Impact of the COVID-19 Pandemic on Cancer Diagnosis in Madrid (Spain) Based on the RTMAD Tumor Registry (2019-2021).

The coronavirus disease 2019 (COVID-19) pandemic has caused a significant disruption to cancer diagnosis, treatment and prevention worldwide that could have serious consequences in the near future. We intend to evaluate the weight of this backlog on a community-wide scale in Madrid during the period 2020-2021, and whether a stage shift towards the advanced stage has occurred. Cancer diagnoses in the Madrid tumor registry (RTMAD) from 2019-2021 were evaluated. Absolute and percentage differences in annual volume and observed-to-expected (O/E) volume ratios were calculated. Standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) were calculated using the O/E ratio. The SIR for 2020-2021 compared to 2019 was 94.5% (95% CI 93.8-95.3), with unequal gender-specific cancer diagnosis recovery (88.5% for males and 102.1% for females). Most cancer types were underdiagnosed in 2020. The tendency worsened in 2021 for colorectal and prostate cancers (87.8%), but lung cancer recovered (102.1%) and breast cancer was over-diagnosed (114.4%) compared with reference pre-COVID-19 data. These changes have modified the ranking of the most frequent malignancies diagnosed in Madrid. Breast cancer has overtaken colorectal and prostate cancers, displaced to second and third position, respectively. Not only was colorectal cancer diagnosis affected more as a consequence of the COVID-19 pandemic but diagnosis of this malignancy at the advance stage also increased by 3.6% in 2020 and 4.2% in 2021 compared to the reference period of 2019. In summary, there is a large volume of undetected cancer in Madrid caused by the reduced access to care secondary to the COVID-19 pandemic, especially regarding colorectal and prostate cancer. Strategies are needed to recover the backlog of diagnoses and effectively treat these cases in the future and solve the negative impact that will be caused by the diagnostic delay. Analyzing the impact of new diagnoses suffered by each different malignancy and their recovery will help to understand how the future allocation of resources should look.

Hyperthermic Mitomycin C in Intermediate-risk Non-muscle-invasive Bladder Cancer: Results of the HIVEC-1 Trial.

BACKGROUND: Optimising therapeutic strategies of intermediate-risk non-muscle-invasive bladder cancer (IR-NMIBC) is needed. OBJECTIVE: To compare recurrence-free survival (RFS) with adjuvant intravesical mitomycin C (MMC) at normothermia or hyperthermia using the COMBAT bladder recirculation system at 43 °C for 30 and 60 min. DESIGN, SETTING, AND PARTICIPANTS: A prospective open-label, phase 3 randomised controlled trial (HIVEC-1) accrued across 13 centres between 2014 and 2020 in Spain. After complete transurethral resection of the bladder and immediate postoperative MMC instillation, patients with IR-NMIBC were randomised (1:1:1) to four weekly followed by three monthly 40-mg MMC instillations at normothermia (control; n = 106), 43 °C for 30 min (n = 107), or 43 °C for 60 min (n = 106) were investigated. Therapeutic compliance was defined as four or more instillations. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was RFS at 24 mo in the intention-to-treat (ITT) and per-protocol (PP) populations. The secondary outcomes included progression-free survival at 24 mo, safety outcome measures, and changes in health-related quality of life. Log-rank, Fisher, χ2, and analysis of variance tests were used. RESULTS AND LIMITATIONS: The ITT 24-mo RFS was 77% for control, 82% for 43 °C-30 min, and 80% for 43 °C-60 min (p = 0.6). The PP 24-mo RFS was 77% for control, 83% for 43 °C-30 min, and 80% for 43 °C-60 min (p = 0.59). Six patients progressed to muscle-invasive disease in the ITT population (four in the control, 43 °C-30 min, and 43 °C-60 min groups each) and four in the PP population (all controls). Serious adverse events occurred in 26 patients (8.1%), and we were unable to demonstrate a difference between groups (p = 0.5). Adverse events, mainly dysuria and spasms, occurred in 124 patients (33% in control, 35% in 43 °C-30 min, and 48% in 43 °C-60 min; p = 0.05). The total International Prostate Symptom Score worsened by 1.2 ±â€¯7.3 points, similarly across groups (p = 0.29). The Functional Assessment of Cancer Therapy-Bladder domains and indexes showed no significant change. CONCLUSIONS: Four-month adjuvant hyperthermic MMC using the COMBAT system for 30 and 60 min in IR-NMIBC is well tolerated, but we did not find it to be superior to normothermic MMC at 24 mo. PATIENT SUMMARY: We were unable to demonstrate the effectiveness of hyperthermia using the COMBAT system in intermediate-risk non-muscle-invasive bladder cancer. Further evaluation of long-term recurrence and progression, and maintenance regimens appears mandatory.

