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Context The European Association of Urology (EAU) has released an updated version of the guidelines on non–muscle-invasive bladder cancer (NMIBC). Objective To present the 2021 EAU guidelines on NMIBC. Evidence acquisition A broad and comprehensive scoping exercise covering all areas of the NMIBC guidelines since the 2020 version was performed. Databases covered by the search included Medline, EMBASE, and the Cochrane Libraries. Previous guidelines were updated, and the level of evidence and grade of recommendation were assigned. Evidence synthesis Tumours staged as Ta, T1 and carcinoma in situ (CIS) are grouped under the heading of NMIBC. Diagnosis depends on cystoscopy and histological evaluation of tissue obtained via transurethral resection of the bladder (TURB) for papillary tumours or via multiple bladder biopsies for CIS. For papillary lesions, a complete TURB is essential for the patient’s prognosis and correct diagnosis. In cases for which the initial resection is incomplete, there is no muscle in the specimen, or a T1 tumour is detected, a second TURB should be performed within 2–6 wk. The risk of progression may be estimated for individual patients using the 2021 EAU scoring model. On the basis of their individual risk of progression, patients are stratified as having low, intermediate, high, or very high risk, which is pivotal to recommending adjuvant treatment. For patients with tumours presumed to be at low risk and for small papillary recurrences detected more than 1 yr after a previous TURB, one immediate chemotherapy instillation is recommended. Patients with an intermediate-risk tumour should receive 1 yr of full-dose intravesical bacillus Calmette-Guerin (BCG) immunotherapy or instillations of chemotherapy for a maximum of 1 yr. For patients with high-risk tumours, full-dose intravesical BCG for 1–3 yr is indicated. For patients at very high risk of tumour progression, immediate radical cystectomy should be considered. Cystectomy is also recommended for BCG-unresponsive tumours. The extended version of the guidelines is available on the EAU website at https://uroweb.org/guideline/non-muscle-invasive-bladder-cancer/ . Conclusions These abridged EAU guidelines present updated information on the diagnosis and treatment of NMIBC for incorporation into clinical practice. Patient summary The European Association of Urology has released updated guidelines on the classification, risk factors, diagnosis, prognostic factors, and treatment of non–muscle-invasive bladder cancer. The recommendations are based on the literature up to 2020, with emphasis on the highest level of evidence. Classification of patients as having low, intermediate, or and high risk is essential in deciding on suitable treatment. Surgical removal of the bladder should be considered for tumours that do not respond to bacillus Calmette-Guerin (BCG) treatment and tumours with the highest risk of progression.

Aim This review article summarizes the current clinical practice guidelines around disease definitions and risk stratifications, and the treatment of non-muscle-invasive bladder cancer (NMIBC). Recently completed and ongoing clinical trials of novel and investigational therapies in Bacillus Calmette-Guerin (BCG)-naive, BCG-recurrent, and BCG-unresponsive patient populations are also described, e.g., those involving immune checkpoint inhibitors, targeted therapies, other chemotherapy regimens, vaccines, and viral- or bacterial-based treatments. Finally, a brief overview of enhanced cystoscopy and drug delivery systems for the diagnosis and treatment of NMIBC is provided. Background A global shortage of access to BCG is affecting the management of BCG-naive and BCG-recurrent/unresponsive NMIBC; hence, there is an urgent need to assist patients and urologists to enhance the treatment of this disease. Methods Searches of ClinicalTrials.gov, PubMed, and Google Scholar were conducted. Published guidance and conference proceedings from major congresses were reviewed. Conclusion Treatment strategies for NMIBC are generally consistent across guidelines. Several novel therapies have demonstrated promising antitumor activity in clinical trials, including in high-risk or BCG-unresponsive disease. The detection, diagnosis, surveillance, and treatment of NMIBC have also been improved through enhanced disease detection.

AIMS To describe the changes in urodynamic parameters after Remeex® placement in women with recurrent stress urinary incontinence (rSUI) or intrinsic sphincteric deficiency (ISD) and to analyze a potential relationship between postoperative bladder outlet obstruction and a successful surgical outcome. METHODS Retrospective analysis of those women who had undergone Remeex® placement due to rSUI or ISD in our department between 2000 and 2017. All patients underwent urodynamic evaluation before and after the surgery. If tension readjustment was required, postoperative urodynamics was performed after the last regulation, once the final continence status had been achieved. The female Bladder Outlet Obstruction Index (BOOIf) was calculated for all patients postoperatively. Obstruction was considered present if BOOIf was >18. Pre- and postoperative urodynamic variables were compared. Postoperative urodynamic changes were also compared between cured and noncured patients. RESULTS A total of 205 women were included. After a follow-up of 89 ± 36 months, 165 women (80.5%) were continent. A significant impairment in the majority of the urodynamic parameters was observed. Mean postoperative BOOIf was -11.8 ± 21.5 in cured patients and -15.3 ± 23.1 in noncured patients (p = 0.365); 15 (9.1%) patients in the cured group had a postoperative BOOIf >18, whereas all (100%) patients in the noncured group had a postoperative BOOIf

BACKGROUND: In patients with non-invasive urothelial carcinoma of the prostatic urethra (PUC), treatment with Bacillus Calmette-Guérin (BCG) could be beneficial. OBJECTIVE: To assess the response rates to BCG in the different tumor stages, to describe the clinical impact of transurethral resection of the prostate (TURP) before BCG treatment, and to review the side effects of BCG treatment for PUC. METHODS: A systematic search was conducted using the PubMed database to identify original studies between 1977 and 2019 reporting on PUC and BCG. RESULTS: Of a total of 865 studies, ten were considered for evidence synthesis. An indication for BCG treatment was found in non-stromal invasive stages (Tis pu, Tis pd) and in stromal infiltrating cases (T1) of primary and secondary PUC when transitional cell carcinoma was the histology of origin. Studies including patients treated with TURP before BCG showed a better local response in the prostatic urethra with a higher disease free survival (DFS) (80–100% vs. 63–89%) and progression free survival (PFS) (90–100% vs. 75–94%) than patients in studies in which no TURP was performed. However, this difference in recurrence and progression in the prostate neither affected the total PFS (57–75% vs. 58–93%), nor the disease specific survival (70–100% vs. 66–100%). CONCLUSIONS: The use of resection loop biopsies of the prostatic urethra in appropriate cases during the primary work-up for suspected PUC, as well as the use of the current TNM classification for PUC, need to be improved. BCG therapy for non-stromal invasive stages of PUC show a good local response. Local response is further improved by a TURP before BCG therapy, although the overall prognosis does not seem to be affected. Further evidence for BCG treatment in the rare cases of stromal invasive PUC is needed. Specific side effects of BCG treatment for PUC are not reported.

Context: Stone recurrence is frequent in stone formers, and repeated diagnostic and therapeutic procedures in recurrent stone formers place patients and urologists at a significant risk of radiatio...

Context Transurethral resection of bladder tumour (TURBT) for bladder cancer (BC) is an underappreciated common urological procedure. TURBT outcomes are highly variable, and results are dependent on judgement and surgical skill. Objective To perform a narrative review and identify optimal best practice in TURBT including preparation, choice of equipment, procedural steps, surgical technique, and management of difficult scenarios and complications. Evidence acquisition Medline, Embase, and the Cochrane Central Register of Controlled Trials were searched. Important studies were identified and reviewed by an international panel of urologists representing major urological societies and guideline panels with a record of academic publication in this field. In areas where the group identified a lack of evidence or agreement, discussions took place until a consensus was reached. Evidence synthesis A total of 814 studies were identified and 43 were included. The majority were retrospective (level of evidence 3), with only two prospective randomised trials. Four broad themes were identified, which formed the basis for the review: (1) the role of TURBT within the overall management of BC, (2) TURBT techniques, (3) measurement of outcomes including quality control and checklists, and (4) postoperative management. Familiarity with all aspects of the procedure is necessary to minimise morbidity and improve oncological outcomes. Development of new instruments and techniques, and prospective audit of TURBT outcomes are important future goals. Conclusions TURBT is a common and challenging operation with known variable outcomes. To reduce these variations and optimise outcomes, best practice based on evidence and expert opinion is recommended. Patient summary Transurethral resection of bladder tumour (TURBT) is a common but deceptively difficult urological operation. Optimal outcomes depend on experience and surgical skill. An international group of experienced TURBT surgeons review critical aspects of the procedure and share best practice to stimulate further discussion.

