Prevalence of urinary tract cancer in the Spanish cohort of the IDENTIFY study

INTRODUCTION

Malignant tumors of the urinary tract are associated with high morbidity and mortality, and their prevalence can vary worldwide. Recently, the IDENTIFY study has published results on the prevalence of urinary tract cancer at a global level. This study evaluates the prevalence of cancer within the Spanish cohort of the IDENTIFY study to determine whether the published results can be extrapolated to our population.

PATIENTS AND METHODS

An analysis of the data from the Spanish cohort of patients in the IDENTIFY study was performed. This is a prospective cohort of patients referred to secondary care with suspected cancer, predominantly due to hematuria. Patients were recruited between December 2017 and December 2018.

RESULTS

A total of 706 patients from 9 Spanish centers were analyzed. Of these, 277 (39.2%) were diagnosed with cancer: 259 (36.7%) bladder cancer, 10 (1.4%) upper tract urothelial carcinoma, 9 (1.2%) renal cancer and 5 (0.7%) prostate cancer. Increasing age (OR 1.05 (95% CI 1.03-1.06; P < 0.001)), visible hematuria (VH) OR 2.19 (95% CI 1.13-4.24; P = 0.02)) and smoking (ex-smokers: OR 2.11(95% CI 1.30-3.40; P = 0.002); smokers: OR 2.36 (95% CI 1.40-3.95; P = 0.001)) were associated with higher probability of bladder cancer.

CONCLUSION

This study highlights the risk of bladder cancer in patients with VH and smoking habits. Bladder cancer presented the highest prevalence; higher than the prevalence reported in previous series and presented in the IDENTIFY study. Future work should evaluate other associated factors that allow us to create cancer prediction models to improve the detection of cancer in our patients.

Influence of laparoscopic surgery on the outcomes of radical cystectomy within a multimodal rehabilitation protocol

INTRODUCTION AND OBJECTIVE

The implementation of Enhanced Recover After Surgery (ERAS) multimodal rehabilitation protocols in radical cystectomy has shown to improve outcomes in hospital stay and complications. The aim of this analysis is to evaluate the impact of laparoscopic surgery on radical cystectomy within a multimodal rehabilitation program.

MATERIAL AND METHODS

The study was carried out in a third level center between 2011 and 2020 including patients with bladder cancer submitted to radical cystectomy according to an ERAS (Enhanced Recovery After Surgery) protocol and the Spanish Multimodal Rehabilitation Group (GERM) with 20 items to be fulfilled.

RESULTS

A total of 250 radical cystectomies were performed throughout the study period, 42.8% by open surgery (OS) and 57.2% by laparoscopic surgery (LS). The groups are comparable in demographic and clinical variables (p > 0.05). Operative time was longer in the LS group (248.4 ± 55.0 vs. 286.2 ± 51.9 min; p < 0.001). However, bleeding was significantly lower in the LS group (417.5 ± 365.7 vs. 877.9 ± 529.7 cc; p < 0.001), as was the need for blood transfusion (33.6% vs. 58.9%; p < 0.001). Postoperative length of stay (11.5 ± 10.5 vs. 20.1 ± 17.2 days; p < 0.001), total and major complications were also significantly lower in this group (LS). The readmission rate was lower in the LS group but not significantly (36.4% vs. 29.4%; p = 0.237). The difference between 90-day mortality in both groups was not statistically significant (2.8% LS vs. 4.3% OS; p = 0.546). The differences were maintained in the multivariate models.

CONCLUSIONS

Laparoscopic surgery within a multimodal rehabilitation program increases operative time but significantly decreases intraoperative bleeding, transfusion requirements, postoperative length of stay, and complications.

The perioperative and long-term outcomes of patients with variant histology bladder cancer undergoing radical cystectomy: A propensity score-matched analysis with pure urothelial carcinoma

OBJECTIVES

To assess the perioperative and long-term outcomes after open radical cystectomy in patients with histological variants versus pure urothelial carcinoma.

METHODS

Patients with a variant histology carcinoma of the urinary bladder were matched through a propensity score analysis with those with pure urothelial carcinoma on a 1:3 ratio. The two groups were compared in terms of perioperative and long-term morbidity and mortality.

