Minimum incision endoscopic radical cystectomy in patients with malignant tumors of the urinary bladder: Clinical and oncological outcomes at a single institution

Trends of radical cystectomy and comparisons of surgical outcomes among surgical approaches focusing on robot-assisted radical cystectomy: A Japanese nationwide database study

OBJECTIVE

To clarify the trends in radical cystectomy and to compare surgical outcomes among surgical approaches focusing on robot-assisted radical cystectomy based on a Japanese nationwide database.

METHODS

The Diagnosis Procedure Combination database was used to extract data on radical cystectomy cases. Trends in open radical cystectomy, laparoscopic radical cystectomy, minimum incision endoscopic radical cystectomy, and robot-assisted radical cystectomy between April 2012 and March 2021 were evaluated. Basic characteristics and peri-operative indicators were compared among the four groups. Propensity score matching was applied to assess the differences between open radical cystectomy and robot-assisted radical cystectomy.

RESULTS

During the study period, a decreasing number of open radical cystectomies and an increasing number of minimally invasive radical cystectomies were shown in the total cohort of 28 345 cases. The number of robot-assisted radical cystectomies rapidly increased after government approval in 2018. Minimally invasive radical cystectomies, including robot-assisted radical cystectomies, had a significantly lower complication rate, a shorter length of stay, and a lower blood transfusion rate, but a longer anesthesia time than open radical cystectomies. In the propensity score matching analysis comparing the surgical outcomes of robot-assisted radical cystectomy and open radical cystectomy, similar results were demonstrated, and blood transfusion rates were equivalent.

CONCLUSION

For the past decade, the number of minimally invasive radical cystectomies has steadily increased without compromised surgical outcomes, except for anesthesia time. Robot-assisted radical cystectomies in particular rapidly became widespread in Japan after government approval in 2018 and became a standard surgery within the first 3 years.

Combination of Muscle Quantity and Quality Is Useful to Assess the Necessity of Surveillance after a 5-Year Cancer-Free Period in Patients Who Undergo Radical Cystectomy: A Multi-Institutional Retrospective Study

BACKGROUND

Although continuous surveillance after a 5-year cancer-free period in patients with bladder cancer (BC) who undergo radical cystectomy (RC) is recommended, optimal candidates for continuous surveillance remain unclear. Sarcopenia is associated with unfavorable prognosis in various malignancies. We aimed to investigate the impact of low muscle quantity and quality (defined as severe sarcopenia) on prognosis after a 5-year cancer-free period in patients who underwent RC.

METHODS

We conducted a multi-institutional retrospective study assessing 166 patients who underwent RC and had five years or more of follow-up periods after a 5-year cancer-free period. Muscle quantity and quality were evaluated using the psoas muscle index (PMI) and intramuscular adipose tissue content (IMAC) using computed tomography images five years after RC. Patients with lower PMI and higher IMAC values than the cut-off values were diagnosed with severe sarcopenia. Univariable analyses were performed to assess the impact of severe sarcopenia on recurrence, adjusting for the competing risk of death using the Fine-Gray competing risk regression model. Moreover, the impact of severe sarcopenia on non-cancer-specific survival was evaluated using univariable and multivariable analyses.

RESULTS

The median age and follow-up period after the 5-year cancer-free period were 73 years and 94 months, respectively. Of 166 patients, 32 were diagnosed with severe sarcopenia. The 10-year RFS rate was 94.4%. In the Fine-Gray competing risk regression model, severe sarcopenia did not show a significant higher probability of recurrence, with an adjusted subdistribution hazard ratio of 0.525 (p = 0.540), whereas severe sarcopenia was significantly associated with non-cancer-specific survival (hazard ratio 1.909, p = 0.047). These results indicate that patients with severe sarcopenia might not need continuous surveillance after a 5-year cancer-free period, considering the high non-cancer-specific mortality.

Oncological and functional outcomes of female reproductive organ-sparing radical cystectomy and ileal neobladder construction

OBJECTIVES

To examine the oncological and urinary functional outcomes of reproductive organ-sparing radical cystectomy (ROS-RC) and U-shaped ileal neobladder construction in females compared with male patients.

METHODS

We retrospectively examined 357 patients (281 male and 76 female) with muscle-invasive bladder cancer who were treated with RC plus U-shaped ileal neobladder construction between May 1996 and July 2021. All female patients were treated with ROS-RC. We compared disease-free survival (DFS), cancer-specific survival (CSS), overall survival (OS), and urinary functional outcomes between male and female patients. We evaluated the effect of gender on DFS, CSS, and OS. Furthermore, urinary functional outcomes were evaluated in 140 males and 48 females using a pressure-flow study at 3, 6, 9, and 12 months postoperatively.