We report the reliability of computerized tomography urography and ureteroscopy in the diagnosis and management of upper tract urothelial carcinoma.From 2015 to November 2018 we prospectively collected and retrospectively analyzed 244 cases of ureteroscopy with available preoperative computerized tomography urography. Computerized tomography urography was categorized as positive, suspicious, unlikely and negative. Correspondence between imaging, ureteroscopy and histology was analyzed. The therapeutic indication, based on 2020 EAU Guidelines and patient clinical data, was recorded before and after ureteroscopy. Cohen's Kappa was used for agreement analysis. Logistic regression was used for prediction of positive ureteroscopy.Ureteroscopy was positive for upper tract urothelial carcinoma in 107/115 (93%), 48/77 (62.3%), 15/27 (55.6%) and 12/25 (48%) cases with positive, suspicious, unlikely and negative computerized tomography urography, respectively. On cytohistology the result was confirmed in 164/182 (90.1%) cases. The positive predictive value of a filling defect, stenosis, thickening and hydronephrosis on computerized tomography urography was 87.7% (121/138 cases), 65.6% (21/32), 69.6% (64/92) and 79.7% (59/74), respectively. On multivariate analysis a filling defect (95% CI 2.76-11.5, OR 5.63, p0.0001) or hydronephrosis (1.04-6.18, OR 2.52, p=0.04) was associated with ureteroscopy outcome. Among cases with positive computerized tomography urography and ureteroscopy, the lesions differed in dimensions (20/107), number (14/107) and site (11/107), for a total of 45/107 (42.1%) cases. The indication of elective treatment changed after ureteroscopy in 37/76 (48.1%) cases (Kappa=0.31), as 17/28 (60.7%), 11/20 (55%) and 11/28 (39.2%) indications were confirmed for endoscopic management, ureterectomy and nephroureterectomy, respectively.The complementary use of computerized tomography urography and ureteroscopy in the diagnostic workup of upper tract urothelial carcinoma should be evaluated.

Introduction: Although the use of transvaginal mesh (TVM) in the repair of pelvic organ prolapse (POP) has been restricted, there are still some cases in which TVM may be the most appropriate approach. The TVM Surelift® anterior repair surgical technique has not been described previously. Objective: The aim of this study was to describe the surgical technique and to report our preliminary results regarding efficacy and complications. Methods: A step-by-step description of surgical technique is presented. A descriptive retrospective analysis was performed to evaluate our preliminary results in 17 women who underwent POP repair using the Surelift® anterior repair system in our department between 2014 and 2017. TVM was offered to patients with symptomatic apical (primary or recurrent) or recurrent anterior POP stage ≥2. POP recurrence was classified as asymptomatic anatomic or symptomatic. Patients rated satisfaction with surgery on a scale from 0 to 10. Complications during follow-up were classified according to the International Urogynecological Association/International Continence Society recommendations. Results: Median (IQR) follow-up was 19.9 months (24.8). Two (11.8%) anatomic recurrences were identified, both symptomatic, but neither required further surgery. No cases of pelvic pain, dyspareunia, voiding, or defecatory dysfunction were detected. Two (11.8%) patients presented a Conclusion: The Surelift® anterior repair system is effective in correcting apical or recurrent anterior POP, with a high patient satisfaction rate. Complications after this surgery are infrequent and are mostly related to vaginal mesh exposure.

Objective: Some attempts have previously been made to stratify patients with CIS for the purpose of risk-adapted clinical management and clinical trial design. In particular, two classification systems have been proposed: clinical classification, comprising primary (P-CIS), concomitant (C-CIS), and secondary (S-CIS) disease, and pathological classification, comprising P-CIS, cTa-CIS, and cT1-CIS. The aim of the present study was to assess the impact of both classifications on BCG response, recurrence-free survival (RFS), progression-free survival (PFS), overall survival (OS), and cancer-specific survival (CSS). Patients and Methods: We performed a retrospective analysis of 386 patients with bladder CIS, with or without associated cTa/cT1 disease, treated with BCG instillations between 2008 and 2015. Patients were stratified according to the two classification systems. Cox multivariate regression models were used to assess the impact of these subtypes on BCG response, RFS, PFS, OS, and CSS. We also performed a cumulative meta-analysis according to PRISMA guidelines. Results: The median follow-up was 70.5 months. According to the clinical classification, 34 (8.8%) patients had P-CIS, 81 (21%) S-CIS, and 271 (70.2%) C-CIS. The pathological classification showed 34 (8.8%) patients to have P-CIS, 190 (49.2%) cTa-CIS, and 162 (42%) cT1-CIS. In the overall cohort, BCG response was reported in 296 (76.7%); 159 (41.2%) had recurrence, 55 (14.2%) had progression, and 67 (17.4%) underwent radical cystectomy. Death from any cause was recorded in 135 (35%) and death from urothelial carcinoma in 38 (9.9%). Cox multivariate regression analysis showed that neither clinical classification nor pathological classification is an independent predictive factor for BCG response, RFS, PFS, OS, or CSS after adjusting for confounders. In the pooled meta-analysis, two studies and the present series were included for evidence synthesis, recruiting a total of 941 patients. We found no statistically significant difference across the groups for both classifications with respect to BCG response, RFS, PFS, and CSS. Conclusions: Currently, the supporting evidence for an impact of clinical classification and pathological classification on oncological outcomes of CIS of the bladder is insufficient to justify their use to guide clinical management or follow-up. (C) 2021 Published by Elsevier Inc.

Background: Encrusted uropathy (EU) is a rare disease caused by urea-splitting bacteria, most commonly Corynebacterium urealyticum, whose incidence is increasing. Standard treatment is based on pathogen-directed antibiotic therapy, urinary diversion, bladder instillations, and surgical resection of urinary calcifications. Case Presentation: We present the case of a 60-year-old man with symptomatic bilateral encrusted pyelitis and cystitis with acute renal failure. We initially treated the patient with antibiotic therapy, urinary diversion, and oral acidification with acetohydroxamic acid, achieving negative urinary cultures. Because of the persistence of encrusted pyelitis, the patient was discharged on oral l-methionine 500 mg bid and 12 months later the encrustations had almost disappeared. Finally, we performed right retrograde intrarenal surgery to remove a persistent small calcification. Conclusion: Oral urinary acidification with l-methionine is a valid treatment for urinary encrustations in EU, with no complications reported. Complete resolution of the calcifications may be achieved without the need for invasive processes and unnecessary manipulation of the urinary system.

Regardless of career intentions, junior doctors will meet patients with urological problems. There are no studies on the status of undergraduate education for urology in Europe. We designed an 18-item online survey using the platform www.surveymonkey.com to assess the current status of undergraduate education in urology. A total of 347 medical students, trainees, and urologists responded to the survey. Medical students' exposure to urology during their undergraduate career was heterogeneous. Although the quality of urology education was valued from moderate to high, urology as a speciality did not influence their future training decision making. Decision making in relation to residency training correlated with the number of hours spent on practical training, duration of urology rotation, and year of medical school in which urological exposure was introduced. The current European exposure to urology at undergraduate level is heterogeneous, with various factors influencing future decisions regarding training and specialisation. A uniform undergraduate curriculum would eliminate such heterogeneous exposure and facilitate a workforce fit for the future urological needs. PATIENT SUMMARY: Junior doctors will meet patients with urological problems in the wards, emergency departments, and primary care. Institutions should work together for a urological curriculum that fits the future clinical requirements.

