The significance of ureteral obstruction in invasive transitional cell carcinoma of the urinary bladder

Management of urothelial cancer in patients with chronic kidney disease receiving platinum-based chemotherapy

Despite recent advances in the management of urothelial cancer (UC), cisplatin-based combination chemotherapy regimens remain critical. However, their use can be complicated in patients with chronic kidney disease (CKD), which is not uncommon in UC patients. Based on the Galsky criteria for cisplatin ineligibility, most patients with CKD will be excluded from receiving cisplatin-based chemotherapy altogether. For patients with borderline kidney function, several strategies - such as the use of split-dose cisplatin, dose reductions, or extra hydration - may facilitate the use of cisplatin, but these need to be prospectively validated. This review highlights the critical need for a multidisciplinary team, including onco-nephrologists, to help manage renal complications and optimize delivery of cancer care in complex UC patients with CKD.

New Hydronephrosis in the Native Kidney Is Associated with the Development of De Novo Urinary Bladder Urothelial Carcinoma in Patients with Post-Kidney Transplantation

Increased malignancy after kidney transplantation (KT) is by far the most troublesome issue. Among these malignancies, urothelial carcinoma (UC) incidence is uniquely high in Taiwan. We want to know whether routine sonography to detect native hydronephrosis is associated with the development of de novo urinary bladder urothelial carcinoma (UBUC) in post-KT recipients. From 2003 to 2018, we retrospectively analyzed 1005 KT patients, 58 of whom were subsequently diagnosed with UBUC. The association between new native hydronephrosis and post-KT UBUC was analyzed with univariate and multivariate logistic regression analyses and a Kaplan-Meier plot. We excluded cases of people who had upper urinary tract urothelial carcinoma (UTUC) and were diagnosed prior to UBUC. There were 612 males (60.9%) and 393 females (39.1%), with a mean age of 48.2 ± 12.0 years old at KT. The mean follow-up period was 118.6 ± 70.2 months, and the diagnosis of UBUC from KT to UBUC was 7.0 ± 5.1 years. New native kidney hydronephrosis occurred more frequently in the UBUC group (56.4% versus 6.4%, p < 0.001) than the non-UBUC group. Multivariate analysis disclosed that native hydronephrosis is the only statistically significant factor for UBUC, with an odds ratio of 16.03 (95% CI, 8.66-29.68; p < 0.001). UBUC in post-KT patients with native hydronephrosis also showed a tendency toward multifocal lesions upon presentation (47.8%). Post-KT UBUC is characterized by pathologically aggressive and multiple foci lesions. Native kidney hydronephrosis may be a deciding factor of post-KT UBUC.

Does Ureteral Stent Drainage Prior to Cystectomy Increase the Risk of Subsequent Upper Tract Urothelial Carcinoma and Ureteral Complications?

OBJECTIVE

To guide management of preoperative hydronephrosis prior to radical cystectomy (RC), we compared post-RC risks of upper tract urothelial carcinoma (UTUC) and ureteroenteric anastomotic complications between ureteral stent and percutaneous nephrostomy tube drainage.

METHODS

Patients who underwent RC for urothelial carcinoma without a prior diagnosis of UTUC at our institution between 2000 and 2015 were included and divided into 4 patient groups: (1) no hydronephrosis (75%, N = 787); (2) hydronephrosis without preoperative upper tract drainage (13%, N = 132); (3) hydronephrosis treated with nephrostomy tube (3%, N = 36); (4) hydronephrosis treated with ureteral stent (9%, N = 94). The incidence of post-RC UTUC and ureteral complications was compared using Kaplan-Meier analyses and multivariable Cox proportional hazard modeling.

RESULTS

We identified a total of 1049 patients who underwent RC (median postoperative follow-up 4.3 years). Five-year post-RC UTUC incidence was 6.6%, 10.2%, 17%, 18.7% for groups 1-4, respectively (P= .13). On multivariable analysis, nephrostomy tube drainage (hazard ratio [HR] 4.10, P = .02) and preoperative ureteral stenting (HR 2.35, P = .04) were both associated with UTUC after RC, but ureteral stenting did not have a significantly higher association with UTUC than nephrostomy tube drainage. Severe hydronephrosis was also associated with development of UTUC (HR 4.03, P = .02). The incidence of ureteroenteric anastomotic complications did not vary by drainage modality.

