Comparative Analysis of Very Reduced vs Full Dose BCG Treatment for High-Risk Non-Muscle Invasive Bladder Cancer: A Contemporary Experience from Chile.

BACKGROUND: Adjuvant bacillus Calmette-Guérin (BCG) is recommended for high-risk (HR) non-muscle invasive bladder cancer (NMIBC), but BCG shortages have led to exploration of reduced-dose regimens and shortened maintenance durations out of necessity, with limited data on treatment efficacy in Latin America. OBJECTIVE: Oncological outcomes of HR-NMIBC patients treated with reduced (RD,1/4th dose) vs full dose (FD) BCG instillations of Danish Strain 1331 BCG. METHODS: We performed a retrospective study of HR-NMIBC patients treated with BCG between 2003 and 2022 at our center in Santiago Chile. We stratified patients according to either RD (1/4th dose) or FD BCG. Univariate and multivariable Cox regression models were used to predict recurrence. Kaplan-Meier method was used to calculate survival estimates. RESULTS: Of a total of 200 patients, 116 (58%) had RD and 84 (42%) FD BCG. Median follow-up was 57 months (IQR: 29-100). Patients who received FD BCG had a lower risk of recurrence (HR: 0.41, 95% CI 0.22-0.74) and high-grade (HG)-recurrence (HR: 0.30, 95% CI 0.15-0.61; p = 0.001). More patients in the RD vs FD group progressed to MIBC (10/84 vs 2/116; p = 0.18). Additionally, patients were less likely to stop BCG treatment in the RD group compared to the FD group due to toxicity (5% vs 11%, p = 0.14). CONCLUSIONS: A 1/4th dose of Danish Strain 1331 BCG treatment was associated with worse recurrence free rate and HG-recurrence rate in our cohort. Patients with RD had lower discontinuation treatment rates due to a reduced toxicity profile. These findings would suggest that RD BCG would compromise oncological outcomes in HR-NMIBC patients.

Mortalidad por cáncer de próstata en Chile: tendencias del período 1955-2019 / Prostate cancer mortality trends in Chile (1955-2019)

BACKGROUND: Prostate cancer is the tumor with the highest incidence among men and one of Chile's leading causes of death. AIM: To analyze temporal trends in prostate cancer mortality in Chile. MATERIAL AND METHODS: Mortality rates in Chile for the period between 1955 and 2019 were calculated. The number of deaths was obtained from the national demographic yearbooks and the Ministery of Health mortality registries. Population estimates from the demographic center of the Economic Commission for Latin America and the Caribbean of the United Nations were used. Chilean census population of 2017 was used as reference to calculate adjusted rates. Trends were analyzed using a join point regression. RESULTS: Crude mortality rates of prostatic cancer increased between 1995 and 2012 in three different phases, namely between 1955 and 1989 with a 2.7% annual increase, between 1989 and 1996 at a 6.8% annual rate, and between 1996 to 2012 with a 2.8% annual increase. From 2012 the rate remained stable. Adjusted mortality rates increased slowly at a 1.7% rate from 1955 to 1993, accelerating between 1993 and 1996, when they increased 12.1% per year. From 1996 onwards there was a significant decrease in mortality at a 1.2% annual rate. This decrease was significant and observed within all age groups but more importantly at older ages. CONCLUSIONS: Prostate cancer mortality in Chile has decreased significantly during the last two decades, like that observed in developed nations.

Long-Term Oncological and Functional Outcomes After Robot-Assisted Partial Nephrectomy for Clinically Localized Renal Cell Carcinoma.

