Survival Outcomes and Predictive Factors for Female Urethral Cancer: Long-term Experience with Korean Patients

The aim of this study was to evaluate female urethral cancer (UCa) patients treated and followed-up during a time period spanning more than 20 yr at single institution in Korea. We reviewed medical records of 21 consecutive patients diagnosed with female UCa at our institution between 1991 and 2012. After exclusion of two patients due to undefined histology, we examined clinicopathological variables, as well as survival outcomes of 19 patients with female UCa. A Cox proportional hazards ratio model was used to identify significant predictors of prognosis according to variables. The median age at diagnosis was 59 yr, and the median follow-up duration was 87.0 months. The most common initial symptoms were voiding symptoms and blood spotting. The median tumor size was 3.4 cm, and 55% of patients had lesions involving the entire urethra. The most common histologic type was adenocarcinoma, and the second most common type was urothelial carcinoma. Fourteen patients underwent surgery, and 7 of these patients received adjuvant radiation or systemic chemotherapy. Eleven patients experienced tumor recurrence after primary therapy. Patients with high stage disease, advanced T stage (≥T3), and positive lymph nodes had worse survival outcomes compared to their counterparts. Particularly, lymph node positivity and advanced T stage were significant predictive factors for all survival outcomes. Tumor location was the only significant predictor for recurrence-free survival. Although our study included a small number of patients, it conveys valuable information about this rare female urologic malignancy in a Korean population.

BCG instillation versus radical cystectomy for high-risk NMIBC with squamous/glandular histologic variants

This study aims to evaluate the effect of Bacillus Calmette-Guérin (BCG) instillation and radical cystectomy on high-risk NMIBC with squamous or glandular variants. We retrospectively reviewed the data of high-risk (T1 or CIS or HG or TaG1/G2 with multiple, recurrent, large tumor) NMIBC patients from January 2000 to December 2017. Comparative analysis of radical cystectomy, intravesical BCG, and observation groups was conducted in high-risk NMIBC with squamous or glandular histologic variants. Among the 1263 high-risk NMIBC patient, 62 (4.9%) were reported squamous or glandular histologic variants. Thirty patients underwent BCG instillation and 15 patients were subjected to radical cystectomy. Statistically significant differences were found between the three treatment groups in terms of underlying hypertension (p = 0.031), T stage (p = 0.022) and tumor multiplicity (p = 0.019). Similar 5-year OS (p = 0.893) and CSS (p = 0.811) were observed in each of BCG instillation and radical cystectomy group. BCG instillation showed survival benefit in both OS (p = 0.019) and CSS (p = 0.038) than in the observation group. In high-risk patients diagnosed with NMIBC bladder cancer with squamous or glandular histologic variants, both intravesical BCG and radical cystectomy showed survival gain. In conclusion, BCG instillation represents an appropriate treatment option in high-risk NMIBC with squamous or glandular histologic variant.

Comparing the clinical efficacy of abiraterone acetate, enzalutamide, and orteronel in patients with metastatic castration-resistant prostate cancer by performing a network meta-analysis of eight randomized controlled trials

Various novel androgen receptor (AR) targeting drugs have been developed recently and have shown beneficial effects on survival in patients with metastatic castration-resistant prostate cancer (mCRPC). However, no consensus has been reached regarding which of these agents provides the most favorable oncological outcomes. Here, we aimed to compare the efficacy of novel AR-targeted agents by performing a network meta-analysis of randomized controlled trials (RCTs). We included eight RCTs for men with mCRPC treated with one of the AR targeting agents: abiraterone acetate, enzalutamide, or orteronel. The primary endpoint was overall survival (OS), while the secondary endpoints were progression-free survival (PFS), prostate-specific antigen (PSA) responsiveness, time to PSA progression, time to first skeletal-related events (SRE), and adverse events (AEs). Pairwise meta-analysis and network meta-analysis were conducted to obtain direct and indirect evidence, respectively. Notably, enzalutamide and abiraterone were significantly associated with improved OS compared with control arms. Enzalutamide was ranked as the most efficacious agent for improving OS (hazard ratio [HR] = 0.71), and abiraterone appeared to be the second-most efficacious drug for this purpose (HR = 0.78). Enzalutamide improved PFS in comparison with control groups (HR = 0.36), but abiraterone and orteronel were not significantly associated with PFS improvements. Enzalutamide (HR = 0.20) and abiraterone (HR = 0.56) were significantly associated with prolonged times to PSA progression as compared with control groups. However, only orteronel was associated with an increased risk of AEs as compared with control groups. In summary, our study can help to guide treatment selection, especially because AR-targeted agents have not been compared directly in head-to-head trials.

