Follow-up after radical cystectomy based on patterns of tumour recurrence and its risk factors

Preoperative risk stratification models after radical cystectomy for bladder cancer: A multi-center study

OBJECTIVE

We investigated preoperative patient factors associated with prognosis in 263 bladder cancer (BC) patients undergoing radical cystectomy (RC). We also developed new risk stratification models for prognosis.

METHODS

This retrospective study included patients treated at Tottori University Hospital and affiliated hospitals between January 2010 and December 2019. The relationship between preoperative patient factors and overall recurrence-free and cancer-specific survival (CSS) was analyzed. The modified Glasgow prognosis score (mGPS) was calculated using serum albumin and C-reactive protein (CRP) levels. Statistical analyses included the log-rank test and Cox proportional hazards regression.

RESULTS

Eastern Cooperative Oncology Group performance status (ECOG-PS), mGPS, and clinical tumor stage independently predicted CSS in multivariate analysis. A new risk stratification model included ECOG-PS ≥2, clinical tumor stage ≥3, serum albumin <3.5 g/dL, and serum CRP >0.5 mg/dL. Risk groups were defined as 0 factors (low risk), 1-2 factors (intermediate risk), and 3-4 factors (high risk). High-risk patients showed significantly poorer 3-year cancer-free survival: 86.9% (low risk), 76.7% (intermediate risk), and 50.0% (high risk).

CONCLUSIONS

ECOG-PS, clinical tumor stage, and mGPS are predictive of poor cancer-free survival post-RC for BC. Our model offers the potential for prognostic prediction in these patients.

[Follow-up after urinary diversion]

Radical cystectomy is currently the standard of care for muscle-invasive bladder cancer. Different parts of the small and large intestines can be utilized for continent and incontinent urinary diversion. The postoperative follow-up after urinary diversion should consider functional, metabolic and oncological aspects. The functional follow-up of (continent) urinary diversion includes stenosis, emptying disorders or incontinence. The oncological follow-up should focus on the detection of local, urethral and upper tract recurrences as well as distant metastases. As 90% of the tumor recurrences occur during the first 3 years, a close follow-up should be carried out during this period. Metabolic disturbances, such as vitamin B12 and bile acid deficits, acidosis and disorders of calcium metabolism can also occur during long-term follow-up. The metabolic follow-up should consider the metabolic consequences of the parts of the intestines utilized for the urinary diversion.

Variation in Follow-Up after Radical Cystectomy for Bladder Cancer-An Inventory Roundtable and Literature Review

Background: Follow-up after radical cystectomy (RC) for bladder cancer can be divided into oncological and functional surveillance. It remains unclear how follow-up after RC should ideally be scheduled. The aim of this report was to gain insight into the organization of follow-up after RC in Europe, for which we conducted a roundtable inventory within the EAU Young Academic Urologists Urothelial Cancer working group. Methods: An inventory semi-structured survey was performed among urologists of the EAU Young Academic Urologists Urothelial Cancer working group to describe the organization of follow-up. The surveys were analyzed using a deductive approach. Similarities and differences in follow-up after RC for bladder cancer were described. Results: The survey included 11 urologists from six different European countries. An institutional follow-up scheme was used by six (55%); three (27%) used a national or international guideline, and two (18%) indicated that there was no defined follow-up scheme. Major divergent aspects included the time points of follow-up, the frequency, and the end of follow-up. Six centers (55%) adopted a risk-adapted follow-up approach tailored to (varying) patient and tumor characteristics. Laboratory tests and CT scans were used in all cases; however, the intensity and frequency varied. Functional follow-up overlapped with oncological follow-up in terms of frequency and duration. Patient-reported outcome measures were only used by two (18%) urologists. Conclusions: Substantial variability exists across European centers regarding the follow-up after RC for bladder cancer. This highlights the need for an international analysis focusing on its organization and content as well as on opportunities to improve patients' needs during follow-up after RC.

Control of bleeding from a recurrent tumor at a uretero-ileal anastomosis by electrocoagulation via an ileal conduit

Introduction

Bladder cancer is characterized by spatial and temporal recurrence in the urinary tract. We describe a case of recurrence at a uretero-ileal anastomosis after radical cystectomy and nephroureterectomy. It was difficult to control bleeding from the tumor, but hemostasis was achieved.

Case presentation

A 73-year-old man with a history of radical cystectomy and reconstruction of the ileal conduit and right nephroureterectomy was diagnosed with recurrence at the uretero-ileal anastomosis site. Bleeding from the tumor could not be controlled by flexible gastrointestinal endoscopy. The patient underwent coagulation via an ileal conduit approach using a rigid scope and bipolar electrocautery, which is usually a modality for transurethral resection.

Conclusion

This is the first report in which a modality normally used for transurethral resection was used to control bleeding in a patient with an ileal conduit. This application is useful in cases open surgery or additional irradiation might be difficult.

A Protocol for Organoids from the Urine of Bladder Cancer Patients

This study investigates the feasibility of establishing urine-derived tumor organoids from bladder cancer (BC) patients as an alternative to tissue-derived organoids. BC is one of the most common cancers worldwide and current diagnostic methods involve invasive procedures. Here, we investigated the potential of using urine samples, which contain exfoliated tumor cells, to generate urine-derived BC organoids (uBCOs). Urine samples from 29 BC patients were collected and cells were isolated and cultured in a three-dimensional matrix. The establishment and primary expansion of uBCOs were successful in 83% of the specimens investigated. The culturing efficiency of uBCOs was comparable to cancer tissue-derived organoids. Immunohistochemistry and immunofluorescence to characterize the uBCOs exhibited similar expressions of BC markers compared to the parental tumor. These findings suggest that urine-derived BC organoids hold promise as a non-invasive tool for studying BC and evaluating therapeutic responses. This approach could potentially minimize the need for invasive procedures and provide a platform for personalized drug screening. Further research in this area may lead to improved diagnostic and treatment strategies for BC patients.

