[Pathological pelvic lymph node involvement in muscle-invasive bladder cancer patients treated with radical cystectomy: A narrative review]

OBJECTIVE

To perform a narrative review of the contemporary literature on the diagnosis, prognosis and adjuvant management of muscle-invasive bladder cancer (MIBC) patients with pathological pelvic lymph node involvement (pN+) at radical cystectomy.

METHOD

A narrative review of the contemporary literature available on Medline was conducted to report studies evaluating the diagnosis, prognosis and/or adjuvant treatments for MIBC patients with pN+ disease at radical cystectomy.

RESULTS

Open or robotic extended pelvic lymph node dissection up to the crossing of the ureter with common iliac vessels can enhance the diagnosis of pN+ MIBC, especially using separate packages for the submission of a maximum number of lymph nodes. The main prognosis factors for pN+ patients are the number of positive and retrieved lymph nodes, lymph node density, extranodal extension as well as lymph node metastasis diameter. Adjuvant chemotherapy is likely to prolong overall survival in pN+ patients treated with radical cystectomy alone while adjuvant immunotherapy using nivolumab has been shown to decrease the risk of recurrence in all pN+ patients, especially those with ypN+ disease after neoadjuvant chemotherapy followed by radical cystectomy. However, few data are currently available on the role of adjuvant radiation therapy, which remains currently experimental for these patients.

CONCLUSION

Multiple parameters have been reported to impact the diagnosis and prognosis of patients with pN+ MIBC at radical cystectomy. Adjuvant management is currently based on chemotherapy and immunotherapy with preliminary data on radiation therapy.

Ureteropelvic junction obstruction and renal calculi: Simultaneous treatment by robot-assisted laparoscopic pyeloplasty and transcutaneous retrograde flexible ureteroscopy. Technique description and early outcomes

BACKGROUND

Ureteropelvic junction obstruction (UPJO) and renal calculi are associated in 20 to 30% of cases and treatment is mandatory. The simultaneous surgical management is a therapeutic challenge that is still a source of controversy. We describe our technique combining robot-assisted laparoscopic pyeloplasty and transcutaneous retrograde flexible ureteroscopy (fURS), assessing the feasibility of simultaneous treatment through an original technique.

METHODS

This single centre series reports our initial experience with 12 patients. From January 2014 to September 2018, 12 patients underwent robot-assisted laparoscopic pyeloplasty with simultaneous fURS for UPJO and renal calculi. Mean age was 46 years (24-68). 92% had multiple renal stones and the mean cumulative stone diameter was 31,3mm. Robot-assisted pyeloplasty was performed with peroperative transcutaneous retrograde fURS through a ureteral access sheath introduced in an incision on the bassinet through a subcostal trocar. Stone extraction was performed using a basket.

RESULTS

All patients underwent surgery successfully, achieving UPJ repair and complete stone extraction. Mean operating time was 92,5min (85-110). All reported Clavien-Dindo complications were grade 1. Non-contrast enhanced abdominal CT performed 1 month after surgery confirmed the absence of residual stones in all patients. Mean follow-up time was 10 months with no recurrence of UPJO.

CONCLUSION

This small series confirms the feasibility with good surgical results of concomitant robot-assisted laparoscopic pyeloplasty and transcutaneous retrograde fURS stone extraction. No major complications were observed. This technique is easily reproducible but requires 2 experienced urologists to be achieved in a contained operative time.

Neuroprotection is improved by watertightness of fetal spina bifida repair in the sheep model

OBJECTIVES

A contributing factor to unsuccessful prenatal spina bifida aperta (SBA) repair via an open approach may be incomplete neurosurgical repair causing persistent in-utero leakage of cerebrospinal fluid (CSF) and exposure of the fetal spinal cord to amniotic fluid. We aimed to investigate the neurostructural and neurofunctional efficacy of watertight prenatal SBA repair in a validated SBA fetal lamb model.

METHODS

A well-powered superiority study was conducted in the validated SBA fetal lamb model (n = 7 per group). The outcomes of lambs which underwent watertight or non-watertight multilayer repair through an open approach were compared to those of unrepaired SBA lambs (historical controls) at delivery (term = 145 days). At ∼75 days, fetal lambs underwent standardized induction of lumbar SBA. At ∼100 days, they were assigned to an either watertight or non-watertight layered repair group based on an intraoperative watertightness test using subcutaneous fluorescein injection. At 1-2 days postnatally, as primary outcome, we assessed reversal of hindbrain herniation using magnetic resonance imaging (MRI). Secondary proxies of neuroprotection were: absence of CSF leakage at the repair site; hindlimb motor function based on joint-movement score, locomotor grade and Motor Evoked Potential (MEP); four-score neuroprotection scale, encompassing live birth, complete hindbrain herniation reversal, absence of CSF leakage and joint-movement score ≥ 9/15; and brain and spinal cord histology and immunohistochemistry. As the watertightness test cannot be used clinically due to its invasiveness, we developed a potential surrogate intraoperative three-score skin-repair-quality scale based on visual assessment of the quality of the skin repair (suture inter-run distance ≤ 3 mm, absence of tear and absence of ischemia), with high quality defined by a score ≥ 2/3 and low quality by a score < 2/3, and assessed its relationship with improved outcome.

RESULTS

Compared with unrepaired lambs, lambs with watertight repair achieved a high level of neuroprotection (neuroprotection score of 4/4 in 5/7 vs 0/7 lambs) as evidenced by: a significant 100% (vs 14%) reversal of hindbrain herniation on MRI; low CSF leakage (14% vs 100%); better hindlimb motor function, with higher joint-movement score, locomotor grade and MEP area under the curve and peak-to-peak amplitude; higher neuronal density in the hippocampus and corpus callosum; and higher reactive astrogliosis at the SBA lesion epicenter. Conversely, lambs with non-watertight SBA repair did not achieve the same level of neuroprotection (score of 4/4 in 1/7 lambs) compared with unrepaired lambs, with: a non-significant 86% (vs 14%) reversal of hindbrain herniation; high CSF leakage (43% vs 100%); no improvement in motor function; low brain neuron count in both the hippocampus and corpus callosum; and small spinal astroglial cell area at the epicenter. Both watertight layered repair and high (≥ 2/3) intraoperative skin-repair-quality score were associated with improved outcome, but the watertightness test and skin-repair-quality scale could not be used interchangeably due to result discrepancies.

