Long-term Outcomes from Re-resection for High-risk Non–muscle-invasive Bladder Cancer: A Potential to Rationalize Use

The impact of second transurethral resection on survival outcomes in patients with non-muscle-invasive bladder cancer treated with bacillus Calmette-Guérin therapy

OBJECTIVE

Several guidelines recommended that second transurethral resection should be performed in patients with diagnosis of high-risk non-muscle-invasive bladder cancer. However, therapeutic benefits of second transurethral resection before bacillus Calmette-Guérin intravesical instillation were conflicting amongst previous studies. We investigated the prognostic impact of second transurethral resection before bacillus Calmette-Guérin instillation in high-risk non-muscle-invasive bladder cancer patients.

METHODS

This retrospective study included 3104 non-muscle-invasive bladder cancer patients who received bacillus Calmette-Guérin instillations between 2000 and 2019 at 31 collaborative institutions. Univariate and multivariate Cox proportional hazards models were used to assess the risk factors of intravesical recurrence, disease progression, cancer-specific mortality and overall mortality.

RESULTS

In the entire population, patients undergoing second transurethral resection (33%, 1026/3104) had a lower risk of intravesical recurrence on univariate analysis (hazard ratio 0.85, 95% confidence interval 0.73-0.98, P = 0.027), although it did not remain significant on multivariate analysis (hazard ratio 0.90, 95% confidence interval 0.76-1.07, P = 0.24). Subgroup analysis revealed that, in pT1 patients (n = 1487), second transurethral resection was significantly correlated with a lower risk of intravesical recurrence on multivariate analysis (hazard ratio 0.80, 95% confidence interval 0.64-1.00, P = 0.048), but lower risks of disease progression (hazard ratio 0.75, 95% confidence interval 0.56-1.00, P = 0.049), cancer-specific mortality (hazard ratio 0.54, 95% confidence interval 0.35-0.85, P = 0.007) and overall mortality (hazard ratio 0.73, 95% confidence interval 0.55-0.97, P = 0.027) on univariate analysis.

CONCLUSIONS

Second transurethral resection confers accurate pathological staging and could be used to safely select good candidates for intravesical bacillus Calmette-Guérin instillation. We further confirm that second transurethral resection could confer an oncological benefit in pT1 bladder cancer patients treated by bacillus Calmette-Guérin instillation, and so strongly recommend second transurethral resection in this patient population.

Repeat Transurethral Resection for Non-muscle-invasive Bladder Cancer: An Updated Systematic Review and Meta-analysis in the Contemporary Era

CONTEXT

Repeat transurethral resection (reTUR) is a guideline-recommended treatment strategy in high-risk non-muscle-invasive bladder cancer (NMIBC) patients treated with transurethral resection of bladder tumor (TURBT); however, the impact of recent procedural/technological developments on reTUR outcomes has not been assessed yet.

OBJECTIVE

To assess the outcomes of reTUR for NMIBC in the contemporary era, focusing on whether temporal differences and technical advancement, specifically, photodynamic diagnosis and en bloc resection of bladder tumor (ERBT), affect the outcomes.

EVIDENCE ACQUISITION

Multiple databases were queried in February 2023 for studies investigating reTUR outcomes, such as residual tumor and/or upstaging rates, its predictive factors, and oncologic outcomes, including recurrence-free (RFS), progression-free (PFS), cancer-specific (CSS), and overall (OS) survival. We synthesized comparative outcomes adjusting for the effect of possible confounders.

EVIDENCE SYNTHESIS

Overall, 81 studies were eligible for the meta-analysis. In T1 patients initially treated with conventional TURBT (cTURBT) in the 2010s, the pooled rates of any residual tumors and upstaging on reTUR were 31.4% (95% confidence interval [CI]: 26.0-37.2%) and 2.8% (95% CI: 2.0-3.8%), respectively. Despite a potential publication bias, these rates were significantly lower than those in patients treated in the 1990-2000s (both p < 0.001). ERBT and visual enhancement-guided cTURBT significantly improved any residual tumor rates on reTUR compared with cTURBT based on both matched-cohort and multivariable analyses. Among studies adjusting for the effect of possible confounders, patients who underwent reTUR had better RFS (hazard ratio [HR]: 0.78, 95% CI: 0.62-0.97) and OS (HR: 0.86, 95% CI: 0.81-0.93) than those who did not, while it did not lead to superior PFS (HR: 0.74, 95% CI: 0.47-1.15) and CSS (HR: 0.94, 95% CI: 0.86-1.03).

