Influence of androgen deprivation therapy on the severity of COVID-19 in prostate cancer patients.

BACKGROUND: The TMPRSS2 protein has been involved in severe acute respiratory syndrome caused by coronavirus 2 (SARS-CoV-2). The production is regulated by the androgen receptor (AR). It is speculated that androgen deprivation therapy (ADT) may protect patients affected by prostate cancer (PC) from SARS-CoV-2 infection. METHODS: This is a retrospective study of patients treated for COVID-19 in our institution who had a previous diagnosis of PC. We analyzed the influence of exposure of ADT on the presence of severe course of COVID-19. RESULTS: A total of 2280 patients were treated in our center for COVID-19 with a worse course of disease in males (higher rates of hospitalization, intense care unit [ICU] admission, and death). Out of 1349 subjects registered in our PC database, 156 were on ADT and 1193 were not. Out of those, 61 (4.52%) PC patients suffered from COVID-19, 11 (18.0%) belonged to the ADT group, and 50 (82.0%) to the non-ADT group. Regarding the influence of ADT on the course of the disease, statistically significant differences were found neither in the death rate (27.3% vs. 34%; p = 0.481), nor in the presence of severe COVID-19: need for intubation or ICU admission (0% vs. 6.3%; p = 0.561) and need for corticoid treatment, interferon beta, or tocilizumab (60% vs. 34.7%; p = 0.128). Multivariate analysis adjusted for clinically relevant comorbidities did not find that ADT was a protective factor for worse clinical evolution (risk ratio [RR] 1.08; 95% confidence interval [CI], 0.64-1.83; p = 0.77) or death (RR, 0.67; 95% CI, 0.26-1.74; p = 0.41). CONCLUSIONS: Our study confirms that COVID-19 is more severe in men. However, the use of ADT in patients with PC was not shown to prevent the risk of severe COVID-19.

Prostate cancer adverse pathology reclassification in patients undergoing active surveillance in a long-term follow-up series.

BACKGROUND: Active surveillance (AS) has become a valid option for patients with a very low risk of prostate cancer (PC) with a widespread application. There are still a few series, with a medium follow-up longer than 5 years, reporting data on pathological upgrading. The objective is to evaluate the changes in surveillance biopsies of patients with low-risk PC in a long-term follow-up and determine if a longer stay in AS could involve worse pathological findings. MATERIALS AND METHODS: A retrospective analysis of our institutional database of patients with PC undergoing AS during 2004 to 2018 was performed. The inclusion criteria were prostate-specific antigen (PSA) ≤ 10 ng/mL, Gleason grade 1 and T1c/T2a. Patients were assessed by serum PSA level and digital rectal examination at 6-month intervals. Transrectal ultrasound-guided prostate biopsies were performed during the first year of follow-up, and every 2 or 3 years thereafter. The pathology details of biopsies were analyzed and compared with the current series on AS. RESULTS: Three-hundred nineteen patients undergoing AS were evaluated with a median follow-up of 5.3 years and a mean age of 67.4 years. Sixty-three patients did not meet all the criteria to be considered low-risk PC but were included in the analysis. Overall, 128 patients (40.1%) underwent active treatment (84.7% of them due to pathological progression in surveillance biopsies). The proportion of patients with a reported upgrading ranged between 19.4% and 35.3%, although only the fourth biopsy showed an upgrading proportion of over 30%. Limitations include the retrospective design of the study and the existence of different protocols between other cohorts that make it difficult to compare their results. CONCLUSIONS: For patients who remained in surveillance the percentage of upgrading increased slightly with the time, being more frequent after the third-surveillance biopsy. These findings support the importance of extending surveillance biopsies for patients who remain candidates for curative treatment.

A comprehensive analysis of cost of an active surveillance cohort compared to radical prostatectomy as primary treatment for prostate cancer.

