Radical Nephroureterectomy Tetrafecta: A Proposal Reporting Surgical Strategy Quality at Surgery

Background

Standardized methods for reporting surgical quality have been described for all the major urological procedures apart from radical nephroureterectomy (RNU).

Objective

To propose a tetrafecta criterion for assessing the quality of RNU based on a consensus panel within the Young Association of Urology (YAU) Urothelial Group, and to test the impact of this tetrafecta in a multicenter, large contemporary cohort of patients treated with RNU for upper tract urothelial carcinoma (UTUC).

Design, setting, and participants

This was a retrospective analysis of 1765 patients with UTUC treated between 2000 and 2021.

Outcome measurements and statistical analysis

We interviewed the YAU Urothelial Group to propose and score a list of items to be included in the “RNU-fecta.” A ranking was generated for the criteria with the highest sum score. These criteria were applied to a large multicenter cohort of patients. Kaplan-Meier curves were built to evaluate differences in overall survival (OS) rates between groups, and a multivariable logistic regression model was used to find the predictors of achieving the RNU tetrafecta.

Results and limitations

The criteria with the highest score included three surgical items such as negative soft tissue surgical margins, bladder cuff excision, lymph node dissection according to guideline recommendations, and one oncological item defined by the absence of any recurrence in ≤12 mo. These items formed the RNU tetrafecta. Within a median follow-up of 30 mo, 52.6% of patients achieved the RNU tetrafecta. The 5-yr OS rates were significantly higher for patients achieving tetrafecta than for their counterparts (76% vs 51%). Younger age, lower body mass index, and robotic approach were found to be independent predictors of tetrafecta achievement. Conversely, a higher Eastern Cooperative Oncology Group score, higher clinical stage, and bladder cancer history were inversely associated with tetrafecta.

Conclusions

Herein, we present a “tetrafecta” composite endpoint that may serve as a potential tool to assess the overall quality of the RNU procedure. Pending external validation, this tool could allow a comparison between surgical series and may be useful for assessing the learning curve of the procedure as well as for evaluating the impact of new technologies in the field.

Patient summary

In this study, a tetrafecta criterion was developed for assessing the surgical quality of radical nephroureterectomy in patients with upper tract urothelial carcinoma. Patients who achieved tetrafecta had higher 5-yr overall survival rates than those who did not.

1459 Intravesical Chemohyperthermia Versus Bacillus Calmette-Guerin Instillation for Intermediate- And High-Risk Non-Muscle Invasive Bladder Cancer: A Systematic Review and Meta-Analysis

Introduction

Traditional intravesical chemotherapy instillations under room temperature post trans-urethral resection (TUR) of non-muscle invasive bladder cancer (NMIBC) have lower efficacies than maintenance BCG installations. Intravesical chemo-hyperthermia (CHT) at higher temperatures is developed to improve the efficacy of chemotherapy instillation. This systematic review aims to compare the use of CHT and BCG instillation post-TUR.

Method

The protocol of this review is registered on PROSPERO(CRD42020223277). A comprehensive literature search was performed on Medline, EMBASE, and Cochrane CENTRAL to identify studies comparing CHT and BCG post-TUR for intermediate- or high-risk NMIBC. Primary outcomes include recurrence-free survival (RFS) and progression-free survival (PFS). Secondary outcomes include adverse events (AE).

Results

From 2,375 identified records, four randomised control trials incorporating 327 patients were included for meta-analysis. The use of CHT was found to be non-inferior to BCG in RFS, PFS and AEs (Grades 1-3) (p > 0.05). Sensitivity analysis, excluding patients with BCG failures, show 24-36 months recurrence rate to be significantly lower in CHT group (RR 0.64, 95% CI 0.42-0.98, p = 0.04) compared to the BCG group. In patients without carcinoma in situ (CIS), RFS is also significantly better in CHT patients (HR 0.52, 95% CI 0.32- 0.85, p < 0.01). Safety profile remains non-inferior to the BCG group in sensitivity analyses. Quality of evidence across all outcomes ranged from moderate to low.

