Cumulative morbidity of ureteroscopy for upper tract urothelial carcinoma.

OBJECTIVE: To assess complications after ureteroscopy (URS) for upper tract urothelial carcinoma (UTUC) management and to assess its postoperative cumulative morbidity burden using the Comprehensive Complication Index (CCI). MATERIALS AND METHODS: Single center retrospective study including patients submitted to URS for UTUC suspicion. URSs were both diagnostic and operative. Postoperative complications were recorded according to the EAU Guidelines and graded according to Clavien-Dindo Classification (CDC). The cumulative postoperative morbidity burden developed by patients experiencing multiple events was assessed using the CCI. Multivariable logistic regression (MLR) analyses identified factors independently associated with the development of any grade and major postoperative complications. RESULTS: Overall, 360 patients with UTUC suspicion were included with a total of 575 URSs performed. The cumulative number of all postoperative complications recorded was 111. In 86 (15%) procedures, patients experienced at least one postoperative complication, while 25 (4.3%) experienced more than one complication. Of these, 16 (14%) were severe (CDC ≥ IIIa). The most frequent type of complications were urinary (34%), bleeding (30%) and infectious (30%). The higher the CDC grade, the higher the median CCI, with a statistically significant increase in median CCI from CDC II to major complications. Patients who experienced intraoperative complications were at higher risk of developing any grade and major postoperative complications at MLR. CONCLUSIONS: Complications after ureteroscopy for UTUC are relatively uncommon events. Patients who experience intraoperative complications are at higher risk of developing postoperative complications. The comprehensive complication index appeared more representative of the cumulative postoperative morbidity rather than the Clavien-Dindo classification.

Reduced- vs full-dose BCG in bladder cancer: A systematic review and meta-analysis.

OBJECTIVE: To assess the oncologic outcomes and the safety profile of a reduced-dose versus full-dose BCG regimen in patients with non-muscle-invasive bladder cancer (NMIBC). MATERIAL AND METHODS: We performed a systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The PubMed, Embase, and Web of Science databases were searched in January 2022 for studies that analyzed oncological outcomes and compared between reduced- and full-dose BCG regimens. RESULTS: Seventeen studies including 3757 patients met our inclusion criteria. Patients who received reduced-dose BCG had significantly higher recurrence rates (OR 1.19; 95%CI, 1.03-1.36; p = 0.02). The risks of progression to muscle-invasive BC (OR 1.04; 95%CI, 0.83-1.32; p = 0.71), metastasis (OR 0.82; 95%CI, 0.55-1.22; p = 0.32), death from BC (OR 0.80; 95%CI, 0.57-1.14; p = 0.22), and all-cause death (OR 0.82; 95%CI, 0.53-1.27; p = 0.37) were not statistically different. When restricting the analyses to randomized controlled trials, we found similar results. In subgroup analysis, reduced dose was associated with a higher rate of BC recurrence in studies that used only an induction regimen (OR 1.70; 95%CI, 1.19-2.42; p = 0.004), but not when a maintenance regimen was used (OR 1.07; 95%CI, 0.96-1.29; p = 0.17). Regarding side effects, the reduced-dose BCG regimen was associated with fewer episodes of fever (p = 0.003), and therapy discontinuation (p = 0.03). CONCLUSION: This review found no association between BCG dose and BC progression, metastasis, and mortality. There was an association between reduced dose and BC recurrence, which was no longer significant when a maintenance regimen was used. In times of BCG shortage, reduced-dose regimens could be offered to BC patients.

Robot-assisted vs. open radical cystectomy: systematic review and meta-analysis of randomized controlled trials.