INTRODUCTION: Active surveillance (AS) seems to be a cost-effective strategy. However, most publications are based on simulation models of theoretical cohorts, and long-term implications are not usually considered. OBJECTIVE: To assess the real cost differences of two cohorts of men with low-risk prostate cancer (PCa) treated with AS or laparoscopic radical prostatectomy (LRP) in a public health system. MATERIALS AND METHODS: Patients diagnosed from 2005 to 2009 were included in an AS program (Group 1) or treated with LRP at diagnosis (Group 2), with a minimum follow-up of 5 years. Actual costs for each patient were calculated on an individual basis: Group 1: semiannual PSA measurements and repeat biopsies are scheduled every 1-3 years. Costs of outpatient clinic visits were calculated, as well as all tests required for monitoring or active treatment. Group 2: costs of the procedure, emergency visits, re-admissions and outpatient clinic visits were calculated, as well as costs of oncological salvage therapies or functional surgical procedures. RESULTS: Out of 151 men diagnosed with low-risk PC, 54 (35.8%) were included in an AS (Group 1) and 97 (64.2%) were submitted to LRP (Group 2). Mean follow-up for both groups was 6.5 years (SD 1.8) and 6.7 years (SD 1.4), respectively, p = 0.49. Group 1 had a total cost per patient of 2970.47€. Group 2 had a total cost per patient of 5694.06€. CONCLUSIONS: AS was associated with cost-saving over LRP. This cost reduction of AS in the management of low-risk PCa is based on the accounting of real costs of individual patients and confirms previously published estimation-based reports.

Feasibility of an implementation strategy for the integration of health promotion in routine primary care: a quantitative process evaluation.

BACKGROUND: Process evaluation is recommended to improve the understanding of underlying mechanisms related to clinicians, patients, context and intervention delivery that may impact on trial or program results, feasibility and transferability to practice. The aim of this study was to assess the feasibility of the Prescribe Healthy Life (PVS from the Spanish "Prescribe Vida Saludable") implementation strategy for enhancing the adoption and implementation of an evidence-based health promotion intervention in primary health care. METHODS: A descriptive study of 2-year implementation indicators for the PVS clinical intervention was conducted in four primary health care centers. A multifaceted collaborative modeling implementation strategy was developed to enhance the integration of a clinical intervention to promote healthy lifestyles into clinical practice. Process indicators were assessed for intervention reach, adoption, implementation, sustainability and their variability at center, practice, and patient levels. RESULTS: Mean rates of adoption by means of active collaboration among the three main professional categories (family physicians, nurses and administrative personnel) were 75% in all centers. Just over half of the patients that attended (n = 11650; 51.9%) were reached in terms of having their lifestyle habits assessed, while more than a third (33.7%; n = 7433) and almost 10% (n = 2175) received advice or a printed prescription for at least one lifestyle change, respectively. Only 3.7% of the target population received a repeat prescription. These process indicators significantly (p < 0.001) varied by center, lifestyle habit and patient characteristics. Sustainability of intervention components changed thorough the implementation period within centers. CONCLUSIONS: The implementation strategy used showed moderate-to-good performance on process indicators related to adoption, reach, and implementation of the evidence-based healthy lifestyle promotion intervention in the context of routine primary care. Sources of heterogeneity and instability in these indicators may improve our understanding of factors required to attain adequate program adoption and implementation through improved implementation strategies.

[Results of active surveillance in low and intermediate risk prostate cancer]. / Resultados de la vigilancia active en cancer de prostata de riesgo bajo e intermedio.

In this article we review the most significant published papers on active surveillance in prostate cancer and present the results of our case series. We used as main response variables the percentage of patients remaining in surveillance and the oncological results presented as global, cancer specific and metastasis free survivals. Globally, in published series 71.2% of patients included in active surveillance programs, 10-year overall survival is 68% in the series with longer follow up, and cancer-specific survival varies from 97% to 100%. In our series of 144 patients with median follow up of 3.2 years, 76.3% of the patients continue on surveillance. 24 patients (15.9%) stopped surveillance due to histological progression. 5 patients (21.3%) out of the 23 undergoing surgery presented unfavorable pathological criteria on prostatectomy specimen. No patient has died or developed metastases.

Second TURB, restaging TURB or repeat TURB in primary T1 non-muscle invasive bladder cancer: impact on prognosis?