Conclusions

In well-selected patients, intravesical CHT has superior oncological outcomes and non-inferior safety profile when compared to BCG maintenance therapy for patients with intermediate- and high-risk NMIBC. CHT is a possible alternative treatment during BCG shortage.

The role of device-assisted therapies in the management of non-muscle invasive bladder cancer: A systematic review

OBJECTIVE

Despite optimal treatment, patients affected by non-muscle invasive bladder cancer (NMIBC) suffer from high risk of recurrence and progression. Intravescical device assisted therapies such as radiofrequency induced thermochemotherapeutic effect (RITE) and electromotive drug administration (EMDA) have shown promising effect in enhancing the effect of intravescical chemotherapies. The aim of the study was to assess clinical outcomes of these two devices in non-muscle invasive bladder cancer.

METHODS

A systematic literature review was performed in December 2019 using the Medline, Embase, and Web of Science databases. Only articles published in the last 10 years were considered (2009-2019). The articles were selected using the following keywords association: "bladder cancer" AND "EMDA' AND "synergo" AND "hyperchemotherapy" AND "electromotive drug administration", AND "radiofrequency induced thermochemotherapeutic" AND "RITE".

RESULTS

We found 16 studies published in the last ten years regarding the efficacy of RITE (12 studies) and EMDA (4 studies) in the treatment of NMIBC. Both RITE and EMDA showed promising results in the treatment of intermediate and high risk NMIBC as well as in patients affected by recurrent BCa after BCG failure. In high-risk BCG naïve NMIBC patients treated with EMDA recurrence and progression rates were 68% and 95%, respectively. Considering RITE, recurrence and progression range rates were 43%-88% and 62%-97%, respectively. Discordance results were reported regarding its effect on patients with carcinoma in situ. However, only few studies could be compared since differences exist regarding inclusion criteria with high patients' heterogeneity. Considering recurrence after BCG, recurrence and progression range rates were 29%-29.2% and 62%-83% for RITE and 25% and 75% for EMDA, respectively.

CONCLUSION

Delivery of intravescical hyperthermia seems to enhance the normal effect of intravescical chemotherapy instillation. Although prospective trials supported its effect on both BCG naïve and BCG failure patients, data are urgently required to validate these findings and to understand its effect on patients with carcinoma in situ.

LEVEL OF PROOF

3.

The 1973 WHO and 2004 WHO grading systems are not equal in prediction of survival among stage T1 bladder cancer patients

INTRODUCTION AND OBJECTIVES

The aim of this study was to analyse prognostic impact of tumour histological grade on survival differences between primary G2 and G3 WHO1973 stage T1 tumours which were graded as HG according to WHO2004 grading system.

MATERIALS AND METHODS

Data from 481 patients with primary T1HG bladder cancer who were treated between 1986 and 2016 in 2university centres were retrospectively reviewed. Log-rank test and Cox regression analysis was performed to compare the groups.

RESULTS

95 (19,8%) tumours were classified as G2 and 386 (80,2%) were G3. Median follow-up was 68 months. The recurrence was observed in 228 (47,5%), and progression in 109 patients (22,7%). Radical cystectomy was performed in 114 pts (23,7%) and there were 64 (13,3%) cancer specific deaths. Recurrence-free rates at 5-years follow-up for G2, G3 and all patients were 68,7%, 51,2% and 56,3% and progression-free rates were 89,3%, 73,2% and 78,1% respectively. For total observation period patients with G3 tumours presented also worse recurrence-free, and progression-free survival levels than patients with G2 tumours. In multivariate analysis, after adjustment for clinical features, the risk of recurrence and progression for G3 tumours was 1,65 and 2,42 fold higher than for G2 tumours.

CONCLUSIONS

It was shown that G3 T1 tumours are characterized by worse recurrence free and progression free survivals when compared to G2 cancers.