RESULTS

Female patients were considerably older than male patients at the time of radical cystectomy. No significant difference was noted in the tumor stage preoperatively. The multivariable Cox regression analysis with an inverse probability treatment weighted model revealed that the female gender was not significantly related to DFS, CSS, and OS. Moreover, urinary functions at 12 months were not markedly different between males and females, except for the capacity of the neobladder, detrusor pressure, and maximum urethral closure pressure.

CONCLUSIONS

This study demonstrates that female patients with ROS-RC and U-shaped ileal neobladder construction did not significantly correlate with worse oncological outcomes. The combination of ROS-RC and U-shaped ileal neobladder construction might attain adequate urinary function without sacrificing oncologic outcomes.

Prognostic impact of eligibility for adjuvant immunotherapy in locally advanced urothelial cancer

Objective

To evaluate the effect of postoperative pathological findings related to the eligibility of adjuvant immunotherapy on oncologic outcomes in patients with localized and locally advanced muscle‐invasive bladder carcinoma (MIBC) and upper tract urothelial carcinoma (UTUC).

Patients and methods

We retrospectively evaluated 1082 patients treated with radical cystectomy (n = 597) and nephroureterectomy (n = 485) between January 2000 and April 2021. Patients were divided into two groups: pT3‐4 or pN+ without neoadjuvant chemotherapy and ypT2‐4 or pN+ treated with neoadjuvant chemotherapy (trial‐eligible group) or others (trial‐ineligible group). The primary outcome was the effect of trial eligibility for adjuvant immunotherapy on disease‐free survival (DFS) and overall survival (OS). Secondary outcomes included the additional effect of lymphovascular invasion (LVI) status to the clinical trial criteria on prognosis and a risk model development.

Results

The median ages of the patients were 69 and 72 years in the MIBC and UTUC groups, respectively. Fifty‐two percent of patients met the trial inclusion criteria. Trial eligibility was significantly associated with poor DFS and OS among patients with MIBC and UTUC. LVI‐positive status was significantly associated with poor prognosis among patients in the trial‐eligible group. A very high risk (LVI+ or pN+ among the pT3‐4 or ypT2‐4) was significantly associated with poor prognosis.

Conclusion

A total of 52% of patients were eligible for adjuvant immunotherapy. Trial eligibility was significantly associated with a poor prognosis. LVI+ and pN+ may play a key role in candidate selection for adjuvant immunotherapy.

Long-term chronological changes in urination status of patients who underwent ileal neobladder reconstruction at a single institution

PURPOSE

This study aimed to investigate the long-term chronological changes in urination status of patients who underwent radical cystectomy (RC) followed by orthotopic ileal neobladder (ONB) reconstruction using the International Prostatic Symptoms Score (IPSS) and the Overactive Bladder Symptoms Score (OABSS).

METHODS

This retrospective study focused on patients who underwent RC followed by ONB reconstruction and those who consented for IPSS, quality of life (QOL) based on urinary symptoms (IPSS-QOL), and OABSS assessments in the follow-up period. The patients were divided according to gender into the male group (M-group) and female group (F-group). All patients were evaluated using IPSS, IPSS-QOL, and OABSS every 3 months. The primary endpoint was to assess chronological changes in the urination status of patients who underwent ONB reconstruction after RC.

RESULTS

The median age of the enrolled patients (n = 122) was 65 years and the median follow-up period was 92.0 months. The median voiding symptom score in IPSS after 10 years of surgery was significantly higher in the M-group than in the F-group. Contrarily, the F-group demonstrated a significantly higher median storage symptom score at 60-66 and 102-114 months than the M-group. The median OABSS scores were relatively higher in the F-group than in the M-group.

CONCLUSIONS

Although long-term urinary function with ONB demonstrated acceptable results, dysfunctional voiding was observed > 10 years after surgery. Thus, the changes in long-term urinary function should be considered when deciding ONB.

