Obstrucción infravesical y retención urinaria aguda : valoración morfométrica del detrusor y correlación urodinámica /

Descripció del recurs: 12 desembre 2002Consultable des del TDXTítol obtingut de la portada digitalitzadaOBJETIVOS Los objetivos eran estudiar la fiabilidad y reproductibilidad de la morfometría del detrusor mediante la valoración del diámetro del miocito y la cuantificación de la ratio colágeno/músculo, estudiar las diferencias entre pacientes con obstrucción infravesical y los varones control y analizar las diferencias, tanto morfológicas como funcionales, de los pacientes obstruidos en función del antecedente de retención urinaria aguda. PACIENTES Y MÉTODOS Se realizó un estudio prospectivo sobre 62 pacientes que se dividieron en tres grupos, pacientes con clínica y diagnóstico urodinámico de obstrucción infravesical (grupo Obstrucción), pacientes con clínica y diagnóstico urodinámico de obstrucción infravesical y antecedentes de episodio de retención urinaria aguda (grupo RAO) y pacientes sin obstrucción infravesical (grupo Control). El estudio fue aprobado por el Comité de Ensayos e Investigación Clínica de la Fundación Puigvert y todos los pacientes firmaron el consentimiento informado para participar en él. Como valoración funcional se realizó un cuestionario de síntomas (IPSS y Calidad de vida) y un estudio urodinámico. El estudio morfométrico se realizó a partir de muestras de detrusor obtenidas durante la resección transuretral (RTU) de próstata (pacientes del grupo Obstrucción y RAO) y RTU de tumor vesical inicial (grupo Control). Tras digitalización de la imagen de microscopía óptica, se valoró el diámetro del miocito y la relación o ratio entre colágeno y músculo (interfascicular y pericelular). Finalmente se realizó un estudio evolutivo funcional temprano a los 6 meses de la cirugía desobstructiva. RESULTADOS Se valoraron un total de 62 pacientes, con una edad media de 63 años. Los pacientes con obstrucción infravesical y antecedentes de RAO tenían una menor puntuación en la escala de síntomas y un mayor residuo postmiccional en la flujometría. En la valoración morfométrica, los pacientes con obstrucción infravesical (grupo Obstrucción y RAO) tenían un mayor diámetro del miocito (hipertrofia), así como una mayor ratio colágeno/músculo (fibrosis). Entre el grupo Obstrucción y RAO no se observaron diferencias en el diámetro del miocito y si un mayor infiltrado de colágeno pericelular en el grupo RAO. Tras la cirugía desobstructiva no se observaron diferencias evolutivas entre los pacientes del grupo Obstrucción y RAO. Existía una relación entre el diámetro del miocito y la recuperación funcional, pero no con la ratio colágeno/músculo. CONCLUSIONES La morfometría del detrusor mediante medición del diámetro del miocito y cuantificación de la ratio colágeno/músculo es una técnica fiable y reproducible. En la obstrucción infravesical existe una hipertrofia del miocito y una fibrosis del detrusor. Existen diferencias morfométricas en los pacientes con obstrucción infravesical en función del antecedente de retención urinaria aguda y no existen diferencias funcionales previas a la cirugía desobtructiva ni en la evolución postoperatoria temprana.OBJECTIVES The objectives were to study reability and efficacy of bladder morphometry by means of measurement of the diameter of detrusor cell and connective tissue-to-smooth muscle ratio, to study differences between bladder outlet obstruction (BOO) and group control and to study morphometric and urodynamic differences in patients with bladder outlet obstruction relation to episode of acute urinary retention (AUR). PATIENTS AND METHODS Sixty-two patients were included. There was three groups; control group, BOO group (lower urinary tracts symptoms and urodynamic bladder outlet obstruction) and AUR group (lower urinary tracts symptoms, urodynamic bladder outlet obstruction and episode of acute urinary retention). Study was accepted by committee of clinical studies of Fundación Puigvert. All patients were informed and they sign written consent. Functional study was made by symptoms (IPSS and quality life) and urodymanic study. Detrusor specimens were obtained from the lateral-posterior wall bladder after finish TURP (BOO and AUR groups) and bladder tumor resection (control group). Each section was viewed under a microscope and digitized using a personal computer. The diameter of detrusor muscle cell and connective tissue-to-smooth muscle ratio (between and within muscles fascicles) was measured. Six months after surgery urodynamic studies was repeat to evaluate patient evolution. RESULTS Sixty-two patients were included (mean age, 63 years). Score IPSS was lower in AUR group than in BOO group and postvoid residual volume was higher in AUR group in flowmetry. The diameter of the detrusor muscle cell and connective tissue-to-smooth muscle ratio determined by morphometry (between muscle fascicles) was higher in BOO and AUR group than control group. In patients with BOO (BOO and AUR group) no differences exist relation to an episode of acute urinary retention. However, in AUR group the connective tissue-to-smooth muscle ratio within fascicles was higher than BOO group. There were no differences in postoperative TURP between BOO and AUR groups. There was relation between diameter of the detrusor muscle cell and functional recovery after TURP. There was no relation between connective tissue-to-smooth muscle ratio and functional recovery after TURP. CONCLUSIONS Measurement of the diameter of detrusor cells and connective tissue-to-smooth muscle ratio is useful to study bladder morphometry. There was increase in the diameter of detrusor muscle cell (hypertrophy) and connective tissue-to-smooth muscle ratio (fibrosis) in BOO. There was morphometric differences in patients with bladder outlet obstruction relation to episode of acute urinary retention. There was no functional and postoperative differences in patients with bladder outlet obstruction relation to episode of acute urinary retention