CONCLUSIONS

reTUR is currently recommended for high-risk NMIBC based on the persistent high rates of residual tumors after primary resection. Improvement of resection quality based on checklist applications and recent technical/procedural advancements hold the promise to omit reTUR.

PATIENT SUMMARY

Recent endoscopic/procedural developments improve the outcomes of repeat resection for high-risk non-muscle-invasive bladder cancer. Further investigations are urgently needed to clarify the potential impact of the use of these techniques on the need for repeat transurethral resection in the contemporary era.

A Restaging Transurethral Resection of Bladder Tumor Is Always Necessary For High-grade T1 Non-muscle-invasive Bladder Cancer

Patients with high-grade T1 non-muscle-invasive bladder cancer (NMIBC) have a high risk of recurrence and upstaging. Restaging transurethral resection of bladder tumor allows better staging so that patients can proceed to the appropriate treatment in a timely manner. This should be done in all patients with high-grade T1 NMIBC.

To determine correlation between VIRADS scoring and pathological staging in bladder cancer: A prospective study and review of literature

The development of standardized reporting systems is of paramount importance in medical-imaging. Based on the "RADS" methodology, PIRADS and BI-RADS have been successfully used. The management of bladder cancer (BC) depends on the stage at the time of identification. Accurate assessment of the muscle-invasive stage can alter therapies that are radically different. MRI can accurately diagnose this in a standardized manner (Vesical Imaging-Reporting and Data System: VIRADS) and spare additional procedures. The aim of the study is to determine diagnostic accuracy of VIRADS scoring in evaluation of muscle invasiveness in patients with BC. This study was conducted in a single center over a period of 2 years from April 2020. A total of 76 patients with bladder SOL/diagnosed BC were included. Final VIRADS scoring was calculated and compared with histopathological report.76 patients were evaluated which included 64 males and 12 females. Most of the cases came under the VIRADS-II category (23, 30.26%) followed by VIRADS-V (17, 22.36%). VIRADS-I was reported in 14 cases (18.42%). A total of 8 cases (10.52 %) were reported as VIRADS III and 14 cases (18.42%) as VIRADS IV. VIRADS-III was taken as cut off and found to have a sensitivity of 94.44%, a specificity of 87.50%, a positive predictive value of 87.17% and a negative predictive value of 94.59%. Though number of cases are still less to accurately predict test characteristics of VIRADS, our results are consistent with previously done retrospective studies and VIRADS has got good correlation with pathological staging.

Precise diagnosis and treatment of non-muscle invasive bladder cancer - A clinical perspective

According to the guidelines, transurethral resection of bladder tumor (TURBT) followed by intravesical therapy remains the standard strategy for the management of non-muscle invasive bladder cancer (NMIBC). However, even if patients receive standard strategy, the risk of postoperative recurrence and progression is high. From the clinical perspective, the standard strategy needs to be optimized and improved. Compared to conventional TURBT, the technique of en bloc resection of bladder tumor (ERBT) removes the tumor tissue in one piece, thus following the principles of cancer surgery. Meanwhile, the integrity and spatial orientation of tumor tissue is protected during the operation, which is helpful for pathologists to make accurate histopathological analysis. Then, urologists can make a postoperative individualized treatment plan based on the patient's clinical characteristics and histopathological results. To date, there is no strong evidence that NMIBC patients treated with ERBT achieve better oncological prognosis, which indicates that ERBT alone does not yet improve patient outcomes. With the development of enhanced imaging technology and proteogenomics technology, en bloc resection combined with these technologies will make it possible to achieve precise diagnosis and treatment of bladder cancer. In this review, the authors analyze the current existing shortcomings of en bloc resection and points out its future direction, in order to promote continuous optimization of the management strategy of bladder cancer.

An Evaluation of Peer-Rated Surgical Skill and its Relationship With Detrusor Muscle Sampling in Transurethral Resection of Bladder Tumor

OBJECTIVE

To assess the reliability of peer-review of TURBT videos as a means to evaluate surgeon skill and its relationship to detrusor sampling.

METHODS

Urologists from an academic health system submitted TURBT videos in 2019. Ten blinded peers evaluated each surgeon's performance using a 10-item scoring instrument to quantify surgeon skill. Normalized composite skill scores for each surgeon were calculated using peer ratings. For surgeons submitting videos, we retrospectively reviewed all TURBT pathology results (2018-2019) to assess surgeon-specific detrusor sampling. A hierarchical logistic regression model was fit to evaluate the association between skill and detrusor sampling, adjusting for patient and surgeon factors.

