Use of Bladder Epicheck® in the follow-up of high-risk non-muscle-invasive Bladder cancer: A systematic literature review.

INTRODUCTION: In recent years, different urinary markers such as the Bladder Epicheck® have been developed in an attempt to reduce the number of cystoscopies in the follow-up of non-muscle invasive bladder cancer (NMIBC). AIM: To provide a systematic review of Bladder Epicheck® and its current clinical utility in the follow-up and detection of recurrence of NMIBC. MATERIAL AND METHODS: Systematic review based on a literature search of PubMed, Web of Science and Scopus databases until October 2023, according to PRISMA and Quadas-2 criteria. Sensitivity (Se), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV) of the marker were calculated. Diagnostic performance was evaluated by the area under the curve (AUC). RESULTS: Fifteen studies were analyzed (n = 3761) including 86.7% prospective studies. Of the patient series, 53.2% had received previous intravesical instillations. The mean Se of the biomarker in the detection of recurrence varied according to tumor grade (87.9%-high grade/HG vs. 44.9%-low grade/LG, respectively). Their weighted mean Se and Sp were 71.6% and 84.5%, respectively. The mean recurrence rate was 29.1%. The weighted mean PPV and NPV were 56.4% and 92.8% (97.7% non-LG), respectively. The mean AUC was 85.63%. CONCLUSION: Bladder Epicheck® is a useful urinary marker in the follow-up of NMIBC, with significantly high Se and NPV in the detection of recurrences, especially in cases of HG disease. Its use can reduce the number of cystoscopies required in the follow-up of NMIBC, improving the quality of life of patients and potentially increasing health economic savings.

Reconstruction Techniques After Partial Nephrectomy: Classic vs. Sutureless Approach-A Narrative Review.

PURPOSE OF REVIEW: The purpose of this review is to update the information about the different types of reconstruction after partial nephrectomy, with special emphasis on the new methods of suture-free hemostasis currently available. RECENT FINDINGS: The aim of renal reconstruction is to avoid bleeding and leakage of the collecting system, but now the renorrhaphy technique used is considered one of the modifiable determinants of renal function after surgery. In an attempt to avoid the loss of renal function implicit in classic reconstruction, new techniques have been described to control hemostasis and urinary leakage, which employ fewer suture layers, different suture materials and designs, and a wide range of commercially available hemostatic materials. Multiple suture characteristics have been studied as a potential factor influencing the renal function observed after partial nephrectomy. Single-plane suture techniques, the use of bearded sutures, and running sutures seem to be associated with less deterioration in postoperative renal function, and deep medullary sutures should be avoided to avoid affecting the arcuate arteries. Sutureless hemostasis systems could prevent the deterioration of renal function and complications derived from suturing, also reducing ischemia time and surgical time without increasing the risk of complications.

Evolution of renal function in patients with cT1 renal tumors after laparoscopic partial and radical nephrectomy. Predictive factors for renal function impairment.

INTRODUCTION AND OBJECTIVES: To analyze the evolution of kidney function after laparoscopic partial nephrectomy (PN) and radical nephrectomy (RN) and to identify predictive factors for renal function impairment. MATERIALS AND METHOD: Retrospective study of patients with two kidneys, glomerular filtration rate (GFR) > 60 mL/min/1.73 m2 and single renal tumor cT1, treated in our center between 2005 and 2018. RESULTS: A total of 372 patients met the inclusion criteria for the study; 156 (41.9%) were treated with RN and 216 (58.1%) with PN. There was a difference of 26.75 mL/min/1.73 m2 in GFR between RN and PN at discharge. Age >60 years, postoperative complications (OR 2.97, p = 0.005) and RN (OR 10.03, p = 0.0001) were predictors of GFR <60 mL/min/1.73 m2 at discharge. Only RN (OR 7.69, p = 0.0001) behaved as an independent prognostic factor for GFR <45 mL/min/1.73 m2 at discharge. The median follow-up of the series was 57 (IQR 28-100) months. At the end of the follow-up period, nine (6%) patients treated with RN developed severe chronic kidney disease (CKD) and three (2%) developed end stage renal disease (ESRD). Age >70 years, diabetes mellitus (DM) (HR 2.12, p = 0.001), arterial hypertension (AHT) (HR 1.73, p = 0.01) and RN (HR 2.88, p = 0.0001) behaved as independent predictors of GFR <60 mL/min/1.73 m2. The independent predictors for GFR <45 mL/min/1.73 m2 were age >70 years, DM (HR 1.99 CI 95% 1.04-3.83, p = 0.04) and RN (HR 5.88 CI 95% 2.57-13.45, p = 0.0001). CONCLUSIONS: RN is a short- and long-term risk factor for CKD although with a low probability of severe CKD or ESRD in patients with preoperative GFR >60 mL/min/1.73 m2. Age, DM and AHT contribute to worsening renal function during follow-up.