High-Intensity Focused Ultrasound in Small Renal Masses

High-intensity focused ultrasound (HIFU) competes with radiofrequency and cryotherapy for the treatment of small renal masses as a third option among ablative approaches. As an emerging technique, its possible percutaneous or laparoscopic application, low discomfort to the patient and the absence of complications make this technology attractive for the management of small renal masses. This manuscript will focus on the principles, basic research and clinical applications of HIFU in small renal masses, reviewing the present literature. Therapeutic results are controversial and from an clinical view, HIFU must be considered a technique under investigation at present time. Further research is needed to settle its real indications in the management of small renal masses; maybe technical improvements will certainly facilitate its use in the management of small renal masses in the near future

Obstrucción infravesical y retención urinaria aguda: valoración morfometrica del detrusor y correlación urodinamica

OBJETIVOSLos objetivos eran estudiar la fiabilidad y reproductibilidad de la morfometría del detrusor mediante la valoración del diámetro del miocito y la cuantificación de la ratio colágeno/músculo, estudiar las diferencias entre pacientes con obstrucción infravesical y los varones control y analizar las diferencias, tanto morfológicas como funcionales, de los pacientes obstruidos en función del antecedente de retención urinaria aguda.PACIENTES Y MÉTODOSSe realizó un estudio prospectivo sobre 62 pacientes que se dividieron en tres grupos, pacientes con clínica y diagnóstico urodinámico de obstrucción infravesical (grupo Obstrucción), pacientes con clínica y diagnóstico urodinámico de obstrucción infravesical y antecedentes de episodio de retención urinaria aguda (grupo RAO) y pacientes sin obstrucción infravesical (grupo Control). El estudio fue aprobado por el Comité de Ensayos e Investigación Clínica de la Fundación Puigvert y todos los pacientes firmaron el consentimiento informado para participar en él. Como valoración funcional se realizó un cuestionario de síntomas (IPSS y Calidad de vida) y un estudio urodinámico. El estudio morfométrico se realizó a partir de muestras de detrusor obtenidas durante la resección transuretral (RTU) de próstata (pacientes del grupo Obstrucción y RAO) y RTU de tumor vesical inicial (grupo Control). Tras digitalización de la imagen de microscopía óptica, se valoró el diámetro del miocito y la relación o ratio entre colágeno y músculo (interfascicular y pericelular). Finalmente se realizó un estudio evolutivo funcional temprano a los 6 meses de la cirugía desobstructiva.RESULTADOSSe valoraron un total de 62 pacientes, con una edad media de 63 años. Los pacientes con obstrucción infravesical y antecedentes de RAO tenían una menor puntuación en la escala de síntomas y un mayor residuo postmiccional en la flujometría. En la valoración morfométrica, los pacientes con obstrucción infravesical (grupo Obstrucción y RAO) tenían un mayor diámetro del miocito (hipertrofia), así como una mayor ratio colágeno/músculo (fibrosis). Entre el grupo Obstrucción y RAO no se observaron diferencias en el diámetro del miocito y si un mayor infiltrado de colágeno pericelular en el grupo RAO. Tras la cirugía desobstructiva no se observaron diferencias evolutivas entre los pacientes del grupo Obstrucción y RAO. Existía una relación entre el diámetro del miocito y la recuperación funcional, pero no con la ratio colágeno/músculo. CONCLUSIONESLa morfometría del detrusor mediante medición del diámetro del miocito y cuantificación de la ratio colágeno/músculo es una técnica fiable y reproducible. En la obstrucción infravesical existe una hipertrofia del miocito y una fibrosis del detrusor. Existen diferencias morfométricas en los pacientes con obstrucción infravesical en función del antecedente de retención urinaria aguda y no existen diferencias funcionales previas a la cirugía desobtructiva ni en la evolución postoperatoria temprana.OBJECTIVESThe objectives were to study reability and efficacy of bladder morphometry by means of measurement of the diameter of detrusor cell and connective tissue-to-smooth muscle ratio, to study differences between bladder outlet obstruction (BOO) and group control and to study morphometric and urodynamic differences in patients with bladder outlet obstruction relation to episode of acute urinary retention (AUR).PATIENTS AND METHODSSixty-two patients were included. There was three groups; control group, BOO group (lower urinary tracts symptoms and urodynamic bladder outlet obstruction) and AUR group (lower urinary tracts symptoms, urodynamic bladder outlet obstruction and episode of acute urinary retention). Study was accepted by committee of clinical studies of Fundación Puigvert. All patients were informed and they sign written consent. Functional study was made by symptoms (IPSS and quality life) and urodymanic study. Detrusor specimens were obtained from the lateral-posterior wall bladder after finish TURP (BOO and AUR groups) and bladder tumor resection (control group). Each section was viewed under a microscope and digitized using a personal computer. The diameter of detrusor muscle cell and connective tissue-to-smooth muscle ratio (between and within muscles fascicles) was measured. Six months after surgery urodynamic studies was repeat to evaluate patient evolution.RESULTSSixty-two patients were included (mean age, 63 years). Score IPSS was lower in AUR group than in BOO group and postvoid residual volume was higher in AUR group in flowmetry. The diameter of the detrusor muscle cell and connective tissue-to-smooth muscle ratio determined by morphometry (between muscle fascicles) was higher in BOO and AUR group than control group. In patients with BOO (BOO and AUR group) no differences exist relation to an episode of acute urinary retention. However, in AUR group the connective tissue-to-smooth muscle ratio within fascicles was higher than BOO group. There were no differences in postoperative TURP between BOO and AUR groups. There was relation between diameter of the detrusor muscle cell and functional recovery after TURP. There was no relation between connective tissue-to-smooth muscle ratio and functional recovery after TURP.CONCLUSIONSMeasurement of the diameter of detrusor cells and connective tissue-to-smooth muscle ratio is useful to study bladder morphometry. There was increase in the diameter of detrusor muscle cell (hypertrophy) and connective tissue-to-smooth muscle ratio (fibrosis) in BOO. There was morphometric differences in patients with bladder outlet obstruction relation to episode of acute urinary retention. There was no functional and postoperative differences in patients with bladder outlet obstruction relation to episode of acute urinary retention