BACKGROUND: To evaluate long-term oncological and renal function outcomes in patients treated with robot-assisted partial nephrectomy (RAPN) for renal cell carcinoma (RCC). PATIENTS AND METHODS: Patients undergoing RAPN for clinically localized RCC between January 2014 and December 2019 at a tertiary robotic reference center were evaluated. Clinical course, pathologic characteristics, and long-term outcomes were obtained from our institutional review board-approved RCC database. RESULTS: A total of 234 patients were available for analysis. Median follow-up was 46 months (10.8-97.8 months), with 77 patients (32.9%) having at least 5-years of follow-up. Pathology revealed clear-cell RCC in 67.5% (n = 158). Among unfavorable factors, nuclear grades 3 or 4 were found in 67 (29.4%), lymphovascular invasion in 10 (4.3%), positive surgical margins in 22 (9.4%), necrosis in 21 (9%), and sarcomatoid pattern in 2 patients (0.9%). At 12 months, mean serum creatinine was 1.04 mg/dL and 12.9% of patients experienced upstaging in chronic kidney disease. Overall recurrence-free survival at 5-years was 97.8%. There were five local (2.1%) and two distant (0.9%) recurrences, none of them resulting in cancer-specific death. Median time to recurrence was 20 months (11-64 months). Warm ischemia time [hazard ratio (HR) = 1.14, p = 0.034] and sarcomatoid pattern (HR = 124.57, p = 0.001) were the only variables associated with local relapse. CONCLUSIONS: Data from this large cohort demonstrate that patients undergoing RAPN have a low incidence of local and distant relapse, resulting in excellent long-term survival while preserving stable renal function in most patients.

[Prostate cancer mortality trends in Chile (1955-2019)]. / Mortalidad por cáncer de próstata en Chile: tendencias del período 1955-2019.

BACKGROUND: Prostate cancer is the tumor with the highest incidence among men and one of Chile's leading causes of death. AIM: To analyze temporal trends in prostate cancer mortality in Chile. MATERIAL AND METHODS: Mortality rates in Chile for the period between 1955 and 2019 were calculated. The number of deaths was obtained from the national demographic yearbooks and the Ministery of Health mortality registries. Population estimates from the demographic center of the Economic Commission for Latin America and the Caribbean of the United Nations were used. Chilean census population of 2017 was used as reference to calculate adjusted rates. Trends were analyzed using a join point regression. RESULTS: Crude mortality rates of prostatic cancer increased between 1995 and 2012 in three different phases, namely between 1955 and 1989 with a 2.7% annual increase, between 1989 and 1996 at a 6.8% annual rate, and between 1996 to 2012 with a 2.8% annual increase. From 2012 the rate remained stable. Adjusted mortality rates increased slowly at a 1.7% rate from 1955 to 1993, accelerating between 1993 and 1996, when they increased 12.1% per year. From 1996 onwards there was a significant decrease in mortality at a 1.2% annual rate. This decrease was significant and observed within all age groups but more importantly at older ages. CONCLUSIONS: Prostate cancer mortality in Chile has decreased significantly during the last two decades, like that observed in developed nations.

A prospective randomized study comparing bipolar plasmakinetic transurethral resection of the prostate and monopolar transurethral resection of the prostate for the treatment of Benign Prostatic Hyperplasia: efficacy, sexual function, Quality of Life, and complications

ABSTRACT Objective: To generate high-quality data comparing the clinical efficacy and safety profile between monopolar transurethral resection of the prostate (M-TURP) and bipolar plasmakinetic resection of the prostate (PK-TURP) for benign prostatic hyperplasia (BPH). Materials and Methods: Prospective, randomized, single-blinded study conducted in a tertiary-care public institution (Dec/2014-Aug/2016). Inclusion criteria: prostate of <80g in patients with drug-refractory lower urinary tract symptoms (LUTS), complications derived from BPH, or both. Exclusion criteria: a history of pelvic surgery/radiotherapy, neurogenic bladder dysfunction or documented/suspected prostate carcinoma. Treatment efficacy evaluated at 1, 3, 6 and 12 months. Efficacy outcomes: international prostate symptom score (IPSS), quality-of-life (QoL) score, international index of erectile function-5 (IIEF-5), maximum urinary flow rate (Qmax), postvoid residual urine (PVRU) volume, and prostate volume (PV). Complications and sequelae also assessed. Comparisons performed with parametric/non-parametric tests. Results: Out of the 100 hundred patients, 84 qualified for the analysis (45 M-TURP/39 PK-TURP). No significant differences found in baseline characteristics or operative data, except for a longer operative time in PK-TURP (MD:7.9min; 95%CI:0.13-15.74; p=0.04). No differences found in IPSS, Qmax or PVRU volume. QoL score at 12 months was higher in PK-TURP (MD:0,9points; 95%CI:0.18-1.64; p=0.01). No differences in sexual function, PV, complications or sequelae were found. This study is "rigorous" (Jadadscale) and has a low risk of bias (Cochrane-Handbook). Conclusions: Based on this controlled trial, there is not significant variation in effectiveness and safety between M-TURP and PK-TURP for the treatment of BPH. The small difference in QoL between PK-TURP and M-TURP at the one-year follow-up is not perceivable by the patients and, therefore, not clinically relevant.