Postoperative weight loss followed by radical cystectomy predicts poor prognosis in patients with muscle-invasive bladder cancer

We aimed to investigate the impact of postoperative weight loss following radical cystectomy (RC) on patients' prognoses. RC and urinary diversion were performed in 512 consecutive patients with muscle-invasive bladder cancer at our hospitals between May 1996 and July 2018. Demographic clinical information, pre- and postoperative serum albumin, hemoglobin, and weight were evaluated retrospectively at 1 month. We also evaluated the association of weight loss with complications and overall survival (OS) as estimated using the Kaplan-Meier method and compared using the log-rank test. Risk factors for poor OS were determined by Inverse Probability of Treatment Weighted (IPTW)-adjusted Cox regression analysis. In 385 patients who met the study search criteria, median postoperative weight loss from baseline at 1 week and 1 month was 1.1 (- 1.8%) and 3.2 (- 5.4%) kg, respectively. Patients with significant weight loss (defined as ≥ 7.5% at 1 month) had higher-grade complications within 1 month and had significantly shorter OS than those with weight loss of < 7.5%. Type of urinary diversion, loss of serum albumin, and loss of hemoglobin were not significantly associated with weight loss. IPTW-adjusted Cox regression analysis showed that such significant weight loss was an independent risk factor for poor OS. Weight loss followed by radical cystectomy was significantly associated with poor prognosis in patients with muscle-invasive bladder cancer.

Robotic cross-folded U-configuration intracorporeal ileal neobladder for muscle-invasive bladder cancer: Initial experience and functional outcomes

BACKGROUND

This study compared the surgical and urinary functional outcomes in patients with muscle-invasive bladder cancer (MIBC) who underwent robot-assisted radical cystectomy (RARC) followed by intracorporeal ileal neobladder reconstruction (ICNB) to those in patients who underwent minimum incision endoscopic radical cystectomy (MIE-RC) followed by extracorporeal ileal neobladder reconstruction (ECNB).

MATERIALS AND METHODS

This study reviewed the clinical records of 153 consecutive MIBC patients who underwent neoadjuvant chemotherapy followed by radical cystectomy and ileal neobladder reconstruction.

RESULTS

The operative time in the ICNB group was significantly longer than that in the ECNB group. The median estimated blood loss was significantly less in the ICNB group than in the ECNB group. The neobladder capacity gradually increased in both groups. The maximum neobladder pressure and urethral closure pressure gradually improved in both groups.

CONCLUSION

Our initial experience with ICNB was favourable, with acceptable surgical and urinary functional outcomes.

Can single positive core prostate cancer at biopsy be considered a low-risk disease?

PURPOSE

Prostate cancer (PCa) may be a multifocal or bilateral disease. A single positive biopsy core is usually associated with indolent PCa, and doctors may choose to perform active surveillance or focal therapy. We investigated the correlation between finding a single positive biopsy core and the pathological outcome after radical prostatectomy (RP).

METHODS

Data from the Michinoku Japan Urological Cancer Study Group database including pre- and post-operative information, on 1928 consecutive patients with PCa treated with RP alone at four institutions was used. Among them, 503 patients with a single positive core PCa were followed up, and the clinical and pathological parameters influencing prognosis were analyzed.

RESULTS

Of the 503 patients, 258 (51.3%) had pathological findings ≥ pT2c and 160 (32%) had an undergraded Gleason Score (GS) based on their biopsy findings. A total of 112 patients (39.5%) with clinical T1c developed bilateral tumors (pT2c-T3). The rate of developing pT3 tumors in the single positive core group was significantly higher than that of the multiple positive core group. Moreover, there was no significant difference in the number of pT3b patients between the single and multiple positive core PCa groups.

CONCLUSIONS

Based on analysis of radical prostatectomy specimens, positive core PCa can lead to clinically significant disease, with considerable rates of pT3. For patients with PCa and a positive prostate biopsy core, definitive therapy such as RP should be considered.

Asymptomatic recurrence detection and cost-effectiveness in urothelial carcinoma

For the management of muscle-invasive bladder cancer or upper tract urothelial carcinoma, the set guidelines recommend regular surveillance after radical cystectomy or radical nephroureterectomy. However, the prognostic benefit of regular oncological surveillance remains controversial in the absence of prospective studies although several retrospective studies with relatively large sample sizes have demonstrated the association between asymptomatic recurrence and better oncological outcomes. Seven out of eight studies reported that patients diagnosed with symptomatic recurrence showed significantly poorer prognosis in comparison to those diagnosed with asymptomatic recurrence. However, potential lead-time and length-time biases prevent the determination of any benefit of regular surveillance. In addition, an optimal surveillance protocol has yet to be established because conventional pathology-based protocols cannot identify the heterogenetic tumor biology of urothelial carcinoma, such as rapid- or slow-growing form of the disease. Several studies suggest that conventional pathology-based surveillance resulted in reduced cost-effectiveness. Recurrence risk-score stratified surveillance protocol including clinical and pathological factors may improve cost-effectiveness. The establishment of optimal risk stratification and surveillance strategies are required to improve the efficacy of regular oncological surveillance. Well-planned prospective studies are necessary to address the prognostic benefit of regular oncological surveillance and shared decision making.