Role of pelvic lymphadenectomy in the treatment of bladder cancer: a mini review

Although radical cystectomy with pelvic lymph node dissection (PLND) is the standard treatment for muscle-invasive bladder cancer, the optimal extent of PLND and the minimum number of nodes that should be examined for pathology remain unclear. However, evidence is growing that extended PLND has additional diagnostic and therapeutic benefits relative to standard PLND. In particular, a more meticulous and extended PLND may improve the disease-free survival of node-negative patients because it removes undetected micrometastases. Indeed, some patients with positive nodes can be cured by surgery alone, even those with gross adenopathy. Increasing lines of evidence also suggest that the extent of the primary bladder tumor, the number of lymph nodes that are removed, and the lymph node tumor burden are important prognostic variables in patients undergoing cystectomy. Therefore, extended PLND may not only provide improved prognostic information, it may also have a clinically significant therapeutic benefit for both lymph node-positive and node-negative patients undergoing radical cystectomy. Although the absolute limits of PLND remain to be determined, evidence supports the notion that a more extended PLND should include the common iliac vessels and presacral lymph nodes at cystectomy. Such PLND should only be performed in patients who are appropriate surgical candidates. Prospective, randomized trials are needed to properly establish the extent of PLND that is required to generate these benefits.

Adjuvant Chemotherapy Correlates with Improved Survival after Radical Cystectomy in Patients with pT3b (Macroscopic Perivesical Tissue Invasion) Bladder Cancer

OBJECT

To elucidate the impact of adjuvant chemotherapy (ACH) on survival in patients with urothelial carcinoma of the bladder (UCB) diagnosed with pT3 disease (perivesical tissue invasion).

METHODS

We reviewed the clinical data of 424 patients who underwent radical cystectomy (RC) with bilateral pelvic lymphadenectomy for UCB in our institution between 1991 and 2012. None of the patients received neoadjuvant chemotherapy. Of all patients, 101 (23.8%) were diagnosed with pT3 disease: pT3a in 43 patients and pT3b in 58 patients. The Kaplan-Meier method with the log-rank test was used to estimate and compare overall survival (OS) and cancer-specific survival (CSS) between groups. Multivariate Cox proportional hazard models were used to identify predictors of OS and CSS.

RESULTS

Five-year OS (48.5% vs. 45.6%) and CSS (56.1% vs. 56.2%) were similar in the pT3a and pT3b groups (p = 0.658 and 0.840, respectively). In all pT3 patients, ACH administration was an independent predictor for OS (p = 0.018), but not CSS (p = 0.623) on multivariate analyses. On multivariate analysis according to the pT3 sub-stage, ACH was significantly associated with improved OS (hazard ratio [HR] 0.35; 95% confidence interval [CI] 0.17-0.72, p = 0.004) and CSS (HR 0.33; 95% CI 0.10-0.85, p = 0.022) in only the pT3b group.

CONCLUSION

Our data suggest that in pT3b disease, characterized by macroscopic perivesical tissue invasion, patients may obtain an OS benefit from the administration of ACH. Thus, our findings provide evidence for establishing appropriate indications for ACH in muscle invasive UCB.

Pathology in repeated transurethral resection of a bladder tumor as a risk factor for prognosis of high-risk non-muscle-invasive bladder cancer

The prognostic value of repeat transurethral resection of bladder tumor (TURBT) in patients with diagnosed high-risk, non-muscle-invasive bladder cancer (NMIBC) was investigated. We retrospectively reviewed the medical records of patients treated from October 2004 to December 2013 at Seoul National University who underwent repeated TURBT within 2-6 weeks after an initial resection. The study enrolled patients who had been diagnosed with NMIBC at both the initial and repeat TURBT; patients with muscle-invasive tumors on repeat TURBT were excluded. We used stepwise multivariate Cox regression models stratified by study to assess the independent effects of the predictive factors and estimated hazard ratios (HRs) from the Cox models. We investigated a total of 198 patients who were diagnosed with high-risk NMIBC. In logistic regression analyses, number of bladder tumors (2-7: OR, 2.319; 8≤: OR, 3.353; p<0.05), initially high tumor grade (OR, 2.435; p = 0.040), and presence of carcinoma in situ lesion (OR, 3.639; p = 0.017) correlated with residual tumor in the repeated-TURBT specimen. T1 stage in repeated-TURBT significantly correlated with recurrence (HR, 1.837; p = 0.010) and progression (HR, 2.806; p = 0.029) in multivariate analysis. The high grades of tumors in repeated-TURBT also significantly correlated with progression but not recurrence in the multivariate analysis (HR 2.152; p = 0.008). In this study, the pathologic findings in repeated-TURBT correlated with recurrence and progression in high-risk NMIBC. Repeated-TURBT is valuable because it can predict the recurrence and progression of high-risk NMIBC in addition to obtaining accurate pathologic findings.

