Postoperative Mortality Rate after Radical Cystectomy: A Systematic Review of Epidemiologic Series.

INTRODUCTION: Mortality after radical cystectomy (RC) varies widely in the literature. In cohort studies, mortality rates can vary from as low as 0.5% in large-volume academic centers (2) to as high as 25% in developing countries series. This study aims to perform a systematic review of population-based studies reporting mortality after RC. METHODS: A Systematic search was performed in Medline (PubMed®), Embase, and Cochrane for epidemiologic studies reporting mortality after RC. Institutional cohorts and those reporting mortality for specific groups within populations were excluded. Case series and non-epidemiologic series were also excluded. The aim of this review is to evaluate in-hospital mortality (IHM), 30-day mortality (30M), and 90-day mortality (90M). RESULTS: Systematic search resulted in 42 papers comprising 449,661 patients who underwent RC from 1984 to 2017. Mean age was 66.1. Overall IHM, 30M, and 90M were 2.6%, 2.7%, and 4.9%, respectively, with 90M being 2.6 times higher than IHM on average. Lowest IHM was found in Canada and Australia (0.2% and 0.6%, respectively), while the highest IHM was 7.8% (Brazil). Canada and Spain showed the highest 90M (6.5%). 159,584 urinary diversions were analyzed, being mostly ileal conduits (76.8%). CONCLUSIONS: The majority of the studies available are from major developed economies with paucity of data in the developing world. 90M after RC tends to be at least twice as high as IHM. The knowledge of such epidemiologic data is vital to guide public policies, such as centralization, in order to reduce mortality.

International Bladder Cancer Group Consensus Statement on Clinical Trial Design for Patients with Bacillus Calmette-Guérin-exposed High-risk Non-muscle-invasive Bladder Cancer.

CONTEXT: A large proportion of patients with non-muscle-invasive bladder cancer (NMIBC) fall in the gap between bacillus Calmette-Guérin (BCG)-naïve and BCG-unresponsive disease. As multiple therapeutic agents move into this gray area, there is a critical need to define the disease state and establish recommendations for optimal trial design. OBJECTIVE: To develop a consensus on optimal trial design for patients with BCG-exposed NMIBC, defined as high-grade recurrence after BCG treatment that does not meet the criteria for BCG-unresponsive disease. EVIDENCE ACQUISITION: We conducted a literature review using the Cochrane Library, Medline, and Embase and a review of clinical trials in ClinicalTrials.gov as a basis to generate consensus recommendations for clinical trial design in BCG-exposed NMIBC. EVIDENCE SYNTHESIS: BCG-exposed NMIBC encompasses BCG resistance (presence of high-grade Ta or carcinoma in situ [CIS] at 3-mo evaluation after induction BCG) and delayed relapse. Randomized controlled trials are required to compare experimental therapies to a control arm receiving additional BCG, although ongoing BCG shortages may impact our ability to follow an optimal trial design. A placebo should be used in combination with BCG if the treatment arm includes BCG plus a study drug. Trials will either need to separate patients with and without CIS into two cohorts, or stratify by the presence of CIS at the time of randomization. If two cohorts are used, the primary endpoint for CIS patients should be complete response within a predetermined time. The primary endpoint in a cohort with Ta/T1 only, or if a single combined cohort is used, should be the duration of event-free survival. Suggested efficacy thresholds and corresponding sample sizes are provided. CONCLUSIONS: The International Bladder Cancer Group has developed recommendations regarding definitions, endpoints, and clinical trial design for BCG-exposed NMIBC to encourage uniformity among studies in this disease state. PATIENT SUMMARY: Our consensus provides a precise definition of the disease state for bladder cancer not invading the bladder muscle and exposed to bacillus Calmette-Guérin (BCG) treatment. Clear guidance for conducting optimal clinical trials in this disease setting was established and we believe that this will promote further progress in this field.

Clinical and cost effectiveness of hexaminolevulinate-guided blue-light cystoscopy: evidence review and updated expert recommendations.

CONTEXT: Non-muscle-invasive bladder cancer (NMIBC) is associated with a high recurrence risk, partly because of the persistence of lesions following transurethral resection of bladder tumour (TURBT) due to the presence of multiple lesions and the difficulty in identifying the exact extent and location of tumours using standard white-light cystoscopy (WLC). Hexaminolevulinate (HAL) is an optical-imaging agent used with blue-light cystoscopy (BLC) in NMIBC diagnosis. Increasing evidence from long-term follow-up confirms the benefits of BLC over WLC in terms of increased detection and reduced recurrence rates. OBJECTIVE: To provide updated expert guidance on the optimal use of HAL-guided cystoscopy in clinical practice to improve management of patients with NMIBC, based on a review of the most recent data on clinical and cost effectiveness and expert input. EVIDENCE ACQUISITION: PubMed and conference searches, supplemented by personal experience. EVIDENCE SYNTHESIS: Based on published data, it is recommended that BLC be used for all patients at initial TURBT to increase lesion detection and improve resection quality, thereby reducing recurrence and improving outcomes for patients. BLC is particularly useful in patients with abnormal urine cytology but no evidence of lesions on WLC, as it can detect carcinoma in situ that is difficult to visualise on WLC. In addition, personal experience of the authors indicates that HAL-guided BLC can be used as part of routine inpatient cystoscopic assessment following initial TURBT to confirm the efficacy of treatment and to identify any previously missed or recurrent tumours. Health economic modelling indicates that the use of HAL to assist primary TURBT is no more expensive than WLC alone and will result in improved quality-adjusted life-years and reduced costs over time. CONCLUSIONS: HAL-guided BLC is a clinically effective and cost-effective tool for improving NMIBC detection and management, thereby reducing the burden of disease for patients and the health care system. PATIENT SUMMARY: Blue-light cystoscopy (BLC) helps the urologist identify bladder tumours that may be difficult to see using standard white-light cystoscopy (WLC). As a result, the amount of tumour that is surgically removed is increased, and the risk of tumour recurrence is reduced. Although use of BLC means that the initial operation costs more than it would if only WLC were used, over time the total costs of managing bladder cancer are reduced because patients do not need as many additional operations for recurrent tumours.