CONCLUSION

Preoperative hydronephrosis was associated with UTUC after RC, but ureteral stent placement did not increase the risk of UTUC or ureteral complications relative to nephrostomy tube placement. The choice of hydronephrosis drainage pre-RC should not be guided by concern for UTUC risk.

Influence of preoperative hydronephrosis and ureteral orifice involvement in the survival of patients undergoing radical cystectomy: A retrospective comparative study

OBJECTIVE

The aim of the present study was to evaluate the influence of preoperative hydronephrosis and ureteral orifice involvement (UOI) on survival of patients undergoing radical cystectomy (RC) for bladder cancer (BC).

MATERIAL AND METHODS

A total of 162 patients with BC underwent RC between January 2006 and March 2017. Patients were divided into two groups for both presences of preoperative hydronephrosis and orifice involvement at final pathology. Additionally, tumors with orifice involvement were subgrouped histopathologically after RC as those with only UOI and those with invasive to the ureter with an additional concurrent site at final pathology.

RESULTS

Preoperative hydronephrosis was detected in 57 patients. Preoperative and postoperative creatinine on month 3 were higher in the preoperative hydronephrosis (+) group (p<0.001). In addition, postoperative T stage, surgical margin positivity, invasion of urethra, and pathological upstaging were higher in this group. Cancer-specific survival (CSS) and overall survival (OS) were better in the hydronephrosis (-) group than in the hydronephrosis (+) group (p=0.001 and p=0.001, respectively). Preoperative hydronephrosis was found to be an independent factor in pathological upstaging. Patients were divided into two groups according to the presence of UOI. Group 1 consisted of patients without UOI, and group 2 with UOI. Preoperative hydronephrosis, hydronephrosis grade, and T stage were statistically higher in tumors with UOI. Moreover, CSS and OS were lower in group 2 than in group 1.

CONCLUSION

Preoperative hydronephrosis and UOI are predicting factors on survival of patients undergoing RC for BC. Preoperative hydronephrosis was found to be an independent factor in pathological upstaging.

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.

CT Imaging of Emergent Renal Conditions

The kidneys are paired intra-abdominal organs which provide essential functions and maintain homeostasis throughout the human body. Numerous disease processes affect the kidneys and cause acute renal dysfunction or other potentially catastrophic complications. These conditions can be broadly categorized into obstructive, infectious, hemorrhagic, traumatic, and vascular diseases. Imaging plays a vital role in the work-up and diagnosis of acute and emergent renal conditions. Evaluation of emergent renal conditions with a focus on CT imaging is discussed.

Stenting Prior to Cystectomy is an Independent Risk Factor for Upper Urinary Tract Recurrence

PURPOSE

Patients with bladder cancer who present with hydronephrosis may require drainage of the affected kidney before receiving further cancer treatment. Drainage can be done by retrograde stenting or percutaneously. However, retrograde stenting carries the risk of tumor cell spillage to the upper urinary tract. The aim of this study was to evaluate whether patients with bladder cancer are at higher risk for upper urinary tract recurrence if retrograde stenting has been performed prior to radical cystectomy.

MATERIALS AND METHODS

We retrospectively analyzed the records of 1,005 consecutive patients with bladder cancer who underwent radical cystectomy at our department between January 2000 and June 2016. Negative intraoperative ureteral margins were mandatory for study inclusion. Patients received regular followup according to our institutional protocol, including imaging of the upper urinary tract and urine cytology.