Objective In the last decade non-technical skills (NTS) have emerged as a vital area for improvement within surgery. This study aims to develop and evaluate a Non-technical Skills for Urological Surgeons (NoTSUS) training curriculum and assessment scale. Methods This international, longitudinal and observational study began with a 3-round Delphi methodology to refine curriculum contents and rating scale. Sessions with up to four participants were delivered where each candidate undertook an independent scenario within the validated full immersion simulation environment. Candidates were assessed using both the NoTSS (Non-technical Skills for Surgeons) and NoTSUS rating scales by NTS-trained and non-trained experts. A post-training evaluation survey was distributed. Results 62 participants comprising trainees (n = 43) and specialists (n = 19) undertook the NoTSUS course. The NoTSS and NoTSUS scales correlated well, with a mean difference of 3.3 in the overall total (p = 0.10, r = 0.53). However, there was significant differences in scores between the NoTSS-trained and non-trained raters (n = 28, p = 0.03). A one-way ANOVA test revealed significant improvement throughout the four simulation scenarios in each session (p = 0.02). The NoTSUS curriculum received positive feedback from participants and demonstrated educational value and acceptability. Conclusions The NoTSUS curriculum has demonstrated high educational value for NTS training aimed at urologists, with marked improvement throughout sessions. Correlation of NoTSUS and NoTSS scales proves its suitability for evaluating NTS in future training. Demonstration of inter-rater reliability indicates that the scale is reliable for use in assessment by expert faculty members. Furthermore, qualitative feedback from participants suggests gain of transferrable skills over the course.

This presentation considers follow-up after successful transurethral resection of a high-grade non-muscle-invasive tumour, with normal cystoscopy, followed by bacillus-Calmette-Guérin (BCG) therapy. Focusing on two possible outcomes, a positive cytology but a negative urinary biomarker result, versus positive biomarkers but a negative cytology, we discuss what the evidence and guidelines recommend and which test is more robust. PATIENT SUMMARY: Bladder cancer is usually assessed by examination of tissue taken from the bladder, either by surgery or by biopsy; however, trace elements in the urine, known as biomarkers, can also provide an assessment. The challenge arises when the two methods do not agree: the tissue sample is positive for cancer, but the biomarker is negative, or the reverse. For now, these authors conclude that the tissue examination is more reliable than the biomarker result.

Context Carcinoma in situ (CIS) of the bladder is defined as a high-grade flat lesion confined to the mucosa. Intravesical treatment with bacillus Calmette–Guerin (BCG) is commonly used to reduce the risk of recurrence and progression; however, CIS of the bladder exhibits a heterogeneous clinical behavior and a significant proportion of patients do not show a primary response. Objective To evaluate the available evidence concerning diagnosis, treatment strategies, follow-up, prognosis, and oncological outcomes in patients with CIS of the bladder. Evidence acquisition A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search was conducted using the databases PubMed/MEDLINE and Embase. We included randomized controlled trials, systematic reviews, meta-analyses, and observational studies. Outcomes of interest were: (1) diagnostic strategies, (2) first- and second-line treatments, (3) follow-up strategies, and (4) prognosis and oncological outcomes. Evidence synthesis Overall 62 articles met the inclusion criteria. Most articles concerned retrospective studies and presented mixed data with other non–muscle-invasive bladder cancer categories. The evidence shows that new optical imaging modalities significantly increase the detection rate of CIS. BCG immunotherapy remains the first-line therapy in patients with CIS of the bladder; however, after treatment, adequate follow-up is necessary. Clinicopathological factors remain the main indicators of response to BCG, recurrence, and progression. Conclusions New optical imaging modalities are superior to white light cystoscopy in the detection of CIS of the bladder. There are no robust data that justify consideration of other agents as an alternative to BCG immunotherapy. Despite efforts to identify relevant biomarkers, clinicopathological factors remain the most important prognostic factors. Patient summary New optical techniques have improved the detection of carcinoma in situ (CIS) of the bladder. Bladder preservation using bacillus Calmette-Guerin immunotherapy remains the cornerstone of the treatment of CIS of the bladder.

Background Although pathological factors remain the main determinate of survival for patients with bladder cancer, quality of surgical care is crucial for satisfactory outcomes. Using a validated quality score, we investigated the impact of surgical factors on the overall survival (OS), recurrence-free survival (RFS) and disease-specific survival (DSS) in patients with locally advanced and organ-confined disease (OCD). Retrospective review of IRCC database includes 2460 patients from 29 institutions across 11 countries. The final cohort included 1343 patients who underwent RARCs between 2005 and 2016. Patients with locally advanced disease (LAD) (> pT2 and/or N +) were compared with OCD (≤ pT2/N0). Validated Quality Cystectomy Score (QCS) based on four sets of quality metrics was used to compare surgical performance. Kaplan–Meier method was used to compute RFS, CSS and OS rates. Multivariable stepwise logistic regression was used to evaluate variables associated with RFS, DSS and OS. Results 48% had LAD. When compared to patients with OCD, they received neobladders less frequently (17% vs. 28%, p p = 0.05). Postoperatively, more patients in the LAD group received adjuvant chemotherapy (24% vs. 4%, p p p Conclusion Quality of surgical care can affect disease control and OS in patients with bladder cancer treated with robot-assisted radical cystectomy.

Background: Papillary urothelial neoplasm of low malignant potential (PUN-LMP) was introduced as a noninvasive, noncancerous lesion and a separate grade category in 1998. Subsequently, PUN-LMP was reconfirmed by World Health Organization (WHO) 2004 and WHO 2016 classifications for urothelial bladder tumors. Objectives: To analyze the proportion of PUN-LMP diagnosis over time and to determine its prognostic value compared to Ta-LG (low-grade) and Ta-HG (high-grade) carcinomas. To assess the intraobserver variability of an experienced uropathologist assigning (WHO) 2004/2016 grades at 2 time points. Materials and methods: Individual patient data of 3,311 primary Ta bladder tumors from 17 hospitals in Europe and Canada were available. Transurethral resection of the tumor was performed between 1990 and 2018. Time to recurrence and progression were analyzed with cumulative incidence functions, log-rank tests and multivariable Cox-regression stratified by institution. Intraobserver variability was assessed by examining the same 314 transurethral resection of the tumorslides twice, in 2004 and again in 2018. Results: PUN-LMP represented 3.8% (127/3,311) of Ta tumors. The same pathologist found 71/314 (22.6%) PUN-LMPs in 2004 and only 20/314 (6.4%) in 2018. Overall, the proportion of PUN-LMP diagnosis substantially decreased over time from 31.3% (1990-2000) to 3.2% (2000-2010) and to 1.1% (2010-2018). We found no difference in time to recurrence between the three WHO 2004/2016 Ta-grade categories (log-rank, P = 0.381), nor for LG vs. PUN-LMP (log-rank, P = 0.238). Time to progression was different for all grade categories (log-rank, P < 0.001), but not between LG and PUN-LMP (log-rank, P = 0.096). Multivariable analyses on recurrence and progression showed similar results for all 3 grade categories and for LG vs. PUN-LMP. Conclusions: The proportion of PUN-LMP has decreased to very low levels in the last decade. Contrary to its reconfirmation in the WHO 2016 classification, our results do not support the continued use of PUN-LMP as a separate grade category in Ta tumors because of the similar prognosis for PUN-LMP and Ta-LG carcinomas. (C) 2019 Elsevier Inc. All rights reserved.

Purpose: To address the safety and feasibility of adjuvant single-dose upper urinary tract instillation of mitomycin (ASDM) immediately after therapeutic ureteroscopy for upper tract urothelial car...

Intravesical immunotherapy with bacille Calmette-Guérin (BCG) vaccine is the main treatment for non-muscle-invasive bladder cancer (NMIBC), with proven effects on reducing recurrence, progression, and death from NMIBC. However, it is not effective in all patients, and recurrence after adequate BCG therapy can frequently lead to progression to more life-threatening disease. This point-counterpoint review considers how to treat a healthy 60-yr-old patient with T1 high-grade NMIBC fitting the new definition of BCG-unresponsive disease, that is, persistent high-grade disease at 6-12mo, despite an adequate course of induction and maintenance with BCG. PATIENT SUMMARY: When T1 high-grade non-muscle-invasive bladder cancer is persistent or recurs shortly after a full course of bacille Calmette-Guérin (BCG) plus maintenance, further BCG is not likely to work; this meets the new definition of a "BCG unresponsive" disease. For this situation, the safest (curative) option is removal of the bladder. If that is not an accepted alternative, then a clinical trial or combination intravesical chemotherapy or hyperchemotherapy may be another option.

