NUM-score: A clinical-analytical model for personalised imaging after urinary tract infections.

AIM: To identify predictive variables and construct a predictive model along with a decision algorithm to identify nephrourological malformations (NUM) in children with febrile urinary tract infections (fUTI), enhancing the efficiency of imaging diagnostics. METHODS: We performed a retrospective study of patients aged <16 years with fUTI at the Emergency Department with subsequent microbiological confirmation between 2014 and 2020. The follow-up period was at least 2 years. Patients were categorised into two groups: 'NUM' with previously known nephrourological anomalies or those diagnosed during the follow-up and 'Non-NUM' group. RESULTS: Out of 836 eligible patients, 26.8% had underlying NUMs. The study identified six key risk factors: recurrent UTIs, non-Escherichia coli infection, moderate acute kidney injury, procalcitonin levels >2 µg/L, age <3 months at the first UTI and fUTIs beyond 24 months. These risk factors were used to develop a predictive model with an 80.7% accuracy rate and elaborate a NUM-score classifying patients into low, moderate and high-risk groups, with a 10%, 35% and 93% prevalence of NUM. We propose an algorithm for approaching imaging tests following a fUTI. CONCLUSION: Our predictive score may help physicians decide about imaging tests. However, prospective validation of the model will be necessary before its application in daily clinical practice.

First-line Management of Metastatic Urothelial Cancer: Current and Future Perspectives After the EV-302 and CheckMate-901 Studies.

The standard of care for the first-line management of metastatic urothelial carcinoma has been recently challenged, with the combination of pembrolizumab and enfortumab vedotin (P-EV) strongly arising as a practice-changing option from classical platinum-based chemotherapies. With this paradigm shift on the horizon new questions, including the most suitable second line of treatment for these patients, and the role that the molecular characterization of these tumours will have when selecting these therapies will inevitably arise. Furthermore, after the negative results of the Keynote 361 and IMvigor 130 trials, the combination of nivolumab with platinum-based chemotherapy followed by nivolumab maintenance (Nivo GC-Nivo) has also shown positive results when compared with chemotherapy alone. Translational studies at a molecular, cellular, and functional level will be key to better explain these discordant results. In this Current Perspective, we discuss the potential impact of these results in clinical practice and propose specific guidance for prospective translational research.

Hyponatremia and other potential markers of ultrasound abnormalities after a first febrile urinary tract infection in children.

Urinary tract infections are the initial manifestation in 30% of urinary tract malformations. Identifying these patients, who could benefit from a specific treatment, is still challenging. Hyponatremia during urinary tract infection has been proposed as a urinary tract malformation marker. We evaluate the prevalence of hyponatremia during febrile urinary tract infections and its association with subjacent urinary tract malformations. We performed a retrospective study of healthy patients under 16 years, diagnosed with a first episode of febrile urinary tract infection, who had undergone blood testing in the acute episode and at least one renal ultrasound during follow-up (January 2014-November 2020). Hyponatremia was defined as (serum sodium ≤ 130 mEq/L). According to imaging findings, we classified patients into three groups: normal kidney ultrasound, mild pelviectasis, and significant urinary tract malformation. We performed logistic regression models to identify independent risk factors for urinary tract malformation and mild pelviectasis. We included 492 patients and 2.8% presented hyponatremia. We identified normal ultrasound in 77%, mild pelviectasis in 10.8%, and urinary tract malformation in 12% of patients. We found an association between mild pelviectasis and hyponatremia [OR 6.6 (CI95% 1.6-26.6)]. However, we found no association between hyponatremia and urinary tract malformation. The parameters that were associated with malformations were presenting a non-E. coli infection, C-reactive-protein levels over 80 mg/L, and bacteremia. CONCLUSION: Hyponatremia during the first episode of febrile urinary tract infection is present in 2.8% of patients and is associated with mild pelviectasis in imaging. However, hyponatremia does not indicate a greater need for complementary tests to screen for urinary tract malformations. WHAT IS KNOWN: • Urinary tract infection is the first manifestation in 30% of children with urinary tract malformation. • Hyponatremia could be a marker to identify these children and guide the imaging approach. WHAT IS NEW: • Around 12% of children with a first episode of febrile urinary tract infection have a urinary tract malformation. • Non-E. coli infection, C-reactive protein levels over 80 mg/L, and bacteremia are markers for malformations to guide diagnostic imaging tests, but hyponatremia (Na ≤ 130 mEq/l) is not a reliable marker.