Histological variant as the significant predictor of survival in patients with lymph node positive urothelial carcinoma of the bladder

The aim of this study was to evaluate the impact of histological variants of urothelial carcinoma (UC) on survival outcomes in patients with lymph node (LN) positive UC of the bladder. We reviewed and analyzed the clinical data from 424 patients who underwent radical cystectomy (RC) with pelvic lymph node dissection (PLND) for UC of the bladder and who did not receive neoadjuvant chemotherapy in our institution between 1991 and 2012. In total, 92 patients (21.7%) had histologically confirmed LN positive disease. In the LN negative group (332 patients), histological variants of UC were not a significant predictor in univariate analysis. However, in the LN positive group, histological variants of UC were a significant independent prognostic factor of overall survival (hazard ratio (HR) 3.54; 95% confidence interval (CI) 1.77-7.08, p < 0.001) and cancer specific survival (HR 3.66; 95% CI 1.69-7.90, p = 0.001) in both uni-variate and multivariate Cox regression analyses. The presence of histological variants of UC may indicate a worse prognosis in LN positive patients after RC with PLND for UC of the bladder and more aggressive adjuvant therapy may be required for the improvement of postoperative survival.

Clinical outcomes of muscle invasive bladder Cancer according to the BASQ classification

BACKGROUND

We evaluated the clinical efficacy and prognosis of muscle-invasive bladder cancer according to the basal/squamous-like (BASQ) classification system based on immunohistochemical staining [CK5/6(+), CK14(+), GATA3(-), and FOXA1(-)].

METHODS

One hundred patients diagnosed with muscle-invasive bladder cancer (cT2-4 N0-3 M0) were included in the study. All patients underwent radical cystectomy after transurethral removal of bladder tumor. Immunostaining was performed for CK5/6, CK14, FOXA1, and GATA3 antibodies on tissue microarray slides, and expression patterns were quantitatively analyzed using a scanning program.

RESULTS

The median follow-up time was 77.4 (interquartile range: 39-120.9) months. The mean age of the patients was 65.1 ± 11.2 years. FOXA1 or CK14 expression greater than 1% was respectively positively and negatively correlated with overall survival (OS; p = 0.011 and p = 0.042, respectively), cancer-specific survival (CSS; p = 0.050 for both), and recurrence-free survival (RFS; p = 0.018 and p = 0.040, respectively). For CK5/6+ and GATA3- or FOXA1- expression, 10% CK5/6+ cells were negatively correlated with OS (p = 0.032 and p = 0.039, respectively) and with RFS in combination with FOXA1- only (p = 0.050).

CONCLUSIONS

In this study, CK14 expression was associated with a poor prognosis. The new classification system of bladder cancer based on molecular characteristics is expected to helpful tool for the establishment of personalized treatment strategies and associated prediction of therapeutic responses.

Pyuria as a Predictive Marker of Bacillus Calmette-Guérin Unresponsiveness in Non-Muscle Invasive Bladder Cancer

This study aims to investigate the clinical role of preoperative pyuria for predicting bacillus Calmette-Guérin (BCG) unresponsiveness in non-muscle invasive bladder cancer (NMIBC). We performed a logistic regression analysis on 453 patients with NMIBC who were treated with BCG immunotherapy after a transurethral resection of bladder tumours, to evaluate predictive factors of BCG unresponsiveness. We also analysed univariate and multivariable survival data to estimate the prognostic impact of pyuria. Of the total study population, 37.6% (170/453) of patients had BCG unresponsiveness. A multivariable logistic regression analysis revealed that a history of upper urinary tract cancer (odds ratio (OR): 1.86, 95% confidence interval (CI): 1.04-3.32, p-value = 0.035) and the presence of pyuria (OR: 1.51, 95% CI: 1.01-2.27, p = 0.047) and tumour multiplicity (OR: 1.80, 95% CI: 1.18-2.75, p-value < 0.001) were significant predictors of BCG unresponsiveness. A Cox proportional hazards analysis model showed that pyuria was a significant prognostic factor for progression-free survival (hazard ratio: 4.51, 95% CI: 1.22-16.66, p = 0.024). A history of upper urinary tract cancer and the presence of pyuria and tumour multiplicity are predictive markers of BCG unresponsiveness. For patients with NMIBC who have preoperative pyuria, treatment using BCG should be considered cautiously.