RESULTS

Overall, 148 individuals were included in the present retrospective study (37 with variant histology and 111 with pure urothelial carcinoma). A total of 107 (72.3%) individuals presented at least one perioperative complication based on the Clavien-Dindo classification. This proportion was similar between patients with urothelial versus variant histology carcinoma (P = .22). In the long term, the number of patients with clinically significant incisional hernia requiring surgery [14 (12.7%) vs 3 (8.3%), P = .68], uretero-intestinal/uretero-cutaneous strictures or any other complication related to the applied urinary diversion [15 (13.6%) vs 7 (19.4%), P = .56], as well as the number of patients presenting with septicemia [17 (15.5%) vs 10 (27.8%), P = .16] or with urinary tract obstruction [12 (10.9%) vs 4 (11.1%), P > .99] at follow-up did not differ between urothelial versus variant histology carcinoma. The survival analysis with Kaplan-Meier curves and the univariate Cox regression model suggested that the risk of death from any cause was increased in patients with variant compared to pure urothelial histology (log-rank test = 0.045, hazard ratio: 1.7, 95% confidence interval: 1.01-2.87, P = .047).

CONCLUSIONS

Perioperative morbidity and mortality are comparable in patients with variant histology versus pure urothelial carcinoma.

Development of an immune-nutritional prognostic index in patients with muscle-infiltrating bladder cancer candidates for radical cystectomy

INTRODUCTION

Muscle-infiltrating bladder tumor (MIBT) has a recurrence-free survival (RFS) of 50% at 5 years. Although neoadjuvant chemotherapy (NCT) has increased it by 8%, which group of patients benefits the most from this treatment remains unclear.

OBJECTIVE

Evaluate the prognostic value of immune-nutritional status in patients with MIBT who are candidates for cystectomy, and to develop a score that allows identifying patients with a worse prognosis (pT3-4 and/or pN0-1).

MATERIAL AND METHODS

A retrospective analysis was carried out on 284 patients with MIBT treated with radical cystectomy. Preoperative laboratory tests were analyzed and immune-nutritional indices were calculated. The Kaplan-Meier method was used to calculate the PFS. Cox regression was used for multivariate analysis.

RESULTS

Univariate analysis showed a statistically significant relationship with leukocyte/lymphocyte index (p = 0.0001), neutrophil/lymphocyte index (p = 0.02), prognostic nutritional index (p = 0.002), and platelet/lymphocyte ratio (p = 0.002). In multivariate analysis, the leukocyte/lymphocyte ratio (p = 0.002) and PNI (p = 0.04) behaved as independent prognostic factors of decreased RFS. Based on these, a prognostic score was developed to classify patients into 3 prognostic groups. Eighty percent of patients with pT3-4 and/or pN0-1 tumors were in the intermediate-poor prognostic groups.

CONCLUSION

The implementation of a precystectomy immune-nutritional score in clinical practice would help in the selection of a group of patients with a more unfavorable pathologic stage and worse PFS. We believe that these patients could benefit more from a NACT.

Risk factors, management, and survival of bladder cancer after kidney transplantation

INTRODUCTION AND OBJECTIVES

Kidney transplantation is associated with an increased risk of bladder cancer; however guidelines have not been established on the management of bladder cancer after kidney transplantation.

MATERIALS AND METHODS

A systematic literature review using PubMed was performed in accordance with the PRISMA statement to identify studies concerning the prevalence and survival of bladder cancer after kidney transplantation. The risk factors and management of bladder cancer after kidney transplantation were also reviewed and discussed.

RESULTS

A total of 41 studies, published between 1996 and 2018, reporting primary data on bladder cancer after kidney transplantation were identified. Marked heterogeneity in bladder cancer prevalence, time to diagnosis, non-muscle invasive/muscle-invasive bladder cancer prevalence, and survival was noted. Four studies, published between 2003 and 2017, reporting primary data on bladder cancer treated with Bacillus Calmette-Guérin (BCG) after kidney transplantation were identified. Disease-free survival, cancer-specific survival, and overall survival were similar between BCG studies (75-100%).

CONCLUSIONS

Carcinogen exposure that led to ESRD, BKV, HPV, immunosuppressive agents, and the immunosuppressed state likely contribute to the increased risk of bladder cancer after renal transplantation. Non-muscle invasive disease should be treated with transurethral resection. BCG can be safely used in transplant recipients and likely improves the disease course. Muscle-invasive disease should be treated with radical cystectomy, with special consideration to the dissection and urinary diversion choice. Chemotherapy and immune checkpoint inhibitors can be safely used in regionally advanced bladder cancer with potential benefit. mTOR inhibitors may reduce the risk of developing bladder cancer, and immunosuppression medications should be reduced if malignancy develops.

