Effect of Bacillus Calmette-Guerin Exposure on Prostate Cancer Detection Using Magnetic Resonance Imaging: A Cohort Study.

BACKGROUND: Granulomatous prostatitis is a medical condition that may mimic prostate cancer. PURPOSE: Granulomatous prostatitis resulting from BCG-exposure can confound the diagnosis of prostate cancer based on prostate imaging and data system (PI-RADS) classification observed on multiparametric prostate magnetic resonance imaging (mpMRI). STUDY TYPE, POPULATION, ASSESSMENT AND STATISTICAL TESTS: A cohort study was conducted, enrolling consecutive males at risk for prostate cancer who underwent an mpMRI-targeted prostate biopsy between February 2016 and August 2023. The focus of the study was on prior BCG-exposure as adjuvant treatment for non-muscle-invasive urothelial carcinoma within the 3 years prior the magnetic resonance imaging (MRI). Exclusion criteria were a prior androgen deprivation therapy, prostate surgery or radiation, and BCG-exposure occurring more than 3 years and less than 3 months before the MRI. Chi-square, logistic-regression, statistical association, and homogeneity tests were used. RESULTS: Total 712 patients, 899 biopsied lesions (218 PI-RADS 3, 521 PI-RADS 4 and 160 PI-RADS 5) and 20 patients with 30 lesions within the BCG-exposed cohort. Chi-square and logistic-regression tests showed an association between PI-RADS with malignancy and significant tumor (ST), considering PI-RADS3 as the reference (OR: 4.9 [95% CI, 3.4-7.1] for PI-RADS4 and OR: 21.7 [95% CI, 12.4-37.8] for PI-RADS5 for malignancy, and OR: 5.3 [95% CI, 3.2-8.7] for PI-RADS4 and OR: 16.5 [95% CI, 9.4-28.9] for PI-RADS5 regarding ST). A statistically significant negative association was demonstrated between malignancy and ST with respect to BCG-exposure (OR: 0.15 [95% CI, 0.06-0.39] and OR: 0.39 [95% CI, 0.15-1.0], respectively). Statistically significant risk-difference for malignancy in patients nonexposed to BCG regarding those exposed was 45% (61.6% vs. 16.7%) for PI-RADS4, and 68.5% (90.7% vs. 22.2%) and 42.7% (64.9% vs. 22.2%) concerning malignancy and ST for PI-RADS5, respectively. DATA CONCLUSIONS: Granulomatous prostate reaction caused by BCG-exposure acts as confounding factor for prostate MRI interpretation. The risk of malignancy and significant tumor on targeted biopsy to PI-RADS 3, 4 and 5 is notably lower in exposed patients.

Risk Factors for Revision After Artificial Urinary Sphincter Implantation in Male Patients With Stress Urinary Incontinence: A 10-Year Retrospective Study.

PURPOSE: To evaluate the preoperative and intraoperative risk factors for revision after artificial urinary sphincter (AUS) implantation in male patients with stress urinary incontinence (SUI). METHODS: A retrospective analysis from a prospectively maintained database was performed. Male patients, with moderate-tosevere SUI, undergoing AUS implantation were included. All patients underwent placement of AMS 800. Cause of revision, type of revision, and time to revision were recorded. Multivariable analyzes were performed using a logistic regression to investigate the risk factors. Competing risk analysis according to Fine-Gray model was used to study time to event data. RESULTS: A total of 70 patients were included. Revision surgery was performed in 22 of 70 patients (31.4%), after a median (interquartile range) time of 26.5 months (6.5-39.3 months). Overall, 19 of 22 repairs (86.4%) and 3 of 22 explants (13.6%) were recorded. Mechanical dysfunction, urethral erosion, urethral atrophy, and device infection were the causes of revision in 11 of 22 (50.0%), 6 of 22 (27.3%), 3 of 22 (13.6%), and 2 of 22 patients (9.1%). Vesicourethral anastomosis stenosis (P=0.02), urethral cuff size of 3.5 cm (P=0.029), and dual implantation (P=0.048) were independent predictors for revision. Vesicourethral anastomosis stenosis (P=0.01) and urethral cuff size of 3.5 cm (P=0.029) predicted a lower survival of the AUS. CONCLUSION: The vesicourethral anastomosis stenosis, urethral cuff size of 3.5 cm, and dual implantation are independent predictors for revision after AUS implantation. However, only the vesicourethral anastomosis stenosis and urethral cuff size of 3.5 cm predict a lower survival of AUS.

[Local and systhemic immunotherapy for bladder cáncer: from bench to bedside.] / Inmunoterapia local y sistémica en cáncer de vejiga: bases moleculares y traslación clínica.