Blood analysis for screening of electrolyte and kidney function alterations in patients with febrile urinary tract infection.

AIM: To describe the prevalence, severity, risk factors, and clinical relevance of electrolyte disturbances and acute kidney injury (AKI) during febrile urinary tract infection (fUTI). METHODS: Retrospective observational study of well/fair-appearing patients between 2 months and 16 years, with no previous relevant medical history, diagnosed with fUTI in the paediatric emergency department (PED) with subsequent microbiological confirmation. Analytical alteration (AA) data were considered: AKI (creatinine elevation × 1.5 the median for age), plasma sodium alteration (≤130 or ≥150 mEq/L), and potassium alteration (≤3 or ≥6 mEq/L). RESULTS: We included 590 patients, 17.8% presented AA (13 hyponatremia, 7 hyperkalaemia, and 87 AKI). No patient presented severe analytic alterations or a higher frequency of symptoms potentially attributable to these alterations (seizures, irritability, or lethargy). Risk factors associated with these AA were clinical dehydration (OR = 3.5 95% CI: 1.04-11.7; p = 0.044) and presenting a temperature >39°C (OR = 1.9 95% CI: 1.14-3.1; p = 0.013). CONCLUSIONS: Electrolyte and renal function disturbances are infrequent in the previously healthy paediatric population with a fUTI. If present, they are asymptomatic and not severe. Based on our results, performing systematic blood analysis to rule out AA appears no longer justified, especially in the absence of risk factors.

Focal Therapy of Prostate Cancer Index Lesion With Irreversible Electroporation. A Prospective Study With a Median Follow-up of 3 Years.

PURPOSE: Our aim was to assess oncologic, safety, and quality of life-related outcomes of focal therapy with irreversible electroporation in men with localized prostate cancer. MATERIALS AND METHODS: This was a single-center, phase II study. INCLUSION CRITERIA: prostate cancer International Society of Urological Pathology grade 1-2, prostate specific antigen ≤15 ng/ml, ≤cT2b. Patients were selected based on multiparametric magnetic resonance imaging and transperineal systematic and targeted magnetic resonance imaging-ultrasound fusion-guided biopsy. Ablation of index lesions with safety margin was performed. Primary end point was cancer control, defined as the absence of any biopsy-proven tumor. A control transperineal biopsy was planned at 12 months and when suspected based on prostate specific antigen and/or multiparametric magnetic resonance imaging information. Quality of life was assessed using Expanded Prostate Cancer Index Composite Urinary Continence domain, International Index of Erectile Function, and International Prostate Symptom Score. RESULTS: From November 2014 to July 2021, 41 consecutive patients were included with a median follow-up of 36 months. Thirty patients (73%) had International Society of Urological Pathology grade 1 tumors, 10 (24%) grade 2, and 1 (2.4%) grade 3. Recurrence was observed in 16 of 41 (39%) of the whole cohort, and 16 of 33 (48.4%) who underwent biopsy. In-field recurrence was detected in 5 (15%) and out-of-field in 11 (33.3%). Ten of 41 (24.6%) including 3 of 5 (60%) with in-field recurrences had significant tumors (Gleason pattern 4-5; more than 1 core or any >5 mm involved). Median recurrence-free survival was 32 months (95% CI 6.7-57.2). Twenty-six patients (63.4%) were free from salvage treatment. All patients preserved urinary continence. Potency was maintained in 91.8%. CONCLUSIONS: Irreversible electroporation can achieve satisfactory 3-year in-field tumor control with excellent quality of life results in selected patients.

What is the impact of post-radical prostatectomy urinary incontinence on everyday quality of life? Linking Pad usage and International Consultation on Incontinence Questionnaire Short-Form (ICIQ-SF) for a COMBined definition (PICOMB definition).

