Procedimiento radioguiado en la cirugía mínimamente invasiva del hiperparatiroidismo primario

Minimally invasive parathyroidectomy, of choice in most cases of primary hyperparathyroidism, shows a high detection rate, based on precise preoperative localization by MIBI scintigraphy (SPECT/CT) and neck ultrasound. Radio-guided minimally invasive parathyroidectomy is an even more effective technique, which shortens surgical times, maintains minimal incision and few complications, allows immediate verification of parathyroid adenoma removal and is especially interesting in patients with ectopic lesions or cervical surgical history. In this paper, the indications, protocols and differences between the two available radio-guided parathyroid surgery procedures (MIBI and ROLL) are exposed.     

Guía clínica del carcinoma urotelial no músculo invasivo de la Asociación Europea de Urología

Context and objectiveTo present the updated version of 2008 European Association of Urology (EAU) guidelines on non-muscle-invasive bladder cancer.Evidence acquisitionA systematic review of the recent literature on the diagnosis and treatment of non-muscle-invasive bladder cancer was performed. The guidelines were updated and the level of evidence and grade of recommendation were assigned.Evidence synthesisThe diagnosis of bladder cancer depends on cystoscopy and histologic evaluation of the resected tissue. A complete and correct transurethral resection (TUR) is essential for the prognosis of the patient. When the initial resection is incomplete or when a high-grade or T1 tumour is detected, a second TUR within 2–6 wk should be performed. The short- and long-term risks of both recurrence and progression may be estimated for individual patients using the scoring system and risk tables. The stratification of patients to low, intermediate, and high-risk groups—separately for recurrence and progression—represents the cornerstone for indication of adjuvant treatment. In patients at low risk of tumour recurrence and progression, one immediate instillation of chemotherapy is strongly recommended. In those at an intermediate or high risk of recurrence and an intermediate risk of progression, one immediate instillation of chemotherapy should be followed by further instillations of chemotherapy or a minimum of 1 yr of bacillus Calmette-Guerin (BCG). In patients at high risk of tumour progression, after an immediate instillation of chemotherapy, intravesical BCG for at least 1 yr is indicated. Immediate cystectomy may be offered to the highest risk patients and in patients with BCG failure. The long version of the guidelines is available on http://www.uroweb.orgConclusionsThese EAU guidelines present the updated information about the diagnosis and treatment of non-muscle-invasive bladder cancer and offer the recent findings for the routine clinical application     

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.     

Escisión total del mesorrecto vía transanal con laparoscopia asistida

One of the most controversial areas in laparoscopic approach is rectal cancer, not only because of the surgical technique but of the best approach to do it. The transanal approach arises like a new alternative for rectal cancer and other rectal pathologies due to solve some of the problems that we can find in conventional laparoscopic approach, mainly in low rectal cancer for the section of the rectum and distal margin.The first case of rectal cancer surgery by transanal approach was published in 2009. Since now, just a few series with a limited number of patients has been done with this technique. Among the different series there are differences, especially with the surgical technique (mainly with the transanal platform). Nowadays, the morbidity and postoperative outcomes have are comparable with the conventional approach. The oncological outcomes have no shown any differences, even long term results are not known at the moment (longer follow-up of 21 months).The results published in transanal approach surgery demonstrate the feasibility and safety of the procedure with an advantage in hostile pelvis (obese, narrow pelvis and males). Randomized studies are needed for long-term functional and oncological outcomes.     

Avances en uro-oncología «OncoForum»: lo mejor del 2019

ObjectiveReview the latest evidence on urologic oncology on kidney, bladder and prostate tumors.MethodsAbstracts on kidney, bladder and prostate cancer presented at the 2019 congresses (EAU, AUA, ASCO and ESMO) and the publications with the greatest impact in this period, with the highest evaluation by the OncoForum committee, are reviewed.ResultsIn patients with metastatic kidney cancer, regimens including immunotherapy (nivolumab + ipilimumab, pembrolizumab) have been shown to be superior to sunitinib in terms of survival. In patients with non-muscle invasive bladder cancer, pembrolizumab has been shown to be an effective alternative in those refractory to bacillus Calmette-Guérin, while in patients with metastatic urothelial cancer, third-line enfortumab vedotin achieved a significant response rate (44%). In patients with localized prostate cancer (PCa), ultrafractionated external radiotherapy did not show any greater acute toxicity than fractionated or hypofractionated radiotherapy. The benefit of enzalutamide and apalutamide associated with castration has been confirmed in M1 PCa patients, regardless of disease volume. In patients with castration-resistant M0 PCa, treatment with enzalutamide, apalutamide or darolutamide has been associated with a delay in the occurrence of metastasis and prolonged survival. Cabazitaxel has demonstrated a survival benefit in patients with metastatic CRPC, while olaparib showed anti-tumor activity after chemotherapy in those tumors with mutations in DNA repair genes.ConclusionsThese data show the implementation of immunotherapy as a novel alternative against renal and bladder cancer. The arrival of new agents for advanced urothelial carcinoma should be highlighted, and the efficacy of enzalutamide and apalutamide in de novo metastatic prostate cancer is established. In metastatic CRPC, cabazitaxel and olaparib (targeting mutations) are promising therapeutic options.     