PURPOSE: A re-transurethral resection of the bladder (re-TURB) is a well-established approach in managing non-muscle invasive bladder cancer (NMIBC) for various reasons: repeat-TURB is recommended for a macroscopically incomplete initial resection, restaging-TURB is required if the first resection was macroscopically complete but contained no detrusor muscle (DM) and second-TURB is advised for all completely resected T1-tumors with DM in the resection specimen. This study assessed the long-term outcomes after repeat-, second-, and restaging-TURB in T1-NMIBC patients. METHODS: Individual patient data with tumor characteristics of 1660 primary T1-patients (muscle-invasion at re-TURB omitted) diagnosed from 1990 to 2018 in 17 hospitals were analyzed. Time to recurrence, progression, death due to bladder cancer (BC), and all causes (OS) were visualized with cumulative incidence functions and analyzed by log-rank tests and multivariable Cox-regression models stratified by institution. RESULTS: Median follow-up was 45.3 (IQR 22.7-81.1) months. There were no differences in time to recurrence, progression, or OS between patients undergoing restaging (135 patients), second (644 patients), or repeat-TURB (84 patients), nor between patients who did or who did not undergo second or restaging-TURB. However, patients who underwent repeat-TURB had a shorter time to BC death compared to those who had second- or restaging-TURB (multivariable HR 3.58, P = 0.004). CONCLUSION: Prognosis did not significantly differ between patients who underwent restaging- or second-TURB. However, a worse prognosis in terms of death due to bladder cancer was found in patients who underwent repeat-TURB compared to second-TURB and restaging-TURB, highlighting the importance of separately evaluating different indications for re-TURB.

Weight of the resected specimen after transurethral resection as a new predictive variable for recurrence of non-muscle-invasive bladder tumour.

OBJECTIVE: To evaluate the role of the weight of the resected specimen after transurethral resection as a predictive factor for recurrence and progression of non-muscle-invasive bladder tumour (NMIBT). PATIENTS AND METHODS: The weight of the resected tumour was measured consecutively in 144 subjects who underwent transurethral resection of bladder tumours at our institution. The median (interquartile range [IQR]) follow-up was 58 (61.3) months. The probability of recurrence and progression at 1 and 5 years were calculated using the currently accepted variables. Thresholds for the specimen weight were determined according to percentiles and receiver-operating characteristic curves. RESULTS: The median (IQR) weight of the specimen was 6 (16) g. Multivariate analysis showed that the weight of the resected specimen was an independent predictive risk factor for recurrence at a threshold value of 6 g with a hazard ratio of 1.7 (95% confidence interval: 1.048-2.761) P = 0.03. Progression was not associated with the weight of the resected specimen. CONCLUSIONS: The weight of the resected specimen is a new variable for predicting the risk of recurrence of NMIBT. Tumours weighing >6 g, according to the present data, have a 1.7-fold higher likelihood of recurrence than those tumours that weigh less.

Feasibility and safety of hospital discharge 24 hours after laparoscopic radical prostatectomy.

OBJECTIVES: Minimally invasive techniques for the surgical treatment of prostate cancer have aimed to achieve the same functional and oncological outcomes of open surgery with a significant decrease in postoperative morbidity and a subsequent decreasing hospital stay. These improvements are important in the current economic context. Our aim was to evaluate the feasibility and safety of hospital discharge 24 h after laparoscopic radical prostatectomy (LRP). METHODS: A total of 266 consecutive patients with clinical diagnosis of localized prostate cancer consecutively treated with extraperitoneal LRP between May 2007 and December 2010 were analyzed. There were no exclusion criteria for the surgical procedure. Patients were discharged in less than 24 h only in the case of absence of medical complications, with drainage of less than 50 mL allowing its removal before discharge, normal oral feeding tolerance, no significant hematuria by bladder catheter and good functional recovery of the patient. All surgery-related complications that occurred within 90 days after surgery were recorded and were classified according to the modified Clavien scale. RESULTS: A total of 266 patients who underwent LRP were studied with a median follow-up of 34 months. 80 (30.1%) patients were discharged from the hospital in less than 24h. 89 (33.4%) patients were discharged within 48 h and 97 (36.5%) after 48 h.The mean hospital stay of the entire case series was 2.9 days (SD 3.08). The mean hospital stay of patients who were discharged after 48 h was 5,5 days (SD 3.94) Thirty-one patients (10.7%). experienced post-surgical complications. 25 (9.31%). of them were classified as Clavien I or II, and 6 (2.2%). Clavien III or IV. A total of 9 (3.3%) patients were readmitted. Of the group of patients who were discharged within 24h only one was readmitted due to hematuria. CONCLUSIONS: Extraperitoneal LRP is the standard treatment for localized prostate cancer in our institution. This treatment reliably and safely allows a hospital stay shorter than 24 h in a significant percentage of our patients.

Survival Differences in High-Risk Prostate Cancer by Age.