Efficacy of robot-assisted radical cystectomy (RARC) in advanced bladder cancer: results from the International Radical Cystectomy Consortium (IRCC).

OBJECTIVE: To characterise the surgical feasibility and outcomes of robot-assisted radical cystectomy (RARC) for pathological T4 bladder cancer. PATIENTS AND METHODS: Retrospective evaluation of a prospectively maintained International Radical Cystectomy Consortium database was conducted for 1118 patients who underwent RARC between 2003 and 2012. We dichotomised patients based on pathological stage (≤pT3 vs pT4) and evaluated demographic, operative and pathological variables in relation to morbidity and mortality. RESULTS: In all, 1000 ≤pT3 and 118 pT4 patients were evaluated. The pT4 patients were older than the ≤pT3 patients (P = 0.001). The median operating time and blood loss were 386 min and 350 mL vs 396 min and 350 mL for p T4 and ≤pT3, respectively. The complication rate was similar (54% vs 58%; P = 0.64) among ≤pT3 and pT4 patients, respectively. The overall 30- and 90-day mortality rate was 0.4% and 1.8% vs 4.2% and 8.5% for ≤pT3 vs pT4 patients (P < 0.001), respectively. The body mass index (BMI), American Society of Anesthesiology score, length of hospital stay (LOS) >10 days, and 90-day readmission were significantly associated with complications in pT4 patients. Meanwhile, BMI, LOS >10 days, grade 3-5 complications, 90-day readmission, smoking, previous abdominal surgery and neoadjuvant chemotherapy were significantly associated with mortality in pT4 patients. On multivariate analysis, BMI was an independent predictor of complications in pT4 patients, but not for mortality. CONCLUSIONS: RARC for pT4 bladder cancer is surgically feasible but entails significant morbidity and mortality. BMI was independent predictor of complications in pT4 patients.

The use of immediate postoperative instillations of intravesical chemotherapy after TURBT of NMIBC among European countries.

PURPOSE: The aim of this study was to assess the use of immediate postoperative instillation of intravesical chemotherapy (IPOIC) after transurethral resection of bladder tumour (TURBT) of nonmuscle invasive bladder cancer (NMIBC) in Europe. METHODS: Urologists based in five European Union nations were asked to extract information from the records of patients with NMIBC-urothelial carcinoma who received at least one TURBT. Multivariate logistic regression models were developed to determine the significant predictors of IPOIC usage. Data were weighted to control for country-to-country and other differences. RESULTS: Overall, 324 urologists (58 France, 72 Germany, 62 Italy, 65 Spain, 67 United Kingdom) were involved; the participation rate was 55 %. Overall, 771 patients received 954 TURBTs (mean-1.2/patient), of which 413 of the TURBTs (43.3 %) were administered IPOIC . Sixty-six of the 413 IPOICs (16.0 %) were for a recurrent tumour. Five of the tested variables were significantly associated with a patient's likelihood of receiving IPOIC after TURBT. Variables in the order of significance are as follows: (1) country (United Kingdom, patients most likely to receive IPOIC; France, least likely); (2) progression risk (physician assessed) [lower-risk conditions (no CIS, tumour < 3 cm) or intermediate risk-more likely]; (3) whether urologist completed a uro-oncology fellowship (completed-more likely); (4) recurrence risk (physician assessed) [higher-risk conditions (≥T2, ≥3 cm, CIS)-more likely]; and (5) physician's NMIBC patients volume (higher volume-more likely). CONCLUSIONS: This study revealed wide practice variation and substantial noncompliance with European Association of Urology Guidelines on the use of IPOIC after TURBT for NMIBC.

Treatment options available for bacillus Calmette-Guérin failure in non-muscle-invasive bladder cancer.