The Impact of Preoperative Severe Renal Insufficiency on Poor Postsurgical Oncological Prognosis in Patients with Urothelial Carcinoma

BACKGROUND

The impact of preoperative renal impairment severity on prognosis in urothelial carcinoma remains unelucidated.

OBJECTIVE

To evaluate the impact of severe preoperative renal insufficiency on oncological outcomes in patients with urothelial carcinoma who underwent radical cystectomy or nephroureterectomy.

DESIGN, SETTING, AND PARTICIPANTS

A total of 1066 patients with urothelial carcinoma who underwent radical cystectomy or nephroureterectomy at six medical centres from February 1995 to November 2017 were retrospectively examined.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Oncological outcomes, stratified using preoperative estimated glomerular filtration rate (eGFR≥60, 45≤eGFR<60, and eGFR<45ml/min/1.73m²), were investigated. Inverse probability of treatment weighting (IPTW)-adjusted Cox proportional hazard regression analysis was performed to evaluate the impact of preoperative eGFR on prognosis.

RESULTS AND LIMITATIONS

Of 610 patients with muscle-invasive bladder cancer (MIBC), 80 (13%) had severe renal insufficiency (eGFR<45ml/min/1.73m²). Of 456 patients with upper tract urothelial carcinoma (UTUC), 101 (22%) had severe renal insufficiency. Significant differences were noted in background and prognosis among the patients with preoperative eGFR≥60, 45≤eGFR<60, and eGFR<45ml/min/1.73m². Findings of IPTW-adjusted Cox regression analysis demonstrated that preoperative eGFR<45ml/min/1.73m² was significantly associated with poor postsurgical recurrence-free, cancer-specific and overall survival rates in patients with either MIBC or UTUC.

CONCLUSIONS

Patients with urothelial carcinoma with preoperative eGFR<45ml/min/1.73m² had a significantly lower survival probability than those without.

PATIENT SUMMARY

In this report, we found that preoperative severe renal insufficiency (estimated glomerular filtration rate<45ml/min/1.73m²) had higher risk for relapse and lower survival probability. Close attention is necessary when urothelial carcinoma patients have severe renal insufficiency before radical cystectomy or nephroureterectomy.

Trends in neoadjuvant chemotherapy use and oncological outcomes for muscle-invasive bladder cancer in Japan: a multicenter study

OBJECTIVE

Despite benefits of neoadjuvant chemotherapy (NAC), the adoption of guideline recommendations for NAC use in patients with muscle-invasive bladder cancer (MIBC) has been slow. We aimed to evaluate temporal trends in NAC use and oncological outcomes in a representative cohort of patients with MIBC.

METHODS

We included 532 patients from 4 hospitals who underwent radical cystectomy (RC) for ≥ cT2 MIBC in 1996-2017. We retrospectively evaluated temporal changes in NAC use and progression-free and overall survival. Candidates for NAC were administered with either cisplatin- or carboplatin-based regimens. The impact of NAC on oncological outcomes was examined using multivariate Cox regression analysis with inverse probability of treatment weighting (IPTW) models.

RESULTS

Of 532 patients, 336 underwent NAC followed by RC (NAC group) and 196 underwent RC alone (Ctrl group). NAC use significantly increased from 10% (1996-2004) to 83% (2005-2016). The number of patients administered with cisplatin- and carboplatin-based regimens was 43 and 280, respectively. Oncological outcomes in the NAC group were significantly improved compared to those in the Ctrl group. Multivariable analysis with IPTW models revealed that NAC significantly improved oncological outcomes in patients with MIBC. A nomogram for 5-year overall survival predicted 16% improvement in patients undergoing NAC.

CONCLUSIONS

NAC use for MIBC increased after 2005. Platinum-based NAC for MIBC potentially improves oncological outcomes.

Presence of transient hydronephrosis immediately after surgery has a limited influence on renal function 1 year after ileal neobladder construction

Background

Urinary tract obstruction and postoperative hydronephrosis are risk factor for renal function deterioration after orthotopic ileal neobladder construction. However, reports of relationship between transient hydronephrosis and renal function are limited.

We assess the influence of postoperative transient hydronephrosis on renal function in patients with orthotopic ileal neobladder construction.