CONCLUSIONS

Watertight layered fetal SBA repair is neuroprotective since it improves brain and spinal-cord structure and function in the fetal lamb model. This translational research has important clinical implications. A neurosurgical technique that achieves watertightness should be adopted in all fetal centers to improve neuroprotection. Future clinical studies could assess whether a high skin-repair-quality score (≥ 2/3) correlates with neuroprotection. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Impact of Renal Cell Carcinoma Histological Variants on Recurrence After Partial Nephrectomy: A Multi-Institutional, Prospective Study (UROCCR Study 82)

BACKGROUND

The prognostic impact of renal cell carcinoma (RCC) morphotype remains unclear in patients who undergo partial nephrectomy (PN). Our objective was to determine the risk factors for recurrence after PN, including RCC morphotype.

METHODS

Patients with RCC who had undergone PN were extracted from the prospective, national French database, UroCCR. Patients with genetic predisposition, bilateral or multiple tumours, and those who had undergone secondary totalization were excluded. Primary endpoint was 5-year, recurrence-free survival (RFS), and secondary endpoint was overall survival (OS). Risk factors for recurrence were assessed by multivariable Cox regression analysis.

RESULTS

Overall, 2,767 patients were included (70% male; median age: 61 years [interquartile range (IQR) 51-69]). Most (71.5%) of the PN procedures were robot-assisted. Overall, 2,573 (93.0%) patients were recurrence free, and 74 died (2.7%). Five-year RFS was 84.9% (IQR 82.4-87.4). A significant difference in RFS was observed between RCC morphotypes (p < 0.001). Surgical margins (hazard ratio [HR] = 2.0 [95% confidence interval (CI): 1.3-3.2], p < 0.01), pT stage >1 (HR = 2.6 [95% CI: 1.8-3.7], p < 0.01]) and Fuhrmann grade >2 (HR = 1.9 [95% CI: 1.4-2.6], p < 0.001) were risk factors for recurrence, whereas chromophobe subtype was a protective factor (HR = 0.08 [95% CI: 0.01-0.6], p = 0.02). Five-year OS was 94.0% [92.4-95.7], and there were no significant differences between RCC subgroups (p = 0.06). The main study limitation was its design (multicentre national database), which may be responsible for declarative bias.

CONCLUSIONS

Chromophobe morphotype was significantly associated with better RFS in RCC patients who underwent PN. Conversely, pT stage, Fuhrman group and positive surgical margins were risk factors for recurrence.

Prediction of peritoneal soiling in acute appendicitis with simple clinical and laboratory data. Prospective, multicenter, cohort study of 2,645 adult patients nationwide

BACKGROUND AND AIMS

In order to facilitate the preoperative prediction of complicated appendicitis, we propose a complementary approach by selecting an endpoint defined by the intraoperative finding of peritoneal soiling (PS).

METHODS

Over a 6-month period, 38 centers (5% of all public hospitals) attending emergency general surgery patients on a 24-hour, 7-days a week basis, enrolled consecutive adult patients requiring appendectomy. Patients were stratified according to the absence or the finding of PS during the surgical procedure.

RESULTS

A total of 2645 patients were included; median age (IQR) was 35 (22-51) years, 44.3% were female. The laparoscopic approach was used in 70.8% of appendectomies. In a third of patients (31.7%), there was PS with pus around the appendix, or bowel contents, free pus, or blood in the peritoneal cavity. To develop the prediction model, 1764 patients were randomly selected for the derivation cohort and the remaining 881 patients were assigned to the validation cohort. On multivariable logistic regression analysis of all patients, two clinical variables (age, and pulse) and three laboratory variables (serum urea, serum sodium, and white blood cell count) were individually associated (P < .05) with a greater probability of having PS (Hosmer-Lemeshow chi, 1.63; P = .99; C-statistic, 0.7). Based on the multivariable regression model, both static and dynamic nomograms were developed for the prediction of PS in patients with acute appendicitis.

CONCLUSIONS

The entry of simple clinical and laboratory variables in the dynamic nomogram may be useful in guiding the initial management of patients with acute appendicitis in resource-limited settings.

High-efficiency grating coupler for an ultralow-loss Si3N4-based platform

Integrated silicon nitride waveguides of 100 nm height can achieve ultralow propagation losses below 0.1 dB/cm at the 1550 nm wavelength band but lack the scattering strength to form efficient grating couplers. An enhanced grating coupler design based on an amorphous silicon layer on top of silicon nitride is proposed and demonstrated to improve the directionality of the coupler. The fabrication process is optimized for a self-alignment process between the amorphous silicon and silicon nitride layers without increasing waveguide losses. Experimental coupling losses of 5 dB and a 3 dB bandwidth of 75 nm are achieved with both regular and focusing designs.

Mid-term functional outcomes of extraperitoneal robot-assisted simple prostatectomy: a single centre experience

For large prostate volume, open simple prostatectomy (OSP) or holmium laser enucleation are the gold standard surgical treatment medical therapy failure. Robot-assisted simple prostatectomy (RASP) has recently been proposed as an alternative to OSP and endoscopic techniques. Our objective was to describe our extraperitoneal RASP technique for patients with benign prostate obstruction (BPO), and to report on perioperative and mid-term functional outcomes. Data were collected prospectively for all consecutive patients who underwent RASP in our high-volume tertiary hospital over a 6-year period. International Prostate Symptom Score (IPSS), International Index of Erectile Function-5 (IIEF-5) and uroflow findings were compared before and after surgery. Intraoperative and postoperative outcomes were also assessed. Forty-seven patients were included in the study. There was no intraoperative incident and no blood transfusion was needed after surgery. Median time to bladder catheter removal was 4 days and patients were discharged the day after. Within 90 postoperative days, 6 patients (12%) experienced at least one complication, all low-grade except one (2.1%) which was Clavien IIIa grade. By univariate analysis, the only risk factor for postoperative complications was the Charlson comorbidity index (OR = 2.1, 95% CI = [1.1-4.7], p = 0.04). At 12 months, a significant improvement IPSS and uroflow rate was observed. No patient reported stress urinary incontinence. Extraperitoneal RASP appears to be a safe and effective technique for men with LUTS related to large BPO. RASP is less invasive than OSP and wide diffusion of the robot-system could lead to the rapid implementation of RASP as a treatment for large prostate.