AIMS: To identify the definition for urinary continence (UC) after radical prostatectomy (RP) which reflects best patients' perception of quality of life (QoL). METHODS: Continence was prospectively assessed in 634 patients, 12 months after RP using the International Consultation on Incontinence Questionnaire Short-Form (ICIQ-SF) and the number of pads employed in a 24-hour period (pad usage). We used the one-way ANOVA technique with posthoc pairwise comparisons according to Scheffé's method (homogeneous subsets) for assessing the degree of QoL deficit related to urinary incontinence (UI). RESULTS: The continence prevalence is 64.4%, 74.1%, 88.3%, and 35.8% using "0 pads," "1 safety pad," "1 pad," and "ICIQ score 0" definitions, respectively. Pad usage is moderately strongly associated with ICIQ 1, 2, and 3 (ρ = 0.744, 0.677, and 0.711, respectively; p < 0.001). Concordance between classical UC definitions is acceptable between "0 pads-ICIQ score 0" (K = 0.466), but poor for "1 safety pad" and "1 pad" (K = 0.326 and 0.137, respectively). Patients with "0 pad usage" have better QoL related to urine leakage than patients with "1 safety pad" or "1 pad" (1.41 vs. 2.44 and 3.11, respectively; p < 0.05). There were no significant differences found regarding QoL between patients with ICIQ score 0 and ICIQ score 2 (1.01 vs. 1.63; p = 0.63). CONCLUSIONS: Pad usage and the ICIQ-SF's answers provide useful information. We propose a combined definition (0 pads and ICIQ score ≤2) as it is the definition with the least impact on daily QoL.

[Effect of surgical approach on radical nephrectomy outcomes: Comparative study between open and laparoscopic nephrectomy.] / Influencia de la vía de acceso para la nefrectomía radical en el tratamiento del cáncer renal: estudio comparativo entre cirugía abierta y cirugía laparoscópica.

OBJECTIVE: The aim of this study is to evaluate the influence of laparoscopy in patients with renal cancer treated with radical nephrectomy in terms of surgical time, hospital stay, postoperative complications and survival.MATERIAL AND METHODS: Retrospective study of 570 patients with renal cancer treated with radical nephrectomyin stage ≤pT3a. Differences between groups were analysed using ANOVA test for quantitative variables and Chi squared test for qualitative. In order to evaluate possible risk factors for longer hospital stay and surgical time, multivariate analysis was performed (lineal regression). For complications we performed binary logistic regression. Overall survival (OS), recurrence free survival (RFS) and cancer specific survival (CSS) were estimated using Kaplan Meier and compared using Log Rank test. Univariate and multivariate analysis was performed using Cox regression in order to identify independent risk factors for overall, cancer specific and recurrence mortality. RESULTS: Two cohorts: 361 (63.3%) open radical nephrectomies (ORN) and 209 (36.7%) laparoscopic (LRN). Surgical time was longer in LRN (p=0.001) globally. After the period when the learning curve was over these differences were no longer significant. Hospital stay was shorter in LRN (p=0.0001). cT stage (p=0.005) and surgical access (p=0.001) acted as independent risk factors for longer surgical time. 33,5% (121 patients) of the ORN had some sort of postoperative complication vs. 11% (23 patients) in the LRN group (p=0.0001). These differences were observed in the Clavien-Dindo's grade II group. Independent risk factors for postoperative complications observed were: ASA≥III (OR=1.82, p=0.004) and stage pT3a (OR=2.29,p=0.0001). Laparoscopy acted as a protective factor for complications (OR=0,26, p=0.0001). Surgical access did not influence RFS (HR=0.87, p=0.50), CSS(HR=0.69, p=0.12). CONCLUSIONS: Laparoscopic access to RN in patients with renal cancer in ≤pT3a stage increased surgical time only in the first years, reduced hospital stayand postoperative complications and did not influence RFS, OS or CSS.

