Cumulative morbidity of ureteroscopy for upper tract urothelial carcinoma.

OBJECTIVE: To assess complications after ureteroscopy (URS) for upper tract urothelial carcinoma (UTUC) management and to assess its postoperative cumulative morbidity burden using the Comprehensive Complication Index (CCI). MATERIALS AND METHODS: Single center retrospective study including patients submitted to URS for UTUC suspicion. URSs were both diagnostic and operative. Postoperative complications were recorded according to the EAU Guidelines and graded according to Clavien-Dindo Classification (CDC). The cumulative postoperative morbidity burden developed by patients experiencing multiple events was assessed using the CCI. Multivariable logistic regression (MLR) analyses identified factors independently associated with the development of any grade and major postoperative complications. RESULTS: Overall, 360 patients with UTUC suspicion were included with a total of 575 URSs performed. The cumulative number of all postoperative complications recorded was 111. In 86 (15%) procedures, patients experienced at least one postoperative complication, while 25 (4.3%) experienced more than one complication. Of these, 16 (14%) were severe (CDC ≥ IIIa). The most frequent type of complications were urinary (34%), bleeding (30%) and infectious (30%). The higher the CDC grade, the higher the median CCI, with a statistically significant increase in median CCI from CDC II to major complications. Patients who experienced intraoperative complications were at higher risk of developing any grade and major postoperative complications at MLR. CONCLUSIONS: Complications after ureteroscopy for UTUC are relatively uncommon events. Patients who experience intraoperative complications are at higher risk of developing postoperative complications. The comprehensive complication index appeared more representative of the cumulative postoperative morbidity rather than the Clavien-Dindo classification.

Diagnóstico incidental del cáncer de vejiga en España. Estudio observacional a nivel nacional / Incidental diagnosis of bladder cancer in a national observational study in Spain

Introducción El cáncer de vejiga (CV) es una neoplasia frecuente en España. Los objetivos de este estudio fueron: identificar la proporción de pacientes diagnosticados de CV de forma incidental o tras la presentación de síntomas en un periodo contemporáneo en España; comparar las características demográficas, clínicas y patológicas entre estos grupos. Métodos El presente fue un análisis retrospectivo de un estudio observacional multicéntrico realizado en 26 hospitales del Sistema Nacional de Salud español, incluyendo a todos los nuevos diagnósticos de CV en 2011. El estudio representó 21,5% de la población española y los hospitales fueron seleccionados de forma proporcional a las regiones españolas para asegurar una muestra representativa. Los pacientes fueron categorizados según el diagnóstico de cáncer incidental o tras la presentación sintomática y se analizaron las características demográficas, patológicas y clínicas basales. Resultados En los 26 hospitales españoles incluidos en el estudio, se diagnosticaron 2.472 casos de CV, de los cuales 308 (12,5%) fueron diagnosticados de forma incidental y 2.164 (87,5%) tras la presentación de síntomas. No se observaron diferencias entre los pacientes diagnosticados incidentalmente frente a los sintomáticos en términos demográficos o de comorbilidades evaluadas. En comparación con los tumores de vejiga con diagnostico posterior a la presentación de síntomas, los diagnósticos incidentales tenían más probabilidades de ser tumores papilares, significativamente más pequeños y de tener una citología positiva/sospechosa. Además, los tumores de vejiga diagnosticados incidentalmente tenían menos probabilidades de ser músculo-invasivos (11,7 vs. 25%, p < 0,01) y de ser agresivos en el estudio patológico, con 33,6% de grado 3 vs. 50,1% (p < 0,01). Conclusiones Identificamos un porcentaje significativo (12,5%) de nuevos diagnósticos de CV realizados de forma incidental en una muestra representativa de la población española (AU)

Introduction Bladder cancer (BC) is a common malignancy in Spain. The aims of this study were: to identify the proportion of patients diagnosed with BC incidentally or after symptomatic presentation in a contemporary period in Spain; to compare demographic, clinical, and pathologic characteristics between these groups. Methods This was a retrospective analysis of a multi-centre observational study of 26 hospitals in the Spanish National Health System of all BCs newly diagnosed in 2011. The study represented 21.5% of the Spanish population and hospitals were selected in proportion to Spain's regions to ensure a representative sample. Patients were categorized by whether the cancer was diagnosed incidentally or after symptomatic presentation and baseline demographic, pathologic, and clinical characteristics were analyzed. Results 2472 were newly diagnosed with BC at the 26 participating Spanish hospitals with 308 (12.5%) of cases diagnosed incidentally and 2164 (87.5%) diagnosed after symptomatic presentation. No differences were observed between patients diagnosed incidentally vs. symptomatically in terms of demographics or measured co-morbidities. Compared to symptomatically diagnosed bladder tumours, those diagnosed incidentally were more likely to have a papillary appearance, to be significantly smaller, and less likely to have positive/suspicious cytology. Additionally, incidentally diagnosed bladder tumours were less likely to be muscle-invasive (11.7% vs. 25.0%, P < .01) nor aggressive at pathology, with 33.6% Grade 3 compared to 50.1%, (P < .01). Conclusions We identified a significant percentage (12.5%) of new bladder cancer diagnosis made incidentally in a representative sample of the Spanish population. These tumours exhibited less aggressive pathologic characteristics than their symptomatic counterparts (AU)