Simplified risk-prediction for benchmarking and quality improvement in emergency general surgery. Prospective, multicenter, observational cohort study

BACKGROUND AND AIMS

Emergency General Surgery (EGS) conditions account for millions of deaths worldwide, yet it is practiced without benchmarking-based quality improvement programs. The aim of this observational, prospective, multicenter, nationwide study was to determine the best benchmark cutoff points in EGS, as a reference to guide improvement measures.

METHODS

Over a 6-month period, 38 centers (5% of all public hospitals) attending EGS patients on a 24-h, 7-days a week basis, enrolled consecutive patients requiring an emergent/urgent surgical procedure. Patients were stratified into cohorts of low (i.e., expected morbidity risk <33%), middle and high risk using the novel m-LUCENTUM calculator.

RESULTS

A total of 7258 patients were included; age (mean ± SD) was 51.1 ± 21.5 years, 43.2% were female. Benchmark cutoffs in the low-risk cohort (5639 patients, 77.7% of total) were: use of laparoscopy ≥40.9%, length of hospital stays ≤3 days, any complication within 30 days ≤ 17.7%, and 30-day mortality ≤1.1%. The variables with the greatest impact were septicemia on length of hospital stay (21 days; adjusted beta coefficient 16.8; 95% CI: 15.3 to 18.3; P < .001), and respiratory failure on mortality (risk-adjusted population attributable fraction 44.6%, 95% CI 29.6 to 59.6, P < .001). Use of laparoscopy (odds ratio 0.764, 95% CI 0.678 to 0.861; P < .001), and intraoperative blood loss (101-500 mL: odds ratio 2.699, 95% CI 2.152 to 3.380; P < .001; and 500-1000 mL: odds ratio 2.875, 95% CI 1.403 to 5.858; P = .013) were associated with increased morbidity.

CONCLUSIONS

This study offers, for the first time, clinically-based benchmark values in EGS and identifies measures for improvement.

Comparison of Peracetic Acid and Chlorine Effectiveness during Fresh-Cut Vegetable Processing at Industrial Scale

ABSTRACT

This study was conducted to compare the efficacy of two sanitizing agents, chlorine and peracetic acid (PAA), in reducing spoilage and pathogenic microorganisms and disinfection by-products in the washing stage of three types of minimally processed vegetables: iceberg lettuce, carrots, and baby leaves. These fresh-cut products are consumed uncooked; thus, proper sanitation is essential in preventing foodborne illness outbreaks. The comparison was done at industrial scale with equipment already used in the fresh-cut industry and with washers designed and manufactured for this purpose. Results showed that for washing water hygiene and final product microbial quality, the use of PAA or chlorine had similar efficacy. Different scenarios combining PAA, chlorine, and water were tested, simulating the current industrial processes for each of the tested vegetables. Overall, results confirmed that the use of a sanitizer, PAA or chlorine, in the washing water is effective for the prevention of cross-contamination during the washing process and hence for produce food safety. For final product microbiological quality and shelf life, the use of chlorine or PAA showed no significant differences in lettuce or baby leaves. Chlorinated disinfection by-products in processing water were not formed in significant amounts when washing water was treated with PAA in all scenarios and for all tested vegetables, whereas washing with chlorine (80 mg/L) generated important amounts of trihalomethanes, chlorates, and chlorites. Although chlorates and chlorites were always below the recommended levels or legal limits established for drinking water, trihalomethanes exceeded the legal limits. For perchlorates, values were below the quantification limit in all scenarios. Our results show that PAA is a reliable alternative to chlorine disinfection strategies in the fresh-cut industry.

HIGHLIGHTS

Positive environmental impact of remote teleconsultation in urology during the COVID-19 pandemic in a highly populated area

Introduction

Greenhouse gas (GHG) emissions are a serious environmental issue. The healthcare sector is an important emitter of GHGs. Our aim was to assess the environmental cost of teleconsultations in urology compared to face-to-face consultations.

Materials and methods

Prospective study of all patients who had a remote teleconsultation over a 2-week period during COVID-19 pandemic. Main outcome was the reduction in CO₂e emissions related to teleconsultation compared to face-to-face consultation and was calculated as: total teleconsultation CO₂e emissions–total face-to-face consultation CO₂e emissions. Secondary outcome measures were the reduction in travel distance and travel time related to teleconsultation.

Results

Eighty patients were included. Face-to-face consultations would have resulted in 6699 km (4162 miles) of travel (83.7 km (52 miles) per patient). Cars were the usual means of transport. CO₂e avoided due to lack of travel was calculated at 1.1 tonnes. Teleconsultation was responsible for 1.1 kg CO₂e while face-to-face consultation emitted 0.5 kg of CO₂e. Overall, the total reduction in GHGs with teleconsultation was 1141 kg CO₂e, representing a 99% decrease in emissions. Total savings on transport were 974 € and savings on travel time were 112 h (1.4 h/patient).

Conclusions

Teleconsultation reduces the environmental impact of face-to-face consultations. The use of teleconsultation in our urology departments resulted in the avoidance of more than 6000 km of travel, equivalent to a reduction of 1.1 tonnes of CO₂e. Teleconsultation should be considered for specific indications as the healthcare system attempts to become greener.

Level of evidence

3.

