The importance of second-look ureteroscopy implementation in the conservative management of upper tract urothelial carcinoma.

PURPOSE: The purpose of the study was to evaluate the effect of second-look ureteroscopy (SU) in the endoscopic operative work-up of patients with upper tract urothelial carcinoma (UTUC). MATERIALS AND METHODS: Patients with UTUC who underwent SU between 2016 and 2021 were included. Cancer detection rate (CDR) at SU was defined as endoscopic visualization of tumor. The effect of SU on recurrence-free survival (RFS), radical nephroureterectomy-free survival (RNU-FS), bladder cancer-free survival (BC-FS), and cancer-specific survival (CSS) was estimated using the Kaplan-Meier method. Multivariate logistic regression analysis (MLR) assessed predictors of negative SU. Finally, we evaluated the effect of SU timing on oncological outcomes, classifying SUs as "early" (≤ 8 weeks) and "late" (> 8 weeks). RESULTS: Overall, 85 patients underwent SU. The CDR at SU was 44.7%. After a median follow-up was 35 (IQR: 15-56) months, patients with positive SU had a higher rate of UTUC recurrence (47.4% vs 19.1%, p = 0.01) and were more frequently radically treated (34.2% vs 8.5%, p = 0.007). Patients with high-grade disease (hazard ratio [HR]: 3.14, 95% CI 1.18-8.31; p = 0.02) had a higher risk of UTUC recurrence, while high-grade tumor (HR: 3.87, 95%CI 1.08-13.77; p = 0.04) and positive SU (HR: 4.56, 95%CI 1.05-22.81; p = 0.04) were both predictors of RNU. Low-grade tumors [odds ratio (OR): 5.26, 95%CI 1.81-17.07, p = 0.003] and tumor dimension < 20 mm (OR: 5.69, 95%CI 1.48-28.31, p = 0.01) were predictors of negative SU. Finally, no significant difference emerged regarding UTUC recurrence, RNU, BC-FS, and CSM between early vs. late SUs (all p > 0.05). CONCLUSIONS: SU may help in identifying patients with UTUC experiencing an early recurrence after conservative treatment. Patients with low-grade and small tumors are those in which SU could be safely postponed after 8 weeks.

[ROWING AGAINST THE CURRENT]. / REMANDO A CONTRACORRIENTE.

At Lalonde we know that the determinants that most influence the health of the population are lifestyle, genetics and the environment. Health represents only 10% and is the determinant that consumes the most resources. It has been shown that a salutogenic approach focused on the social determinants of health and the support of public policies to improve the environment are more efficient in the long term than medicine focused on hospitals, technology and super-specialization. Primary Care (PC) that has an approach centered on the person and families with a community vision, is the ideal level to provide health care, and to influence lifestyles. However it is not invested in PC. In this article we review the socioeconomic and political factors that globally influence the lack of interest in the development of PC.

Thulium Fiber Laser Versus Holmium:Yttrium Aluminum Garnet for Lithotripsy: A Systematic Review and Meta-analysis.

CONTEXT: Thulium fiber laser (TFL) emerged as a competitor of holmium:yttrium aluminum garnet (Ho:YAG) laser for the treatment of urinary stones. OBJECTIVE: To compare the efficacy between Ho:YAG and TFL for laser lithotripsy of renal and ureteral stones. EVIDENCE ACQUISITION: A literature search was conducted using PubMed/Medline, Embase, and Web of Science databases to identify reports published until May 2023. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed to identify eligible studies. The primary outcome was to compare the stone-free rate (SFR) between Ho:YAG and TFL for laser lithotripsy. EVIDENCE SYNTHESIS: Eleven studies met our inclusion criteria, and data from 1286 and 880 patients who underwent, respectively, Ho:YAG and TFL laser lithotripsy were reviewed. Most studies included ureteroscopy (URS) and retrograde intrarenal surgeries as procedures, two included percutaneous nephrolithotomy, and one included URS exclusively. Only two studies reported results in pediatric patients. TFL was associated with a higher SFR (odds ratio [OR] 1.84, 95% confidence interval [CI]: 1.06-3.20; p = 0.031) when no residual fragment is considered, but not when SFR refers to the presence of fragments <3 mm (OR 2.48, 95% CI: 0.98-6.29; p = 0.055) or when only Ho:YAG with MOSES is considered (p = 0.068). According to the stones' location, TFL was associated with higher SFRs than Ho:YAG for renal (OR 3.14, 95% CI: 1.69-5.86; p < 0.001) but not for ureteral (p = 0.8) stones. TFL was associated with a lower intraoperative complication rate (OR 0.34, 95% CI: 0.19-0.63; p < 0.001). No difference was found in major (p = 0.4) or overall (p = 0.4) complication rate, operative time (p = 0.051), and laser time (p = 0.9). CONCLUSIONS: TFL is a promising laser for the treatment of urinary stones with some advantages over Ho:YAG. Further high-quality studies are needed to confirm these findings and optimize the surgical settings. PATIENT SUMMARY: The use of thulium fiber laser rather than holmium:yttrium aluminum garnet permits to reach a higher stone-free rate in stones located in the kidney rather than in the ureter.