Therapeutic approaches for treatment of urothelial transitional cell carcinoma based on immune system modulation, as well as the contribution of intravesica Bacillus de Calmette-Guérin (BCG) and the recentin corporation of checkpoint inhibitors had found irrefutable proofs of concept for the indication of antitumoral immunontherapy in such tumors. Its extension and development at the present time covers all the locations of the wide spectrum of presentation and evolution of these tumors. Nowadays, apart for the low grade non muscle-invasive tumors, we are facingan unpredictable development of antitumoral immunotherapy in bladder cancer not only as an option in the primary treatment, but also in other scenarios such asnon-responders when it comes to BCG, or the situation of ineligibility for systemic chemotherapy indication. The main objective of this review article is trying to translate the current basic mechanisms involved in different phases of transitional cell carcinomas antitumoral response, regardless of whether they are muscle-invasive or not, and to establish the rationale for their therapeutic intravesical or systemic administration. The role of the interactions established between urothelial tumor cells and the cellular and molecular elements of the immune system of patients is described, incorporating the relevant and recent advances in immunobiology and the molecular characterization of these tumors thatwill undoubtedly introduce far-reaching modifications intherapeutic regimes that will contrast with the traditional options available. Investigational lines that are already active in the clinical research phase with BCG and, checkpoints inhibitors ofthe immune response are also analyzed, high lighting theneed to find predictive response markers as a real option for treatments personalization. The approach to the knowledge of the individual reactivity of the immune system of each patient as a determining factor to achieve it is proposed.

Los abordajes terapéuticos para los carcinomas de células transicionales del urotelio desarrollados en torno a la modulación del sistema inmune encuentran, en la contribución del Bacillus de Calmettey Guérin (BCG) intravesical y más reciente la de los fármacos inhibidores de los puntos de control de la respuesta inmunitaria, indiscutibles pruebas de concepto de la indicación inmunoterapia antitumoral. Su extensión y desarrollo en el momento actual abarca todas las localizaciones del amplio espectro de presentación y evolución de estos tumores. A excepción, por el momento, de los tumores no-músculo infiltrantes debajo grado, acudimos a un desarrollo impredecible de la inmunoterapia antitumoral en el cáncer de vejiga no solo como opción en el tratamiento primario de alguno de ellos sino también en pacientes no-respondedores cuando se trata del BCG, de la quimioterapia sistémicao la situación de no-elegibilidad para su indicación. El objetivo de este artículo de revisión es intentar trasladar los mecanismos básicos actuales implicados en las distintas fases de la respuesta antitumoral de los carcinomas de células transicionales con independencia de que sean o no músculo infiltrantes y establecer los fundamentos para su traslación terapéutica por vía intravesical o sistémica. Se describe el papel de las interacciones que se establecen entre las células tumorales uroteliales y los elementos celulares y moleculares del sistema inmune de los pacientes incorporando los relevantes y recientes avances de la inmunobiológica y la caracterización molecular de estos tumores que sin duda introducirán modificaciones de alcance en su evolución y tratamiento que contrastaran con las opciones hasta hace poco tiempo disponibles. También se analizan las líneas de futuro ya activas en fase de investigación clínica con BCG y con inhibidores de los puntos de control de la respuesta inmunitaria destacando la necesidad de avanzar en la búsqueda de marcadores predictivos de respuesta como opción real para la personalización de los tratamientos planteando la aproximación al conocimiento de la reactividad individual del sistema inmune de cada paciente como factor determinante para poder alcanzarla.

[Laparoscopic Boari Flap ureteral reimplantation.] / Reimplante ureteral laparoscópico con Flap de Boari.

OBJECTIVES: To report our initial experience with laparoscopic Boari flap ureteral reimplantation and to review the main technical elements in ureteral reconstructive surgery. METHODS: In a 10-year period we performed 23 laparoscopic ureteral reimplantations. Three cases required a Boari flap. Two patients presented ureteral stenosis above the iliac vessels and the third one a urothelial tumor of the pelvic ureter. RESULTS: Two cases were completed laparoscopically; the third one was electively converted to open surgery to avoid prolonged OR time. Mean operative time was 276 minutes (270-290 min). There were no intraoperative complications. Mean hospital stay was 6.6 days. One patient presented postoperative UTI (Clavien 2). One patient developed with history of sever arteriopathy and aortorenal by pass developed ureteral stenosis proximal to the ureteral reimplantation eight months after the operation. CONCLUSIONS: Laparoscopic Boari flap ureteral reimplantation is an affective technique for ureteral reconstruction, safe and reproducible, reserved for cases of ureteral pathology in which the distance to bridge between the bladder and the ureteral stump is long.

Underlying mechanisms involved in progesterone-induced relaxation to the pig bladder neck.