Avances en uro-oncología «OncoForum»: lo mejor del 2017

Objective

To put forth new findings of urologic oncology with impact on clinical practice presented during 2017 in the main annual meetings.

Anestesia en la cirugía del aneurisma toracoabdominal: 17 años de experiencia

ObjectiveTo review the results after thoracoabdominal aortic aneurysms repair performed by the same team of surgeons and anesthesiologists over a 17 year period.Material and methodsA prospective and observational study carried out on 65 patients (97% male) who were operated on from 1995 until July 2011 for thoracoabdominal aneurysm, Crawford type i 5 (7.6%), ii 22 (33.8%), iii 17 (26.11%) and iv 21 (32.31%).ResultsThe 30-day mortality was 9.2% (6/65 patients), which was the same as the incidence of paraplegia. This complication only occurred in the Crawford types ii and iii aneurysms. Paraplegia was present in 4.5% (1/22) of patients in whom “left bypass” was used, compared with 29% (5/17) in which the intervention was performed by cross-clamping without distal aortic perfusion (P = .068).The most frequent complication was respiratory, with prolonged mechanical ventilation (>48 h) in 20% (13 patients) of cases. The mean hospital stay was 28 days (7-92).DiscussionThe average mortality in referral centers is 9.7%, ranging between 5% and 16%. In other centres the mortality at 30 days is between 19% and 31% per year. Our group had a 9.2% of mortality rate at 30 days. The incidence of paraplegia in hospitals with greater experience ranges between 2.7% and 16%. Nowadays, an incidence of less than 10% is accepted as good. We had 9.2%. The use of CSF drainage in these patients, as well as the use of left bypass and moderate hypothermia in the Crawford types i, ii and iii appear to be acceptable for prophylaxis of paraplegia.     

Linfografía y embolización del conducto torácico como tratamiento del quilotórax tras esofagectomía por cáncer de esófago

IntroductionChylothorax is a rare complication in esophagectomies that is associated with increased postoperative mortality. Several factors have been described that may favor its appearance. Its treatment is controversial, and lymphography with percutaneous embolization of the thoracic duct is used by several groups.Material and methodOur retrospective study included patients who underwent esophagectomy for cancer of the esophagus or the esophagogastric junction (Siewert I/II) between January 2010 and April 2019 and developed chylothorax as a complication. Epidemiological data, type of surgery, morbidity and treatment were analyzed.Results274 cancer-related esophagectomies were performed in the study period. Thirteen patients (4.7%) were diagnosed with chylothorax in the postoperative period; 3 were resolved with conservative treatment. In the remaining 10 patients, lymphography was performed with aspiration of the cisterna chyli and thoracic duct embolization, which resolved the chylothorax in 9. One patient (10%) presented a biliary fístula after the procedure.ConclusionsLymphography with aspiration of the cisterna chyli and thoracic duct embolization is a technique with low morbidity that provides good results for the resolution of chylothorax after esophagectomy.     

Manejo anestésico del síndrome del ligamento arcuato medio

Median arcuate ligament syndrome, also known as celiac artery compression syndrome, is a rare and unusual clinical disorder. Its symptoms are non-specific, which complicates its diagnosis, and a multidisciplinary approach is required to treat the disorder. The ligament is circumferentially cleared by laparoscopy. Selective angiography and endovascular techniques may be used after laparoscopy. Vital organs and important vascular structures can be injured during the surgery. The combination of different procedures, as well as the high risk of damage, make this process a significant challenge for the anaesthetist. During corrective surgery for median arcuate ligament syndrome, general anaesthesia must be adapted to the various haemodynamic and ventilatory requirements, and strict control of pain established, as oral tolerance is a key factor in the post-operative recovery of these patients     

Valor pronóstico de la citología urinaria en la recidiva del carcinoma urotelial vesical tras la cistectomía radical

IntroductionUrethral or upper urinary tract (UUT) recurrence of urothelial carcinoma (UC) after radical cystectomy (RC) are rare (4-6%), and their diagnosis usually occurs within the first two years. Although it is known that its early detection offers benefit in terms of survival, currently there are no clear recommendations for the detection of recurrence in the remnant urothelium (RU). Our aim is to determine the diagnostic value of urinary cytology for the detection of recurrences in the RU and to estimate its impact as an early diagnostic method on survival.Material and methodsRetrospective review of patients who underwent RC for urothelial carcinoma between 2008-2016, with a follow-up of at least 24 months.ResultsThe study included 142 patients. In a median follow-up of 68.5 months, nine patients (6.3%) presented recurrences in the RU (urethra: four, UUT: four, synchronous: one). The sensitivity and specificity of urinary cytology for the diagnosis of UUT recurrences were 20% and 96%, respectively. No significant differences were found between overall survival and cancer-specific survival among patients according to the urinary cytology results.ConclusionRecurrences in the RU after RC are infrequent; our study has shown that urinary cytology offers a low sensitivity for their diagnoses. For these reasons, we do not consider that urinary cytology provides useful information for surveillance of these patients.     

