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OBJECTIVES: To present our surgical experience in laparoscopic adrenalectomy after 70 procedures, comparing our results with the published series and analyzing the learning curve. METHODS: Between June 1997 and December 2007 we performed 87 adrenalectomies (70 transperitoneal laparoscopy, 1 retroperitoneoscopy and 16 open surgery); 60% were female. Mean age was 54 years 15-80); 35 were left adrenalectomies, 33 right and one bilateral. Mean mass size was 3,7 cm (1-10). All patients were assessed regarding the following variables: preoperative diagnosis, histopathology, operative time, blood loss, complications, conversion to open surgery and hospital stay. We compared the results of the first 40 surgical procedures (Group 1) and the last 30 (Group 2). We also compared our re-sults with published series. Mean time follow-up was 12 months (2-60). RESULTS: The most frequent preoperative diagnoses were: active suprarenal mass (50%), incidentaloma (20%), pheochromocytoma (20%). Histopathology confirmed 60% adenomas, 14% pheochromocytomas and 11% cortical nodular hyperplasia. Mean operative time was 161 minutes (60-300). Average blood loss (hematocrit) was 5.2 (1-10). Conversion and complication rate were 8.5 and 7%, respectively. Mean hospital stay was 4 days (2-30). In group 2, only reduction on mean operative time (120 min) and hospital stay (3 days) was statistically significant. CONCLUSIONS: Transperitoneal laparoscopic adrenalectomy is a feasible and safe procedure in urological groups with previous laparoscopic experience. Our results are similar to the published series and confirm the efficacy, safety and reproducibility of this technique.

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Objetivo: Presentar nuestra experiencia en adrenalectomía laparoscópica transperitoneal tras 70 procedimientos, comparando nuestros resultados con las series publicadas y analizando la curva de aprendizaje. Métodos: Entre junio de 1997 y diciembre de 2007 se han practicado 87 adrenalectomías (70 laparoscópica transperitoneal, 1 retroperitoneoscopia, 16 por cirugía abierta). El 60% fueron mujeres. La edad media fue de 54 años (15-80); 35 fueron izquierdas, 33 derechas y 1 bilateral. El tamaño medio de las masas fue de 3.7 cm (1-10). Se analizaron las siguientes variables: diagnóstico preoperatorio y resultado anatomopatológico, tiempo quirúrgico, pérdida sanguínea, complicaciones, reconversión a cirugía abierta y estancia hospitalaria. Se han comparado los resultados entre los primeros 40 procedimientos (grupo 1) y los 30 últimos (grupo 2). Se han analizado los resultados en comparación con las principales series publicadas. La media de seguimiento ha sido de 12 meses (2-60). Resultados: Los diagnósticos preoperatorios principales fueron: masa funcionante (50%), incidentaloma (20%) y feocromocitoma (20%). La anatomía patológica confirmó un 60% de adenomas, 14% feocromocitomas y un 11% hiperplasia nodular cortical. El tiempo medio quirúrgico fue de 161 minutos (60-300). La pérdida media de hematocrito fue de 5.2 puntos (1-10). La tasa de reconversión fue del 8.5% y la de complicaciones del 7%. La estancia media hospitalaria fue de 4 días (2-30). En el grupo 2 (las 30 últimas adrenalectomías) se obtuvieron diferencias estadísticamente significativas reduciendo el tiempo quirúrgico, 120 min (60-200) y la estancia hospitalaria, 3 días (2-14). Conclusiones: La adrenalectomía laparoscópica transperitoneal es una técnica factible y segura en grupos urológicos con cierta experiencia en cirugía laparoscópica. Nuestros resultados son equiparables con las principales series publicadas y confirman la eficacia, seguridad y reproducibilidad de la técnica (AU)

Objectives: To present our surgical experience in laparoscopic adrenalectomy after 70 procedures, comparing our results with the published series and analyzing the learning curve. Methods: Between June 1997 and December 2007 we performed 87 adrenalectomies (70 transperitoneal laparoscopy, 1 retroperitoneoscopy and 16 open surgery); 60% were female. Mean age was 54 years 15-80); 35 were left adrenalectomies, 33 right and one bilateral. Mean mass size was 3,7 cm (1-10). All patients were assessed regarding the following variables: preoperative diagnosis, histopathology, operative time, blood loss, complications, conversion to open surgery and hospital stay. We compared the results of the first 40 surgical procedures (Group 1) and the last 30 (Group 2). We also compared our results with published series. Mean time follow-up was 12 months (2-60). Results: The most frequent preoperative diagnoses were: active suprarenal mass (50%), incidentaloma (20%), pheochromocytoma (20%). Histopathology con-firmed 60% adenomas, 14% pheochromocytomas and 11% cortical nodular hyperplasia. Mean operative time was 161 minutes (60-300). Average blood loss (hematocrit) was 5.2 (1-10). Conversion and complication rate were 8.5 and 7%, respectively. Mean hospital stay was 4 days (2-30). In group 2, only reduction on mean operative time (120 min) and hospital stay (3 days) was statistically significant. Conclusions: Transperitoneal laparoscopic adrenalectomy is a feasible and safe procedure in urological groups with previous laparoscopic experience. Our results are similar to the published series and confirm the efficacy, safety and reproducibility of this technique (AU)