PURPOSE: Age is an established determining factor in survival in low-risk prostate cancer (PC), being this evidence weaker in high-risk tumors. Our aim is to evaluate the survival of patients with high-risk PC treated with curative intent and to identify differences across ages at diagnosis. METHODS: We did a retrospective analysis of patients with high-risk PC treated with surgery (RP) or radiotherapy (RDT) excluding N+ patients. We divided patients by age groups: < 60, 60-70, and > 70 years. We performed a comparative survival analysis. A multivariate analysis adjusted for clinically relevant variables and initial treatment received was performed. RESULTS: Of a total of 2383 patients, 378 met the selection criteria with a median follow-up of 8.9 years: 38 (10.1%) < 60 years, 175 (46.3%) between 60-70 years, and 165 (43.6%) >70 years. Initial treatment with surgery was predominant in the younger group (RP:63.2%, RDT:36.8%), and with radiotherapy in the older group (RP:17%, RDT:83%) (p = 0.001). In the survival analysis, significant differences were observed in overall survival, with better results for the younger group. However, these results were reversed in biochemical recurrence-free survival, with patients < 60 years presenting a higher rate of biochemical recurrence at 10 years. In the multivariate analysis, age behaved as an independent risk variable only for overall survival, with a HR of 2.8 in the group >70 years (95%CI: 1.22-6.5; p = 0.015). CONCLUSION: In our series, age appeared to be an independent prognostic factor for overall survival, with no differences in the rest of the survival rates.

Prognosis of Primary Papillary Ta Grade 3 Bladder Cancer in the Non-muscle-invasive Spectrum.

BACKGROUND: Ta grade 3 (G3) non-muscle-invasive bladder cancer (NMIBC) is a relatively rare diagnosis with an ambiguous character owing to the presence of an aggressive G3 component together with the lower malignant potential of the Ta component. The European Association of Urology (EAU) NMIBC guidelines recently changed the risk stratification for Ta G3 from high risk to intermediate, high, or very high risk. However, prognostic studies on Ta G3 carcinomas are limited and inconclusive. OBJECTIVE: To evaluate the prognostic value of categorizing Ta G3 compared to Ta G2 and T1 G3 carcinomas. DESIGN, SETTING, AND PARTICIPANTS: Individual patient data for 5170 primary Ta-T1 bladder tumors from 17 hospitals were analyzed. Transurethral resection of the tumor was performed between 1990 and 2018. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Time to recurrence and time to progression were analyzed using cumulative incidence functions, log-rank tests, and multivariable Cox-regression models with interaction terms stratified by institution. RESULTS AND LIMITATIONS: Ta G3 represented 7.5% (387/5170) of Ta-T1 carcinomas of which 42% were classified as intermediate risk. Time to recurrence did not differ between Ta G3 and Ta G2 (p = 0.9) or T1 G3 (p = 0.4). Progression at 5 yr occurred for 3.6% (95% confidence interval [CI] 2.7-4.8%) of Ta G2, 13% (95% CI 9.3-17%) of Ta G3, and 20% (95% CI 17-23%) of T1 G3 carcinomas. Time to progression for Ta G3 was shorter than for Ta G2 (p < 0.001) and longer than for T1 G3 (p = 0.002). Patients with Ta G3 NMIBC with concomitant carcinoma in situ (CIS) had worse prognosis and a similar time to progression as for patients with T1 G3 NMIBC with CIS (p = 0.5). Multivariable analyses for recurrence and progression showed similar results. CONCLUSIONS: The prognosis of Ta G3 tumors in terms of progression appears to be in between that of Ta G2 and T1 G3. However, patients with Ta G3 NMIBC with concomitant CIS have worse prognosis that is comparable to that of T1 G3 with CIS. Our results support the recent EAU NMIBC guideline changes for more refined risk stratification of Ta G3 tumors because many of these patients have better prognosis than previously thought. PATIENT SUMMARY: We used data from 17 centers in Europe and Canada to assess the prognosis for patients with stage Ta grade 3 (G3) non-muscle-invasive bladder cancer (NMIBC). Time to cancer progression for Ta G3 cancer differed from both Ta G2 and T1 G3 tumors. Our results support the recent change in the European Association of Urology guidelines for more refined risk stratification of Ta G3 NMIBC because many patients with this tumor have better prognosis than previously thought.

T1G1 Bladder Cancer: Prognosis for this Rare Pathological Diagnosis Within the Non-muscle-invasive Bladder Cancer Spectrum.