A prospective randomized study comparing bipolar plasmakinetic transurethral resection of the prostate and monopolar transurethral resection of the prostate for the treatment of Benign Prostatic Hyperplasia: efficacy, sexual function, Quality of Life, and complications.

OBJECTIVE: To generate high-quality data comparing the clinical efficacy and safety profile between monopolar transurethral resection of the prostate (M-TURP) and bipolar plasmakinetic resection of the prostate (PK-TURP) for benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: Prospective, randomized, single-blinded study conducted in a tertiary-care public institution (Dec/2014-Aug/2016). INCLUSION CRITERIA: prostate of <80g in patients with drug-refractory lower urinary tract symptoms (LUTS), complications derived from BPH, or both. EXCLUSION CRITERIA: a history of pelvic surgery/radiotherapy, neurogenic bladder dysfunction or documented/suspected prostate carcinoma. Treatment efficacy evaluated at 1, 3, 6 and 12 months. Efficacy outcomes: international prostate symptom score (IPSS), quality-of-life (QoL) score, international index of erectile function-5 (IIEF-5), maximum urinary flow rate (Qmax), postvoid residual urine (PVRU) volume, and prostate volume (PV). Complications and sequelae also assessed. Comparisons performed with parametric/non-parametric tests. RESULTS: Out of the 100 hundred patients, 84 qualified for the analysis (45 M-TURP/39 PK-TURP). No significant differences found in baseline characteristics or operative data, except for a longer operative time in PK-TURP (MD:7.9min; 95%CI:0.13-15.74; p=0.04). No differences found in IPSS, Qmax or PVRU volume. QoL score at 12 months was higher in PK-TURP (MD:0,9points; 95%CI:0.18-1.64; p=0.01). No differences in sexual function, PV, complications or sequelae were found. This study is "rigorous" (Jadad-scale) and has a low risk of bias (Cochrane-Handbook). CONCLUSIONS: Based on this controlled trial, there is not significant variation in effectiveness and safety between M-TURP and PK-TURP for the treatment of BPH. The small difference in QoL between PK-TURP and M-TURP at the one-year follow-up is not perceivable by the patients and, therefore, not clinically relevant.

Postadmixture Selection on Chileans Targets Haplotype Involved in Pigmentation, Thermogenesis and Immune Defense against Pathogens.

Detection of positive selection signatures in populations around the world is helping to uncover recent human evolutionary history as well as the genetic basis of diseases. Most human evolutionary genomic studies have been performed in European, African, and Asian populations. However, populations with Native American ancestry have been largely underrepresented. Here, we used a genome-wide local ancestry enrichment approach complemented with neutral simulations to identify postadmixture adaptations underwent by admixed Chileans through gene flow from Europeans into local Native Americans. The top significant hits (P = 2.4×10-7) are variants in a region on chromosome 12 comprising multiple regulatory elements. This region includes rs12821256, which regulates the expression of KITLG, a well-known gene involved in lighter hair and skin pigmentation in Europeans as well as in thermogenesis. Another variant from that region is associated with the long noncoding RNA RP11-13A1.1, which has been specifically involved in the innate immune response against infectious pathogens. Our results suggest that these genes were relevant for adaptation in Chileans following the Columbian exchange.

Arsenic exposure is associated with significant upper tract urothelial carcinoma health care needs and elevated mortality rates.