Utility of preoperative vascular embolization of renal tumors with left renal vein tumor thrombus.

INTRODUCTION AND OBJECTIVES: Preoperative renal artery embolization (PRAE) for large renal masses may be performed prior to nephrectomy in order to simplify the procedure and reduce intraoperative bleeding. The objective of this work is to determine the role of PRAE on intraoperative bleeding and postoperative complications in left renal tumors with tumor thrombus limited to the left renal vein (level 0). MATERIAL AND METHODS: Retrospective analysis to evaluate 46 patients who underwent left radical nephrectomy and thrombectomy for the treatment of renal cell carcinoma with level 0 tumor thrombus during the period 1990-2020. PRAE was limited to those cases in which surgical access to the main renal artery was presumed a priori difficult in the preoperative imaging study (n = 9; 19.6%). Intraoperative bleeding was estimated based on the perioperative transfusion rate, and postoperative complications were categorized according to the Clavien-Dindo classification. The Chi-squared test was used for comparisons. A multivariate analysis was performed to identify predictors of transfusion and complications. RESULTS: There were no significant differences in the overall complication rate (11.1% vs. 32.4%, p = 0.19), major complication rate (0% vs. 8.1%, p = 0.51), or transfusion rate (11.1% vs. 19%, p = 0.49) between both groups (PRAE vs. non-PRAE). In the multivariate analysis, PRAE did not behave as a predictor of complications (OR: 0.11, 95%CI 0.01-2.86; p = 0.18) nor transfusion (OR: 0.46, 95%CI 0.02-7.38; p = 0.58). CONCLUSIONS: In our study on left RCC with level 0 tumor thrombus and difficult access to the main renal artery, PRAE was not associated with increased bleeding or postoperative complications, and it did not behave as an independent predictor of these variables. Therefore, it could be used as a preoperative maneuver to facilitate vascular management in selected cases.

Evolution of renal function in patients with CT1 renal tumors after laparoscopic partial and radical nephrectomy. Predictive factors for renal function impairment. / Evolución de la función renal en pacientes con cáncer renal cT1 después de nefrectomía parcial y radical laparoscópica. Factores predictores de deterioro de función renal.