Topical instillation of BCG immunotherapy for biopsy-proven primary upper urinary tract carcinoma in situ: A single institution series and systematic review.

Primary upper tract carcinoma in situ (UTcis) is a rare disease whose diagnosis and natural history are poorly understood. Radical nephroureterectomy is the standard of care but in imperatives or selected cases, topical instillations of Bacillus Calmette-Guérin (BCG) may represent a good alternative. The aim of this study was to report the histologic response to BCG instillations for the treatment of biopsy-proven UTcis and to systematically assess the current evidence on topical BCG instillation for the treatment of UTcis. This is a retrospective analysis of patients with biopsy-proven UTcis treated with BCG instillation between 1995 and 2020 in an expert center. The initial diagnosis was performed by a standardized random biopsy scheme during ureterorenoscopy (URS) in patients with positive cytology but negative CT and bladder biopsies. BCG course consisted of 6 weekly instillation of 81 mg Immucyst (Sanofi Pasteur MSD AG, Baar, Switzerland). Administration techniques were single-J, double-J and nephrostomy tube. The primary outcome was the rate of complete histological response at the 3-month 2nd-look-URS. Kaplan-Meier analysis curves assessed recurrence- and progression-free survival. A total of 22 patients (23 renal units) were included. Twenty-one (91.3%) patients completed the planned 6-week instillation cycle. Only one major complication was recorded (renal tuberculosis). Twenty patients had a 3-month 2nd-look-URS, with a complete histological response achieved in 17/20 cases (85%). After a median time of follow-up of 40 months (30-62), 8/20 patients harbored disease recurrence, including 5 cases of disease progression (≥pT2). The main limitations are the retrospective and non-comparative design of the study. Our systematic review (CRD42022324876) identified 15 studies (289 renal units). UTcis suffers from the lack of a standardized definition, and considerable heterogeneity has been found in making the diagnosis and assessing the response to treatment. Our study is the first to propose a histological diagnosis of UTcis as well as a histological re-evaluation of the response to treatment. Topical instillations of BCG appear to be a promising alternative, avoiding radical treatment in the majority of cases.

Implementing a Checklist for Transurethral Resection of Bladder Tumor to Standardize Outcome Reporting: When High-quality Resection Could Influence Oncological Outcomes.

Several randomized controlled trials (RCTs) comparing en bloc resection of bladder tumor (ERBT) to conventional transurethral resection of bladder tumor (cTURBT) have reported controversial results. In particular, the 1-yr recurrence rate ranged from 5% to 40% for ERBT and from 11% to 31% for cTURBT. We provide an updated analysis of an RCT comparing the 1-yr recurrence rate for ERBT versus cTURBT for a cohort of 219 patients comprising 123 (56.2%) in the ERBT group and 96 (43.8%) in the cTURBT group. At 1 yr, 11 patients in the ERBT group and 12 in the cTURBT group experienced recurrence. The heterogeneity in recurrence observed in other RCTs could be explained by the scarce and heterogeneous adoption of tools and techniques that have been proved to lower the recurrence rate, supporting the need for implementation of a TURBT checklist. This prompted us to create a checklist of items for RCTs to standardize how TURBT is performed in trials, facilitate comparison between studies, assess the applicability of results in real-life practice, and provide a push towards high-quality resections to improve oncological outcomes. The checklist could have utility as a user-friendly guide for reporting TURBT procedures to improve our understanding of trials involving this procedure. Patient summary: We compared the recurrence rate at 1 year for bladder cancer treated with two different approaches to remove bladder tumors in our center. The rates were comparable for the two groups. Other studies have found widely differing recurrence rates, so we propose use of a checklist to standardize these procedures and provide more consistent outcomes for patients.

Long-Term Oncologic Outcomes of Endoscopic Management of High-Risk Upper Tract Urothelial Carcinoma: The Fundació Puigvert's Experience.

Objectives: Many patients with upper tract urothelial carcinoma (UTUC) outside of the low-risk criteria may possess low absolute risks of distant progression. Herein, we hypothesized that careful selection of high-risk patients undergoing an endoscopic approach could result in acceptable oncologic outcomes. Materials and Methods: Patients with high-risk UTUC managed endoscopically between 2015 and 2021 were retrospectively identified from a prospectively maintained single academic institution database. Elective and imperative indications for endoscopic treatment were considered. Regarding elective indications, the decision to perform endoscopic treatment was systematically proposed to high-risk patients in whom macroscopically complete ablation was deemed feasible, excluding invasive appearance on CT scan, and without histologic variant. Results: A total of 60 patients with high-risk UTUC met our inclusion criteria (29 imperative and 31 elective indications). The median follow-up in patients without any event was 36 months. At 5 years, the estimated overall survival, cancer-specific survival, metastasis-free survival, UTUC recurrence-free survival, radical nephroureterectomy-free survival, and bladder recurrence-free survival were 57% (41-79), 75% (57-99), 86% (71-100), 56% (40-76), 81% (70-93), and 69% (54-88), respectively. All oncologic outcomes were similar between patients with elective and imperative indications (all log-rank p > 0.05). Conclusions: In conclusion, we report the first large series of endoscopic treatment in patients with high-risk UTUC, arguing that promising oncologic outcomes can be achieved in properly selected candidates. We encourage multi-institutional collaborative work as a large cohort of high-risk patients treated endoscopically may allow subgroup analyses to define the best candidates.

