A. Carrión

Prior Lubrication of the Urethra Does Not Reduce Pain Perception in Men Undergoing Flexible Cystoscopy

Objective: The study aimed to test the hypothesis that the instillation of lidocaine gel does not reduce the pain related to flexible cystoscopy. Material and Methods: A prospective randomized study was designed to compare the pain perception between intraurethral instillation of lidocaine gel and saline solution in flexible cystoscopy. One hundred consecutive male patients attending for flexible cystoscopy were randomized to receive 10 ml of lidocaine gel or 10 ml of saline solution. Saline solution was also used for the irrigation pressure. Patients recorded their pain on a 10 cm Visual Analog Scale before and after the procedure. Patients also assessed whether the cystoscopy was more painful than the previous one. Statistical comparison was made using the t test for parametrical data and the Mann-Whitney U test for non-parametrical data. Results: Mean pain score in the lidocaine group was 0.67 ± 1.11 cm (range 0-5) compared to 0.55 ± 1.10 cm (range 0-5) in the saline solution group. Pain perception did not differ significantly between the 2 groups (mean difference 0.12 cm, 95% CI -0.32 to 0.55, p = 0.40). Conclusions: Prior lubrication of the urethra does not reduce the pain produced during flexible cystoscopy. The introduction of flexible cystoscopes under direct vision and with an irrigation pressure might guarantee sufficient comfort and the lubricant gel instillation could be avoided.

Urinary cell microRNA-based prognostic classifier for non-muscle invasive bladder cancer

Current prognostic tools for non-muscle invasive bladder cancer (NMIBC) do not have enough discriminative capacity to predict the risk of tumour progression. This study aimed to identify urinary cell microRNAs that may be useful as non-invasive predictive biomarkers of tumour progression in NMIBC patients. To this end, 210 urine samples from NMIBC patients were included in the study. RNA was extracted from urinary cells and expression of 8 microRNAs, previously described by our group, was analysed by quantitative PCR. A tumour progression predicting model was developed by Cox regression analysis and validated by bootstrapping. Regression analysis identified miR-140-5p and miR-92a-3p as independent predictors of tumour progression. The risk score derived from the model containing these two microRNAs was able to discriminate between two groups with a highly significant different probability of tumour progression (HR, 5.204; p<0.001) which was maintained when patients were stratified according to tumour risk. The algorithm was also able to identify two groups with different cancer-specific survival (HR, 3.879; p=0.021). Although the data needs to be externally validated, miRNA analysis in urine appears to be a valuable prognostic tool in NMIBC patients.

Perfil hormonal preoperatorio en pacientes sometidos a prostatectomía radical por cáncer de próstata

OBJECTIVE There is controversial evidence regarding preoperative testosterone (T) levels related to poor prognosis factors after radical prostatectomy (RP). The aim of this manuscript is to determine the relationship between preoperative T levels and final pathologic report together to biochemical recurrence after RP. MATERIALS AND METHODS We prospectively analysed 143 patients submitted to RP from February 2008 to June 2010 in our centre. Pretreatment T and sex hormone-binding globulin levels were determined as part of our clinical protocol. Free calculated (fT) and bioavailable (bioT) T were calculated using Vermeulens formula. Low T levels were defined as 346 ng/dL or less. A comparative analysis with variables pTNM, positive margins, tumour burden, Gleason score, multifocality and biochemical recurrence (using both PSA>0.4 ng/dL and PSA>0.2 ng/dL as cut-off values) was performed, according to preoperative levels of T. RESULTS Variables Gleason score, rate and number of positive margins, tumour burden, tumour multifocality, time to biochemical recurrence and pathological stage were not related to preoperative hormonal levels. Preoperative T<346 ng/dL was not found to be related to PSA recurrence (PSA>0,4 ng/dL log-rank, P=.512), although a trend was observed when PSA>0,2 ng/dL (log-rank, P=.097). CONCLUSION Preoperative T levels were not related to final pathological report or to biochemical recurrence.

Intraoperative prognostic factors and atypical patterns of recurrence in patients with upper urinary tract urothelial carcinoma treated with laparoscopic radical nephroureterectomy