Diabetes and Cancer: a Review of Current Knowledge

Diabetes mellitus (DM), one of the most common life-threatening illnesses worldwide, is a group of metabolic diseases, characterized by sustained hyperglycemia. The global prevalence of diabetes mellitus among adults reached 387 millions in 2014 and is still rising. It is suggested there is a strong association between diabetes mellitus (especially type 2 diabetes mellitus) and carcinogenesis. The possible biological links between diabetes mellitus and cancer comprise hyperinsulinemia, hyperglycemia and fat-induced chronic inflammation. Although, the strongest association refers to pancreas and liver, there are many other organs involved in carcinogenesis in diabetic patients including breast, endometrium, bladder and kidney.Recent studies suggest that there is also association between cancer incidence and anti-diabetic medications. It was observed that some medications decrease the risk of carcinogenesis and some increase that risk. The majority of studies concern metformin, a drug of choice in type 2 diabetes mellitus, and its anti-neoplastic and tumor-suppressing activity. The positive effect of metformin was found in numerous researches investigating breast, pancreas, liver, colon, ovaries and prostate tumors.Because a variety of studies have suggested that diabetes mellitus and cancer are frequently coexisting diseases, recently published studies try to explain the influence of diabetes mellitus and anti-diabetic medications on carcinogenesis in different organs.We present the review of the latest studies investigating the association between both diabetes mellitus and anti-diabetic medications and cancer incidence and prognosis.Particularly we highlight the problem of concomitant head and neck cancers in diabetics, rarely analysed and often omitted in studies.

Can ficolin-2 (L-ficolin) insufficiency be established by a single serum protein measurement?

Serum ficolin-2 was measured in multiple (2-27) samples from 68 paediatric sepsis patients. Fourteen individuals (21%) gave values that included a change in status from 'normal' to 'insufficient' or vice versa. Therefore, if possible, ficolin-2 concentration should be determined in samples obtained when a disease is inactive.

Impaired vitamin B12 metabolic status in healthcare workers occupationally exposed to nitrous oxide

BACKGROUND

Previous studies demonstrated inactivation of vitamin B12 by nitrous oxide (N(2)O). The intraoperative exposure to N(2)O was shown to induce megaloblastic anaemia and myelopathy in subjects with subclinical vitamin B12 deficiency. In contrast, no data concerning the influence of occupational exposure to N(2)O on vitamin B12 metabolic status are available to date. In the present study, the vitamin B12 status in operating theatre personnel was assessed in relation to the extent of exposure.

METHODS

Ninety-five operating theatre nurses with the history of exposure to N(2)O and 90 unexposed counterparts were examined. Vitamin B12 and folic acid were measured by immunoassay. Total homocysteine (tHcy), an indicator of impaired vitamin B12 metabolism, was determined by high performance liquid chromatography. N(2)O concentration was monitored by adsorption gas chromatography and mass spectrometry.

RESULTS

No significant differences were found between both groups with respect to haematological parameters and folic acid. However, subjects exposed to N(2)O presented with lower vitamin B12 [372.8 (12.1) vs 436.8 (13.2) pmol litre(-1), P<0.001] and higher tHcy [11.2 (0.5) vs 8.9 (0.5) micromol litre(-1), P=0.006]. The changes in vitamin B12 status were aggravated in subjects exposed to N(2)O in concentrations substantially exceeding occupational exposure limit (180 mg m(-3)) [vitamin B12: 341.9 (17.7) vs 436.8 (13.2) pmol litre(-1), P=0.006; tHcy: 12.9 (0.7) vs 8.9 (0.5) micromol litre(-1), P=0.047].

CONCLUSIONS

Exposure to N(2)O in healthcare workers is associated with alterations of vitamin B12 metabolic status, the extent of which depends on the level of exposure.