Progesterone increases bladder capacity and improves the bladder compliance by its relaxant action on the detrusor. A poor information, however, exists concerning to the role of this steroid hormone on the bladder outflow region contractility. This study investigates the progesterone-induced action on the smooth muscle tension of the pig bladder neck. To this aim, urothelium-denuded bladder neck strips were mounted in myographs for isometric force recordings and for simultaneous measurements of intracellular Ca(2+) concentration ([Ca(2+)]i) and tension. On phenylephrine (PhE)-precontracted strips, progesterone produced concentration-dependent relaxations only at high pharmacological concentrations. The blockade of progesterone receptors, nitric oxide (NO) synthase, guanylyl cyclase, large conductance Ca(2+)-activated K(+) (BKCa) or ATP-dependent K(+) (KATP) channels reduced the progesterone relaxations. The presence of the urothelium and the inhibition of cyclooxygenase (COX), intermediate- and small-conductance Ca(2+)-activated K(+) channels failed to modify these responses. In Ca(2+)-free potassium rich physiological saline solution, progesterone inhibited the contraction to CaCl2 and to the L-type voltage-operated Ca(2+) (VOC) channel activator BAY-K 8644. Relaxation induced by progesterone was accompanied by simultaneous decreases in smooth muscle [Ca(2+)]i. These results suggest that progesterone promotes relaxation of pig bladder neck through smooth muscle progesterone receptors via cGMP/NO pathway and involving the activation of BKCa and KATP channels and inhibition of the extracellular Ca(2+) entry through L-type VOC channels.

[The basics of laser and its application in urology]. / Fundamentos del láser y su aplicación en urología.

A laser, light amplification by stimulated emission of radiation, is a device able to transform other energies into electromagnetic radiation with emission of light beams of different wavelengths. They amplify the light and produce coherent light beams, the frequency of which varies from infrared to X ray. Stimulated emission, the process laser is based on, was described by A. Einstein in 1917, but it was not until the decade of the '60s when the first laser process was observed in a ruby crystal. Depending on the environment they use, lasers may be named as solid-state, gas, semiconductors or liquid. The possibility of uses for laser is almost unlimited, becoming a very valuable tool in biomedical sciences thanks to the various effects they produce when interacting with tissues (photovaporization, photodisruption, photocoagulation or photostimulation). For this reason, today, the use of lasers in the field of urology offers a wide range of possibilities, going from surgery for the treatment of obstruction, such as the fragmentation of a urinary stone or resection/ablation of prostatic tissue, to reconstructive surgery, such as tissue welding in vasovasostomy or urethral stenosis repair.

[Fuzzy logic in urology. How to reason in inaccurate terms]. / La lógica borrosa en urología. Cómo razonar con términos imprecisos.

The Occidental thinking is basically binary, based on opposites. The classic logic constitutes a systematization of these thinking. The methods of pure sciences such as physics are based on systematic measurement, analysis and synthesis. Nature is described by deterministic differential equations this way. Medical knowledge does not adjust well to deterministic equations of physics so that probability methods are employed. However, this method is not free of problems, both theoretical and practical, so that it is not often possible even to know with certainty the probabilities of most events. On the other hand, the application of binary logic to medicine in general, and to urology particularly, finds serious difficulties such as the imprecise character of the definition of most diseases and the uncertainty associated with most medical acts. These are responsible for the fact that many medical recommendations are made using a literary language which is inaccurate, inconsistent and incoherent. The blurred logic is a way of reasoning coherently using inaccurate concepts. This logic was proposed by Lofti Zadeh in 1965 and it is based in two principles: the theory of blurred conjuncts and the use of blurred rules. A blurred conjunct is one the elements of which have a degree of belonging between 0 and 1. Each blurred conjunct is associated with an inaccurate property or linguistic variable. Blurred rules use the principles of classic logic adapted to blurred conjuncts taking the degree of belonging of each element to the blurred conjunct of reference as the value of truth. Blurred logic allows to do coherent urologic recommendations (i.e. what patient is the performance of PSA indicated in?, what to do in the face of an elevated PSA?), or to perform diagnosis adapted to the uncertainty of diagnostic tests (e.g. data obtained from pressure flow studies in females).

[New urodynamic data of sensory urgency in women]. / Nuevos datos urodinámicos de la urgencia sensorial en la mujer.

OBJECTIVES: Irritative bladder symptoms are common in females. Besides, micturition disorders are occasionally associated. Sensory urgency is one of the syndromes that include the symptoms. This entity is a urodynamic condition defined by the presence of pain or urgency during the filling phase without associated involuntary detrusor contractions. Although it is well defined urodynamically, the corresponding nosological entity is unknown. The objective of this study is to check if it has any relationship with the capability of the abdominal press to participate during micturition. METHODS: We perform a transversal study comparing a group of 25 females (mean age 50.2 yr.) with the diagnosis of sensory urgency and a group of 48 patients paired by age. Urodynamic data from both groups were reviewed, and the existence of significant differences was determined for flowmetry, bladder capacity (cystometry), and participation of the abdominal press during voiding (voiding flow-detrusor pressure test). RESULTS: Patients with sensory urgency showed significantly lower maximum and mean flow rates than controls. Bladder capacity was similar in both groups, but bladder capacity at first desire to void was significantly lower in the sensory urgency group. No significant differences were observed between the groups on participation of the abdominal press. However, if the comparison was performed between the subgroup of patients with sensory urgency who also referred suprapubic pain during filling and controls, then there was a significantly higher participation of the abdominal press during voiding in this group. CONCLUSIONS: Data from this study are compatible with the hypothesis that sensory urgency is associated with bladder contractile capacity alterations. This association would be more evident in the group of patients in which sensory urgency is accompanied by hypogastric pain during filling, which could constitute a subgroup with higher progression risk.