PURPOSE: The aim of the study was to assess upper tract urothelial carcinoma (UTUC) health care needs and specific mortality rates in an arsenic-exposed region in Northern Chile and compare them to those of the rest of the country. MATERIAL AND METHODS: Arsenic levels of drinking water were correlated with UTUC hospital discharges and cancer-specific mortality rates. Mortality and hospital admission rate ratios were estimated using a Poisson regression model. RESULTS: There were 257 UTUC-specific deaths in Chile between 1990 and 2016; 81 (34%) of them occurred in Antofagasta, where only 3.5% of the population lives. The peak mortality rate observed in Antofagasta was 2.15/100,000 compared to 0.07/100,000 in the rest of the country. Mortality in the exposed region was significantly higher when compared to the rest of the country (MRR 17.6; 95%CI: 13.5-22.9). The same trend was observed for UTUC hospital discharges (RR 14.8; 95%CI: 11.5-19.1). CONCLUSION: Even stronger than for bladder cancer, exposure to arsenic is related to a significant need for UTUC health care and high mortality rates, even 25 years after having controlled arsenic levels in drinking-water. Awareness of this ecologic factor in these affected regions is therefore mandatory.

Adaptation to Extreme Environments in an Admixed Human Population from the Atacama Desert.

Inorganic arsenic (As) is a toxic xenobiotic and carcinogen associated with severe health conditions. The urban population from the Atacama Desert in northern Chile was exposed to extremely high As levels (up to 600 µg/l) in drinking water between 1958 and 1971, leading to increased incidence of urinary bladder cancer (BC), skin cancer, kidney cancer, and coronary thrombosis decades later. Besides, the Andean Native-American ancestors of the Atacama population were previously exposed for millennia to elevated As levels in water (∼120 µg/l) for at least 5,000 years, suggesting adaptation to this selective pressure. Here, we performed two genome-wide selection tests-PBSn1 and an ancestry-enrichment test-in an admixed population from Atacama, to identify adaptation signatures to As exposure acquired before and after admixture with Europeans, respectively. The top second variant selected by PBSn1 was associated with LCE4A-C1orf68, a gene that may be involved in the immune barrier of the epithelium during BC. We performed association tests between the top PBSn1 hits and BC occurrence in our population. The strongest association (P = 0.012) was achieved by the LCE4A-C1orf68 variant. The ancestry-enrichment test detected highly significant signals (P = 1.3 × 10-9) mapping MAK16, a gene with important roles in ribosome biogenesis during the G1 phase of the cell cycle. Our results contribute to a better understanding of the genetic factors involved in adaptation to the pathophysiological consequences of As exposure.

Epidemiology, prevention, screening, diagnosis, and evaluation: update of the ICUD-SIU joint consultation on bladder cancer.

PURPOSE: To update current recommendations on prevention, screening, diagnosis, and evaluation of bladder cancer (BC) based on a thorough assessment of the most recent literature on these topics. METHODS: A non-systematic review was performed, including articles until June 2017. A variety of original articles, reviews, and editorials were selected according to their epidemiologic, demographic, and clinical relevance. Assessment of the level of evidence and grade of recommendations was performed according to the International Consultation on Urological Diseases grading system. RESULTS: BC is the ninth most common cancer worldwide with 430,000 new cases in 2012. Currently, approximately 165,000 people die from the disease annually. Absolute incidence and prevalence of BC are expected to rise significantly during the next decades because of population ageing. Tobacco smoking is still the main risk factor, accounting for about 50% of cases. Smoking cessation is, therefore, the most relevant recommendation in terms of prevention, as the risk of developing BC drops almost 40% within 5 years of cessation. BC screening is not recommended for the general population. BC diagnosis remains mainly based on cystoscopy, but development of new endoscopic and imaging technologies may rapidly change the diagnosis algorithm. The same applies for local, regional, and distant staging modalities. CONCLUSIONS: A thorough understanding of epidemiology, risk factors, early detection strategies, diagnosis, and evaluation is essential for correct, evidence-based management of BC patients. Recent developments in endoscopic techniques and imaging raise the hope for providing better risk-adopted approaches and thereby improving clinical outcomes.

Prevalence of Chlamydia Trachomatis, Neisseria Gonorrhoeae, and Trichomonas Vaginalis Infection in Chilean Adolescents and Young Adults.