The influence of serum sodium concentration on prognosis in patients with urothelial carcinoma treated by radical cystectomy

Serum sodium concentration has been found to be associated with poor survival in many solid tumors. This study investigated the effect of basal serum sodium concentration on prognostic in patients with muscle-invasive bladder cancer (MIBC) undergoing radical cystectomy (RC). MIBC patients with histologically proven urothelial carcinoma treated by RC were retrospectively reviewed. According to the optimal cutoff value, we divided the patients into 2 groups: high-serum sodium concentration group (≥140 mmol/L, n = 39) and low-serum sodium concentration group (<140 mmol/L, n = 32). Overall survival (OS) was estimated with the Kaplan-Meier method and the significance was examined by the log-rank test. Multivariable Cox regression for OS was performed for lymphatic metastasis, hypertension, diabetes mellitus, and tumor size. A total of 71 MIBC patients (60 males and 11 females) were included who underwent cystectomy between 2014 and 2018. The patients' ages at the time of operation ranged from 44 to 86 years (mean, 66.66 years). Patients' serum sodium concentration <140 mmol/L had shorter median OS (1224 days (HR: 2.454 [95% CI, 1.083-5.561; P = .031]). In multivariate analysis, lower serum sodium concentration was significantly associated with worse OS after adjusted (adjusted HR: 2.422 [95% CI, 1.055-5.561; P = .037]). Serum sodium concentration <140 mmol/L was independently associated with a poorer prognosis in patients with MIBC used who underwent RC.

Routine urethroscopic surveillance is of limited value after radical cystectomy: a single centre retrospective cohort analysis

PURPOSE

The incidence of urethral recurrence (UR) following radical cystectomy (RC) for transitional cell carcinoma (TCC) of the bladder varies between 1.5 and 6%. There is debate over the timing of urethrectomy for patients undergoing RC. We evaluated the requirement for a formal surveillance programme for UR in patients after RC.

METHODS

We retrospectively reviewed the outcomes of patients who underwent RC between 2006 and 2019. Females, non-TCC cases and patients with neo-bladder diversions were excluded. Histological prostatic urethral involvement at the time of RC was deemed high risk for UR. Carcinoma in-situ, multifocal tumours and bladder neck involvement were deemed intermediate risk and the absence of the above features was considered low risk.

RESULTS

417 patients underwent RC, 300 cases remained after exclusion criteria were applied. 42 patients were high-risk for UR, 102 patients were intermediate risk and 156 were low risk. Of the 300, 24 urethrectomy cases were recorded. Six cases of UR occurred. Of these, 5 presented with symptoms and only 1 case was detected by surveillance. Only 1 low-risk patient developed UR, 7 years post RC. Using our risk stratification, UR rates for high, intermediate and low-risk cohorts were 25%, 10.5% and 0.8%, respectively.

CONCLUSIONS

In our cohort, routine surveillance for all patients with annual urethroscopy was of limited value in detecting UR post RC. Staged Urethrectomy for high and intermediate-risk patients, and patient counselling in self-identification of recurrence symptoms for low-risk patients will improve the early detection of UR.

Pre-clinical and clinical studies on the role of RBM3 in muscle-invasive bladder cancer: longitudinal expression, transcriptome-level effects and modulation of chemosensitivity

Background

The response to neoadjuvant cisplatin-based chemotherapy (NAC) in muscle-invasive bladder cancer (MIBC) is impaired in up to 50% of patients due to chemoresistance, with no predictive biomarkers in clinical use. The proto-oncogene RNA-binding motif protein 3 (RBM3) has emerged as a putative modulator of chemotherapy response in several solid tumours but has a hitherto unrecognized role in MIBC.

Methods

RBM3 protein expression level in tumour cells was assessed via immunohistochemistry in paired transurethral resection of the bladder (TURB) specimens, cystectomy specimens and lymph node metastases from a consecutive cohort of 145 patients, 65 of whom were treated with NAC. Kaplan-Meier and Cox regression analyses were applied to estimate the impact of RBM3 expression on time to recurrence (TTR), cancer-specific survival (CSS), and overall survival (OS) in strata according to NAC treatment. The effect of siRNA-mediated silencing of RBM3 on chemosensitivity was examined in RT4 and T24 human bladder carcinoma cells in vitro. Cellular functions of RBM3 were assessed using RNA-sequencing and gene ontology analysis, followed by investigation of cell cycle distribution using flow cytometry.

Results

RBM3 protein expression was significantly higher in TURB compared to cystectomy specimens but showed consistency between primary tumours and lymph node metastases. Patients with high-tumour specific RBM3 expression treated with NAC had a significantly reduced risk of recurrence and a prolonged CSS and OS compared to NAC-untreated patients. In high-grade T24 carcinoma cells, which expressed higher RBM3 mRNA levels compared to RT4 cells, RBM3 silencing conferred a decreased sensitivity to cisplatin and gemcitabine. Transcriptomic analysis revealed potential involvement of RBM3 in facilitating cell cycle progression, in particular G₁/S-phase transition, and initiation of DNA replication. Furthermore, siRBM3-transfected T24 cells displayed an accumulation of cells residing in the G₁-phase as well as altered levels of recognised regulators of G₁-phase progression, including Cyclin D1/CDK4 and CDK2.

Conclusions

The presented data highlight the potential value of RBM3 as a predictive biomarker of chemotherapy response in MIBC, which could, if prospectively validated, improve treatment stratification of patients with this aggressive disease.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-09168-7.

Long noncoding RNAs to predict postoperative recurrence in bladder cancer and to develop a new molecular classification system

BACKGROUND

Reliable molecular markers are much needed for early prediction of recurrence in muscle-invasive bladder cancer (MIBC) patients. We aimed to build a long-noncoding RNA (lncRNA) signature to improve recurrence prediction and lncRNA-based molecular classification of MIBC.

