The risk of bladder cancer in patients with urinary calculi: a meta-analysis

Practical Guide to VI-RADS: MRI Protocols, Lesion Characterization, and Pitfalls

Urothelial carcinoma is the most common type of bladder cancer (BC), accounting for approximately 90% of all cases. Evaluating the depth of tumor invasion in the bladder wall (tumor staging) is essential for determining the treatment and prognosis in patients with BC. Neoadjuvant therapy followed by radical cystectomy is the most common treatment of localized muscle-invasive BC (MIBC). Therefore, it is vital to differentiate non-MIBC from MIBC. Transurethral resection of bladder tumor (TURBT) is the reference standard to determine the extent of tumor invasion into the bladder wall through tissue sampling. However, this diagnostic and therapeutic method may not adequately sample the muscularis propria, leading to a higher risk of residual disease, early recurrence, and tumor understaging in approximately 50% of patients during the initial TURBT. Multiparametric MRI can overcome some of the limitations of TURBT when evaluating BC, particularly regarding tumor staging. In this context, the Vesical Imaging Reporting and Data System (VI-RADS) classification was developed to establish standards for bladder multiparametric MRI and interpretation. It uses a 5-point scale to assess the likelihood of detrusor muscle invasion. T2-weighted MR images are particularly useful as an initial guide, especially for categories 1-3, while the presence of muscular invasion is determined with diffusion-weighted and dynamic contrast-enhanced sequences. Diffusion-weighted imaging takes precedence as the dominant method when optimal image quality is achieved. The presence of a stalk or a thickened inner layer and no evidence of interruption of the signal intensity of the muscular layer are central for predicting a low likelihood of muscle invasion. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material. See the invited commentary by Hoegger in this issue.

Pan-immune-inflammation value as a prognostic tool for overall survival and disease-free survival in non-metastatic muscle-invasive bladder cancer

PURPOSE

To evaluate the association between preoperative pan-immune inflammation value (PIV) and overall survival (OS) and disease-free survival (DFS) in patients who underwent radical cystectomy for non-metastatic muscle-invasive bladder cancer.

METHODS

A total of 119 patients with non-metastatic muscle-invasive bladder cancer who underwent radical cystectomy at our institution between January 2014 and January 2022 were included in this retrospective study. PIV was calculated using the formula (monocyte count × neutrophil count × platelet count)/lymphocyte count. Ideal cut-off values for PIV were determined using ROC curve analysis. Kaplan-Meier analysis was used to evaluate the impact of PIV on survival outcomes.

RESULTS

The mean age of patients was 65 ± 14 years, and the mean follow-up duration was 36 months. The ideal cutoff value for PIV was determined to be 406.29, and a PIV above this value was associated with poorer OS (p < 0.001) (73 months vs. 21 months) and DFS (p = 0.002) (35 months vs 19 months). Higher neutrophil-to-lymphocyte ratio (NLR) values were also associated with poorer OS (p < 0.001) and DFS (p < 0.001), with similar effectiveness to PIV. PIV was found to be significantly more effective than platelet-to-lymphocyte ratio (PLR) and systemic immune inflammation index (SII) in predicting DFS.

CONCLUSION

Preoperative PIV may serve as an independent prognostic factor for OS in patients who undergo radical cystectomy with non-metastatic muscle-invasive bladder cancer. A high PIV value was associated with poorer survival outcomes. Prospective multicenter studies are needed to further validate the relationship between PIV and histopathological features of bladder cancer.

European Association of Urology Guidelines on Muscle-invasive and Metastatic Bladder Cancer: Summary of the 2023 Guidelines

CONTEXT

We present an overview of the updated 2023 European Association of Urology (EAU) guidelines for muscle-invasive and metastatic bladder cancer (MMIBC).

OBJECTIVE

To provide practical evidence-based recommendations and consensus statements on the clinical management of MMIBC with a focus on diagnosis and treatment.

