The Neutrophil-to-Lymphocyte Ratio as a Prognostic Factor for Patients with Urothelial Carcinoma of the Bladder Following Radical Cystectomy

Introduction: Pre-treatment neutrophil-to-lymphocyte ratio (NLR) has been associated with adverse pathology or survival in a variety of malignancies, including urothelial carcinoma of the bladder (UCB) treated with radical cystectomy (RC). Whether the prognostic value of NLR is retained, or even increased, when measured postoperatively remains not well studied. In this study, we evaluated the association of preoperative and postoperative NLR with oncological outcomes following RC. Methods: 132 consecutive patients with UCB treated with open RC were analyzed. NLR was analyzed both as a continuous variable and as a categorical variable using a cut-off of 2.7 based on previous studies. NLR was recorded as followed: before surgery (within 15 days prior to RC, [NLR1]), postoperatively (within 2 days [NLR2], between 7 and 15 days after RC before discharge [NLR3], few days before the evidence of recurrence or last available follow up [NLR4]. ∆NLR was calculated as the difference between NLR2 and NLR1 (NLR∆1) and between NLR 2 and NLR3 (NLR∆2). Tumour stage, lymphovascular invasion (LVI) and lymph node involvement were collected. Cancer-specific mortality (CSM), all-cause mortality (ACM) and recurrence-free survival (RFS) were estimated using the Kaplan-Meier method and compared using the log-rank test. Univariable and multivariate logistic regression and Cox proportional hazard models were used to analyze the association of NLR with extravesical disease, LVI, lymph node involvement, recurrence of disease and mortality. Results: During a follow up of 15.9 months, 45 (34.1%) patients had a recurrence of UBC, 60 (45.4%) patients died, 38 (28.8%) of UCB and 22 (16.7%) of other cause. 64 (48.5%) have no evidence of disease at follow-up. When assessed by multivariable analysis NLR1 remained independently associated with a significantly increased risk of extravescical disease (pT 3-4) [OR: 1.4, p<0.01] and Lymphovascular invasion [OR: 1.40, p<0.01]. NLR4 was independently associated with a significantly increased risk of CSM [HR=1.14, p=0.013]. In a postoperative model, NLR3 was found to be an independent predictor of ACM [HR=1.11, 95%, p=0.01]. NLR1 was associated with a significantly increased risk of recurrence in the univariable preoperative model [HR=1.9, p=0.05] while in the postoperative model, NLR4 remained independently associated with a significantly increased risk of recurrence [HR 1.13, p=0.03]. Conclusions: In patients with UCB treated with RC, NLR is associated with more advanced tumour stage, LVI, lymph node metastasis and higher CSM. Furthermore, the variation of NLR after surgery might play a role to predict higher ACM and RFS

Vaginal cuff recurrence after radical cystectomy: an under - studied site of bladder cancer relapse

Vaginal cuff recurrence of tumor following radical cystectomy is a rare site of disease recurrence, however it has never been specifically studied. The aim of the study is to evaluate incidence, risk factors, and long-term oncologic outcomes of vaginal cuff recurrence in a cohort of female patients treated with radical cystectomy for invasive urothelial carcinoma of the bladder

Effect of allogeneic intraoperative blood transfusion on survival in patients treated with radical cystectomy for nonmetastatic bladder cancer: Results from a single high-volume institution

Transfusion has been related to poor survival after surgery in several cancers. Recently, timing of transfusion has been proposed as crucial in the determination of poor survival expectanies after surgery, in fact, intra- operative but not postoperative transfusion were found to be related. We confirmed these findings in patients who underwent radical cystectomy because of bladder cancer; physicians should avoid use of transfusion intraoperatively. Background: Previous studies have demonstrated that perioperative blood transfusion (BT) is associated with a significantly increased risk of cancer recurrence and mortality after radical cystectomy (RC). Recently, it was shown for the first time that intraoperative transfusion has a detrimental effect on cancer survival. The aim of the current study was to validate this finding in a single European institution. Patients and Methods: The study focused on 1490 consecutive nonmetastatic bladder cancer patients treated with RC at a single tertiary care referral center between January 1990 and August 2013. KaplaneMeier analyses and Cox regression analyses were used to assess the effect of timing of BT administration (no transfusion vs. intraoperative transfusion vs. postoperative transfusion vs. intra- operative and postoperative transfusion) on cancer-specific mortality (CSM), overall mortality (OM), and disease recurrence. Results: Mean age at the time of RC was 67 years. Overall, 322 (21.6%) patients received intraoperative BT and 97 (6.5%) received postoperative BT. At a mean follow-up time of 125 months (median, 110 months), the 5- and 10-year CSM rate was 846 (58%) and 715 (48%), respectively. In multivariable analyses patients who received intraoperative BT had greater risk of disease recurrence (hazard ratio [HR], 1.24; P .2). Conclusion: Our study confirms that intraoperative, but not postoperative BT, are related to a detrimental effect on survival after RC. These results should be take into account by physicians to administer BT using the correct timing

