Efecto de la mitomicina en comparación con la gemcitabina intravesical en el tratamiento del cáncer de vejiga sin invasión muscular: metaanálisis

IntroductionWe performed a meta-analysis to evaluate the effect of intravesical mitomycin compared with gemcitabine on the treatment of non-muscle invasive bladder cancer.MethodsA systematic literature search up to November 2021 was done and 6 studies included 389 subjects with non-muscle invasive bladder cancer at the start of the study; 197 of them were provided with intravesical-mitomycin and 192 with intravesical gemcitabine. The studies reported the relationships about the effect of intravesical mitomycin compared with gemcitabine on the treatment of non-muscle invasive bladder cancer. We calculated the odds ratio (OR) with 95% confidence intervals (CIs) to assess the effect of intravesical mitomycin compared with gemcitabine on the treatment of non-muscle invasive bladder cancer using the dichotomous method with a random or fixed-effect model.ResultsIntravesical mitomycin had significantly higher recurrence rates (OR, 2.41; 95% CI, 1.43-4.08, P = .001) and chemical cystitis (OR, 4.39; 95% CI, 2.27-8.51, P < .001) compared to intravesical gemcitabine in subjects with non-muscle invasive bladder cancer. However, intravesical mitomycin had no significant difference in its effect on hematuria (OR, 1.71; 95% CI, .68-4.33, P = .26), skin reaction (OR, 2.04; 95% CI, .59-7.07, P = .26), and liver and kidney functions damage (OR, 1.96; 95% CI, 0.35-10.96, P = .44) compared to intravesical gemcitabine in subjects with non-muscle invasive bladder cancer.ConclusionsIntravesical mitomycin had significantly higher recurrence rates and chemical cystitis and no significant difference in its effect on hematuria, skin reaction, and liver and kidney functions damage compared to intravesical gemcitabine in subjects with non-muscle invasive bladder cancer. Further studies are required to validate these findings.     

Una actualización en el protocolo en cáncer de próstata metastásico hormonosensible

To review and update last protocols in hormone sensitive metastatic prostate cancer for improving clinical management in routine. Evidence analysis available about recent updates protocols in hormone sensitive metastatic prostate cancer according to expert panel of clinicians about this field. A nominal consensus group for unify and improve the recommendations to the management of sensitive metastatic prostate cancer patients is currently needed. This document unifies and improve the management of patients with hormone sensitive metastatic prostate cancer, with a methodology that combines data quantitative and qualitative and based on the participation of a broad scientific committee appointed by the Spanish Association of Urology.     

Enzalutamida y apalutamida en el tratamiento del cáncer de próstata no metastásico resistente a la castración: comparación indirecta de la eficacia

ObjectivesTo perform an adjusted indirect comparison of the efficacy of enzalutamide and apalutamide in patients with non-metastatic castration-resistant prostate cancer (nmCRPC) with a high risk of progression to metastatic disease.Material and methodsAfter carrying out a literature search, we performed an adjusted indirect comparison (Bucher et al.) of the relative efficacy of enzalutamide and apalutamide in patients with nmCRPC with a high risk of progression to metastatic disease. The outcomes included were metastasis-free survival (MFS) and PSA response rate (PSARR).ResultsThere were no statistically significant differences between enzalutamide and apalutamide regarding the analysed outcomes. For the comparison enzalutamide + ADT vs. apalutamide + ADT: MFS a HR (95% CI) = 1,036 (0.781-1.373) was obtained. For PSARR, a RR (95% CI) = 0.81 (0.339-1.938) was obtained.ConclusionsThe adjusted indirect comparison performed in this study shows that there are no statistically significant differences in terms of efficacy regarding MFS and PSARR between enzalutamide + ADT and apalutamide + ADT in patients with nmCRPC with a high risk of progression to metastatic disease. However, in order to confirm these results, an independent trial with direct comparison between both drugs would be required.     