BACKGROUND: The pathological existence and clinical consequence of stage T1 grade 1 (T1G1) bladder cancer are the subject of debate. Even though the diagnosis of T1G1 is controversial, several reports have consistently found a prevalence of 2-6% G1 in their T1 series. However, it remains unclear if T1G1 carcinomas have added value as a separate category to predict prognosis within the non-muscle-invasive bladder cancer (NMIBC) spectrum. OBJECTIVE: To evaluate the prognostic value of T1G1 carcinomas compared to TaG1 and T1G2 carcinomas within the NMIBC spectrum. DESIGN, SETTING, AND PARTICIPANTS: Individual patient data for 5170 primary Ta and T1 bladder tumors from 17 hospitals in Europe and Canada were analyzed. Transurethral resection (TUR) was performed between 1990 and 2018. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Time to recurrence and progression were analyzed using cumulative incidence functions, log-rank tests, and multivariable Cox regression models stratified by institution. RESULTS AND LIMITATIONS: T1G1 represented 1.9% (99/5170) of all carcinomas and 5.3% (99/1859) of T1 carcinomas. According to primary TUR dates, the proportion of T1G1 varied between 0.9% and 3.5% per year, with similar percentages in the early and later calendar years. We found no difference in time to recurrence between T1G1 and TaG1 (p = 0.91) or between T1G1 and T1G2 (p = 0.30). Time to progression significantly differed between TaG1 and T1G1 (p < 0.001) but not between T1G1 and T1G2 (p = 0.30). Multivariable analyses for recurrence and progression showed similar results. CONCLUSIONS: The relative prevalence of T1G1 diagnosis was low and remained constant over the past three decades. Time to recurrence of T1G1 NMIBC was comparable to that for other stage/grade NMIBC combinations. Time to progression of T1G1 NMIBC was comparable to that for T1G2 but not for TaG1, suggesting that treatment and surveillance of T1G1 carcinomas should be more like the approaches for T1G2 NMIBC in accordance with the intermediate and/or high risk categories of the European Association of Urology NMIBC guidelines. PATIENT SUMMARY: Although rare, stage T1 grade 1 (T1G1) bladder cancer is still diagnosed in daily clinical practice. Using individual patient data from 17 centers in Europe and Canada, we found that time to progression of T1G1 cancer was comparable to that for T1G2 but not TaG1 cancer. Therefore, our results suggest that primary T1G1 bladder cancers should be managed with more aggressive treatment and more frequent follow-up than for low-risk bladder cancer.

Laser microperforated biodegradable microbial polyhydroxyalkanoate substrates for tissue repair strategies: an infrared microspectroscopy study.

Flexible and biodegradable film substrates prepared by solvent casting from poly(3-hydroxybutyrate-co-3-hydroxyvalerate) (PHBHV) solutions in chloroform were microperforated by ultraviolet laser ablation and subsequently characterized using infrared (IR) microspectroscopy and imaging techniques and scanning electron microscopy (SEM). Both transmission synchrotron IR microspectroscopy and attenuated total reflectance microspectroscopy measurements demonstrate variations in the polymer at the ablated pore rims, including evidence for changes in chemical structure and crystallinity. SEM results on microperforated PHBHV substrates after cell culture demonstrated that the physical and chemical changes observed in the biomaterial did not hinder cell migration through the pores.

Urethral stricture in women. Morphofunctional diagnosis and treatment.

OBJECTIVES: The objective of this article is to describe the diagnosis of bladder outlet obstruction in women and the treatment of urethral strictures as a cause of it. METHOD: A bibliographic review was performed in the Medline (PubMed) data base on articles published on the diagnosis of bladder outlet obstruction in women and the treatment of urethral stricture in the period between 1989-2009. RESULTS: The prevalence of obstruction in women varies between 2.7% and 23% in the literature. Videourodynamic studies are the gold standard for diagnosis. 78% of obstructions are functional, and only 6.8% are secondary to urethral stricture. Strictures commonly affect urethral meatus and distal third of the urethra, the most frequent cause being yatrogenic, secondary to incontinence surgery, urethral dilations and traumatic catheterization. The treatment of urethral stricture will depend on the location and length of the stricture, length of the healthy proximal urethra, bladder neck integrity and coexistence of incontinence. The repeat failure of non-invasive techniques and the presence of partial or total urethral defects will be subsidiary to urethral reconstruction techniques by means of flaps or grafts, although the technique of choice is still controversial. CONCLUSION: The diagnosis of bladder outlet obstruction in women is limited by the absence of clearly defined urodynamic parameters. Urethral stricture is an infrequent cause of obstruction, the treatment of which may constitute a therapeutic challenge. Early stricture relapse may constitute ground for considering early surgical reconstruction. Vaginal flaps are the cornerstone of urethral reconstructions. Extensive vulvar scarring may require the use of grafts.