Increased incidence of micronuclei assessed with the micronucleus assay and the fluorescence in situ hybridization (FISH) technique in peripheral blood lymphocytes of nurses exposed to nitrous oxide

It has been postulated that exposure to nitrous oxide and halogenated anaesthetics is associated with various adverse health effects such as neurological and reproductive abnormalities or impairment of hepatic functions. In spite of the quite well known genotoxic effects of exposure to nitrous oxide in vivo, the mechanisms of these effects are still not clear. The aim of this study was to assess the frequency of micronuclei and to identify the type of chromosomal damage (clastogenic or aneugenic) in peripheral blood lymphocytes of operating-room nurses exposed to nitrous oxide. The study group comprised 46 women working at departments where the concentration of nitrous oxide ranged from 14 to 2308 mg/m3. The control population was composed of 28 women employed in the same hospitals but in non-surgical departments. The clastogenic/aneugenic effect of nitrous oxide was evaluated in lymphocytes using the standard micronucleus (MN) assay in combination with the fluorescence in situ hybridization (FISH) technique with pancentromeric probes. The results show a significant increase of the MN frequency in lymphocytes of exposed nurses compared with the control group (4.36+/-2.23 versus 9.02+/-4.67). The multiple regression analysis revealed a statistically significant relationship (p=0.0009) between MN frequency and exposure status, indicating that the level of exposure was the main factor affecting chromosomal damage. As assessed by FISH analysis, the overall frequencies of centromere-positive MN in the control and exposed groups were 43 and 49%, respectively. The increase observed in the exposed group may suggest a slight, statistically insignificant pro-aneugenic effect of exposure to nitrous oxide.

[Croup in children--results of prospective, multicenter observation]

Croup syndrome is an urgent and frequent reason for hospitalization of children.

MATERIAL AND METHODS

632 children with croup syndrome (422 boys and 210 girls aged 2 months-17 years) admitted to 15 pediatric departments in Lower Silesia were prospectively observed for 12 months (from April 2001 to March 2002). We conducted prospective survey of clinical and laboratory data from all study centers.

RESULTS

Following diagnoses were accepted as the croup syndrome: subglottic laryngitis in 482 patients (75.4%), laryngotracheobronchitis in 75 (11.8%), laryngitis in 50 (7.8%) and epiglottitis in 20 children (3%). The most severe course was observed in children with epiglottitis. Four of them required airway intervention and had endotracheal intubation. H. influenzae b was cultured from blood of one patient. The most cases of epiglottitis occurred in the 3rd year of life (45%).

CONCLUSIONS

1. The most common reason of croup was subglottic laryngitis. 2. Epiglottitis was rare with serious course of disease; frequency was comparable with the frequency seen in European countries before the implementation of Hib vaccine. The routine use of Hib vaccine in Poland may prevent from children life threatening epiglottis cases.

[Treatment of croup syndrome in children in Poland: results of the prospective multi-center observation]

The aim of the study was to estimate treatment practice in hospital management of croup syndrome (laryngitis subglottica) in children in Poland.

MATERIAL AND METHODS

During the period of 12 months, we have prospectively observed 482 children with croup syndrome admitted to 15 pediatric departments in Lower Silesia (south-west region of Poland). Data concerning epidemiology, clinical course and treatment were collected from uniform observation cards. There were 326 boys and 156 girls aged between 2 and 174 months in our study.

RESULTS

Among 482 observed children, received glucocorticoids 424 (88%) mainly parenteral, L-epinephrine--211 (43.8%), mist therapy--241 (50%), antihistamines--308 (63.9%), antibiotics--280 (58.1%). Children treated with antibiotics were younger (p=0.0316), their temperature, amount of leukocytes and value of C-reactive protein was higher when compared with those not treated (p=0.0002; p=0.0081, p=0.0172 respectively).

CONCLUSIONS

Children in Lower Silesia with croup syndrome were treated in agreement with recent standards with glucocorticoids and/or epinephrine. There was an excessive usage of antihistamines which have no established treatment role. It seems that in many cases antibiotic treatment could have been avoided.