CONTEXT: Intravesical bacillus Calmette-Guérin (BCG) is a standard conservative treatment for patients with high-risk non-muscle-invasive bladder cancer (NMIBC). Many patients will experience recurrence or progression following BCG and are termed BCG failures. OBJECTIVE: To summarise the current treatment options available for patients with high-risk NMIBC who experience BCG failure. EVIDENCE ACQUISITION: We searched the Medline, Embase, and Cochrane Trials databases for studies of BCG failure using predetermined relevant Medical Subject Heading terms and free text terms. EVIDENCE SYNTHESIS: Radical cystectomy (RC) should be strongly recommended when a patient has been deemed to fail BCG, if the patient is fit and fully informed of the risks, benefits, and quality-of-life issues. RC achieves long-term survival in excess of 90% with ongoing improvements in morbidity. While other salvage intravesical therapies have to be considered oncologically inferior to RC, several options are now available if bladder preservation is the objective. The options can be categorised as immunotherapy, chemotherapy, device-assisted therapy, and sequential combinations of these newer modalities with conventional therapy. Some agents have shown specific promise in BCG-failure patients (eg, gemcitabine, thermochemotherapy, taxane chemotherapy), and some modalities have been shown to be effective only in non-BCG-failure cohorts (eg, electromotive mitomycin). CONCLUSIONS: The definition, prediction, and treatment of BCG failure remain unclear secondary to inconsistent studies and the heterogeneous entity of patients with NMIBC. RC should be the default position upon failing BCG, but if bladder preservation is sought, then several promising intravesical salvage options are available. It will be necessary to individually tailor the management of such patients based on tumour risk and medical profiles. Currently data are still inadequate to formulate definitive recommendations, and larger studies of salvage intravesical agents are urgently required.

EAU guidelines on non-muscle-invasive urothelial carcinoma of the bladder, the 2011 update.

CONTEXT AND OBJECTIVE: To present the 2011 European Association of Urology (EAU) guidelines on non-muscle-invasive bladder cancer (NMIBC). EVIDENCE ACQUISITION: Literature published between 2004 and 2010 on the diagnosis and treatment of NMIBC was systematically reviewed. Previous guidelines were updated, and the level of evidence (LE) and grade of recommendation (GR) were assigned. EVIDENCE SYNTHESIS: Tumours staged as Ta, T1, or carcinoma in situ (CIS) are grouped as NMIBC. Diagnosis depends on cystoscopy and histologic evaluation of the tissue obtained by transurethral resection (TUR) in papillary tumours or by multiple bladder biopsies in CIS. In papillary lesions, a complete TUR is essential for the patient's prognosis. Where the initial resection is incomplete or where a high-grade or T1 tumour is detected, a second TUR should be performed within 2-6 wk. In papillary tumours, the risks of both recurrence and progression may be estimated for individual patients using the scoring system and risk tables. The stratification of patients into low-, intermediate-, and high-risk groups-separately for recurrence and progression-is pivotal to recommending adjuvant treatment. For patients with a low risk of tumour recurrence and progression, one immediate instillation of chemotherapy is recommended. Patients with an intermediate or high risk of recurrence and an intermediate risk of progression should receive one immediate instillation of chemotherapy followed by a minimum of 1 yr of bacillus Calmette-Guérin (BCG) intravesical immunotherapy or further instillations of chemotherapy. Papillary tumours with a high risk of progression and CIS should receive intravesical BCG for 1 yr. Cystectomy may be offered to the highest risk patients, and it is at least recommended in BCG failure patients. The long version of the guidelines is available from the EAU Web site (www.uroweb.org). CONCLUSIONS: These abridged EAU guidelines present updated information on the diagnosis and treatment of NMIBC for incorporation into clinical practice.

[Laparoscopic renal cryotherapy: preliminary experience]. / Crioterapia renal laparoscópica: experiencia inicial.

OBJECTIVE: Renal cryotherapy has been described as a minimally invasive procedure that represents an alternative for selected patients with small renal tumors. Our preliminary experience with this procedure is reported. MATERIAL AND METHODS: [corrected] Eighteen patients with 21 tumors with a mean tumor size of 2.2 cm (1-4) in the preoperative CT scan underwent renal cryotherapy using a double freeze-thaw cycle. The group consisted of 14 males (64%) and 4 females (18% with a mean age of 68 years (32-84). All patients had undergone prior surgery for renal tumor in the treated or the opposite kidney. A transperitoneal laparoscopic approach was used in all patients. RESULTS: Mean operating time was 196 minutes (120-140), and no patient received transfusions during or after surgery. No complications occurred in 14 patients (64%). Perirenal abscess, splenic laceration, ureteral lesion, and polar artery lesion occurred in one patient each. Peroperative biopsy was performed in 5 patients (22.7%) and was positive for renal cancer in two cases, while material was insufficient in three patients. Mean hospital stay was 6 days (2-16). Creatinine levels were 106 mg% (48-230) before surgery and 123 mg/% (52-270) 6 months after surgery. A CT scan was performed in all patients one and six months after surgery, showing a residual enhancement area in two of them. Sixteen patients (88.8%) are disease-free after a mean follow-up time of 46 months (6-116). Metastatic disease occurred in two patients (11%) in the setting of a prior renal tumor in the same or the opposite kidney and required treatment with antiangiogenic agents. CONCLUSIONS: This is the largest series reporting renal cryosurgery in Spain, in complex cases and with adequate follow-up. Results are encouraging and allow for considering renal cryotherapy among the minimally invasive procedures for nephron-sparing surgery.

