Actas urologicas espanolas最新文献

Urachal adenocarcinoma is an extremely rare malignancy, accounting for less than 1% of all bladder tumors. Diagnosis is often delayed due to nonspecific symptoms and low clinical suspicion. We report the case of a 52-year-old male with no relevant medical history who presented with lower urinary tract symptoms. Cystoscopy revealed a cystic lesion at the bladder dome. Transurethral resection confirmed mucinous urachal adenocarcinoma. CT imaging showed no locoregional or distant spread, and tumor markers were within normal limits. The patient underwent laparoscopic partial cystectomy with en bloc excision of the urachus and umbilicus plus bilateral pelvic lymphadenectomy. Final pathology confirmed a Sheldon stage IIIA mucinous cystadenocarcinoma. At 25 months of follow-up, the patient remains free of disease recurrence. Given its low prevalence and aggressive nature, accurate diagnosis and appropriate surgical management are critical. While surgery remains the cornerstone in localized disease, the role of systemic therapy remains unclear. Immunotherapy and targeted therapies are emerging as promising options in advanced stages. This case illustrates the diagnostic challenges and emphasizes the importance of surgical planning and long-term surveillance in the absence of standardized treatment guidelines. Midline bladder lesions should prompt suspicion of urachal adenocarcinoma. Complete surgical excision is essential, with lymphadenectomy and systemic therapy considered on a case-by-case basis. Long-term follow-up is necessary due to the high risk of recurrence.

Introduction: Adrenal incidentalomas (AI) measuring 4-6 cm present a diagnostic challenge, as size alone inadequately predicts malignancy and creates uncertainty in surgical decisions.

Objective: To evaluate the Systemic Immune-Inflammation Index (SII) as a predictor of malignancy in adrenal tumors ≥4 cm, with a focus on the 4-6 cm "gray zone."

Methods: Retrospective single-center cohort of 91 adrenalectomy patients with AI ≥ 4 cm (ACC n = 19, ACA n = 72). A predefined subgroup included 46 patients with 4-6 cm tumors (ACC n = 9, ACA n = 37). SII was calculated from preoperative complete blood counts (CBC) as platelets × neutrophils / lymphocytes. Predictive performance was assessed using ROC analysis and logistic regression.

Results: In the ≥4 cm cohort, SII was higher in ACC vs. ACA (1107.4 vs. 711.3, p < 0.001). SII independently predicted ACC (per 100-unit increase: OR 0.78, 95% CI 0.67-0.90; p = 0.002). SII showed AUC 0.778 with a cut-off of 811 (sensitivity 78.9%, specificity 73.6%). Tumor size was not predictive (AUC ≈ 0.50). In the 4-6 cm subgroup, SII remained an independent predictor (per 100-unit increase: OR 0.61, 95% CI 0.45-0.82; p = 0.004), with AUC 0.898 at a cut-off of 945 (sensitivity 88.9%, specificity 83.8%).

Conclusions: SII-derived from routine CBC-is a low-cost, adjunctive biomarker that improves preoperative malignancy risk stratification beyond size in AI, particularly in 4-6 cm tumors. External prospective validation is warranted before routine implementation.

Introduction: Focal therapy (FT) has emerged as an intermediate therapeutic strategy between active surveillance (AS) and radical treatments for the management of localized prostate cancer (PCa) in patients with clinically significant disease and a well-defined index lesion (IL). The development of ablative and imaging techniques has enabled the selective treatment of the IL, preserving healthy tissue and reducing adverse effects.

Objectives: o review the current evidence on FT in localized PCa, including technological modalities, selection criteria, diagnostic tools, post-treatment surveillance strategies, and barriers to its clinical implementation in the Spanish healthcare setting.

Materials and methods: A structured narrative review was conducted through a search in PubMed, Scopus, and Web of Science, including studies published up to April 2025. Original articles, reviews, clinical guidelines, and meta-analyses focusing on FT for localized PCa were selected. Prospective and comparative studies addressing oncological and functional outcomes, as well as associated technologies such as fusion biopsy, multiparametric magnetic resonance imaging (mpMRI), prostate-specific membrane antigen positron emission tomography (PSMA-PET), and artificial intelligence (AI), were prioritized.