RESULTS

Preoperative drainage of the upper urinary tract was performed in 114 of the 1,005 patients (11%), including in 53 (46%) by Double-J® stenting and in 61 (54%) by percutaneous nephrostomy. Recurrence developed in the upper urinary tract in 31 patients (3%) at a median of 17 months after cystectomy, including 7 of 53 (13%) in the Double-J group, 0% in the nephrostomy group and 24 of 891 (3%) in the no drainage group. Multivariate regression analysis revealed a higher risk of upper urinary tract recurrence if patients underwent Double-J stenting (HR 4.54, 95% CI 1.43-14.38, p = 0.01) and preoperative intravesical instillations (HR 2.94, 95% CI 1.40-6.16, p = 0.004).

CONCLUSIONS

Patients who undergo Double-J stenting prior to radical cystectomy are at higher risk for upper urinary tract recurrence. If preoperative upper urinary tract drainage is required, percutaneous drainage might be recommended.

The prognostic value of hydronephrosis in bladder cancer treated by radical cystectomy

OBJECTIVES

To evaluate the prognostic impact of hydronephrosis in bladder cancer treated by radical cystectomy.

METHODS

We performed a retrospective review of 126 patients with transitional cell carcinoma of bladder, who underwent radical cystectomy at our hospital from January 2003 through May 2010. The relationship between hydronephrosis, tumor stage, and lymph node status was analyzed. We evaluated the effect of hydronephrosis on the recurrence-free survival of bladder cancer by using log-rank test and multivariate Cox regression analysis.

RESULTS

Thirty-four patients had unilateral hydronephrosis and five patients had bilateral hydronephrosis. There were 59.0% of tumors with stage ≥pT3a, and 30.8% with pT2, 10.2% with pT1 in the Hydronephrosis group respectively compared to 14.9%, 59.8%, and 25.3% in the Non-hydronephrosis group (χ2 = 25.680, P<0.001). The 5-year recurrence-free survival rates in the Hydronephrosis group were significantly lower than the Non-hydronephrosis group (42.5±10.3% vs. 68.8±8.1%, P=0.001). When adjusted to the different stages stratum, the recurrence-free survival rates among patients with stage pT1-2pN- or lymph node metastasis did not differ significantly whether they had evidence of preoperative hydronephrosis or not, while they differed significantly in the subgroup of stage ≥pT3a,pN-. Multivariate analysis showed that hydronephrosis was not an independent prognostic factor for recurrence-free survival except pathological stage and lymph node status.

CONCLUSIONS

Preoperative hydronephrosis predicts advanced stages in transitional cell carcinoma of bladder and exactly effects the survival mainly in higher stage tumor without metastasis.

High-grade hydronephrosis predicts poor outcomes after radical cystectomy in patients with bladder cancer

We examined whether the presence and severity of preoperative hydronephrosis have prognostic significance in patients who underwent radical cystectomy for transitional cell carcinoma of the bladder. The medical records of 457 patients who underwent radical cystectomy for bladder cancer between 1986 and 2005 were retrospectively reviewed. Following the Society for Fetal Urology grading system, patients were divided into low-, and high-grade hydronephrosis groups. Clinicopathologic factors associated with preoperative hydronephrosis and survival were evaluated. Of a total of 406 patients, unilateral hydronephrosis was found in 74 (18.2%), bilateral hydronephrosis in 11 (2.7%), and no hydronephoris in 321 (79.1%). Low-grade hydronephrosis was found in 57 (12.2%) patients and high-grade hydronephrosis in 28 (6%). Preoperative hydronephrosis was related to higher pT stage and lymph node invasion. In univariate analysis, the presence of hydronephrosis, hydronephrosis grade, age, pT and pN stage, tumor grade, surgical margin, number of retrieved nodes, carcinoma in situ, and lymphovascular invasion were significant prognostic factors for cancer-specific survival. In multivariate analysis, bilateral hydronephrosis and high-grade hydronephrosis remained significant predictors for decreased survival. The presence of preoperative hydronephrosis, and high-grade hydronephrosis are significant prognostic factors in patients with bladder cancer after radical cystectomy.

The frequency of hydronephrosis at initial diagnosis and its effect on recurrence and progression in patients with superficial bladder cancer

PURPOSE

We determined the frequency of hydronephrosis at initial diagnosis, and its effect on recurrence and progression in patients with superficial bladder cancer.