Crioterapia renal laparoscópica: experiencia inicial / Laparoscopic renal cryotherapy: preliminary experience

Objetivo: La crioterapia renal se ha descrito como una técnica mínimamente invasiva que constituye una alternativa para pacientes seleccionados con tumores renales de pequeño tamaño. Presentamos nuestra experiencia preliminar con este procedimiento. Material y métodos: Dieciocho pacientes (21 tumores) con un tamaño medio de 2,2 cm (1-4) en TC prequirúrgico se trataron mediante crioterapia renal con doble ciclo de congelación. Catorce (64%) varones y 4 (18%) mujeres con una edad media de 68 años (32-84). Todos los pacientes habían tenido cirugías previas: 3 por tumor renal en el riñón que recibió el tratamiento o en el contralateral. El abordaje fue laparoscópico transperitoneal en todos los pacientes. Resultados: La media de tiempo operatorio fue de 196 min (120-420) y ningún paciente recibió transfusión intra o postoperatoria. No presentaron complicaciones 14 (64%) pacientes, y hubo un absceso perirrenal en 1 caso, laceración esplénica (1), lesión ureteral (1) y lesión de la arteria polar (1). Se realizó biopsia peroperatoria en 5 (22,7%) casos, que resultó positiva para carcinoma renal en 2 casos y material insuficiente en 3. La estancia media fue de 6 días (2-16). Los valores de creatinina preoperatorios fueron de 106 mg/% ( 48-230) y a los 6 meses de 123 mg/% (52-270). En todos los pacientes se realizó una tomografía computariza al mes y a los 6 meses de la cirugía; en 2 de ellos había una zona hipercaptante residual. Con un tiempo medio de seguimiento de 46 meses (6-116), 16 (88,8%) pacientes se encuentran libres de enfermedad. En 2 (11%) casos apareció enfermedad metastásica en el contexto de un enfermedad previa tumoral en el mismo riñón o en el contralateral, que requirió tratamiento con antiangiogénicos. Conclusiones: Se trata de la serie más amplia en nuestro país, en casos complejos y con un buen seguimiento. Los resultados son prometedores y permiten considerar la crioterapia del tumor renal dentro de las técnicas mínimamente invasivas de cirugía conservadora renal (AU)

Objective: Renal cryotherapy has been described as a minimally invasive procedure that represents an alternative for selected patients with small renal tumors. Our preliminary experience with this procedure is reported. Material y methods: Eighteen patients with 21 tumors with a mean tumor size of 2.2 cm (1-4) in the preoperative CT scan underwent renal cryotherapy using a double freeze-thaw cycle. The group consisted of 14 males (64%) and 4 females (18% with a mean age of 68 years (32-84). All patients had undergone prior surgery for renal tumor in the treated or the opposite kidney. A transperitoneal laparoscopic approach was used in all patients. Results: Mean operating time was 196 minutes (120-140), and no patient received transfusions during or after surgery. No complications occurred in 14 patients (64%). Perirenal abscess, splenic laceration, ureteral lesion, and polar artery lesion occurred in one patient each. Peroperative biopsy was performed in 5 patients (22.7%) and was positive for renal cancer in two cases, while material was insufficient in three patients. Mean hospital stay was 6 days (2‑16). Creatinine levels were 106 mg% (48-230) before surgery and 123 mg/% (52-270) 6 months after surgery. A CT scan was performed in all patients one and six months after surgery, showing a residual enhancement area in two of them. Sixteen patients (88.8%) are disease-free after a mean follow-up time of 46 months (6-116).Metastatic disease occurred in two patients (11%) in the setting of a prior renal tumor in the same or the opposite kidney and required treatmet with antiangiogenic agents. Conclusions: This is the largest series reporting renal cryosurgery in Spain, in complex cases and with adequate follow-up. Results are encouraging and allow for considering renal cryotherapy among the minimally invasive procedures for nephron-sparing surgery (AU)

[EAU guidelines on non-muscle-carcinoma of the bladder]. / Guía clínica del carcinoma urotelial no mísculo invasivo de la Asociación Europea de Urología.

CONTEXT AND OBJECTIVE: To present the updated version of 2008 European Association of Urology (EAU) guidelines on non-muscle-invasive bladder cancer. EVIDENCE ACQUISITION: A systematic review of the recent literature on the diagnosis and treatment of non-muscle-invasive bladder cancer was performed. The guidelines were updated and the level of evidence and grade of recommendation were assigned. EVIDENCE SYNTHESIS: The diagnosis of bladder cancer depends on cystoscopy and histologic evaluation of the resected tissue. A complete and correct transurethral resection (TUR) is essential for the prognosis of the patient. When the initial resection is incomplete or when a high-grade or T1 tumour is detected, a second TUR within 2-6 wk should be performed. The short- and long-term risks of both recurrence and progression may be estimated for individual patients using the scoring system and risk tables. The stratification of patients to low, intermediate, and high-risk groups-separately for recurrence and progression-represents the cornerstone for indication of adjuvant treatment. In patients at low risk of tumour recurrence and progression, one immediate instillation of chemotherapy is strongly recommended. In those at an intermediate or high risk of recurrence and an intermediate risk of progression, one immediate instillation of chemotherapy should be followed by further instillations of chemotherapy or a minimum of 1 yr of bacillus Calmette-Guerin (BCG). In patients at high risk of tumour progression, after an immediate instillation of chemotherapy, intravesical BCG for at least 1 yr is indicated. Immediate cystectomy may be offered to the highest risk patients and in patients with BCG failure. The long version of the guidelines is available on www.uroweb.org. CONCLUSIONS: These EAU guidelines present the updated information about the diagnosis and treatment of non-muscle-invasive bladder cancer and offer the recent findings for the routine clinical application.

