Urethrectomy at the time of radical cystectomy for non-metastatic urothelial carcinoma of the bladder: a collaborative multicenter study

Oncological outcomes of prophylactic urethrectomy at the time of radical cystectomy for bladder cancer: A nationwide multi-institutional study

OBJECTIVES

To determine the effects of prophylactic urethrectomy (PU) on oncological and perioperative outcomes in patients with bladder cancer (BC) undergoing radical cystectomy (RC).

METHODS

This retrospective study analyzed data on 1976 evaluable patients with BC who underwent RC. Patients were drawn from 36 institutions within the Japanese Urological Oncology Group. Oncological outcomes were compared using restricted mean survival times (RMSTs) based on inverse probability of treatment weighting (IPTW)-adjusted Kaplan-Meier curves for non-urinary tract recurrence-free survival (NUTRFS), cancer-specific survival (CSS), and overall survival (OS). Interaction terms within IPTW-adjusted Cox regression models were examined to assess the heterogeneity of treatment effect based on the risk of urethral recurrence (UR). The association between PU, estimated blood loss (EBL), and the incidence of severe postoperative surgical complications (SPSCs) (Clavien-Dindo grade 3 or higher) was analyzed.

RESULTS

Of 1976 patients, 1448 (73.3%) received PU. IPTW adjustment was used to balance baseline characteristics between the treatment groups. Within the 107-month window of patient monitoring, PU showed no survival benefits (NUTRFS difference: 0.2 months [95% confidence interval: -6.8 to 7.3]; CSS, 1.2 [-4.9 to 7.3]; OS, 0 [-6.5 to 6.5]). No significant interactions were observed with factors associated with UR, and PU was associated with unfavorable perioperative outcomes (EBL, 1179 mL vs. 983 mL; SPSC, 14.6% vs. 7.0%).

CONCLUSIONS

This study showed that (1) PU was not associated with survival in patients with BC undergoing RC, regardless of UR-associated factors, and (2) PU was associated with unfavorable perioperative outcomes.

Safety of urethral preservation using urethral frozen section analysis in radical cystectomy

Background

The objective of this study is to assess whether urethral preservation can be performed safely using frozen section analysis (FSA) of the urethral stump on urethral recurrence after radical cystectomy.

Methods

Between June 2012 and July 2022, we investigated consecutive male patients who underwent urethral FSA during radical cystectomy for urothelial carcinoma. For FSA-abnormal cases, urethrectomy was performed, and for FSA-normal cases, the urethra was preserved. The diagnostic accuracy of FSA was assessed in comparison with the pathological findings of the permanent sections of the same tissue. Postoperatively, computed tomography and urinary cytology were performed as routine surveillance of recurrence.

Results

Of the 77 patients included in this study, three patients with abnormal FSA underwent concurrent urethrectomy. The negative predictive value of urethral FSA was 100%. With a median postoperative follow-up of 38 months (interquartile ranges 21-71), no urethral recurrence was observed.

Conclusions

FSA may be useful in determining the indication for urethrectomy.

Impact of Urethra-Preserving Surgery During Radical Cystectomy: An Optimal Urethral Management in the Robotic Era

OBJECTIVES

The optimal indication and survival benefits of prophylactic urethrectomy (PU) during radical cystectomy remain unclear. Therefore, this study aims to evaluate the impact of urethra-preserving surgery (UPS) on oncological outcome including its recurrence patterns, and to establish an optimal urethral management strategy with a novel UPS technique in the robotic era.

PATIENTS AND METHODS

We retrospectively analyzed 281 male patients with bladder cancer who received radical cystectomy (RC) (115 with and 166 without PU) at our institutions between 2010 and 2023. Subsequently, perioperative and oncological outcomes were assessed between propensity score-matched cohorts.