INTRODUCTION AND OBJECTIVES: To analyze the evolution of kidney function after laparoscopic partial nephrectomy (PN) and radical nephrectomy (RN) and to identify predictive factors for deterioration in kidney function. MATERIALS AND METHOD: Retrospective study of patients with two kidneys, glomerular filtration rate (GFR) > 60 mL/min/1.73 m2, and single renal tumor cT1, treated in our center between 2005 and 2018. RESULTS: A total of 372 patients met the inclusion criteria for the study; 156 (41.9%) were treated by RN and 216 (58.1%) by PN. There was a difference of 26.75 mL/min/1.73 m2 in GFR between RN and PN at discharge. Age > 60 years, postoperative complications (OR 2.97, p = 0.005) and RN (OR 10.03, p = 0.0001) were predictors of GFR < 60 mL/min/1.73 m2 at discharge. Only RN (OR 7.69, p = 0.0001) behaved as an independent prognostic factor for GFR < 45 mL/min/1.73m2 at discharge. The median follow-up of the series was 57 (IQR 28-100) months. At the end of the follow-up period, nine (6%) patients treated with RN developed severe chronic kidney disease (CKD) and three (2%) developed end stage renal disease (ESRD). Age > 70 years, diabetes mellitus (DM) (HR 2.12, p = 0.001), arterial hypertension (AHT) (HR 1.73, p = 0.01) and RN (HR 2.88, p = 0.0001) behaved as independent predictors of GFR < 60 mL/min/1.73 m2. The independent predictors for GFR< 45 mL/min/1.73m2 were age >70 years, DM (HR 1.99 CI 95% 1.04-3.83, p = 0.04) and RN (HR 5.88 CI 95% 2.57-13.45, p = 0.0001). CONCLUSIONS: RN is a short- and long-term risk factor for CKD, although with a low probability of severe CKD or ESRD in patients with preoperative GFR > 60 mL/min/1.73 m2. Age, DM and AHT contribute to worsening renal function during follow-up.

Utility of preoperative vascular embolization of renal tumors with left renal vein tumor thrombus. / Utilidad de la embolización vascular prequirúrgica de tumores renales con trombo tumoral en la vena renal izquierda.

INTRODUCTION AND OBJECTIVES: Preoperative renal artery embolization (PRAE) for large renal masses may be performed prior to nephrectomy in order to simplify the procedure and reduce intraoperative bleeding. The objective of this work is to determine the role of PRAE on intraoperative bleeding and postoperative complications in left renal tumors with tumor thrombus limited to the left renal vein (level 0). MATERIAL AND METHODS: Retrospective analysis to evaluate 46 patients who underwent left radical nephrectomy and thrombectomy for the treatment of renal cell carcinoma with level 0 tumor thrombus during the period 1990-2020. PRAE was limited to those cases in which surgical access to the main renal artery was presumed a priori difficult in the preoperative imaging study (n=9; 19.6%). Intraoperative bleeding was estimated based on the perioperative transfusion rate, and postoperative complications were categorized according to the Clavien-Dindo classification. The Chi-squared test was used for comparisons. A multivariate analysis was performed to identify predictors of transfusion and complications. RESULTS: There were no significant differences in the overall complication rate (11.1% vs. 32.4%, P=.19), major complication rate (0% vs.8.1%, P=.51), or transfusion rate (11.1% vs. 19%, P=.49) between both groups (PRAE vs. non-PRAE). In the multivariate analysis, PRAE did not behave as a predictor of complications (OR:0.11, 95%CI 0.01-2.86; P=.18) nor transfusion (OR:0.46, 95%CI 0.02-7.38;P=.58). CONCLUSIONS: In our study on left renal cell carcinomas with level 0 tumor thrombus and difficult access to the main renal artery, PRAE was not associated with increased bleeding or postoperative complications, and it did not behave as an independent predictor of these variables. Therefore, it could be used as a preoperative maneuver to facilitate vascular management in selected cases.

Comparison between laparoscopic and open prostatectomy: Oncological progression analysis. / Comparación entre prostatectomía laparoscópica y abierta: análisis de la evolución oncológica.

INTRODUCTION: There are very few Spanish studies that compare oncological outcomes following radical prostatectomy (RP) based on surgical approach, and their methodology is not appropriate. OBJECTIVE: To compare oncological outcomes in terms of surgical margins (SM) and biochemical recurrence (BR) between open radical prostatectomy (ORP) and laparoscopic radical prostatectomy (LRP). MATERIAL AND METHODS: Comparison of two cohorts (307 with ORP and 194 with LRP) between 2007-2015. Surgical margin status was defined as positive or negative, and BR as a PSA rise of >0.4 ng/ml after surgery. To compare the qualitative variables, we employed the Chi-squared test, and ANOVA was used for quantitative variables. We performed a multivariate analysis using logistic regression to evaluate the predictive factors of SM, and a multivariate analysis using Cox regression to evaluate the predictive factors of BR. RESULTS: Gleason 7 (3+4) was determined in the surgical specimens of 43.5% of patients, and 31.7% had positive SM. The most frequent pathological stage was pT2c, on the 61.9% of the cases. No significant differences were found between both groups, except for extracapsular extension (p=0.001), more frequent in LRP. The median follow-up was 49 months. BR was seen in the 23% of patients, without significant differences between groups. In the multivariable analysis, only the D'Amico risk group behaved as an independent predictive factor of positive SM, and Gleason score and positive SM acted as independent predictive factors of BR. CONCLUSION: The surgical approach did not influence SM status or BR.