Methods

Between January 2006 and June 2013, we performed radical cystectomy in 164 patients, and 101 received orthotopic ileal neobladder construction. This study included data available from 64 patients with 128 renal units who were enrolled retrospectively. The hydronephrosis grade of each renal unit scored 0–4. The patients were divided into 4 groups according to the grade of hydronephrosis: control, low, intermediate, and high. The grade of postoperative hydronephrosis was compared with renal function 1 month and 1 year after surgery.

Results

There were no significant differences in renal function before surgery between groups. One month after surgery, the presence of hydronephrosis was significantly associated with decreased renal function. However, 1 year after urinary diversion hydronephrosis grades were improved significantly, and renal function was comparable between groups. Postoperative hydronephrosis at 1 month had no significant influence on renal function 1 year after ileal neobladder construction. Limitations include retrospective design, short follow-up periods, and a sample composition.

Conclusions

The presence of transient hydronephrosis immediately after surgery may have limited influence on renal function 1 year after ileal neobladder construction.

Risk-stratified surveillance and cost effectiveness of follow-up after radical cystectomy in patients with muscle-invasive bladder cancer

Background

The recurrence risk stratification and the cost effectiveness of oncological surveillance after radical cystectomy are not clear. We aimed to develop a risk stratification and a surveillance protocol with improved cost effectiveness after radical cystectomy.

Results

Of 581 enrolled patients, 175 experienced disease recurrences. The pathology-based protocol presented significant differences in recurrence-free survival between normal- and high-risk patients, but the medical expense was high, especially in normal-risk (≤pT2pN0) patients. Cox regression analysis identified six factors associated with recurrence-free survival. Risk score-based 5-year follow-up was significantly more cost effective than the pathology-based protocol.

Materials and Methods

We retrospectively evaluated 581 patients with radical cystectomy for muscle-invasive bladder cancer at 4 hospitals. Patients with routine oncological follow-up were stratified into normal- and high-risk groups by a pathology-based protocol utilizing pT, pN, lymphovascular invasion, and histology. Cost effectiveness of the pathology-based protocol was evaluated and a risk-score-based protocol was developed to optimize cost effectiveness. Risk-scores were calculated by summing risk factors independently associated with recurrence-free survival. Patients were stratified by low-, intermediate-, and high-risk score. Estimated cost per one recurrence detection by the pathology and by risk-scores were compared.

Conclusions

Risk-score-stratified surveillance protocol has potential to reduce over-evaluation after radical cystectomy without adverse effects on medical cost.

Preoperative chronic kidney disease predicts poor oncological outcomes after radical cystectomy in patients with muscle-invasive bladder cancer

OBJECTIVE

To evaluate the impact of preoperative chronic kidney disease (CKD) on oncologic outcomes in muscle-invasive bladder cancer patients who underwent radical cystectomy.

METHODS

A total of 581 patients who underwent radical cystectomy at four medical centers between January 1995 and February 2017 were examined retrospectively. We investigated oncologic outcomes, including progression-free, cancer-specific, and overall survival (PFS, CSS, and OS, respectively) stratified by preoperative CKD status (pre-CKD vs. non-CKD). We performed a Cox proportional hazards regression analysis using inverse probability of treatment weighting (IPTW) to evaluate the impact of preoperative CKD on prognosis and developed the prognostic factor-based risk stratification nomogram.

RESULTS

Of the 581 patients, 215 (37%) were diagnosed with CKD before radical cystectomy. Before the background adjustment, PFS, CSS, and OS after radical cystectomy were significantly lower in the pre-CKD group compared to the non-CKD group. Background-adjusted IPTW analysis showed that preoperative CKD was significantly associated with poor PFS, CSS, and OS after radical cystectomy. The nomogram for predicting 5-year PFS and OS probability showed significant correlation with actual PFS and OS (c-index = 0.73 and 0.77, respectively).

CONCLUSIONS

Muscle-invasive bladder cancer patients with preoperative CKD had a significantly lower survival probability than those without CKD.

The feasibility and effectiveness of robot-assisted radical cystectomy after neoadjuvant chemotherapy in patients with muscle-invasive bladder cancer

Objectives

The aim of this study was to compare 29 muscle-invasive bladder cancer patients who received neoadjuvant chemotherapy (NAC) followed by immediate robot-assisted radical cystectomy (RARC) with those who underwent minimum-incision endoscopic RC (MIE-RC).

Methods

We retrospectively reviewed the charts of 430 consecutive patients who underwent RC and bilateral pelvic node dissection (PLND) between May 1994 and July 2016. Our study focused on patients with MIBC who had histologically confirmed stage T2-T4aN0M0 urothelial carcinoma of the bladder and received NAC prior to surgery. Accordingly, 225 patients were included in this analysis, of whom, 29 underwent RARC (RARC group) and 196 underwent MIE-RC (MIE-RC group). The primary endpoints in this study were the positive surgical margin (PSM) rate and lymph node (LN) count.