RESULTS

Urethral recurrence (UR) occurred in 5 patients (5/166, 3.0%), all of whom underwent open-RC. Three among those (1.8%) with concomitant metastasis were died of cancer. There were no statistically significant differences between the PU and UPS groups in urethral-recurrence free survival (urethral-RFS) (P = .14), local-RFS (P = .59) and overall survival (OS) (P = .84) in the entire cohort. However, the UPS group showed significantly worse urethral-RFS (P = .008), local-RFS (P = .005) and OS (P = .03) in patients with high-risk of UR. Analysis of recurrence patterns revealed that UPS in high-risk patients significantly increased local recurrence (25.8% vs. 5.0%, P = .02). Conversely, a novel robotic-UPS technique demonstrated significantly favorable perioperative outcomes, comparable local-RFS (P = .79) and OS (P = .16) without UR (0/134, 0%) when compared to robotic-PU. Robotic-UPS also exhibited significantly better local-RFS (P =.007) and OS (P < .001) than open-UPS.

CONCLUSIONS

UR-related death was rare and PU did not show a survival benefit for the entire cohort. However, inappropriate UPS in patients at high-risk of UR may increase local recurrence which might be responsible for poor survival after UPS rather than disease progression derived from UR. The robotic-UPS has the potential to reduce unnecessary PU, urethral and local recurrence without compromising survival.

Long-Term Cardiovascular Mortality among 80,042 Older Patients with Bladder Cancer

Simple Summary

We conducted a large-scale population-based study with long-term follow-up to obtain a comprehensive assessment of death causes, especially cardiovascular disease death, among 80,042 older bladder cancer patients from a national cancer registry containing 44 years of data. To our knowledge, this was the first study to report the importance of CVD-related death as a competing risk among older patients with bladder cancer. CVD-related death surpassed BC as the leading cause of death 5–10 years after diagnosis among older BC patients, especially for patients with localized-stage and low-grade tumors. Furthermore, older BC patients had a higher risk of CVD-related death than the general population. Although BC management should be the primary focus of older BC patients, our results emphasized the importance of competing risks, the most prominent being CVD. Individual follow-up and management should focus not only on primary cancer but also on CVD-related death to minimize the risk of death in older patients with bladder cancer.

Abstract

Background: To identify the risk of death from cardiovascular disease (CVD) in older patients with bladder cancer (BC). Methods: This population-based study included 80,042 older BC patients (≥65 years) diagnosed between 1975 and 2018, with a mean follow-up of 17.2 years. The proportion of deaths, competing risk models, standardized mortality ratio (SMR), and absolute excess risk (AER) per 10,000 person-years were applied to identify the risk of CVD-related deaths among older BC patients. Results: For older patients with BC, CVD-related death was the chief cause of death, and cumulative CVD-related mortality also exceeded primary BC as the leading cause of death mostly 5–10 years after BC diagnosis, especially in localized-stage and low-grade subgroups. The risk of short- and long-term CVD-related death in older BC patients was higher than in the general older adult population (SMR = 1.30, 95% CI 1.28–1.32; AER = 105.68). The risk of sex-specific CVD-related deaths also increased compared to the general population of older adults, including heart disease, cerebrovascular diseases, hypertension without heart disease, atherosclerosis, aortic aneurysm and dissection, and other diseases of the arteries, arterioles, and capillaries. Conclusions: CVD-related death is an important competing risk among older BC patients and has surpassed primary BC as the chief cause of death, mainly 5–10 years after BC diagnosis. The risk of CVD-related death in older patients with BC was greater than in the general population. The management of older patients with BC should focus not only on the primary cancer but also on CVD-related death.

Neobladder "Function": Tips and Tricks for Surgery and Postoperative Management

Orthotopic neobladder (ONB) reconstruction is a continent urinary diversion procedure increasingly used in patients with muscle-invasive bladder cancer following radical cystectomy (RC). It represents a valid alternative to the ileal duct in suitable patients who do not prefer a stoma and are motivated to undergo adequate training of the neobladder. Careful patient selection, taking into account the absolute and relative contraindications for ONB as well as an adequate recovery protocol after surgery are integral to the success of this procedure and the oncological and functional outcomes. The objective of this review is to summarize the current data on RC with ONB in terms of patient selection, preoperative preparation, surgical techniques and functional (continence and sexual activity) and oncological outcomes, with particular attention to the management of complications and the impact on quality of life (QoL).