INTRODUCTION: Several randomized controlled trials (RCTs) have been launched in the last decade to examine the surgical safety and oncological efficacy of robot-assisted (RARC) vs open radical cystectomy (ORC) for patients with bladder cancer. The aim of the study was to perform a systematic review and meta-analysis of RCTs to compare the perioperative and oncological outcomes of RARC vs ORC. METHODS: A literature search was conducted through July 2022 using PubMed/Medline, Embase, and Web of Science databases. Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed to identify eligible studies. The outcomes were intraoperative, postoperative, and oncological outcomes of RARC vs ORC. RESULTS: A total of eight RCTs comprising 1,024 patients met our inclusion criteria. RARC was associated with longer operative time (mean 92.34min, 95% CI 83.83-100.84, p<0.001) and lower blood transfusion rate (Odds ratio [OR] 0.43, 95% CI 0.30-0.61, p<0.001). No differences emerged in terms of 90-day overall (p=0.28) and major (p=0.57) complications, length of stay (p=0.18), bowel recovery (p=0.67), health-related quality of life (p=0.86), disease recurrence (p=0.77) and progression (p=0.49) between the two approaches. The main limitation is represented by the low number of patients included in half of RCTs included. CONCLUSIONS: This study supports that RARC is not inferior to ORC in terms of surgical safety and oncological outcomes. The benefit of RARC in terms of lower blood transfusion rate need to be balanced with the cost related to the procedure.

[CLINICAL IMPACT OF THE SUSPENSION OF THE ERAS PROTOCOL ON PATIENTS UNDERGOING RADICAL CYSTECTOMY DURING THE COVID-19 PANDEMIC.] / IMPACTO CLÍNICO DE NO APLICAR EL PROTOCOLO ERAS EN LOS PACIENTES SOMETIDOS A CISTECTOMÍA DURANTE LA PANDEMIA COVID-19.

INTRODUCTION: During the beginning of the COVID-19 pandemic in our center, neither prehabilitation nor multimodal rehabilitation could be applied due to the excessive patient load on the health system and to reduce SARS-CoV-2 transmission. The objective of our study was to analyze the evolution, complications, and survival up to one year of patients who underwent radical cystectomy in our hospital from March 1st to May 31st, 2020 (period of the first wave COVID-19 pandemic in Spain). We also compared the results with cystectomized patients outside the pandemic period and with application of the ERAS (Enhanced Recovery After Surgery) protocol. MATERIAL AND METHODS: Single-center, retrospective cohort study of patients scheduled for radical cystectomy from March 1st,2020 to May 31st, 2020. They were matched with previously operated patients using a 1:2 propensity matching score. The matching variables were demographic data, preoperative and intraoperative clinical conditions. RESULTS: A total of 23 radical cystectomies with urinary diversion were performed in the period described. In none of the cases the prehabilitation or the follow-up of our ERAS protocol could be applied, and this was the only difference we found between the 2 groups. Although the minimally invasive approach was more frequent in the pandemic group, the difference was not statistically significant. Three patients were diagnosed with COVID-19 during their admission, presenting severe respiratory complications and high in-hospital mortality. Apart from respiratory complications secondary to SARS-CoV-2, we also found statistically significant differences in other postoperative complications. The hospital stay increased by 3 days in the pandemic group. CONCLUSIONS: Patients who underwent radical cystectomy at our center during the first wave of the COVID-19 pandemic had a higher number and severity of respiratory and non-respiratory complications. Discontinuation of the ERAS protocol was the main difference in treatment between groups.

Clinical impact of the suspension of the ERAS protocol on patients undergoing radical cystectomy during the COVID-19 pandemic.