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INTRODUCTION: It has been well documented that the outcome of prostate cancer treatment depends on the dose administered. Hence, techniques have been developed that allow high-dose administration without increasing the complications, e.g. external radiotherapy combined with high-dose radiation (HDR) brachytherapy. In this article we analyse the technique and protocol of real-time HDR brachytherapy together with the preliminary results that support its use. Materials and methods. Between June 1998 and December 2004, 100 patients with adenoma of the prostate were treated with 46 Gy of external irradiation to the pelvis and 2 HDR brachytherapy fractions (each of 1150 cGy) at the end of weeks 1 and 3 of a 5-week radiotherapy course. The 1997 American Joint Commission on Cancer (AJCC) system was used to establish disease stage. Patients with intermediate-risk (PSA 10-20 ng/ml or Gleason = 7 or T2c) and high-risk (two intermediate risk factors or PSA > 20 ng/ml or Gleason > 7 or > T2c) without metastases were eligible for the brachytherapy. Biochemical failure was defined according to the American Society for Therapeutic Radiology and Oncology (ASTRO) consensus panel statement. SPSS statistical package was used to quantify survival (Kaplan-Meier method). Toxicity was scored according to RTOG guidelines. RESULTS: The mean age of patients was 67 years (range 49-78). Clinical stage was T2a in 22% of the patients, 26% T2b and 52% T3. Initial PSA was = 10 ng/ml in 22% of the patients and > 10 ng/ml in 78%. Median follow-up was 28 months (range: 12-79). The 5-year overall survival and actuarial biochemical control were 99% and 87% respectively. No chronic severe complications were noted. CONCLUSIONS: The good results of local control, disease-free survival and few complications that the external radiotherapy combined with HDR brachytherapy have shown suggest that the method should be considered as first-choice in the treatment of prostate tumours of high- and intermediate-risk.

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Introduction. It has been well documented that the outcome of prostate cancer treatment depends on the dose administered. Hence, techniques have been developed that allow high-dose administration without increasing the complications, e.g. external radiotherapy combined with high-dose radiation (HDR) brachytherapy. In this article we analyse the technique and protocol of real-time HDR brachytherapy together with the preliminary results that support its use. Materials and methods. Between June 1998 and December 2004, 100 patients with adenoma of the prostate were treated with 46 Gy of external irradiation to the pelvis and 2 HDR brachytherapy fractions (each of 1150 cGy) at the end of weeks 1 and 3 of a 5week radiotherapy course. The 1997 American Joint Commission on Cancer (AJCC) system was used to establish disease stage. Patients with intermediate-risk (PSA 10-20 ng/ml or Gleason = 7 or T2c) and high-risk (two intermediate risk factors or PSA > 20 ng/ml or Gleason > 7 or > T2c) without metastases were eligible for the brachytherapy. Biochemical failure was defined according to the American Society for Therapeutic Radiology and Oncology (ASTRO) consensus panel statement. SPSS statistical package was used to quantify survival (Kaplan-Meier method). Toxicity was scored according to RTOG guidelines. Results. The mean age of patients was 67 years (range 49-78). Clinical stage was T2a in 22% of the patients, 26% T2b and 52% T3. Initial PSA was = 10 ng/ml in 22% of the patients and > 10 ng/ml in 78%. Median follow-up was 28 months (range: 12-79). The 5-year overall survival and actuarial biochemical control were 99% and 87% respectively. No chronic severe complications were noted. Conclusions. The good results of local control, di-sease-free survival and few complications that the external radiotherapy combined with HDR brachytherapy have shown suggest that the method should be considered as first-choice in the treatment of prostate tumours of high- and intermediate-risk