Factores clínicos determinantes para la realización de pruebas de imagen en cáncer de próstata resistente a la castración no metastásico en la práctica clínica: resultados del estudio IDENTIFICA

IntroductionThe aim of the study was to describe the clinical drivers that lead physicians to perform imaging tests in search of metastasis in non-metastasic castration prostate resistant cancer (nmCRPC) patients.MethodsObservational, cross-sectional study conducted at the Departments of Urology of 38 Spanish hospitals. The study included 188 patients diagnosed with nmCRPC who underwent an imaging test for the assessment of metástasis. In one study visit, physicians were requested to specify the clinical factors that led them to perform these tests. The results of the imaging tests and the clinical characteristics of the patients since the time of prostate cancer (PC) diagnosis, were reported. Regression analyses were used to determine predictors of imaging test results.ResultsProstate-specific antigen (PSA) level was the most important driver to order imaging tests (57.1%), followed by regular follow-up (16.5%) and PSA doubling time (PSADT) (12.0%). Although these drivers were not associated to detection of metastasis, patients with PSA levels ≥20 ng/mL had a greater risk of metastasis than patients with PSA levels < 4ng/mL (P=.004) and CRPC patients diagnosed with metastasis (mCRPC) had higher median PSA levels (20.9; interquartile range [IQR]: 6.7-38.6) than nmCRPC (9.1; IQR: 5.0-18.0) (P=.005). Sixty-six percent of the patients did not undergo any imaging test after CRPC diagnosis until the study visit (10.6, IQR: 4.0-19.5 months). Curative-intent treatment at PC diagnosis and Gleason score predicted longer time from PC to CRPC diagnosis.ConclusionsPhysicians based their decisions to order imaging tests for metastasis detection in nmCRPC patients mainly on PSA and PSA kinetics, including the regular follow-up stated by guideline recommendations.     

Factores relacionados con la resistencia a la castración precoz en el cáncer de próstata metastásico. Resultados del Registro nacional de cáncer de próstata en España

IntroductionThe objective of the study was to determine the factors independently related with the development of castration resistance (CR) in prostate cancer (PC) in the medium term.Material and methods155 patients diagnosed with metastatic PC with a follow-up of up to 39 months. Data taken from the National PC Registry.The evaluated variables were age, PSA, nadir PSA, Gleason, perineural invasion, TNM stages, and ADT type (intermittent/continuous).ResultsMean follow-up 26,2 ± 13,4 months. 47.1% developed early CR, with mean time until onset of 12,2 ± 8,7 months.Univariate analysis the mean PSA was correlated with CR (290 ± 905,1 ng/mL in non CR, 519,1 ± 1437,2 ng/mL in CR, P < .001), mean age (73,3 ± 8,3 years in non CR, 69,1 ± 9,3 in CR P = .01), mean PSA nadir (15,5 ± 57,3 ng/mL in non CR, 15,9 ± 23,7 ng/mL in CR, p < 0,001), Gleason (in ≥8, HR:2,11. 95% CI: 1.22-3.65, p = 0.006), and T stage (in T3-T4, HR: 2.85. 95% CI: 1.57-5.19, P < .001).Multivariate analysis the independent variables associated to CR are age (HR: 0.96. 95% CI: 0.94-0.99, P = .01), PSA nadir (HR: 1.65. 95% CI: 1,43-1,91, P < .001), and T3-T4 stage (HR: 2.11. 95% CI: 1.10-4.04, P = .02).ConclusionsPSA nadir and T3-T4 tumor stage at diagnosis are associated to an increased risk of developing CR. In addition, age at diagnosis is shown as a variable that decreases risk. Therefore, an older age would be associated with lower risk probability of CR in the medium term.     

Actualización de las Guías Clínicas de la Asociación Europea de Urología sobre el carcinoma vesical músculo-invasivo y metastásico