Anatomical variations of the renal artery based on the surgeon's direct observation: A French perspective

INTRODUCTION

Renal arterial vasculature presents a great anatomical variation. A good knowledge of this anatomy is essential in the field of kidney transplantation. The aim of this study is to describe the anatomical variations of the renal arterial vasculature based on the retrieved but not transplanted kidneys (RNTK) and their contralateral grafted kidneys (CGK), which anatomy is described by surgeons themselves after aortic dissection during multi-organ procurement (MOP).

MATERIAL AND METHODS

Using the "Crystal" database of the French "Agence de la biomédecine" (ABM), all RNTK were retrospectively selected over one year. Then, the arterial anatomy of each RNTK and their CGK was studied using the surgical and the histopathological reports. The surgical report was completed by the surgeon at the end of the MOP from deceased donors. The qualitative variables were expressed in numbers (percentage of the population) and were compared by a Chi² test or an exact Fisher test depending on the sample size. A P-value of less than 0.05 was considered statistically significant.

RESULTS

In total, 356 kidneys were studied (241 RNTK - 115 CGK), 69% had a single artery and 31% had multiple arteries (26% with two arteries and 5% with three or more). The incidence of multiple arteries was similar between the right and left kidneys (32% vs. 30% respectively). A modal arrangement with 1 artery on each side was present in 51% of cases. Thus, 1 in 2 donors had at least 2 arteries on one side. Multiple arteries were bilateral in 12% of cases. The RNTK group presented more kidneys with multiple arteries than the CGK group (35% vs. 22%).

CONCLUSION

Our study shows a higher incidence of multiple renal arteries than the literature (31% vs. 25%). Thus, MOP can be considered as an accurate and reliable method of describing renal arterial anatomy, especially that some small arteries may be missed when using radiological or cadaveric dissection techniques.

Preliminary assessment of patient and physician satisfaction with the use of teleconsultation in urology during the COVID-19 pandemic

PURPOSE

Lockdown during the COVID-19 pandemic compelled urologists to change access to healthcare, especially for oncology patients. Teleconsultation is a safe way to receive medical advice without a risk of infection, and was implemented urgently in our academic centres. Our purpose was to evaluate patient and physician satisfaction with teleconsultation set up during the COVID-19 pandemic.

METHODS

From March 16th 2020, all face-to-face consultations were cancelled in France, except for emergencies. Teleconsultation was started immediately by five senior urologists in two academic hospitals. All patients received an email survey including the validated Teleconsultation Satisfaction Questionnaire (TSQ) and demographic questions. Data were collected prospectively. Physicians also responded to the TSQ. Patient satisfaction was measured objectively with the validated 14-item TSQ. Each item was scored on a 5-point Likert scale. Factors associated with positive satisfaction with teleconsultation were assessed by multivariable logistic regression.

RESULTS

Overall, 105 patients replied to the survey (91.3%). Median age was 66 years (IQR: 55‒71) and 95 were men (90.5%). Median overall TSQ score was 67 (IQR: 60‒69); teleconsultation was judged to be a good experience by 88 patients (83.8%) and four physicians (80%). Patients who met their surgeon for the first time were more likely to have a good experience (OR = 1.2 [95% CI 1.1‒1.5], p = 0.03).

CONCLUSION

Introduced rapidly during the COVID-19 lockdown, urology teleconsultation attained a high level of satisfaction among both patients and physicians. A major change in telemedicine use is foreseen in the post COVID-19 era.

There is value in treating elevated levels of diabetes distress: the clinical impact of targeted interventions in adults with Type 1 diabetes

AIM

To compare the effect of targeted interventions to reduce high diabetes distress among adults with Type 1 diabetes with a comparison sample of similar but untreated individuals, and to document the stability of untreated diabetes distress over time.

METHODS

A total of 51 adults with Type 1 diabetes with elevated baseline diabetes distress (distress score ≥ 2.0) and HbA_1c levels (≥ 58 mmol/mol) were identified from a longitudinal, non-intervention study, and compared with a similar sample of 51 participants in an intervention study. Both groups completed the T1-DDS diabetes distress questionnaire at baseline and 9 months.

RESULTS

Large and significant reductions in diabetes distress scores were recorded in the intervention group (mean ± sd change = -0.6 ± 0.6), while minimal change was found in the non-intervention group (-0.2 ± 0.6, group effect P = 0.002; effect size d = 0.67). Additional analyses using the established minimal clinically important difference for the T1-DDS showed that diabetes distress increased significantly (minimal clinically important difference ≥ 1) or persisted at high levels for 51% of participants in the non-intervention group, compared with 23.5% in the intervention group.

CONCLUSION

Our results showed that targeted interventions led to dramatic reductions in diabetes distress compared with a lack of treatment. We also conclude that elevated diabetes distress, when left unaddressed, does not resolve over time and often remains chronic. (Clinical Trials Registry no.: NCT02175732).

Influence of cervical cerclage interventions upon the incidence of neonatal death: a retrospective study comparing prophylactic versus rescue cerclages

OBJECTIVE

The purpose of this study was to compare the efficacy of prophylactic and rescue cervical cerclages for pregnant patients with an incompetent cervix, and to assess the neonatal outcomes of both clinical conditions.

METHODS

This was a retrospective observational study of all women who had an elective or rescue cerclage between January 2008 and December 2016 in our institution. Prophylactic cerclage was defined as a cerclage before 16 weeks of gestation, while rescue cerclages were performed between 16 and 23 weeks of gestation.

RESULTS

In total, we analyzed the outcomes of 212 cervical interventions; 71% of the recruited patients experienced prophylactic cerclage, while 29% underwent rescue cerclage. Most of the patients delivered vaginally (70%) and were able to leave the hospital with a healthy newborn (78%). The mean pregnancy prolongation time after cerclage in the prophylactic and rescue groups were 21 weeks and 10 weeks, respectively.