INTRODUCTION: During the beginning of the COVID-19 pandemic in our center, neither prehabilitation nor multimodal rehabilitation could be applied due to the excessive patient load on the health system and to reduce SARS-CoV-2 transmission. The objective of our study was to analyze the evolution, complications, and survival up to one year of patients who underwent radical cystectomy in our hospital from March 1st to May 31st, 2020 (period of the first wave COVID-19 pandemic in Spain). We also compared the results with cystectomized patients outside the pandemic period and with application of the ERAS (Enhanced Recovery After Surgery) protocol. MATERIAL AND METHODS: Single-center, retrospective cohort study of patients scheduled for radical cystectomy from March 1st, 2020 to May 31st, 2020. They were matched with previously operated patients using a 1:2 propensity matching score. The matching variables were demographic data, preoperative and intraoperative clinical conditions. RESULTS: A total of 23 radical cystectomies with urinary diversion were performed in the period described. In none of the cases the prehabilitation or the follow-up of our ERAS protocol could be applied, and this was the only difference we found between the 2 groups. Although the minimally invasive approach was more frequent in the pandemic group, the difference was not statistically significant. Three patients were diagnosed with COVID-19 during their admission, presenting severe respiratory complications and high in-hospital mortality. Apart from respiratory complications secondary to SARS-CoV-2, we also found statistically significant differences in other postoperative complications. The hospital stay increased by 3 days in the pandemic group. CONCLUSIONS: Patients who underwent radical cystectomy at our center during the first wave of the COVID-19 pandemic had a higher number and severity of respiratory and non-respiratory complications. Discontinuation of the ERAS protocol was the main difference in treatment between groups.

Management of primary upper urinary tract carcinoma in situ diagnosed by ureteroscopic biopsy: Is bacillus Calmette-Guerin an alternative to nephroureterectomy?

BACKGROUND: Radical nephroureterectomy (RNU) represents the gold standard treatment for upper tract urothelial carcinoma (UTUC); however, attempts have been made to treat upper urinary tract CIS (UT-CIS) conservatively. The aim of this study was to compare the outcome of patients with primary UT-CIS treated in our center by means of RNU vs. bacillus Calmette-Guérin (BCG) instillations. METHODS: This retrospective study included patients with diagnosis of primary UT-CIS between 1990 and 2018. All patients had histological confirmation of UT-CIS in the absence of other concomitant UTUC. Histological confirmation was obtained by ureteroscopy with multiple biopsies. Patients were treated with BCG instillations, RNU or distal ureterectomy. Clinicopathological features and outcomes were compared between RNU and BCG groups. RESULTS: A total of 28 patients and 29 renal units (RUs) were included. Sixteen (57.1%) patients (17 RUs) received BCG. BCG was administered via nephrostomy tube in 4 patients, with a single-J ureteral stent in 5, and using a Double-J stent in 7. Complete response and persistence or recurrence were detected in ten (58.8%) and seven (41.2%) RUs treated with BCG, respectively. Eight (27.6%) RUs underwent RNU, and 4 (13.8%) Rus distal ureterectomy. No differences were found in recurrence-free survival (p=0.841) and cancer-specific survival (p=0.77) between the RNU and BCG groups. CONCLUSIONS: Although RNU remains the gold standard treatment for UT-CIS, our results confirm that BCG instillations are also effective. Histological confirmation of UT-CIS is mandatory before any treatment.

Indications and histology of 489 orchiectomies analyzed by patient age.

OBJECTIVE: To evaluate the indications and histology of our series of orchiectomies, analysing the results by patient's age. METHODS: We included the orchiectomies realized in our hospital between 2005 and 2020 in patients older than 18 years. We estimated demographic data, indications, histology and effectiveness of testicular ultrasound by three groups of age. RESULTS: We included 489 orchiectomies, which 364 (74%) belonged to Group A (patients between 18-50 years), 59 (12%) to Group B (50-70 years) and 66 (14%) to Group C (older than 70 years). In Group A, 284 (78%) orchiectomies were indicated due to malignancy suspect. In 91.9% cases (261) malign neoplasm was confirmed at final histology and 253 (89%) were germinal cells. Testicular ultrasound had a positive predictive value (PPV) of 90% in this group. In Group B, 34 (57%) orchiectomies were indicated because of malignancy suspect. At final histologic analysis, 25/34 (73.5%) confirmed malign neoplasm. Ultrasound had a PPV of 68%. In Group C, orchiepididymitis was the main cause of testicular removal with 30 cases (45,5%). From the 20 cases (30.3%) with suspicion of malignancy, only 6 had confirmed malign histology. Testicular ultrasound PPV for malignancy was 31%. CONCLUSION: In patients younger than 70 years the main orchiectomy's indication was suspect of malignancy and in older than 70, testicular inflammation. The germinal neoplasm was the predominant histology in younger than 70 years. In older than that, malignancy was infrequent. The positive predictive value of testicular ultrasound for malignancy decreased with patient's age. In patients older than 50 years proper image diagnosis to assess malignancy should be considered before orchiectomy is done.