ContextNew data regarding diagnosis and treatment of muscle-invasive and metastatic bladder cancer (MiM-BC) has emerged and led to an update of the European Association of Urology (EAU) guidelines for MiM-BC.ObjectiveTo review the new EAU guidelines for MiM-BC.Evidence acquisitionA comprehensive workup of the literature obtained from Medline, the Cochrane central register of systematic reviews, and reference lists in publications and review articles was developed and screened by a group of urologists, oncologists, and radiologist appointed by the EAU Guideline Committee. Previous recommendations based on the older literature on this subject were taken into account.Levels of evidence and grade of guideline recommendations were added, modified from the Oxford Centre for Evidence-based Medicine Levels of Evidence.Evidence synthesisThe diagnosis of muscle-invasive bladder cancer (BCa) is made by transurethral resection (TUR) and following histopathologic evaluation. Patients with confirmed muscle-invasive BCa should be staged by computed tomography (CT) scans of the chest, abdomen, and pelvis, if available. Adjuvant chemotherapy is currently only advised within clinical trials. Radical cystectomy (RC) is the treatment of choice for both sexes, and lymph node dissection should be an integral part of cystectomy. An orthotopic bladder substitute should be offered to both male and female patients lacking any contraindications, such as no tumour at the level of urethral dissection. Multimodality bladder-preserving treatment in localised disease is currently regarded only as an alternative in selected, well-informed, and compliant patients for whom cystectomy is not considered for clinical or personal reasons. An appropriate schedule for disease monitoring should be based on: a) natural timing of recurrence; b) probability of disease recurrence; c) functional deterioration at particular sites; and d) consideration of treatment of a recurrence. In metastatic disease, the first-line treatment for patients fit enough to sustain cisplatin is cisplatin-containing combination chemotherapy. Presently, there is no standard second-line chemotherapy.ConclusionsThese EAUguidelines are a short, comprehensive overview of the updated guidelines of (MiM-BC) as recently published in the EAU guidelines and also available in the National Guideline Clearinghouse.     

Radio-223 en la secuencia terapéutica del cáncer de próstata resistente a la castración metastásico

Context

Radium-223 is an □ -particle transmitter with specific action on bone metastases. The Alpharadin in Symptomatic Prostate Cancer Patients (ALSYMPCA) study showed that radium-223 extended overall survival and delayed the onset of bone events in patients with symptomatic castration-resistant prostate cancer with bone metastases (mCRPC) and without visceral metastases, with a good safety profile.

Repercusión clínica y urodinámica de la presencia de hiperactividad del detrusor en mujeres con vejiga hiperactiva

ObjectiveTo evaluate the clinical and urodynamic differences (associated with the presence or absence of detrusor overactivity [DO]) in women with overactive bladder (OAB) referred to Functional Urology and Urodynamic Units in Spain.Material and methodsObservational, cross-sectional, multicenter and prospective study conducted in Spain in women with clinical diagnosis of OAB, who had been referred to urodynamic study (UDS) of which centralized reading was performed. Patients completed the 3-day voiding diary (DM3d) with the PPIUS scale (Patient Perception of Intensity of Urgency Scale), the B-SAQ (Bladder Self-Assessment Questionnaire) and the OABq-SF (Overactive Bladder Questionnaire Short Form). The questionnaires and UDS variables of women with OAV, with or without DO, were compared using the Mann-Whitney test (continuous variables) and the chi-square test (χ²) (categorical variables).ResultsA total of 247 women with OAB were evaluated, and 103 of them had DO. According to the presence or absence of DO, significant differences were observed in the number of episodes of urge urinary incontinence (UUI), urinary frequency, nocturia, mean micturition volume and number of pads (P < .05 for all comparisons). A higher percentage of patients with OAB and DO presented reduced bladder capacity, urgency, urge urinary incontinence (UUI) and lower volume for first voiding desire, strong desire to void and maximum cystomanometric capacity in UDS compared with patients without DO (P < .05 for all comparisons). The only significant differences between both groups were regarding the B-SAQ symptoms scale (P = .011).ConclusionsThe presence of DO in women with OAB is related to a more severe alteration of the bladder filling phase.     

Radio-223 en el tratamiento del cáncer de próstata resistente a la castración metastásico: una ventana de oportunidad

Context

The elimination of bone metastases, restoration and/or preservation of bone morphology and prevention and/or delay of skeletal events are a fundamental objective in the management of metastatic castration-resistant prostate cancer (mCRPC). Radium-223 is the first targeted alpha therapy with effects on bone that has been shown to increase survival in these patients, besides providing other bone-related benefits.