EVIDENCE ACQUISITION

A broad and comprehensive scoping exercise covering all areas of the MMIBC guidelines has been performed annually since 2017. Searches cover the Medline, EMBASE, and Cochrane Libraries databases for yearly guideline updates. A level of evidence and strength of recommendation are assigned. The evidence cutoff date for the 2023 MIBC guidelines was May 4, 2022.

EVIDENCE SYNTHESIS

Patients should be counselled regarding risk factors for bladder cancer. Pathologists should describe tumour and lymph nodes in detail, including the presence of histological subtypes. The importance of the presence or absence of urothelial carcinoma (UC) in the prostatic urethra is emphasised. Magnetic resonance imaging (MRI) of the bladder is superior to computed tomography (CT) for disease staging, specifically in differentiating T1 from T2 disease, and may lead to a change in treatment approach in patients at high risk of an invasive tumour. Imaging of the upper urinary tract, lymph nodes, and distant metastasis is performed with CT or MRI; the additional value of flurodeoxyglucose positron emission tomography/CT still needs to be determined. Frail and comorbid patients should be evaluated by a multidisciplinary team. Postoperative histology remains the most important prognostic variable, while circulating tumour DNA appears to be an interesting predictive marker. Neoadjuvant systemic therapy remains cisplatin-based. In motivated and selected women and men, sexual organ-preserving cystectomy results in better functional outcomes without compromising oncological outcomes. Robotic and open cystectomy have comparable outcomes and should be combined with (extended) lymph node dissection. The diversion type is an individual choice after taking patient and tumour characteristics into account. Radical cystectomy remains a highly complex procedure with considerable morbidity and risk of mortality, although lower rates are observed for higher hospital volumes (>20 cases/yr). With proper patient selection, trimodal therapy (chemoradiation) has comparable outcomes to radical cystectomy. Adjuvant chemotherapy after surgery improves disease-specific survival and overall survival (OS) in patients with high-risk disease who did not receive neoadjuvant treatment, and is strongly recommended. There is a weak recommendation for adjuvant nivolumab, as OS data are not yet available. Health-related quality of life should be assessed using validated questionnaires at baseline and after treatment. Surveillance is needed to monitor for recurrent cancer and functional outcomes. Recurrences detected on follow-up seem to have better prognosis than symptomatic recurrences.

CONCLUSIONS

This summary of the 2023 EAU guidelines provides updated information on the diagnosis and treatment of MMIBC for incorporation into clinical practice.

PATIENT SUMMARY

The European Association of Urology guidelines panel on muscle-invasive and metastatic bladder cancer has released an updated version of the guideline containing information on diagnosis and treatment of this disease. Recommendations are based on studies published up to May 4, 2022. Surgical removal of the bladder and bladder preservation are discussed, as well as updates on the use of chemotherapy and immunotherapy in localised and metastatic disease.

A machine learning-based nomogram model for predicting the recurrence of cystitis glandularis

Background

Cystitis glandularis is a chronic inflammatory disease of the urinary system characterized by high recurrence rates, the reasons for which are still unknown.

Objectives

This study aims to identify potential factors contributing to recurrence and propose a simple and feasible prognostic model through nomogram construction.

Design

Patients with confirmed recurrence based on outpatient visits or readmissions were included in this study, which was subsequently divided into training and validation cohorts.

Methods

Machine learning techniques were utilized to screen for the most important predictors, and these were then employed to construct the nomogram. The reliability of the nomogram was assessed through receiver operating characteristic curve analysis, decision curve analysis, and calibration curves.

Results

A total of 252 patients met the screening criteria and were enrolled in this study. Over the 12-month follow-up period, the relapse rate was found to be 57.14% (n = 144). The five final predictors identified through machine learning were urinary infections, urinary calculi, eosinophil count, lymphocyte count, and serum magnesium. The area under curve values for all three time points assessing recurrence exceeded 0.75. Furthermore, both calibration curves and decision curve analyses indicated good performance of the nomogram.

