[COVID-19 Pandemic: Impact and rapid reaction of Urology]

The COVID-19 pandemic caused by the SARS-CoV-2 virus has caused tens of thousands of deaths in Spain and has managed to breakdown the healthcare system hospitals in the Community of Madrid, largely due to its tendency to cause severe pneumonia, requiring ventilatory support. This fact has caused our center to collapse, with 130% of its beds occupied by COVID-19 patients, thus causing the absolute cessation of activity of the urology service, the practical disappearance of resident training programs, and the incorporation of a good part of the urology staff into the group of medical personnel attending these patients. In order to recover from this extraordinary level of suspended activity, we will be obliged to prioritize pathologies based on purely clinical criteria, for which tables including the relevance of each pathology within each area of urology are being proposed. Technology tools such as online training courses or surgical simulators may be convenient for the necessary reestablishment of resident education.

Health questionnaire analysis and development of satisfaction questionnaire for patients treated with extracorporeal shock wave lithotripsy (SATISLIT)

INTRODUCTION

Due to the absence of specific instruments to study the psychosocial sphere of patients undergoing extracorporeal shock wave lithotripsy (SWL), the objective of this study is to develop a satisfaction questionnaire regarding the SWL treatment from a health questionnaire which was already designed and had been previously validated.

MATERIAL AND METHODS

The design of the satisfaction questionnaire was carried out in 5 phases, based on a previously validated health scale in patients treated with SWL (ESPTL), including a total cohort of 135 patients treated at our center who received a phone interview. Phase 1: descriptive analysis of the series and scores of the 8 items of ESPTL. Phase 2: U-Mann Whitney comparison of ESPTL based on the patients' sex. Phase 3: study of ESPTL correlation with age using Spearman's Rho. Phase 4: grouping by factors of ESPTL, comparison by sex and correlation with age, as performed in phases 2 and 3 with the global score. Phase 5: obtaining the satisfaction subscale -SATISLIT-, descriptive analysis, comparison according to sex, correlation with age and linear regression model of SATISLIT with respect to ESPTL.

RESULTS

135 patients, 85(63%) men, 50(37%) women. Median (minimum-maximum) age 56 (27-79) and ESPTL score 31 (8-39). Differences in global ESPTL score between men and women (p <.001), as well as in items 1 (p =.029), 3 (p =.002), 6 (p =.006), 7 (p =.005) and 8 (p =.025). Non-significant correlation of ESPTL regarding age. Significant correlation in items 2, 4, 5 and 8 but, very weak (<0.2). 4 factors, each one with 2 items, with statistically significant differences regarding sex in F2 (p =.001), F3 (p =.007) and F4 (p =.001). Significant correlation with age only in F1 and F3, but very weak (<0.2). Median (minimum-maximum) SATISLIT 18 (4-20). Statistically significant differences regarding patients' sex (p =.001). Non- significant correlation with age (p =.836). Significant linear regression of SATISLIT with respect to ESPTL (p <.001).

CONCLUSIONS

Based on validated health questionnaire, the present work has provided a new instrument called SATISLIT for assessing patients' satisfaction after treatment with SWL. Future studies with external and temporal validation will be necessary to contrast its real clinical usefulness.

Risk models for patients with localised renal cell carcinoma

INTRODUCTION

We conducted a retrospective analysis of our series to assess the factors that influenced disease-free survival (DFS) and cancer-specific survival (CSS) for patients with localised renal cell carcinoma (RCC). We also created our own risk groups.

MATERIAL AND METHODS

Between January 1990 and December 2012, 596 patients underwent surgery for localised RCC (clear cell, papillary or chromophobe). Using Cox regression models, we analysed the clinical-pathological variables that influenced DFS and CSS and designed risk groups for DFS and CSS with the variables.

RESULTS

The median follow-up for the series was 5.96 years. By the end of the study, 112 patients (18.8%) had a recurrence of the disease, with DFS rates of 82%, 77% and 72% at 5, 10 and 15 years, respectively. The independent factors that influenced DFS in the multivariate study were the following: A Furhman grade of 3-4, haematuria, lymphocytic or vascular invasion, the presence of tumour necrosis and a disease stage pT3-pT4. Furthermore, by the end of the study, 57 patients (9.6%) died due to renal cancer, with CSS rates of 92%, 86% and 83% at 5, 10 and 15 years, respectively. The independent factors that influenced CSS in the multivariate study were the following: A Furhman grade of 3-4, perinephric fat invasion and the presence of tumour necrosis.

CONCLUSIONS

Factors in addition to the disease stage pT3-pT4 in patients with localised RCC are important, such as the presence of haematuria and lymphocytic or vascular invasion for DFS. A Furhman grade of 3-4 and the presence of tumour necrosis are especially relevant for DFS and CSS.