METHODS

LncRNAs of 320 MIBC patients from the Cancer Genome Atlas (TCGA) database were analyzed, and a nomogram was established. A molecular classification system was created, and immunotherapy and chemotherapy response predictions, immune score analysis, immune infiltration analysis, and mutational data analysis were conducted. Survival analysis validation was also performed.

RESULTS

An eight-lncRNA signature classifed the patients into high- and low-risk subgroups, and these groups had significantly different (disease-free survival) DFS. The ability of the eight-lncRNA signature to make an accurate prognosis was tested using a validation dataset from our samples. The nomogram achieved a C-index of 0.719 (95% CI, 0.674-0.764). Time-dependent receiver operating characteristic curve (ROC) analysis indicated the superior prognostic accuracy of nomograms for DFS prediction (0.76, 95% CI, 0.697-0.807). Further, the four clusters (median DFS = 11.8, 15.3, 17.9, and 18.9 months, respectively) showed a high frequency of TTN (cluster 1), fibroblast growth factor receptor-3 (cluster 2), TP53 (cluster 3), and TP53 mutations (cluster 4), respectively. They were enriched with M2 macrophages (cluster 1), CD8⁺ T cells (cluster 2), M0 macrophages (cluster 3), and M0 macrophages (cluster 4), respectively. Clusters 2 and 3 demonstrated potential sensitivity to immunotherapy and insensitivity to chemotherapy, whereas cluster 4 showed potential insensitivity to immunotherapy and sensitivity to chemotherapy.

CONCLUSIONS

The eight-lncRNA signature risk model may be a reliable prognostic signature for MIBC, which provides new insights into prediction of recurrence of MIBC. The model may help clinical decision and eventually benefit patients.

Extreme body mass index is associated with poor survival outcomes after radical cystectomy: a retrospective cohort study in a Chinese population

Background

Body mass index (BMI) has been evidenced to be a significant prognostic factor in multiple cancers. This retrospective study aimed to investigate the association between BMI and survival outcomes after radical cystectomy (RC) in patients with bladder cancer (BCa).

Methods

Clinical and pathological parameters of patients who were diagnosed with BCa and received RC between 2010 and 2018 were collected. The associations between BMI at surgery and clinicopathological features were examined. The prognostic value of BCa for overall survival (OS) and cancer-specific survival (CSS) was examined using the Kaplan-Meier method and Cox regression models.

Results

Among the 217 patients enrolled in this study, 13 (6.0%), 121 (55.8%), 60 (27.6%), and 23 (10.6%) had a BMI value of <18.5 kg/m² (underweight), 18.5–23.9 kg/m² (normal), 24–27.9 kg/m² (overweight), and ≥28 kg/m² (obese), respectively. Underweight and obese patients tended to have poorer survival after RC than normal and overweight patients (P<0.05). Multivariable Cox regression revealed that extreme BMI was an independent predictor of both OS (BMI <18.5 vs. 18.5–27.9 kg/m², OR =2.675, 95% CI: 1.131–6.327, P=0.025; BMI ≥28 vs. 18.5–27.9 kg/m², OR =3.693, 95% CI: 1.589–8.583, P=0.002) and CSS (BMI <18.5 vs. 18.5–27.9 kg/m², OR =3.012, 95% CI: 1.180–7.687, P=0.021; BMI ≥28 vs. 18.5–27.9 kg/m², OR =3.801, 95% CI: 1.526–9.469, P=0.004), along with tumor stage and urinary diversion type.

Conclusions

Being underweight or obese is associated with a poor prognosis in patients with BCa undergoing RC. For patients who are preparing to undergo RC for BCa, controlling the BMI index through diet or exercise before surgery may contribute to the surgical curative effect and an improved prognosis.

Significance of prophylactic urethrectomy at the time of radical cystectomy for bladder cancer

BACKGROUND

Prophylactic urethrectomy at the time of radical cystectomy is frequently recommended for patients with bladder cancer at a high risk of urethral recurrence without definitive evidence. The present study attempted to clarify the survival benefits of performing prophylactic urethrectomy.

METHODS

We identified 214 male patients who were treated by radical cystectomy with an incontinent urinary diversion in our seven institutions between 2004 and 2017. We used propensity score matching and ultimately identified 114 patients, 57 of whom underwent prophylactic urethrectomy (prophylactic urethrectomy group) and 57 who did not (non-prophylactic urethrectomy group).

RESULTS

No significant differences were observed in the 5-year overall survival rate between the prophylactic urethrectomy and non-prophylactic urethrectomy groups in the overall. However, the local recurrence rate was significantly lower in the prophylactic urethrectomy group than in the non-prophylactic urethrectomy group (P = 0.015). In the subgroup of 58 patients with multiple tumours and/or concomitant carcinoma in situ at the time of transurethral resection of bladder tumour, the 5-year overall survival rate was significantly higher in the prophylactic urethrectomy group than in the non-prophylactic urethrectomy group (P = 0.021). A multivariate analysis revealed that performing prophylactic urethrectomy was the only independent predictor of the overall survival rate (P = 0.016). In those patients who were treated without neoadjuvant chemotherapy (n = 38), the 5-year overall survival rate was significantly higher in the prophylactic urethrectomy group than in the non-prophylactic urethrectomy group (P = 0.007).

CONCLUSIONS

Prophylactic urethrectomy at the time of radical cystectomy may have a survival benefit in patients with multiple tumours and/or concomitant carcinoma in situ, particularly those who do not receive neoadjuvant chemotherapy.