MATERIALS AND METHODS

Between January 1993 and April 2006 we retrospectively reviewed the records of 931 patients with superficial transitional cell carcinoma of the bladder at our institute. Hydronephrosis status was determined by excretory urogram, ultrasound or computerized tomography of the abdomen and pelvis at initial evaluation. The number of tumors, tumor size, tumor location, T category (pTa vs pT1) and histological grade were assessed at study entry. The absence or presence of unilateral or bilateral upper tract obstruction/hydronephrosis was recorded for all cohorts. We examined the frequency of hydronephrosis in patients with superficial bladder carcinoma according to T status and investigated the relationship between hydronephrosis, and recurrence-free and progression-free survival for pTa and pT1 stage. The end points assessed were recurrence and progression.

RESULTS

Histopathological results showed that 63.8% of all superficial bladder cancer cases were pT1 stage. Preoperative radiological evaluation revealed unilateral and bilateral hydronephrosis in 70 (7.5%) and 19 (2.1%) patients in all cohorts, respectively. Of patients with pTa tumors 304 (90.2%) had low grade lesions and 207 (61.4%) had a single tumor. Unilateral and bilateral hydronephrosis was detected in 16 (4.7%) and 4 (1.2%) patients with pTa, respectively. Of patients with pT1 tumors 196 (33.0%) had low grade lesions and 283 (47.6%) had a single tumor. Unilateral and bilateral hydronephrosis was detected in 54 (9.1%) and 15 (2.5%) patients with pT1 disease, respectively. The increased probability of hydronephrosis was detected in higher stage, higher grade multiple tumors and in tumors larger than 3 cm. Of 931 patients 37.9% had at least 1 recurrence with an incidence of 27.3% for Ta and 43.9% for T1 disease. The recurrence rate was 52.8% for patients with hydronephrosis, that is 35.0% for Ta and 58.0% for T1 disease. Median time to first recurrence was 22 months. Multivariate Cox analysis confirmed that T category, grade, tumor size and hydronephrosis were significant prognostic variables of recurrence. Of the cases 11% progressed to muscle invasive bladder cancer. Multivariate analysis revealed that progression was statistically significant for T category, disease grade, multiplicity, tumor size and the presence or absence of hydronephrosis.

CONCLUSIONS

Unilateral/bilateral hydronephrosis detected at the first evaluation at diagnosis of superficial bladder tumors is an independent prognostic factor for recurrence and progression.

Systemic chemotherapy for advanced bladder cancer: update and controversies

Despite improvements in surgical techniques and outcomes, 5-year survival rates for patients with muscle-invasive bladder cancer remain suboptimal. Almost 50% of patients will eventually progress and develop systemic disease. Although various single agents have shown activity in patients with advanced or metastatic disease, randomized trials have demonstrated the utility of cisplatin-based combinations regimens. Despite relatively high objective response rates, the impact on survival in patients with advanced disease has been quite limited. Surgical resection in selected patients achieving significant objective response to cytotoxic therapy can contribute to long-term survival rates. The role of salvage therapy in advanced disease remains undefined. Evaluation of several active compounds has yielded unimpressive results with low objective response rates and overlapping CIs. Recognition that the maximum benefit from conventional cytotoxics has been achieved has led to the recent initiation of a number of clinical trials evaluating targeted agents in the management of advanced urothelial cancer.

The management of hydronephrosis in patients undergoing TURBT

OBJECTIVE

Previous studies have shown the negative prognostic correlation of hydronephrosis in bladder cancer; however, practical uncertainties remain regarding the management of these patients.

METHODS

We retrospectively reviewed the notes of patients undergoing TURBT over a three year period and recorded the management and outcome of patients with hydronephrosis.

RESULTS

Six percent with bladder cancer had hydronephrosis. Nearly all the cases had muscle invasive disease. At TURBT, the ureteric orifice was seen in 41%; in the remaining 59% of patients, the ureteric orifice was involved and resected. This resolved the hydronephrosis in only one patient (who had superficial disease).