Conclusion

We have developed a reliable machine learning-based nomogram for predicting recurrence in cystitis glandularis.

Polymorphic variations and mRNA expression of the genes encoding interleukins as well as enzymes of oxidative and nitrative stresses as a potential risk of nephrolithiasis development

Urolithiasis is one of the most common urological diseases worldwide with an unclear aetiology. However, a growing body of evidence suggests the potential role of molecular disturbances of the inflammation as well as oxidative and nitrative stresses, in the pathogenesis of urolithiasis. Therefore, we aimed to detect the potential association between six selected single-nucleotide polymorphisms (SNPs) and the development of nephrolithiasis. Moreover, we verified the association of urolithiasis development and mRNA expression of IL-6, IL-8, SOD2, and NOS2 in peripheral blood mononuclear cells (PBMCs). Total genomic DNA and mRNA were isolated from the peripheral blood of 112 patients with urolithiasis and 114 healthy subjects. Using Taq-Man® probes, we genotyped the following SNPs: rs1800797 and rs2069845 in IL-6, rs2227307 in IL-8, rs4880 in SOD2, rs2297518 and rs2779249 in NOS2. In turn, the evaluation of mRNA expression was performed using real-time PCR and 2-ΔCt methods. We found that the C/T genotype of the c.47 T>C-SOD2 SNP increased the frequency of urolithiasis occurrence whereas the T/T homozygote of the same polymorphism decreased the risk of urolithiasis development in the Polish population. Moreover, our study confirmed that patients with urolithiasis were characterised by decreased IL-6, IL-8, and SOD2 mRNA expression levels compared to the controls. In conclusion, our results suggest that polymorphic variants and changes in mRNA expression of IL-6, IL8, SOD2, and NOS2 may be involved in the pathophysiology of urolithiasis.

Epidemiology of Bladder Cancer in 2023: A Systematic Review of Risk Factors

CONTEXT

Bladder cancer (BC) is common worldwide and poses a significant public health challenge. External risk factors and the wider exposome (totality of exposure from external and internal factors) contribute significantly to the development of BC. Therefore, establishing a clear understanding of these risk factors is the key to prevention.

OBJECTIVE

To perform an up-to-date systematic review of BC's epidemiology and external risk factors.

EVIDENCE ACQUISITION

Two reviewers (I.J. and S.O.) performed a systematic review using PubMed and Embase in January 2022 and updated it in September 2022. The search was restricted to 4 yr since our previous review in 2018.

EVIDENCE SYNTHESIS

Our search identified 5177 articles and a total of 349 full-text manuscripts. GLOBOCAN data from 2020 revealed an incidence of 573 000 new BC cases and 213 000 deaths worldwide in 2020. The 5-yr prevalence worldwide in 2020 was 1 721 000. Tobacco smoking and occupational exposures (aromatic amines and polycyclic aromatic hydrocarbons) are the most substantial risk factors. In addition, correlative evidence exists for several risk factors, including specific dietary factors, imbalanced microbiome, gene-environment risk factor interactions, diesel exhaust emission exposure, and pelvic radiotherapy.

CONCLUSIONS

We present a contemporary overview of the epidemiology of BC and the current evidence for BC risk factors. Smoking and specific occupational exposures are the most established risk factors. There is emerging evidence for specific dietary factors, imbalanced microbiome, gene-external risk factor interactions, diesel exhaust emission exposure, and pelvic radiotherapy. Further high-quality evidence is required to confirm initial findings and further understand cancer prevention.

PATIENT SUMMARY

Bladder cancer is common, and the most substantial risk factors are smoking and workplace exposure to suspected carcinogens. On-going research to identify avoidable risk factors could reduce the number of people who get bladder cancer.

The bladder microbiome of NMIBC and MIBC patients revealed by 2bRAD-M

Background

Bladder cancer (BCa) is the most common malignancy of the urinary tract which can be divided into non-muscle-invasive bladder cancer (NMIBC) and muscle-invasive bladder cancer (MIBC), and their microbial differences are not fully understood. This study was conducted by performing 2bRAD sequencing for Microbiome (2bRAD-M) on NMIBC and MIBC tissue samples to investigate the microbiota differences between NMIBC and MIBC individuals.