STUDY OBJECTIVE: To determine the prevalence of Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis infection in sexually active Chilean adolescents and young adults. A comparative analysis was performed between genders to identify demographic, clinical, and sexual behavior characteristics to predict the occurrence of C trachomatis. DESIGN: Analytical observational study. SETTING: Santiago, Chile. PARTICIPANTS: Two hundred eighty-six sexually active volunteers aged 24 years or younger (171 female and 115 male); 82.9% (237/286) of them were classified as having high socioeconomic status. INTERVENTIONS: Confidential survey and self-collected samples (urine for men and vaginal swabs for women). MAIN OUTCOME MEASURES: Prevalence, demographic characteristics, symptoms, and sexual behavior characteristics. RESULTS: The prevalence rate of C trachomatis was 8.7% (10/115) in men and 8.8% (15/171) in women (P = .58). N gonorrhoeae was detected in 1 subject, whereas no T vaginalis cases were detected. In multivariate analysis, having some college education was protective (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.09-0.89), whereas having a higher number of sexual partners was a risk factor (OR, 1.19; 95% CI, 1.1-1.3) for C trachomatis infection. The latter was also predicted by postcoital bleeding (OR, 4.6; 95% CI, 1.30-16.23) in the female model. CONCLUSION: C trachomatis infection rates were similar between both genders. Protective characteristics for the occurrence of this infection were having some college education, lower number of sexual partners, and if female, the absence of postcoital bleeding. This study highlights the importance of C trachomatis screening among the Chilean affluent population younger than 25 years. However, further studies are needed in a more diverse and representative sample to recommend universal screening in Chilean adolescents and young adults.

[Adolescents find it easy to collect their own samples to study sexually transmitted infections]. / Adolescentes encuentran fácil tomar sus propias muestras para estudio de infecciones de transmisión sexual.

BACKGROUND: As alternative for patients that fear genital examination, we assessed adolescent's comfort and ease with self-collected samples for nucleic acid amplification testing for sexually transmitted infections. PATIENTS AND METHODS: Sexually active Chilean adolescents and youth under 25 years (174 males and 117 females) were enrolled. Females used self-collected vaginal swabs and males collected first-stream urine. A satisfaction survey evaluating self-sampling system was applied. RESULTS: Self-collection was considered easy in 99.3% of the interviewees (CI 95% 0.88-0.98). In women, 79.3% preferred vaginal self-collected samples than pelvic exam (CI 95% 0.73-0.85). In men, 80.3% preferred self-collected first-stream urine to urethral swabs (CI 95% 0.73-0.87). Assuming that self-collected sampling were available, 89.6% of women (CI 95% 0.85-0.94) and 93.2% of men (CI 95% 0.89-0.98) would be prone to be tested more often. Ease of self-collected sampling is not associated with age, gender, educational level or poverty. CONCLUSIONS: Chile currently does not have sexually transmitted infections surveillance or screening programs for youth and adolescents. Given self-collected sampling's good acceptability, it could be successfully used when these programs are implemented.

Adolescentes encuentran fácil tomar sus propias muestras para estudio de infecciones de transmisión sexual / Adolescents find it easy to collect their own samples to study sexually transmitted infections

Background: As alternative for patients that fear genital examination, we assessed adolescent's comfort and ease with self-collected samples for nucleic acid amplification testing for sexually transmitted infections. Patients and Methods: Sexually active Chilean adolescents and youth under 25 years (174 males and 117 females) were enrolled. Females used self-collected vaginal swabs and males collected first-stream urine. A satisfaction survey evaluating self-sampling system was applied. Results: Self-collection was considered easy in 99.3% of the interviewees (CI 95% 0.88-0.98). In women, 79.3% preferred vaginal self-collected samples than pelvic exam (CI 95% 0.73-0.85). In men, 80.3% preferred self-collected first-stream urine to urethral swabs (CI 95% 0.73-0.87). Assuming that self-collected sampling were available, 89.6% of women (CI 95% 0.85-0.94) and 93.2% of men (CI 95% 0.89-0.98) would be prone to be tested more often. Ease of self-collected sampling is not associated with age, gender, educational level or poverty. Conclusions: Chile currently does not have sexually transmitted infections surveillance or screening programs for youth and adolescents. Given self-collected sampling's good acceptability, it could be successfully used when these programs are implemented.