European Association of Urology (EAU) Prognostic Factor Risk Groups for Non-muscle-invasive Bladder Cancer (NMIBC) Incorporating the WHO 2004/2016 and WHO 1973 Classification Systems for Grade: An Update from the EAU NMIBC Guidelines Panel.

BACKGROUND: The European Association of Urology (EAU) prognostic factor risk groups for non-muscle-invasive bladder cancer (NMIBC) are used to provide recommendations for patient treatment after transurethral resection of bladder tumor (TURBT). They do not, however, take into account the widely used World Health Organization (WHO) 2004/2016 grading classification and are based on patients treated in the 1980s. OBJECTIVE: To update EAU prognostic factor risk groups using the WHO 1973 and 2004/2016 grading classifications and identify patients with the lowest and highest probabilities of progression. DESIGN, SETTING, AND PARTICIPANTS: Individual patient data for primary NMIBC patients were collected from the institutions of the members of the EAU NMIBC guidelines panel. INTERVENTION: Patients underwent TURBT followed by intravesical instillations at the physician's discretion. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Multivariable Cox proportional-hazards regression models were fitted to the primary endpoint, the time to progression to muscle-invasive disease or distant metastases. Patients were divided into four risk groups: low-, intermediate-, high-, and a new, very high-risk group. The probabilities of progression were estimated using Kaplan-Meier curves. RESULTS AND LIMITATIONS: A total of 3401 patients treated with TURBT ± intravesical chemotherapy were included. From the multivariable analyses, tumor stage, WHO 1973/2004-2016 grade, concomitant carcinoma in situ, number of tumors, tumor size, and age were used to form four risk groups for which the probability of progression at 5 yr varied from <1% to >40%. Limitations include the retrospective collection of data and the lack of central pathology review. CONCLUSIONS: This study provides updated EAU prognostic factor risk groups that can be used to inform patient treatment and follow-up. Incorporating the WHO 2004/2016 and 1973 grading classifications, a new, very high-risk group has been identified for which urologists should be prompt to assess and adapt their therapeutic strategy when necessary. PATIENT SUMMARY: The newly updated European Association of Urology prognostic factor risk groups for non-muscle-invasive bladder cancer provide an improved basis for recommending a patient's treatment and follow-up schedule.

[Recommendations on bladder cancer Management during COVID-19 pandemia: lessons learned and future plans.] / Recomendaciones sobre el manejo del carcinoma de vejiga en situación de pandemia por Covid-19. Experiencia aprendida y preparación para el futuro.

OBJECTIVES: The guidelines and recommendation sof good clinical practice have been disrupted by new and urgent policies, marked by the COVID-19 pandemic. Urothelial carcinoma has a significant prevalence in Spain, whose population has been greatly affected by COVID-19, directly by the disease and indirectly by the confinement. The objective of this work is to offer recommendations on protocols and guidelines adjusted to different phases of the pandemic. MATERIAL AND METHODS: This document on the management of bladder carcinoma is based on few evidence on urological oncological practice during the first months of the pandemic and on the authors' experience in this pathology during the crisis of COVID-19. Hospital experts in infectious disseases and radiology have participated to design a common strategy to reorganize the activity. RESULTS: Different proposals for treatment and follow-up of patients diagnosed with bladder cancer adjusted for oncological risk and the different phases of the pandemic are presented. CONCLUSIONS: The pandemic's spread was unimaginable just a few months ago. Health systems have been shaken by the disease in the most critical phases. It is necessary, at this time, to make an additional effort to develop tools that can facilitate the care of bladder carcinoma and minimize the impact and risks for patients and health professionals in the future.

 OBJETIVOS: Las directrices y recomendaciones de la buena práctica clínica se han visto trastocadas por las nuevas y urgentes prioridades, marcadas po rla pandemia COVID-19. El carcinoma urotelial es una enfermedad de prevalencia significativa en España, cuya población se ha visto muy afectada por la COVID-19, directamente por la enfermedad e indirectamente por el confinamiento. El objetivo de este trabajo es ofrecer recomendaciones sobre protocolos y circuitos asistenciales ajustados a diferentes fases de la pandemia. MATERIAL Y MÉTODOS: El presente documento sobre el manejo del carcinoma vesical, se basa en la escasa evidencia sobre la práctica oncológica urológica durante los primeros meses de la pandemia y en la experiencia de los autores en esta patología durante la crisis del COVID-19. En ella, han participado expertos hospitalarios en patología infecciosa y radiodiagnóstico para diseñar una estrategia común y reorganizar así la actividad. RESULTADOS: Se presentan distintas propuestas de tratamiento y seguimiento de los pacientes diagnosticados de cáncer vesical ajustados al riesgo oncológico en las diferentes fases de la pandemia. CONCLUSIONES: La velocidad de expansión de la pandemia era inimaginable hace solo unos meses. Los sistemas sanitarios se han visto sacudidos por la enfermedad en las fases más críticas. Es necesario, en estos momentos, realizar un esfuerzo más para desarrollar herramientas que puedan facilitar la asistencia del carcinoma vesical y minimizar el impacto y los riesgos para los pacientes y los profesionales de la salud en el futuro.