Results

In the RARC group, 20 patients underwent RARC with intracorporeal urinary diversion and nine patients underwent RARC with extracorporeal urinary diversion. The median surgical duration for RC and bilateral PLND was 125 min in the RARC group and 98 min in the MIE-RC group (P < 0.001). The rate of PSM was 0% in the RARC group and 0.5% in the MIE-RC group. The median LN counts were 15 in the RARC group and 18 in the MIE-RC group. No intra-operative complication or mortality was associated with RARC or MIE-RP. All complications were grade 2 according to the Clavien-Dindo classification.

Conclusions

Our initial experience with NAC followed by RARC appears to be favorable, with acceptable operative and perioperative clinical outcomes when compared with those of MIE-RC.

Detecting asymptomatic recurrence after radical cystectomy contributes to better prognosis in patients with muscle-invasive bladder cancer

The prognostic benefit of oncological follow-up to detect asymptomatic recurrence after radical cystectomy (RC) remains unclear. We aimed to assess whether routine follow-up to detect asymptomatic recurrence after RC improves patient survival. We retrospectively analyzed 581 RC cases for muscle-invasive bladder cancer at four hospitals between May 1996 and February 2017. All patients had regular follow-up examinations with urine cytology, blood biochemical tests, and computed tomography after RC. We investigated the first site and date of tumor recurrence. Overall survival in patients with recurrence stratified by the mode of recurrence (asymptomatic group vs. symptomatic group) was estimated using the Kaplan-Meier method with the log-rank test. Cox proportional hazards regression analysis via inverse probability of treatment weighting (IPTW) was used to evaluate the impact of the mode of diagnosing recurrence on survival. Of the 581 patients, 175 experienced relapse. Among those, 12 without adequate data were excluded. Of the remaining 163 patients, 76 (47%) were asymptomatic and 87 (53%) were symptomatic at the time of diagnosis. The most common recurrence site and symptom were lymph nodes (47%) and pain (53%), respectively. Time of overall survival after RC and from recurrence to death was significantly longer in the asymptomatic group than in the symptomatic group. A multivariate Cox regression analysis using IPTW showed that in the patients with symptomatic recurrence was an independent risk factor for overall survival after RC and survival from recurrence to death. Routine oncological follow-up for detection of asymptomatic recurrence contributes to a better prognosis after RC.

The utility of neoadjuvant gemcitabine plus carboplatin followed by immediate radical cystectomy in patients with muscle-invasive bladder cancer who are ineligible for cisplatin-based chemotherapy

BACKGROUND

There are currently no data supporting carboplatin-based regimens in muscle-invasive bladder cancer patients who are unsuitable for neoadjuvant cisplatin treatment. The aim of this study was to investigate the potential benefit of carboplatin-based regimens in patients with muscle-invasive bladder cancer who were unsuitable for cisplatin.

METHODS

We focused on 171 patients ineligible for cisplatin, including 98 patients who received neoadjuvant gemcitabine and carboplatin (GCarbo) followed by immediate radical cystectomy (GCarbo cohort) and 73 patients who underwent radical cystectomy (RC alone cohort) at Hiroaki University or Aomori Prefectural Hospital. In the neoadjuvant GCarbo cohort, patients underwent two 21-day cycles of GCarbo the two courses of neoadjuvant chemotherapy were followed by radical cystectomy at an interval of 1 month.

RESULTS

Of the enrolled patients, 165 (95.3 %) had renal impairment. The median age of the enrolled patients was 71 years, and the median follow-up period was 63 months. The 5-year overall survival rates for the GCarbo and the RC-alone cohorts were 79.5 and 53.8 %, respectively (P < 0.001), while the 5-year disease-free survival rates were 75.5 and 55.4 %, respectively (P = 0.013). Surgical specimens of 16 (16.3 %) patients in the GCarbo cohort indicated stage pT0 disease. The rate of positive surgical margins in the RC-alone cohort was significantly higher than that in the GCarbo cohort (P < 0.001).

CONCLUSIONS

In this study, the oncological outcomes were significantly improved in cisplatin-unfit patients with muscle-invasive bladder cancer who received neoadjuvant GCarbo chemotherapy, compared with those in patients who underwent RC alone. The standard of care for muscle-invasive bladder cancer, especially for patients who are unfit for cisplatin, may include neoadjuvant carboplatin chemotherapy followed by radical cystectomy.