Contains fulltext : 220546.pdf (Publisher’s version ) (Closed access) OBJECTIVE: To provide a contemporary update and recommendations for the diagnosis and management of low-grade non-muscle-invasive bladder cancer (BCa) based on current literature and expert consensus of the International Bladder Cancer Group. METHODS: We reviewed published trials, guidelines, meta-analyses and reviews (up to March 2019) and provide recommendations on baseline evaluations, treatment, endpoints, study design and surveillance protocols. RESULTS: Low-grade Ta BCa poses minimal risk to patients in terms of progression and disease-specific survival. Thus, to minimize patient morbidity, this entity should be managed appropriately. After initial diagnosis of low-grade Ta tumour, subsequent stable, low-grade-appearing recurrences can be managed conservatively with office cystoscopy and fulguration or even followed using an active surveillance protocol. Intravesical therapy other than single-dose peri-operative chemotherapy instillation should be used judiciously, and only after assigning appropriate risk points. Routine use of urinary cytology - other than at initial risk stratification, or for patients on active surveillance without therapy - is not recommended; and surveillance cystoscopy may be discontinued after 5 years. Clinical studies in this group of patients should focus on recurrence rates, and time to recurrence, rather than progression events. CONCLUSIONS: The International Bladder Cancer Group has developed formal recommendations regarding the diagnosis, treatment and surveillance of low-grade non-muscle-invasive BCa to minimize morbidity and encourage uniformity among studies in this disease.

The best predictors of response to intravesical immunotherapy are tumor grade and stage, tumor recurrence pattern, nomograms, panels of urinary cytokines, and fluorescent in situ hybridization patterns of urine cytology examinations. Future investigations on predictors of Bacillus Calmette-Guerin efficacy are needed to better select those patients who will really benefit from a conservative treatment. Hardly any of the proposed nomograms were designed to precisely predict the outcome of Bacillus Calmette-Guerin immunotherapy. A new nomogram for NMIBC recurrence and progression based on all non-muscle-invasive bladder cancer subgroups would include factors already proven in cancer prognosis and prediction.

Background: Renal cell carcinoma (RCC) is a lethal neoplasia. Data from Latin America are scarce, and the distinct ethnic origins of this population could affect predictive or prognostic factors. Objective: We aim to describe a large cohort of non-metastatic renal cell carcinoma, identifying the demographic, clinical, and pathological prognostic factors for survival. Methods: We used a multi-institutional retrospective cohort involving 5,670 patients who underwent radical or partial nephrectomy across seven Latin American countries and Spain from 1980 to 2016. The variables were compared, and Kaplan–Meier curves were used to estimate the overall survival (OS) and cancer-specific survival (CSS). Results: The clear cell subtype represented 66.7% of RCC, followed by chromophobe (13.7%), papillary (5.2%), and others (14.4%). Furthermore, 72.3% of renal masses were 7 cm (HR: 1.64). Conclusions: Our findings agreed with those reported for some developed countries. We emphasize that ASA and peri-renal fat invasion as prognostic factors deserve further study. Information regarding microvascular invasion should be regularly incorporated in pathological reports.

Funder: Victorian Cancer Agency, Funder: NIHR Manchester Biomedical Research Centre, Funder: Cancer Research UK, Funder: Cancer Council Tasmania, Funder: Instituto de Salud Carlos III, Funder: Cancer Australia, Funder: NIHR Oxford Biomedical Research Centre, Funder: Fundación Científica de la Asociación Española Contra el Cáncer, Funder: Cancer Council South Australia, Funder: Swedish Cancer Society, Funder: NIHR Cambridge Biomedical Research Centre, Funder: Institut Català de la Salut, Funder: Cancer Council Victoria, Funder: Prostate Cancer Foundation of Australia, Funder: National Institutes of Health, BACKGROUND: Lynch syndrome is a rare familial cancer syndrome caused by pathogenic variants in the mismatch repair genes MLH1, MSH2, MSH6, or PMS2, that cause predisposition to various cancers, predominantly colorectal and endometrial cancer. Data are emerging that pathogenic variants in mismatch repair genes increase the risk of early-onset aggressive prostate cancer. The IMPACT study is prospectively assessing prostate-specific antigen (PSA) screening in men with germline mismatch repair pathogenic variants. Here, we report the usefulness of PSA screening, prostate cancer incidence, and tumour characteristics after the first screening round in men with and without these germline pathogenic variants. METHODS: The IMPACT study is an international, prospective study. Men aged 40-69 years without a previous prostate cancer diagnosis and with a known germline pathogenic variant in the MLH1, MSH2, or MSH6 gene, and age-matched male controls who tested negative for a familial pathogenic variant in these genes were recruited from 34 genetic and urology clinics in eight countries, and underwent a baseline PSA screening. Men who had a PSA level higher than 3·0 ng/mL were offered a transrectal, ultrasound-guided, prostate biopsy and a histopathological analysis was done. All participants are undergoing a minimum of 5 years' annual screening. The primary endpoint was to determine the incidence, stage, and pathology of screening-detected prostate cancer in carriers of pathogenic variants compared with non-carrier controls. We used Fisher's exact test to compare the number of cases, cancer incidence, and positive predictive values of the PSA cutoff and biopsy between carriers and non-carriers and the differences between disease types (ie, cancer vs no cancer, clinically significant cancer vs no cancer). We assessed screening outcomes and tumour characteristics by pathogenic variant status. Here we present results from the first round of PSA screening in the IMPACT study. This study is registered with ClinicalTrials.gov, NCT00261456, and is now closed to accrual. FINDINGS: Between Sept 28, 2012, and March 1, 2020, 828 men were recruited (644 carriers of mismatch repair pathogenic variants [204 carriers of MLH1, 305 carriers of MSH2, and 135 carriers of MSH6] and 184 non-carrier controls [65 non-carriers of MLH1, 76 non-carriers of MSH2, and 43 non-carriers of MSH6]), and in order to boost the sample size for the non-carrier control groups, we randomly selected 134 non-carriers from the BRCA1 and BRCA2 cohort of the IMPACT study, who were included in all three non-carrier cohorts. Men were predominantly of European ancestry (899 [93%] of 953 with available data), with a mean age of 52·8 years (SD 8·3). Within the first screening round, 56 (6%) men had a PSA concentration of more than 3·0 ng/mL and 35 (4%) biopsies were done. The overall incidence of prostate cancer was 1·9% (18 of 962; 95% CI 1·1-2·9). The incidence among MSH2 carriers was 4·3% (13 of 305; 95% CI 2·3-7·2), MSH2 non-carrier controls was 0·5% (one of 210; 0·0-2·6), MSH6 carriers was 3·0% (four of 135; 0·8-7·4), and none were detected among the MLH1 carriers, MLH1 non-carrier controls, and MSH6 non-carrier controls. Prostate cancer incidence, using a PSA threshold of higher than 3·0 ng/mL, was higher in MSH2 carriers than in MSH2 non-carrier controls (4·3% vs 0·5%; p=0·011) and MSH6 carriers than MSH6 non-carrier controls (3·0% vs 0%; p=0·034). The overall positive predictive value of biopsy using a PSA threshold of 3·0 ng/mL was 51·4% (95% CI 34·0-68·6), and the overall positive predictive value of a PSA threshold of 3·0 ng/mL was 32·1% (20·3-46·0). INTERPRETATION: After the first screening round, carriers of MSH2 and MSH6 pathogenic variants had a higher incidence of prostate cancer compared with age-matched non-carrier controls. These findings support the use of targeted PSA screening in these men to identify those with clinically significant prostate cancer. Further annual screening rounds will need to confirm these findings. FUNDING: Cancer Research UK, The Ronald and Rita McAulay Foundation, the National Institute for Health Research support to Biomedical Research Centres (The Institute of Cancer Research and Royal Marsden NHS Foundation Trust; Oxford; Manchester and the Cambridge Clinical Research Centre), Mr and Mrs Jack Baker, the Cancer Council of Tasmania, Cancer Australia, Prostate Cancer Foundation of Australia, Cancer Council of Victoria, Cancer Council of South Australia, the Victorian Cancer Agency, Cancer Australia, Prostate Cancer Foundation of Australia, Asociación Española Contra el Cáncer (AECC), the Instituto de Salud Carlos III, Fondo Europeo de Desarrollo Regional (FEDER), the Institut Català de la Salut, Autonomous Government of Catalonia, Fundação para a Ciência e a Tecnologia, National Institutes of Health National Cancer Institute, Swedish Cancer Society, General Hospital in Malmö Foundation for Combating Cancer.

