Surgeon experience in second-look transurethral resection of bladder cancer - a prospective study

INTRODUCTION AND OBJECTIVES

Transurethral resection of bladder tumor (TURBT) is crucial in the treatment of bladder tumors and when incorrectly performed can cause staging mistakes. To avoid these errors, a second resection is recommended in selected cases. The aim of this study is to evaluate the surgeon's ability to predict histologically complete primary resection of newly diagnosed bladder tumors avoiding the need for a second TURBT.

METHODS

This is a prospective, observational study involving 47 consecutive patients with newly diagnosed bladder tumors who had previously undergone primary TURBT, and met EAU criteria for second-look TURBT. Second-look TURBT specimens were analyzed for routine histological assessment and compared with the surgeon's impression of the tumor at initial resection.

RESULTS

Of 91 patients submitted to primary TURBT, 47 met the criteria for second-look TURBT. Second-look specimens revealed residual disease in 20.9% of patients and 3 (6.4%) of patients showed upstaging disease. The sensitivity of a senior to detect disease on second-look TURBT in relation to muscle invasion was 75%, and the specificity was 85%.

CONCLUSIONS

Second-look TURBT is crucial in the treatment of bladder cancer and cannot be replaced by a surgeon's opinion, so international recommendations should be followed. Supervision of less experienced surgeons is a cornerstone.

[Secondary prevention in acute myocardial infarction]

Myocardial infarction is still one of the main causes of mortality and morbidity in Western countries. The advances made in the last 30 years have made it possible to reduce mortality significantly (which is currently below two digits) as well as morbidity. The subject of secondary prevention of myocardial infarction gains particular significance in this context since 10 to 15% of the patients who survive the hospital phase of myocardial infarction die during the first year following discharge and, of these deaths, half occur in the first three months. Therefore, it is necessary to make an early definition of the risk of another coronary event, that is, to make a risk stratification. This should occur throughout hospitalization and should be complete at the time of discharge, never beyond the first weeks of evolution. Bearing in mind the age, sex, coronary risk factors, ischemia persistence, the degree of left ventricular dysfunction and the presence of malignant disrhythmias, there are three risk levels: high; intermediate; and low. An overall approach to secondary prevention of infarction should take into account that, apart from the factors of such high prognostic value (Chapter II) assessed in the definition of risk groups, the measures to reduce reinfarction and sudden death (Chapter III) and the control of the risk factors for heart disease (Chapter IV) should also be considered. The principal late complications of infarction with significant prognostic influence are described in Chapter III: left ventricular dysfunction; rhythm disturbances and residual ischemia. The diagnostic criteria and therapeutic objectives are considered in each of the groups with relevance to consolidated advances according to the modern concept of evidence based medicine, according to international regulations. The grading of scientific evidence into three distinct categories (A, B and C), based on five levels of evidence classified from I to V, is presented accordingly in relation to the therapeutic proposals. Chapter III deals with a set of therapeutic interventions used in secondary prevention because they reduce reinfarction and sudden death: platelet antiaggregants; anticoagulants; Beta blockers; calcium channel blockers; antioxidants and nitrates. A concept of particular clinical significance is presented for each of these groups of drugs. The last part contains an eminently clinical overall review of the principal advances in coronary risk factor control, new therapeutic acquisitions in atherosclerotic disease with natural relevance to hypolipidemic agents and statins, which apart from controlling the plasmatic levels of cholesterol, also stabilize the atherosclerotic plaque and reduce acute coronary events significantly. Apart from dyslipidemia, the classic risk factors are: smoking; hypertension; obesity; diabetes and sedentary life. In each case, reference is made to the general measures and specific approaches, as well as the pharmacological therapy according to evidence based medicine. The recommended attitudes are pointed out. The role of cardiac rehabilitation and postmenopausal hormone replacement therapy are also discussed in the last part of these recommendations, in which the on-going controversy regarding hormone replacement therapy is pointed out in view of the results of more recent clinical trials.

Ecotoxicity hazard assessment of styrene

The ecotoxicity of styrene was evaluated in acute toxicity studies of fathead minnows (Pimephales promelas), daphnids (Daphnia magna), amphipods (Hyalella azteca), and freshwater green algae (Selenastrum capricornutum), and a subacute toxicity study of earthworms (Eisenia fostida). Stable exposure levels were maintained in the studies with fathead minnows, daphnids, and amphipods using sealed, flowthrough, serial dilution systems and test vessels. The algae were evaluated in a sealed, static system. The earthworms were exposed in artificial soil which was renewed after 7 days. Styrene concentrations in water and soil were analyzed by gas chromatography with flame ionization detection following extraction into hexane. Test results are based on measured concentrations. Styrene was moderately toxic to fathead minnows, daphnids, and amphipods: fathead minnow: LC50 (96 hr), 10 mg/liter, and NOEC, 4.0 mg/liter; daphnids: EC50 (48 hr), 4.7 mg/liter, and NOEC, 1.9 mg/liter; amphipods: LC50 (96 hr), 9.5 mg/liter, and NOEC, 4.1 mg/liter. Styrene was highly toxic to green algae: EC50 (96 hr), 0.72 mg/liter, and NOEC, 0.063 mg/liter; these effects were found to be algistatic rather than algicidal. Styrene was slightly toxic to earthworms: LC50 (14 days), 120 mg/kg, and NOEC, 44 mg/kg. There was no indication of a concern for chronic toxicity based on these studies. Styrene's potential impact on aquatic and soil environments is significantly mitigated by its volatility and biodegradability.