Effect of organic matter and liming on the reduction of cadmium uptake from soil by triticale and spring oilseed rape

The aim of the study conducted on triticale and spring oilseed rape was to determine the role of liming, brown coal and compost medium in reducing the effect of cadmium contamination (at the rates of 0, 7.5, 15 and 22.5 mg Cd kg(-1) of soil) on yield and chemical composition of the crop. In the series of experiments without liming, a considerable decline in the yield of spring triticale grain, straw, root weight and green mass yield of rape was observed in response to the soil contamination with cadmium. Brown coal and especially compost medium added to soil neutralised the negative effect of cadmium on the grain yield and reduced a decrease in the yield of straw and roots of triticale. Soil liming proved to reduce the yield drop in oilseed rape caused by the contamination of soil with cadmium. The content of cadmium in roots and grain of spring triticale far exceeded that determined in triticale straw. The pollution of soil with cadmium caused a 26-fold increase in the content of this metal in grain, a 10-fold increase in roots of triticale and a twofold in oil-seed rape. Application of compost medium, brown coal and, to a smaller extent, liming reduced the level of cadmium in the parts of triticale brought to investigation. The soil contamination with cadmium caused certain modifications in the content of nitrogen, potassium, magnesium, calcium and sodium in spring triticale and in the content of N-total, potassium and magnesium in spring oilseed rape.

A monomeric derivative of the cellular transcription factor CREB functions as a constitutive activator

The mammalian transcriptional activator CREB binds as a dimer to a broad spectrum of inducible promoters. CREB activity is modulated by several signalling agents (protein kinase A [PKA], Ca2+, and transforming growth factor beta) and via functional interactions with cell-specific transcription factors. In addition, CREB can activate transcription constitutively and repress the activity of several other transcriptional activators. The mechanisms that allow CREB to act in such a malleable manner and the role that CREB dimerization might play in this are poorly understood. To probe the latter issue, we have created monomeric forms of CREB by fusing CREB to the DNA-binding domain of a protein (B-cell specific activator protein [BSAP]) that binds to DNA as a monomer. Remarkably, monomeric CREB acts as a potent, constitutive activator under conditions in which native CREB is inducible by PKA. Thus, CREB contains constitutive activation regions that are unable to function in native CREB. Two glutamine-rich domains that are important for native, PKA-inducible CREB activity are required for the constitutive activity of monomeric CREB. In contrast, two elements within the kinase-inducible domain of CREB are dispensable for constitutive activity. We discuss our results in relation to inducible and constitutive CREB activity and the potential modes of action of other activators that directly interact with CREB.

[O2 uptake in the recovery period. The effect of the anesthetic procedure and the postoperative administration of pethidine]

General anesthesia leads to a marked reduction in oxygen uptake (VO2), but during the recovery period O2 consumption can increase dramatically. A controversial discussion has continued in the literature concerning the role of different types of anesthesia with regard to metabolic changes. The aim of this comparative study was to evaluate the effects of two different techniques for general anesthesia and of postoperative meperidine on VO2, especially in the postanesthetic recovery period.

METHODS

Twelve patients (K1: ASA class I-II, age: 39.9 +/- 16.1 years, height: 176 +/- 10.1 cm, weight: 76 +/- 12.8 kg) scheduled for urological lower abdominal surgery were given isoflurane-N2O-O2 (1.3 MAC); another group of 12 patients (K2: ASA class I-II, 35.9 +/- 14.5 years, 181.8 +/- 11.4 cm, 77.3 +/- 8.4 kg) received total intravenous anesthesia (TIVA) with propofol and alfentanil (ED95). Both groups were studied under steady-state conditions. Duration of anesthesia was 124.2 +/- 27.5 min (K2) versus 139.2 +/- 35.5 min (K1). VO2 was measured by an indirect calorimetric device (MMC Horizon, STPD).

RESULTS

Preanesthetic values of VO2 were in the predicted range for basal metabolism. Steady-state general anesthesia led to approximately 30% reduction in VO2 (K1: 121-225 ml min, K2: 107-230 ml/min) compared to preanesthetic values (P less than 0.05). Both groups showed an increase in VO2 during the recovery period. When compared to the preanesthetic measurements, only K1 showed a statistically significant change. Shivering was observed during the recovery period in 8 patients in K1 (max VO2: 639 ml min) and 2 in K2 (max VO2: 584 ml min (P less than 0.05). Meperidine (25 mg i.v.) given to 5 patients from K1 because of postanesthetic shivering decreased VO2 significantly to the range of VO2 measured in K2.