Carcinoma escamoso de uretra metastático / Metastasic urethral squamous-cell a cancer

El carcinoma primario de uretra es una neoplasia poco común, constituyendo menos del 1% de los tumores genitourinarios. Éste es más habitual en el sexo femenino, en una proporción 4:1, apareciendo en la sexta o séptima década de la vida, siendo el tipo histológico más frecuente el carcinoma de células escamosas. Los primeros signos y síntomas son más propios de estenosis benigna de uretra que de malignidad. El periodo entre los primeros síntomas y el diagnóstico suele ser de alrededor de tres años. Por consiguiente la mayoría de estos tumores son localmente avanzados en el momento del diagnóstico y a pesar de ser sometidos a tratamientos agresivos tiene mal pronóstico. El tratamiento depende del estadio y la localización de la lesión. Debido a la rareza de esta neoplasia no existe un consenso de tratamiento, pero parece ser que éste debe ser multimodal, con cirugía, radioterapia y quimioterapia. Presentamos el caso de un varón de 80 años afecto de un carcinoma escamoso de uretra, localmente avanzado en el momento del diagnóstico. Ante la imposibilidad de recibir tratamiento quirúrgico fue tratado con quimioterapia más radioterapia, presentando al poco tiempo progresión precoz de la enfermedad (AU)

Urethral cancer is an infrequent pathology, less than 1% of the genitourinary tumors. It is more frequent in women (4:1), in the sixth or seventh decade of life. The most frequent histology being squamous cell carcinoma. First signs and symptoms usually are more attributable to benign stricture disease, rather than malignicy. The interval between the onset of symptoms and diagnosis may be as long as three years. Therefore most of these tumors are locally advanced at the time of diagnosis with generally poor prognosis despite aggressive treatment. Therapeutic management varies with the stage and location of the lesion. Because of the rarity of this pathology, no consensus has been reached on treatment modalities, but seems to be that must be a multimodal one, including surgery, radiotherapy and chemotherapy. We present the case of an 80 year-old male, with a diagnosis of urethral squamous-cell cancer, locally advanced at the time of diagnosis. Surgery was not feasible. The patient underwent chemotherapy and radiotherapy with evidence of quick progression thereafter (AU)

[Robotic radical prostatectomy: first 100 patients in Fundació Puigvert]. / Prostatectomía radical robótica: análisis después de 100 casos en la Fundació Puigvert.

OBJECTIVE: We present the 100 first robotic radical prostatectomy with Da Vinci (RRPdaV), corresponding to the first experience in Spain. METHODS: We reviewed the first 100 patients that underwent transperitoneal RRPda performed in Fundació Puigvert between July 2005 and January 2007. All cases were performed by 5 surgeons, being the learning curve for all of them. We analyzed surgical time, blood loss, conversion rate, intra and postoperative complications, hospital stay and days of bladder catheterization. Also, rates and location of surgical margins, as well as functional outcomes with an average follow up of 10.3 months. RESULTS: Mean operating time was 180 minutes (100-310) and blood loss 210 mL (100-390). Blood transfusion was required in 2 cases. There were no intraoperative complications and neither any conversion to open surgery. There were 3 outstanding postoperative events, a compartmentalize syndrome, an acute urinary retention after removal of urethral catheter, and a paresthesias due to brachial plexus compression. Mean hospital stay were 3.7 days. (2-21). We had 21 cases of positive surgical margins (21%). The most frequent location was posterior lateral. 69 of 100 patients (69%) reached early (<3 months) total continence, 91% achieved in 9 months, and remaining 9% required use of at least one pad. Concerning to sexual function, 13 of 100 patients (13%) had preoperative erectile dysfunction, of remaining cases, 62% preserved potency at review, and 38% had postoperative erectile dysfunction. CONCLUSIONS: RRPDAv is a safe and reproducible procedure, and offers promising oncological and functional results with a minimal invasive technique. In spite of include the learning curve of 5 surgeons; we obtain an excellent rate of continence, and an acceptable sexual function. The individual improvement, with more experience, and a longer follow-up, will allow to value evolution of the technique, and it results.