Risk factors, management, and survival of bladder cancer after kidney transplantation

INTRODUCTION AND OBJECTIVES

Kidney transplantation is associated with an increased risk of bladder cancer; however guidelines have not been established on the management of bladder cancer after kidney transplantation.

MATERIALS AND METHODS

A systematic literature review using PubMed was performed in accordance with the PRISMA statement to identify studies concerning the prevalence and survival of bladder cancer after kidney transplantation. The risk factors and management of bladder cancer after kidney transplantation were also reviewed and discussed.

RESULTS

A total of 41 studies, published between 1996 and 2018, reporting primary data on bladder cancer after kidney transplantation were identified. Marked heterogeneity in bladder cancer prevalence, time to diagnosis, non-muscle invasive/muscle-invasive bladder cancer prevalence, and survival was noted. Four studies, published between 2003 and 2017, reporting primary data on bladder cancer treated with Bacillus Calmette-Guérin (BCG) after kidney transplantation were identified. Disease-free survival, cancer-specific survival, and overall survival were similar between BCG studies (75-100%).

CONCLUSIONS

Carcinogen exposure that led to ESRD, BKV, HPV, immunosuppressive agents, and the immunosuppressed state likely contribute to the increased risk of bladder cancer after renal transplantation. Non-muscle invasive disease should be treated with transurethral resection. BCG can be safely used in transplant recipients and likely improves the disease course. Muscle-invasive disease should be treated with radical cystectomy, with special consideration to the dissection and urinary diversion choice. Chemotherapy and immune checkpoint inhibitors can be safely used in regionally advanced bladder cancer with potential benefit. mTOR inhibitors may reduce the risk of developing bladder cancer, and immunosuppression medications should be reduced if malignancy develops.

Usefulness of neoadjuvant chemotherapy in non-metastatic muscle-invasive bladder cancer

OBJECTIVE

We analyzed the profile of patients who were candidates for neoadjuvant chemotherapy (NACT) in stage pT2-4aN0M0, the tolerability and adherence of our cisplatin-based protocol and oncological outcomes.

MATERIAL AND METHODS

Retrospective observational cohort study including patients diagnosed with muscle-invasive bladder carcinoma treated with NACT. Clinical, histopathological, therapeutic and evolutionary characteristics of the patients were analyzed. The use of NACT was evaluated by the complete response in the surgical specimen (pT0). This and other pathological factors were related to overall survival and progression-free survival.

RESULTS

We included 90 patients with muscle-invasive bladder carcinoma (clinical stage T2a-T4aN0M0) who received a cisplatin-based NACT regimen between January 2011 and December 2018, prior to radical surgery. Forty percent of patients presented an adverse reaction, with a compliance with the NACT regimen of 92.2%. There were no deaths related to systemic treatment and no adverse reaction to treatment made radical cystectomy impracticable. After performing radical cystectomy, the presence of complete response (pT0) was observed in 20 patients (21%), lower stage in the surgical specimen (<pT2) in 36 patients (40%), positive surgical margins in 7 patients (8%), lymph node involvement (N1) in 16 patients (17.8%). A shorter time to progression was observed in the group of patients who did not achieve a complete pathological response (53 months vs. 83.1 in pT0 patients, P=0.012), in patients with lymph node involvement compared to pN0 (65.4 vs. 28, 2 months, P=0.014) and in those with positive surgical margins compared to those with tumor-free margins (63.5 vs. 8.5 months, P=0.021).

CONCLUSION

The adequate selection of patients with muscle-invasive bladder carcinoma has shown a good tolerance to NACT, with a high compliance rate prior to RC. The improvement in the complete response rate implies a greater survival in this group of patients, with lymph node involvement and positive surgical margins being important prognostic factors.

[Current treatment options and future perspectives on first line metastatic bladder cancer.]

OBJECTIVE

Over the last 30 years researchon metastatic bladder cancer has been slow and limited to chemotherapy. Chemotherapy has provided high initial response rates but very few complete responses that remain overtime. Recently, European medical agency has granted approval to immunotherapy inmetastatic disease. We will review the clinical trials that drove to EMA approval as well as new promising therapies for metastatic bladder cancer.