Primary urethral carcinoma: Results from a single center experience.

INTRODUCTION AND AIM OF THE STUDY: Primary urethral carcinoma (PUC) is a rare neoplastic disease arising in the urethra, without any evidence of a previous or synchronous carcinoma of the entire urinary tract. Since rare diseases are often incorrectly diagnosed and managed, the aim of this study was to analyze the experience of a single urology center in the treatment of PUC, focusing on neoplasms arising from the male anterior urethra. MATERIALS AND METHODS: Medical records of patients with neoplasms at the level of the penile and bulbar urethra who presented at our tertiary referral center between January 1988 and December 2018 were retrospectively reviewed. Patients with carcinoma of the prostatic urethra were excluded. The diagnosis was obtained with the aid of urethroscopy and lesion biopsy. Local staging was performed by means of contrast-enhanced MRI in selected patients. Staging was achieved by clinical examination, ultrasonography, and CT scan. Radical surgery (radical cystectomy + total penectomy + bilateral inguinal lymphadenectomy) was proposed to patients with ≥T2 tumors or cN+ with a good performance status, proximal tumor and without severe comorbidities. In case of nodal involvement, neoadjuvant chemotherapy was additionally offered. Patients with localized disease (

History of urological malignancies before kidney transplantation, oncological outcome on the long term.

INTRODUCTION: We aimed to report the oncological outcomes of ESRD patients with histories of urological malignancies who were subsequently submitted to kidney transplantation (KT). MATERIAL AND METHOD: Retrospective study lead in the Puigvert Foundation (Barcelona) registry of 1,200 KT performed from 1988 to 2018. Eighty-five urological malignancies that were treated before KT in 81 patients were identified: 15 (18%) prostate cancers, 49 (58%) RCC, 19 (22%) urothelial carcinomas and 2 (2%) testicular cancers. Baseline characteristics, cancer staging, treatment and follow-up were registered as well as the chronology of the start of dialysis, inscription on the waiting list and kidney transplantation. Endpoints included were cancer recurrence, metastatic progression, cancer-specific death and overall survival. RESULTS: In a median follow-up of 13.1 years (2.2-32), 16/85 (19%) cancer recurrences were reported, with 3 (4%) who progressed to metastasis and died of cancer. Median overall survival after cancer treatment was 25.3 years and cancer-specific survival was 95% at 25 years. Median time from cancer treatment to kidney transplantation was 4.8 years: 3.7 years in prostate cancer, 3.9 years in RCC and 8.8 years in bladder cancer. The median time from start of dialysis to kidney transplantation was 1.8 years in patients with histories of urological malignancy versus 0.5 year in the total cohort of 1,200 renal transplanted over the same period. CONCLUSIONS: Well-selected patients with histories of urological malignancies greatly benefit from kidney transplantation with infrequent and late cancer recurrence. Waiting time could be optimized in low-risk prostate cancer and RCC, but more robust data are needed.

Primary urethral carcinoma: Results from a single center experience. / Carcinoma uretral primario: resultados de la experiencia de un único centro.

INTRODUCTION AND AIM OF THE STUDY: Primary urethral carcinoma (PUC) is a rare neoplastic disease arising in the urethra, without any evidence of a previous or synchronous carcinoma of the entire urinary tract. Since rare diseases are often incorrectly diagnosed and managed, the aim of this study was to analyze the experience of a single urology center in the treatment of PUC, focusing on neoplasms arising from the male anterior urethra. MATERIALS AND METHODS: Medical records of patients with neoplasms at the level of the penile and bulbar urethra who presented at our tertiary referral center between January 1988 and December 2018 were retrospectively reviewed. Patients with carcinoma of the prostatic urethra were excluded. The diagnosis was obtained with the aid of urethroscopy and lesion biopsy. Local staging was performed by means of contrast-enhanced MRI in selected patients. Staging was achieved by clinical examination, ultrasonography, and CT scan. Radical surgery (radical cystectomy + total penectomy + bilateral inguinal lymphadenectomy) was proposed to patients with ≥T2 tumors or cN + with a good performance status, proximal tumor and without severe comorbidities. In case of nodal involvement, neoadjuvant chemotherapy was additionally offered. Patients with localized disease (

Risk factors for residual disease at re-TUR in a large cohort of T1G3 patients.