The value of tumour weight as a predictive factor for recurrence and progression in non-muscle invasive bladder cancer.

Objective: To further assess the influence of the weight after TURBT as a predictive factor for recurrence and progression in NMIBC.Materials and methods: A cohort of patients with a first episode of NMIBC between 1999 and 2016 was analysed retrospectively. We studied the correlation between the tumour's size and weight, the time-dependent ROC curves for the optimal weight value for the prediction of recurrence and progression and their association with the risk of recurrence and progression at one and five years.Results: We analysed 470 patients who met inclusion criteria. Median (IQR) follow-up time was four years (2.2-6.7), 227 (48.3%) patients had a recurrence and 46 (9.8%) progressed. Median (IQR) weight after resection was 2 g (0.8-6) and its correlation with size was 0.56. The optimal value for the prediction of recurrence was 4 g. The RFS at one and five years with a weight <4 g was 77.7% and 53.5%, respectively, compared to 57.8% and 34.7% with higher weight (p < .001). PFS at one and five years was 98% and 92.7% for a weight <4 g compared to 91.4% and 83.1% for tumours >4 g, respectively (p = .02). On multivariate analysis, a higher weight was associated with an increased risk of recurrence: HR [95%:CI] = 1.52[1.05-1.86], and progression: HR[95%:CI] = 1.87[1.01-3.47] (p < .05).Conclusion: The weight of the specimen obtained after TURBT is a predictive factor of both recurrence and progression in NMIBC that may be more accurate than tumour size and easily and objectively measured. An increase of 52% and 87% in the risk of recurrence and progression, respectively, was found in tumours weighing more than 4 g.

Papillary urothelial neoplasm of low malignant potential (PUN-LMP): Still a meaningful histo-pathological grade category for Ta, noninvasive bladder tumors in 2019?

BACKGROUND: Papillary urothelial neoplasm of low malignant potential (PUN-LMP) was introduced as a noninvasive, noncancerous lesion and a separate grade category in 1998. Subsequently, PUN-LMP was reconfirmed by World Health Organization (WHO) 2004 and WHO 2016 classifications for urothelial bladder tumors. OBJECTIVES: To analyze the proportion of PUN-LMP diagnosis over time and to determine its prognostic value compared to Ta-LG (low-grade) and Ta-HG (high-grade) carcinomas. To assess the intraobserver variability of an experienced uropathologist assigning (WHO) 2004/2016 grades at 2 time points. MATERIALS AND METHODS: Individual patient data of 3,311 primary Ta bladder tumors from 17 hospitals in Europe and Canada were available. Transurethral resection of the tumor was performed between 1990 and 2018. Time to recurrence and progression were analyzed with cumulative incidence functions, log-rank tests and multivariable Cox-regression stratified by institution. Intraobserver variability was assessed by examining the same 314 transurethral resection of the tumorslides twice, in 2004 and again in 2018. RESULTS: PUN-LMP represented 3.8% (127/3,311) of Ta tumors. The same pathologist found 71/314 (22.6%) PUN-LMPs in 2004 and only 20/314 (6.4%) in 2018. Overall, the proportion of PUN-LMP diagnosis substantially decreased over time from 31.3% (1990-2000) to 3.2% (2000-2010) and to 1.1% (2010-2018). We found no difference in time to recurrence between the three WHO 2004/2016 Ta-grade categories (log-rank, P = 0.381), nor for LG vs. PUN-LMP (log-rank, P = 0.238). Time to progression was different for all grade categories (log-rank, P < 0.001), but not between LG and PUN-LMP (log-rank, P = 0.096). Multivariable analyses on recurrence and progression showed similar results for all 3 grade categories and for LG vs. PUN-LMP. CONCLUSIONS: The proportion of PUN-LMP has decreased to very low levels in the last decade. Contrary to its reconfirmation in the WHO 2016 classification, our results do not support the continued use of PUN-LMP as a separate grade category in Ta tumors because of the similar prognosis for PUN-LMP and Ta-LG carcinomas.