Overexpression of GAS6 Promotes Cell Proliferation and Invasion in Bladder Cancer by Activation of the PI3K/AKT Pathway

Background

Growth arrest-specific 6 (GAS6) is a secreted vitamin K-dependent protein abnormally expressed in various human tumor tissues and can activate the receptor Tyro3, Axl, and Mer to promote cancer cell proliferation and invasion. Until now, the role of GAS6 has been poorly understood in bladder cancer (BCa).

Materials and Methods

Using bioinformatics analysis, we screened genes significantly associated with overall survival in BCa. The association between GAS6 and survival was evaluated by tissue microarray and IHC staining. We investigated the effect of GAS6 on the development of BCa through in vitro and in vivo experiments.

Results

Here, we report that GAS6 is highly expressed in bladder cancer and is significantly associated with tumor grade, T stage, and worse prognosis. We found that GAS6 depletion inhibited proliferation, migration, and invasion of BCa cells. In addition, bioinformatics analysis revealed that GAS6 may be involved in the regulation of PI3K-AKT signaling pathway by binding to receptor TAM and has a significant positive correlation with PI3K family gene expression. Furthermore, Western blot experiments have shown that GAS6 might modulate the PI3K-AKT signaling to regulate proliferation and invasion of BCa cells. Treatment of BCa cells with SC79, an AKT activator, partially restored the effect of GAS6 silencing on cell proliferation and invasion.

Conclusion

The present study suggests that GAS6 may play a pivotal role in the development of BCa and may be a potential target for its treatment.

EAU-ESMO Consensus Statements on the Management of Advanced and Variant Bladder Cancer-An International Collaborative Multistakeholder Effort†: Under the Auspices of the EAU-ESMO Guidelines Committees

BACKGROUND

Although guidelines exist for advanced and variant bladder cancer management, evidence is limited/conflicting in some areas and the optimal approach remains controversial.

OBJECTIVE

To bring together a large multidisciplinary group of experts to develop consensus statements on controversial topics in bladder cancer management.

DESIGN

A steering committee compiled proposed statements regarding advanced and variant bladder cancer management which were assessed by 113 experts in a Delphi survey. Statements not reaching consensus were reviewed; those prioritised were revised by a panel of 45 experts prior to voting during a consensus conference.

SETTING

Online Delphi survey and consensus conference.

PARTICIPANTS

The European Association of Urology (EAU), the European Society for Medical Oncology (ESMO), experts in bladder cancer management.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Statements were ranked by experts according to their level of agreement: 1-3 (disagree), 4-6 (equivocal), and 7-9 (agree). A priori (level 1) consensus was defined as ≥70% agreement and ≤15% disagreement, or vice versa. In the Delphi survey, a second analysis was restricted to stakeholder group(s) considered to have adequate expertise relating to each statement (to achieve level 2 consensus).

RESULTS AND LIMITATIONS

Overall, 116 statements were included in the Delphi survey. Of these statements, 33 (28%) achieved level 1 consensus and 49 (42%) achieved level 1 or 2 consensus. At the consensus conference, 22 of 27 (81%) statements achieved consensus. These consensus statements provide further guidance across a broad range of topics, including the management of variant histologies, the role/limitations of prognostic biomarkers in clinical decision making, bladder preservation strategies, modern radiotherapy techniques, the management of oligometastatic disease, and the evolving role of checkpoint inhibitor therapy in metastatic disease.

CONCLUSIONS

These consensus statements provide further guidance on controversial topics in advanced and variant bladder cancer management until a time when further evidence is available to guide our approach.

PATIENT SUMMARY

This report summarises findings from an international, multistakeholder project organised by the EAU and ESMO. In this project, a steering committee identified areas of bladder cancer management where there is currently no good-quality evidence to guide treatment decisions. From this, they developed a series of proposed statements, 71 of which achieved consensus by a large group of experts in the field of bladder cancer. It is anticipated that these statements will provide further guidance to health care professionals and could help improve patient outcomes until a time when good-quality evidence is available.

EAU-ESMO consensus statements on the management of advanced and variant bladder cancer-an international collaborative multi-stakeholder effort: under the auspices of the EAU and ESMO Guidelines Committees†

BACKGROUND

Although guidelines exist for advanced and variant bladder cancer management, evidence is limited/conflicting in some areas and the optimal approach remains controversial.

OBJECTIVE

To bring together a large multidisciplinary group of experts to develop consensus statements on controversial topics in bladder cancer management.

DESIGN

A steering committee compiled proposed statements regarding advanced and variant bladder cancer management which were assessed by 113 experts in a Delphi survey. Statements not reaching consensus were reviewed; those prioritised were revised by a panel of 45 experts before voting during a consensus conference.

SETTING

Online Delphi survey and consensus conference.

PARTICIPANTS

The European Association of Urology (EAU), the European Society for Medical Oncology (ESMO), experts in bladder cancer management.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Statements were ranked by experts according to their level of agreement: 1-3 (disagree), 4-6 (equivocal), 7-9 (agree). A priori (level 1) consensus was defined as ≥70% agreement and ≤15% disagreement, or vice versa. In the Delphi survey, a second analysis was restricted to stakeholder group(s) considered to have adequate expertise relating to each statement (to achieve level 2 consensus).

RESULTS AND LIMITATIONS

Overall, 116 statements were included in the Delphi survey. Of these, 33 (28%) statements achieved level 1 consensus and 49 (42%) statements achieved level 1 or 2 consensus. At the consensus conference, 22 of 27 (81%) statements achieved consensus. These consensus statements provide further guidance across a broad range of topics, including the management of variant histologies, the role/limitations of prognostic biomarkers in clinical decision making, bladder preservation strategies, modern radiotherapy techniques, the management of oligometastatic disease and the evolving role of checkpoint inhibitor therapy in metastatic disease.

CONCLUSIONS

These consensus statements provide further guidance on controversial topics in advanced and variant bladder cancer management until a time where further evidence is available to guide our approach.