OBJETIVO: El objetivo del estudio es evaluarla influencia de la laparoscopia en pacientes concáncer renal tratados con nefrectomía radical (NR) en términos de tiempo quirúrgico, estancia media, complicaciones postoperatorias y supervivencia.MATERIAL Y MÉTODO: Análisis retrospectivo de 570 pacientes con cáncer renal tratados con NR en estadio ≤pT3a comparando cohorte de acceso abierto (NRA) y laparoscópico (NRL). Contraste de variables cualitativas con el test de Chi cuadrado y cuantitativas con ANOVA. Para identificar factores de riesgo (FR) de tiempo quirúrgico y estancia media se utilizó regresión lineal multivariante y para complicaciones la regresión logística binaria. Estimación de la supervivencia libre de recidiva (SLR), global (SG) y cáncer específica (SCE) mediante Kaplan-Meier y test de log-rank para analizar las diferencias. Análisis multivariante mediante regresión de Cox para identificar variables predictoras independientes (VPI) de SLR y SCE. Todos los cálculos se han realizado con el paquete estadístico IBM® SPSS® statisticsv-21. RESULTADOS: Dos cohortes: 361 (63,3%) NRA y 209(36,7%) NRL. El tiempo de cirugía fue mayor en NRL (p=0,001) de forma global siendo las diferencias entre ambas en el periodo tras la curva de aprendizaje no significativas. La estancia media fue menor en NRL(p=0,0001). El estadio cT (p=0,005) y la vía de acceso (p=0,001) se comportaron como VPI de prolongación del tiempo quirúrgico. El 33,5% (121 casos) de las NRA presentaron algún tipo de complicación en el postoperatorio, frente al 11% (23 casos) de las NRL (p=0,0001). Esta diferencia se observó en complicaciones tipo II de Clavien. VPI de complicaciones postoperatorias: ASA≥III (OR=1,82, p=0,004) y el estadio pT3a (OR=2,29, p=0,0001). La laparoscopia se comportó como factor protector de complicaciones (OR=0,26, p=0,0001). La vía de acceso no influyó en la SLR (HR=0,87, p=0,50) ni en la SCE (HR=0,69,p=0,12). CONCLUSIONES: El acceso laparoscópico a la nefrectomía radical en pacientes con cáncer renal en estadio ≤pT3a aumentó el tiempo quirúrgico pero solo en los primeros años, presentó menor estancia y complicacionespostoperatorias y no influyó en la SG,SLR y SCE.

Influencia de la vía de acceso para la nefrectomía radical en el tratamiento del cáncer renal: estudio comparativo entre cirugía abierta y cirugía laparoscópica / Effect of surgical approach on radical nephrectomy outcomes: Comparative study between open and laparoscopic nephrectomy

OBJETIVO: El objetivo del estudio es evaluarla influencia de la laparoscopia en pacientes concáncer renal tratados con nefrectomía radical (NR) en términos de tiempo quirúrgico, estancia media, complicaciones postoperatorias y supervivencia. MATERIAL Y MÉTODO: Análisis retrospectivo de 570 pacientes con cáncer renal tratados con NR en estadio ≤ pT3a comparando cohorte de acceso abierto (NRA) y laparoscópico (NRL). Contraste de variables cualitativas con el test de Chi cuadrado y cuantitativas con ANOVA. Para identificar factores de riesgo (FR) de tiempo quirúrgico y estancia media se utilizó regresión lineal multivariante y para complicaciones la regresión logística binaria. Estimación de la supervivencia libre de recidiva (SLR), global (SG) y cáncer específica (SCE) mediante Kaplan-Meier y test de log-rank para analizar las diferencias. Análisis multivariante mediante regresión de Cox para identificar variables predictoras independientes (VPI) de SLR y SCE. Todos los cálculos se han realizado con el paquete estadístico IBM® SPSS® statisticsv-21. RESULTADOS: Dos cohortes: 361 (63,3%) NRA y 209(36,7%) NRL. El tiempo de cirugía fue mayor en NRL (p = 0,001) de forma global siendo las diferencias entre ambas en el periodo tras la curva de aprendizaje no significativas. La estancia media fue menor en NRL(p = 0,0001). El estadio cT (p = 0,005) y la vía de acceso (p = 0,001) se comportaron como VPI de prolongación del tiempo quirúrgico. El 33,5% (121 casos) de las NRA presentaron algún tipo de complicación en el postoperatorio, frente al 11% (23 casos) de las NRL (p = 0,0001). Esta diferencia se observó en complicaciones tipo II de Clavien. VPI de complicaciones postoperatorias: ASA ≥ III (OR=1,82, p = 0,004) y el estadio pT3a (OR=2,29, p = 0,0001). La laparoscopia se comportó como factor protector de complicaciones (OR=0,26, p = 0,0001). La vía de acceso no influyó en la SLR (HR=0,87, p = 0,50) ni en la SCE (HR = 0,69, p = 0,12). CONCLUSIONES: El acceso laparoscópico a la nefrectomía radical en pacientes con cáncer renal en estadio ≤ pT3a aumentó el tiempo quirúrgico pero solo en los primeros años, presentó menor estancia y complicaciones postoperatorias y no influyó en la SG,SLR y SCE