Abordaje del uréter distal en la nefroureterectomía laparoscópica

IntroductionNephroureterectomy is one of the procedures for which a laparoscopic approach is more clearly indicated. However, despite the long experience available, management of the distal ureter is still difficult.Materials and methodsThirty-two laparoscopic nephroureterectomies were performed from November 2004 to December 2008. The procedure used was endoscopic resection of distal ureter and earlier ligation of the ureter in the laparoscopic time in 13 patients, a laparoscopic bladder cuff in 13 patients, and an open bladder cuff in 3 patients.ResultsMean operating time was 221.53 min (125-315 min), and mean postoperative stay of 27 patients was 4.6 days. Conversion to open surgery and discontinuation of the procedure for local tumor progression were required in one patient each. Mean patient follow-up was 17.8 months. No local relapse or metastasis occurred in the ports.ConclusionThe most common procedures continue to be endoscopic resection and the open bladder cuff depending on indication. Any laparoscopic approach to upper urothelial tumors must strictly comply with oncological principles. The reported procedure is in our experience the fastest, most simple, and most effective for this purpose. In our opinion, the therapeutic algorithm provided is adequate for management of the distal ureter in laparoscopic nephroureterectomy.     

Utilidad del estudio molecular de nódulos tiroideos con citología indeterminada

Even though cytology remains the gold standard to assess the nature of thyroid nodules, up to 30% of the results are indeterminate (Bethesda III and IV). In these cases, current guidelines recommend performing diagnostic surgery, which proves malignancy in only 15-30% of cases. A more precise method is needed to avoid unnecessary surgeries, surgical complications and costs in the process of diagnosing indeterminate nodules. Complementary use of molecular profiling tests seems to help in this complex scenario. We present a review of the current literature on the usefulness of molecular profiling of thyroid nodules so as to define its indications, costs and usability for clinical practice.     

Bloqueo lumbar del plano del músculo erector de la columna: control exitoso del dolor agudo tras cirugía de la columna lumbar. Un caso clínico

We report the successful clinical case of a patient scheduled for lumbar spine surgery in which we performed a bilateral single-shot erector spinae plane block as part of a multimodal analgesic strategy for pain control. Performing the block preoperatively dismissed the need for extra intraoperative opioids other than those for intubation, and enabled the use of paracetamol for analgesia only. Further, there was no need for hypotensive techniques, as the block provided satisfactory sympathetic blockade and regional vasodilation with a clear surgical field. Postoperatively, the patient had minor opioid consumption and was able to freely move without any motor impairment or pain from early on in the Post Anaesthesia Care Unit. The use of single-shot erector spinae plane block at the lumbar level for lumbar spine surgery analgesia emphasises its wide application and analgesic efficacy.     

Tromboelastometría como guía de administración de hemoderivados en cirugía cardiaca

Objective

Thromboelastometry is a viscoelastometric method for haemostasis testing in a whole blood sample. The aim of this study was to assess the results of using thromboelastometry as guidance for blood management in cardiac surgery, postoperative adverse events and ICU stay.

Autoevaluación de una vía clínica para mejora del proceso quirúrgico carcinoma de recto

ObjectivesTo analyse whether the self-evaluation of a clinical pathway improves the results of rectal cancer (RC) treatment.Patients and methodPatients operated on for RC were divided into 3 groups according to biannual modifications of a clinical pathway analysing several indicators.Results166 patients: Group A: 2002 – 3 n=50, B: 2004 – 5 n=53 and C: 2006 – 7 n=63, without any differences in age, gender or comorbidity. Preoperative study improved with the introduction of CT scan: 76% in Group C vs. 6% in Group A (P<0.001). All Group C tumours were staged using MR, rectal ultrasound or both, compared to 84% in Group A (P<0.001). The rate of abdominal-perineal resections was reduced from 42% (Group A) to 17% (Group C); (P=0.007) and about 48% of surgeons in Group A vs. 94% in the C had a specific activity in coloproctology (P<0.001). The average lymph node count was: Group A=6.2±4.5 vs. 13±6.5 in the C and circumferential margin analysis was reported in 24% of Group A vs. 76% in Group C (P<0.001). Parameters such as perioperative blood transfusion, ICU admission, use of nasogastric tube, early feeding or epidural analgesia also improved progressively. Operative mortality decreased non-significantly to 4.7% and anastomotic leaks from 24% to 9.5% with a reduction in postoperative stay from 15 to 11 days during the period analysed (P=0.029).ConclusionsSeveral indicators have significantly improved in a relatively short period of time due to self-evaluations of the process.