Reduced- vs full-dose BCG in bladder cancer: A systematic review and meta-analysis.

OBJECTIVE: To assess the oncologic outcomes and the safety profile of a reduced-dose versus full-dose BCG regimen in patients with non-muscle-invasive bladder cancer (NMIBC). MATERIAL AND METHODS: We performed a systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The PubMed, Embase, and Web of Science databases were searched in January 2022 for studies that analyzed oncological outcomes and compared between reduced- and full-dose BCG regimens. RESULTS: Seventeen studies including 3757 patients met our inclusion criteria. Patients who received reduced-dose BCG had significantly higher recurrence rates (OR 1.19; 95%CI, 1.03-1.36; p = 0.02). The risks of progression to muscle-invasive BC (OR 1.04; 95%CI, 0.83-1.32; p = 0.71), metastasis (OR 0.82; 95%CI, 0.55-1.22; p = 0.32), death from BC (OR 0.80; 95%CI, 0.57-1.14; p = 0.22), and all-cause death (OR 0.82; 95%CI, 0.53-1.27; p = 0.37) were not statistically different. When restricting the analyses to randomized controlled trials, we found similar results. In subgroup analysis, reduced dose was associated with a higher rate of BC recurrence in studies that used only an induction regimen (OR 1.70; 95%CI, 1.19-2.42; p = 0.004), but not when a maintenance regimen was used (OR 1.07; 95%CI, 0.96-1.29; p = 0.17). Regarding side effects, the reduced-dose BCG regimen was associated with fewer episodes of fever (p = 0.003), and therapy discontinuation (p = 0.03). CONCLUSION: This review found no association between BCG dose and BC progression, metastasis, and mortality. There was an association between reduced dose and BC recurrence, which was no longer significant when a maintenance regimen was used. In times of BCG shortage, reduced-dose regimens could be offered to BC patients.

Robot-assisted vs. open radical cystectomy: systematic review and meta-analysis of randomized controlled trials.

INTRODUCTION: Several randomized controlled trials (RCTs) have been launched in the last decade to examine the surgical safety and oncological efficacy of robot-assisted (RARC) vs open radical cystectomy (ORC) for patients with bladder cancer. The aim of the study was to perform a systematic review and meta-analysis of RCTs to compare the perioperative and oncological outcomes of RARC vs ORC. METHODS: A literature search was conducted through July 2022 using PubMed/Medline, Embase, and Web of Science databases. Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed to identify eligible studies. The outcomes were intraoperative, postoperative, and oncological outcomes of RARC vs ORC. RESULTS: A total of eight RCTs comprising 1,024 patients met our inclusion criteria. RARC was associated with longer operative time (mean 92.34min, 95% CI 83.83-100.84, p<0.001) and lower blood transfusion rate (Odds ratio [OR] 0.43, 95% CI 0.30-0.61, p<0.001). No differences emerged in terms of 90-day overall (p=0.28) and major (p=0.57) complications, length of stay (p=0.18), bowel recovery (p=0.67), health-related quality of life (p=0.86), disease recurrence (p=0.77) and progression (p=0.49) between the two approaches. The main limitation is represented by the low number of patients included in half of RCTs included. CONCLUSIONS: This study supports that RARC is not inferior to ORC in terms of surgical safety and oncological outcomes. The benefit of RARC in terms of lower blood transfusion rate need to be balanced with the cost related to the procedure.