Analysis of recurrence trends according to risk groups after renal cancer nephrectomy. / Evaluación de los patrones de recurrencia por grupos de riesgo tras nefrectomía por cáncer renal.

INTRODUCTION: Recurrence trends after renal cell cancer nephrectomy are not clearly defined. OBJECTIVE: To evaluate recurrence trends according to recurrence risk groups (RRG). MATERIAL AND METHOD: Retrospective analysis of 696 patients with renal cell cancer treated with nephrectomy between 1990-2010. Three RRG were defined according to the presence of anatomopathological variables (pTpN stage, nuclear grade, tumor necrosis [TN], sarcomatoid differentiation [SD], positive resection margin [RM]): -Low RG (LRG): pT1pNx-0 G1-4, pT2pNx-0 G1-2; no TN, SD and/or RM (+). -Intermediate RG (IRG): pT2pNx-0 G3-4; pT3-4pNx-0 G1-2; LRG with TN. -High RG (HRG): pT3-4pNx-0 G3-4; pT1-4pN+; IRG with TN and/or SD; LRG with SD and/or RM (+). The Kaplan-Meier method has been used to evaluate recurrence-free survival as a function of RRG. The log-rank test was used to evaluate differences between survival curves. RESULTS: The median follow-up was 105 (IQR 63-148) months. Of the total series, 177 (25.4%) patients presented recurrence: distant 15.9%, local 4.9% and 4.6% distant and local. The recurrence rate varied according to the RRG with values of 72.9% for HRG, 16.9% for IRG and 10.2% for LRG (p=.0001). Most cases in LRG presented single organ recurrence (72.2%) (p=.006). The LRG experienced recurrence as single metastasis in 50% of cases, compared to 30% and 18.6% in IRG and HRG, respectively (p=.009). The most common sites of recurrence were lung and abdomen. Lung recurrence predominated in the HRG (72.9%) (p=.0001) and abdominal, in the LRG (83.3%) with a tendency to significance (p=.15). CONCLUSIONS: Recurrence rates (especially bone and lung) increase with higher RG. Single organ recurrences and single metastases are more frequent in LRG.

Survival analysis of patients with prostate cancer and unfavorable risk factors treated with radical prostatectomy and salvage radiotherapy after biochemical recurrence and persistence. / Análisis de supervivencia de los pacientes con cáncer de próstata con factores patológicos desfavorables tratados con prostatectomía radical y radioterapia de rescate tras la recidiva y persistencia bioquímica.