Alongshore upwelling modulates the intensity of marine heatwaves in a temperate coastal sea.

Analyses of long-term temperature records based on satellite data have revealed an increase in the frequency and intensity of marine heatwaves (MHWs) in the world oceans, a trend directly associated with global change according to climate model simulations. However, these analyses often target open ocean pelagic systems and rarely include local scale, field temperature records that are more adequate to assess the impact of MHWs close to the land-sea interface. Here, we compared the incidence and characteristics of open ocean MHWs detected by satellites with those observed in the field over two decades (1998-2019) at two temperate intertidal locations in the central Cantabrian Sea, southern Bay of Biscay. Satellite retrievals tended to smooth out cooling events associated with intermittent, alongshore upwelling, especially during summer. These biases propagated to the characterization of MHWs and resulted in an overestimation of their incidence and duration close to the coast. To reconcile satellite and field records, we developed a downscaling approach based on regression modeling that enabled the reconstruction of past temperatures and analyze MHW trends. Despite the cooling effect due to upwelling, the temperature reconstructions revealed a six-fold increase in the incidence of MHWs in the Cantabrian Sea over the last four decades. A comparison between static (no trend) vs. dynamic (featuring a linear warming trend) MHW detection thresholds allowed us to attribute over half of the increase in MHW incidence to the ocean warming trend. Our results highlight the importance of local processes to fully characterize the complexity and impacts of MHWs on marine coastal ecosystems and call for the conservation of climate refugia associated with coastal upwelling to counter the impacts of climate warming.

Martensitic transformation of austenitic stainless steel orthodontic wires during intraoral exposure.

INTRODUCTION: Our purpose was to study the mechanical properties and phase transformations of orthodontic wires submitted to in-vivo exposure in the mouth for different periods of time. METHODS: Stainless steel wires were tied to fixed orthodontic appliances of 30 patients from the orthodontics clinic of Universidade Federal do Rio de Janeiro School of Dentistry in Brazil. According to the duration of the clinical treatment, the patients were divided into 3 groups. After in-vivo exposure, the samples were studied by mechanical testing (torsion) and ferromagnetic resonance. Statistical analyses were carried out to evaluate the correlation between time of exposure, mechanical properties, and austenite-to-martensite transformation among the groups. RESULTS: The results were compared with as-received control samples. The torque values increased as time in the mouth increased. The increase in torque resistance showed high correlations with time of exposure (P = 0.005) and austenite-martensite phase transformation. CONCLUSIONS: The resistance of stainless steel orthodontic wires increases as the time in the mouth increases; this effect is attributed to the austenite-to-martensite transformation.

A planetesimal orbiting within the debris disc around a white dwarf star.

Many white dwarf stars show signs of having accreted smaller bodies, implying that they may host planetary systems. A small number of these systems contain gaseous debris discs, visible through emission lines. We report a stable 123.4-minute periodic variation in the strength and shape of the Ca ii emission line profiles originating from the debris disc around the white dwarf SDSS J122859.93+104032.9. We interpret this short-period signal as the signature of a solid-body planetesimal held together by its internal strength.

Puberdade precoce: informações de interesse para o ortodontista / Early puberty: information of interest to the orthodontist

A puberdade é um período de modificações biopsicossociais intensas, pelo qual os indivíduos passam até que alcancem a maturidade sexual. Pode ser diagnosticada, clinicamente, por meio do surgimento das características sexuais secundárias. Nesse período, ocorrem as taxas de crescimento mais significativas da face, constituindo um momento de grande interesse para o ortodontista, no manejo das desarmonias esqueléticas faciais. Algumas crianças atingem a puberdade em idade anterior à média populacional, o que é denominado puberdade precoce. Este trabalho visa apresentar uma revisão da literatura sobre puberdade normal e puberdade precoce, direcionada ao diagnóstico ortodôntico, ilustrando idades dentária e esquelética precoces, em relação à idade cronológica, em uma paciente de 8 anos de idade. A idade óssea é a forma mais indicada para determinar o melhor momento de intervenção ortopédica na face, inclusive em pacientes portadores de puberdade precoce, nos quais o crescimento puberal pode ser finalizado antes mesmo de ser completada a troca dos molares decíduos.