CONCLUSION

Prophylactic cerclage interventions are most likely to be associated with a reduction of fetal demise because of the correlation between fetal prognosis and the gestational age at which cerclage is performed. Once the diagnosis of cervical insufficiency is confirmed, cerclage should be recommended as this will help to prolong the pregnancy.

Prognostic impact of percentage of squamous differentiation in patients with nonbilharzial squamous cell carcinoma and transitional cell carcinoma treated with radical cystectomy

498

Background: Squamous differentiation has been reported to occur in 10-22 % of transitional cell carcinoma. The prognostic impact of squamous differentiation is controversial. In addition, it remains unclear whether the percentage of squamous differentiation impact outcome of patients with nonbilharzial squamous cell carcinoma and transitional cell carcinoma treated with radical cystectomy Methods: We performed a retrospective study of patients with non-bilharzial squamous variants or squamous bladder carcinoma treated in two French institutions. The percentage of squamous differentiation was determined by an expert GU pathologist on radical cystectomy specimens. Progression-free survival (PFS) and cancer-specific survival (CSS) were analyzed according to the percent of squamous differentiation. Survivals were estimated using the Kaplan-Meier method and compared using multivariate Cox proportional hazard regression analysis. Results: Forty patients were identified including 28 and 12 patients which tumors were classified as transitional cell carcinomas cases with squamous cell differentiation and pure non-bilharzial squamous bladder carcinoma, respectively. Patients with tumors harboring more than 50% of squamous differentiation had a PFS of 6.3 months as compared to 60.2 months for those with squamous differentiation present in less than 50% (p = 0.014). In multivariate analysis, the percentage of squamous differentiation was the only independent prognostic factor for PFS (HR = 2.63 (IC 95%: 1.22-5.67). First site of recurrence of patients with squamous differentiation ≥50% were more frequently the pelvis (72% versus 17 %; p = 0.049). No difference in CSS were observed between patients with tumors < 50% or ≥50% squamous differentiation (16.3 months versus 62 months) (p = 0.2). Conclusions: Extensive squamous differentiation in bladder cancer is associated with poor PFS and pelvic progression, suggesting that those patients might benefit from adjuvant pelvic radiotherapy. Larger studies are needed to validate these findings.

Abstract P3-01-19: Relationship of axillary total tumor load (TTL) by OSNA (one step nucleic acid amplification) in early breast cancer and clinical outcomes using strict Z0011 study criteria for axilla management

Background: The study of sentinel lymph node (SNL) assessed by OSNA provides a new variable, Total Tumoral Load (TTL).This variable is defined as the amount of CK19 mRNA copies number in all positives SLN. TTL has been showed to predict the axillary node status and has been analysed to determine its usefulness in the axillary surgical management. Based on TTL values different cut-off points have been proposed (last 25.000 copies) to establish a new tool to practice axillary lymph node dissection (ALND). We present the follow-up data of at least 5 years of breast cancer patients who underwent ALND according, strictly, to Z0011 trial criteria. We hypothesized that there will be no correlation between TTL and locoregional relapse if Z0011 are followed.

Methods: Clinicopathological and follow up data were obtained from patients with invasive breast cancer and SLN assessed by OSNA between 2011 and 2012 at Complejo Asistencial de Ávila, Spain. ALND was decided based on Z0011 study criteria independently of TTL. All patients have been followed for a minimun of 5 years.

Results: A total of 106 patients underwent SN assessed by OSNA, age range 27-85 years (mean 58,96). Of them 90% were ductal, 7,5% lobular and 2% others. By inmunophenotype: Luminal A 55%, Luminal B 28%, Triple Negative 9,4%, Her2 positive 3,7% and Luminal B-Her2 positive 2,8%. TTL was equal to zero in 58 cases and greater than zero in 48 cases with a range of 280-2.700.000 copies. Only 5 cases met ALND criteria (average TTL 68.164). Average TTL in cases without ALND was 111.000. For the time being, none of them has had locoregional relapse (median follow up 65 months). 3 patients have died one metastatic desease (Negative SN), one uterine cervix cancer and one neutropenic fever.

Baseline and outcomes dataVARIABLE N%Age, years (median, range) 59 (27-85) Tumour TypeDuctal9690,5 Lobular87,5 Others21,8InmunophenotypeLuminal A5955,6 Luminal B3028,3 Luminal B-Her232,8 Her243,7 Triple Negative109,4Total Tumoral Load (TTL)=05854,7 &gt;04845,2Axillary Lymph Node Dissection (ALND) 254,7TTL &gt;25.000 2321,7Locoregional relapse 00Overall Survival  95,2

Conclusions:

-Using Z0011 criteria and OSNA no locoregional recurrence has been observed so far.

-TTL did not predict risk of recurrence

-If we had based axillary management only on TTL values (i.e higher than 25.000 copies) we would have unnecessarily increased the number of lymphadenectomies in a 22%.

This is an ongoing study that designed to increased the sample size and obtain longer follow-up data.

Citation Format: Tur R, De Grado C, Martin MR, De Castro J, Filipovich E, Segovia B, Ceballos J, Parra J, Revestido R, Alés-Martínez JE. Relationship of axillary total tumor load (TTL) by OSNA (one step nucleic acid amplification) in early breast cancer and clinical outcomes using strict Z0011 study criteria for axilla management [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-01-19.

Long-term oncological outcomes after robotic partial nephrectomy for renal cell carcinoma: a prospective multicentre study

PURPOSE

This study aimed at reporting the long-term oncological outcomes of robotic partial nephrectomy (RPN) for renal cell carcinoma (RCC).

METHODS

Data from all consecutive patients who underwent RAPN for RCC from July 2009 to January 2012 in three departments of urology were prospectively collected. Overall survival (OS), cancer-specific survival (CSS) and disease free-survival (DFS) were estimated using the Kaplan-Meier method. Prognostic factors associated with CSS were sought in univariate analysis. The log-rank test was used for categorical variables and the Cox model for continuous variables.