Guía clínica del carcinoma urotelial no músculo invasivo de la Asociación Europea de Urología / EAU Guidelines on Non-Muscle-Carcinoma of the Bladder

Contexto y objetivos: Presentar una puesta al día de la versión del 2008 de la guía clínica de la Asociación Europea de Urología (EUA) sobre el cáncer vesical no músculo invasivo. Evidencia adquirida: Se ha realizado una revisión sistemática de la literatura reciente acerca del diagnóstico y tratamiento del cáncer vesical no músculo invasivo. Las guías clínicas fueron puestas al día y se asignó un nivel de evidencia así como un grado de recomendación. Evidencia sintetizada: El diagnóstico del cáncer vesical depende de la cistoscopia y de los hallazgos histológicos del tejido resecado. Una correcta y completa resección transuretral (RTU) es esencial en el pronóstico del paciente. Cuando la primera resección es incompleta o cuando se diagnostica un tumor de alto grado o T1, se debe realizar una segunda resección a las 2-6 semanas. El riesgo a corto y a largo plazo tanto de la recidiva como de la progresión serán calculados de manera individual a través de tablas de riesgo y sistemas de puntuación. La estratificación de los pacientes en grupos de bajo, intermedio y alto riesgo (separando la recidiva y la progresión), supone la piedra angular para indicar un tratamiento adyuvante. Es altamente recomendable en pacientes de bajo riesgo de recidiva y progresión, una instilación inmediata de quimioterapia. En aquellos que tienen riesgo intermedio o alto de recidiva y un riesgo intermedio de progresión, se debe administrar una instilación inmediata de quimioterapia seguido de instilaciones periódicas de quimioterapia o un mínimo de un año con Bacilo de Calmette-Guerin (BCG). En pacientes con alto riesgo de progresión tumoral, tras una administración inmediata de quimioterapia, está indicado BCG intravesical como mínimo durante un año. Una cistectomía inmediata debería ser ofrecida a pacientes de altísimo riesgo y en pacientes en los que ha fallado la BCG. La versión extensa de las guías clínicas está disponible en www.uroweb.org. Conclusiones: Esta guía clínica de la EUA presenta una información actualizada sobre el diagnóstico y tratamiento del cáncer vesical además de ofrecer recientes hallazgos con el fin de aplicarlos a la práctica clínica diaria (AU)

Context and objective: To present the updated version of 2008 European Association of Urology (EAU) guidelines on non-muscle-invasive bladder cancer. Evidence acquisition: A systematic review of the recent literature on the diagnosis and treatment of non-muscle-invasive bladder cancer was performed. The guidelines were updated and the level of evidence and grade of recommendation were assigned. Evidence synthesis: The diagnosis of bladder cancer depends on cystoscopy and histologic evaluation of the resected tissue. A complete and correct transurethral resection (TUR) is essential for the prognosis of the patient. When the initial resection is incomplete or when a high-grade or T1 tumour is detected, a second TUR within 2–6 wk should be performed. The short- and long-term risks of both recurrence and progression may be estimated for individual patients using the scoring system and risk tables. The stratification of patients to low, intermediate, and high-risk groups—separately for recurrence and progression—represents the cornerstone for indication of adjuvant treatment. In patients at low risk of tumour recurrence and progression, one immediate instillation of chemotherapy is strongly recommended. In those at an intermediate or high risk of recurrence and an intermediate risk of progression, one immediate instillation of chemotherapy should be followed by further instillations of chemotherapy or a minimum of 1 yr of bacillus Calmette-Guerin (BCG). In patients at high risk of tumour progression, after an immediate instillation of chemotherapy, intravesical BCG for at least 1 yr is indicated. Immediate cystectomy may be offered to the highest risk patients and in patients with BCG failure. The long version of the guidelines is available on www.uroweb.org. Conclusions: These EAU guidelines present the updated information about the diagnosis and treatment of non-muscle-invasive bladder cancer and offer the recent findings for the routine clinical application (AU)

Prostatectomía radical robótica: Análisis después de 100 casos en la Fundació Puigvert / Robotic radical prostatectomy: first 100 patients in Fundació Puigvert

Objetivo: Realizar un análisis de los primeros 100 casos de nuestra serie de prostatectomía radical robótica con Da Vinci (PRRdaV) realizadas en nuestro Centro, que corresponden a la primera serie en España. Material y Métodos: Se realiza un estudio retrospectivo de las 100 primeras PRRdaV consecutivas realizadas en la Fundació Puigvert entre Julio de 2005 y Enero de 2007. El procedimiento fue realizado por 5 cirujanos distintos, siendo la curva de aprendizaje para todos ellos. El abordaje fue transperitoneal en todos los casos. Se analizan, tiempo operatorio, pérdidas hemáticas, tasa de conversión, complicaciones intra y postoperatorias, estancia hospitalaria y días de sonda vesical. También se revisan las tasas y la localización de los márgenes positivos, así como los resultados funcionales, con un seguimiento medio de 10,3 meses. Resultados: La media de tiempo operatorio fue de 180 minutos (100-310) y la pérdida hemática media de 210 mL (100- 390). En 2 casos se realizó transfusión postoperatoria. No se presentaron complicaciones intraoperatorias, y tampoco ninguna reconversión. Como acontecimientos postoperatorios destacan un síndrome compartimental, una retención aguda urinaria tras retirada de sonda vesical, y unas parestesias por compresión del plexo braquial. La estancia hospitalaria media fue 3,7 días (2-21). Se obtuvieron 21 casos con márgenes quirúrgicos positivos (21%). La localización más frecuente fue posterolateral. El 69% fueron continentes de forma precoz (<3 meses), el 91% lo fueron a los 9 meses, el 9% restante requiere de compresa de seguridad. Referente a la función sexual, el 62% conservan potencia y el 38% presentaron disfunción eréctil postoperatoria. Conclusiones: La PRRdaV es un procedimiento seguro, reproducible y que ofrece unos resultados oncológicos y funcionales muy prometedores con un abordaje mínimamente invasivo. A pesar de incluir la curva de aprendizaje de 5 cirujanos, obtenemos una excelente tasa de continencia, y una buena función sexual. La mejora individual, con mayor experiencia, así como un mayor seguimiento, permitirá valorar la evolución de la técnica, así como de sus resultados (AU)