CONCLUSION

Oxygen consumption during general anesthesia was not defined by the type of anesthetic administered. During the recovery period however, VO2 depended on the type of anesthetic, as muscular hyperactivity was prominent in the isoflurane group. Meperidine could suppress visible shivering and reduce postoperative VO2 to the levels seen after TIVA.

[O2 uptake and CO2 production during total intravenous propofol-alfentanil anesthesia under steady-state conditions. Is O2 uptake a parameter for assessing the depth of anesthesia?]

Depending on surgical and anaesthesiological procedures, anaesthesia leads to a reduction of O2 uptake (VO2), CO2 production (VCO2) and resting energy expenditure (REE). A controversial discussion on the degree of metabolic depression has continued in the literature fueled by a lack of studies in patients under standardised conditions. The goal of this study was to evaluate whether O2 consumption and/or CO2 production can be correlated to various depths of anaesthesia and whether VO2 could be a parameter to control narcosis. 12 patients (ASA I-II) scheduled for urological surgery of the lower abdomen, were given total intravenous anaesthesia with propofol and alfentanil. During a 60 minutes period the patients were first anaesthesized with an ED50 and then titrated to a dosage correlating with an ED95. The premedicated but awake patients each showed a REE which was about 10% below the calculated basal metabolism. Steady-state general anaesthesia led to an approximately 30% reduction of VO2, VCO2 an REE. Patients with adequate anaesthesia revealed no changes in oxidative metabolism with increased or decreased depth of anaesthesia. VO2 as a leading parameter proves to be problematic. It is useful as a measure for insufficient depth of general anaesthesia but fails to indicate overshooting anaesthesia depth.

[Oxygen uptake and blood circulation parameters during anesthesia using EEG-assisted determination of anesthetic dosages]

Anaesthesia has significant effects on circulation and oxidative metabolism which are closely related to each other. Usually there is a marked reduction of oxygen uptake (VO2) and energy expenditure. A controversial discussion on the effects of the drugs administered and the degree of metabolic depression has continued in the literature fuelled by a lack of studies in patients under standardized conditions. 18 patients (ASA I-II) scheduled for major abdominal surgery were given closed-loop feedback control anaesthesia by quantitative EEG analysis. Group 1 received a total intravenous anaesthesia with methohexital and fentanyl whereas group 2 was given a combined anaesthesia with alfentanil and N2O. The aim of this comparative study was to evaluate the effects of different techniques for general anaesthesia on oxygen uptake and on the cardiovascular system. Preanaesthetic values of VO2 taken after flunitrazepam premedication were slightly below the predicted range determined by indirect calorimetry for basal metabolism. Steady-state general anaesthesia led to an approximately 30% reduction of VO2 for both groups. In contrast to oxygen uptake, blood pressure and especially heart rate were defined by the type of anaesthesia as in the methohexital fentanyl group higher values of both blood pressure and heart rate were observed.

[A case of glossopharyngeal neuralgia with paroxysmal asystole]

A 74-year-old patients is described who had typical attacks of glossopharyngeal neuralgia associated with very frequent episodes of cardiac arrest. Pacemaker implantation made possible controlling of episodes of cardiac arrest while full remission of attacks was obtained after carbamazepine treatment 900 mg daily.

An attempt at comparing the results of carboxyhaemoglobin level in blood and gasometric determinations in capillary blood in cases of carbon monoxide poisoning when treatment began at the place of accident

The authors observed disturbances of acid-base equilibrium and levels of carboxyhaemoglobin in 116 cases of CO intoxication. The patients were treated early -- at the place of the accident and during transport to hospital. Oxygen treatment was applied, the acid-base equilibrium disturbances were corrected, especially the metabolic acidosis by using alkaline substances. This management enabled rapid elimination of the poison from the organism and an improvement in the general condition of the patients.