Association Between Preoperative Hydronephrosis and Prognosis After Radical Cystectomy Among Patients With Bladder Cancer: A Systemic Review and Meta-Analysis

Background: Preoperative hydronephrosis (HN) might be associated with adverse outcomes in patients who underwent radical cystectomy (RC). The aim of this study was to evaluate the effect of preoperative HN on the oncological outcomes in patients with bladder cancer who underwent RC by performing a systemic review and meta-analysis. Methods: A systematic literature review in PubMed, EMBASE, and Scopus was conducted by searching the terms "bladder cancer," "cystectomy," and "hydronephrosis" until December 2016, in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. The calculated end points were advanced disease stage, cancer-specific survival (CSS), and overall survival (OS). Results: Twenty-four studies involving 10,461 patients who underwent RC were included. Among the patients, 3,121 (29.8%) had preoperative HN. The pooled analysis showed that preoperative HN had a significant association with advanced stage (odds ratio, 2.56, 95% confidence interval [CI], 1.91-3.42, p < 0.00001), lymph node invasion (OR, 2.44, 95% CI, 1.79-3.34, p < 0.00001), CSS (hazard ratio [HR], 1.67, 95% CI, 1.34-2.08, p < 0.00001), and OS (HR, 1.51, 95% CI, 1.30-1.75, p < 0.00001). Conclusions: Among patients with bladder cancer who underwent RC, preoperative HN could be a significant predictor of bladder cancer survival. However, large well-designed prospective studies are required to confirm the precise prognostic significance of preoperative HN.

The characteristics of recurrent upper tract urothelial carcinoma after radical nephroureterectomy without bladder cuff excision

PURPOSE

To investigate oncological outcomes based on bladder cuff excision (BCE) during radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC) and to provide clinical evidence of tumor recurrence in patients without BCE.

MATERIALS AND METHODS

We retrospectively collected data of 372 consecutive patients who underwent RNU at our institution from May 1989 through October 2010. After excluding some data, we reviewed 336 patients for the analysis.

RESULTS

Of the patients who underwent RNU with BCE (n=279, 83.0%) and without BCE (n=57, 17.0%), patients without BCE had poorer cancer-specific and overall survival rates. Among 57 patients without BCE, 35 (61.4%) experienced tumor recurrence. Recurrence at the remnant ureter resulted in poor oncological outcomes compared to those in patients with bladder recurrence, but better outcomes were observed compared to recurrence at other sites. No significant predictors for tumor recurrence at the remnant ureter were identified. In patients without BCE, pathological T stage [hazard ratio (HR), 5.73] and lymphovascular invasion (HR, 3.65) were independent predictors of cancer-specific survival, whereas age (HR, 1.04), pathological T stage (HR, 5.11), and positive tumor margin (HR, 6.50) were independent predictors of overall survival.

CONCLUSION

Patients without BCE had poorer overall and cancer-specific survival after RNU than those with BCE. Most of these patients experienced tumor recurrence at the remnant ureter and other sites. Patients with non-organ confined UTUC after RNU without BCE may be considered for adjuvant chemotherapy with careful follow-up.

Conditional Survival and Associated Prognostic Factors in Patients with Upper Tract Urothelial Carcinoma after Radical Nephroureterectomy: A Retrospective Study at a Single Institution

PURPOSE

The purpose of this study is to evaluate the changes of conditional survival (CS) probabilities and to identify the prognostic parameters that significantly affect CS over time post-surgery in upper tract urothelial carcinoma (UTUC) patients.

MATERIALS AND METHODS

A total of 330 patients were examined in the final analysis. Primary end point was conditional cancer-specific survival (CSS), overall survival (OS), and intravesical recurrence-free survival (IVRFS) after surgery. The Kaplan-Meier method was used for calculation of CS. Cox regression hazard ratio model was used to determine the predictors of CS.

RESULTS

UTUC patients who had already survived 5 years after radical nephroureterectomy had a more favorable CS probability in all given survivorships compared to those with shorter survival times. Patients with unfavorable pathologic features showed a higher increment of 5-year conditional CSS and OS compared to their counterparts. For 5-year conditional CSS, several factors, including high-grade tumor, lymphovascular invasion, and tumor location showed significant association with risk elevation over time. Only age remained as a predictor of 5-year conditional OS with increased risk in all given survivorships. For 5-year IVRFS, no variables remained as significant predictive factors over time after surgery.

CONCLUSION

Our study provides valuable information for practical survival estimation and relevant prognostic factors for patients with UTUC after surgery.

Localized resectable genitourinary sarcoma in adult Korean patients: experiences at a single center

PURPOSE

To evaluate the clinicopathological characteristics and prognosis of localized resectable genitourinary sarcomas in adults.

MATERIALS AND METHODS

Between September, 1996 and November, 2008, 18 consecutive cases of adults (12 men and 6 women; median age 48.8 years) who were treated for primary genitourinary sarcomas were identified. The following variables were analyzed: patient age, gender, body mass index, American Society of Anesthesiologists (ASA) score, primary organ, tumor histology, size, necrosis, Fédération Nationale des Centres de Lutte Contre le Cancer (FNCLCC) grade, and surgical margin positivity. Recurrence- free survival and disease-specific survival were the study end-points.