Predicting the effectiveness of extracorporeal shock wave lithotripsy on urinary tract stones. Risk groups for accurate retreatment

INTRODUCTION

Extracorporeal shock wave lithotripsy (ESWL) is a non-invasive, safe and effective treatment for urinary tract lithiasis. Its effectiveness varies depending on the location and size of the stones as well as other factors; several sessions are occasionally required. The objective is to attempt to predict its success or failure, when the influential variables are known beforehand.

MATERIAL AND METHODS

We analysed 211 patients who had had previous CT scans and were treated with ESWL between 2010 and 2014. The influential variables in requiring retreatment were studied using binary logistic regression models (univariate and multivariate analysis): maximum density, maximum diameter, area, location, disintegration and distance from the adipose panniculus. With the influential variables, a risk model was designed by assessing all possible combinations with logistic regression (version 20.0 IBM SPSS).

RESULTS

The independent influential variables on the need for retreatment are: maximum density >864HU, maximum diameter >7.5mm and pyelocaliceal location. Using these variables, the best model includes 3risk groups with a probability of requiring significantly different retreatment: group 1-low risk (0 variables) with 20.2%; group 2-intermediate risk (1-2 variables) with 49.2%; and group 3-high risk (3 variables) with 62.5%.

CONCLUSIONS

The density, maximum diameter and pyelocaliceal location of the stones are determinant factors in terms of the effectiveness of treatment with ESWL. Using these variables, which can be obtained in advance of deciding on a treatment, the designed risk model provides a precise approach in choosing the most appropriate treatment for each particular case.

Influential factors in the response to salvage radiotherapy after radical prostatectomy

OBJECTIVE

To analyze the influential factors in the response in prostatectomized patients with subsequent biochemical relapse (BCR) and treated with salvage radiotherapy (RTP).

MATERIAL AND METHODS

We analyzed 313 patients with pT2/pT3 prostate cancer who were receiving salvage therapy due to biochemical relapse (from a series of 1,310 radical prostatectomies between 1989-2012). Of the 313 patients; 159 (50.8%) only received androgen deprivation (AD), 63 (20.1%) Radiotherapy (RTP) plus concomitant AD and 91 (29.1%) only RTP. Of these, 57 (62.6%) have maintained complete response and 34 (37.4%) had failure response with post-RTP BCR.

RESULTS

Study of the group treated exclusively with salvage RTP. Ninety-one patients were treated with salvage RTP. Median follow-up was 6.4 years and median to recurrence 11 months. Post-RTP biochemical relapse-free survival (PRBRFS) was 68 ± 7% and 30 ± 10% in 5 to 10 years. Median PRBRFS was 7.3 years (6.3-8.3). Initial PSA (HR: 1.08; 95% CI: 1.01-1.1 P=.02) with best PSA cut-off point PSA>20 ng/ml (HR: 13.6; 95% CI: 2.1-86 P=.005) and PSA pre-RTP (HR: 1.9; 95% CI: 1.2-3.3; P=.009), best PSA cut-off point PSA preRTP 0.92 ng/ml (HR: 4.5; 95% CI: 1.3-15.6; P=.01) showed independent influence in the response in the multivariate study. PRBRFS at 5 years, 81 ± 9% versus 58 ± 9% with initial PSA <20 or >20 ng/ml (P=.03). PRBRFS at 5 years, 93 ± 5% versus 53 ± 10% according to PSA pre-RTP <0.9 or >0.9 ng/ml (P=.02).

CONCLUSIONS

In patients treated with salvage RTP after radical prostatectomy, the preoperative PSA>20 ng/ml and PSA preRTP>0.92 ng/ml shows an independent influence on the response.

Bladder cancer in Spain 2011: population based study

PURPOSE

We estimate the annual incidence of bladder cancer in Spain and describe the clinical profile of patients with bladder cancer enrolled in a population based study.

MATERIALS AND METHODS

Using the structure of the Spanish National Health System as a basis, in 2011 the AEU (Spanish Association of Urology) conducted this study with a representative sample from 26 public hospitals and a reference population of 10,146,534 inhabitants, comprising 21.5% of the Spanish population.

RESULTS

A total of 4,285 episodes of bladder cancer were diagnosed, of which 2,476 (57.8%) were new cases and 1,809 (42.2%) were cases of recurrence, representing an estimated 11,539 new diagnoses annually in Spain. The incidence of bladder cancer in Spain, age adjusted to the standard European population, was 20.08 cases per 100,000 inhabitants (95% CI 13.9, 26.3). Of patients diagnosed with a first episode of bladder cancer 84.3% were male, generally older than 59 years (81.7%) with a mean ± SD age of 70.5 ± 11.4 years. Of these patients 87.5% presented with some type of clinical symptom, with macroscopic hematuria (90.8%) being the most commonly detected. The majority of primary tumors were nonmuscle invasive (76.7%) but included a high proportion of high grade tumors (43.7%). According to the ISUP (International Society of Urologic Pathology)/WHO (2004) classification 51.1% was papillary high grade carcinoma. Carcinoma in situ was found in 2.2% of primary and 5.8% of recurrent cases.