Assessment of the Grades of Vesicoureteral Reflux in Stented Ureters: An Experimental Study.

INTRODUCTION: The aim of this experimental study is to assess, in a porcine model, the onset and grades of vesicoureteral reflux associated with ureteral stents. METHODS: Twenty-four female porcine models were used. A 4.7-Fr ureteral stent was placed in all right ureters and kept in place for 6 weeks. Follow-ups were performed on weeks 1, 3, 6, and 12. Ultrasonography, cystoscopy, and fluoroscopy were used to analyze grade of hydronephrosis, presence and grade of vesicoureteral reflux, bacteriuria, and macroscopic changes of the ureteral orifices. Vesicoureteral reflux was classified using a modification of the International Reflux Study Committee grades. RESULTS: 91.7% animals present vesicoureteral reflux, 89.5% grade IA, 3.5% grade IB, and 7% grade II. There is a significant increase in reflux during follow-ups at 3 and 6 weeks, whereas 6 weeks after removal, 26.3% of the ureters still present vesicoureteral reflux. Hydronephrosis and macroscopic changes of the ureteral orifice increase significantly with stenting, but there is no significant association between them and vesicoureteral reflux; the relationship between bacteriuria and the presence of vesicoureteral reflux is not significant either. CONCLUSION: Vesicoureteral reflux caused by ureteral stents in an animal model is mostly low grade and mainly affects the distal ureter.

Ureteroiliac Fistula: Bleeding of Unknown Origin-Case Report and Review of the Literature.

Background: Ureteroiliac fistula is a rare cause of gross hematuria and lateralizing flank pain. Risk factors include previous pelvic surgery, pelvic radiotherapy, or chronic ureteral stentings. Diagnosis is challenging and requires arteriography and ureteroscopy. Management ranges from open surgery to minimally invasive means such as the use of an endovascular stent. Case Report: A 62-year-old man with postradical cystoprostatectomy and cutaneous ureterostomy presented an intermittent gross hematuria with anemia that required blood transfusions. Some CT arteriographies were performed but none of them could identify the bleeding origin. Therefore, a flexible ureteroscopy was performed that showed a left ureteroiliac fistula. Subsequently, an endovascular stent was placed in the left common iliac without complications. Conclusion: The ureteroiliac fistula is a life-threatening condition. CT arteriography or ureteroscopy might help in the diagnosis but the sensitivity is ∼64%. Arteriography with endovascular stenting is a viable and safe option. However, because of its rarity, long-term durable benefits still need to be documented.

[Video endoscopic inguinal lymphadenectomy in penile cancer: Systematic review.] / Linfadenectomía inguinal videoendoscópica en cáncer de pene: revisión sistemática.