RESULTS

The most common presenting symptom was a palpable mass (six cases, 33.3%), the most common site was the kidney (six cases, 33.3%), and the most common histological subtype was leiomyosarcoma (eight patients, 44.4%). Complete resection with negative surgical margins was achieved in 13 patients (72.2%). The median follow-up period was 49.9 months (range 6.4 to 147.6). The recurrence- free survival rates at 1, 3, and 5 years were 81.6%, 66.5%, and 66.5%, respectively. Recurrence-free survival only associated significantly with ASA score (p=0.018). The disease-specific survival rate at 1, 3, and 5 years was 88.9%, 76.2%, and 67.7%, respectively. Disease-specific survival was associated significantly only with FNCLCC grade (p=0.042).

CONCLUSION

Although genitourinary sarcomas in adults are a rare group of tumors with a poor prognosis, some patients may have a favorable prognosis. Our findings suggest that FNCLCC grade is the most important prognostic factor for these patients.

Lymphovascular invasion have a similar prognostic value as lymph node involvement in patients undergoing radical cystectomy with urothelial carcinoma

To determine the prognostic value of lymphovascular invasion (LVI) in patients with bladder cancer who underwent radical cystectomy. Total of 747 patients underwent radical cystectomy; of these, only 164 did not undergo lymph node dissection (LND). The patients were divided into 4 groups: N0, N1, LVI without LND, and non-LVI without LND. Patients in the N1 and LVI groups had significantly higher T stages and grades, as well 1.5- to 2-fold higher recurrence and mortality rates. Overall survival (OS) was significantly poorer in the N1 group, compared with the N0 and non-LVI groups (p = 0.001 and 0.012), and in the LVI group relative to the N0 and non-LVI groups (p = < 0.001 and <0.001). Recurrence-free survival (RFS) was also significantly poorer in the N1 group relative to the N0 and non-LVI groups (p = < 0.001 and <0.001), and in the LVI group relative to the N0 and non-LVI groups (p = < 0.001 and <0.001). Among patients undergoing radical cystectomy, the clinical results predicted by LVI were similar to those predicted by lymph node involvement. Therefore, the role of adjuvant chemotherapy or immunotherapy may need to be prospectively evaluated in LVI-positive patients regardless of T stage after radical cystectomy.

Urinary Markers for Bladder Cancer Diagnosis and Monitoring

Hematuria is a typical symptom of bladder cancer which enables early detection of bladder cancer. However, reliable diagnostic tools for bladder cancer using urine samples or other non-invasive methods are lacking. Tremendous attempts have been tried and revealed fancy works to convey definitive diagnostic power using urine samples. In this paper, we reviewed urinary markers for bladder cancer and compared their efficacies.

Intravesical Chemotherapy after Radical Nephroureterectomy for Primary Upper Tract Urothelial Carcinoma: A Systematic Review and Network Meta-Analysis

The aim of this study was to determine the prophylactic effect of intravesical chemotherapy. Furthermore, it aimed to compare the efficacy of regimens on the prevention of bladder recurrence, after nephroureterectomy, for upper tract urothelial carcinoma by systematic review and network meta-analysis. A comprehensive literature search was conducted to search for studies published before 22 December 2016 using PubMed, Embase, and Scopus. All studies comparing nephroureterectomy alone with prophylactic intravesical chemotherapy after nephroureterectomy were included. The primary outcome was intravesical recurrence-free survival rate. In addition, we conducted indirect comparisons among regimens using network meta-analysis, as well as three randomized controlled trials (RCTs) on multicenter setting, and one large retrospective study with a total of 532 patients were analyzed. The pooled hazard ratio (HR) of bladder recurrence was 0.54 (95% CI: 0.38-0.76) in intravesical instillation patients. On network meta-analysis, pirarubicin was ranked the most effective regimen, while maintenance therapy of mitomycin C (MMC) with Ara-C and induction therapy of MMC were ranked as the second and third most effective regimens, respectively. Our study demonstrates that intravesical chemotherapy can prevent bladder recurrence in patients with upper tract urothelial carcinoma after nephroureterectomy. It also suggests that a single instillation of pirarubicin is the most efficacious intravesical regimen.