OBJECTIVE: The aim of this study is to evaluate the influence of laparoscopy in patients with renal cancer treated with radical nephrectomy in terms of surgical time, hospital stay, postoperative complications and survival. MATERIAL AND METHODS: Retrospective study of 570 patients with renal cancer treated with radical nephrectomy in stage ≤pT3a. Differences between groups were analysed using ANOVA test for quantitative variables and Chi squared test for qualitative. In order to evaluate possible risk factors for longer hospital stay and surgical time, multivariate analysis was performed (lineal regression). For complications we performed binary logistic regression. Overall survival (OS), recurrence free survival (RFS) and cancer specific survival (CSS) were estimated using Kaplan Meier and compared using Log Rank test. Univariate and multivariate analysis was performed using Cox regression in order to identify independent risk factors for overall, cancer specific and recurrence mortality. RESULTS: Two cohorts: 361 (63.3%) open radical nephrectomies (ORN) and 209 (36.7%) laparoscopic (LRN). Surgical time was longer in LRN (p=0.001) globally. After the period when the learning curve was over these differences were no longer significant. Hospital stay was shorter in LRN (p=0.0001). cT stage (p=0.005) and surgical access (p=0.001) acted as independent risk factors for longer surgical time. 33,5% (121 patients) of the ORN had some sort of postoperative complication vs. 11% (23 patients) in the LRN group (p=0.0001). These differences were observed in the Clavien-Dindo’s grade II group. Independent risk factors for postoperative complications observed were: ASA≥III (OR=1.82, p=0.004) and stage pT3a (OR=2.29, p=0.0001). Laparoscopy acted as a protective factor for complications (OR=0,26, p=0.0001). Surgical Access did not influence RFS (HR=0.87, p=0.50), CSS (HR=0.69, p=0.12). CONCLUSIONS: Laparoscopic access to RN in patients with renal cancer in ≤pT3a stage increased surgical time only in the first years, reduced hospital stay and postoperative complications and did not influence RFS, OS or CSS

[Intense urethrorrhagia after retropubic radical prostatectomy with selective embolization of the internal pudendal artery.] / Uretrorragia intensa tras prostatectomía radical retropúbica tratada con embolización selectiva de la arteria pudenda interna.

OBJECTIVE: Urethrorrhagia after radicalprostatectomy(RP) is very uncommon, regardless of the surgicalapproach used. Arterio-urethral fistula formation betweeninternal pudendal artery branches(IPA) and bulbarurethra is an exceptional finding. METHODS: We report what we consider the first series oftwo cases (one has already been published) of urethrorrhagiaafter open retropubic RP due to urethrovascular fistulaformation with its origin in the IPA or in one of its terminalbranches. RESULTS: Both cases were diagnosed with contrast-enhancedCT, confirmed with arteriography, and they weretreated with superselective transarterial embolization(STE)with spongostan. After 5 years, the first case maintainserectile function using tadalafil on demand. The other caseis in the 2nd postoperative month. CONCLUSION: Severe urethrorrhagia after RP is an exceptionalcomplication. The existence of an arterio-urethralfistula must be considered when both urethrorrhagia andabnormal bulbar enhancement in CT are present. Arteriographyallows to confirm the diagnosis, most frequently involvingIPA distal branches. STE is an effective and safetreatment.