CONCLUSIONS

The incidence of bladder cancer in Spain, age adjusted to the standard European population, confirms that Spain has one of the highest incidences in Europe. Most primary nonmuscle invasive bladder cancer corresponded to high risk patients but with a low detected incidence of carcinoma in situ.

[Haemostasis control during laparoscopic partial nephrectomy without parenchymal renorrhaphy: the VIVOSTAT(®) experience]

OBJECTIVE

To present our experience using an autologous fibrin sealant prepared with the Vivostat system(®) to control haemostasis without any renal parenchymal reconstruction.

MATERIAL AND METHODS

We performed 45 laparoscopic partial nephrectomies using this haemostatic agent. The surgical steps were: colon mobilization, identification of ureter, renal vessels and renal tumor, renal artery control with Rummel tourniquet, tumor excision with harmonic scalpel, application of fibrin glue to the resection bed twice (before and after kidney reperfusion). Patients were evaluated for acute or delayed bleeding.

RESULTS

Mean age was 63.9 years (33-80); mean tumor size was 2.5cm (1.5-4); mean operative time was 136.1min (90-180). Mean warm ischemia time was 19.2min (10-30). Mean blood loss was 97ml (50-300). Individual haemostatic stitches were performed before application of the sealant if acute bleeding was observed (14 cases). We did not achieve any case of postoperative bleeding from resection bed or renal failure. 1 patient required transfusion due to an abdominal wall haematoma. 65% were clear cell carcinoma, 10% were papillary carcinoma, 20% were oncocitoma. Free margin rate was 100%. Mean hospital stay was 4 days (2-6). Mean follow-up was 14 months (5-45).

CONCLUSIONS

Excluding renorrhaphy during laparoscopic partial nephrectomy is feasible and safe. Our initial experience with the vivostat system in laparoscopic partial nephrectomy has been encouraging, but longer follow-up is needed to determine the real benefit of this surgical technique in laparoscopic partial nephrectomy.

[Intima-media thickness in obese adolescents and their relation with metabolic syndrome]

INTRODUCTION

Obese adolescents have higher cardiovascular risk (CVR). Intima-media thickness (IMT) detects early arterial vascular compromise.

OBJECTIVE

To evaluate whether obese adolescents have higher vascular compromise measured by IMT than nonobese adolescents, and if this is greater in those with metabolic syndrome (MS).

METHOD

The study group (SG), obese children (BMI/age > p95), with and without MS and control group (CG), non-obese (BMI/age p10-85) and non nutritional or endocrine disease. We measured serum lipids, oral glucose tolerance test with insulin and carotid artery ultrasound. To evaluate the differences between test groups we used parametric and nonparametric statistics.

RESULTS

We evaluated 45 obese adolescents (20 women), 19 with MS, age 13 (9-16) years and 18 controls (14 women), aged 13 (11-16) years. IMT of carotid bulb and internal carotid artery (ICA) were significantly higher in SG than CG (0.54 vs. 0.34, 0.34 vs. 0.25, p < 0.05). There was no difference between obese groups. IMT of ICA and bulb correlated positively with BMIz (r = 0.3 and 0.6, p < 0.05) and with waist circumference (CC) (r = 0.3 and 0.55, p < 0, 05). IMT of ICA was positively correlated with fasting insulin, HOMA and systolic blood pressure. In multivariate analysis only BMI and CC were associated independently to IMT.

CONCLUSION

Obesity is an early risk factor for cardiovascular damage measured by IMT and IMT of ICA demonstrated a higher correlation with cardiovascular risk factors.

Randomized phase III trial comparing adjuvant paclitaxel/gemcitabine/cisplatin (PGC) to observation in patients with resected invasive bladder cancer: Results of the Spanish Oncology Genitourinary Group (SOGUG) 99/01 study

LBA4518

Background: Approximately half of patients with resected invasive bladder cancer will die within the first three years after surgery due to disease relapse, most of the recurrences being systemic. We have studied in a randomized phase III trial the role of 4 courses of the PGC triplet as compared to observation in this clinical setting.

Methods: Eligibility criteria included: (1) resected high-risk muscle invasive bladder carcinoma (pT3-4 and/or pN+), (2) ECOG PS 0-1, (3) adequate renal function (CrCl > 50 ml/min), (4) ≤ 8 weeks post-cystectomy, (5) no relevant co-morbidities, and (6) signed informed consent. Eligible patients were assigned to observation or 4 courses of PGC (P 80 mg/m2 d1 and 8, G 1000 mg/m2 d1 and 8 and C 70 mg/m2 d1) q21 days. The primary objective was overall survival (OS).