Estimación de las proyecciones del cáncer de vejiga en España

IntroductionOne of the most frequent cancers in the world is bladder cancer that affects, according to some authors, 5.4 million persons in the most developed countries. Our study has aimed to estimate the impact projections of this disease in Spain between 2007 and 2022.Material and methodsMortality data for bladder cancer mortality was used International Classification of Diseases 10th revision (ICD-10 C67), and the population data from 1998 to 2007. The data were obtained from the National Institute of Statistics (INE). Relative survival was obtained form the EUROCARE study. The projections of incidence, prevalence, and mortality were estimated using the statistical program Mortality-Incidence Analysis MODel (MIAMOD) and after the joinpoint regression that calculates the Annual Percentage of Change (APC).ResultsBetween the years 1998 and 2022, it is foreseen that there will be a decrease in prevalence in the men, from 156.93 (adjusted rate AR=128.71) to 132.99 (AR=84.68) cases per 100,000 inhabitants/year in the year 2022. The incidence rate would decrease from 30.2 (AR=24.93) to 24.87 (AR=15.88) and mortality from 14.96 (AR=12.25) to 12.08 (AR=7.67). In women, an increase is expected in prevalence from 21.18 (AR=13.23) to 35.6 (AR=21.46) cases per 100.000 inhabitants/year. The incidence of 4.8 (AR=2.91) in 1998 to 7.79 (AR=4.69), Mortality will increase from 2.25 (AR=1.32) to 3.37 (AR=1.89) between the years 1998 and 2022. In men, the APCs found for prevalence, incidence and mortality were, respectively, 0.69 (95% CI%: ?6.9/8.9); 0.69 (95% CI: ?6.9/8.95) and ?4.18 (95% CI: ?11.32/3.51), these not being statistically significant. In women, the APC for prevalence was ?4.44 (95% CI: ?13.4/5.44). from 19.24 (95% CI: 8.93/30.52).and from ?3.28 (95% CI: ?20.26/17.20) for mortality.ConclusionsThis cancer should be monitored and in turn prevented based on the controllable risk factors, especially in women.     

Estudio genético de RNASEL en cáncer de próstata y su relación con la estadificación clínica

ObjectivesThis study has aimed to find a possible genetic relationship between sporadic prostate cancers. An attempt is made to establish population subgroups in patients based on the genotype found and the aggressiveness of the cancer.Material and methodsA total of 231 patients with sporadic prostate cancer and 68 controls were selected. The subjects were selected by an urologist using clinical parameters such as PSA level and Gleason score. Both groups (patients and controls) were genotyped in RNASEL gene by sequencing the exons 1 and 3.ResultsStatistically significant differences were found between controls and patients in some of the genotyped regions of the RNASEL gene (I97L, D541E and R462Q).ConclusionsThanks to the genetic profile in some regions of the genoma, such as the RNASEL gene, together with the combination of the clinical and environmental parameters, we can suggest a care and more personalized follow-up of each patient.     

Manejo de la ginecomastia en pacientes con cáncer de próstata y deprivación androgénica

ContextGynecomastia, defined as benign proliferation of glandular breast tissue has a prevalence of 32% to 72% in the male. In the urology setting, it is associated to patients with prostate cancer and hormone treatment with a prevalence of 15% in the case of complete hormone blockage and 75% in monotherapy. The different options of treatment in prostate cancer have changed in recent decades. Thus, we have focused on this subject to evaluate the different therapy options of hormone manipulation induced gynecomastia in prostate cancer patients.ObjectiveTo synthesize the available evidence on the different therapeutic options in prostate cancer patients who develop gynecomastia due to the use of nonsteroidal antiandrogens and to generate a diagnostic algorithm and treatment.Acquisition of evidenceUsing the PICO type structured search strategy (Patient or problem, Intervention, Comparison, Outcome or result) in the data bases of PubMed-Medline and Cochrane, identification was made of the relevant studies related to the treatment of gynecomastia in Prostate Cancer patients treated with nonsteroidal antiandrogens.Synthesis of evidenceWe have found 3 possible therapeutic options for the treatment of gynecomastia and mastodynia in patients with hormone deprivation therapy for prostate cancer. The 10 Gy radiotherapy would be an option for the treatment of gynecomastia, although not all the patients need prophylactic treatment since only 50% report moderate-severe discomfort. Another option is the use of drugs such as tamoxifen 20 mg/day that lead to a significant decrease in the mammary effects.ConclusionsGynecomastia and mastodynia, given their high incidence, make the physical examination a fundamental tool for all patients before initiating treatment with antiandrogens. The use of tamoxifen 20 mg/day is the best treatment and prevention option against gynecomastia and mastodynia, while in the case of long-course established gynecomastia, surgery is the gold standard.     