[Follow-up surveillance of muscle-invasive urinary bladder cancer after curative treatment]

Follow-up care of patients with muscle-invasive bladder cancer is subdivided into oncological and functional surveillance. More than 80% of local relapses and distant metastases occur within the first 2 years. Recurrences in the remnant urothelium also occur several years after radical cystectomy. Urinary cytology and a computed tomography (CT) scan of the abdomen and thorax including a urography phase are the standard diagnostics for tumor follow-up. There is no clear evidence for a survival benefit for the detection of asymptomatic vs. symptomatic recurrences. After partial cystectomy or trimodal treatment, there is no established follow-up schedule; however, the relatively high incidence of intravesical recurrences should be considered as there are curative treatment approaches including salvage cystectomy. Functional surveillance, which should be carried out lifelong, encompasses prevention and diagnostics of metabolic complications, urethral/ureteral strictures, problems with the urinary stoma, urinary incontinence, sexual dysfunction and urinary tract infections.

Accurate Quantification of Residual Cancer Cells in Pelvic Washing Reveals Association with Cancer Recurrence Following Robot-Assisted Radical Cystectomy

PURPOSE

Bladder cancer recurrence following cystectomy remains a significant cause of bladder cancer specific mortality. Residual cancer cells contribute to cancer recurrence due to tumor spillage or undetectable preexisting micrometastatic tumor clones. We detected and quantified residual cancer cells in pelvic washing using ultradeep targeted sequencing. We compared the levels of residual cancer cells with clinical variables and cancer recurrence.

MATERIALS AND METHODS

The primary tumor specimen was available in 17 patients who underwent robot-assisted radical cystectomy. All tumors had negative surgical margins. Pelvic washes and blood were collected intraoperatively before and after robot-assisted radical cystectomy, after pelvic lymph node dissection and in the suction fluid collected during the procedure. Two-step sequencing, including whole exome sequencing followed by ultradeep targeted sequencing (× greater than 50,000), was done to quantify residual cancer cells in each sample. Eight patients were excluded from study due to sample quality issues. The final analysis cohort comprised 9 patients. The residual cancer cell level was quantified for each sample as the relative cancer cell fraction and compared between time points. The peak relative cancer cell fraction of each patient was correlated with clinical and pathological variables.

RESULTS

Residual cancer cells were detected in approximately half of the pelvic washing specimens during or after but not before robot-assisted radical cystectomy. Higher residual cancer cell levels were associated with aggressive variant histology and cancer recurrence. Verifying the feasibility of using residual cancer cells as a novel biomarker for recurrence requires larger cohorts.

CONCLUSIONS

Detection of residual cancer cells in intraoperative peritoneal washes of patients with bladder cancer who undergo radical cystectomy may represent a robust biomarker of tumor aggressiveness and metastatic potential.

Influence of laparoscopic access in cancer-specific mortality of patients with pTa-2pN0R0 bladder cancer treated with radical cistectomy

INTRODUCTION AND OBJECTIVE

Minimally invasive surgery represents an attractive surgical approach in radical cystectomy. However, its effect on the oncological results is still controversial due to the lack of definite analyses. The objective of this study is to evaluate the effect of the laparoscopic approach on cancer-specific mortality.

MATERIAL AND METHOD

A retrospective cohort study of two groups of patients in a pT0-2pN0R0 stage, undergoing open radical cystectomy (ORC) (n=191) and laparoscopic radical cystectomy (LRC) (n=74). Using Cox regression, an analysis has been carried out to identify the predictor variables in the first place, and consequently, the independent predictor variables related to survival.

RESULTS

90.9% were males with a median age of 65years and a median follow-up period of 65.5 (IQR27.75-122) months. Patients with laparoscopic access presented a significantly higher ASA index (P=.0001), a longer time between TUR and cystectomy (P=.04), a lower rate of intraoperative transfusion (P=.0001), a lower pT stage (P=.002) and a lower incidence of infection associated with surgical wounds (P=.04). When analyzing the different risk factors associated with cancer-specific mortality, we only found the ORC approach (versus LRC) as an independent predictor of cancer-specific mortality (P=.007). Open approach to cystectomy multiplied the risk of mortality by 3.27.

CONCLUSIONS

In our series, the laparoscopic approach does not represent a risk factor compared to the open approach in pT0-2N0R0 patients.

Oncologic outcomes after robot-assisted versus open radical cystectomy: a systematic review and meta-analysis

PURPOSE

The efficacy of RARC in oncologic outcomes compared ORC is controversial. We assess potential differences in oncologic outcomes between robot-assisted radical cystectomy (RARC) and open radical cystectomy (ORC).

METHODS

We performed the literature search systematically according to the Preferred Reporting Items for Systematic Review and Meta-analysis statement. A pooled meta-analysis was performed to assess the difference in oncologic outcomes between RARC and ORC, separately in randomized controlled trials (RCTs) and non-randomized studies (NRCTs).

RESULTS

Five RCTs and 28 NRCTs were included in this systematic review and meta-analysis. There was no difference in the rate of overall positive surgical margin (PSM) in RCTs, while NRCTs showed a lower rate for RARC. There was no difference in the soft tissue PSM rate between RARC and ORC in both RCTs and NRCTs. There was no difference in the lymph node yield by standard and extended lymph node dissection between RARC and ORC in both RCTs and NRCTs. There was no significant difference in survival outcomes between RARC and ORC in both RCTs and NRCTs.

CONCLUSIONS

Based on the current evidence, there is no difference in the rate of PSMs, lymph node yield, recurrence rate and location as well as short-term survival outcomes between RARC and ORC in RCTs. In NRCTs, only PSM rates were better for RARC compared to ORC, but this was likely due to selection and reporting bias which are inherent to retrospective study designs.

Influence of the laparoscopic approach on cancer-specific mortality of patients with stage pt3-4 bladder cancer treated with cystectomy

INTRODUCTION AND AIM

The main aim of the study was to establish the oncological safety of the laparoscopic approach to radical cystectomy for high-risk, non-organ-confined urothelial tumours.