INTRODUCTION AND OBJECTIVES: The goals of transurethral resection of a bladder tumor (TUR) are to completely resect the lesions and to make a correct diagnosis in order to adequately stage the patient. It is well known that the presence of detrusor muscle in the specimen is a prerequisite to minimize the risk of under staging. Persistent disease after resection of bladder tumors is not uncommon and is the reason why the European Guidelines recommended a re-TUR for all T1 tumors. It was recently published that when there is muscle in the specimen, re-TUR does not influence progression or cancer specific survival. We present here the patient and tumor factors that may influence the presence of residual disease at re-TUR. MATERIAL AND METHODS: In our retrospective cohort of 2451 primary T1G3 patients initially treated with BCG, pathology results for 934 patients (38.1%) who underwent re-TUR are available. 74% had multifocal tumors, 20% of tumors were more than 3 cm in diameter and 26% had concomitant CIS. In this subgroup of patients who underwent re-TUR, there was no residual disease in 267 patients (29%) and residual disease in 667 patients (71%): Ta in 378 (40%) and T1 in 289 (31%) patients. Age, gender, tumor status (primary/recurrent), previous intravesical therapy, tumor size, tumor multi-focality, presence of concomitant CIS, and muscle in the specimen were analyzed in order to evaluate risk factors of residual disease at re-TUR, both in univariate analyses and multivariate logistic regressions. RESULTS: The following were not risk factors for residual disease: age, gender, tumor status and previous intravesical chemotherapy. The following were univariate risk factors for presence of residual disease: no muscle in TUR, multiple tumors, tumors > 3 cm, and presence of concomitant CIS. Due to the correlation between tumor multi-focality and tumor size, the multivariate model retained either the number of tumors or the tumor diameter (but not both), p < 0.001. The presence of muscle in the specimen was no longer significant, while the presence of CIS only remained significant in the model with tumor size, p < 0.001. CONCLUSIONS: The most significant factors for a higher risk of residual disease at re-TUR in T1G3 patients are multifocal tumors and tumors more than 3 cm. Patients with concomitant CIS and those without muscle in the specimen also have a higher risk of residual disease.

History of urological malignancies before kidney transplantation, oncological outcome on the long term. / Antecedentes de neoplasias urológicas previos al trasplante renal. Resultados oncológicos a largo plazo.

INTRODUCTION: We aimed to report the oncological outcomes of ESRD patients with histories of urological malignancies who were subsequently submitted to kidney transplantation (KT). MATERIAL AND METHOD: Retrospective study lead in the Puigvert Foundation (Barcelona) registry of 1,200 KT performed from 1988 to 2018. Eighty-five urological malignancies that were treated before KT in 81 patients were identified: 15 (18%) prostate cancers, 49 (58%) RCC, 19 (22%) urothelial carcinomas and 2 (2%) testicular cancers. Baseline characteristics, cancer staging, treatment and follow-up were registered as well as the chronology of the start of dialysis, inscription on the waiting list and kidney transplantation. Endpoints included were cancer recurrence, metastatic progression, cancer-specific death and overall survival. RESULTS: In a median follow-up of 13.1 years (2.2-32), 16/85 (19%) cancer recurrences were reported, with 3 (4%) who progressed to metastasis and died of cancer. Median overall survival after cancer treatment was 25.3 years and cancer-specific survival was 95% at 25 years. Median time from cancer treatment to kidney transplantation was 4.8 years: 3.7 years in prostate cancer, 3.9 years in RCC and 8.8 years in bladder cancer. The median time from start of dialysis to kidney transplantation was 1.8 years in patients with histories of urological malignancy versus 0.5 year in the total cohort of 1,200 renal transplanted over the same period. CONCLUSIONS: Well-selected patients with histories of urological malignancies greatly benefit from kidney transplantation with infrequent and late cancer recurrence. Waiting time could be optimized in low-risk prostate cancer and RCC, but more robust data are needed.

