EAU guidelines on non-muscle-carcinoma of the bladder

Context and objective: To present the updated version of 2008 European Association of Urology (EAU) guidelines on non-muscle-invasive bladder cancer. Evidence acquisition: A systematic review of the recent literature on the diagnosis and treatment of non-muscle-invasive bladder cancer was performed. The guidelines were updated and the level of evidence and grade of recommendation were assigned. Evidence synthesis: The diagnosis of bladder cancer depends on cystoscopy and histologic evaluation of the resected tissue. A complete and correct transurethral resection (TUR) is essential for the prognosis of the patient. When the initial resection is incomplete or when a high-grade or T1 tumour is detected. a second TUR within 2-6 wk should be performed. The short- and long-term risks of both recurrence and progression may be estimated for individual patients using the scoring system and risk tables. The stratification of patients to low, intermediate, and high-risk groups-separately for recurrence and progression-represents the cornerstone for indication of adjuvant treatment. In patients at low risk of tumour recurrence and progression, one immediate instillation of chemotherapy is strongly recommended. In those at an intermediate or high risk of recurrence and an intermediate risk of progression, one immediate instillation of chemotherapy should be followed by further instillations of chemotherapy or a minimum of 1 yr of bacillus Calmette-Guerin (BCG). In patients at high risk of tumour progression, after an immediate instillation of chemotherapy, intravesical BCG for at least 1 yr is indicated. Immediate cystectomy may be offered to the highest risk patients and in patients with BCG failure. The long version of the guidelines is available on www.uroweb.org. Conclusions: These EAU guidelines present the updated information about the diagnosis and treatment of non-muscle-invasive bladder cancer and offer the recent findings for the routine clinical application

Guía clínica del carcinoma urotelial de vejiga no músculo-invasivo de la Asociación Europea de Urología, actualización de 2011

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Clinical and cost effectiveness of hexaminolevulinate-guided blue-light cystoscopy: Evidence review and updated expert recommendations

Context Non-muscle-invasive bladder cancer (NMIBC) is associated with a high recurrence risk, partly because of the persistence of lesions following transurethral resection of bladder tumour (TURBT) due to the presence of multiple lesions and the difficulty in identifying the exact extent and location of tumours using standard white-light cystoscopy (WLC). Hexaminolevulinate (HAL) is an optical-imaging agent used with blue-light cystoscopy (BLC) in NMIBC diagnosis. Increasing evidence from long-term follow-up confirms the benefits of BLC over WLC in terms of increased detection and reduced recurrence rates. Objective To provide updated expert guidance on the optimal use of HAL-guided cystoscopy in clinical practice to improve management of patients with NMIBC, based on a review of the most recent data on clinical and cost effectiveness and expert input. Evidence acquisition PubMed and conference searches, supplemented by personal experience. Evidence synthesis Based on published data, it is recommended that BLC be used for all patients at initial TURBT to increase lesion detection and improve resection quality, thereby reducing recurrence and improving outcomes for patients. BLC is particularly useful in patients with abnormal urine cytology but no evidence of lesions on WLC, as it can detect carcinoma in situ that is difficult to visualise on WLC. In addition, personal experience of the authors indicates that HAL-guided BLC can be used as part of routine inpatient cystoscopic assessment following initial TURBT to confirm the efficacy of treatment and to identify any previously missed or recurrent tumours. Health economic modelling indicates that the use of HAL to assist primary TURBT is no more expensive than WLC alone and will result in improved quality-adjusted life-years and reduced costs over time. Conclusions HAL-guided BLC is a clinically effective and cost-effective tool for improving NMIBC detection and management, thereby reducing the burden of disease for patients and the health care system. Patient summary Blue-light cystoscopy (BLC) helps the urologist identify bladder tumours that may be difficult to see using standard white-light cystoscopy (WLC). As a result, the amount of tumour that is surgically removed is increased, and the risk of tumour recurrence is reduced. Although use of BLC means that the initial operation costs more than it would if only WLC were used, over time the total costs of managing bladder cancer are reduced because patients do not need as many additional operations for recurrent tumours.SCOPUS: re.jinfo:eu-repo/semantics/publishe

Evaluation of a remote-controlled laparoscopic camera holder for basic laparoscopic skills acquisition: a randomized controlled trial