Results: The study was open in July 2000 and prematurely closed due to poor recruitment in July 2007, with 142 patients randomized (74 to observation and to 68 to PGC treatment). Baseline characteristics were well balanced among study arms. Median age was 63 yrs, pT3-4N0: 44%, anyTpN+:56%, PS 0: 59%, median time cystectomy-randomization: 48 days (14-91). In the PGC arm 76% of pts completed all 4 courses of therapy. Main Gr 3-4 toxicities were neutropenia 41%, febrile neutropenia 8%, thrombocytopenia 14%, anemia 5%, fatigue 14%, alopecia 10%, vomiting 8%, renal 5%. There was one toxic death (sepsis). At a median follow up of 30 months (range 1-95), 69 patients have died (45 in control arm and 24 in PGC arm). OS (ITT population) was significantly prolonged in the PCG arm (median NR; 5yr OS: 60%) compared to observation (median 26m; 5yr OS: 31%) (p<0.0009). DFS (p<0.0001), TTP (p<0.0001) and disease specific survival (p<0.0002) were also superior in the PGC arm.

Conclusions: The results of this study strongly suggest that adjuvant PGC improves OS and DFS following cystectomy in high risk invasive bladder cancer. As the study was prematurely closed, the power for firm conclusions is however limited.

[Table: see text]

[Non-deployment of branches of a vena cava filter. Elements of prevention]

Non-deployment of an L.G.M. percutaneous vena cava filter is rare. The aim of this paper is to report a new case of this complication. A second filter was inserted between the non-deployed filter and the renal veins to prevent proximal migration of the transvenous interruption device to the pulmonary artery or the right side of the heart, and to guarantee an effective prophylaxis of further pulmonary embolization. Two years later, the vena cava was still patent. The best way to avoid this accident is a perfect insertion technique: after a preoperative cavography to check diameter and patency of the vena cava, the filter must be deployed by retracting the introducer sheath while maintaining the position of the inner canula, and not pushing the filter out of the introducer sheath. A second filter must always be available in the operating room in case of incomplete opening of the filter. The use of vena cava filter is not devoid of risks. Restricted indications are therefore recommended.

[Cryo-stripping: an advance in the treatment of varicose veins. 3811 operated limbs]

OBJECTIVES

Stripping varicose veins can cause invalidating durable dysaesthesia in 25% of the cases due to saphenous vein damage. Postoperative varicosis is also frequently encountered. Cicatrization may be inaesthetic at the ankle and the operation may even be impossible due to infected ulcerations. Alternative methods are therefore needed. Cryosurgery using a freezing probe can be used to remove the entire saphenous vein via the inguinal incision alone.

METHODS

Over a 6 year period, 2,009 patients (3,811 members) underwent cryosurgery for varicose veins. The indication in 88% of the cases was based on functional or aesthetic reasons and in 7% hypodermitis, in 3% ulcerations resistant to medical treatment and in 2% superficial venous thrombosis.

RESULTS

Postoperatively, a single case of sural phlebitis was observed (0.02%). Dysaesthesia occurred in the saphenous nerve territory in 2% of the cases and resolved in a few months. Functional signs present preoperatively had disappeared within one month of surgery in 98%. The aesthetic result was excellent since there is no scar tissue on the limb excepting the inguinal incision and since postoperative varicosis was rare (0.1%). All varicose ulcerations had healed in less than 3 months of surgery and no case of deep vein failure was observed.

CONCLUSION

Cryosurgery for varicose veins is as effective as the stripping procedure and avoids certain complications. The aesthetic result and functional results are better. Cryosurgery is an important progress in the treatment of varicose veins of the lower limbs, especially in case of ulcerations.

Observations on the birth of goats

The parturient behavior of 90 Murciano-Granadina goats was analyzed. Hourly frequencies of births showed a unimodal distribution with a maximum number of births between 10:00 and 18:00 h (74.45%). Twenty-four births (26.66%) took place with the goat standing, and sixty-six births (73.33%) took place with the goat recumbent. Fetuses were presented head-first (80.95%), breech (14.97%) and forelegs first (4.08%). Length of labor was 19.49 min for single birth and 30.36 min for twins (first born and second born, 14.52 and 15.84 min, respectively). Time for complete expulsion of placental tissue for goats with single and twin births was 86.58 ± 4.93 and 106.57 ± 4.80 min, respectively. Finally, placentophagy for goats with single or twin births was: total ingestion (0%; 0%), partial ingestion (33.33%; 52%), licking (46.67%; 36%), and no contact (20%; 12%), respectively. Key words: Goat, parturition, placentophagy