METHODS

A search on PubMed and clinicaltrials.gov through the combination of the following words in English and Spanish was performed: "carcinoma urotelial","cáncer de vejiga", "localmente avanzado","metastásico", "inmunoterapia", "CTLA-4", "PD1","PDL-1", "atezolizumab", "nivolumab", "ipilimubab", "pembrolizumab", "avelumab", "durvalumab", "tremelimumab", "terapia antiangiogénica", "terapia molecular dirigida" e "inhibidores VEGF".

RESULTS

Cisplatin chemotherapy-based regimens remain standard treatment for metastatic bladder cancer as per phase III trials. Immunotherapy is available for cisplatin-ineligible patients with high PD-L1 expression,including atezolizumab or pembrolizumab. Trials comparing immunotherapy, chemotherapy or antiangiogenic drugs o targeted drugs are recruiting.

CONCLUSIONS

The publication of the comparative studies on chemotherapy and immunotherapy as well as targeted therapy would provide a window of opportunity for an effective personalized treatment. Those treatment would decrease side-effects as well.

Incidence and prognosis of clinically significant incidental prostate cancer after radical cystectomy for bladder cancer

OBJECTIVE

To evaluate the prevalence and significance of incidental prostate cancer in patients after radical cystectomy for bladder cancer, as well as its impact in terms of overall survival and biochemical recurrence.

METHODS

Patients with bladder cancer treated with radical cystectomy in our hospital between 1998 and 2014 were included in the study. None of the patients had previous history of prostatic adenocarcinoma. Complete embedding of the prostate gland as whole mount serial section of the radical cystectomy specimens was done.

RESULTS

180 patients were included. The mean age was 69.71 years with a median follow-up of 34.2 months. Three groups were analyzed: non-incidental prostate cancer (n=136), non-significant incidental prostate cancer (n=28) and significant incidental prostate cancer (n=16). During follow-up, 50 patients (27.78%) died from bladder cancer. There were no differences in overall survival between patients with or without prostate cancer, neither between patients with significant nor insignificant prostate cancer in the radical cystectomy specimens. Biochemical recurrence was not observed in any patient.

CONCLUSIONS

Incidental prostate cancer had a higher prevalence than previously expected in our cohort (24.4%), but it had no impact in overall survival of patients not even in those with a significant prostate cancer. No biochemical recurrence was reported during the study.

Urinary markers in the surveillance of non-muscle invasive bladder cancer. A literature review

BACKGROUND

The surveillance of non-muscle-invasive bladder cancer (NMIBC) is usually performed by cystoscopy and cytology. Until today, no effective urinary biomarker has been used to reduce the morbidity and cost associated with these procedures.

OBJECTIVE

To describe the performance of urinary biomarkers in the surveillance of NMIBC.

EVIDENCE ACQUISITION

on August 1, 2018, a bibliographic search was carried out in Pubmed, Embase and Cochrane Library, limited to the last 10 years, with the terms: bladder cancer, recurrence, detection and urine marker.973 registers were obtained, and 27 publications were selected following the PRISMA recommendations.

EVIDENCE SYNTHESIS

The negative predictive values (NPV) of several assays could reduce the number of cystoscopies in NMIBC surveillance. Six transcription-factor trials had an NPV rate greater than 90%, and one of them can be performed at the control point. Six transcription-factors evaluations describe anticipated diagnosis between 68% and 83% of their "false positives". Two transcription factors and one protein assays proved reduction between 23% and 35% of surveillance cystoscopies. Nowadays, cell-based assays are restricted to reflex test after doubtful cytologies.

CONCLUSION

There are few studies analysing the improvement of the NMIBC surveillance protocols. Several transcription factor assays are more precise and allow anticipatory diagnosis. Currently, there are no comparative studies between alternative surveillance protocols and classic ones.

Urinary bladder xanthoma: Two case reports and a review of the literature

OBJECTIVE

We present two rare cases ofbladder xanthomata associated with transitional cell carcinoma.

METHOD AND RESULTS

Cases description and selectionof related pictures. Review of the existing literature.