Dosis reducida vs. dosis completa de BCG en el cáncer de vejiga: revisión sistemática y metaanálisis / Reduced- vs full-dose BCG in bladder cancer: a systematic review and meta-analysis

Objetivo Evaluar los resultados oncológicos y el perfil de seguridad de un régimen de Bacilo Calmette-Guérin (BCG) de dosis reducida frente a uno de dosis completa en pacientes con cáncer de vejiga no músculo infiltrante (CVNMI). Material y métodos Se realizó una revisión sistemática de acuerdo con la declaración Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Se realizaron búsquedas de estudios que analizaran los resultados oncológicos entre los regímenes de BCG con reducción de dosis y dosis completa en las bases de datos PubMed, Embase y Web of Science en enero del 2022. Resultados Diecisiete estudios que incluían a 3.757 pacientes cumplieron los criterios de inclusión. Los pacientes que recibieron reducción de dosis de BCG tuvieron tasas de recidiva significativamente mayores (OR 1,19; IC del 95%, 1,03-1,36; p = 0,02). Los riesgos de progresión a un cáncer de vejiga (CV) músculo infiltrante (OR 1,04; IC 95%, 0,83-1,32; p = 0,71), de metástasis (OR 0,82; IC 95%, 0,55-1,22; p = 0,32), de muerte por CV (OR 0,80; IC 95%, 0,57-1,14; p = 0,22) y de muerte por cualquier causa (OR 0,82; IC 95%, 0,53-1,27; p = 0,37) no fueron estadísticamente diferentes. Al restringir los análisis a ensayos controlados aleatorizados, se encontraron resultados similares. En el análisis de subgrupos, la reducción de dosis se asoció con una mayor tasa de recidiva de CV en los estudios que utilizaron solo un régimen de inducción (OR 1,70; IC 95%, 1,19-2,42; p = 0,004), lo cual no se observó cuando se empleó un régimen de mantenimiento (OR 1,07; IC 95%, 0,96-1,29; p = 0,17). En cuanto a los efectos secundarios, el esquema reducido de BCG se asoció con menos episodios de fiebre (p = 0,003) y de interrupción del tratamiento (p = 0,03). Conclusión Esta revisión no encontró ninguna asociación entre la dosis de BCG y la progresión, la metástasis y la mortalidad del CV (AU)

Objective To assess the oncologic outcomes and the safety profile of a reduced-dose versus full-dose BCG regimen in patients with non-muscle-invasive bladder cancer (NMIBC). Material and Methods We performed a systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The PubMed, Embase, and Web of Science databases were searched in January 2022 for studies that analyzed oncological outcomes and compared between reduced- and full-dose BCG regimens. Results seventeen studies including 3757 patients met our inclusion criteria. Patients who received reduced-dose BCG had significantly higher recurrence rates (OR 1.19; 95%CI, 1.03-1.36; p = 0.02). The risks of progression to muscle-invasive BC (OR 1.04; 95%CI, 0.83-1.32; p = 0.71), metastasis (OR 0.82; 95%CI, 0.55-1.22; p = 0.32), death from BC (OR 0.80; 95%CI, 0.57-1.14; p = 0.22), and all-cause death (OR 0.82; 95%CI, 0.53-1.27; p = 0.37) were not statistically different. When restricting the analyses to randomized controlled trials, we found similar results. In subgroup analysis, reduced dose was associated with a higher rate of BC recurrence in studies that used only an induction regimen (OR 1.70; 95%CI, 1.19-2.42; p = 0.004), but not when a maintenance regimen was used (OR 1.07; 95%CI, 0.96-1.29; p = 0.17). Regarding side effects, the reduced-dose BCG regimen was associated with fewer episodes of fever (p = 0.003), and therapy discontinuation (p = 0.03). Conclusion This review found no association between BCG dose and BC progression, metastasis, and mortality. There was an association between reduced dose and BC recurrence, which was no longer significant when a maintenance regimen was used. In times of BCG shortage, reduced-dose regimens could be offered to BC patients (AU)

Percutaneous puncture during PCNL: new perspective for the future with virtual imaging guidance.

CONTEXT: Large and complex renal stones are usually treated with percutaneous nephrolithotomy (PCNL). One of the crucial steps in this procedure is the access to the collecting system with the percutaneous puncture and this maneuver leads to a risk of vascular and neighboring organs' injury. In the last years, the application of virtual image-guided surgery has gained wide diffusion even in this specific field. OBJECTIVES: To provide a short overview of the most recent evidence on current applications of virtual imaging guidance for PCNL. EVIDENCE ACQUISITION: A non-systematic review of the literature was performed. Medline, PubMed, the Cochrane Database and Embase were screened for studies regarding the use virtual imaging guidance for PCNL. EVIDENCE SYNTHESIS: 3D virtual navigation technology for PCNL was first used in urology with the purpose of surgical training and surgical planning; subsequently, the field of surgical navigation with different modalities (from cognitive to augmented reality or mixed reality) had been explored. Finally, anecdotal preliminary experiences explored the potential application of artificial intelligence guidance for percutaneous puncture. CONCLUSION: Nowadays, many experiences proved the potential benefit of virtual guidance for surgical simulation and training. Focusing on surgery, this tool revealed to be useful both for surgical planning, allowed to achieve a better surgical performance, and for surgical navigation by using augmented reality and mixed reality systems aimed to assist the surgeon in real time during the intervention.