[ICG lymphography and fluorescence in pelvic lymphadenectomy for bladder and prostate cancer.]

ICG navigation in cancer surgery may help during pelvic lymphadenectomy

Free-indocyanine green-guided pelvic lymph node dissection during radical prostatectomy

Extended Pelvic Lymph Node Dissection (ePLND) remains the most accurate technique for the detection of occult lymph node metastases (LNMs) in prostate cancer (CaP) patients. Here we aim to examine whether free-Indocyanine Green (F-ICG) could accurately assess the pathological nodal (pN) status in CaP patients during real-time lymphangiography as a potential replacement for ePLND

Personalised indocyanine-guided lymphadenectomy for prostate cancer: a randomised clinical trial

Objectives To study the safety and efficacy of a personalised indocyanine-guided pelvic lymph node dissection (PLND) against extended PLND (ePLND) during radical prostatectomy (RP).Patients and Methods Patients who were candidates for RP and lymphadenectomy, with intermediate- or high-risk prostate cancer (PCa) according to the National Comprehensive Cancer Network guidelines, were enrolled in this randomised clinical trial. Randomisation was made 1:1 to indocyanine green (ICG)-PLND (only ICG-stained LNs) or ePLND (obturator fossa, external, internal, and common iliac and presacral LNs). The primary endpoint was the complication rate within 3 months after RP. Secondary endpoints included: rate of major complications (Clavien-Dindo Grade III-IV), time to drainage removal, length of stay, percentage of patients classified as pN1, number of LNs removed, number of metastatic LNs, rate of patients with undetectable prostate-specific antigen (PSA), biochemical recurrence (BCR)-free survival, and rate of patients with androgen-deprivation therapy at 24 months.Results A total of 108 patients were included with a median follow-up of 16 months. In all, 54 were randomised to ICG-PLND and 54 to ePLND. The postoperative complication rate was higher in the ePLND (70%) vs the ICG-PLND group (32%) (P < 0.001). Differences between major complications in both groups were not statically significant (P = 0.7). The pN1 detection rate was higher in the ICG-PLND group (28%) vs the ePLND group (22%); however, this difference was not statistically significant (P = 0.7). The rate of undetectable PSA at 12 months was 83% in the ICG-PLND vs 76% in the ePLND group, which was not statistically significant. Additionally, there were no statistically significant differences in BCR-free survival between groups at the end of the analysis.Conclusions Personalised ICG-guided PLND is a promising technique to stage patients with intermediate- and high-risk PCa properly. It has shown a lower complication rate than ePLND with similar oncological outcomes at short-term follow-up