CONCLUSIONS

Xanthomata are non-neoplastic lesionsconsisting of group of foamy lipidstoring histiocytes in thedermis of skin or in the lamina propria of mucosa. Urinarybladder is an uncommon localization for these lesions andtheir etiology isn't still well understood, being variably associatedwith abnormalities of lipid metabolism. Althoughsometimes they are described in association with urothelialneoplasms, they were not believed to have any biologicalneoplastic potential and so they are treated consequently.

hTERT mRNA expression in urine as a useful diagnostic tool in bladder cancer. Comparison with cytology and NMP22 BladderCheck Test®

INTRODUCTION

To study the relationship between quantitative mRNA determination (hTERT) in patients with bladder tumor, history of bladder tumor, and in subjects without a history of this neoplasia.

MATERIAL AND METHODS

A prospective randomized controlled study with 91 subjects included. The value of mRNA-hTERT_N was determined in 63 patients with a history or suspicion of bladder tumor and in 28 controls. Urine samples were sent for evaluation of the mRNA level (hTERT), the cytological study and the NMP22 result.

RESULTS

Differences were observed in mean hTERT_N levels in each of the groups: tumor presence 21.33+/- 40.66, tumor history 2.16+/- 2.67, controls 0.9+/- 1, 75 (p<0.001). In patients with tumor, there was no difference in mean hTERT_N levels between the different grades and stages, although there was a tendency: low grade tumor 9.04+/- 16.95, high grade 28.95+/- 48.36 (p=.069), stage Ta 10.33+/- 19.39, T1 17.88+/- 27.14, T2 54.8+/- 74.05 (p=.056). In addition, the sensitivity of hTERT_N was superior to that of other test (76%), although specificity and positive and negative predictive values were better for cytology (94%, 88.4% and 72.3% respectively) and NMP22 (88%, 80.6% and 73.3% respectively).

CONCLUSIONS

hTERT_N mRNA levels in urine were higher in patients with bladder tumors compared to patients with a history of bladder tumor and with negative cystoscopy, as well as in the control group. This determination showed a higher diagnostic yield compared with the detection of NMP22 and urinary cytology.

Role of imaging techniques in the diagnosis and follow-up of muscle-invasive bladder carcinoma

INTRODUCTION

Muscle-invasive bladder malignancies represent 20-30% of all bladder cancers. These patients require imaging tests to determine the regional and distant staging.

OBJECTIVE

To describe the role of various imaging tests in the diagnosis, staging and follow-up of muscle-invasive bladder cancer. To assess recent developments in radiology aimed at improving the sensitivity and specificity of local staging and treatment response.

ACQUISITION OF EVIDENCE

We conducted an updated literature review.

SYNTHESIS OF THE EVIDENCE

Computed tomography and magnetic resonance imaging (MRI) are the tests of choice for performing proper staging prior to surgery. Computed tomography urography is currently the most widely used technique, although it has limitations in local staging. Ultrasonography still has a limited role. Recent developments in MRI have improved its capacity for local staging. MRI has been suggested as the test of choice for the follow-up, with promising results in assessing treatment response. Positron emission tomography could improve the detection of adenopathies and extrapelvic metastatic disease.

CONCLUSIONS

Imaging tests are essential for the diagnosis, staging and follow-up of muscle-invasive bladder cancer. Recent technical developments represent important improvements in local staging and have opened the possibility of assessing treatment response.

Safety and efficacy of various strains of bacille Calmette-Guérin in the treatment of bladder tumours in standard clinical practice

BACKGROUND

The natural progression of bladder tumours (nonmuscle-invasive bladder cancer [NMIBC]) is recurrence with a high rate of progression. Bacille Calmette-Guérin (BCG) has been shown effective in reducing these rates, but there are few comparative studies between strains.

MATERIAL AND METHODS

An observational, prospective and multicentre registry studied 433 patients with a 12-month follow-up visit from 961 registered patients, assessing disease-free survival (DFS), progression-free survival (PFS) cancer-specific survival (CSS) and adverse effects. We studied the Tice, Russian, Tokyo, Connaught and RIVM strains.