Post-mortem distribution of mephedrone and its metabolites in body fluids and organ tissues of an intoxication case.

New psychoactive substances (NPS) are substances that continue to appear on the drug market to bypass controlled substance legislation. Mephedrone or 4-methylmethcathinone is becoming the most popular new psychoactive substance among youth as a recreational drug. The present study describes the optimization and validation of a sensitive method that combined clean up procedure and LC-MS/MS technique designed to simultaneously determine the presence of Mephedrone and its two metabolites (normephedrone as active metabolite and dyhidromephedrone) in post-mortem specimens (body fluids and organ tissues). To date, this is the first determination of Mephedrone metabolites in post-mortem specimens. The validated method was applied to a fatal Mephedrone intoxication case. The distribution of the three analytes in different post-mortem matrices was presented. The toxicological results of the studied case are discussed, along with autopsy, histopathological evidence and crime-scene information. The toxicological results presented in the study provide new data relative to mephedrone and the distribution of its metabolites in post-mortem specimens. In our opinion, the metabolite concentration database must be developed because the metabolites may be linked to toxicity. The pattern of parent drug and its metabolites can be helpful in the interpretation of fatal cases involving mephedrone, which will contribute to the currently limited knowledge about mephedrone and metabolites concentrations.

Cannabinoids Determination in Brain: A Supplemental Helpful in Postmortem Evaluation.

The scientific interest in cannabis has been documented by a wide literature, but postmortem studies and interpretations of autopsy findings are lacking or limited to few cases, few matrices analyzed or a small number of analytes. The present study describes the development and full in-house validation of a sensitive and simple method based on an optimized rapid clean-up procedure combined with a robust and highly sensitive liquid chromatography coupled with tandem mass spectrometry (LC-MS-MS) technique, designed to simultaneous determination of Δ9-tetrahydrocannabinol (THC), cannabidiol (CBD), 11-hydroxy-Δ9-tetrahydrocannabinol (11-OH-THC), 11-nor-Δ9-tetrahydrocannabinol-carboxylic acid (THC-COOH) and 11-nor-Δ9-tetrahydrocannabinol-carboxylic acid glucuronated (THC-COOH gluc.) in postmortem samples: central blood (CB), femoral blood (FB) and brain tissue (BR). The developed method was validated and applied to 24 postmortem cases involving cannabinoids. In this study, we presented a full optimization and validation of target analyses for each matrix. The procedure had proven to be reliable and accurate. This study adds new data, particularly about the cannabinoids concentrations in BR samples. Combined pattern (CB, FB, BR) can be used in the interpretation of postmortem cases, proving and strengthening the assessments made on blood data. BR matrix is a helpful supplement in the investigation of the role of cannabinoids as crucial or contributory factor in leading to death.

[Neonatal group B Streptococcus infection: an integrated approach (of clinical pathologists, gynecologists, midwives, pediatricians-neonatologists) of the functional area of Cuneo (Italy)]. / Infezione neonatale da Streptococco B: un approccio multidisciplinare integrato (di laboratoristi, ginecologi, ostetriche e pediatri-neonatologi) del Quadrante di Cuneo.

The frequency of early-onset neonatal sepsis without prophylaxis is 1-5/1.000 live births. Since year '70 the most frequent causative microorganism is the group B Streptococcus (S. agalactiae, GBS), followed by Escherichia coli. The mortality rate is now reduced to 4% due to the improvement of neonatal intensive care. In the USA, the incidence of GBS early-onset neonatal sepsis has been markedly reduced by the application of the guidelines released by the Centers for Disease Control (CDC). This strategy, however, is not effective on occurrence of late-onset neonatal group B streptococcal disease. In Italy, the application of CDC guidelines is not customary, and different, often complex, protocols of obstetrical-neonatological integrated approach are applied. The frequency of infectious risk has made the GBS a paramount problem for the neonatologist, even for the legal responsibility issues resulting from the multiplicity of possible options. To reach the best level of protection of the newborn against early-onset GBS infection, the working group of providers of prenatal, obstetric, and neonatal care of the functional area of Cuneo issued an integrated protocol, in order to perform the GBS screening with the optimal culture method suggested by CDC guidelines in the highest possible number of pregnant women, and to standardize the obstetrical and neonatal management.