Objective: We present the 100 first robotic radical prostatectomy with Da Vinci (RRPdaV), corresponding to the first experience in Spain. Methods: We reviewed the first 100 patients that underwent transperitoneal RRPda performed in Fundació Puigvert between July 2005 and January 2007. All cases were performed by 5 surgeons, being the learning curve for all of them. We analyzed surgical time, blood loss, conversion rate, intra and postoperative complications, hospital stay and days of bladder catheterization. Also, rates and location of surgical margins, as well as functional outcomes with an average follow up of 10.3 months. Results: Mean operating time was 180 minutes (100-310) and blood loss 210 mL (100-390). Blood transfusion was required in 2 cases. There were no intraoperative complications and neither any conversion to open surgery. There were 3 outstanding postoperative events, a compartmentalize syndrome, an acute urinary retention after removal of urethral catheter, and a paresthesias due to brachial plexus compression. Mean hospital stay were 3.7 days. (2-21). We had 21 cases of positive surgical margins (21%). The most frequent location was posterior lateral. 69 of 100 patients (69%) reached early (<3 months) total continence, 91% achieved in 9 months, and remaining 9% required use of at least one pad. Concerning to sexual function, 13 of 100 patients (13%) had preoperative erectile dysfunction, of remaining cases, 62% preserved potency at review, and 38% had postoperative erectile dysfunction. Conclusions: RRPDAv is a safe and reproducible procedure, and offers promising oncological and functional results with a minimal invasive technique. In spite of include the learning curve of 5 surgeons; we obtain an excellent rate of continence, and an acceptable sexual function. The individual improvement, with more experience, and a longer follow-up, will allow to value evolution of the technique, and it results (AU)

EAU guidelines on non-muscle-invasive urothelial carcinoma of the bladder.

CONTEXT AND OBJECTIVE: To present the updated version of 2008 European Association of Urology (EAU) guidelines on non-muscle-invasive bladder cancer. EVIDENCE ACQUISITION: A systematic review of the recent literature on the diagnosis and treatment of non-muscle-invasive bladder cancer was performed. The guidelines were updated and the level of evidence and grade of recommendation were assigned. EVIDENCE SYNTHESIS: The diagnosis of bladder cancer depends on cystoscopy and histologic evaluation of the resected tissue. A complete and correct transurethral resection (TUR) is essential for the prognosis of the patient. When the initial resection is incomplete or when a high-grade or T1 tumour is detected, a second TUR within 2-6 wk should be performed. The short- and long-term risks of both recurrence and progression may be estimated for individual patients using the scoring system and risk tables. The stratification of patients to low, intermediate, and high-risk groups-separately for recurrence and progression-represents the cornerstone for indication of adjuvant treatment. In patients at low risk of tumour recurrence and progression, one immediate instillation of chemotherapy is strongly recommended. In those at an intermediate or high risk of recurrence and an intermediate risk of progression, one immediate instillation of chemotherapy should be followed by further instillations of chemotherapy or a minimum of 1 yr of bacillus Calmette-Guerin (BCG). In patients at high risk of tumour progression, after an immediate instillation of chemotherapy, intravesical BCG for at least 1 yr is indicated. Immediate cystectomy may be offered to the highest risk patients and in patients with BCG failure. The long version of the guidelines is available on www.uroweb.org. CONCLUSIONS: These EAU guidelines present the updated information about the diagnosis and treatment of non-muscle-invasive bladder cancer and offer the recent findings for the routine clinical application.

[Determination of P53 in infiltrative primary bladder tumors as a prognostic factor for understaging]. / La determinación de p53 en tumor vesical primario infiltrante como factor pronóstico de subestadiaje.

OBJECTIVES: To determine if p53 expression in patients with infiltrative bladder cancer is a prognostic factor on clinical staging and cancer specific survival. METHODS: Immunohistochemical analysis of p53 in 34 patients (33 males and 1 female) undergoing radical cystectomy for infiltrative bladder cancer, with a mean follow-up of 16 months. RESULTS: p53 overexpression was detected in 18 patients (64%). In the p53 positive group two patients were stage T1G3, 18 patients T2, 1 patient T3, and 2 patients T4. In the negative group a better correspondence between TUR and cystectomy stage was found, with stage worsening only in 3 patients. On follow-up, p53 positive patients showed worse outcomes due to their worse stages, although no statistical differences were found (p = 0.24). In the group of patients following a bladder sparing protocol (n = 6), p53 negative patients had complete remission of the disease. CONCLUSIONS: We see significant differences on understaging/more aggressive local outcome in p53 positive patients, with no greater mortality in this group. P53 expression does not contraindicate the inclusion of a patient in a bladder sparing protocol, although larger studies would be necessary to confirm these results.

