Pedro Peralta

Introduction: Hyperthermic intravesical chemotherapy (HIVeC) with mitomycin C (MMC) is an emerging strategy in the management of intermediate-risk non-muscle-invasive bladder cancer (Ir-NMIBC). By combining chemotherapy with controlled hyperthermia (43°C), this approach aims to enhance drug absorption, increase cytotoxicity, and stimulate immune activation, potentially improving efficacy compared to standard MMC. The aim of this study was to compare oncologic efficacy, adverse effects, and safety between HIVeC and standard normothermic MMC in patients with Ir-NMIBC.Patients and methods: we conducted a retrospective cohort study including 76 patients with Ir-NMIBC treated between January 2020 and december 2023. Patients received HIVeC (n=36) or standard MMC (n=40) following complete transurethral resection of bladder tumor (TUrBT). The instillation schedule consisted of four weekly induction instillations followed by three monthly maintenance instillations. The primary endpoint was recurrence-free survival (rFs); secondary endpoints included progression-free survival (PFs), adverse events (Aes), and treatment compliance.Results: A total of 76 patients were included: 36 received HIVeC and 40 received standard MMC. Baseline characteristics were balanced across groups, with a median age of 68 years and 86.8% male. Most tumors were unifocal (85.5%), stage pTa (88.2%), and low-grade (61.8%). At a median follow-up of 36 months (IQr 24-36), recurrence occurred in 38.9% of HIVeC patients vs 30.0% in the MMC group. Median time to recurrence was longer with HIVeC (15.0 vs 10.5 months). The 24-months recurrence-free survival was 62.2% for HIVeC and 69.4% for MMC (p=0.365). Progression to muscle-invasive disease occurred in one MMC patient (2.5%); none progressed in the HIVeC arm (PFs at 24 months: 100% vs 97.5%, p=0.343). Compliance was high in both arms (HIVeC 88.9%, MMC 87.5%). Adverse events were mild (grade 1-2) and evenly distributed; no grade ≥3 events were observed. Treatment discontinuation due to toxicity occurred in 13% of HIVeC and 7% of MMC patients (p=0.47).Conclusions: HIVeC with MMC demonstrated comparable oncologic outcomes to normothermic MMC in Ir-NMIBC, with a longer time to recurrence and similar tolerability. These findings suggest its potential use in selected patients, but should be interpreted with caution due to the retrospective design and limited sample size.

Introduction: Hemorrhagic cystitis is defined by the presence of hematuria, lower urinary tract symptoms and cystoscopy findings indicative of underlying urothelial damage. It is common in patients with prior radiotherapy for pelvic malignancies. The severity of the bleeding can vary from mild to severe hematuria refractory to conservative therapy and with a continuous need for transfusions. Treatment can be challenging not only by the lack of clear guidelines but also the multiple comorbidities of these patients. Urinary diversion with or without cystectomy should be reserved for those who have failed all the previously available therapy, because of the morbidity/mortality associated with this type of procedure. Supratrigonal cystectomy can be an option in patients with intense fibrosis of the pelvic region. The purpose of this article is to present the results of our institution with supratrigonal cystectomy with urinary diversion as a last line treatment for radiation-induced hemorrhagic cystitis. Materials and methods: We retrospectively analyzed 17 patients who underwent supratrigonal cystectomy and bladder mucosa fulguration with urinary diversion for refractory radiation-induced hemorrhagic cystitis in our institution from January 2010 to December 2020. Results and discussion: Median patient age at time of cystectomy was 69 years and 64.7% (11) were females. The most common etiology was prior radiation therapy for gynecologic malignancies (11-64.7%). All the patients had prior therapy with bladder irrigation and fulguration. Besides that, 29.4% (n=5) received intravesical therapy with formalin, 11.8% (n=2) hyperbaric oxygen therapy and 5.9% (n=1) prior urinary diversion. Median time between radiation therapy and cystectomy was 65 months. Median ASA score of 3, median preoperative hemoglobin was 9,6mg/dl and 10.5 mg/dl at time of discharge after surgery. Ileal conduit was used in 52.9% (9), cutaneous ureterostomy in 41.2% (7) and ureterosigmoidostomy in 5.9% (1). Majority of patients (10-58.8%) did not require any blood transfusion during surgery or during their stay. Clavien-Dindo complications grade III or higher occurred in 29,4% (5). Median hospital stay postoperative was 12 days. No mortality was reported in the 30 days after surgery. Median follow-up after cystectomy was 28 months, with a 1-year survival of 93.3% (14 of 15) and 3-year survival of 83.3% (10 of 13). There was no difference in the presence of postoperative complications or overall survival between the types of urinary diversion. Conclusions: This represents one of the largest series on cystectomy in hemorrhagic cystitis, that we found to this date. Supratrigonal cystectomy is a valid option as a last line treatment for radiation-induced hemorrhagic cystitis, reducing the risks associated with simple cystectomy in patients with prior pelvic radiation.

Background: Most men diagnosed with prostate cancer will be candidates for active treatment and 20 to 50% of patients treated with organ preserving strategies recur within the prostate. Optimal treatment of recurrence is controversial. Prostate cryosurgery has been increasingly used as primary, recurrence and focal treatment for prostate cancer. Methods: We analysed 55 patients submitted to cryotherapy as salvage treatment after recurrence. Results: Study population presented with a mean age of 70.9 ± 6.2 years, mean initial PSA of 7.6 ng/ml and average prostate volume by ultrasound of 43.2 ± 14.7 grams. Mean follow-up was of 18.0 months. Biochemical free survival at one year of follow-up was of 85%. Conclusions: Cryotherapy can be an effective and safe treatment for recurrence after primary curative treatment failure.