Renal Function Outcomes and Risk Factors for Stage 3B Chronic Kidney Disease after Urinary Diversion in Patients with Muscle Invasive Bladder Cancer [corrected]

Objectives

To assess the effects of urinary diversion on renal function, we retrospectively investigated renal function over 5 years after urinary diversion using a propensity score matching strategy.

Methods

Between May 1996 and November 2013, 345 consecutive adult patients underwent radical cystectomy and urinary diversion in our hospital; one hundred and fifteen patients with more than a 5-year follow-up were enrolled. Propensity scores were calculated using logistic analysis, and the data used in the analyses included age, gender, Eastern Cooperative Oncology Group Performance Status (ECOG-PS), clinical tumor stage, presence of cardiovascular disease; hypertension; and type 2 diabetes and preoperative eGFR at the initial visit. Multivariate logistic regression analysis was used to assess the risk factors for stage 3B chronic kidney disease (CKD) after the different types of urinary diversion.

Results

Continent and incontinent diversion were performed in 68 and 47 patients, respectively. The mean preoperative eGFR was significantly lower in the incontinent than in the continent group (P < 0.001). In propensity score-matched patients (n = 34 each), no significant differences were observed in pre- and postoperative eGFR and 5-year eGFR decrease rates between the groups. In the incontinent group, the number of postoperative stage 3B CKD patients was significantly increased than the continent group. Using multivariate analysis, independent risk factors significantly associated with stage 3B CKD at 5 years after surgery were older age, eGFR before surgery, incontinent diversion (cutaneous ureterostomy), and postoperative hydronephrosis.

Conclusions

The types of urinary diversion had no significant impact on renal function decline, whereas older age, preexisting impaired renal function, postoperative hydronephrosis, and cutaneous ureterostomy were independent risk factors for stage 3B CKD at 5 years after radical cystectomy.

Diversity in treatment modalities of Stage II/III urothelial cancer in Japan: sub-analysis of the multi-institutional national database of the Japanese Urological Association

OBJECTIVE

We aimed to survey treatment modalities for the patients with Stage II/III urothelial cancer in Japan.

METHODS

We used the multi-institutional national database of the Japanese Urological Association from 348 Japanese institutions, in which a total of 3707 patients with muscle-invasive bladder cancer and 1538 with upper urinary tract urothelial carcinoma were registered in 2008 and 2011, respectively. Primary treatment was classified as surgery alone, surgery with chemotherapy, surgery with radiation, radiation alone, chemotherapy alone, combination of radiation and chemotherapy and observation. Overall and cancer-specific survivals were examined using the Kaplan-Meier method, and survival in the subgroups was analyzed using the log-rank test.

RESULTS

In Stage II/III bladder cancer patients, 49.7% of those were treated with radical operation and 22.3% received observation only. A total 97.2% of Stage II/III upper urinary tract urothelial carcinoma patients treated with radical surgery. A total 30.4% of Stage II/III bladder cancer patients received chemotherapy. Majority of the patients received cisplatin-based regimen, however, regimens of chemotherapy was rich in variety up to 13 regimens. Chemotherapy regimens for the patients with upper urinary tract urothelial carcinoma were also various up to eight regimens. Overall and cancer-specific survivals were statistically significantly stratified according to the clinical stage. The upper urinary tract urothelial carcinoma patients diagnosed with clinical stage T3 had significantly poor prognosis compared with those diagnosed with clinical stage T2.

CONCLUSIONS

This study demonstrated the variety of treatments used for Japanese patients with Stage II/III urothelial cancer. Treatment standardization for these entities may be necessary.

Differences in the recurrence pattern after neoadjuvant chemotherapy compared to surgery alone in patients with muscle-invasive bladder cancer

In patients with muscle-invasive bladder cancer (MIBC), neoadjuvant chemotherapy (NAC) confers a survival benefit compared to radical cystectomy (RC) alone. Recurrence is observed in many cases and is the most common cause of death in MIBC patients. However, the rate and pattern of recurrence after NAC in MIBC patients remain unclear. We retrospectively reviewed the charts of 348 consecutive patients who underwent RC and bilateral pelvic node dissection between May 1994 and July 2012. Our study focused on patients with MIBC who had histologically confirmed stage T2-T4a urothelial carcinoma of the bladder without lymph node or distant metastasis. Accordingly, 265 patients were included in this analysis, of whom 130 received NAC and 135 underwent RC alone. Propensity score matching was used to adjust for potential selection biases associated with treatment type. Recurrence was defined as local recurrence and distant metastasis, according to site. Propensity score matching analysis identified 130 matched pairs from the two groups. For the neoadjuvant gemcitabine and carboplatin (GCarbo) and RC alone groups, the 5-year overall survival rates were 89.2 and 51.4 %, respectively (P < 0.0001), and the recurrence-free survival rates were 85.4 and 57.0 %, respectively (P < 0.0001). However, the total number of local recurrences was markedly lower in the neoadjuvant GCarbo group than in the RC alone group. Neoadjuvant GCarbo was associated with improved oncological outcomes and a different recurrence pattern in MIBC patients compared to RC alone.