RESULTS

110 patients were included with a median follow-up of 64.4 months [95% CI = (61.0-66.7)]. Median age was 61 years (29-83) with 62.7% of men and 37.3% of women. Median RENAL score was 6 (4-10) with elective indications accounting for 95% of cases. Out of 27 patients (24.5%) who experienced peri-operative complication, 12 patients (10.9%) had a major complication (Clavien-Dindo grade ≥ 3). The TRIFECTA achievement rate was 52.7%. Three patients (2.7%) experienced local recurrence and seven patients (6.4%) progressed to a metastatic disease. 5-year OS, CSS, DFS were 94.9, 96.8, 86.4%, respectively. In univariate analysis, no pre/peri-operative characteristic was associated with DFS. No port-site metastasis was observed and there was one case of peritoneal carcinomatosis.

CONCLUSION

In this multicenter series, long-term OS, DFS and CSS after RPN appeared comparable to large series of open partial nephrectomy, with no port-site metastasis and one case of peritoneal carcinomatosis.

Impact of thyroid autoimmunity in euthyroid women on live birth rate after IUI

Study question

Does thyroid autoimmunity (TAI) predict live birth rate in euthyroid women after one treatment cycle in IUI patients?

Summary answer

TAI as such does not influence pregnancy outcome after IUI treatment.

What is known already

The role of TAI on pregnancy outcome in the case of IVF/ICSI is largely debated in the literature. This is the first study to address this issue in the case of IUI.

Study design, size, duration

This was a retrospective cohort study. A two-armed study design was performed: patients anti-thyroid peroxidase (TPO)+ and patients anti-TPO-. All patients who started their first IUI cycle in our fertility center between 1 January 2010 and 31 December 2014 were included. After exclusion of those patients with or being treated for thyroid dysfunction, 3143 patients were finally included in the study.

Participants/materials, setting, methods

After approval by the institutional review board we retrospectively included all patients who started their first IUI cycle in our center between 1 January 2010 and 31 December 2014 with follow-up of outcome until 31 December 2015. Patients with clinical thyroid dysfunction were excluded (thyroid-stimulating hormone (TSH) <0.01 mIU/l; TSH >5 mIU/l) as were patients under treatment with levothyroxine or anti-thyroid drugs. These patients were then divided into two main groups: patients anti-TPO+ and patients anti-TPO- (= control group). Live birth delivery after 25 weeks of gestation was taken as the primary endpoint of our study. As a secondary endpoint, we evaluated differences in live birth delivery after IUI according to different upper limits of preconception TSH thresholds (<2.5 and <5.0 mIU/l). Furthermore, the influence of thyroid function (TSH, free thyroxine (fT4)), anti-TPO status, age, smoking, BMI, parity, ovarian reserve (anti-mullerian hormone (AMH) and FSH), IUI indication and IUI stimulation on live birth rate was analyzed.

Main results and the role of chance

Between-group comparison did not show any significant difference between the anti-TPO+ and anti-TPO- group with respect to live birth delivery-, pregnancy- or miscarriage rate with odds ratio at 1.04 (95% CI: 0.63; 1.69), 0.98 (95% CI: 0.62; 1.55) and 0.74 (95% CI: 0.23; 2.39), respectively. In addition, there were no significant differences in live birth delivery-, pregnancy- or miscarriage rate when comparing subgroups according to TSH level (TSH ≥2.5 mIU/l vs. TSH <2.5 mIU/l) with an odds ratio at 1.05 (95% CI: 0.76; 1.47), 1.04 (95% CI: 0.77; 1.41) and  0.95 (95% CI: 0.47; 1.94), respectively.

Limitations, reasons for caution

This study was powered for the primary aim, live birth rate. The limitations of this study are the absence of region-specific reference ranges for thyroid hormones and the absence of follow-up of TSH values during ART and subsequent pregnancy. Moreover, there was a time difference of 5 months between thyroid assessment and the start of stimulation. The area where the study was conducted corresponds to a mild iodine deficient area and data should be translated with caution to areas with different iodine backgrounds.

Wider implications of the findings

Our findings indicate comparable pregnancy-, abortion- and delivery rates in women with and without TAI undergoing IUI. Moreover, we were unable to confirm a negative effect of TSH level above 2.5 mIU/l on live birth delivery rate. We therefore believe that advocating Levothyroxine treatment at TSH levels between 2.5 and 4 mIU/l needs to be considered with caution and requires further analysis in a prospective cohort study.

Study funding/competing interest(s)

No external funding was used for this study. No conflicts of interest are declared.

Preparation and characterization of injectable PMMA-strontium-substituted bioactive glass bone cement composites

In most minimally-invasive procedures used to address severe pain arising from compression fractures of the vertebral bodies, such as percutaneous vertebroplasty (PVP), a poly(methyl methacrylate) (PMMA) bone cement is used. Shortcomings of this type of cement, such as high exotherm temperature and lack of bioactivity, are well known. We prepared different formulations of a composite bone cement, whose solid constituents consisted of PMMA beads and particles of a bioactive glass (BG), where 0-20%(w/w) of the calcium component was substituted by strontium. The difference between the formulations was in the relative amounts of the solid phase constituents and in the Sr-content of BG. We determined the influence of the mixture of solid phase constituents of the cement formulation on a collection of properties, such as maximum exotherm temperature (T_max ), setting time (t_set ), and injectability (I). The selection of the PMMA beads was crucial to obtain cement composite formulations capable to be efficiently injected. Results allowed to select nine solid phase mixtures to be further tested. Then, we determined the influence of the composition of these composite bone cements on T_max , t_set , I, and cell proliferation. The results showed that the performance of various of the selected composite cements was better than that of PMMA cement reference, with lower T_max , lower t_set , and higher I. We found that incorporation of Sr-substituted BGs into these materials bestows bioactivity properties associated with the role of Sr in bone formation, leading to some composite cement formulations that may be suitable for use in PVP. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 1245-1257, 2018.