MATERIAL AND METHODS

A retrospective cohort study of 216 stage pT3-4 cystectomies operated between 2003 and 2016; using an open approach (ORC, n=108), and using a laparoscopic approach (LRC, n=108).

RESULTS

Both groups have similar pathological features except, in G3 TUR, there were more lyphadenectomies and greater pN+, and more adjuvant chemotherapies using the LRC. The median follow-up of the series was 15 (IQR: 8-10.5) months. Sixty-eight point one percent of the series relapsed, with no differences between either group (p=.11). The estimated differences for cancer-specific survival was greater in the LRC group (p=.03), as was overall survival (p=.009). There were no differences between either group in estimated recurrence-free survival (p=.26). The type of surgical approach (p=.03), pTpN stage (p=.0001), and administration of adjuvant chemotherapy (p=.003) were related to cancer-specific mortality (CSM) in the univariate analysis. Only the pTpN stage (p=.0001), and not giving adjuvant chemotherapy (p=.003) behaved as independent predictive factors of CSM.

CONCLUSION

The type of surgical approach to cystectomy (ORC vs. LRC) did not influence CSM. Lymph node involvement and not giving adjuvant chemotherapy were identified as predictive factors of CSM. Our study supports the oncological safety of the laparascopic approach for cystectomy in patients with locally advanced muscle-invasive bladder tumours.

Recommendations for follow-up of muscle-invasive bladder cancer patients: A consensus by the international bladder cancer network

RATIONALE

Several guidelines exist that address treatment of patients with nonmetastatic muscle-invasive bladder cancer (MIBC). However, most only briefly mention follow-up strategies for patients and hence the treating physician is often left to infer on what the preferred follow-up schema would be for an individual patient. Herein, we aim to synthesize recommendations for follow-up of patients with MIBC for easy reference.

METHODS

A multidisciplinary MIBC expert panel from the International Bladder Cancer Network was assembled to critically assess currently available major guidelines on surveillance of MIBC patients. Recommendations for follow-up were extracted and critically evaluated. Important considerations for guideline assessment included both aspects of oncological and functional follow-up-frequency of visits, the use of different imaging modalities, the role of cytology and molecular markers, and the duration of follow-up.

OUTCOME

An International Bladder Cancer Network expert consensus recommendation was constructed for the follow-up of patients with MIBC based on the currently available evidence-based data.

[Follow-up of bladder cancer : The right examinations at the right time]

Schedules for the follow-up (FU) of bladder cancer patients are predominantly based on studies with low level of evidence and the resulting guidelines' recommendations that are often founded on expert consensus. FU of non-muscle invasive bladder cancer (NMIBC) includes cystoscopy and cytology as standard, and imaging modalities to a lower extent. FU of muscle-invasive bladder cancer (MIBC) depends primarily on the therapeutic modality chosen and on the stage of disease. In this scenario, FU is complemented by functional and quality of life related aspects. These apply even more for FU in palliative situations. Here, the individual focus is on examinations that might have a consequence in terms of survival and/or symptom relief.

Follow-up Management of Cystectomy Patients

Bladder cancer is the sixth leading cancer in the United States. Radical cystectomy is a lifesaving procedure for bladder cancer with or without muscle invasion. Radical cystectomy is performed on 39% of these patients, and 35% will have a life-threatening recurrence. Distant metastases are the most common; local, upper tract, and urethral recurrence can also occur. Surveillance after cystectomy is critical to diagnosing recurrence early. Functional complications after urinary diversion include bowel dysfunction, vitamin B12 deficiency, acidosis, electrolyte abnormalities, osteopenia, nephrolithiasis, urinary tract infections, renal functional decline, and urinary obstruction, which can be reversed when diagnosed early.

Risk factors, follow-up, and treatment of urethral recurrence following radical cystectomy and urinary diversion for bladder cancer: a meta-analysis of 9498 patients

Purpose

Patients frequently undergo radical cystectomy and urinary diversion for treatment of bladder cancer. However, they remain at risk of urethral recurrence (UR). Studies have determined various risk factors leading to urethral recurrence. However, no publications have weighed the predictive values of these factors.

Materials and Methods

Studies published between 1971 and 2016 were retrieved from PubMed, EMBASE and MEDLINE. We used STATA software (Version 12.0) to estimate the pooled risk ratio.

Results

Twenty-five publications with 9498 patients were included. Overall, male patients, especially those with concomitant carcinoma in situ, superficial or intravesical bladder cancer, non-orthotopic diversion, prostatic involvement, bladder neck involvement, positive urethral margins or multifocal bladder cancer were at higher risk of urethral recurrence. The overall risks of recurrence, reported as risk ratios, varied widely. Among all 25 studies, 118 (60.2%) cases in 9 studies were diagnosed through routine follow-up. Another 82 (40.8%) patients in 11 studies first reported symptomatic abnormalities. Prognoses were worse for patients with symptomatic recurrence. Urethral cytology was the most common diagnostic method. Treatment after UR was reported for 272 cases in 14 publications, and 190 patients underwent urethrectomy and 52 underwent urethra-sparing treatments. Outcomes after UR were described in 12 studies reporting 180 cases, and 41 patients were alive through the end of follow-up and 65 patients died of bladder cancer.

Conclusions

UR following radical cystectomy for bladder cancer was closely related to risk factors. Precautions, strict follow-up protocols and rational therapies were critical to patients with high risks of urethral recurrences.

Gender-related Outcome in Bladder Cancer Patients undergoing Radical Cystectomy

Background: The impact of gender on oncological outcome after radical cystectomy (RC) is not fully understood yet. The aim of the study was to evaluate gender-related differences in histopathological parameters and prognosis of patients with bladder cancer undergoing RC.