RESULTS

The sociodemographic data, NMIBC history, comorbidities, size, number, stage, grade, associated carcinoma in situ and transurethral resection were well balanced. DFS: There were 85 relapses (19.6%). The median DFS time was 20months. When comparing the various strains, we detected no statistically significant differences (log-rank test; P=.93). LPS: There were 33 cases of progression (7.62%). When comparing the various strains, we detected no statistically significant differences (log-rank test; P=.69). CSS: Seven patients died (1.68%). When comparing the various strains, we detected no statistically significant differences (log-rank test; P=.93). In terms of safety, 33.3% of the patients presented some type of adverse effect, mostly lower urinary symptoms (no urinary tract infections) <48h, >48h and haematuria. According to the Common Toxicity Criteria of the European Organisation for Research and Treatment of Cancer, 92.7% of the patients were grade1. There were no statistically significant differences between the strains.

CONCLUSIONS

In this intermediate analysis, the risk of recurrence, progression, specific death and safety were independent of the BCG strain employed.

Infiltrating bladder cancer: prognostic factors, follow-up and treatment of relapses

CONTEXT

Bladder cancer is the cause of more than 150,000 deaths per year. The overall rate of survival is approximately 45%, with a 10-year recurrence-free rate of 50-59%, with no changes in the last decade.

OBJECTIVE

Due to a lack of agreement on the follow-up of cystectomy or on a uniform treatment when faced with the various types of recurrence, we have analysed the most recent literature in an attempt to unify the criteria for the diagnosis and treatment of bladder cancer.

ACQUISITION OF EVIDENCE

Review of Spanish and English publications in the medical literature in the last 10 years, highlighting the most significant series in terms of the number of patients, follow-up time, as well as the existing meta-analyses.

SYNTHESIS OF THE EVIDENCE

Recurrence after cystectomy can occur in the urinary apparatus (upper urinary tract or distal urethra) and local (cystectomy bed) and/or distant metastases. Despite strict control, more than 60% of the relapses are discovered based on symptoms and not by the routine follow-up test. Locoregional and distant relapses are more common the more advanced the stage at the time of cystectomy, going from 11-21% in pT2N0 to 52-72% when there is lymphocytic N+ involvement. Recurrence in the urethra and/or upper urinary track has other prognostic factors such as multiplicity, the presence of Cis and involvement of prostatic stroma. There are various treatments for tumour relapses. Increasingly, the patient's comorbidity is considered when deciding on the therapeutic strategy. Treatments are typically multimodal and include surgery, radiotherapy and chemotherapy.

CONCLUSION

The follow-up of patients who undergo cystectomy should be individualised, taking into account the prognostic factors of recurrence and the patient's comorbidity, assuming that in some cases, multimodal treatment is indicated.

Revealing the production process of Joaquín Albarrán's Les Tumeurs de la Vessie 125 years after its writing

OBJECTIVE

Investigate how in 1891 Joaquín Albarrán organised and wrote his Les Tumeurs de la Vessie, a manuscript printed by Georges Steinheil in 1892.

MATERIAL AND METHODS

An analysis was conducted of the manuscript that compiles the casuistry set forth in the work, which helps us understand his production process. The contents of the text are analysed, revealing the originality and value of the text in the manuscript.

RESULTS

The book describes the author's personal histopathology findings from surgical and autopsied cases in Necker Hospital between 1868 and 1891: 28 numbered autopsy specimens and 67 identified by the patient's name (or, in lieu thereof, the physician's name, bed, ward and date of surgery). The notebook also contains the preliminary design of a number of photomicrographs printed in the book. Histopathology data are provided on the classification of bladder cancer, the pathway of lymphocytic spread, the genesis of cancer, tumoural heterogeneity and a number of original descriptions (squamous cell carcinoma, Von Brunn nests). Other notable clinical concepts include diagnostic symptomatology, prognosis assessment, extirpation by vesical height (with primary closure of the bladder and abdominal wall), the role of nascent endoscopic tumour extirpation and the experimental development of radical cystectomy with urinary diversion.

CONCLUSIONS

Joaquín Albarrán analysed his experience and that of professors Reverdin, Guyon and Horteloup. He reviewed autopsies and surgical specimens from patients and performed the histopathology study in each case. The main original observations from the work are discussed.

[De novo urologic tumors in kidney transplant patients]

CONTEXT

The ability of a transplant recipient to accept a graft depends on the ability of immunosuppressive drugs to regulate the immune system. Such treatments have been associated with tumor promotion and progression.

EVIDENCE ACQUISITION

A systematic literature review was carried out. Electronic searches were performed in PubMed database. The searching criterion was "urological tumors in kidney transplant recipients". The most important issues regarding incidence, urological tumor-specific features, and relevant ones about the treatment are summarized.