Significance of preoperative butyrylcholinesterase as an independent predictor of survival in patients with muscle-invasive bladder cancer treated with radical cystectomy

OBJECTIVES

Butyrylcholinesterase (BChE) is an alpha-glycoprotein found in the nervous system and liver. Its serum level is reduced in many clinical conditions, such as liver damage, inflammation, injury, infection, malnutrition, and malignant disease. In this study, we analyzed the potential prognostic significance of preoperative BChE levels in patients with muscle-invasive bladder cancer (MIBC) undergoing radical cystectomy (RC).

METHODS AND MATERIALS

We retrospectively evaluated 327 patients with MIBC who underwent RC from 1996 to 2013 at a single institution. Serum BChE level was routinely measured before operation in all patients. Covariates included age, gender, preoperative laboratory data (anemia, BChE, lactate dehydrogenase, and C-reactive protein), clinical T (cT) and N stage (cN), tumor grade, and RC with/without neoadjuvant chemotherapy. Univariate and multivariate analyses were performed to identify clinical factors associated with overall survival (OS) and disease-free survival (DFS). Univariate analyses were performed using the Kaplan-Meier and log-rank methods, and the multivariate analysis was performed using a Cox proportional hazard model.

RESULTS

The median BChE level was 187 U/l (normal range: 168-470 U/l). The median age of the enrolled patients was 69 years, and the median follow-up period was 51 months. The 5-year OS and DFS rates were 69.6% and 69.3%, respectively. The 5-year OS rates were 90.1% and 51.3% in the BChE ≥ 168 and<168 U/l groups, respectively (P<0.001). The 5-year DFS rates were 83.5% and 55.4% in the BChE ≥ 168 and ≤167 U/l groups, respectively (P<0.001). In the univariate analysis, BChE, cT, cN, and RC with/without neoadjuvant chemotherapy were significantly associated with both OS and DFS. Multivariate analysis revealed that BChE was the factor most significantly associated with OS, and BChE, cT, and cN were significantly associated with DFS.

CONCLUSIONS

This study validated preoperative serum BChE levels as an independent prognostic factor for MIBC after RC.

Neoadjuvant gemcitabine and carboplatin followed by immediate cystectomy may be associated with a survival benefit in patients with clinical T2 bladder cancer

Neoadjuvant cisplatin-based chemotherapy for muscle-invasive bladder cancer (MIBC) is more beneficial for clinical T3/4 than clinical T2 (cT2) disease. The aim of this study was to assess whether neoadjuvant GCarbo has a survival impact on cT2 bladder cancer. We retrospectively reviewed the medical records of 363 consecutive patients who underwent radical cystectomy (RC) between April 1997 and May 2012. We focused on 150 patients with cT2 MIBC. Seventy-nine patients received neoadjuvant GCarbo between March 2005 and April 2013. These patients received two courses of GCarbo and RC, and bilateral pelvic lymph node dissection (PLND) was performed at an interval of 1 month after chemotherapy. The control cohort included 71 patients with cT2 bladder cancer treated with RC and bilateral PLND alone between May 1994 and May 2007. Propensity score matching was used to adjust for potential selection biases associated with the treatment types. The endpoints were overall (OS), disease-specific (DSS), and disease-free survival (DFS). Propensity score-matched analysis resulted in 71 matched pairs from both groups. The 5-year OS rate was 98.6 % for the neoadjuvant GCarbo group and 66.6 % for the RC-alone group (p < 0.0001). The 5-year DSS rate was 100 % for the neoadjuvant GCarbo group and 69.7 % for the RC-alone group (p < 0.0001). The 5-year DFS rate was 94.2 % for the neoadjuvant GCarbo group and 72.7 % for the RC-alone group (p < 0.0001). In cT2 MIBC patients, neoadjuvant GCarbo chemotherapy followed by immediate cystectomy may improve OS and DFS compared to RC alone.