INTRODUCTION AND OBJECTIVE:Kidney auto-transplantation is a useful technique to be reserved for cases where kidney function is compromised by a complex anatomical configuration, such as long ureter...

INTRODUCTION AND OBJECTIVE:The diagnosis and risk stratification of upper urinary tract urothelial carcinoma (UTUC) can be challenging. Urinary cytology (UC) has low sensitivity and CT scan is not ...

INTRODUCTION AND OBJECTIVE:Transurethral resection of bladder tumor (TURBT) is considered the gold standard in the diagnosis and risk stratification bladder cancer (BC). En-bloc resection of bladde...

INTRODUCTION AND OBJECTIVE:Robot-assisted kidney transplantation (RAKT) has been shown promising results in grafts coming from living donation. However, this technique has two main limitations. Fir...

OBJECTIVE To assess whether bacillus Calmette-Guerin (BCG) responsiveness after initiation of an adequate BCG treatment (at least five of six instillations of induction and at least two of three instillations of maintenance) impacts oncological outcomes in patients with carcinoma in situ (CIS) of the bladder treated with BCG immunotherapy. PATIENTS AND METHODS Data were available for 193 patients with bladder CIS with or without associated cTa/cT1 disease who received an adequate BCG treatment between 2008 and 2015. Bladder biopsies were taken at 6 months and patients were then stratified as either BCG responsive (negative biopsies) or BCG unresponsive (positive biopsies). Inverse probability weighting (IPW)-adjusted Kaplan-Meier and IPW-adjusted Cox regression were performed to compare progression-free survival (PFS), radical cystectomy-free survival (RCFS), overall survival OS, and cancer-specific survival (CSS) in the two groups. RESULTS AND LIMITATIONS Comparing the BCG-responsive and BCG-unresponsive groups, IPW-adjusted Kaplan-Meier analysis revealed, respectively, a median (interquartile range) of PFS of 9 (5-15) vs 48.5 (28-77) months (P = 0.001), a RCFS of 11 (9-15) vs 49 (24-76) months (P

Basic simulation training in endourology was established with the endoscopic stone treatment step 1 (EST-s1), which is now recognized worldwide for training and examination. Following on from EST-s1, the endoscopic stone treatment step 2 (EST-s2) was started by the European Association of Urology (EAU) sections. Objective: We describe the methodology used in the development of EST-s2 assessment curriculum. Materials and Methods: The "full-life cycle curriculum development"template was followed for curriculum development, focusing on intermediate training of EST protocol with complex endourologic tasks. A cognitive task analysis (CTA) was run in accordance with EAU Urolithiasis guidelines. The protocol and its details underwent a first consensus by Delphi method with EAU Urolithiasis Section experts in March 2017. Once the outcome and metrics were decided, curriculum development was carried out. Purpose-built stones were developed, and simulator system requirement was defined. Preliminary testing was done in European Urology Residents Education Programme 2019 and in phase five the protocol was finalized with full tutor instruction sheet. Results: The EST-s2/A curriculum development took 38 months and involved EAU Uro-technology and urolithiasis sections with coordination from the European School of Urology training group. Starting from the initial CTA, a 1277-word revision with preliminary task description was produced. Nine intermediate skills were identified and included in the final training protocol. The training content and session evaluations were carried out by 26 experts and 16 final year trainees, respectively. Although the experts agreed that EST-s2/A protocol was well structured (96%), covered the complex endourologic maneuvers (92%), and was useful to optimize and improve hands-on-training (HoT) sessions (92%), the overall evaluation was scored 4.25/5 by trainees. Conclusion: We describe the development methodology for intermediate EST curriculum, which also provides a roadmap on developing other HoT protocols in future. Patients Summary: In this report we described the development of the novel intermediate training curriculum for EST, called EST-s2, which took 3 years of collaborative work inside the EAU. This article is aimed to strengthen the standards in curriculum development and clearly describe the background of this new EAU official endourology protocol.

Introduction: Appropriate risk stratification and complete tumor ablation are the key factors to optimize the oncologic outcomes of patients undertaking endoscopic management for upper urinary trac...

Background: In the current European Association of Urology (EAU) non-muscle invasive bladder cancer (NMIBC) guideline, two classification systems for grade are advocated: WHO1973 and WHO2004/2016. Objective: To compare the prognostic value of these WHO systems. Design, setting, and participants: Individual patient data for 5145 primary Ta/T1 NMIBC patients from 17 centers were collected between 1990 and 2019. The median follow-up was 3.9 yr. Outcome measurements and statistical analysis: Univariate and multivariable analyses of WHO1973 and WHO2004/2016 stratified by center were performed for time to recurrence, progression (primary endpoint), cystectomy, and duration of survival, taking into account age, concomitant carcinoma in situ, gender, multiplicity, tumor size, initial treatment, and tumor stage. Harrell's concordance (C-index) was used for prognostic accuracy of classification systems. Results and limitations: The median age was 68 yr; 3292 (64%) patients had Ta tumors. Neither classification system was prognostic for recurrence. For a four-tier combination of both WHO systems, progression at 5-yr follow-up was 1.4% in lowgrade (LG)/G1, 3.8% in LG/G2, 7.7% in high grade (HG)/G2, and 18.8% in HG/G3 (log rank, p < 0.001). In multivariable analyses with WHO1973 and WHO2004/2016 as independent variables, WHO1973 was a significant prognosticator of progression (p < 0.001), whereas WHO2004/2016 was not anymore (p = 0.067). C-indices for WHO1973, WHO2004, and the WHO systems combined for progression were 0.71, 0.67, and 0.73, respectively. Prognostic analyses for cystectomy and survival showed results similar to those for progression. Conclusions: In this large prognostic factor study, both classification systems were prognostic for progression but not for recurrence. For progression, the prognostic value of WHO1973 was higher than that of WHO 2004/2016. The four-tier combination (LG/G1, LG/G2, HG/G2, and HG/G3) of both WHO systems proved to be superior, as it divides G2 patients into two subgroups (LG and HG) with different prognoses. Hence, the current EAU-NMIBC guideline recommendation to use both WHO classification systems remains correct. Patient summary: At present, two classification systems are used in parallel to grade non-muscle-invasive bladder tumors. Our data on a large number of patients showed that the older classification system (WHO1973) performed better in terms of assessing progression than the more recent (WHO2004/2016) one. Nevertheless, we conclude that the current guideline recommendation for the use of both classification systems remains correct, since this has the advantage of dividing the large group of WHO1973 G2 patients into two subgroups (low and high grade) with different prognoses. (c) 2020 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Background: The European Association of Urology (EAU) prognostic factor risk groups for non–muscle-invasive bladder cancer (NMIBC) are used to provide recommendations for patient treatment after transurethral resection of bladder tumor (TURBT). They do not, however, take into account the widely used World Health Organization (WHO) 2004/2016 grading classification and are based on patients treated in the 1980s. Objective: To update EAU prognostic factor risk groups using the WHO 1973 and 2004/2016 grading classifications and identify patients with the lowest and highest probabilities of progression. Design, setting, and participants: Individual patient data for primary NMIBC patients were collected from the institutions of the members of the EAU NMIBC guidelines panel. Intervention: Patients underwent TURBT followed by intravesical instillations at the physician's discretion. Outcome measurements and statistical analysis: Multivariable Cox proportional-hazards regression models were fitted to the primary endpoint, the time to progression to muscle-invasive disease or distant metastases. Patients were divided into four risk groups: low-, intermediate-, high-, and a new, very high-risk group. The probabilities of progression were estimated using Kaplan-Meier curves. Results and limitations: A total of 3401 patients treated with TURBT ± intravesical chemotherapy were included. From the multivariable analyses, tumor stage, WHO 1973/2004–2016 grade, concomitant carcinoma in situ, number of tumors, tumor size, and age were used to form four risk groups for which the probability of progression at 5 yr varied from 40%. Limitations include the retrospective collection of data and the lack of central pathology review. Conclusions: This study provides updated EAU prognostic factor risk groups that can be used to inform patient treatment and follow-up. Incorporating the WHO 2004/2016 and 1973 grading classifications, a new, very high-risk group has been identified for which urologists should be prompt to assess and adapt their therapeutic strategy when necessary. Patient summary: The newly updated European Association of Urology prognostic factor risk groups for non–muscle-invasive bladder cancer provide an improved basis for recommending a patient's treatment and follow-up schedule. The updated European Association of Urology prognostic factor risk groups for patients with non–muscle-invasive bladder cancer provide urologists with information that they should take into account when choosing a patient's treatment and scheduling follow-up.