Efficacy of additional chemotherapy following failure of currently approved therapies in patients with castration-resistant prostate cancer

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Background: Approved therapies for patients with castration resistant prostate cancer (CRPC) include next generation androgen receptor inhibitors as well as taxanes which are given sequentially. After failure of these drugs, physicians may use additional chemotherapy such as carboplatin, paclitaxel, mitoxantrone and vinorelbine. The clinical benefit of these drugs in this setting remains fully unknown. Methods: A retrospective monocentric study of patients treated for CRPC was performed. Presence of metastasis and visceral involvement at diagnosis and at castration resistance, time between start of hormonotherapy and castration resistance were recorded as well as several clinical and biological parameters at start of CRPC first line. The cohort was divided into two groups according to the use of additional chemotherapies following failure of currently approved therapies. Results: Fourty subjects out of 138 cases (28.9%) fulfilled the inclusion criteria. At diagnosis, median patients age was 68 years (range, 53-86), median Gleason grade was 8 (6-10) and 53% of them harbored distant metastasis. At castration-resistance stage, 93% were metastatic including 27% out of them wihich harbored visceral involvement. Median overall survival (OS) of patients since castration-resistance was 34.9 months (range, 7.4-88.0). The two groups were comparable in terms of age, PSA level, and Gleason grade. Median OS for patients in the additional chemotherapy group (n = 16) was 42.4 months as compared to 37.3 months in the non additional treatment group (n = 24), with no statistical difference (p = 0.961). Main treatments administered consisted of carboplatin (n = 6), paclitaxel (n = 4) and mitoxantrone (n = 4). PSA response rate (decrease > 50%) obtained with use of additional treatment was 12%. Median progression-free survival was 1.9 months (range, 0.7-13.1) and median overall survival was 4.2 months (range, 2.2-17.8). Conclusions: Our retrospective study suggests that additional treatment after standard treatment failure for CRPC is associated with limited benefit. Further studies are needed to clarify the role of new agents therapies in this setting.

Antitumor activity of abiraterone, enzalutamide, and docetaxel following treatment with diethystilbestrol in castration-resistant prostate cancer

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Background: Docetaxel and Next-Generation Anti-Androgens (NGAA) including abiraterone and enzalutamide represent the standard of treatment for patients with castration-resistant prostate cancer (CRPC). Treatment sequencing of these agents is a challenge. Recent studies identified cross-resistances between hormonal therapies and taxanes, as well as between different NGAA. In aiming to elucidate whether synthetic oestrogen diethylstilbestrol (DES) therapy impacts the efficacy of later-line treatments or not, we evaluated the antitumor activity of NGAA and docetaxel following DES therapy in CRPC patients. Methods: All patients with CRPC treated at Pitié-Salpêtrière hospital in first-line setting with DES from September 1995 to July 2016 were retrospectively identified. We evaluated further activities of abiraterone, enzalutamide and docetaxel in those patients after DES therapy, using Prostate Cancer Working Group 3 criteria. Clinicopathologic characteristics, including age, performans status, metastatic sites at diagnosis and treatments initiation, and data survival were also assessed. Results: Twenty-three patients with CRPC were initially treated with DES with a median time to prostate-specific antigen (PSA) progression of 9.7 months (range, 4.7-20.3). Thirteen patients(56.5%) received abiraterone or enzalutamide before docetaxel and 21 patients (91.3%) after. Median age at first NGAA initiation was 79 years) range, 55-91). Only one patient (7.7%) achieved a PSA decline before docetaxel and two out of 18 evaluable patients (11.1%) after docetaxel. Median time to PSA progression and overall survival with a NGAA treatment were respectively 2.8 (range, 2.0-4.1) and 16.5 months(range, 4.3-31.0). Fifty percent of patients showed a PSA response with docetaxel. No clinical factors were found to be significantly associated with PSA response to NGAA treatment, nor to docetaxel. Conclusions: The activity of NGAA appears markedly limited after a DES therapy, regardless of the PSA response to docetaxel. These data suggest the likelihood of a cross-resistance mechanism between DES and NGAA, without no impact on taxanes pathways.

Clinical and ultrasound features of benign, borderline, and malignant invasive mucinous ovarian tumors

OBJECTIVE

To compare clinical and sonographic features of benign, borderline, and malignant invasive mucinous ovarian tumors (MOTs).

MATERIALS AND METHODS

Retrospective observational multicenter study comprising 365 women (mean age: 46.1 years) with a histologically confirmed benign, borderline or malignant invasive MOT. Clinical data (patient's age, patient's complaints), tumor markers (CA-125 and CA-1 9.9), and sonographic data (tumor size, bilaterality, morphology -unilocular, multilocular, unilocular-solid, multilocular-solid and solid-, and IOTA color score) were reviewed and compared among these three groups. Women with ultrasound evidence on intra-abdominal disease spread were excluded.

RESULTS

Three hundred seventy-eight MOTs (14 women had bilateral lesions) were analyzed. Histologically, 287 tumors were benign, 51 were borderline, and 40 were malignant. No difference in patient's mean age was observed. Women with borderline or invasive tumors were less frequently asymptomatic. Tumors were larger in case of invasive lesions. Borderline and invasive tumors showed solid components and exhibited IOTA color score 3 or 4, more frequently than benign lesions (p < 0.001). However, the authors discovered that 16 out of 51 (31.4%) of borderline tumors and six out of 40 (15.0%) of invasive cancers had no solid components and a color score 1 or 2, and were considered as a benign lesion by the sonolo- gist. On the other hand, 96 out of 287 (33.4%) benign mucinous cystadenoma exhibited solid components and/or a color score of 3 or 4.

CONCLUSIONS

In spite of statistical differences, the authors observed significant overlapping in ultrasound features among benign, borderline, and invasive ovarian mucinous tumors that renders a difficult accurate preoperative discrimination among these lesions.