BACKGROUND: Unsteady camera movement and poor visualization contribute to a difficult learning curve for laparoscopic surgery. Remote-controlled camera holders (RCHs) aim to mitigate these factors and may be used to overcome barriers to learning. Our aim was to evaluate performance benefits to laparoscopic skill acquisition in novices using a RCH. METHODS: Novices were randomized into groups using a human camera assistant (HCA) or the FreeHand v1.0 RCH and trained in the (E-BLUS) curriculum. After completing training, a surgical workload questionnaire (SURG-TLX) was issued to participants. RESULTS: Forty volunteers naïve in laparoscopic skill were randomized into control and intervention groups (n = 20) with intention-to-treat analysis. Each participant received up to 10 training sessions using the E-BLUS curriculum. Competency was reached in the peg transfer task in 5.5 and 7.6 sessions for the ACH and HCA groups, respectively (P = 0.015), and 3.6 and 6.8 sessions for the laparoscopic suturing task (P = 0.0004). No significance differences were achieved in the circle cutting (P = 0.18) or needle guidance tasks (P = 0.32). The RCH group experienced significantly lower workload (P = 0.014) due to lower levels of distraction (P = 0.047). CONCLUSIONS: Remote-controlled camera holders have demonstrated the potential to significantly benefit intra-operative performance and surgical experience where camera movement is minimal. Future high-quality studies are needed to evaluate RCHs in clinical practice. TRIAL REGISTRATION: ISRCTN 8373397

European Association of Urology Section of Urolithiasis (EULIS) consensus statement on simulation, training, and assessment in urolithiasis

BACKGROUND: Simulation-based training offers an acceptable adjunct to the traditional mentor-apprentice model in helping trainees to traverse the early stages of the learning curve for ureteroscopy and percutaneous renal surgery. In addition, nontechnical skills are increasingly important in preventing adverse events in the operating room, and simulation-based training can be used for training in such skills. Incorporation of simulation into formalised, standardised, and validated curricula offers an applicable method for training residents.OBJECTIVE: To develop a curriculum for urolithiasis procedures incorporating technical and nontechnical skills training for implementation across Europe.DESIGN, SETTING, AND PARTICIPANTS: An international panel of experts from EULIS, EUREP, ESU and ESUT was consulted in five stages. The study incorporated a mix of qualitative and quantitative data for collection and analysis. Responses were drawn out in (1) an opinion survey and (2) a curriculum development survey, which were discussed in (3) a focus group meeting. Group responses from this meeting were analysed for themes, which were discussed at (4) a focus group meeting, where consensus was reached among the group. Data analysis and integration at this stage were used to draft the curriculum.RESULTS AND LIMITATIONS: All group meetings were transcribed from the focus group discussion. Eight themes were generated, into which all data were categorised. These were: need for a training curriculum; curriculum objectives; curriculum structure; curriculum content; teaching platforms and tools; assessment and certification; validation and implementation; and global integration of the curriculum. A curriculum, including recommended simulators for use, was subsequently proposed.CONCLUSIONS: We propose a comprehensive curriculum for training in urolithiasis. Additional planning is required for full validation and implementation before it can be used to train residents.PATIENT SUMMARY: Stone disease accounts for a major proportion of surgical interventions worldwide. We describe a consensus guideline for effective training of stone surgeons.</p

Relapses Rates and Patterns for Pathological T0 after Robot-Assisted Radical Cystectomy: Results from the International Robotic Cystectomy Consortium

OBJECTIVES: To investigate the oncologic outcomes of pT0 after robot-assisted radical cystectomy (RARC). METHODS: A retrospective review of the International Robotic Cystectomy Consortium database was performed. Patients with pT0 after RARC were identified and analyzed. Data were reviewed for demographics and pathologic outcomes. Kaplan Meier(KM) curves were used to depict recurrence free survival(RFS), disease specific survival(DSS), and overall survival(OS). Multivariate stepwise Cox regression models were used to identify variables associated with RFS and OS. RESULTS: 471 patients (18%) with pT0 were identified. Median age was 68 years (IQR 60-73), with a median follow up of 20 months (IQR 6-47). Thirty-seven percent received neoadjuvant chemotherapy (NAC) and 5% had pN+ disease. Seven percent of patients experienced disease relapse; 3% had local and 5% had distant recurrence. Most common sites of local and distant recurrences were pelvis (1%) and lungs (2%). Five-year RFS, DSS, and OS were 88%, 93% and 79%, respectively. Age (HR 1.05, 95% CI 1.01-1.09, p=0.02), pN+ve (HR 11.48, 95%CI 4.47 - 29.49, p\u3c0.01), and reoperations within 30 days (HR 5.53, 95% CI 2.08-14.64, p\u3c0.01) were associated with RFS. Chronic kidney disease (HR 3.24, 95% CI 1.45 - 7.23,p\u3c0.01), neoadjuvant chemotherapy (HR 0.41, 95%CI 0.18-0.92, p=0.03), pN+ve (HR 4.37, 95% CI 1.46-13.06, p\u3c0.01), and reoperations within 30 days (HR 2.64, 95% CI, 1.08 - 6.43, p=0.03) were associated with OS. CONCLUSIONS: Despite pT0 status at RARC, 5% had pN+ disease and 7% of patients relapsed. Node status was the strongest variable associated with RFS and OS in pT0