Is Onabotulinum Toxin-A Combined Injection in the Bowel Patch and the Bladder Remnant a Safe Alternative to Bladder Re-Augmentation?

OBJECTIVE: To assess both the safety and efficacy, in terms of symptomatic improvement, of botulinum toxin injections distributed in the bowel patch and the bladder remnant of failed augmented bladders. MATERIALS AND METHODS: A retrospective study was performed on patients with augmented bladders who had presented with clinical and/or urodynamic failure and had received an onabotulinum1 toxin-A (BTX-A) injection at both the bowel and the bladder level due to refractoriness to oral treatment. The primary variable tested was safety, which was assessed by analysing the adverse effects according to the Clavien-Dindo classification. Subjective improvement was assessed by means of the Treatment Benefit Scale (TBS) as a secondary variable. RESULTS: Eight patients who underwent a total of 23 procedures were analysed. The mean age at first injection was 23 years. The mean interval between bladder augmentation and first BTX-A injection was 65.11 months. The mean interval between BTX-A injections was 11.6 months. No adverse effects due to systemic absorption were recorded. The only postoperative complication was an afebrile urinary infection (Clavien-Dindo 2) in 2 out of 23 procedures (8.7%). Eighty-six percent (19/22) of the procedures yielded a symptomatic benefit (TBS 1 and 2). CONCLUSION: Injection of onabotulinum toxin-A in both the bowel patch and the bladder remnant appears to be a safe and efficient technique for the symptomatic treatment of patients with bladder augmentation who have shown clinical and/or urodynamic failure in response to a conservative treatment. This procedure allows bladder re-augmentation to be delayed or even avoided.

Whole and hemi-gland cryoablation for primary localized prostate cancer: Short and medium-term oncological and functional outcomes. / Crioablación total o hemiglandular para el cáncer de próstata primario localizado: resultados oncológicos y funcionales a corto y medio plazo.

INTRODUCTION: To compare oncological, functional and post-operative outcomes of hemi (HC) vs. whole gland (WGC) cryoablation as first line treatment of localized prostate cancer. MATERIAL AND METHOD: Sixty-six consecutive patients undertaking whole-gland cryoablation (WGC=40) or hemi-cryoablation (HC=26) in a tertiary referral centre between 2010 and 2018 were included. All patients had a low-intermediate risk prostate cancer according to D'Amico risk classification. Hemi-ablation was proposed in case of biopsy and prostate MRI proven unilateral prostate cancer. Primary endpoint was Cryotherapy Failure for which 3 definitions were considered and compared: 1) biochemical failure (> PSA nadir+≥ 2 ng/mL), 2) positive prostate re-biopsy with Gleason score ≥ 7, 3) initiation of further prostate cancer treatment. RESULTS: Median patients age at treatment was 74 [42-81] vs. 76 [71-80] years in WGC vs. HC group, respectively (p=.08). Low and intermediate D'Amico risk group were 15% and 85% vs. 23% and 77% (p=.75), respectively. Median follow- up time was 41 [1.5-99.0] vs. 27 [0.9-93] months (p=.03). Four-years cryotherapy failure free survival in WGC vs. HC were 69% vs. 53% with definition 1 (p=.24), 82% vs. 80% with definition 2 (p=.95), 83% vs. 77% with definition 3 (p=.73). Early and 1-year urinary continence were 60% and 83% in WGC vs. 72% and 83% in HC (p=.26). De novo impotency after cryotherapy was 75% vs. 46% (p=.33) in WGC vs. HC. CONCLUSIONS: In our cohort of highly selected patients with unilateral low/intermediate risk PCa, hemi-cryoablation may provide similar oncological outcomes and less early complications compared to whole-gland cryoablation.