OBJECTIVES: Penile cancer is not very frequent. To control the disease oncologically, we must perform inguinal lymphadenectomy in cases of high-risk histology, poor prognosis and palpable lymph nodes. The open inguinal lymphadenectomy has a high rate of morbidity. Consequently, this systematic review intends to summarize the published literature regarding the oncologic and post-surgery outcomes in video-endoscopic inguinal lymphadenectomy (VEIL). METHODS: A literature search has conducted through Pubmed, EMBASE and Cochrane library for English and Spanish articles. RESULTS: Our literature search identified 12 articles. In total, 161 patients have been subjected to 226 VEIL. Their average age was 55.66 years. In the case of open inguinal lymphadenectomy, 90 patients have been subjected to 106 operations. The rate of cutaneous complications was 6% for VEIL and 55.6% for open lymphadenectomy. The rate of lymphatic complications was very similar in both types of lymphadenectomy. The average number of lymph nodes obtained was 9.12 for VEIL and 7.02 lymph nodes for the open approach. CONCLUSION: Video-endoscopic inguinal lymphadenectomy contributes to less morbidity with a lower- rate of cutaneous complications and less severity. Furthermore, VEIL gives lower hospital stay without changing in initial oncologic outcomes. Although we need longer series to stablish the oncologic long-term results.

OBJETIVO: El cáncer de pene es una entidad poco frecuente. Para realizar un buen control oncológico, se recomienda la realización de linfadenectomía inguinal en casos de factores de riesgo de mal pronóstico, grado histológico alto o ganglios palpables o positivos. La linfadenectomía inguinal abierta presenta una alta tasa de morbilidad, por lo que en esta revisión se pretende resumir la literatura publicada en cuanto a los resultados oncológicos y postquirúrgicos en la linfadenectomía inguinal videoendoscópica (VEIL).MATERIAL Y MÉTODOS: Se realiza revisión sistemática de la literatura obtenida en "Pubmed", "EMBASE" y Cochrane library para artículos en inglés y español. RESULTADOS: Se han analizado un total de 12 artículos, que globalmente incluyen a 161 pacientes con 226 VEIL y una edad media de 55,66 años y 90 pacientes a los que se les ha realizado 106 linfadenectomías abiertas. En el caso del VEIL se han presentado 6% de complicaciones cutáneas y del 55,6% en el caso de la vía abierta. En cuanto a las complicaciones linfáticas, no hay diferencias significativas. La media de ganglios extraídos en el caso de VEIL de 9,12 ganglios y de 7,09 ganglios en abordaje abierto. CCONCLUSIONES: La linfadenectomía inguinal videoendoscópica aporta una menor morbilidad, con una menor tasa de complicaciones cutáneas, y de menor gravedad. Asimismo, aporta menor estancia hospitalaria, sin afectación de los resultados oncológicos iniciales. Aunque se necesitan series con mayor tiempo de seguimiento para valoración de resultados oncológicos a largo plazo.

Evaluation of a New Design of Antireflux-biodegradable Ureteral Stent in Animal Model.

OBJECTIVE: To determine the effects in urinary tract of a new antireflux-biodegradable ureteral stent. MATERIALS AND METHODS: Thirty six ureters belonging to 24 pigs were used. The study began with endoscopic, nephrosonographic, and fluoroscopic assessments. Three study groups of ureters (n = 12) were then specified. In group I, a biodegradable antireflux ureteral stent (BDG-ARS) was inserted in the right ureter of 12 pigs. Group II comprised the left ureter of the same animals, in which a double-pigtail stent was placed for 6 weeks. Group III ureters, belonging to 12 additional animals, were subjected to a ureteropelvic junction obstruction model that was then treated by endopyelotomy and stenting with BDG-ARS. Follow-ups were performed at 3-6 weeks and at 5 months. RESULTS: None of the ureters receiving the BDG-ARS showed any evidence of vesicoureteral reflux (VUR). BDG-ARS degradation took place in a controlled and predictable fashion from the third to the sixth weeks, and no obstructive fragments appeared. No differences were found between groups I and II regarding passive ureteral dilation, but significant differences were found regarding VUR and ureteral orifice damage. BDG-ARS always maintained distal ureteral peristalsis. BDG-ARS in group III showed a 50% positive urine culture rate and a 16.6% migration rate in both BDG-ARS groups. CONCLUSION: BDG-ARS avoided VUR and bladder trigone irritation. In addition, this polymer combination and stent-braided design achieved a consistent biodegradation rate with no obstructive fragments and with uniform degradation between the third and the sixth weeks. Consequently, morbidity associated with ureteral stents might be reduced.