OBJECTIVE: Survival analysis of patients with prostate cancer (PCa) with adverse prognostic factors (APF) treated with radical prostatectomy (RP) and salvage radiotherapy (SRT) after biochemical recurrence (BR) or biochemical persistence (BP). MATERIALS AND METHODS: Retrospective analysis of 446 patients with at least one of the following APF: Gleason score ≥8, pathologic stage ≥pT3 and/or positive surgical margins. BR criteria used was PSA level over 0.4ng/ml. A survival analysis using Kaplan-Meier was performed to compare the different variable categories with log-rank test. In order to identify risk factors for SRT response and cancer specific survival (CSS) we performed univariate and multivariate analyses using Cox regression. RESULTS: Mean follow up: 72 (IQR 27-122) months, mean time to BR: 42 (IQR 20-112) months, mean PSA level at BR: 0.56 (IQR 0.42-0.96). BR was present in 36.3% of the patients. Biochemical response to SRT was observed in 121 (75.7%) patients. Recurrence-free survival (RFS) rates after SRT at 3, 5, 8 and 10years were 95.7%, 92.3%, 87.9%, and 85%; overall survival (OS) rates after 5, 10 and 15years was 95.6%, 86.5% and 73.5%, respectively. CSS rates at 5, 10 and 15years were 99.1%, 98.1% and 96.6%. Only time to BR <24months (HR=2.55, P=.01) was identified as an independent risk factor for RFS after SRT. CONCLUSIONS: In these patients, RP only controls the disease in approximately half of the cases. Multimodal sequential treatment (RP+SRT when needed) increases this control, achieving high CSS rates and biochemical control in over 87% of the patients. Patients with time to recurrence >24months responded better to rescue treatment.

Influence of venous tumour extension on local and remote recurrence of stage pT3a pN0 cM0 kidney tumours. / Influencia de la extensión tumoral venosa en la recidiva local y a distancia de los tumores renales en un estadio pT3a pN0 cM0.

INTRODUCTION AND OBJECTIVE: One of the inherent features of kidney tumours is the capacity to spread inside the venous system as tumour thrombi. The aim of this study was to assess in patients with stage pT3apN0cM0 kidney cancer whether venous tumour involvement influenced tumour recurrence. MATERIALS AND METHODS: A retrospective analysis of patients with stage pT3apN0cM0 kidney cancer treated with radical nephrectomy between 1990-2015. Univariate and multivariate Cox regression analysis to identify predictive variables and independent predictive variables relating to recurrence. RESULTS: The results of 153 patients were studied. The median follow-up was 82 (IQR 36-117) months. Recurrence-free survival at 5 years was 58.9% with a median of 97 (95% CI 49.9-144.1) months. Seventy-seven (50.3%) patients recurred. Seventy cases 70 (90.9%) had distant metastases, 17 (14.2%) of these patients had local recurrence in the bed of nephrectomy. Tumour necrosis (p=.0001), and microvascular invasion (p=.001) were identified as independent predictors of tumour recurrence in the multivariable analysis. CONCLUSIONS: In our series, after multivariable analysis, venous tumour extension was not related to recurrence. Tumour necrosis and microvascular infiltration did behave as independent predictive factors of tumour recurrence.

Postsurgical complications in patients with renal tumours with venous thrombosis treated with surgery. / Complicaciones posquirúrgicas en los pacientes con tumor renal con trombosis venosa tratados con cirugía.

BACKGROUND AND OBJECTIVE: Surgery on renal tumours with venous thrombosis suffers a high rate of complications and non-negligible perioperative mortality. Our objective was to analyse the postoperative complications, their relationship with the level of the thrombus and its potential predisposing factors. MATERIALS AND METHODS: A retrospective analysis was conducted of 101 patients with renal tumours with venous thrombosis operated on between 1988 and 2017. Two patients were excluded because of intraoperative pulmonary thromboembolism and exitus (2%). The postsurgical complications were classified according to Clavien-Dindo. To compare the qualitative variables, we employed the chi-squared test. We performed a multivariate analysis using binary logistic regression to identify the independent predictors. RESULTS: Some type of postsurgical complication occurred in 34 (34.3%) patients, 11 (11.1%) of which were severe (Clavien III-V). There were significant differences in the total complications (P=.003) and severe complications (Clavien≥III; P=.03) depending on the level of the tumour thrombus.

Prognostic factors for vesical relapse in patients with upper urothelium tumours treated with surgery. / Factores pronósticos de recidiva vesical en los pacientes con tumor de urotelio superior tratados con cirugía.