Introducción: Como alternativa para pacientes que temen al examen genital o para aquellos asintomáticos, se evaluó la satisfacción de adolescentes con el sistema de autotoma -muestra tomada por el propio paciente- para amplificación de ácidos nucleicos y determinación de infecciones de transmisión sexual (ITS). Material y Método: Se enrolaron 174 mujeres y 117 hombres menores de 25 años sexualmente activos. Las mujeres se realizaron autotoma con tórula vaginal. Los hombres, autotoma de orina de primer chorro. Se aplicó encuesta de satisfacción. Resultados: A 99,3%, le resultó fácil obtener muestras mediante autotoma (IC 95% 0,88-0,98). En mujeres, 79,3% prefirió la autotoma vaginal por sobre el examen pélvico (IC 95% 0,73-0,85). En hombres, 80,3% prefirió la autotoma de orina por sobre el hisopado uretral (IC 95% 0,73-0,87). Si la autotoma estuviera disponible, 89,7% de las mujeres (IC 95% 0,85-0,94) y 93,2% de los hombres (IC 95% 0,89-0,98) estarían dispuestos a someterse a un examen de ITS en forma más seguida. Encontrar fácil la autotoma no se asoció con edad, género, escolaridad ni pobreza. Conclusiones: Chile aún no tiene programas de vigilancia o detección de ITS para jóvenes y adolescentes. Dada la buena aceptabilidad de la autotoma, se podría emplear exitosamente cuando estos programas se implementen.

[Advances in the treatment of castration-resistant prostate cancer: emphasis in new hormonal therapies]. / Avances en el tratamiento de cáncer de próstata resistente a la castración: énfasis en nuevas terapias hormonales.

Prostate cancer represents the second cancer-related cause of death in North American and Chilean men. The main treatment for incurable stages of disease is surgical or pharmacological castration. However, with time and despite the addition of anti-androgens, the disease progresses to a clinical state that has been commonly referred to as “hormone refractory”. In recent years, the concept of hormone refractoriness has been challenged and replaced by “castration resistance”, acknowledging that further and optimal hormonal manipulation can be attained, beyond achieving testosterone levels at castration range. The purpose of this review is to summarize the recent therapeutic breakthroughs in the management of metastatic castrate resistant prostate cancer (mCRPC), with greater emphasis in the newer hormonal therapy agents such as Abiraterone and Enzalutamide. Future combination and sequential treatment strategies are contextualized in the current era of personalized cancer medicine and genomic characterization of prostate cancer.

Avances en el tratamiento de cáncer de próstata resistente a la castración: énfasis en nuevas terapias hormonales / Advances in the treatment of castration-resistant prostate cancer: emphasis in new hormonal therapies

Prostate cancer represents the second cancer-related cause of death in North American and Chilean men. The main treatment for incurable stages of disease is surgical or pharmacological castration. However, with time and despite the addition of anti-androgens, the disease progresses to a clinical state that has been commonly referred to as “hormone refractory”. In recent years, the concept of hormone refractoriness has been challenged and replaced by “castration resistance”, acknowledging that further and optimal hormonal manipulation can be attained, beyond achieving testosterone levels at castration range. The purpose of this review is to summarize the recent therapeutic breakthroughs in the management of metastatic castrate resistant prostate cancer (mCRPC), with greater emphasis in the newer hormonal therapy agents such as Abiraterone and Enzalutamide. Future combination and sequential treatment strategies are contextualized in the current era of personalized cancer medicine and genomic characterization of prostate cancer.

Immediate postoperative morbidity in patients with indwelling double-J stent versus overnight-externalized ureteral catheter after tubeless percutaneous nephrolithotomy: a prospective, randomized study.

The conventional technique for percutaneous nephrolithotomy (PNL) ends by placing a nephrostomy tube within the access tract. However, feasibility and safety of tubeless PNL have been widely demonstrated. In this modification, a ureteral stent is usually left in place instead of the nephrostomy tube. The aim of this study is to compare the use of a postoperative indwelling double-J stent versus an overnight-externalized ureteral catheter in patients undergoing tubeless PNL. Sixty-eight patients undergoing tubeless PNL were randomized either for a postoperative double-J stent (group 1) or for an overnight-externalized ureteral catheter (group 2). Outcomes evaluated included postoperative pain, hospital stay length, incidence of hemorrhagic complications, residual lithiasis and urinary leakage. Groups were similar according to age, sex, body mass index and stone burden. There were no significant differences in terms of postoperative pain, incidence of perirenal hematomas, residual lithiasis and urinary leakage. However, patients in group 1 presented longer hospital stays (3.7 ± 1.7 vs. 1.9 ± 0.3 days; p < 0.001) and greater hematocrit drops (4.9 ± 2.2 vs. 2.1 ± 1.8 %; p < 0.001). Our results confirm that among patients undergoing tubeless PNL, both alternatives (i.e. leaving a double-J stent or an overnight-externalized ureteral catheter) are reliable and safe. However, further considerations, like the need of double-J stent removal under cystoscopy, need to be taken into account when deciding which modality to use.