OBJETIVO: La uretrorragia tras prostatectomía radical (PR) es muy infrecuente, independientemente del abordaje quirúrgico utilizado. La formación de fístulas arterio-uretrales entre ramas de la arteria pudenda interna (API) y la uretra bulbar, es un hallazgo excepcional.MATERIAL Y MÉTODOS: Presentamos la primera serie de 2 casos (uno ya publicado) de uretrorragia tras PR retropúbica abierta debidos a la formación de una fístula vascular con origen en la API o una de sus ramas terminales. RESULTADOS: Ambos casos fueron diagnosticados mediante TC con contraste intravenoso, confirmados con arteriografía, y tratados con embolización transarterial supraselectiva (STE) con espongostán. Tras 5 años, el primer caso conserva la función eréctil con tadalafilo a demanda. El 2º caso se encuentra en el 2º mes postoperatorio.CONCLUSIÓN: La uretrorragia severa tras PR es una complicación excepcional. Se debe sospechar la presencia de una fístula arterio-uretral ante la coexistencia de uretrorragia y realce bulbar anómalo en la TC, que suele ser la prueba de elección en el enfoque diagnóstico. La arteriografía permite confirmar los hallazgos, que suelen interesar a ramas dislates del territorio de la API. La STE es un tratamiento efectivo y seguro.

Uretrorragia intensa tras prostatectomía radical retropúbica tratada con embolización selectiva de la arteria pudenda interna / Intense urethrorrhagia after retropubic radical prostatectomy with selective embolization of the internal pudendal artery

OBJETIVO: La uretrorragia tras prostatectomía radical (PR) es muy infrecuente, independientemente del abordaje quirúrgico utilizado. La formación de fístulas arterio-uretrales entre ramas de la arteria pudenda interna (API) y la uretra bulbar, es un hallazgo excepcional. MATERIAL Y MÉTODOS: Presentamos la primera serie de 2 casos (uno ya publicado) de uretrorragia tras PR retropúbica abierta debidos a la formación de una fístula vascular con origen en la API o una de sus ramas terminales. RESULTADOS: Ambos casos fueron diagnosticados mediante TC con contraste intravenoso, confirmados con arteriografía, y tratados con embolización transarterial supraselectiva (STE) con espongostán. Tras 5 años, el primer caso conserva la función eréctil con tadalafilo a demanda. El 2º caso se encuentra en el 2º mes postoperatorio. CONCLUSIÓN: La uretrorragia severa tras PR es una complicación excepcional. Se debe sospechar la presencia de una fístula arterio-uretral ante la coexistencia de uretrorragia y realce bulbar anómalo en la TC, que suele ser la prueba de elección en el enfoque diagnóstico. La arteriografía permite confirmar los hallazgos, que suelen interesar a ramas dislates del territorio de la API. La STE es un tratamiento efectivo y seguro

OBJECTIVE: Urethrorrhagia after radical prostatectomy(RP) is very uncommon, regardless of the surgical approach used. Arterio-urethral fistula formation between internal pudendal artery branches(IPA) and bulbar urethra is an exceptional finding. METHODS: We report what we consider the first series of two cases (one has already been published) of urethrorrhagia after open retropubic RP due to urethrovascular fistula formation with its origin in the IPA or in one of its terminal branches. RESULTS: Both cases were diagnosed with contrast-enhanced CT, confirmed with arteriography, and they were treated with superselective transarterial embolization(STE) with spongostan. After 5 years, the first case maintains erectile function using tadalafil on demand. The other case is in the 2nd postoperative month. CONCLUSION: Severe urethrorrhagia after RP is an exceptional complication. The existence of an arterio-urethral fistula must be considered when both urethrorrhagia and abnormal bulbar enhancement in CT are present. Arteriography allows to confirm the diagnosis, most frequently involving IPA distal branches. STE is an effective and safe treatment