CONCLUSIONS

Hydronephrosis in bladder cancer is associated with a poor prognosis. The hydronephrosis does not resolve with resection alone. As awaiting it's resolution may delay definitive treatment, we suggest aggressive management of hydronephrosis from the time of initial diagnosis with ureteric stenting in order to protect renal units and optimize renal function prior to further definitive treatment of bladder cancer.

Assessing interactions between mdm-2, p53, and bcl-2 as prognostic variables in muscle-invasive bladder cancer treated with neo-adjuvant chemotherapy followed by locoregional surgical treatment

BACKGROUND

Tumor proliferation and apoptosis may be influenced by the mdm-2 gene product, which can block the antiproliferative effects of p53. bcl-2, one of a family of related genes that regulates the apoptotic pathway, exhibits a negative influence. Both individual and cooperative effects of these gene products may affect the biological behavior of primary bladder cancers and long-term outcome to standard therapy.

METHODS

This study retrospectively evaluated the association with survival of mdm-2, p53, and bcl-2 expression in 59 patients with muscle-invasive, node-negative transitional cell carcinoma (TCC) treated with neo-adjuvant chemotherapy followed by locoregional surgery. Each marker was defined as an altered phenotype if >or=20% malignant cells in the primary tumor exhibited staining; normal or minimal expression was defined as <20% cells exhibiting staining.

RESULTS

Altered mdm-2, p53, and bcl-2 expression was observed in 37%, 54%, and 46% of patients, respectively. In single marker analysis, altered p53 expression correlated with long-term survival (P = 0.05) but mdm-2 (P = 0.42) or bcl-2 (P = 0.17) did not. In the multiple-marker analysis, a prognostic index simultaneously assessing mdm-2, p53, and bcl-2 correlated with survival (P = 0.01). The 5-year survival for patients in which all markers were normally expressed was 54% compared with 25% in those with all three markers aberrantly expressed. Patients with aberrant expression of either one or two markers had an intermediate 5-year survival (49%). There was no association of molecular markers either alone or in combination with pathologic downstaging after neo-adjuvant chemotherapy.

CONCLUSION

The cooperative effects of phenotypes determined by mdm-2, p53, and bcl-2 expression may predict survival in patients with muscle-invasive TCC of the bladder.

Use of nomograms as predictive tools in bladder cancer

Bladder cancer is a common genitourinary malignancy that demonstrates a great variation in risk of tumor recurrence and progression following treatment. The dramatic differences in clinical behavior dictate vastly differing treatments, which may range from simple surveillance to combination radical surgery with systemic chemotherapy. For non-muscle invasive bladder cancer prediction of the risk of recurrence and progression is necessary to assess the need for intravesical therapy and possible early cystectomy. In contrast, prediction of advanced disease response to primary treatment such as cystectomy and the response to systemic chemotherapy plays an important role in treatment assignment for patients with muscle invasive disease. To estimate these risk traditional risk grouping schemes such as the present TNM staging system has been used to guide patient treatment. More recently, improved prognostic tools such as nomograms have been developed to provide a more accurate assessment of outcomes. Clinicians are enthusiastically working to utilize these statistical methods in bladder cancer. We summarize the current status of outcome predictive models for bladder cancer; and focus particularly on the ability of nomograms to predict disease recurrence, progression, and patient survival.

Hydronephrosis as a prognostic marker in bladder cancer in a cystectomy-only series

OBJECTIVES

Hydronephrosis in patients with bladder cancer is caused by tumour at the ureteral orifice, secondary ureteral tumours, intramural or extravesical tumour infiltration, or compression of the ureter. This study investigated the prognostic impact of hydronephrosis in bladder cancer.

METHODS

A series of 788 patients were treated with radical cystectomy with curative intent for transitional cell carcinoma of the bladder without neoadjuvant/adjuvant radiotherapy/chemotherapy between January 1986 and September 2003. All patients had a complete follow-up until death or until the study's end date. Survival rates were calculated using the Kaplan-Meier method. A multivariate analysis with a Cox regression model was performed with respect to potential influencing factors.