Robot-assisted radical cystectomy: Where we are in 2023

Open radical cystectomy (ORC) is associated with high rates of perioperative morbidity and mortality, owing to its extensive surgical nature and the high frequency of multiple co-morbidities among patients. As an alternative, robot-assisted radical cystectomy (RARC) has been increasingly adopted worldwide, being a reliable treatment option that utilizes minimally invasive surgery. Seventeen years have passed since the advent of the RARC, and comprehensive long-term follow-up data are now becoming available. The present review focuses on the current knowledge of RARC in 2023, and analyzes various aspects, including oncological outcomes, peri/post-operative complications, post-operative quality of life (QoL) change, and cost-effectiveness. Oncologically, RARC showed comparable oncological outcomes to ORC. With regard to complications, RARC was associated with lower estimated blood loss, lower intraoperative transfusion rates, shorter length of stay, lower risk of Clavien-Dindo grade III-V complications, and lower 90-day rehospitalization rates than ORC. In particular, RARC with intracorporeal urinary diversion (ICUD) performed by high-volume centers significantly reduced the risk of post-operative major complications. In terms of post-operative QoL, RARC with extracorporeal urinary diversion (ECUD) showed comparable results to ORC, while RARC with ICUD was superior in some respects. As the RARC implementation rate increases and the learning curve is overcome, more prospective studies and randomized controlled trials with large-scale patients are expected to be conducted in the future. Accordingly, sub-group analysis in various groups such as ECUD, ICUD, continent and non-continent urinary diversion, etc. is considered to be possible.

Disease-Free Survival at 2 and 3 Years is a Significant Early Surrogate Marker Predicting the 5-Year Overall Survival in Patients Treated with Radical Cystectomy for Urothelial Carcinoma of the Bladder: External Evaluation and Validation in a Cohort of Korean Patients

PURPOSE

We aimed to externally validate the association of 2- and 3-year disease-free survival (DFS) with 5-year overall survival (OS) in patients treated with radical cystectomy (RC) for urothelial carcinoma (UC) of the bladder.

MATERIALS AND METHODS

We reviewed the clinical data of 422 patients who underwent RC for UC of the bladder in our institution between 1991 and 2012. Survival curves were plotted with the Kaplan-Meier method. The Kappa statistic and Kendall tau-b test were used to assess the agreements between 2- and 3-year DFS and 5-year OS.

RESULTS

In the entire study population, 2- and 3-year DFS and 5-year OS rates were 76.4, 71.5, and 67.4%, respectively. All Kappa and Kendall's tau-b test values for agreements between 2- and 3-year DFS and 5-year OS were more than 0.40, indicating moderate agreement for all patients and in each patient subgroup selected according to specific variables (all p-values <0.05). Kaplan-Meier analysis for DFS and Cox-proportional hazard models for landmark analysis at each time point indicated that most recurrences occurred within 3 years after surgery. The 5-year OS rates of patients who were recurrence-free at each time point gradually increased to more than 95% in an extended recurrence-free interval of 12-36 months.

CONCLUSION

Our external validation results support the existing finding that 2- and 3-year DFS can be a valid early surrogate end point to predict 5-year OS after RC in patients with UC of the bladder.

Clinical Practice Pattern of Immediate Intravesical Chemotherapy following Transurethral Resection of a Bladder Tumor in Korea: National Health Insurance Database Study

We evaluated the frequency and practice pattern of immediate postoperative intravesical chemotherapy (PIC) after transurethral resection of a bladder tumor (TURBT) in suspected non-muscle-invasive bladder cancer (NMIBC). Information from the Health Insurance Review and Assessment Service database from January 1, 2008 to December 31, 2013 was used. Patients with bladder cancer who received TURBT were considered as the cases (37,941 patients and 59,568 cases). The time of PIC after TURBT, types of PIC regimens, and the potential effect of PIC on the delay for additional treatment were analyzed. The study cohort included 23,726 subjects and 30,473 cases with a mean age of 66.8 ± 12.0 years, including 19,362 (81.6%) male patients. The rate of immediate PIC was 11.0% of cases (3,359 cases). There was significant difference in the frequency rate of additional treatment among patients with immediate PIC and patients without immediate PIC within 1 year from the first TURBT (15.2% vs 16.6%, p = 0.035). However, no difference was revealed for whole observational period (33.7% vs 34.5%, p = 0.373). The frequency rate of immediate PIC after TURBT for suspected NMIBC was low in real clinical practice. More efforts are needed to improve the usage rate of PIC after TURBT for suspected NMIBC.