Outpatient holmium laser treatment for recurrent low-grade superficial bladder cancer under local anesthesia.

BACKGROUND: The aim of this paper is to analyze the results of a prospective study conducted on a cohort of patients undergoing outpatient holmium laser fulguration. The "gold standard" treatment of superficial bladder cancer is transurethral resection, although in recent years improvements in laser technology and endoscopy equipment have allowed further therapeutic alternatives. METHODS: This is a descriptive study of a cohort of 37 patients with low-risk recurrent superficial bladder cancer undergoing holmium laser fulguration after bladder instillation of local anesthesia. The study included patients with a history of low-risk primary superficial bladder cancer with papillary tumor recurrence, tumor size ≤10 mm, fewer than 5 tumors, absence of carcinoma in situ, negative cytology, no coagulation disorders and no local anesthesia allergies. Demographic variables, previous history of transurethral resection, safety and oncological results after fulguration were analyzed using the SPSS software. Statistical analyses include calculating mean and frequency, and Kaplan-Meier curve for recurrence. RESULTS: Mean age of the patients was 69.2 years with 86.5% being male. The number of tumors was 1.5±0.8 and the overall average size of 5.5±2.7 mm. The mean duration of the endoscopic procedure was 12±4.3 minutes. Hundred percent of patients had scores on the Visual Analogue Scale ≤3. There was only one case of hematuria, who required hospitalization. After a median follow-up period of 13 months, there was a 35.1% recurrence rate with one case of tumor progression. CONCLUSIONS: Holmium laser treatment of recurrent low-risk superficial bladder tumor is a safe and effective alternative, but long-term clinical trials are necessary to increase the current scientific evidence base.

[Effects of preventive double-J stent placement in ureteral obstruction treatment with metal stents on animal model]. / EFECTOS DE LA COLOCACIÓN PREVENTIVA DE UN CATÉTER URETERAL JJ DURANTE EL TRATAMIENTO DE LA OBSTRUCCIÓN URETERAL CON STENTS METÁLICOS EN MODELO ANIMAL.

OBJECTIVES: The purpose of this experimental study is to assess the additive effects of temporary JJ stent placement together with metal stents (MS) in the treatment obstructive uropathy, in order to reduce urothelial hyperplasia formation. METHODS: Twenty-four pigs were included, and an experimental model of obstructive uropathy was created. Six weeks after obstructive uropathy model induction, ureteral obstruction was confirmed using ultrasonography, ureteropyelography and endoluminal ultrasound. Afterwards, animals were randomly distributed into 2 groups. Group I underwent covered MS placement and JJ ureteral stenting for 3 weeks. Animals in Group II received the same MS without simultaneous JJ stenting. The follow-up was at 3 weeks and at 6 months. RESULTS: Incidence of urothelial hyperplasia was higher in Group I than Group II, but without statically significant differences. On the other hand, Group II showed a significantly higher degree of obstruction severity due to hyperplasia. The migration rate in both groups was 33.3% at the end of the study. Significant differences were shown on animals showing urinary tract infection (UTI) and hyperplasia against those with hyperplasia but no infection. There was a high rate of correlation between UTI and obstructive urothelial hyperplasia. CONCLUSIONS: Placement of JJ ureteral catheter does not inhibit urothelial hyperplasia associated with placement of metal mesh stents, although it significantly reduces its obstructive severity in long-term follow-up. Urinary tract infection is directly related to the development and magnitude of the urothelial hyperplasia.

Seminal vesicle biopsies: an useful staging procedure-exposure of seminal vesicle biopsies protocol and review of the literature.