Long-term impact of arsenic in drinking water on bladder cancer health care and mortality rates 20 years after end of exposure.

PURPOSE: In this study we assessed bladder cancer health care and mortality trends in recent decades in a well studied arsenic exposed area in Northern Chile. MATERIALS AND METHODS: Arsenic levels in the affected region were obtained for the last 60 years, and correlated with bladder cancer hospital discharge and mortality rates in recent decades. RESULTS: Bladder cancer hospital discharge rates were significantly higher in the affected region (peak RR 3.6, 95% CI 3.0-4.7). Mortality rates for bladder cancer showed a trend of increase during the period analyzed, reaching peak mortality rates of 28.4 per 100,000 for men and 18.7 per 100,000 for women in the last 10 years. Poisson regression models showed an increased mortality risk in the studied region compared to the rest of the country until the present for men (IRR 5.3, 95% CI 4.8-5.8) and women (IRR 7.8, 95% CI 7.0-8.7). Mean age at cancer specific death was significantly lower in the exposed region (69.6 years, 95% CI 68.4-70.7 vs 73.7 years, 95% CI 73.3-74.2, p <0.01). CONCLUSIONS: Exposure to arsenic is related to a significant need for bladder cancer health care and to high mortality rates even 20 years after having controlled arsenic levels in drinking water. Affected individuals should be aware of the significant impact of this ecological factor. Further research is required to identify strategies for the management of bladder cancer in arsenic exposed populations.

Postoperative morbidity of tubeless versus conventional percutaneous nephrolithotomy: a prospective comparative study.

Percutaneous Nephrolithotomy (PNL) is an established technique for the treatment of renal calculi. Some reports have challenged the need for a nephrostomy tube at the end of the procedure, arguing that it accounts for a longer hospital stay and increased postoperative pain. During the last years, several series have addressed the feasibility and safety of tubeless PNL, where a double-J ureteral stent is left in place after the end of intervention instead of a nephrostomy tube. The aim of our study was to compare conventional versus tubeless PNL in terms of postoperative morbidity. Eighty-five patients who underwent PNL at a single center met the inclusion criteria (complete intraoperative stone clearance, no evidence of active intraoperative bleeding, single percutaneous access, and operative time shorter than 2 h) and were randomized at the end of the procedure to have placed either a nephrostomy tube (group 1) or a double-J ureteral stent (group 2). Outcomes assessed were postoperative pain, bleeding complications, leakage complications, and length of hospital stay. The patients in the tubeless group had a shorter hospital stay (3.7 vs. 5.8 days; P < 0.001), and less postoperative pain at postoperative days 2 and 3 (P < 0.001). No significant difference in bleeding or leakage complications was observed. This study supports the feasibility and safety of tubeless PNL in a selected group of the patients, suggesting some intraoperative criteria to be considered when performing it. However, further controlled studies will have to determine its impact on stone-free rates prior to be considered the standard technique in these selected cases.