RESULTS

A total of 108 patients (13.7%) had unilateral and 25 patients (3.2%) had bilateral hydronephrosis. The rate of organ-confined tumours was significantly higher in patients without hydronephrosis (67.9% vs. 37.6%; p<0.001). Forty-three (32.3%) of the 133 hydronephrotic patients had a tumour involving the ureteral orifice. In this group the rate of organ-confined tumours was significantly higher than in the other patients with hydronephrosis (53.5% vs. 30.0%; p=0.009). In the multivariate analysis, preoperative hydronephrosis was determined as an independent prognostic marker for recurrence-free survival besides the pT classification and lymph node status (p=0.0015). The etiology of hydronephrosis did not affect the tumour-specific survival.

CONCLUSIONS

Hydronephrosis at the time of diagnosis of bladder cancer is associated with a high probability of advanced tumours. It is an independent prognostic factor for recurrence-free survival.

Clinico-pathological features of bladder carcinoma: Experience from a tertiary care hospital of Pakistan

Bladder carcinoma is most common urological malignancy in Pakistan. The objective of the study was to determine the clinico-pathological characteristics of histologically confirmed bladder carcinoma at a tertiary care hospital of South Punjab, Pakistan.

METHODS

In two hundreds and twenty one patients (172 male and 49 female) bladder carcinoma was diagnosed from Jan 1998 to June 2005. All patients were evaluated with regards to clinical presentation, cystoscopic findings and histo-pathological data.

RESULTS

Male female ratio was 3.5:1. The median age was 58 years (range 18-87 years). 65% men had history of cigarette smoking while 51% women had long history of smokeless tobacco (nasal snuff or chewable) use. Most patients presented with painless hematuria. Primary transitional cell carcinoma was the most common (i.e. 96%) histological variety of bladder carcinoma. 63% patients had muscle invasive disease at the time of presentation. Even in superficial bladder carcinoma, most patients had invasion of lamina propria (pT1 disease).

CONCLUSION

More than 90% of primary bladder carcinoma are of transitional cell variety and over 60% having muscle invasive disease at the time of diagnosis. Even in patients with superficial disease, majority (i.e. 98%) have invasion of lamina propria.

Bladder cancer with obstructive uremia: oncologic outcome after definitive surgical management

OBJECTIVES

To report the surgical and oncologic outcomes of patients with bladder cancer who present with obstructive uremia.

METHODS

A total of 61 patients presented to our institute with obstructive oliguria or anuria concomitant with bladder cancer. The mean serum creatinine at presentation was 11.4 +/- 5.1 mg%. After stabilization of kidney function following nephrostomy drainage, only 38 patients were eligible for radical cystectomy. Analysis of the intraoperative findings, early postoperative course, definitive histopathologic findings, and long-term functional and oncologic outcome was performed. The mean follow-up period was 16.2 +/- 8.1 months (range 8 to 134).

RESULTS

Radical cystectomy with bilateral iliac lymphadenectomy was feasible in 26 patients, palliative cystectomy in 10, and ileal conduit only without cystectomy in 2. The postoperative morbidity was minimal and treated conservatively. Bladder cancer causing uremia was invasive in 94.5%, and was pathologic Stage T4 in 30.5% of cases. At the mean follow-up, treatment failure was observed in 26 patients (68.4%), with only 12 patients living free of disease and a mean serum creatinine of 1.4 +/- 0.7 mg%. Although none of the preoperative variables proved to be predictive of the oncologic outcome, significant correlation was found between the tumor stage and grade, as well as lymph node involvement, and treatment failure.

CONCLUSIONS

Although bladder cancer causing obstructive uremia is almost always muscle invasive, with a large proportion of patients presenting with locally advanced disease, an adequate number of these patients could achieve long-term disease-free survival.