Abstract Objective The aims of this study were to identify clinical, intraoperative and pathological prognostic factors for predicting extraurothelial recurrence and cancer-specific survival (CSS) in patients with upper urinary tract urothelial carcinoma (UTUC) who had undergone laparoscopic radical nephroureterectomy (LRNU), and to investigate the site-specific patterns of recurrence and the associated outcomes. Materials and methods A retrospective revision was undertaken of 117 consecutive patients who had undergone transperitoneal LRNU for UTUC between 2007 and 2012. Univariate and multivariate Cox regression analyses were used to identify prognostic factors and Kaplan–Meier was used to estimate CSS. Results With a median follow-up of 20 months, 36 patients (30%) developed extraurothelial recurrence (local and/or distant). In the multivariate analysis, entering the urinary tract during LRNU was related to local recurrence (p = 0.04), management of the distal ureter to CSS (p = 0.003), pathological stage and positive margins to local (p = 0.001, p = 0.013), distant (p = 0.028, p = 0.009) and global recurrence (p = 0.05, p = 0.012) and CSS (p = 0.011, p = 0.042), and multifocality to distant recurrence (p = 0.024). Median time to recurrence was 11.4 months after LRNU. Of 36 patients with progression, 23 (64%) had simultaneous local and distant recurrence and eight had atypical metastases: two port-site metastases, five peritoneal, two subcutaneous and two abdominal wall implants. The 5 year CSS was 61% for all patients with UTUC and 9% for those with recurrence. Conclusions Intraoperative events could have a negative impact on the oncological outcomes of patients with UTUC treated with LRNU. The use of laparoscopy for advanced UTUC may be related to atypical ways of spreading.

La colocación de catéteres doble J con anestesia local en régimen ambulatorio es un procedimiento seguro y eficiente para el manejo de distintas patologías ureterales

OBJECTIVE To assess the outcomes of ureteral stent placement under local anesthesia for the management of multiple ureteral disorders. METHODS Retrospective study of 45 consecutive ureteral stents placed under local anesthesia from January 2015 to July 2016. Inclusion criteria were hemodynamically stable patients with urinary obstruction, urinary fistula or for prophylactic ureteral localization during surgery. Five minutes before the procedure, 10ml of lidocaine gel and 50ml of lidocaine solution were instilled in the bladder. A 4.8Fr ureteral stent was placed using a 15.5Fr flexible cystoscope under fluoroscopic control. Characteristics of procedures and outcomes were analysed. RESULTS A total of 45 procedures (33 placement, 12 replacements) were attempted in 37 patients, of which 40 (89%) were successful. There were 10 male (27%) and 27 female patients (73%) with a mean age of 58.6 years (±17.5). Main indications for stent placement were stones (37.8%), extrinsic ureteral compression (28.9%) and surgery ureteral localization (22.2%). The reasons for failing to complete a procedure were the inability to pass the guidewire/stent in 4 cases (8.8%) or to identify the ureteral orifice in 1 (2.2%). Postoperative complications occurred in 8 patients (17.8%) (7 Clavien I, 1 Clavien IIIa). No procedure was prematurely terminated due to pain. Statistical analysis did not find significant successful predictors. The outpatient setting provided a fourfold cost decrease. CONCLUSIONS Ureteral stent placement can be safely and effectively performed under local anesthesia in the office cystoscopy room. This procedure could free operating room time, reduce costs and minimize side effects of general anesthesia.

Un mayor índice de comorbilidad de Charlson se relaciona con características más agresivas de los tumores vesicales de novo

OBJECTIVE To analyze the relationship between the age--adjusted Charlson Comorbidity Index (aCCI) and pathological outcomes of transurethral resection of de novo bladder tumours (BT). MATERIAL AND METHODS Data from 208 patients who underwent a transurethral resection (TUR) of a de novo BT between 2007 and 2008 were collected. We recorded the following variables: age, sex, tobacco consumption, comorbidities assessed according to the ICCa (score and mortality rate), disease stage, tumour grade and risk of recurrence and progression. The relationship between the preoperative variables and the final pathological characteristics was analyzed. The multivariate study was conducted with the significant variables (P<.05) from the univariate analysis. RESULTS The mean age of the patients was 69.5 ± 12 years, and 77% were men. The mean ICCa was 6.4 ± 2.5. The final pathology results showed a Tx, T0, Ta, T1 and T ≥ 2 in 5.3, 6.7, 31.7, 26.9, and 28.8% of the cases, respectively. 33.3% of the tumours were low-grade and 66.7% were high-grade. 14.3% of the tumours were associated with carcinoma in situ. Among those non musculo-invasive bladder tumour (non-MIBT), 34.7% had a low risk of recurrence and progression, 18.1% had an intermediate risk and 47.2% had a high risk. The patients with a ICCa ≥ 5 had an increased number of MIBT (RR: 2.29; 1.1-4.8; P=.032), high-grade tumours (RR: 3.1; CI: 1.6-6; P=.001) and tumours with a high risk of recurrence and progression (RR: 2.9; CI: 1.4-5.9; P<.001). CONCLUSION The ICCa is related to the pathological characteristics of de novo BT. Patients with greater comorbidity can present more aggressive tumours. The ICCa could therefore be useful in clinical practice for identifying patients with worse prognosis.