Methods

A total of 22 patients with BCa, including 7 NMIBC and 15 MIBC, were recruited. Tumor tissues were surgically removed as samples and DNA was extracted. Type IIB restriction endonucleases were used to enzymatically cleave the microbial genome for each microbe's tag and map it to species-specific 2bRAD markers to enable qualitative and quantitative studies of microbes between MIBC and NMIBC tissues.

Results

A total of 527 species were detected. The microbial diversity of NMIBC tissues was significantly higher than that of MIBC tissues. Microbial composition of the two tumor tissues was similar, where Ralstonia_sp000620465 was the most dominant species. 4 species (Acinetobacter_guillouiae, Anoxybacillus_A_rupiensis, Brevibacillus_agri and Staphylococcus_lugdunensis) were enriched in NMIBC, while Ralstonia_mannitolilytica, Ralstonia_pickettii, and Ralstonia_sp000620465 were overrepresented in MIBC. 252 discriminatory character taxa were also revealed by linear discriminant analysis effect sizea (LEfSe). Species importance point plots identified Ralstonia_sp000620465, Cutibacterium_acnes and Ralstonia_pickettii as the three most important species between the two groups. Meanwhile, functional annotation analysis showed 3011 different COGs and 344 related signaling pathways between MIBC and NMIBC microbiome.

Conclusion

This first 2bRAD-M microbiome study on MIBC and NMIBC tissues revealed significant differences in the microbial environment between the two groups, which implies a potential association between tumor microbial dysbiosis and BCa, and provides a possible target and basis for subsequent studies on the mechanisms of BCa development and progression.

Juxta-Vesical Urinary Stones: An Extremely Rare Finding Secondary to Bladder Rupture and Squamous Cell Carcinoma in a Patient on Clean Intermittent Self-Catheterization

We present a rare case of juxta-vesical urinary stones in the lesser pelvis, incidentally diagnosed during the investigation of a urinary tract infection (UTI). The patient (male) had a history of neurogenic bladder and performed self-catheterizations. After the initial workup, the patient was admitted with a complicated UTI diagnosis. CT scan of the abdomen and pelvis depicted multiple bladder stones, some calculi lying juxta- and retro-vesically, an abscess cavity, and diffuse thickening of the bladder. The abscess was adherent to the bladder wall, containing calculi, too. We presumed that the patient self-inflicted a bladder rupture when performing clean intermittent self-catheterization (CISC) and stones dislodged in the pelvis due to his poor bladder sensation. Flexible cystoscopy was attempted but was not completed due to stone obstruction and poor bladder compliance. The patient underwent open surgical exploration. Several calculi were removed, the abscess was drained, and bladder wall biopsies were taken. Pathology results revealed invasive squamous bladder carcinoma; the patient was listed for radical cystectomy. We aim to familiarize the clinician with rare complications that should be taken into consideration when treating patients on CISC and present an extremely rare clinical finding of juxta-vesical lithiasis.

Global trends in the epidemiology of bladder cancer: challenges for public health and clinical practice

Bladder cancer is among the ten most common cancers globally, causes considerable morbidity and mortality and is, therefore, a substantial burden for health-care systems. The incidence of bladder cancer is affected by demographic trends, most notably population growth and ageing, as well as exposure to risk factors, especially tobacco smoking. Consequently, the incidence has not been stable throughout the world over time, nor will it be in the near future. Further primary prevention efforts are of the utmost importance to reduce the medical and financial burden of bladder cancer on populations and health-care systems. Simultaneously, less-invasive and lower-cost approaches for the diagnosis of both primary and recurrent bladder cancers are required to address challenges posed by the increasing shortage of health-care professionals and limited financial resources worldwide. In this regard, urinary biomarkers have demonstrated promising diagnostic accuracy and efficiency. Awareness of the risk factors and symptoms of bladder cancer should also be increased in society, particularly among health-care professionals and high-risk groups. Studies investigating the associations between lifestyle factors and bladder cancer outcomes are scarce and should be a research priority. In this Review, we outline global trends in bladder cancer incidence and mortality, and discuss the main risk factors influencing bladder cancer occurrence and outcomes. We then discuss the implications, challenges and opportunities of these epidemiological trends for public health and clinical practice.