La edad es un factor predictor independiente para recurrencia tumoral en el cáncer de vejiga no músculo invasor: resultados de una serie local / Age is an independent predictor for tumoral recurrence in non muscle-invasive bladder cancer: results of a local series

Introducción: El cáncer de vejiga es en su mayoría una enfermedad de pacientes de edad avanzada. El objetivo del estudio fue evaluar la edad como factor pronóstico en una cohorte de pacientes chilenos con cáncer de vejiga no músculo invasor. Material y métodos: Se revisaron retrospectivamente los registros clínicos de 107 pacientes tratados por un cáncer no-músculo invasor de vejiga confirmado histológicamente. Se determinaron asociaciones de la edad con parámetros clínicos e histopatológicos, así como con recurrencia y progresión tumoral. Finalmente se realizó un análisis multivariado para identificar factores predictores de los desenlaces mencionados. Resultados: La mediana de edad fue 65 años (rango 29-94). Se observó una significativa asociación de unos pacientes jóvenes con el tabaquismo activo. Por otro lado, los pacientes mayores a 65 años mostraron una asociación significativa con la presencia de recurrencia y progresión tumoral en el análisis univariado. Finalmente, una edad por sobre los 65 años fue el predictor independiente más importante para la recurrencia en el análisis multivariado, por sobre el estadío pT. Conclusiones: Existen varios factores clínicos y psicosociales que contribuyen al significativo poder predictor de una edad > 65 años en el pronóstico de un paciente con un cáncer de vejiga no músculo invasor. Por lo mismo, cada paciente debe ser evaluado en forma integral, tomando en cuenta las distintas dimensiones involucradas. En un escenario de progresivo envejecimiento de la población, el urólogo debe estar preparado para resolver adecuadamente esta situación.

Introduction: Bladder cancer is most frequently a disease of the elderly. The aim of the study was to evaluate the impact of age on prognosis in a cohort of Chilean patients with non muscle-invasive bladder cancer. Methods: The medical records of 107 patients treated for non muscle-invasive bladder cancer at our institution were retrospectively reviewed. Associations of age with clinical and histopathological parameters were assessed, as well as with tumoral recurrence and progression. Finally, a multivariate analysis was performed in order to identify predictive factors for the mentioned outcomes. Results: The median age was 65 years (range 29-94). Younger patients showed a significant association with an active smoking status. On the other hand, a significant association of age > 65 years with tumoral recurrence and progression was observed on univariate analysis. Age was also the most important predictive factor for recurrence on the multivariate analysis, even more than the pT stage. Conclusions: There are several clinical and psychosocial factors related to the significant predictive power of a higher age on the prognosis of patients with non muscle-invasive bladder cancer. Therefore, every patient should be assessed integrally, taking into account all the different dimensions involved. In an era of an aging population, the urologist must be prepared to handle with this situation.

Tumour necrosis is an indicator of aggressive biology in patients with urothelial carcinoma of the upper urinary tract.

BACKGROUND: Prognostic factors after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC) are inconclusive, because most data in the literature have been obtained from small series. OBJECTIVE: To assess the association of tumour necrosis with cancer recurrence and survival in a large international series of patients treated with RNU. DESIGN, SETTING, AND PARTICIPANTS: Data were collected from 1425 patients treated with RNU at 13 centres and combined into a relational database. Pathologic slides were re-reviewed by genitourinary pathologists according to strict criteria. Extensive tumour necrosis was scored as >10% of the tumour area. INTERVENTION: Patients underwent either open or laparoscopic RNU. Lymph node dissection was performed in the presence of enlarged nodes. MEASUREMENTS: Recurrence was defined as tumour relapse in the operative field, lymph node (LN) metastasis, and/or distant metastases. Bladder recurrences were not considered. Associations of extensive tumour necrosis with recurrence-free survival and cancer-specific survival were evaluated by univariate and multivariate analyses. RESULTS AND LIMITATIONS: Extensive tumour necrosis was observed in 364 patients (25.5%) and was associated with advanced tumour stage, high tumour grade, sessile architecture, lymphovascular invasion (LVI), concomitant carcinoma in situ, and LN metastasis (p<0.0001 each). Extensive tumour necrosis was independently associated with disease recurrence and survival (p=0.037 and p=0.046, respectively) after adjusting for the effects of pathologic stage, grade, LVI, and LN status. The addition of extensive tumour necrosis to a base model comprising standard pathologic predictors marginally improved its predictive accuracy for both cancer-specific recurrence (1.5%) and survival (1.4%). CONCLUSIONS: Extensive tumour necrosis is an independent predictor of clinical outcomes in patients who undergo RNU for UTUC. Assessment of tumour necrosis may help to identify patients who could benefit from multimodal therapy after RNU in the future. Evaluation of extensive tumour necrosis should be part of standard pathologic reporting.