La determinación de P53 en tumor vesical primario infiltrante como factor pronóstico de subestadiaje / Determination of P53 in infiltrative primary bladder tumors as a prognostic factor for understaging

OBJETIVO: Determinar si la expresión de p53 en pacientes con carcinoma vesical infiltrante tiene valor pronóstico en el estadiaje clínico y supervivencia del tumor.MÉTODOS: El análisis inmunohistoquímico de p53 se realizó en 34 pacientes (33 hombres y 1 mujer) tratadoscon cistectomía por carcinoma vesical infiltrante con seguimiento medio de 16 meses.RESULTADOS: Se detectó sobreexpresión de p53 en 18 pacientes (64%). En el grupo con positividad p53 se encontraron 2 pacientes con estadio T1G3, 18 pacientesT2, 1 paciente T3 y 2 pacientes T4. En el grupo con negatividad inmunohistoquímica se encontró una mejor correspondencia entre el estadiaje de la RTU y de la cistectomíaencontrándose empeoramiento del estadio en solo 3 pacientes. Tras el seguimiento los pacientes p53 positivos presentaron peor evolución al tener peor estadio,aunque no significativa estadísticamente (p 0,24). En los pacientes que pasaron a protocolo de conservaciónvesical (n=6), los p53 negativos experimentaron una remisión completa de la enfermedad.CONCLUSIONES: Observamos una diferencia significativade infraestadiaje/evolución local más agresiva en pacientes p53 positivos y no mayor mortalidad en este grupo. La expresión de p53 no contraindica la entrada de un paciente en protocolo de conservación vesical aunque serán necesarios estudios más amplios para confirmar estos resultados

OBJECTIVES: To determine if p53 expression in patients with infiltrative bladder cancer is a prognostic factor on clinical staging and cancer specific survival. METHODS: Immunohistochemical analysis of p53 in 34 patients (33 males and 1 female) undergoing radical cystectomy for infiltrative bladder cancer, with a mean follow-up of 16 months. RESULTS: p53 overexpression was detected in 18 patients (64%). In the p53 positive group two patients were stage T1G3, 18 patients T2, 1 patient T3, and 2 patients T4. In the negative group a better correspondence between TUR and cystectomy stage was found, with stage worsening only in 3 patients. On follow-up, p53 positive patients showed worse outcomes due to their worse stages, although no statistical differences were found (p = 0.24). In the group of patients following a bladder sparing protocol (n = 6), p53 negative patients had complete remission of the disease. CONCLUSIONS: We see significant differences on understaging/more aggressive local outcome in p53 positive patients, with no greater mortality in this group. P53 expression does not contraindicate the inclusion of a patient in a bladder sparing protocol, although larger studies would be necessary to confirm these results

Intravesical instillations with bacillus calmette-guérin for the treatment of carcinoma in situ involving prostatic ducts.

OBJECTIVES: Bacillus Calmette-Guérin (BCG) has proven its efficacy in the treatment of carcinoma in situ (CIS) of the prostatic urethra. We performed a retrospective study to evaluate the use of intravesical instillations of BCG in patients with carcinoma in situ involving prostatic ducts after complete transurethral resection (TUR). MATERIAL AND METHODS: Eligibility for the study was CIS of the prostatic urethra involving prostatic ducts. Previous instillation with BCG was an exclusion criterion. Patients were treated with intravesical BCG Connaught (81 mg) administered once a week, over a 6-wk period. TUR loop biopsies of the prostate were performed only when a macroscopic tumor was present. RESULTS: In this retrospective study of 11 patients, 8 (73%) presented with macroscopic tumor in the prostatic urethra. Ten patients (91%) had a simultaneous superficial bladder carcinoma. Eight patients (73%) had tumoral involvement of the bladder neck region. After a median follow-up of 27 mo (n=10 patients), the response in the prostatic urethra was 82%, and the response in the bladder due to superficial tumor recurrence was 64%. Two patients with residual ductal disease in the prostatic urethra were subsequently treated with cystoprostatectomy and are currently free of disease. In one of those patients, the cystoprostatectomy specimen did show prostatic stromal invasion. Another patient developed distant metastatic disease and died a few months after diagnosis. Thus, progression was encountered in two patients (18%). Currently, 90% of patients are alive without evidence of disease and 72.7% have benefitted from this bladder preservation strategy. CONCLUSION: Intravesical BCG is a feasible treatment option for patients with CIS involving prostatic ducts. In this retrospective study, bladder preservation was successful in 8 of 11 patients (70%) and there was only one oncologic death. Obviously, these patients need a careful follow-up with cystoscopy and cytology to detect either recurrence or progression and in those with persistent disease after the initial BCG induction therapy, prompt cystectomy is indicated.