Efficacy of Flexible Ureteroscopic Lithotripsy and Percutaneous Nephrolithotomy in the Treatment of Complex Upper Urinary Tract Nephrolithiasis

Objective

A case-control study was conducted to compare the efficacy and prognostic factors of flexible ureteroscopic lithotripsy (FURL) and percutaneous nephrolithotomy (PCNL) when treating complex upper urinary tract renal calculi based on a retrospective cohort study.

Methods

The study period was from October 2019 to December 2021. A retrospective study was carried out on 100 patients with complicated upper urinary tract nephrolithiasis who underwent surgery in the Urology Department of our hospital. They were assigned into two groups: FURL and PCNL groups. The intraoperative blood loss, operation time, hematuria duration, hospital stay, primary stone removal rate, incidence of intraoperative and postoperative complications, VAS score, level of inflammatory factors, and micturition function were compared. According to the postoperative prognosis, the patients were reassigned into two groups: good prognosis group (n = 38) and poor prognosis group (n = 106). The factors related to poor prognosis after FURL and PCNL were screened, and multivariate loglistic regression analysis was adopted to determine the risk factors.

Results

The primary stone clearance rate in the PCNL group was significantly higher than that in the FURL group, and there was no significant difference in the incidence of intraoperative and postoperative complications between the two groups (P > 0.05). The intraoperative blood loss and the duration of hematuria in the PCNL group were significantly shorter than those in the FURL group, and the operation time and postoperative hospital stay in the FURL group were longer than those in the FURL group. The postoperative VAS score in the study group was significantly lower than that in the control group (P < 0.05). The levels of CRP, IL-1, TNF-α, and NF-κB in both groups decreased after operation, and the level of inflammatory factors in the PCNL group was significantly lower than that in the FURL group (P < 0.05). The indexes of IPSS and Q max in the PCNL group were significantly lower than those in the control group 3 months after operation. The index of micturition function in the PCNL group was significantly lower than that in the FURL group. Preoperative use of immunosuppressant, preoperative stone fever, positive preoperative urine culture, preoperative urinary leukocyte count ≥ 544 × L, intraoperative urinary opacity, and pus fur were significantly correlated with poor prognosis of ureteral patients (P < 0.05). Preoperative stone fever, high preoperative urinary leukocyte count, intraoperative urinary turbidity, and suppurative fur were independent risk factors for postoperative SIRS in patients with ureteral calculi.

Conclusion

PCNL is effective when treating complex upper urinary tract renal calculi. Compared with FURL, PCNL can remarkably reduce intraoperative blood loss and hematuria duration, can enhance micturition function, and will not remarkably increase the incidence of intraoperative and postoperative complications, high safety. High white blood cell count in urine before operation, fever due to stone before operation, turbid urine, and purulent fur during operation are independent risk factors for postoperative adverse outcome in patients with complex upper urinary tract renal calculi. Patients should be fully treated before surgery.

Application of CTU-Assisted Doppler Ultrasound Puncture in Nontube Percutaneous Nephrolithotomy, Its Effect on Patients' Complications, and Its Clinical Value

Objective

To research the application of CTU-assisted Doppler ultrasound puncture in uncatheterized PCNL, its influence on patients' complications, and its clinical value in a case-control study.

