 patients who underwent radical prostatectomy as the only treatment for prostate cancer was selected as a control group. RESULTS The mean pretreatment BAP serum concentration was similar in both groups (10.8 and 10.4 ng/mL, P >0.05). However, after 5 years, the mean BAP serum concentration increased 64.8% in the study group (from 10.8 to 17.6 ng/mL, P < 0.001); it remained stable in the control group (from 10.4 to 10.4 ng/mL). The increase of serum BAP in patients receiving androgen deprivation was 32.4% during the first year (from 10.8 to 14.3 ng/ml), 16.7% during the second (from 14.3 to 16.1 ng/mL), 7.4% during the third (from 16.1 to 16.9 ng/mL), 5.5% during the fourth (from 16.9 to 17.3 ng/mL), and 2.8% during the fifth year (from 17.3 to 17.6 ng/mL). CONCLUSIONS Androgen deprivation produces an increase in the BAP serum concentration. A major increase seems to be produced during the first year of follow-up and thereafter this increase is reduced around 50% annually.

Analysis of bone alkaline phosphatase as a marker for the diagnosis of osteoporosis in men under androgen ablation

The objective of this study was to evaluate the usefulness of serum determination of bone alkaline phosphatase (BAP) in the diagnosis of osteoporosis in men with prostate cancer under androgen ablation. Serum levels of BAP and bone mineral density (BMD) were assessed in 110 patients with non-metastatic, treated prostate cancer. Fifty-eight patients were under androgen deprivation during a period between two and 96 months and 52 had been submitted only to radical prostatectomy. Mean serum BAP was 11.8 ng/mL in patients with normal BMD, 16.7 ng/mL in patients with osteopenia (p. 0.058), and 19.3 ng/mL in patients with osteoporosis (p = 0.044). The correlation between serum BAP and BMD was significant (p. 0.006) but with an index of only 0.26. Receiver operating characteristic analysis for the diagnosis of osteoporosis showed an area under the curve of 0.608. None of the cutoff points that provided specificities of 75%, 90% and 95% gave significant distributions. The positive and negative predictive values as well as the odds ratios were not of any clinical usefulness. We conclude that serum BAP should not be considered a good marker for the diagnosis of osteoporosis in men with prostate cancer. Therefore, BAP serum determination cannot replace bone densitometry as a diagnostic tool.

Aspectos quirúrgicos actuales de la nefrectomía de donante vivo

CONTEXT Living donor renal transplant surgery has evolved from the classical nephrectomy by lumbotomy to less invasive surgery, the laparoscopic and robotic nephrectomy currently being the most important. It is important to know the available evidence on whether nephrectomy in patients with multiple arteries, right kidney and in obese patients can be performed safely when there is a correct indication. OBJECTIVE To perform a review of the different surgical techniques in living donor nephrectomy, adapted to the current surgical evidence and other aspects related to the indication. EVIDENCE ACQUISITION A systematic review was made in PubMed (1997-2011). This included previous reviews randomized controlled clinical studies, cohort studies, and meta-analyses of this surgical aspects of living donor nephrectomy. CONCLUSIONS Currently, there is sufficient evidence to consider living donor laparoscopic nephrectomy as the technique of choice, although the role of hand-assisted retroperitoneoscopic technique is still not totally clear. Open surgery techniques using mini-incision are an acceptable alternative for the sites that have not yet implemented laparoscopic surgery. Right kidney nephrectomy, of those cases that present multiple pedicles and in obese donors, is justified in selected cases.

Límites de la cirugía laparoscópica en el tratamiento del tumor renal

Laparoscopic radical nephrectomy is considered to be the technique of choice in the mangement of stage T1 and T2 renal cancer, though increased mastery of this alternative type of surgery has served to expand its indications. In any case, these procedures have a series of limitations which are tied to the intrinsic characteristics of laparoscopic surgery, and which are associated with the patient and tumor characteristics, and the experience of the surgeon. The present study discusses the different indications and establishes the current limits of laparoscopic surgery applied to the management of renal tumors. Its role in cell-reducing therapy in metastatic disease, and the methods available for reducing tumor implantation in the surgical ports are also commented.