BACKGROUND AND OBJECTIVES: Although new MRI techniques have a high sensitivity but varying specificity with regard to diagnosing the seminal vesicle invasion (SVI) of prostate cancer, the low availability and high cost involved demands incorporating an inexpensive and accessible technique that might support adequate staging. Currently, uniformity does not exist with regard to the indication criteria of seminal vesicle biopsies (SVBs). Our objective is to analyse the protocol of SVBs at Morales Meseguer Hospital and conduct an exhaustive review of the literature in this field. METHODS AND MATERIALS: SVBs were performed in patients who were amenable to a curative treatment and who showed at least one of the following indication criteria: prostate-specific antigen greater than or equal to 15 ng/ml, a prostate cancer nodule in the base of the prostate, or ultrasound abnormalities suggestive of vesicular involvement. SVBs were performed in 70 patients. RESULTS: These results revealed a rate of SVI of 15.7 and 25.58 % among all patients and patients diagnosed with prostate cancer, respectively. All biopsied patients who tested positive for the three indication criteria had T3b prostate cancer. Patients with a prostate cancer that altered the base of the prostate according to either digital rectal examination or ultrasound showed a T3b rate of 53.8 %. CONCLUSIONS: SVBs should be considered a complementary procedure for prostate cancer staging because provide important information and it is easy, inexpensive and has few complications.

[Spontaneous pneumopyelography for enteroureteral fistula]. / Neumopielografía espontánea por fistula enteroureteral.

OBJECTIVES: To report one outstanding case of fever and flank pain with the radiologic finding of air outlining the whole left upper urinary tract (pneumopyelography). METHODS: The patient subject of this case had a history of gynaecologic surgery five years before presentation and subsequent diverticulitis one year later requiring discharge colostomy followed by reconstruction 7 months later. We performed a MEDLINE search using the terms "entero urinary fistula". Most papers are case reports with reviews of the diagnostic and therapeutic procedures, as well as the etiologic factors. RESULTS: Radiologic tests are key to make this finding clear and to determine its location. In our patient, once the acute picture was controlled and the confirmatory diagnosis was made by means of barium enema, we proceeded with left simple nephrectomy and lower intestine resection including the fistula tract. Real incidence is unknown; there is a female predominance in the published cases. Depending on the casual mechanism, they may be classified as spontaneous or traumatic. Most of them are secondary to bowel inflammatory diseases like diverticulitis, Crohn's disease, tumors, ulcers,... They can also be secondary to impacted urinary lithiasis, urothelial tumor, endoscopic procedures, etc. Other cases are secondary to previous surgery and radiotherapy. CONCLUSIONS: The finding of pneumopyelogram should prompt and interventional algorithm including radiologic tests and other examinations to allow a proper diagnosis and to perform an effective treatment.

[Significance and management of testicular microlithiasis]. / Significado y manejo de la microlitiasis testiculares.

OBJECTIVES: Testicular microlithiasis is an infrequent urologic diagnosis of non well-known etiology; it has been observed in patients with infertility, testicular atrophy, chromosomopathies, etc., and it had been considered as a benign non progressive disease for a long time. Recent reports have shown its occasional association with malignant tumors. We look for evidences about the significance of testicular microlithiasis and its relationship with gonadal pathologies. METHODS: We perform an electronic bibliographic search in both The Cochrane library and MEDLINE. We performed a manual search in the AUA Update Series, Current Opinion Urology, and bibliographic citations from selected studies. We report one case of bilateral testicular microlithiasis studied at our center which is illustrative. Most published articles are case reports with bibliographic review. RESULTS: The real incidence is unknown, although depending on the series varies from 0.04% in autopsies to 18.1% in testicular ultrasound series. It is more frequent in chryptorchidism, infertility, varicocele, testicular torsion, brain and sympathetic nervous system calcifications, pseudohermaphroditism, Down's syndrome, Klinefelter and Carney, cystic fibrosis, germ cell tumors and carcinoma in situ. There are series which report testicular tumor up to 46% of patients with testicular microlithiasis. It has been described tumor development during follow-up of testicular microlithiasis between 15 months and 11 years, so that it is believed to be a predisposing factor, a possible indirect indicator of premalignant disease, or a tumor marker. It has been also described in normal testicles. CONCLUSIONS: The presence of testicular microlithiasis and its association to both benign diseases and malignant tumors makes a careful evaluation and follow-up necessary, mainly in patients with chryptorchidism, infertility, testicular atrophy, and contralateral testicular tumor; it is recommended testicular ultrasound each semester/year, physical examination, and testicular markers determination; to proceed with testicular biopsy is reasonable in patients of high risk (focal unilateral microlithiasis without mass, or the aforementioned chryptorchidism, infertility, testicular atrophy, and testicular tumor).