Results: FT offers encouraging short- and medium-term oncological outcomes, with notable functional preservation. Modalities such as high-intensity focused ultrasound (HIFU) and cryotherapy are currently the most widely used and have the longest clinical trajectory, while irreversible electroporation (IRE) stands out among emerging techniques with results. Surveillance after FT should be multifactorial and include serial PSA monitoring, systematic and targeted biopsies, as well as imaging techniques such as mpMRI. Specific tools such as PI-FAB (Prostate Imaging after Focal Ablation) and TARGET (Transatlantic Recommendations for MRI Evaluation after Focal Therapy) systems allow for standardized interpretation of mpMRI after FT. In Spain, its adoption remains limited, reinforcing the need for specific guidelines and multicenter registries.

Introduction: Surgical training in urology has undergone significant transformation due to the increasing complexity of procedures and the integration of advanced technologies. Simulation-based education is recognized as a fundamental component of residency programs. This study aimed to evaluate the current status of surgical training and the availability of simulation resources for urology residents and early-career urologists in the countries represented by the American Confederation of Urology.

Methods: A descriptive, cross-sectional survey was conducted with 402 participants from 19 countries. The questionnaire included multiple-choice questions addressing demographics, access to surgical procedures, simulation tools, evaluation methods, mentorship, and the impact of the COVID-19 pandemic.

Results: The study revealed significant heterogeneity in surgical training. Only 17.9% had access to robotic surgery and 32.8% to prostate enucleation. Over 80% reported the absence of virtual or wet labs at their institutions. Training was based on step-by-step instruction (89.9%), in laparoscopic (45%) and endoscopic (50.7%). However, 15.7% used simulators during surgical procedures. Additionally, 50.6% reported the absence of formal assessment or mentorship. Fellowship training was considered in 84.7%. The COVID-19 pandemic negatively impacted academic (50.3%) and surgical (66.9%) training.

Conclusions: The findings highlight considerable variability in surgical training, limited access to simulation resources, and a general absence of standardized evaluation and mentorship systems. These results emphasize the need to implement structured and equitable training that incorporate simulation, these offer a safe and effective environment for developing surgical skills.

Introduction: The prognosis of localized prostate cancer (PCa) following radical treatment is generally favorable, although up to 46% of patients may still experience adverse outcomes. The impact of delayed surgery in intermediate-risk (IR) or high-risk (HR) patients remains under discussion. This study evaluates its association with oncological outcomes.

Materials and methods: Retrospective study of 2296 patients with IR and HR PCa who underwent radical prostatectomy (RP) between 1986 and 2025. Upgrading, upstaging, positive margins, PSA persistence, and lymph node involvement were analyzed. Waiting time was grouped into <3, 3-6, and >6 months.

Results: The median waiting time was 3.5 months. Eighty-five percent of patients were operated on within 6 months. At 5 years, no difference was detected between waiting time and time to biochemical recurrence (BCR) when comparing the <3-month group with the 3-6-month group (HR 0.93; 95% CI 0.76-1.13) and the >6 months group (HR 0.74; 95% CI 0.53-1.04) among IR patients. In HR patients, no differences were observed either: 3-6 months (HR 0.85; 95% CI 0.71-1.01) and >6 months (HR 0.79; 95% CI 0.61-1.03). No increased risk of adverse pathological outcomes was found with longer delays.

Conclusions: A waiting time of ≤6 months was not associated with worse oncological prognosis, supporting its safety in IR or HR PCa.

Objective: In this study, the success of the Modified Frailty Index-5 (mFI-5) score in predicting postoperative morbidity in elderly patients who underwent radical cystectomy (RC) for bladder cancer was evaluated, and this score was compared with the widely used Charlson Comorbidity Index (CCI) and Geriatric 8 (G8) screening tools.