Methods

One hundred and forty-four patients who went through percutaneous nephrolithotomy (PCNL) from March 2019 to June 2021 in our hospital were arbitrarily assigned into the CTU group (n = 72) and CT plain scan group (n = 72). CTA+CTU was adopted to determine the puncture passage in the CTU group, and CT scan was employed in the CT group. The intraoperative blood loss, postoperative blood loss, operation time, hospital stay, primary stone removal rate, and the incidence of intraoperative and postoperative complications were compared. The visual analogue score (VAS) was employed to assess the degree of postoperative wound pain.

Results

The first-stage stone removal rate in the CTU group was 95.83% (69/72), which was remarkably higher compared to the CT plain scan group, which was 81.94% (59/72), and the difference was statistically significant (P < 0.05). The overall rates of intraoperative complications were 6.94% (5/72) in the CTU group and 18.06% (13/72) in the CT plain scan group, respectively, which exhibited great differences (P < 0.05). In addition, the overall rates of intraoperative complications were 2.78% (2/72) in the CTU and 13.89% (10/72) in the CT plain scan group, respectively, and the difference was statistically significant (P < 0.05). The operation time and postoperative hospital stays in the CTU group were remarkably shorter compared to the CT group, and the difference was statistically significant (P < 0.05). The intraoperative and postoperative blood loss of CTU group displayed obvious less than that of the CT group, and the difference was statistically significant (P < 0.05). The VAS were compared 24 hours after surgery. After operation, the VAS of 24 hours after operation in the CTU group (0.92 ± 0.12) were remarkably lower compared to the CT group (1.22 ± 0.15), and the difference was statistically significant (P < 0.05). Discussion. PCNL is constantly being optimized by CTU-assisted Doppler ultrasound puncture to improve stone clearance rates, reduce postoperative bleeding, be less painful, provide rapid recovery, and provide safe and feasible results. It is therefore worthwhile to standardize and then widely promote it in clinical practice.

A submucosal bladder stone in a 65-year-old woman

We describe a case of a 65-year-old woman with a submucosal bladder stone with no apparent underlying cause. She presented with lower abdominal pain, dysuria, and a history of recurrent cystitis. Ultrasound and computed tomography of the lower abdomen revealed the presence of lithiasis nearby to the left ostium. During ureterorenoscopy, stone was found neither in the bladder nor in the left ureter. Instead, we observed a macroscopic bulge close to the left ureter. After opening of the mucosa, a stone became visible and could be removed. Mostly, imaging of the calculus was done some time before surgery. During this time interval, it is a possibility that the stone has already passed the urinary tract. Our case illustrates that it is important for each patient to search for the calculus extensively to prevent needless symptoms and investigations.

The Molecular Aspect of Nephrolithiasis Development

Urolithiasis is the third most common urological disease after urinary tract infections and prostate diseases, and it is characterised by an occurrence rate of about 15%, which continues to rise. The increase in the incidence of kidney stones observed in recent decades, is most likely caused by modifications in dietary habits (high content of protein, sodium and sugar diet) and lifestyle (reduced physical activity) in all industrialised countries. Moreover, men are more likely than women to be diagnosed with kidney stones. A growing body of evidence suggests that inflammation, oxidant-antioxidant imbalance, angiogenesis, purine metabolism and urea cycle disorders may play a crucial role in nephrolithiasis development. Patients with urolithiasis were characterised by an increased level of reactive oxygen species (ROS), the products of lipid peroxidation, proinflammatory cytokines as well as proangiogenic factors, compared to controls. Furthermore, it has been shown that deficiency and disorders of enzymes involved in purine metabolism and the urea cycle might be causes of deposit formation. ROS generation suggests that the course of kidney stones might be additionally potentiated by inflammation, purine metabolism and the urea cycle. On the other hand, ROS overproduction may induce activation of angiogenesis, and thus, allows deposit aggregation.