Survival Benefits Based on the Number of Lymph Nodes Removed during Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma: Systematic Review and Meta-Analysis

The role of lymph node dissection (LND) is still controversial for upper tract urothelial carcinoma (UTUC), and there are no guidelines regarding its use. This study was conducted to find a higher level of evidence for the survival benefits based on the number of LNs removed during radical nephroureterectomy (RNUx) through a systematic review and meta-analysis. We included studies comparing patients who underwent LND during RNUx for UTUC. We searched the major electronic databases (Pubmed, Embase®, and Scopus®) and conducted manual searches of the electronically available abstracts of the major international urology cancer meetings [American Society of Clinical Oncology (ASCO), American Urological Association (AUA), and Eropean Association of Urology (EAU)] prior to April 2019 using grouped terms of nephroureterectomy (nephroureterectom*) and lymph node excision (lymphadenectomy; lymph + node*; lymph* + metasta*) with variations in the terms. Study selection, data collection, and risk of bias assessment were performed by two independent authors (A and B). Six retrospective case-control studies included a total of 33,944 patients who underwent RNUx for UTUC, 5071 of whom underwent LND and were finally included in the meta-analysis. The pooled hazard ratio (HR) in these studies revealed that an increased number of LNs removed during RNUx was associated with improved cancer-specific survival (CSS) in patients with UTUC (HR = 0.95, 95% CI: 0.91-0.99; p = 0.07). In addition, increased numbers of LNs removed were associated with improved overall survival (OS) in pN0 patients. However, in pN+ patients, the number of LNs removed showed no survival benefit on CSS, overall survival (OS), or progression-free survival (PFS). Higher numbers of LNs removed during RNUx were associated with improved survival outcomes in patients with UTUC. This study confirmed that LND also has oncological benefits in UTUC patients. Although still a controversial topic, meticulous LND must be considered, and efforts should be made to eliminate as many LNs as possible when administering RNUx for UTUC, especially in patients without clear evidence of LN metastasis.

Impacts of the quinazoline-based alpha1-antagonist, terazosin, and of the sulfonamide derivative, tamsulosin, on serum prostate-specific antigen and prostate volume

The aim of this study was to compare the impacts of terazosin and tamsulosin, on prostate activity, i.e., serum prostate-specific antigen, total prostate volume (TPV), and transition zone volume (TZV). A total of 90 patients who presented with lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH), ranging in age from 52 to 83 yr (median 65 yr), were included in the study. Patients were given 0.2 mg tamsulosin, 2 mg terazosin, or 4 mg terazosin once daily for an average of 14 months (range, 6-56 months). Subjective (International Prostate Symptom Scores, I-PSS) and objective (maximal flow rate and post-void residual) parameters were assessed both at baseline and at treatment cessation. Serum prostate-specific antigen (PSA) levels were found to be unaffected by treatment (1.2 and 1.3 ng/mL). In total patients, multivariate analysis showed that baseline TPV was the only independent predictor of treatment-related TPV reduction. Moreover, baseline TPV > or =30 g was found to be associated with a higher likelihood of TPV reduction (odds ratio [OR], 3.939; 95% confidence interval [CI], 1.506-10.304; p=0.005), and a baseline TZV of > or =10 g was associated with a 7.1-times greater chance of TZV reduction (OR, 7.100; 95% CI, 2.428-20.763; p<0.001). The same model showed that patients on 2 mg terazosin had a 10.8-fold greater likelihood (OR, 10.770; 95% CI, 1.409-82.323; p=0.022) and that those on 4 mg terazosin had a 9.0-fold greater likelihood (OR, 9.001; 95% CI, 1.724-46.995; p=0.009) of a TZV reduction than those on 0.2 mg tamsulosin. In addition, symptoms improved regardless of prostate activity after taking alpha1-blockers. Our findings suggest that terazosin reduces TZV and demonstrate that the relief of symptoms associated with BPH may not be due to a prostate activity reduction induced by apoptosis in the prostate gland.

Accuracy of a high prostate-specific antigen level for prostate cancer diagnosis upon initial biopsy in Korean men

PURPOSE

This study aimed to evaluate the cancer detection rate in a Korean population with prostate-specific antigen (PSA) levels greater than or equal to 20.0 ng/mL.

MATERIALS AND METHODS

A total of 174 men 50 to 79 years old (median 69) included in the study. The median prostate volume of the patients was 44.8 mL (range 14.1 to 210.0) and their serum PSA ranged from 20.0 to 9725.0 ng/mL (median 44.8).

RESULTS

Of 174 men 141 (81.0%) were diagnosed with prostate cancer on initial biopsy. In the total number of patients, the positive predictive value (PPV) was 62.9% for PSA 20 to 29.9, 72.7% for PSA 30 to 39.9 and 100% for PSA 40 to 49.9 ng/mL. In patients with an abnormal digital rectal examination (DRE), the values for these PSA ranges increased to 89.5%, 91.7% and 100%, respectively. The PPV was 81.0% for PSA cutoff of 20, 89.2% for a cutoff of 30, 95.4% for a cutoff of 40, and 94.7% for a cutoff of 50 ng/mL. In conjunction with an abnormal DRE, the values for these PSA cutoffs increased to 95.9%, 98.1%, 100%, and 100%, respectively.