Incidence and prognosis of clinically significant incidental prostate cancer after radical cystectomy for bladder cancer. / Incidencia y pronóstico del cáncer de próstata incidental en pacientes tras cistectomía radical por cáncer vesical.

OBJECTIVE: To evaluate the prevalence and significance of incidental prostate cancer in patients after radical cystectomy for bladder cancer, as well as its impact in terms of overall survival and biochemical recurrence. METHODS: Patients with bladder cancer treated with radical cystectomy in our hospital between 1998 and 2014 were included in the study. None of the patients had previous history of prostatic adenocarcinoma. Complete embedding of the prostate gland as whole mount serial section of the radical cystectomy specimens was done. RESULTS: 180 patients were included. The mean age was 69.71 years with a median follow-up of 34.2 months. Three groups were analyzed: non-incidental prostate cancer (n=136), non-significant incidental prostate cancer (n=28) and significant incidental prostate cancer (n=16). During follow-up, 50 patients (27.78%) died from bladder cancer. There were no differences in overall survival between patients with or without prostate cancer, neither between patients with significant nor insignificant prostate cancer in the radical cystectomy specimens. Biochemical recurrence was not observed in any patient. CONCLUSIONS: Incidental prostate cancer had a higher prevalence than previously expected in our cohort (24.4%), but it had no impact in overall survival of patients not even in those with a significant prostate cancer. No biochemical recurrence was reported during the study.

OBJETIVO: Evaluar la prevalencia y el pronóstico del cáncer de próstata incidental en pacientes tras cistectomía radical con cáncer vesical, así como su impacto en la supervivencia global y la recidiva bioquímica en su seguimiento. METODO: Se analizan pacientes con cáncer vesical tratados con cistectomía radical en nuestro hospital entre los años 1998 y 2014, sin presentar ninguno de ellos antecedentes de cáncer de próstata. Se dividen los pacientes según no presenten cáncer de próstata, éste sea no significativo clínicamente o significativo clínicamente y se compara su pronóstico entre ellos. RESULTADOS: Se incluyen 180 pacientes en el análisis con una edad media de 69,7 años y una mediana de seguimiento de 34,2 meses. Entre los grupos: 136 no presentaban cáncer de próstata, 28 lo presentaban no significativo y 16 clínicamente significativo. Durante el seguimiento, 50 (27,8%) fallecieron por su cáncer vesical. No se encontraron diferencias entre los grupos en términos de supervivencia global, además no se objetivó ningún caso de recidiva bioquímica entre los pacientes con cáncer de próstata. CONCLUSION: El cáncer de próstata incidental tiene una prevalencia más alta de lo esperado en nuestra serie (24,4%), aunque su presencia no impacta en la supervivencia global de los pacientes, incluso aunque sea clínicamente significativo. No hubo ningún caso de recidiva bioquímica durante el seguimiento.

Collaborative modeling of an implementation strategy: a case study to integrate health promotion in primary and community care.

BACKGROUND: Evidence-based interventions are more likely to be adopted if practitioners collaborate with researchers to develop an implementation strategy. This paper describes the steps to plan and execute a strategy, including the development of structure and supports needed for implementing proven health promotion interventions in primary and community care. RESULTS: Between 10 and 13 discussion and consensus sessions were performed in four highly-motivated primary health care centers involving 80% of the primary care staff and 21 community-based organizations. All four centers chose to address physical activity, diet, and smoking. They selected the 5 A's evidence-based clinical intervention to be adapted to the context of the health centers. The planned implementation strategy worked at multiple levels: bottom-up primary care organizational change, top-down support from managers, community involvement, and the development of innovative e-health information and communication tools. Shared decision making and practice facilitation were perceived as the most positive aspects of the collaborative modeling process, which took more time than expected, especially the development of the new e-health tools integrated into electronic health records. CONCLUSIONS: Collaborative modeling of an implementation strategy for the integration of health promotion in primary and community care was feasible in motivated centers. However, it was difficult, being hindered by the heavy workload in primary care and generating uncertainty inherent to a bottom-up decision making processes. Lessons from this experience could be useful in diverse settings and for other clinical interventions. Two companion papers report the evaluation of its feasibility and assess quantitatively and qualitatively the implementation process.