To determine the current status of surgical training amongst European Urology Residents, including their satisfaction with training and their confidence in performing procedures. A 23-item survey was distributed to the 15th European Urology Residents Education Programme (EUREP) 2017 participants. An analysis of demographics, workload, training resources, surgical exposure, surgical caseload, satisfaction and confidence in performing each procedure was performed. A total of 152/350 participants completed the survey (response rate 43%), of which 14% think they perform enough surgeries during their training, and 83% would like to continue training with a fellowship. Confidence in performing procedures without supervision and satisfaction with training was associated with higher surgical caseloads. Confidence in all laparoscopic/robotic procedures (except for laparoscopic/robotic partial nephrectomy) was associated with laparoscopic and robotics training, participation in practical courses and having training resources in hospitals. Satisfaction with surgical training was statistically associated with working ≤ 50 h per week, laparoscopic training and having laparoscopic training boxes. Surgical exposure of European Urology residents for major/minimally invasive procedures, confidence in performing these procedures, and overall satisfaction with training is low. A higher volume of cases, as well as resources for training are associated with higher individual confidence and satisfaction with training.

Context The oncological efficacy of routine lymphadenectomy (lymph node dissection [LND]) at the time of radical nephroureterectomy (RNU) remains controversial. Objective To systematically review the available literature assessing the impact of LND in upper tract urothelial carcinoma (UTUC) patients. Evidence acquisition Embase, Medline, and Cochrane databases were searched for all studies comparing outcomes of patients undergoing RNU without LND versus any form of LND. We identified nine retrospective studies eligible for inclusion in this systematic review. We took cancer-specific survival (CSS) as the primary end point, and performed a narrative review and risk of bias assessment. Evidence synthesis Six studies compared outcomes of no LND versus LND. Three studies compared complete LND versus incomplete LND versus no LND. The incidence of pN+ in patients with high-stage (≥pT2) tumours ranged from 14.3% to 40%. Pre- and postoperative characteristics differed among the study groups, potentially biasing the results, as demonstrated by the risk of bias assessment, potentially favouring the LND group. Oncological outcomes such as cancer-specific, overall, recurrence-free, and metastasis-free survival were reviewed, demonstrating a survival benefit with LND in high-stage disease of the renal pelvis. Conclusions Template-based and complete LND improves CSS in patients with high-stage (≥pT2) UTUC and reduces the risk of local recurrence. The impact of LND in ureteral tumours remains uncertain. Patient summary Studies comparing radical nephroureterectomy with or without the removal of nodes (lymph node dissection [LND]) were analysed. LND improves survival in patients with high-stage disease of the renal pelvis, if it is performed according to an anatomical template-based approach.

Background Despite the recent growing interest in the conservative management of upper tract urothelial carcinoma (UTUC), the diagnostic process is still a challenge for the risk of tumor undergrading. Real-time confocal laser endomicroscopy (CLE) provides in vivo microscopic images of tissues using a low-energy laser light source. Objective To describe our initial experience with CLE for the real-time characterization of UTUC. Design, setting, and participants Fourteen flexible ureteroscopies (f-URS) were performed at our center with CLE for UTUC. Lesions were preoperatively identified at computed tomography-intravenous urography. Cellvizio system was used during f-URS to perform CLE on the targeted lesions. Biopsies were then performed. Intervention f-URS with CLE. Outcome measurements and statistical analysis Surgeon’s CLE readings (low-grade/high-grade/carcinoma in situ [CIS]) were documented in the operation notes. A dedicated genitourinary pathologist—blinded to the surgeon reading—examined all specimens. A third person collected prospectively the CLE readings and the histopathological reports. Cohen’s Kappa analysis was performed to test interobserver agreement. Results and limitations The mean diameter of tumors at computed tomography scan was 26 mm (range, 5–50 mm). In eight patients, CLE allowed to obtain images compatible with low-grade UTUC, in five patients with high-grade UTUC, and in one case with CIS. We found correspondence between the CLE images and the final histopathological results in seven out of seven cases of low-grade UTUC (100%), in five out of six cases of high-grade UTUC (83%), and in one out of one case of CIS (100%). Substantial agreement was found at interobserver agreement (k = 0.64) between CLE and histological reading. No complications and/or limitations related to the use of CLE were recorded. Conclusions CLE is a promising new technology in providing a reliable real-time histological characterization of UTUC lesions. Ideal targets might be UTUC patients potentially candidates for conservative management. Patient summary We believe that a conservative treatment for low-grade upper tract urothelial carcinoma is an option that must be considered. The diagnostic process is still lacking of accurate tools. In this study, we find that confocal laser endomicroscopy, using the Cellvizio system, seems to help the clinician to have a real-time histological characterization of upper tract urothelial carcinoma lesions. This could better select patients for a conservative treatment.

Introduction The European Association of Urology guidelines recommend offering kidney-sparing surgery (KSS) as a primary treatment option to patients with low-risk tumours. Cystoscopy, urinary cytology, and computed tomography urography (CTU) do not always allow correct disease staging and grading, and sometimes there is even a lack of certainty regarding the diagnosis of UTUC. Diagnostic ureteroscopy (d-URS) may therefore be of crucial importance within the diagnostic framework and fundamental in establishing the appropriate therapeutic approach. Evidence acquisition and synthesis A systematic review of the literature was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Risk of bias was assessed using Risk of Bias in Non-randomized Studies of interventions (ROBINS-I). Overall, from 3791 identified records, 186 full-text articles were assessed for eligibility. Finally, after a quantitative review of the selected literature, with the full agreement of all authors, 62 studies were considered relevant for this review. Results CTU has a sensitivity and specificity for UTUC of 92% and 95% respectively, but is not able to detect small or flat lesions with adequate accuracy. The sensitivity of voided urinary cytology for UTUC is around 67–76% and ranges from 43% to 78% for selective ureteric urine collection. As no technique offers a diagnosis of certainty, d-URS can allow an increase in diagnostic accuracy. In the present review the pros and cons of d-URS were analysed. This technique may provide additional information in the selection of patients suitable for neoadjuvant chemotherapy or KSS, distinguishing between normal tissue and low- and high-grade UTUC thanks to the emerging technologies. Conclusions Information obtainable from d-URS and ureteroscopic-guided biopsy can prove extremely valuable when the diagnosis of UTUC is doubtful or KSS is being considered. Notwithstanding concerns remain regarding the potential risk of bladder recurrence, cancer dissemination, and/or delay in radical treatment. Abbreviations: CLE: confocal laser endomicroscopy; CSS: cancer-specific survival; CTU: CT urography; d-URS: diagnostic ureteroscopy; EAU: European Association of Urology; HR: hazard ratio; IMAGE1S: Storz professional imaging enhancement system; IVR: intravesical recurrence; KSS: kidney-sparing surgery; MFS: Metastasis-free survival; NAC: neoadjuvant chemotherapy; NBI: narrow-band imaging; OCT: optical coherence tomography; RFS: Recurrence-free survival; RNU: radical nephroureterectomy; ROBINS-I: Risk of Bias in Non-randomized Studies of interventions; URS(-GB): Ureteroscopy(-guided biopsy); UTUC: upper tract urothelial carcinoma; UUT: upper urinary tract

Background The Female Sexual Function Index (FSFI) is a commonly used scale for the assessment of female sexual function. Our aim was to develop and validate a Spanish short version of the FSFI. Methods A parallel exploratory, sequential mixed-methods approach was used, involving 2 sites. The process consisted of 2 steps: (1) cognitive and content validation of the previously translated FSFI in the Spanish population, both through a focus group; and item selection based on the difficulty and discrimination parameters using item response theory (IRT), thereby obtaining a short version of the scale (sFSFI-sv); (2) assessment of test–retest reliability (intraclass correlation coefficient, ICC) of the sFSFI-sv. The presence or absence of a sexual disorder variable based on clinical interview was used on the Receiver Operating Characteristic (ROC) to establish the cut off point whose Area Under the Curve (AUC) based on sensibility and specificity was maximum. Results Specific modifications of the FSFI were made according to the focus group results. 114 women were included for IRT analysis. The initial IRT model pointed to the exclusion of items 1, 2, 5, 11, 18, and 19 (S-χ2 p Conclusion A focus group and the IRT analysis allowed the development of a 6-item Spanish version of the FSFI, which showed good reliability in a group of Spanish women.