Comparación entre la prostatectomía con preservación del espacio de Retzius y la prostatectomía radical estándar asistida por robot para el cáncer de próstata

Introduction and objectivesWe aim to compare the first year oncological and functional outcomes of Retzius-sparing robot-assisted radical prostatectomy (Rs-RARP) and standard robot-assisted radical prostatectomy (RARP).Materials and methodsEighty-eight patients who underwent robotic radical prostatectomy between 2018-2019 were included. We compared the minimum one-year follow-up results of patients who underwent Rs-RARP or RARP in terms of oncological and functional outcomes. Potency was assessed with the Sexual Health Inventory for Men (SHIM) score and was defined as an erection sufficient for penetration. Continence was defined as the absence of urinary incontinence with no safety pad. Patients were evaluated in the first month of follow-up and subsequently, every three months.ResultsForty-six patients in Rs-RARP and 42 patients in the RARP group were enrolled. Catheter removal time was shorter in the Rs-RARP group (12 vs. 14 days, P = .001). At the 1^st month visit, 41 patients (%89) were continent (no pads) in the Rs-RARP group while 25 patients (%59) were continent in the RARP group (P = .001). Patients who underwent Rs-RARP achieved faster recovery of urinary continence (Log-rank, P = .001). After one year of follow-up, 43 patients (93%) in Rs-RARP group and 38 patients (90%) in RARP group were continent (P = .6). Potency rates were 38.7% in Rs-RARP and 34.4% in RARP group (P = .28). There were no cases of biochemical recurrence in any group.ConclusionsRs-RARP is a feasible technique, providing early return of continence. However, overall continence rates were similar at the end of the one-year follow-up.     

Cirugía citorreductora en pacientes con cáncer de próstata oligometastásico. Revisión sistemática de la literatura científica

IntroductionInterest in oligometastatic prostate cancer has spiked due to the emergence of new evidence regarding more specific and accurate imaging, and the wider use of minimally invasive techniques. Nevertheless, the optimal management of this pathology is yet to be determined.ObjectiveAssess the efficacy and safety of cytoreductive surgery in patients suffering from oligometastatic prostate cancer.Evidence gatheringSystematic review of the scientific literature (01/01/2010-31/12/2021) within the MedLine, Embase, Cochrane Library, Cinahl, Scopus, Spanish Healthcare Technology Assessment Agencies (AETS, Agencias de Evaluación de Tecnologías Sanitarias) and ClinicalTrials.gov databases. The keywords used were prostatectomy, prostatic neoplasm, radical prostatectomy; the free search terms were prostatectomy and oligometastatic prostate. The inclusion criteria comprised studies on patients with oligometastatic prostate cancer who had been operated on using radical cytoreductive prostatectomy.Evidence synthesisThe systematic review included 4 observational studies, 2 clinical trials, and 2 case series, of moderate quality. The results observed suggest that oligometastatic prostate cancer patients who had undergone cytoreductive prostate surgery obtained a benefit in terms of efficacy. Conversely, the majority of these studies showed a reduction in the number of localized complications, when compared to the best systemic treatments.ConclusionsCytoreductive surgery in this group of patients is a safe procedure that reduces the incidence of localized complications and that presents promising results with regard to survival rates. To date, the lack of prospective trials limits the use of this therapeutic option to experimental environments.     

Proyectos de estandarización del tratamiento del cáncer de la unión esofagogástrica: centralización,registros y formación

Surgical treatment of oesophagogastric junction adenocarcinomas is based on total gastrectomies or oesophagectomies, which are complex procedures with potentially high morbidity and mortality. Population-based registers show a considerable variability of protocols and outcomes among different hospitals and regions. One of the main strategies to improve global results is centralization at high-volume hospitals, a process that should take into account the benchmarking of processes and outcomes at referral hospitals. Minimally invasive surgery can improve postoperative morbidity while maintaining oncological guaranties, but is technically more demanding than open surgery. This fact underlines the need for structured training and mentorship programs that minimize the impact of surgical teams’ training curves without affecting morbidity, mortality or oncologic radicality.