OBJECTIVE: To identify the prognostic factors for vesical relapse in patients with tumours of the upper urothelium treated with surgery. MATERIAL AND METHODS: We conducted a retrospective analysis of patients with tumours of the upper urothelium who underwent surgery between 1999 and 2011 at our centre (139 patients). We collected demographic, clinical, diagnostic and pathological variables, as well as the treatment, complications and progression. A descriptive analysis was performed using the chi-squared test for categorical variables and the ANOVA test for continuous variables. We also performed a univariate and multivariate analysis using the Cox proportional hazards model. Statistical significance was considered when P<.05. All calculations were performed with SPSS Statistics version 21. RESULTS: During the follow-up, 26.6% of the patients (37 cases) showed vesical relapse. Some 19.6% of the patients with no history of bladder tumours showed a bladder tumour relapse compared with 48.6% of the patients with a history of bladder tumours (P<.001). In the multivariate analysis, only the presence of bladder tumours prior to or concomitant with the upper urinary tract tumour diagnosis was identified as an independent predictor of bladder tumour relapse (P=.007). CONCLUSION: In our series, only the presence of a prior or synchronous bladder tumour behaved as an independent predictor of bladder tumour relapse in patients with tumours of the upper urothelium treated with surgery.

The need for re-TUR of the bladder in non-muscle invasive bladder cancer: risk factors of tumor persistence in re-TUR specimens.

AIM: This study evaluated the need for re-TUR of the bladder in non-muscle invasive bladder cancer (NMIBC) with complete transurethral resection (TUR) and examined the risk factors for disease occurrence in re-TUR of the bladder. METHODS: A cohort of 211 patients diagnosed consecutively of NMIBC (July 2009 to October 2011) underwent re-TURB 4-6 weeks after the initial TURB. Association with tumor presence in re-TURB of the following parameters was analyzed: sex, primary/recurrent, number, size, stage, grade, association of carcinoma in situ, early instillation of Mitomycin C, and its classification according to the EORTC risk groups. RESULTS: Fifty-seven (27%) cases exhibited residual tumors in the re-TURB and understaging was observed in 3 (1.4%) patients. The EORTC classified 151 (71.6%) patients as high risk; 124 (58.7%) patients received postoperative instillations of Mitomycin C. 31.8% of high risk patients exhibited tumors in the re-TUR compared to 14% of the low/intermediate risk (P<0.05). A total of 19.4% of patients with early instillation of Mitomycin C had tumor in re-TURB compared to 38.4% of patients without it (P<0.05). Multivariate analysis showed that high-risk tumors behaved as an independent risk factor for the tumor presence in re-TURB (HR=12.65, P=0.008), but early postoperative instillation of Mitomycin C was a protective factor (HR=2.16, P=0.02). The limitations of the study are the absence of randomization and its unicentric character. CONCLUSION: Patients who were at a high risk of tumor recurrence and/or progression according to the EORTC classification exhibited a higher percentage of tumors in re-TURB. Therefore, these patients are optimal candidates for re-TURB.

Urethral bleeding after open radical prostatectomy treated with selective arterial embolization. A rare complication.

OBJECTIVE: Gross hematuria in the immediate postoperative radical prostatectomy is a rare complication. According to different series reviewed, significant bleeding after this surgery appears between 0.5-1.5% of the cases. METHODS: 58 year old male with localized prostate cancer who underwent open radical prostatectomy with preservation of the neurovascular bundles and a left accessory pudendal branch. In the 4th postoperative day patient presented severe hematuria and urethral bleeding requiring continuous bladder irrigation and blood transfusion. Given the persistence of bleeding despite conservative measures CT-angiography was performed demonstrating active bleeding at a bulbar artery from the left internal pudendal artery without associated pelvic hematoma RESULTS: Given the findings selective embolization was performed with absorbable material stopping the bleeding. Three months later the patient maintains urinary continence and erectile function with tadalafil. CONCLUSIONS: Urethral bleeding after radical prostatectomy is a rare complication the cause of which is distal to the urinary sphincter unrelated to the pelvic vessels. The performance of CT angiography and subsequent embolization is the treatment of choice, avoiding open surgical revision, with less morbidity.