The Standardization in Surgical Education (SISE) program is a collaborative venture of European Association of Urology (EAU) Section of Uro-Technology (ESUT) and Urolithiasis (EULIS) along with the educational office, the European School of Urology (ESU). It is a reference framework in which a hands-on-training (HOT) program offers the development and practice of individual skills for trainees and trainers.

Background: Kidney transplantation (KT) is the best renal replacement treatment. The rewarming time is associated with ischemia/reperfusion damage. In both the open (open KT [OKT]) and the robotic (robotic-assisted KT [RAKT]) approaches, ice slush is used to maintain graft temperature (T degrees) below 20 degrees C. This may result in nonhomogeneous graft T degrees maintenance and, particularly during RAKT where the graft is completely inside the abdominal cavity, rises concerns regarding systemic hypothermia. Objective: To design a cold ischemia device (CID) to maintain a constant and homogeneous low graft T degrees during surgery. Design, setting, and participants: In IDEAL phase 0, a CID was developed and tested to determine its cooling effect on the kidney inside a closed system at 37.5 degrees C, by comparing it with kidney alone versus a gauze-jacket filled with ice slush. The CID was evaluated in pigs undergoing OKT and RAKT, assessing feasibility and adverse reactions. In IDEAL phase 1, the CID was tested in human OKT and RAKT. Surgical procedure: OKT and RAKT. Measurements: In all phases, T degrees was evaluated at scheduled time points. Results and limitations: In the preliminary tests of IDEAL phase 0, the CID was able to maintain a low graft T degrees and superiority to other groups (p = 0.002). In the in vivo animal model, the CID maintained a low and constant graft T degrees in OKT (n = 3) and RAKT (n = 3), with a mean T degrees at 50 min of 10.8 degrees C and 14.9 degrees C, respectively. IDEAL phase 1 demonstrated feasibility of both approaches (OKT, n = 2 and RAKT, n = 3) using the CID, and graft T degrees never exceeded 20 degrees C (mean T degrees: OKT 15.7 degrees C vs RAKT 18.3 degrees C). No complications were recorded. The main limitation consists in the low number of participants. Conclusions: The CID assured a constant low graft T degrees during rewarming time, in both OKT and RAKT. Patient summary: A cold ischemia device (CID) is the first step toward a feasible, safe, and reproducible method to maintain a low graft temperature during surgery. The employment of a CID may optimize the functional outcomes. (c) 2021 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Purpose To investigate the association of patients’ sex with recurrence and disease progression in patients treated with intravesical bacillus Calmette–Guérin (BCG) for T1G3/HG urinary bladder cancer (UBC). Materials and methods We analyzed the data of 2635 patients treated with adjuvant intravesical BCG for T1 UBC between 1984 and 2019. We accounted for missing data using multiple imputations and adjusted for covariate imbalance between males and females using inverse probability weighting (IPW). Crude and IPW-adjusted Cox regression analyses were used to estimate the hazard ratios (HR) with their 95% confidence intervals (CI) for the association of patients’ sex with HG-recurrence and disease progression. Results A total of 2170 (82%) males and 465 (18%) females were available for analysis. Overall, 1090 (50%) males and 244 (52%) females experienced recurrence, and 391 (18%) males and 104 (22%) females experienced disease progression. On IPW-adjusted Cox regression analyses, female sex was associated with disease progression (HR 1.25, 95%CI 1.01–1.56, p = 0.04) but not with recurrence (HR 1.06, 95%CI 0.92–1.22, p = 0.41). A total of 1056 patients were treated with adequate BCG. In these patients, on IPW-adjusted Cox regression analyses, patients’ sex was not associated with recurrence (HR 0.99, 95%CI 0.80–1.24, p = 0.96), HG-recurrence (HR 1.00, 95%CI 0.78–1.29, p = 0.99) or disease progression (HR 1.12, 95%CI 0.78–1.60, p = 0.55). Conclusion Our analysis generates the hypothesis of a differential response to BCG between males and females if not adequately treated. Further studies should focus on sex-based differences in innate and adaptive immune system and their association with BCG response.

Urinary diversion (UD) is a technically demanding surgery even after decades of its implementation. Although multiple UD techniques have been described, ileal conduit remains the most frequent, probably due to its easy and quick construction. The individual selection of UD should be based on the balance between the oncological control and quality of life, taking into account the technical feasibility, health status performance, and life expectancy. In this chapter, we describe step by step the specific technical aspects for incontinent urinary diversions construction with special emphasis on the ileal conduit. Despite the surgical experience accumulated in specialized centers, the ileal conduit is associated with significant morbidity, the incidence of complications for ileal is about 66%, and there have been classified in early ( 90 days), which, they will be discussed in this chapter. For these reasons, current efforts are focused on the implementation of the enhanced recovery after surgery protocol, which has shown to be useful in the postoperative recovery of the patients. In this chapter, we cover the indications, surgical aspects, complications, and follow-up of patients undergoing incontinent UD.

PURPOSE To assess the effect of clinical and pathological variables on cancer-specific and overall survival (OS) in de novo metastatic patients from a collaborative of primarily Latin American countries. PATIENTS AND METHODS Of 4,060 patients with renal cell carcinoma diagnosed between 1990 and 2015, a total of 530 (14.5%) had metastasis at clinical presentation. Relationships between clinical and pathological parameters and treatment-related outcomes were analyzed by Cox regression and the log-rank method. RESULTS Of 530 patients, 184 (90.6%) had died of renal cell carcinoma. The median OS of the entire cohort was 24 months. American Society of Anesthesiology classification 3-4 (hazard ratio [HR]: 1.64), perirenal fat invasion (HR: 2.02), and ≥ 2 metastatic organ sites (HR: 2.19) were independent prognostic factors for 5-year OS in multivariable analyses. We created a risk group stratification with these variables: no adverse risk factors (favorable group), median OS not reached; one adverse factor (intermediate group), median OS 33 months (HR: 2.04); and two or three adverse factors (poor risk group), median OS 14 months (HR: 3.58). CONCLUSION Our study defines novel prognostic factors that are relevant to a Latin American cohort. With external validation, these easily discerned clinical variables can be used to offer prognostic information across low- and middle-income countries.

Metastatic lymph node dissection (LND) in nodal recurrent PCa after radical treatments has become a feasible salvage approach, and salvage LND (sLND) has been proposed in patients with “node-only” biochemical recurrence (BCR) after definitive treatment of primary PCa. This chapter examines the salvage lymph node dissection.

After primary RT for PCa, treatment failure can be distinguished in biochemical and clinical relapse. According to the available literature, cancer is confined to the prostate and seminal vesicles in over one-third of RT failures, while almost 60% of disease recurrence occurs in the bone, visceral organs, and pelvic and abdominal lymph nodes. This chapter examines salvage re-irradiation therapy after loco-regional failure.