[Neurogenic bladder caused by hemorrhagic necrotizing myelitis]. / Vejiga neurógena por mielitis necrotizante hemorrágica.

OBJECTIVES: To report one case of flank pain irradiated to lower extremities, progressive paresthesias and functional difficulty leading to functional impotence of the lower limbs, and difficult voiding. METHODS: Neurologic physical examination showed abolished osteotendinous reflexes, indifferent plantar, L1 hypoesthesia, L3 anesthesia, and lower limbs hypotony. Multiple complementary exams were performed to get the final diagnosis of hemorrhagic necrotizing myelitis by MRI, after differential diagnosis with cavernous haemangioma. We performed a bibliographic search in Pub-Med (MEDLINE) using the terms "bladder, neurogenic (MESH) and myelitis (MESH)". Most publications correspond to case reports and prospective studies of cases of acute myelitis of different etiologies (arteriovenous malformations, multiple sclerosis, neoplasia, sarcoidosis, HIV infection, spinal cord compression,...) reviewing the diagnostic and therapeutic procedures. RESULTS: Neurologic examination, imaging studies and analytical determinations in cerebrospinal fluid (CSF) and blood were conclusive to confirm the level of the lesion and the most probable etiology in both the present case and those provided by the literature. Urodynamic study showed a neurologic bladder both at 4 and 24 months, being this the main sequel in our patient. The clinical repercussion derived from the level of the lesion improved in relation to walking and muscular balance, but the voiding condition persisted with bladder hyperreflexia and dyssynergia. CONCLUSIONS: The clinical picture alerts about spinal involvement. Radiological tests, supported by analysis, allow to identify the level of the lesion, and in many cases the cause. Bladder dysfunction is common in acute myelopathies, and urodynamic studies help to label the picture and manage it.

[Lower massive hematuria deferred by arteriovenous fistula following percutaneous nephrostomy]. / Hematuria masiva diferida baja por fistula arteriovenosa tras nefrostomía percutánea.

OBJECTIVES: To report one case of severe lower hematuria 48 hours after urinary diversion by percutaneous nephrostomy for obstructive uropathy. METHODS: The clinical picture, its severity, and previous procedure probably causing it made the study by arteriography essential to identify the existence of an arteriovenous fistula after stabilization of the acute anaemia; it was confirmed and selective embolization was undertaken with an optimal result. We performed a bibliographic search on Pub-Med (MEDLINE) using the terms "percutaneous nephrostomy", "complications", and "arteriovenous fistula". Most published papers are case reports and series of nephrostomies analyzing their complications and the management of them. RESULTS: Complications attributable to percutaneous nephrostomy are very rare varying from pneumothorax/hydrothorax, infection, perforation and injuries to neighbour organs, allergic reactions to contrasts, urinomas, to pictures of mild to severe hematuria due to vessel laceration and arteriovenous fistula, either high or through bladder. In the case we report as well as in those from the literature, initial treatment of hematuria was watchful waiting; only severity or persistence for more than 3-4 days should make to suspect the existence of arteriovenous fistula, and then arteriography is mandatory to obtain confirmation and if possible treat it by selective embolization; there are various materials to do it. Clinical repercussion was severe but thanks to radiological interventional techniques the case was solved with preservation of the renal unit. CONCLUSIONS: Complications after percutaneous nephrostomy are very rare, and the clinical picture alerts about the possibility of some of them. Radiological tests allow to identify the great majority of them and to perform an effective treatment.