Locally advanced and metastatic bladder cancer

Metastatic transitional cell carcinoma of the bladder is an aggressive neoplasm characterized by rapid growth and dissemination with a median survival of typically less than 1 year. Despite the availability of a myriad of antineoplastics with moderate-significant anti-tumor activity yielding overall response rates in the 40% to 80% range, randomized trials continue to demonstrate median survival rates in the 13- to14-month range, with very limited long-term survival. Subsets of patients with advanced bladder cancer present additional management problems, including those with renal insufficiency or nontransitional-cell histology. Various observers have noted the similarity in treatment outcomes in advanced bladder cancer and extensive small cell lung cancer where chemotherapy produces relatively high response rates but with limited impact on survival. The optimal chemotherapy combination for patients with advanced bladder cancer remains undefined, however, there is increasing recognition that in order to achieve tangible improvements in complete response rates and survival in this disease will likely require a combination of chemotherapy and targeted molecular therapies and in some settings adjunctive surgery.

Treatment of patients with metastatic urothelial carcinoma and impaired renal function with single-agent docetaxel

OBJECTIVES

To evaluate the efficacy and toxicity of single-agent docetaxel in patients with metastatic urothelial carcinoma and impaired renal function.

METHODS

Eleven consecutive patients previously untreated for metastatic disease with renal impairment (median serum creatinine level of 2.6 mg/dL) were treated with intravenous docetaxel 100 mg/m2 for 1 hour every 21 days. Granulocyte colony-stimulating factor was administered at a dose of 5 microg/kg/day subcutaneously from days 5 to 14.

RESULTS

Five of 11 patients achieved a partial response, with time to progression of responding patients ranging from 5 to 22 months or more. The median overall survival rate was 11 months. Renal function improved in 5 of 8 patients with tumor-related renal impairment. Toxicity was primarily hematologic, with 5 patients developing grade 3 or 4 neutropenia; nonhematologic toxicities were manageable.

CONCLUSIONS

Our preliminary data indicate that single-agent docetaxel therapy may represent an effective therapeutic alternative for patients with advanced urothelial carcinoma and renal insufficiency precluding cisplatin-based combination chemotherapy.

Paclitaxel in advanced urothelial carcinoma: its role in patients with renal insufficiency and as salvage therapy

PURPOSE

We evaluated the role of paclitaxel in patients with advanced urothelial carcinoma and renal insufficiency or as second line therapy for metastatic disease.

MATERIALS AND METHODS

Nine patients with advanced urothelial carcinoma received 175 to 250 mg./m2. paclitaxel intravenously as a 24-hour infusion. Six patients had renal insufficiency with a median serum creatinine of 2.25 mg./dl. (range 1.9 to 3.2) and 3 with normal renal function were treated after disease progression following 1 to 2 prior chemotherapy regimens.

RESULTS

Of 9 patients 5 (56%) achieved a partial response, including 4 of 6 with renal insufficiency. Toxicity was primarily hematological with 4 patients experiencing febrile neutropenia. There was no adverse impact on renal function.

CONCLUSIONS

Paclitaxel as a single agent represents an effective therapeutic alternative for patients with advanced transitional cell carcinoma of the urothelium and renal insufficiency precluding cisplatin or gallium nitrate based chemotherapy. Additionally, paclitaxel appears to be effective in patients in whom prior cisplatin based therapy failed.

Results of radiotherapy on ureteric obstruction in muscle-invasive bladder cancer

OBJECTIVE

To evaluate the effect of radiotherapy on ureteric obstruction due to muscle-invasive bladder cancer.

PATIENTS AND METHODS

Retrospective evaluation of the records of 574 patients with muscle-invasive bladder cancer revealed 90 patients (16%) with ureteric obstruction; the obstruction was bilateral in 24%. The effect of radiotherapy was assessed in 55 patients with 68 obstructed kidneys. Six patients with eight obstructed kidneys required percutaneous nephrostomy or ureteric catheters in addition to radiotherapy.

RESULTS

Drainage improved in 20% of kidneys and the diverting catheter was withdrawn permanently in one (17%) of the diverted patients. The median survival was 11 months. Irradiation was followed by significant complications in 37 patients (67%).

CONCLUSION

The results of this study raise doubts about the assumed beneficial effect of irradiation on ureteric obstruction due to muscle-invasive bladder cancer. The short median survival of 11 months confirms that ureteric obstruction is a poor prognostic factor in muscle-invasive bladder cancer.