Dairy Product Consumption and Bladder Cancer Risk in the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cohort

Evidence has suggested that dairy product consumption lowers the risk of several cancers, but these benefits may not occur with bladder cancer. In a cohort of 101,721 subjects in the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, we analyzed the effects of dairy product intake on bladder cancer risk using Cox proportional hazards regression. After a median of 12.5 years of follow-up, 776 new cases of bladder cancer were identified. We found no statistically significant association between total milk intake and bladder cancer risk. The multivariate-adjusted hazard ratio (HR) of bladder cancer for participants in the highest category of total milk intake compared with those in the lowest category was 1.13 (95% CI: 0.92–1.40; p for trend = 0.436). Among individual dairy foods, no statistically significant association was observed for a broad range of dairy products, including whole milk, 2% milk, 1% milk, skim milk, yogurt, regular butter, low fat butter, regular cheese, low fat cheese, and no fat cheese. These associations were not modified by smoking status (p for interaction > 0.05). In conclusion, findings from this large prospective analysis do not support an inverse association between dairy product consumption and bladder cancer risk.

European Association of Urology Guidelines on Muscle-invasive and Metastatic Bladder Cancer: Summary of the 2020 Guidelines

CONTEXT

This overview presents the updated European Association of Urology (EAU) guidelines for muscle-invasive and metastatic bladder cancer (MMIBC).

OBJECTIVE

To provide practical evidence-based recommendations and consensus statements on the clinical management of MMIBC with a focus on diagnosis and treatment.

EVIDENCE ACQUISITION

A broad and comprehensive scoping exercise covering all areas of the MMIBC guideline has been performed annually since its 2017 publication (based on the 2016 guideline). Databases covered by the search included Medline, EMBASE, and the Cochrane Libraries, resulting in yearly guideline updates. A level of evidence and a grade of recommendation were assigned. Additionally, the results of a collaborative multistakeholder consensus project on advanced bladder cancer (BC) have been incorporated in the 2020 guidelines, addressing those areas where it is unlikely that prospective comparative studies will be conducted.

EVIDENCE SYNTHESIS

Variant histologies are increasingly reported in invasive BC and are relevant for treatment and prognosis. Staging is preferably done with (enhanced) computerised tomography scanning. Treatment decisions are still largely based on clinical factors. Radical cystectomy (RC) with lymph node dissection remains the recommended treatment in highest-risk non-muscle-invasive and muscle-invasive nonmetastatic BC, preceded by cisplatin-based neoadjuvant chemotherapy (NAC) for invasive tumours in "fit" patients. Selected men and women benefit from sexuality sparing RC, although this is not recommended as standard therapy. Open and robotic RC show comparable outcomes, provided the procedure is performed in experienced centres. For open RC 10, the minimum selected case load is 10 procedures per year. If bladder preservation is considered, chemoradiation is an alternative in well-selected patients without carcinoma in situ and after maximal resection. Adjuvant chemotherapy should be considered if no NAC was given. Perioperative immunotherapy can be offered in clinical trial setting. For fit metastatic patients, cisplatin-based chemotherapy remains the first choice. In cisplatin-ineligible patients, immunotherapy in Programmed Death Ligand 1 (PD-L1)-positive patients or carboplatin in PD-L1-negative patients is recommended. For second-line treatment in metastatic disease, pembrolizumab is recommended. Postchemotherapy surgery may prolong survival in responders. Quality of life should be monitored in all phases of treatment and follow-up. The extended version of the guidelines is available at the EAU website: https://uroweb.org/guideline/bladder-cancer-muscle-invasive-and-metastatic/.

CONCLUSIONS

This summary of the 2020 EAU MMIBC guideline provides updated information on the diagnosis and treatment of MMIBC for incorporation into clinical practice.

PATIENT SUMMARY

The European Association of Urology Muscle-invasive and Metastatic Bladder Cancer (MMIBC) Panel has released an updated version of their guideline, which contains information on histology, staging, prognostic factors, and treatment of MMIBC. The recommendations are based on the current literature (until the end of 2019), with emphasis on high-level data from randomised clinical trials and meta-analyses and on the findings of an international consensus meeting. Surgical removal of the bladder and bladder preservation are discussed, as well as the use of chemotherapy and immunotherapy in localised and metastatic disease.