The role of human papilloma virus test in men: First exhaustive review of literature. / Evaluación del virus del papiloma humano en varones: primera revisión exhaustiva de la literatura.

Human papilloma virus (HPV) infection is the most common sexually transmitted infection worldwide. There is a high detection rate in sexually active young people but the risk, in males, persists over years. Currently, the American Center for Disease Control and Prevention does not recommend the evaluation of men for HPV and, the extant bibliography, backs up this stance for several reasons. Objective of the paper was to evaluate the usefulness of HPV detection methods for men; A comprehensive and exhaustive review of the literature was performed. Many are methods for HPV detection used in cervical cancer screening as well as in the study and management of patients with cytological alterations of the lower genital tract. Need for HPV detection methods in men are numerous: screening for both partner/gender; anogenital warts; recurrent respiratory papillomatosis; HPV-related cancer in men; fertility. No HPV test for men has been approved by the FDA, nor has any test been approved for detection of the virus in areas other than the cervix. Many are methods for HPV detection that have shown their usefulness in some of the pathologies associated with male HPV but, despite this, none of them has been approved for man.

EAU-ESMO consensus statements on the management of advanced and variant bladder cancer-an international collaborative multi-stakeholder effort: under the auspices of the EAU and ESMO Guidelines Committees†.

BACKGROUND: Although guidelines exist for advanced and variant bladder cancer management, evidence is limited/conflicting in some areas and the optimal approach remains controversial. OBJECTIVE: To bring together a large multidisciplinary group of experts to develop consensus statements on controversial topics in bladder cancer management. DESIGN: A steering committee compiled proposed statements regarding advanced and variant bladder cancer management which were assessed by 113 experts in a Delphi survey. Statements not reaching consensus were reviewed; those prioritised were revised by a panel of 45 experts before voting during a consensus conference. SETTING: Online Delphi survey and consensus conference. PARTICIPANTS: The European Association of Urology (EAU), the European Society for Medical Oncology (ESMO), experts in bladder cancer management. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Statements were ranked by experts according to their level of agreement: 1-3 (disagree), 4-6 (equivocal), 7-9 (agree). A priori (level 1) consensus was defined as ≥70% agreement and ≤15% disagreement, or vice versa. In the Delphi survey, a second analysis was restricted to stakeholder group(s) considered to have adequate expertise relating to each statement (to achieve level 2 consensus). RESULTS AND LIMITATIONS: Overall, 116 statements were included in the Delphi survey. Of these, 33 (28%) statements achieved level 1 consensus and 49 (42%) statements achieved level 1 or 2 consensus. At the consensus conference, 22 of 27 (81%) statements achieved consensus. These consensus statements provide further guidance across a broad range of topics, including the management of variant histologies, the role/limitations of prognostic biomarkers in clinical decision making, bladder preservation strategies, modern radiotherapy techniques, the management of oligometastatic disease and the evolving role of checkpoint inhibitor therapy in metastatic disease. CONCLUSIONS: These consensus statements provide further guidance on controversial topics in advanced and variant bladder cancer management until a time where further evidence is available to guide our approach.

Updates on intravesical therapy.

PURPOSE OF REVIEW: To review the current literature concerning the intravesical treatment of nonmuscle invasive bladder cancer. RECENT FINDINGS: Bladder cancer is a high prevalent disease. Despite the recognized efficacy of traditional intravesical therapies, the best treatment strategy still needs to be found. Improvement in bladder cancer research lead to develop new intravesical agents and drug delivery systems for nonmuscle invasive bladder cancer tumours. Moreover, the emerging knowledge of bladder cancer immune profile strongly improves and provides new available treatment strategies. SUMMARY: The future of nonmuscle invasive bladder cancer therapy will be influenced by the development of immunotherapy and new technologies for device-assisted treatment. Moreover, nanotechnology and delivery systems present promising results.