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Objetivo: La Braquiterapia prostática con implantes permanentes de semillas de 125I ó 103Pd es una opción terapéutica en el tratamiento del cáncer prostático organoconfinado. Analizamos la técnica basada en la planificación previa (preplanificación), así como nuestro proceder actual de planificación intraoperatoria y los motivos que nos llevaron a realizar este cambio de técnica. Métodos: Los cambios observados en el volumen y en la localización espacial de la próstata, entre las imágenes obtenidas durante la preplanificación y posteriormente en el acto quirúrgico, junto a la posibilidad de dificultades para implantar las semillas por interferencia con el arco púbico, son algunos de los motivos que nos llevaron al cambio de técnica. Resultados: Previamente a la intervención calculamos el volumen prostático por ecografía transrectal; con este dato determinamos la actividad total del implante siguiendo el nomograma de Wu y cols y la actividad por semilla, por lo tanto se trata de un proceso individualizado para cada paciente. Realizamos un implante periférico situando el 75-80 por ciento de las semillas en la zona periférica de la próstata, habitualmente a través de 12-15 agujas, el resto de semillas se sitúan en la parte central de la próstata utilizando 3 ó 4 agujas como máximo, en próstatas voluminosas. El día de la intervención, tras posicionar al paciente y sondarle, comprobamos de nuevo la volumetría, transferimos las imágenes ecográficas (cada 5 cm. de base de apex) al planificador, donde se halla la distribución idónea de las semillas. Posteriormente realizamos el implante colocando la totalidad de las agujas sin cargar y, tras realizar una cistoscopia flexible para asegurarnos de que ninguna de las agujas estén en uretra o vejiga, realizamos una postplanificación intraoperatoria que nos permita comprobar la precisión del implante. Finalizaremos con la colocación de las semillas en el interior de la próstata. El tiempo total del proceso es de más o menos 90 minutos. Conclusión: La planificación intraoperatoria es un paso más en el tratamiento de los tumores prostáticos con braquiterapia de implantes permanentes, que evita las desventajas de la preplanificación y mejora la cobertura del tumor por las dosis ideales de irradiación, lo que se traducirá en un mejor control local de la enfermedad (AU)

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OBJECTIVES: Prostatic brachytherapy with permanent 125I or 123Pd seeds implantation is a therapeutic option for organ-confined prostate cancer. We analyze the technique based on previous planning, our current intraoperative planning procedure and the reasons that moved us to introduce this change. METHODS: Changes in prostate volume and spatial localization observed between previous planning and intraoperative images, and possible difficulties for seed implantation due to pubic arch interference are some of the reasons that induce us to change technique. RESULTS: Before the operation, we calculate the prostatic volume by transrectal ultrasound; with this information we determine the total implant activity following Wu's nomogram, and per-seed activity; therefore, it is an individual process for each patient. We perform a peripheral implant, placing 75-80% of the seeds within the peripheral prostatic zone, generally through 12-15 needles, the rest of the seeds are placed in the central prostatic zone using a maximum of 3-4 needles in high volume prostates. The day of intervention, after positioning and catheter insertion, volumetry is re-checked. Ultrasound images (from base to apex every 5 mm) are transferred to the planner were a suitable seed distribution is determined. Implantation is then performed placing all needles unloaded, and then intraoperative post-planning to allow us to check implant precision is performed after cistoscopically check that there is no urethral or bladder penetration by any needle. We finish with the insertion of seeds into the prostate. Total time for the procedure is around 90 minutes. CONCLUSIONS: Intraoperative planning is an additional step for the treatment of prostate cancer with permanent seeds brachytherapy, which avoids the disadvantages of previous planning and improves tumor inclusion in the ideal irradiation dose area, which will translate into better local disease control.

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OBJETIVOS: Pretendemos estudiar el comportamiento de la cat-D citosólica, marcador pronóstico ya conocido en cáncer de mama, en la hiperplasia benigna de próstata (HBP) y cáncer de próstata (CaP): su variación en función del volumen glandular, sus relaciones con otros marcadores séricos (PSA, PAP...), con el grado histológico, el estadio tumoral y la supervivencia. MÉTODO: Incluimos 376 pacientes intervenidos por patología prostática en el HCA entre los años 91 y 96. En todas las muestras de tejido prostático obtenidas, se realizó una determinación de Cat-D citosólica según estudio inmunoradiométrico CIS Bio internacional. RESULTADOS: Los valores de cat-D citosólica en HBP oscilaron entre 0,2 y 86,5 pmol/mg con una media de 14,9, observándose mayores valores (p=0,004) conforme el volumen prostático era superior. También en los casos de HBP se encontró una diferencia significativa (p=0,024) entre pacientes portadores y no portadores de sonda vesical, siendo mayor en aquellos. Los valores de Cat-D en CaP oscilar on entre 0,5 y 74 pmol/mg con una media de 18,13, existiendo una diferencia estadísticamente significativa entre medias (p=0,047) con relación a la HBP. También la diferencia fue estadísticamente significativaen el CaP (p=0,04) entre pacientes con y sin sonda. No se observó ninguna relación entre la Cat-D y el resto de los parámetros estudiados. CONCLUSIONES: Al igual que en la mayor parte de la bibliografía revisada, observamos que la catepsina D no se comporta como marcador pronóstico en el cáncer de próstata ni tiene relación alguna con otros marcadores estudiados. El escaso número de muestras tumorales y el corto tiempo de seguimiento podría ser la causa de este resultado (AU)

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