OBJECTIVE To report on the characteristics of pregnancy in female patients with EEC (exstrophy-epispadias complex), determining in particular whether they are at higher risk of spontaneous abortion or complications. MATERIALS AND METHOD Fifty patients diagnosed with EEC and treated in a reference center for this pathology were reviewed. Those with an incomplete medical history were excluded, leaving a total of 37 women with a median follow-up of 26 years (1-48 years). The outcome measurements were successful pregnancies, miscarriages, urological, gynecological and obstetric complications, impaired renal function, newborn characteristics, and postpartum urogynecological complications. Descriptive statistics was used. RESULTS Eight patients achieved 17 pregnancies (88.2% spontaneous). Of these pregnancies, 10 (58.8%) were successful, while 7 (41.2%) terminated in miscarriages. Urinary tract infection (UTI) was the most frequent complication (41.6%) and intestinal occlusion was the most severe. A total of 62.5% of the patients presented genital prolapses after pregnancies. A total of 85.7% of patients were dry during the follow-up after their pregnancies. No newborn presented EEC or any other type of malformation. Our study has the limitation of being a retrospective review of a very heterogeneous and small group of patients. CONCLUSION EEC patients can achieve spontaneous pregnancies but have an increased risk of miscarriage. For this reason, monitoring and control by a specialized and integrated multidisciplinary team is required to minimize complications. (C) 2021 Elsevier Inc.

espanolAntecedentes: la incidencia del carcinoma de celulas renales (CCR) esta aumentando a nivel mundial debido al envejecimiento de la poblacion y al uso generalizado de estudios de imagenes. Objetivo: El objetivo de este estudio fue describir las caracteristicas y resultados perioperatorios de la cirugia de CCR en pacientes muy ancianos (PEV), ≥ 75 anos. Metodos: se trata de un estudio comparativo retrospectivo de 3656 pacientes que se sometieron al tratamiento por CCR entre 1990 y 2015 en 28 centros de ocho paises de America Latina. Comparamos las caracteristicas basales, asi como los resultados clinicos y perioperatorios segun los grupos de edad ( Resultados: Hubo 410 pacientes con PEV (11,2%). En el analisis bivariado, VEP tuvo un indice de masa corporal mas bajo (p 2 en 26.3% vs 12.4%, p estadio pT2 (OR 1,63, p = 0,04) se asociaron de forma independiente con complicaciones perioperatorias. Conclusiones: La reseccion quirurgica del CCR fue segura y exitosa en PEV. La edad ≥75 anos se asocio de forma independiente con complicaciones perioperatorias a los 30 dias. Sin embargo, la gran mayoria fueron complicaciones de bajo grado. La edad por si sola no debe orientar la toma de decisiones en estos pacientes, y el tratamiento debe adaptarse de acuerdo con el estado funcional y la gravedad de las comorbilidades. (REV INVEST CLIN.2020; 72 (5): 308-15) EnglishBackground: The incidence of renal cell carcinoma (RCC) is increasing globally due to an aging population and widespread use of imaging studies. Objective: The aim of this study was to describe the characteristics and perioperative outcomes of RCC surgery in very elderly patients (VEP), ≥ 75 years of age. Methods: This is a retrospective comparative study of 3656 patients who underwent the treatment for RCC from 1990 to 2015 in 28 centers from eight Latin American countries. We compared baseline characteristics as well as clinical and perioperative outcomes according to age groups ( Results: There were 410 VEP patients (11.2%). On bivariate analysis, VEP had a lower body mass index (p 2 in 26.3% vs. 12.4%, p pT2 stage (OR 1.63, p = 0.04) were independently associated with perioperative complications. Conclusions: Surgical resection of RCC was safe and successful in VEP. Age ≥75 years was independently associated with 30-day perioperative complications. However, the vast majority were low-grade complications. Age alone should not guide decision-making in these patients, and treatment must be tailored according to performance status and severity of comorbidities. (REV INVEST CLIN. 2020;72(5):308-15)

Background Percutaneous nephrolithotomy (PCNL) is the gold-standard for complex renal stones treatment in the pediatric population. While the miniaturization of PCNL reduces the risk of bleeding, it can hinder surgical and functional outcomes. The aim of the study is to assess the safety and feasibility of semiclosed-circuit vacuum-assisted Mini-PCNL (vmPCNL) in pediatric patients. Methods From January 2017 to December 2018, we prospectively collected data on consecutive vmPCNLs from two European tertiary referral centers. The procedure was performed with the ClearPetra® access sheath equipped with a lateral arm connected to the aspiration system (pressure setting ~ 120-150 cmH2O) by a 200 ml plastic stone collector. Pre-, intra- and post-operative data and costs were analyzed. The stone-free rate (SFR) was defined as absence of residual fragments > 4 mm with either ultrasound or kidney, ureter, and bladder x-ray. Results Eighteen vmPCNLs were performed in 16 renal units of 13 children. The median age was 119 months (IQR: 97-160) and the weight was 29 Kg (IQR: 25-40). The median cumulative stone size was 32 mm (22-46) with 8 (44.4%) cases of staghorn stones. The OT was 128 min (IQR: 99-167). The basketing was unnecessary in 6/18 (33%) cases. Neither intra-operative complications nor blood transfusions occurred. Post-operative fever was observed in 5/18 (27.8%) cases; in one case a double J ureteral stent was placed for concomitant hydronephrosis. The SFR was 81.3% (13/16), rising to 93.8% (15/16) after ancillary procedures. The materials costs of a vmPCNL (734.8 €) were comparable to mini-PCNL using a reusable set (710.7 €). Conclusions The vmPCNL seems to be sustainable, safe and feasible for kidney stones treatment in the pediatric population.

Background To evaluate demographic, clinical and pathological characteristics of small renal masses (SRM) (≤ 4 cm) in a Latin-American population provided by LARCG (Latin-American Renal Cancer Group) and analyze predictors of survival, recurrence and metastasis. Methods A multi-institutional retrospective cohort study of 1523 patients submitted to surgical treatment for non-metastatic SRM from 1979 to 2016. Comparisons between radical (RN) or partial nephrectomy (PN) and young or elderly patients were performed. Kaplan-Meier curves and log-rank tests estimated 10-year overall survival. Predictors of local recurrence or metastasis were analyzed by a multivariable logistic regression model. Results PN and RN were performed in 897 (66%) and 461 (34%) patients. A proportional increase of PN cases from 48.5% (1979–2009) to 75% (after 2009) was evidenced. Stratifying by age, elderly patients (≥ 65 years) had better 10-year OS rates when submitted to PN (83.5%), than RN (54.5%), p = 0.044. This disparity was not evidenced in younger patients. On multivariable model, bilaterality, extracapsular extension and ASA (American Society of Anesthesiologists) classification ≥3 were predictors of local recurrence. We did not identify significant predictors for distant metastasis in our series. Conclusions PN is performed in Latin-America in a similar proportion to developed areas and it has been increasing in the last years. Even in elderly individuals, if good functional status, sufficiently fit to surgery, and favorable tumor characteristics, they should be encouraged to perform PN. Intending to an earlier diagnosis of recurrence or distant metastasis, SRM cases with unfavorable characteristics should have a more rigorous follow-up routine.

Onabotulinumtoxin A (BoNT-A) injection has been used for bladder pain syndrome (BPS) treatment with good results. Our aim was to assess the efficacy and safety of BoNT-A injection with or without hydrodistension (HD). Retrospective analysis of patients treated with BoNT-A injection with or without HD because of BPS between 2008 and 2014 in our department. One hundred U of Botox® was injected in the trigone and 100 U in the bladder wall. Follow-up included a VAS of pain (0–10), a patient satisfaction scale (0–10) and a treatment benefit scale (1–2: response to treatment; 3–4: non-response to treatment). Complications were classified according to the Clavien-Dindo (CD) classification. BoNT-A retreatment was offered at the patient’s request. Reasons for non-retreatment request were collected. Postoperative outcomes were compared between BoNT-A and BoNT-A + HD. Forty-one patients were included (39 females, 2 males), median age: 73 years (69–78.5). Reduction in VAS, postoperative VAS = 0, satisfaction with surgery and responders to treatment were significantly higher after BoNT-A + HD (n = 26) than after BoNT-A (n = 15). Eleven (26.8%) complications (CD ≤ 2) were detected, with no differences between treatment groups. Mean follow-up was 153 (± 83) months. Twelve (46.2%) patients in the BoNT-A + HD group and seven (46.7%) patients in the BoNT-A group requested retreatment. Lack of severe pain was a common reason for treatment discontinuation. BoNT-A injection could represent a safe and effective BPS treatment. BoNT-A + HD seems to be better than BoNT-A alone for pain relief, with no significant additional morbidity.