Totally fluoroless retrograde intrarenal surgery technique in prestented patients: tips and tricks.

Treatment of urolithiasis has evolved greatly as retrograde intrarenal surgery (RIRS) has gained popularity nowadays being a gold standard therapy for renal stones up to 2 cm. Endourological procedures are traditionally fluoroscopic guided; thus, an increasing concern is the harm of radiation exposure, especially in the pediatric population. Therefore, performing fluoroless RIRS should be a feasible option for pediatric urologists. Herein, we describe the technique of totally fluoroless RIRS in presented patients and the tips to avoid radiation use at most.

The 1973 WHO and 2004 WHO grading systems are not equal in prediction of survival among stage T1 bladder cancer patients. / Los sistemas de clasificación de la OMS de 1973 y 2004 difieren en la predicción de supervivencia entre los pacientes con cáncer de vejiga en estadio T1.

INTRODUCTION AND OBJECTIVES: The aim of this study was to analyse prognostic impact of tumour histological grade on survival differences between primary G2 and G3 WHO1973 stage T1 tumours which were graded as HG according to WHO2004 grading system. MATERIALS AND METHODS: Data from 481 patients with primary T1HG bladder cancer who were treated between 1986 and 2016 in 2university centres were retrospectively reviewed. Log-rank test and Cox regression analysis was performed to compare the groups. RESULTS: 95 (19,8%) tumours were classified as G2 and 386 (80,2%) were G3. Median follow-up was 68 months. The recurrence was observed in 228 (47,5%), and progression in 109 patients (22,7%). Radical cystectomy was performed in 114 pts (23,7%) and there were 64 (13,3%) cancer specific deaths. Recurrence-free rates at 5-years follow-up for G2, G3 and all patients were 68,7%, 51,2% and 56,3% and progression-free rates were 89,3%, 73,2% and 78,1% respectively. For total observation period patients with G3 tumours presented also worse recurrence-free, and progression-free survival levels than patients with G2 tumours. In multivariate analysis, after adjustment for clinical features, the risk of recurrence and progression for G3 tumours was 1,65 and 2,42 fold higher than for G2 tumours. CONCLUSIONS: It was shown that G3 T1 tumours are characterized by worse recurrence free and progression free survivals when compared to G2 cancers.

Validation of the CUETO scoring model for predicting recurrence and progression in T1G3 urothelial carcinoma of the bladder. / Validación de las tablas del grupo CUETO para predecir la recurrencia y progresión del carcinoma urotelial de vejiga T1G3.

INTRODUCTION AND OBJECTIVES: Various studies tried to validate Club Urológico Español de Tratamiento Oncológico (CUETO) tables, yet, none of this papers focused on the high and very high risk bladder cancers. The aim of the study was to externally validate the CUETO model for predicting disease recurrence and progression in group of T1G3 tumors treated with BCG immunotherapy. PATIENTS OR MATERIALS AND METHODS: Data from 414 patients with primary T1G3 bladder cancer were analysed. To evaluate the model discrimination, Cox proportional hazard regression models were created and concordance indexes were calculated. RESULTS: The median follow-up was 68 months. The recurrence was observed in 212 (51.2%) and 64 patients (15.5%) experienced the recurrence more than once during the study follow-up. Progression of the cancer was observed in 106 patients (25.6%). Radical cystectomy was performed in 115 patients (27.8%) and there were 64 (15.5%) cancer specific deaths. For recurrence and progression probability, the concordance index of the CUETO models was 0.633 and 0.697 respectively. CUETO tables underestimated significantly the risk of recurrence and marginally the risk of progression in the first year of observation. For 5 years of observation, the trend for the recurrence was much less clear. On the contrary, there was slight overestimation in the risk of progression. The study is limited by retrospective nature. CONCLUSIONS: It was shown that the CUETO risk tables exhibit a fair discrimination for both disease recurrence and progression in T1G3 patients treated with BCG. CUETO scoring model underestimates the risk of tumor recurrence, but predicts well risk of progression.