SYNTHESIS OF EVIDENCE

In renal transplant, 15% of all tumors are urological neoplasias; furthermore, they are the leading neoplastic cause of death. In transplant population the incidence rate of renal cell carcinoma (RCC), transitional cell bladder carcinoma (TCBC), testicular carcinoma (TC) and prostate cancer are increased 15, 3, 3 and 2 times respectively. Treatments used in transplant patients are similar to those employed in the general population:radical nephrectomy for the native kidney and conservative surgery for the graft are indicated for RCC. Radical prostatectomy is technically feasible for localized PC.Regarding to transitional cell carcinoma BCG or MMC is not contraindicated.

CONCLUSIONS

The incidence rate of cancer has increased among transplant population. These tumors can be managed following the same criteria than in general population. Because in this population the prognosis is worse for the immunosuppression, closer monitoring is required.

A comparative study between open and laparoscopic approach in radical cystectomy with orthotopic ileal neobladder

OBJECTIVE

Probably, laparoscopic radical cystectomy with ileal neobladder and neovesicourethral anastomosis is one of the most complex procedures in minimally invasive surgery.

MATERIAL AND METHODS

Prospective study carried out in 72 patients surgically treated for invasive bladder neoplasia between January 2008 and October 2013. Patients were undergone to radical cystectomy with ileal neobladder (open approach in 33 patients and laparoscopic approach in 39). The study assessed comparatively surgical outcomes, continence rate and postoperative complications.

RESULTS

Mean age was 63.5±9 years (64.3 open vs. 62.7 laparoscopic, P=.46) mean surgery time 323.6±78.7 minutes (321.3 vs. 326.5, P=.77), average hospital stay 14.8 days±8,1 (16.2 vs. 13.6, P=.2), transfusion rate 40.3% (66.7% vs. 17.9%, P<.0001) and complications rate 47.2% (63.6% vs. 33.3%, P=.01). Major complications were reported in 29.1% of cases (39.4% open vs. 20,5% laparoscopic, P=.07). With a mean follow-up rate of 42.5±19.2 months (range 15-70), 50 (69.4%) patients remain alive and free of disease. Continence was evaluated in these patients: total continence rate was 38% (50% vs. 27%, P=.09) and diurnal continence rate 58% (70.8% vs. 46.1%, P=.07). Self-catheterization rate was 8% (4.2% vs. 11.5%, P=.67). Total incontinence rate was 34% (25% vs. 42.3%, P=.19).

CONCLUSION

According to our experience, transfusion rate, number and severity of complications are lower in laparoscopic cystectomy with ileal neobladder. No statistically significant impact on operative time and on hospital stay was observed. In patients undergone to laparoscopic approach, continence rate is lower but not statistically significant.

Indiana continent catheterizable urinary reservoir

INTRODUCTION

Radical pelvic surgery requires continent or incontinent urinary diversion. There are many techniques, but the orthotopic neobladder is the most used. A continent catheterizable urinary reservoir is sometimes a good alternative when this derivation is not possible or not indicated. This paper has aimed to present our experience with the Indiana pouch continent urinary reservoir.

MATERIAL AND METHODS

The series is made up of 85 patients, 66 women and 19 men, with a mean age of 56 years (31-77 years). Variables analyzed were operating time, estimated blood loss, transfusion rate, hospital stay and peri-operatory complications.

RESULTS

The main indication in 49 cases was resolution of complications related to the treatment of cervical cancer. Average operation time was 110.5 minutes (range 80-130 minutes). Mean blood loss was 450 cc (100-1000 cc). Immediate postoperative complications, all of which were treated medically, occurred in 16 patients (18.85%). One patient suffered anastomotic leakage. Hospital stay was 19 days (range 5-60 days) and there was no mortality in the series. Late complications occurred in 26 patients (32%), these being ureteral anastomotic stenosis in 11 cases, cutaneous stoma stenosis in 9 cases and reservoir stones in 6 cases.

CONCLUSION

The Indiana continent catheterizable urinary reservoir is a valid option for the treatment of both urological and gynecological malignancies as well as for the management of pelvic morbidity related to the treatment of pelvic cancers.