Methods: A retrospective analysis of a 10-year single-center cystectomy database was performed. Kaplan-Meier survival and Cox-regression analyses with sex-specific interactions were performed to determine the impact of gender on recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS), in addition to established clinicopathological factors.

Results: 259 patients (212 [81.8%] men and 47 [18.2%] women) were enrolled. Although women had a greater propensity for extravesical (≥pT3) disease (53.2% vs. 33.9%, p=0.03) and heterotopic urinary diversion (72.3% vs. 49.5%, p=0.006), gender did not independently predict RFS, CSS or OS on multivariate analysis. Extravesical tumor disease was the sole independent predictor concerning RFS (hazard ratio [HR]=4.70; p<0.001), CCS (HR=2.77; p=0.013), and OS (HR=1.93; p=0.041). Orthotopic urinary diversion (HR=0.36; p=0.002) had an independent effect only on RFS. Rates of 5-year RFS (73.7% vs. 48.3%; p=0.001), CSS (72.5% vs. 44.9%; p<0.001) and OS (62.6% vs. 37.8%; p<0.001) were higher in orthotopic versus heterotopic diversions.

Conclusion: In our series, women presented with more advanced tumors and higher rates of heterotopic urinary diversions, but their survival outcome was not significantly inferior to that of men. Extravesical disease was independently related to poorer survival after RC.

Infiltrating bladder cancer: prognostic factors, follow-up and treatment of relapses

CONTEXT

Bladder cancer is the cause of more than 150,000 deaths per year. The overall rate of survival is approximately 45%, with a 10-year recurrence-free rate of 50-59%, with no changes in the last decade.

OBJECTIVE

Due to a lack of agreement on the follow-up of cystectomy or on a uniform treatment when faced with the various types of recurrence, we have analysed the most recent literature in an attempt to unify the criteria for the diagnosis and treatment of bladder cancer.

ACQUISITION OF EVIDENCE

Review of Spanish and English publications in the medical literature in the last 10 years, highlighting the most significant series in terms of the number of patients, follow-up time, as well as the existing meta-analyses.

SYNTHESIS OF THE EVIDENCE

Recurrence after cystectomy can occur in the urinary apparatus (upper urinary tract or distal urethra) and local (cystectomy bed) and/or distant metastases. Despite strict control, more than 60% of the relapses are discovered based on symptoms and not by the routine follow-up test. Locoregional and distant relapses are more common the more advanced the stage at the time of cystectomy, going from 11-21% in pT2N0 to 52-72% when there is lymphocytic N+ involvement. Recurrence in the urethra and/or upper urinary track has other prognostic factors such as multiplicity, the presence of Cis and involvement of prostatic stroma. There are various treatments for tumour relapses. Increasingly, the patient's comorbidity is considered when deciding on the therapeutic strategy. Treatments are typically multimodal and include surgery, radiotherapy and chemotherapy.

CONCLUSION

The follow-up of patients who undergo cystectomy should be individualised, taking into account the prognostic factors of recurrence and the patient's comorbidity, assuming that in some cases, multimodal treatment is indicated.

Early Oncologic Failure after Robot-Assisted Radical Cystectomy: Results from the International Robotic Cystectomy Consortium

PURPOSE

We sought to investigate the prevalence and variables associated with early oncologic failure.

MATERIALS AND METHODS

We retrospectively reviewed the IRCC (International Radical Cystectomy Consortium) database of patients who underwent robot-assisted radical cystectomy since 2003. The final cohort comprised a total of 1,894 patients from 23 institutions in 11 countries. Early oncologic failure was defined as any disease relapse within 3 months of robot-assisted radical cystectomy. All institutions were surveyed for the pneumoperitoneum pressure used, breach of oncologic surgical principles, and techniques of specimen and lymph node removal. A multivariate model was fit to evaluate predictors of early oncologic failure. The Kaplan-Meier method was applied to depict disease specific and overall survival, and Cox proportional regression analysis was used to evaluate predictors of disease specific and overall survival.

RESULTS

A total of 305 patients (22%) experienced disease relapse, which was distant in 220 (16%), local recurrence in 154 (11%), peritoneal carcinomatosis in 17 (1%) and port site recurrence in 5 (0.4%). Early oncologic failure developed in 71 patients (5%) at a total of 10 institutions. The incidence of early oncologic failure decreased from 10% in 2006 to 6% in 2015. On multivariate analysis the presence of any complication (OR 2.87, 95% CI 1.38-5.96, p = 0.004), pT3 or greater disease (OR 3.73, 95% CI 2.00-6.97, p <0.001) and nodal involvement (OR 2.14, 95% CI 1.21-3.80, p = 0.008) was a significant predictor of early oncologic failure. Patients with early oncologic failure demonstrated worse disease specific and overall survival (23% and 13%, respectively) at 1 and 3 years compared to patients who experienced later or no recurrences (log rank p <0.001).

CONCLUSIONS

The incidence of early oncologic failure following robot-assisted radical cystectomy has decreased with time. Disease related rather than technical related factors have a major role in early oncologic failure after robot-assisted radical cystectomy.

Updated 2016 EAU Guidelines on Muscle-invasive and Metastatic Bladder Cancer

CONTEXT

Invasive bladder cancer is a frequently occurring disease with a high mortality rate despite optimal treatment. The European Association of Urology (EAU) Muscle-invasive and Metastatic Bladder Cancer (MIBC) Guidelines are updated yearly and provides information to optimise diagnosis, treatment, and follow-up of this patient population.

OBJECTIVE

To provide a summary of the EAU guidelines for physicians and patients confronted with muscle-invasive and metastatic bladder cancer.

EVIDENCE ACQUISITION

An international multidisciplinary panel of bladder cancer experts reviewed and discussed the results of a comprehensive literature search of several databases covering all sections of the guidelines. The panel defined levels of evidence and grades of recommendation according to an established classification system.