Endourological management of uretero-ileal anastomosis stricture after cystectomy and Vescica Ileale Padovana (V.I.P.) orthotopic neobladder reconstruction

ABSTRACT Aim To report an endourology management of uretero-ileal anastomosis stricture after cystectomy and orthotopic neobladder reconstruction (Vescica Ileale Padovana, VIP). Materials and methods A nephrostomy was placed to provide a route of access for an anterograde canalization and a secure and working guide placement. These were than taken with a cystoscopy grasp and pulled out trough the neobladder. Laser endoureterotomy of the stricture over a stiff working guide wire was than performed. A DJ stent was than placed in order to protect the urinary flow for the first month after surgery. Results No immediate and late complications occurred during a follow up of 1 year according to the Clavien Dindo classification. The patient continued to be asymptomatic with a renal function stable over the years. Discussion Endourological management of uretero-ileal anastomosis stricture after cystectomy and orthotopic neobladder (VIP) is safe and reproducible. It may avoid the difficulties and complications of invasive surgery and has durable results

Wunderlich's syndrome: Three cases of acute spontaneous renal bleeding, conservately treated

Wunderlich's syndrome is a clinical condition defined as a spontaneous renal bleeding of non traumatic origin, contained within the Gerota's fascia. Wunderlich's syndrome is rare. Spontaneous bleeding of kidney tumors, either benign or malignant, represents the more common causes. Classically it presents with acute flank pain, tender palpable mass and clinical hemodynamic deterioration. These symptoms are defined as the Lenk's classic triad. We present three cases of spontaneous renal bleeding

Robotic treatment of a rare paramedian cystic lesion of the lower male urogenital tract

Abstract Objectives To report the diagnosis and the mini-invasive treatment of a rare paramedian cystic lesion of the lower male urogenital tract (CLMGU). Material and methods This is a case of a 46 old male with low urinary tract symptoms, azoospermia and mild erectile dysfunction. MRI Imaging showed a midline high signal intensity cystic lesion of a tear drop shape, extending above the base of the prostate to the level of the seminal vesicles. The lesion was located between the seminal vesicles and the urinary bladder. A direct communication of the intra-abdominal portion of both vas deferens with the cyst was found. MRI also showed small solid nodule within the upper portion of the cyst. The patient underwent a robotic surgery of the CLMGU. A Retzius-sparing approach was used to gain access to the seminal vesicles in order to carefully dissect and excise the lesion without any dissection of the anterior compartment. The CLMGU was excised with a nerve sparing technique. Results Operative time was 115 min. Blood loss was minimal. Length of stay was three days. No post-operative complications occurred. One month after surgery patient's IPSS improved considerably. Final pathology showed a cystic lesion containing papillary projections with squamous metaplasia. At 2 months follow up, urinary symptoms improved with no postoperative complications. Conclusion Robotic surgery allows a direct access to the Douglas space with an easy removal of the neoplasia. Our video represents a case of possible application of robotic surgery to improve dissection, overall surgical precision and functional outcomes

Enhancing Prostate Cancer Detection Accuracy in Magnetic Resonance Imaging–targeted Prostate Biopsy:Optimizing the Number of Cores Taken