Elective bladder-sparing treatment for muscle invasive bladder cancer

OBJETIVES

Radical cystectomy is the standard treatment for localised muscle invasive bladder cancer (MIBC). We offer a bladder-sparing treatment with TURB +/- Chemotherapy+Radiotherapy to selected patients as an alternative.

MATERIAL AND METHODS

We analyze, retrospectively, 30 patients diagnosed with MIBC from March 1991 to October 2010. The mean age was 62.7 years (51-74). All patients were candidates for a curative treatment, and underwent strict selection criteria: T2 stage, primary tumor, solitary lesion smaller than 5cm with a macroscopic disease-free status after TURB, negative random biopsy without hydronephrosis. Staging CT evaluation was normal. Restaging TURB or tumor bed biopsy showed a disease-free status or microscopic muscle invasion. 14 patients underwent TURB alone, 13 TURB+Chemotherapy and 3 TURB+Chemotherapy+Radiotherapy.

RESULTS

The mean follow up was 88.7 months (19-220). 14 patients remained disease free (46.6%), 10 had recurrent non-muscle invasive bladder cancer (33%). 81.3% complete clinical response. 71% bladder preserved at 5-years. Overall, 5-years survival rate was 79% and 85% cancer-specific survival rate.

CONCLUSIONS

Although radical cystectomy is the standard treatment for localised MIBC, in strictly selected cases, bladder-sparing treatment offers an alternative with good long term results.

Environmental non-occupational risk factors associated with bladder cancer

CONTEXT

Bladder carcinoma (BC), due its high morbidity and relapsing course, generates significant economic and health care costs. Accordingly, review the environmental nonoccupational risk factors (RF), more or less evidence-based, in the etiology and pathogenesis of BC, because the involvement of urologists is essential for prevention.

ACQUISITION OF EVIDENCE

Review of the peer-reviewed literature (1987-2012) on nonoccupational environmental RF associated with BC retrieved from Medline, Embase and Science Citation Index. The search profiles have been "Risk factors/Epidemiology/Tobacco-smoking/Diet-nutrition-water-liquids/Radiation/Infectious/Farmacological drugs" and "Bladder cancer".

SYNTHESIS OF EVIDENCE

Smoking was associated with 50% of BC in both sexes. Smokers have a 2-5 times higher risk than nonsmokers, directly proportional to the amount and duration of addiction. Drinking water contaminated with arsenic and chromium chlorination byproducts increases the risk of BC. High consumption of red meat and saturated fat may increase the risk, while high intake of fruits and vegetables decreases it. Patients treated with cyclophosphamide, ifosfamide and ionizing radiation have an increased risk of BC. Frequent and prolonged use of hair dyes and Schistosoma haematobium infestation increases the risk of BC.

CONCLUSIONS

The reduction or the cessation of smoking decrease BC. The contaminant-free water consumption with the increase of vegetal foods favour BC prevention. Cancer survivors treated with cyclophosphamide, ifosfamide and radiation therapy should be monitored for early diagnosis of BC.

Constitutional and occupational risk factors associated with bladder cancer

OBJECTIVE

Bladder carcinoma (BC) is the fourth most common type of cancer in males from Western countries, with primary prevention an important healthcare challenge. We review the associated constitutional and occupational risk factors (RF), with greater or lesser scientific evidence, in the aetiology of BC.

MATERIAL AND METHODS

Literature review of the last 25 years of the constitutional and occupational RF associated with BC, conducted on MedLine, CancerLit, Science Citation Index and Embase. The search profiles were Risk factors/Genetic factors/Genetic polymorphisms/Epidemiology/Occupational factors and Bladder cancer.

RESULTS

The main RF were a) age and gender (diagnosed at age 65 and over, with a 4:1 ratio of males to females); b) race, ethnicity and geographic location (predominantly in Caucasians and in Southern European countries); c) genetic (N-acetyltransferase-2 and glutathione s-transferase M1 gene mutations, which significantly increase the risk for BC); d) occupational, which represent 5%-10% of BC RF; and f) occupations with high BC risk, such as aluminium production, the manufacture of dyes, paints and colourings, the rubber industry and the extraction and industrial use of fossil fuels.

CONCLUSIONS

BC is the end result of the variable combination of constitutional and environmental RF, the majority of which are unknown. The most significant constitutional RF are related to age, gender, race, ethnicity geographic location and genetic polymorphisms. The main occupational RF are those related to aromatic amines and polycyclic aromatic hydrocarbons.