EVIDENCE SYNTHESIS

Epidemiology and aetiology of bladder cancer are discussed. The proper diagnostic pathway, including demands for pathology and imaging, is outlined. Several treatment options, including bladder-sparing treatments and combinations of treatment modalities (different forms of surgery, radiation therapy, and chemotherapy) are described. Sequencing of these modalities is discussed. Potential indications and contraindications, such as comorbidity, are related to treatment choice. There is a new paragraph on organ-sparing approaches, both in men and in women, and on minimal invasive surgery. Recommendations for chemotherapy in fit and unfit patients are provided including second-line options. Finally, a follow-up schedule is provided.

CONCLUSIONS

The current summary of the EAU Muscle-invasive and Metastatic Bladder Cancer Guidelines provides an up-to-date overview of the available literature and evidence dealing with diagnosis, treatment, and follow-up of patients with metastatic and muscle-invasive bladder cancer.

PATIENT SUMMARY

Bladder cancer is an important disease with a high mortality rate. These updated guidelines help clinicians refine the diagnosis and select the appropriate therapy and follow-up for patients with metastatic and muscle-invasive bladder cancer.

Anterior urethra sparing cystoprostatectomy for bladder cancer: a 10-year, single center experience

Purpose

Decision making regarding the urethra before and after radical cystectomy due to urothelial carcinoma has always been controversial. To determine whether anterior urethra sparing cystoprostatectomy for bladder cancer is an oncologically-safe procedure, we evaluated the long-term oncologic clinical outcome.

Patients and methods

A total of 51 male patients with cTa-4N0-2M0 bladder cancer were treated with anterior urethra sparing cystoprostatectomy and simultaneous urinary diversion between 2000 and 2013, and underwent follow up for 4 months or more. We assessed differences in the perioperative outcomes, oncologic outcomes and recurrence rates according to the urinary diversion.

Results

The median patient age and follow-up period were 66 years and 35 months, respectively. The 5- and 10-year recurrence free survival (RFS) rates in ileal conduit (IC) group vs. orthotopic neobladder reconstruction (NB) group were 45.0 and 20.3% vs. 39.3 and 19.6%, respectively. Likewise, the 5- and 10-year disease specific survival (DSS) were 52.7 and 32.1% vs. 39.3 and 29.5%, respectively. Multivariate analysis revealed two independent prognostic factors for RFS and DSS, including age at surgery and lymph node status. Local recurrence in the remnant anterior urethra occurred in only 1 patient (2.0%) at 57 months after surgery.

Conclusions

Our long-term data show that anterior urethra sparing cystoprostatectomy is an oncologically-safe procedure regardless of the type of urinary diversion in a subset of carefully selected patients with bladder cancer without evidence of urothelial carcinoma in the urethra/bladder neck and urethral surgical margin.

Electronic supplementary material

The online version of this article (doi:10.1186/s40064-015-1200-7) contains supplementary material, which is available to authorized users.

Novel technique of sampling the urinary bladder for urothelial carcinoma specimens

Sampling of the urinary bladder (UB) in radical cystectomy specimens is usually performed by obtaining sections through the lesions taken in rather random planes. The technique is hindered by the difficulty in identifying the anatomical relationship of the tumor with the remaining urinary bladder. Fifty radical cystectomy specimens were bisected in the horizontal plane at the middle portion of the UB then fixed without tissue stretching in 10% buffered formalin for at least 24 hours. The UBs were serially sectioned in parallel horizontal planes from the UB neck to the dome into rings of 3 to 10 mm thickness. The sections were orderly arranged and photographed. At least one ring of tissue was entirely submitted along with areas of interest or representative areas. Our proposed technique of transverse sections results in a mild increase in the number of sections submitted for microscopic examination. The advantages of our methods are (a) consistency and ease of sampling that help the microscopic-macroscopic correlation, (b) suitability for gross examination and for determining depth of invasion and largest tumor diameter, (c) improved identification of satellite lesions, and (d) suitability for neoplastic mapping and suitability for reexamination. The technique was validated by comparing with results of current technique.

A retrospective analysis of incidence and its associated risk factors of upper urinary tract recurrence following radical cystectomy for bladder cancer with transitional cell carcinoma: the significance of local pelvic recurrence and positive lymph node

Objective

The aim of this study is to examine the incidence and risk factors of upper urinary tract recurrence (UUTR) following radical cystectomy (RC) in bladder cancer and to evaluate its relationship with neobladder (Neo) or ileal conduit (IC).

Materials and Methods

All clinicopathologic parameters and perioperative parameters of 311 patients who underwent RC with either Neo or IC by a single surgeon from 1999 to 2012 were retrospectively included in this study. Patients with a history of renal surgery, concomitant UUTR, or a histopathology of non-transitional cell carcinoma were excluded. For statistical analyses of predictive risk factors of UUTR, a multivariate analysis was performed with known risk factors of UUTR, including type of urinary diversion with significance defined as P < 0.05.

Results

During the median follow-up period of 53 months, 143 (46.0%) IC and 168 (54.0%) Neo were performed, resulting in 11 (3.5%) cases of UUTR (Neo 7 and IC 4) after RC and all patients then underwent nephroureterectomy. No significant differences in incidence and overall survival in UUTR were observed according different types of urinary diversion (p = 483), and the prognosis for survival of Neo was insignificantly better than that of IC (5-year overall survival 78% vs 74%, respectively, p>0.05). Higher number of positive lymph nodes (HR 9.03) and the presence of pelvic local recurrence (HR 7286.08) were significant predictive factors of UUTR (p<0.05).

Conclusion

This study reports a UUTR rate of 3.5%, and positive lymph nodes and presence of local recurrence at the pelvis as important risk factors. No significant differences in incidence and survival were observed between Neo and IC.