Background and objective: The shift toward targeted biopsy (TBx) aims at enhancing prostate cancer (PCa) detection while reducing overdiagnosis of clinically insignificant disease. Despite the improved ability of TBx in identifying clinically significant PCa (csPCa), the optimal number and location of targeted cores remain unclear. This review aims to assess the optimal number of prostate biopsy magnetic resonance imaging (MRI)-targeted cores to detect csPCa. Methods: A narrative literature search was conducted using PubMed, focusing on studies published between January 2014 and January 2024, addressing factors influencing targeted core numbers during prostate biopsy. The search included both retrospective and prospective studies, prioritizing those with substantial sample sizes and employing terms such as “prostate biopsy”, “mpMRI”, “core number”, and “cancer detection”. Key findings and limitations: Two biopsy cores identified csPCa in 55–65% of cases. This detection rate improved to approximately 90% when the number of cores was ≥5. The inclusion of perilesional and systematic biopsies could maximize the detection of csPCa (from 10% to 45%), especially in patients under active surveillance or with prior negative biopsy results, although there is an increase in the overdiagnosis of indolent tumors (from 4% to 20%). Transperineal software-assisted target prostate biopsy may enhance cancer detection, particularly for tumors located at the apex/anterior part of the prostate. Increasing the number of TBx cores may incrementally raise the risk of complications (by 2–14% with each added core) and result in severe pain and significant discomfort for up to 17% and 25% of TBx patients, respectively. However, the overall rate and severity of these complications remain within acceptable limits. Conclusions and clinical implications: The optimal number of cores for targeted prostate biopsies should balance minimizing sampling errors with effective cancer detection and should be tailored to each patient's unique prostate characteristics. Up to five cores per MRI target may be considered to enhance the detection of csPCa, with adjustments based on factors such as prostate and lesion volume, Prostate Imaging Reporting and Data System, biopsy techniques, complications, patient discomfort, and anxiety. Patient summary: In this report, we found that increasing the number of biopsy cores up to ≥5 improves the detection rates of significant prostate cancer significantly to around 90%. Although inclusion of nearby and systematic biopsies enhances detection, increasing the biopsy count may lead to higher risks of complications and indolent tumors. A customized biopsy approach based on multiple variables could be helpful in determining the appropriate number of targeted biopsies on a case-by-case basis.</p

Enhancing Prostate Cancer Detection Accuracy in Magnetic Resonance Imaging–targeted Prostate Biopsy:Optimizing the Number of Cores Taken

Background and objective: The shift toward targeted biopsy (TBx) aims at enhancing prostate cancer (PCa) detection while reducing overdiagnosis of clinically insignificant disease. Despite the improved ability of TBx in identifying clinically significant PCa (csPCa), the optimal number and location of targeted cores remain unclear. This review aims to assess the optimal number of prostate biopsy magnetic resonance imaging (MRI)-targeted cores to detect csPCa. Methods: A narrative literature search was conducted using PubMed, focusing on studies published between January 2014 and January 2024, addressing factors influencing targeted core numbers during prostate biopsy. The search included both retrospective and prospective studies, prioritizing those with substantial sample sizes and employing terms such as “prostate biopsy”, “mpMRI”, “core number”, and “cancer detection”. Key findings and limitations: Two biopsy cores identified csPCa in 55–65% of cases. This detection rate improved to approximately 90% when the number of cores was ≥5. The inclusion of perilesional and systematic biopsies could maximize the detection of csPCa (from 10% to 45%), especially in patients under active surveillance or with prior negative biopsy results, although there is an increase in the overdiagnosis of indolent tumors (from 4% to 20%). Transperineal software-assisted target prostate biopsy may enhance cancer detection, particularly for tumors located at the apex/anterior part of the prostate. Increasing the number of TBx cores may incrementally raise the risk of complications (by 2–14% with each added core) and result in severe pain and significant discomfort for up to 17% and 25% of TBx patients, respectively. However, the overall rate and severity of these complications remain within acceptable limits. Conclusions and clinical implications: The optimal number of cores for targeted prostate biopsies should balance minimizing sampling errors with effective cancer detection and should be tailored to each patient's unique prostate characteristics. Up to five cores per MRI target may be considered to enhance the detection of csPCa, with adjustments based on factors such as prostate and lesion volume, Prostate Imaging Reporting and Data System, biopsy techniques, complications, patient discomfort, and anxiety. Patient summary: In this report, we found that increasing the number of biopsy cores up to ≥5 improves the detection rates of significant prostate cancer significantly to around 90%. Although inclusion of nearby and systematic biopsies enhances detection, increasing the biopsy count may lead to higher risks of complications and indolent tumors. A customized biopsy approach based on multiple variables could be helpful in determining the appropriate number of targeted biopsies on a case-by-case basis.</p