Methods: Between January 2017 and April 2025, 102 patients aged ≥65 years who underwent open RS for T2-T4a N0M0 bladder cancer were retrospectively reviewed. mFI-5, CCI, and G8 scores were calculated from preoperative data. Patients were divided into two groups based on mFI-5 scores: <2 (Group 1, non-frail) and ≥2 (Group 2, frail). Major complications were defined as Clavien-Dindo (CD) ≥3. Clinical data, complication rates, hospital stay duration, and readmission rates after discharge were compared.

Results: Of the patients, 40 (39.2%) were in Group 1 and 62 (60.8%) were in Group 2. The rates of any complications and CD ≥ 3 complications were higher in Group 2 (p = 0.006 and p = 0.018, respectively). In multivariate analysis, mFI-5 ≥ 2 approximately tripled the risk of CD ≥ 3 complications (OR = 3.036; 95% CI 0.966-9.546; p = 0.043). In ROC analysis, the AUC value of mFI-5 for CD ≥ 3 complications was 0.718 (95% CI: 0.613-0.822), which was higher than that of CCI and G8. The AUC value of mFI-5 for predicting readmission was 0.704 (95% CI: 0.599-0.810).

Conclusion: mFI-5 is a practical frailty assessment tool that predicts postoperative morbidity in elderly RS patients with higher accuracy than CCI and G8.

Introduction: Novel trifecta has been proposed to define surgical success in patients undergoing partial nephrectomy (PN). This study aimed to evaluate its role in predicting survival outcomes and to identify the predictors of trifecta achievement via a machine-learning based model.

Methods: Data from consecutive patients who underwent minimally invasive PN between 2003 and 2022 were retrospectively analysed. Surgical success was defined through the achievement of novel trifecta (No Clavien-Dindo ≥ 3 postoperative complications, negative surgical margins and <30% reduction in postoperative eGFR). Kaplan-Meier curves were used to assess the impact of trifecta achievement on survival. Automated chi-squared interaction detection (CHAID), a recursive machine-learning algorithm, was applied to predict trifecta achievement.

Results: A total of 465 patients were included, with a median follow-up of 72 (IQR 38-108) months. The trifecta was achieved in 73% of cases and was associated with significantly improved overall survival (85% vs. 69.8%; P = .04). Solitary kidney status, patient age, and surgical experience were the most relevant predictors, allowing classification into three clusters. Trifecta rates were 43.6% in cluster #1 (solitary kidney), 71.2% in cluster #2 (non-solitary kidney with surgical experience ≤ 80 cases or >80 cases and patients-age ≥ 65), and 88.5% in cluster #3 (non-solitary kidney, patients-age < 65, surgical experience > 80 cases).

Conclusions: Novel trifecta achievement after PN correlates with overall survival but not with other oncological outcomes. A predictive model was developed, highlighting surgical experience as the only modifiable factor. Tailored perioperative strategies and advanced surgical training may improve trifecta achievement.

Introduction and objective: uROLOGIC health is a global priority, particularly in Latin America, where access to quality services remains limited. This underscores the importance of collaboration among key societal sectors, including the public, private, and academic domains. The MEDIUVer-UROLATAM model emerges as a university-led urological health strategy aimed at promoting socially impactful health initiatives. It is grounded in core university functions, collaborative work, and a targeted approach to specific social needs. The objective was to demonstrate the utility of the MEDIUVer-UROLATAM model as a framework for facilitating prostate cancer (PCa) detection and prevention actions.

Material and methods: The MEDIUVer model was implemented in three stages through a urological campaign coordinated by the Latin American Institute of Urology (UROLATAM) and the Faculty of Medicine at Universidad Veracruzana. The initiative involved collaboration with the private sector, government agencies, and the community to facilitate the early detection of prostate cancer. Medical evaluations, diagnostic tests, and educational activities were conducted.

Results: A total of 1656 individuals were attended, with 1352 urological evaluations performed. The first stage focused on social action, the second strengthened inter-institutional collaboration, and the third incorporated educational research and healthcare services for the transgender population. This approach led to greater stakeholder integration and an expanded social impact.

Conclusions: The MEDIUVer-UROLATAM model is an educational, training, and care-oriented tool for both the general population and healthcare professionals in terms of timely prostate cancer (PCa) detection and prevention.