La adición de Enterococcus faecium aumenta la respuesta inmune intestinal en cerdos en crecimiento

El destete produce un periodo breve de ayuno y adaptación a una nueva ración sólida, la cual provoca disminución de la supervivencia de los lechones y proliferación de la microbiota patógena. Se ha propuesto la utilización de probióticos, evitando que los seres humanos consuman alimentados tratados con antibióticos. El objetivo de este trabajo fue determinar el efecto de la adición de cepas de probióticos en cerdos en crecimiento sobre las poblaciones celulares del sistema inmune (eosinófilos, basófilos, neutrófilos, monocitos y linfocitos) en intestino delgado. Se sacrificaron 35 lechones escalonadamente los días 1 (21 días de edad), 15 y 30 posdetete, y se extrajo completamente el intestino. Los animales fueron alimentados con dos dietas: dieta comercial con y sin la adición de antibiótico; a esta última se adicionaron los diferentes probióticos (Lactobacillus casei, Lactobacillus acidophilus o Enterococcus faecium) en el agua de bebida. Se utilizó un diseño de bloques al azar en un arreglo de parcelas divididas. Los aislamientos realizados a partir de las muestras intestinales de E. faecium presentaron un mayor número de poblaciones celulares del sistema inmune a nivel intestinal (p<0.01). Además, se realizó medición del pH intestinal, el cual presentó una disminución estadística significativa (p<0.01), donde los animales que consumieron E. faecium presentaron los valores más bajos de pH intestinal, frente a aquellos que consumieron la dieta con adición de antibiótico. La adición de la cepa E. faecium en el alimento de lechones recién destetados, estimula el aumento en el número de poblaciones celulares intestinales del sistema inmune y alcanzan una mayor disminución del pH intestinal.

Crecimiento y desarrollo intestinal de aves de engorde alimentadas con cepas probióticas

A través de la alimentación, los animales se exponen a agentes extraños, donde el epitelio intestinal actúa como una barrera natural contra las bacterias y sustancias tóxicas que estén presentes en el lumen intestinal. No obstante, la ingesta de bacterias probióticas podría influir sobre el desarrollo y función de órganos digestivos, específicamente el intestino, mejorando los parámetros fisiológicos, nutricionales e inmunológicos de este. El objetivo de este trabajo fue evaluar diferentes cepas probióticas sobre el crecimiento alométrico y desarrollo intestinal de pollos de engorde durante su etapa productiva. Se utilizaron 125 pollos machos (Cobb) de un día de edad y alimentados con dos dietas: dieta comercial con y sin la adición de antibiótico. Los diferentes probióticos (Lactobacillus casei, Lactobacillus acidophilus ó Enterococcus faecium) se suministraron en el agua de bebida de los animales que consumieron la dieta basal sin antibiótico garantizando una concentración de 107 UFC/ml. El diseño estadístico utilizado fue de bloques al azar en arreglo de parcelas divididas. La inclusión de probióticos, específicamente E. faecium, en la alimentación de pollos de engorde mejoraron el peso, desarrollo y crecimiento de órganos de importancia digestiva, específicamente intestino, lo cual se ve reflejado en vellosidades con mayor altura y ancho, y criptas menos profundas (p

Prevalence of alternative diagnoses in patients with suspected uncomplicated renal colic undergoing computed tomography: a prospective study

OBJECTIVES

Unenhanced computed tomography (CT) has become a standard imaging technique for uncomplicated renal colic in many countries. The appropriate timing of CT imaging has not been established, and guidelines recommend that this imaging be performed between 1 and 7 days of presentation. The primary objective of this study was to determine the prevalence of alternative diagnosis identified with low-dose unenhanced CT in the emergency department (ED) in patients with suspected uncomplicated renal colic.

METHODS

This prospective single-centre study was carried out in a large university hospital ED. Over a 6-month period, all patients with clinically diagnosed renal colic and a plan to be discharged underwent low-dose unenhanced CT in the ED. Pregnant women, women of childbearing age not willing to have a pregnancy test, and patients who had already undergone diagnostic imaging were excluded. The primary outcome was the number and nature of the alternative diagnosis. Univariate analyses were performed to assess factors associated with the primary outcome.

RESULTS

A total of 178 patients were screened, and 155 underwent CT in the ED. The mean age was 42.2 years; 69% were male. The diagnosis of uncomplicated renal colic was confirmed in 118 participants (76%); 27 (17%) had an inconclusive CT scan. Overall, 10 patients (6%; 95% confidence interval [CI] 3-10) had an alternative diagnosis, 5 of whom were subsequently hospitalized.

CONCLUSION

Low-dose unenhanced CT in the ED detects alternative diagnoses in 6% (95% CI 3-10) of patients with suspected uncomplicated renal colic, half of whom are subsequently hospitalized. Our prospective findings, which were similar to those reported in retrospective studies, are a potential argument for a systematic approach to ED imaging in suspected renal colic. Future research involving intervention and control groups would be helpful.

[Functional outcomes obtained after vesicoureteral reimplantation surgery in adults: A review]

OBJECTIVES

Vesico-ureteral reimplantations (VUR) for adults are complex procedures, often practicing for distal ureteral lesions. Our goal was to synthesis the main indications for VUR, different techniques and their functional outcomes.

MATERIAL AND METHODS

A literature review in English by Medline, Embase and Google scholar was performed using the following keywords: ureter; laparoscopy; robotics, reimplantation; surgery; obstruction; morbidity; complications; psoas hitch; Boari flap; ureteroneocystostomy.

RESULTS

In more than half of the cases, aetiology was a iatrogenic ureteral lesion. When the ureteral defect was less than 2 cm, direct or non-refluxing VUR was the technique of choice. If defect was superior than 2 cm the Boari flap or vesicopsoas hitch were preferred. Several surgical approaches were feasible: open, laparoscopic only, robot assisted laparoscopic. Estimated blood loss, pain and mean hospital stay seemed better with conventional or robotic coelioscopy. Nevertheless, complications, pre-/post-operative renal function and mean operative time seemed similar. The most frequent major complication was the anastomotic urine leakage.

CONCLUSIONS

The VUR techniques are well codified now even if it's a rare procedure. Functional outcomes are satisfied according to literature and morbidity is more and more decreasing but the level of evidence of the studies is low.