Introduction: Patients with localized prostate cancer (PCa) are active participants in the choice of treatment. Objectives: To access the effects of social and demographic factors in the choice of treatment in cases of localized PCa, in a Portuguese population. Methods: Identification of all patients with the diagnosis of localized PCa in the last four years in an oncological centre. Evaluation of the effects of sociodemographic factors (age, profession, literacy, marital status, district and number of inhabitants of the place of residence) in the choice of treatment. Results: 300 patients with localized PCa were evaluated: 17.3% (n = 52) opted for radical prostatectomy (RP); 39,3% had (n = 118) external radiotherapy; brachytherapy in 29.3% (n = 88) and other options (active surveillance, cryotherapy and hormonal therapy) in 14.1% (n = 42). In relation to surgical treatment (RP) the following results were obtained: a) > 70 years: 3.9% (n = 5); ≤ 70 years: 27.5% (n = 47), p < 0.001; b) primary sector: 10.3% (n = 3); secondary sector: 16.2% (n = 27); tertiary sector: 24.1% (n = 21); quaternary sector: 8.3% (n = 1), p = 0.296; c) marital status married: 17.9% (n = 47); single: 0% (n = 0); divorced: 25.0% (n = 5); widow: 0% (n = 0), p = 0.734; d) residency in a city: 14.1% (n = 13); city > 4000 habitants: 22.7% (n = 15); city ≤ 4000 habitants: 16.9% (n = 24), p = 0.701. Using multinomial regression with age (p = 0.001), district (p = 0.035), marital status (p = 0.027) and profession (0.179), this model explained 17.2%-28.4% of therapeutic choices (p < 0.001). Conclusions: The main socioeconomical factor that influence treatment choice was age. Unmarried patients over 70 years choose less radical prostatectomy. Other sociodemographic factors have minor influence in the choice of the treatment.

Bladder cancer is the most frequent malignancy of the urinary system and is ranked the seventh most diagnosed cancer in men worldwide. About 70-75% of all newly diagnosed patients with bladder cancer will present disease confined to the mucosa or submucosa, the non-muscle invasive bladder cancer (NMIBC) subtype. Of those, approximately 70% will recur after transurethral resection (TUR). Due to this high rate of recurrence, patients are submitted to an intensive follow-up program that should be maintained throughout many years, or even throughout life, resulting in an expensive follow-up, with cystoscopy being the most cost-effective procedure for NMIBC screening. Currently, the gold standard procedure for detection and follow-up of NMIBC is based on the association of cystoscopy and urine cytology. As cystoscopy is a very invasive approach, over the years, many different non-invasive (both in serum and urine samples) assays have been developed in order to search genetic and protein alterations related to the development, progression and recurrence of bladder cancer. TERT promoter mutations and FGFR3 hotspot mutations are the most frequent somatic alterations in bladder cancer and constitute the most reliable biomarkers for bladder cancer. Based on these findings, an ultra-sensitive assay called Uromonitor ^® was developed that corresponds to a urine-based assay capable of detecting trace amounts of the two most common alterations in NMIBC, TERT promoter and FGFR3 mutation, in urine samples. The Uromonitor ^® test was performed in a cohort of 72 patients, firstly diagnosed with bladder cancer and under surveillance for NMIBC, to access its sensitivity and specificity in the detection of NMIBC recurrence. Uromonitor ^® was shown to be highly sensitive and specific in detecting recurrence of bladder cancer in patients under surveillance of non-muscle invasive bladder cancer.

The authors report a case of a 72-year-old patient who underwent radical prostatectomy in 2003 due to prostate cancer. During follow-up, he presented with permanent and severe urinary stress incontinence for which he underwent an artificial urinary sphincter implantation in 2009. After infection of the device, followed by the development of a urinary fistula, the artificial urinary sphincter was removed. He presented no new signs or symptoms for 2 years, during which he remained completely incontinent. In April 2012, he developed a painless scrotal swelling close to the median raphe. On manual compression, it showed urinary leakage and disappeared completely, only to reappear several hours later. Auxiliary examinations revealed a bulbar urethral diverticulum which was subsequently excised. A urethroplasty was performed during the same procedure. The patient presented with no further complications. Although still suffering from complete urinary incontinence, he refused any kind of surgery for the time being.

The authors report a case of a 53-year-old male patient who came to the urologic clinic with symptoms of a left-sided testicular mass with 4 years of evolution. A left inguinal approach was decided for scrotal exploration. High clamping of the spermatic cord was performed with complete excision of the lesion, which was sent for pathology, preserving the spermatic cord and the testicle. The peroperative result was a well-differentiated liposarcoma of the spermatic cord. We then chose to preserve the ipsilateral testis (organ-sparing surgery). Postoperatively, the final pathology confirmed a well-differentiated spermatic cord liposarcoma, revealing negative surgical margins and no signs of local invasion, namely of the underlying structures. The patient is currently doing well, with no signs of recurrence after one and a half year of follow-up.