MP67-05 LAROSCOPIC RADICAL PROSTATECTOMY USING A REAL-TIME LYMPHANGIOGRAPHY WITH TRANSPERINEAL INJECTION OF INDOCYANINE GREEN: RESULTS FROM A PROSPECTIVE STUDY

INTRODUCTION AND OBJECTIVE: Current standard imaging procedures have limited ability to predict lymph node (LN) involvement in clinically localized prostate cancer (PCa) and extended pelvic lymph node dissection (ePLND) during radical prostatectomy (RP) remains the most accurate staging procedure. However, meticulous ePLND is time-consuming and associated with an increased risk of morbidity. In order to improve these aspects, sentinel LN mapping with different guided techniques has been proposed over the years. The primary aim of this study is to evaluate the effectiveness of indocyanine green (ICG)-guided ePLND to assess regional LN status in patients who underwent RP. Secondary objective is to evaluate the potential role of a selective ICG lymph node dissection (LND) in patients with 64 2 LN metastasis which according to the literature are those who may more benefit from ePLND. METHODS: Data about 226 consecutive patients underwent laparoscopic RP with ICG-guided ePLND at our Department were prospectively evaluated. A solution of 25 mg ICG in 5 ml sterile water was transperineally injected. PLND started with the ICG stained nodes followed by extended template. Primary outcome measures were sensitivity (S), negative predictive value (NPV) and likelihood ratio of a negative test (LRn) of ICG-guided procedure. To our knowledge this study shows data about the largest cohort of patients underwent ICG-guided ePLND. RESULTS: Overall, median age of patients was 64.8 years with a median PSA of 6.6 ng/ml. Extracapsular disease occurred in 50.9% of patients, Gleason score 65 8 was reported in 11.9% cases and positive surgical margins rate was 24.3%. Median number of nodes retrieved was 22 (IQR 16-27) and median number of ICG stained per patient nodes was 6 (IQR 4-9). Overall 4939 nodes were removed and 1599 (32.4%) were fluorescent in vivo. Node-positive disease was found in 58 (25.7%), of which 53 (91.4%) had some of the metastatic LNs stained by ICG, while 5 (8.6%) were false negative. Therefore 97.8% of the sample was properly classified by ICG-guided ePNLD (S: 91.4%, NPV: 97.1% and LRn: 8.6%). Considering 209 (92.5%) patients with 0, 1 or 2 metastatic LNs, 39 (18.7%) had a node-positive disease of which 34 (87.2%) had metastatic ICG stained LNs. Again, 97.6% were properly classified by ICG approach (S: 87.2%, NPV: 97.1% and LRn: 12.8%). These 39 node-positive patients had a total of 48 metastatic LNs and all except 9 (18.8%) were fluorescent in vivo (S: 81.2%). CONCLUSIONS: ICG guidance correctly stage 97% of cases. Furthermore, its high NPV will allow to avoid ePLND as soon as an accurate intraoperative analysis is available. Among those patients in whom the LND may have a potentially curative role, ICG alone would have lost only 9 metastatic LNs. This suggest that maybe there is a place for selective LND in patients with limited LN metastatic burden

Indocyanine green guidance improves the efficiency of extended pelvic lymph node dissection during laparoscopic radical prostatectomy

OBJECTIVES: To evaluate whether indocyanine green guidance can improve the quality of extended pelvic lymph node dissection in patients undergoing radical prostatectomy. METHODS: A total of 214 patients underwent laparoscopic radical prostatectomy with indocyanine green-guided lymph node dissection plus extended pelvic lymph node dissection. These patients (group A) were matched 1:1 for clinical risk groups according to the National Comprehensive Cancer Network classification with patients who underwent the same procedure without fluorescence guidance (group B). Biochemical recurrence was defined as two consecutive prostate-specific antigen rises of at least 0.2 ng/mL. The Kaplan-Meier method and Cox regression models were used to identify predictors of biochemical recurrence. RESULTS: The median number of retrieved nodes was significantly higher in group A (22 vs 14, P < 0.001). The rate of lymph node metastases was higher in group A (65.9% vs 34.1%, P = 0.01). Increasing the yield of lymph node dissection was independently and negatively correlated with the biochemical recurrence risk in both overall and pN-positive patients (hazard ratio 0.97, P = 0.03; and hazard ratio 0.95, P = 0.02). The 5-year biochemical recurrence-free survival rates were (75.8% vs 65.9, P = 0.09) and (54.1% vs 24.9%, P = 0.023) for group A and group B in the overall cohort and pN-positive cohort, respectively. CONCLUSION: Indocyanine green-guided lymph node dissection plus extended pelvic lymph node dissection improves identification of lymphatic drainage, resulting in a higher number of lymph nodes and retrieved lymph node metastases, and allowing a more accurate local staging and a prolonged biochemical recurrence-free survival