CONCLUSION

Our data suggest the ability to predict the presence of prostate cancer reliably on initial biopsy when PSA threshold is greater than or equal to 50 ng/mL. This PSA threshold may be lowered to 40 ng/mL in the presence of an abnormal DRE. In Korean men with high PSA, the detection rate of prostate cancer on biopsy appears to be comparable to that for American men.

A comparative study of patient experiences of conventional fluoroscopic and four-hour ambulatory urodynamic studies

We assessed several emotional variables in patients experiencing conventional urodynamic and ambulatory urodynamic monitoring (AUM) to verify the hypothesis that AUM is tolerated as well as conventional urodynamics. A total of 33 women and 7 men from 23 to 72 years of age who were undergoing both procedures were prospectively included in this study. Prior to and immediately after the procedures, each patient completed a self-administered questionnaire. Answers were given on a visual analogue scale. The degree of anxiety was higher for conventional urodynamics than for AUM (p = 0.045), while the degree of boredom experienced during AUM was higher than that during conventional urodynamics (p= 0.013). There was no significant difference in the degree of shame or bother experienced by the patients during the two procedures. In general, patients tolerated both examinations extremely well. The examiner-rated degree of intolerance during conventional urodynamics was influenced by the subjective pain score (p=0.001), while all other emotional variables except bother were not significantly related with the degree of intolerance during AUM (p=0.007). A total of 74.4% and 84.6% responded that they were willing to repeat conventional urodynamics and AUM, respectively, which were not significantly different. Although AUM produced a significantly higher level of boredom than conventional urodynamics, our data demonstrates that patients are as tolerant of AUM as they are of conventional urodynamic procedures.

Second-Line Systemic Treatment for Metastatic Urothelial Carcinoma: A Network Meta-Analysis of Randomized Phase Clinical Trials

Purpose: We aimed to evaluate and compare relative impacts of various second-line treatments on overall survival (OS) in metastatic urothelial carcinoma (mUC). Method: A literature search was conducted in PubMed, Embase, and the Cochrane Library for all articles published prior to December 2018 in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines. Seven randomized controlled trials with phase III design that met study eligibility criteria were selected for final analysis. A Bayesian framework network meta-analysis (NMA) was applied to indirectly compare the effect of each treatment on OS. Results: In NMA, atezolizumab (HR, 0.90; 95% CI, 0.57-1.40) and pembrolizumab (HR, 0.77, 95% CI, 0.48-1.20) showed no significant effect on OS improvement compared to vinflunine. Gemcitabine/paclitaxel combination (HR, 1.30; 95% CI, 0.80-1.90) and lapatinib (HR, 0.95; 95% CI, 0.57-1.60) was not significantly associated with OS improvement compared to atezolizumab and best supportive care, respectively. However, results of rankograms revealed that pembrolizumab and atezolizumab were the first and second rank therapeutic agents for OS improvement in post-platinum mUC. Conclusions: Our NMA results are inconclusive. The optimal second-line treatment for OS improvement could not be determined because there were no significant OS differences among evaluated therapeutic agents. However, the use of immunotherapeutic agents such as atezolizumab and pembolizumab may have priority for improving OS in second-line setting of mUC.

Differences in Pathologic Results of Repeat Transurethral Resection of Bladder Tumor (TURBT) according to Institution Performing the Initial TURBT: Comparative Analyses between Referred and Nonreferred Group

OBJECTIVE

Although transurethral resection of bladder tumor (TURBT) is a standard treatment and determines staging for nonmuscle invasive bladder cancer, many deficiencies persist. There is a risk of upstaging and residual cancer when repeat TURBT is performed. Authors compared the results of repeat TURBT by institution performing the initial TURBT.

METHODS

We retrospectively reviewed the medical records of 289 patients who underwent repeat TURBT within 2-6 weeks after initial TURBT between 1998 and 2013. The patients were divided into the referred group and the nonreferred group by institution performing the initial TURBT. And we analyzed the intergroup differences in residual tumor and upstaging rate and the factors significantly correlated with residual tumor.

RESULTS

The mean age was 69.6 ± 11.1 years and the mean follow-up was 49.7 (range: 0-191) months. The referred group included 69 patients, while the nonreferred group included 220 patients. The referred group included 57 (82.6%) patients with residual tumor after repeat TURBT. Overall upstaging occurred in 15 (21.7%), and upstaging to T2 occurred in 11 (15.9%) of the initial Ta and T1 patients. In the nonreferred group, there were 123 (55.9%) patients with residual tumor. Overall upstaging occurred in 10 (4.5%) and upstaging to T2 occurred in 7 (3.2%) patients.

CONCLUSIONS

Gross hematuria, grade, and tumor quantity and size were significantly associated with residual cancer on multivariate analysis. In the referred group, repeat TURBT and restaging are necessary.