Increased risk of bladder cancer recurrence due to bacillus Calmette-Guérin shortage in Brazil

SUMMARY OBJECTIVE: Our study aimed to evaluate the impact of bacillus Calmette-Guérin shortage on recurrence and progression in patients with non-muscle invasive bladder cancer in a Brazilian cohort. METHODS: We retrospectively reviewed the clinicopathological data of 409 patients who had their first transurethral resection of the bladder tumor for intermediate or high-risk non-muscle invasive bladder cancer between June 2014 and May 2021 in a tertiary public hospital in Brazil. Patients included had non-muscle-invasive urothelial carcinoma of the bladder resected completely for the first time, regardless of bacillus Calmette-Guérin use. Low-risk disease patients were excluded from the analysis. Demographic, clinicopathological, and bacillus Calmette-Guérin use data were collected from our database. Recurrence and progression data were obtained from patient records or through telephone interviews. Recurrence-free survival and progression-free survival were calculated from the date of transurethral resection of the bladder tumor until the events of recurrence, progression, last office visit, or phone interview. RESULTS: Within a median follow-up period of 26.7 months, 168 (41.1%) patients experienced a recurrence in a median time of 27 months (95%CI 16.1-38). Bacillus Calmette-Guérin was administered to 57 (13.9%) individuals after transurethral resection of the bladder tumor. Patients with ≥3 lesions (p<0.001), those with lesions >3 cm (p=0.02), and those without bacillus Calmette-Guérin treatment (p<0.001) had shorter recurrence-free survival. According to a Cox multivariate regression model, bacillus Calmette-Guérin use was independently associated with a reduced recurrence rate, with an HR of 0.43 (95%CI 0.25-0.72). Out of the patients studied, 26 (6.4%) experienced progression. T1 stage (p<0.001) and high-grade (p<0.001) were associated with shorter progression-free survival. Bacillus Calmette-Guérin did not influence bladder cancer progression. In the Cox multivariate analysis, high-risk disease was independently associated with progression (p<0.001). CONCLUSION: Our study confirms that non-muscle invasive bladder cancer exhibits a high recurrence rate. The use of adjuvant bacillus Calmette-Guérin in intermediate and high-risk patients significantly reduces this rate. Furthermore, the bacillus Calmette-Guérin shortage could have negatively impacted these patients.

Factors associated with complications after percutaneous nephrolithotomy: an analysis of 1,066 cases

SUMMARY OBJECTIVE: The aim of this study was to identify predictive factors for complications after percutaneous nephrolithotomy. METHODS: We prospectively analyzed patients who underwent percutaneous nephrolithotomy from June 2011 to October 2018. The association of preoperative and intraoperative factors with the presence of complications was assessed using univariate and multivariate analyses. The significance level was set at p<0.05. RESULTS: A total of 1,066 surgeries were evaluated, and the overall complication rate was 14.9%. In all, 105 (9.8%) surgeries were performed in the prone position, and 961 (90.2%) were performed in the supine position. Univariate analysis demonstrated that surgical position, upper pole puncture, surgical time, number of tracts, and Guys Stone Score were associated with complications. In multivariate analyses, prone position (odds ratio [OR] 2.10; p=0.003), surgical time ≥90 min (OR 1.76; p=0.014), upper pole puncture (OR 2.48; p<0.001), and Guys Stone Score 3 or 4 (OR 1.90; p=0.033) were independent predictive factors for complications after percutaneous nephrolithotomy. CONCLUSION: Performing percutaneous nephrolithotomy in the supine position, in under 90 min, and avoiding upper pole punctures may reduce complications during the treatment of large kidney stones.

Ultrasound guided endoscopic combined Intrarenal surgery - 10 steps for the success

ABSTRACT Background: Endoscopic combined intrarenal surgery (ECIRS) has been used to treat complex kidney stones (1). The combined use of ultrasound (US) has the potential to improve safety and reduce radiation exposure, however, it is still underutilized (2). Objectives: Our objective is to describe, in a step-by-step manner, the ultrasound-guided ECIRS (USG ECIRS) technique, in order to facilitate learning by urologists. Materials and Methods: We describe the 10 standardized steps that we recommend to achieve a good outcome, based on our previous experience on a high-volume kidney stone center. We recorded a case of a 37-year-old female patient with complex bilateral kidney stones that underwent a left simultaneous combined retrograde and antegrade approach. The 10 described steps are: 1 - case evaluation with CT scan (3); 2 - preoperative care with antibiotics and tranexamic acid; 3 - warm-up and training with phantoms; 4 - patient positioning in Barts flank free position; 5 - retrograde nephroscopy with flexible ureteroscope; 6 - US and endoscopic guided puncture; 7 - tract dilation under endoscopic view; 8 - stone fragmentation; 9 - status free checking and 10, kidney drainage. Images were captured by external and internal cameras, promoting a complete understanding of the procedure. The patient has signed a written informed consent form. Results: Puncture was achieved under US guidance with one attempt. Another puncture was necessary in the lower pole, parallel to the initial puncture, due to a large fragment. Surgical time was 140 min. Stone-free status was verified by retrograde and antegrade view. Kidney drainage was done with ureteral stent on string, removed after 7 days. Hb drop was 1.1 Hb/dL. The first postoperative day CT scan showed no residual stones and no complications. The patient was discharged after the CT and urethral catheter removal. Conclusion: The USG ECIRS seems to be a very efficient and reproducible technique for the treatment of complex kidney stones. Its use should be widespread.