RESULTS

Surgeon skill scores and detrusor sampling rates were determined for 13 surgeons performing 245 TURBTs. Skill scores varied from -6.0 to 5.1 [mean: 0; standard deviation (SD): 2.40]. Muscle was sampled in 72% of cases, varying considerably across surgeons (mean: 64.5%; SD: 30.7%). Among 8 surgeons performing >5 TURBTs during the study period, adjusted detrusor sampling rate was associated with sending separate deep specimens (odds ratio [OR]: 1.97; 95% confidence interval [CI]: 1.02-3.81, P = .045) but not skill (OR: 0.81; 95% CI: 0.57-1.17, P = .191).

CONCLUSION

Surgeon skill was not associated with detrusor sampling, suggesting there may be other drivers of variability of detrusor sampling in TURBT.

Application of Vesical Imaging-Reporting and Data System in Evaluation of Urinary Bladder Cancer Using Multiparametric Magnetic Resonance Imaging: A Hospital-Based Cross-Sectional Study

Background  Multiparametric magnetic resonance imaging (mp-MRI) of urinary bladder (UB) is a novel imaging to predict detrusor muscle invasion in Bladder cancer (BC). The Vesical Imaging-Reporting and Data System (VI-RADS) was introduced in 2018 to standardize the reporting of BC with mp-MRI and to diagnose muscle invasion. This study was performed to evaluate the role of mp-MRI using VI-RADS to predict muscle invasive BC. Methods  This prospective study was carried from June 2020 to May 2021 in a tertiary care institute. Thirty-six patients with untreated BC underwent mp-MRI followed by transuretheral resection of the tumor (TURBT). Mp-MRI findings were evaluated by two radiologists and BC was categorized according to VI-RADS scoring system. Resected tumors along with separate biopsy from the base were reported by two pathologists. Histopathological findings were compared with VI-RADS score and the performance of VI-RADS for determining detrusor muscle invasion was analyzed. Results  VI-RADS scores of 4 and 5 were assigned to 9 (25%) and 15 (41.7%) cases, respectively, while 4 (13.3%) cases had VI-RADS score 3 on mp-MRI. VI-RADS 1 and 2 lesions were observed in six (16.7%) and two (5.5%) cases, respectively. On histopathology, 23 cases (63.9%) had muscle-invasive cancer and 13 cases (36.1%) had non-muscle-invasive cancer. The sensitivity and diagnostic accuracy of mp-MRI in predicting muscle invasive BC was 95.6 and 80.6%, respectively. Conclusion  Mp-MRI has high sensitivity and diagnostic accuracy in predicting muscle invasive BC and should be advocated for evaluation of BC prior to surgery.

Can a reresection be avoided after initial en bloc resection for high-risk nonmuscle invasive bladder cancer? A systematic review and meta-analysis

Background

This study aims to evaluate the effectiveness of en bloc resection for patients with nonmuscle invasive bladder cancer (NMIBC) and explore whether a reresection can be avoided after initial en bloc resection.

Material and methods

We conducted research in PubMed, EMBASE, Cochrane Library, and Web of Science up to October 12, 2021, to identify studies on the second resection after initial en bloc resection of bladder tumor (ERBT). R software and the double arcsine method were used for data conversion and combined calculation of the incidence rate.

Results

A total of 8 studies involving 414 participants were included. The rate of detrusor muscle in the ERBT specimens was 100% (95%CI: 100%–100%), the rate of tumor residual in reresection specimens was 3.2% (95%CI: 1.4%–5.5%), and the rate of tumor upstaging was 0.3% (95%CI: 0%–1.5%). Two articles compared the prognostic data of the reresection and non-reresection groups after the initial ERBT. We found no significant difference in the 1-year recurrence-free survival (RFS) rate (OR = 1.44, 95%CI: 0.67–3.09, P = 0.35) between the two groups nor in the rate of tumor recurrence (OR = 0.72, 95%CI: 0.44–1.18, P = 0.2) or progression (OR = 0.98, 95%CI: 0.33–2.89, P = 0.97) at the final follow-up.

Conclusions

ERBT can almost completely remove the detrusor muscle of the tumor bed with a very low postoperative tumor residue and upstaging rate. For high-risk NMIBC patients, an attempt to appropriately reduce the use of reresection after ERBT seems to be possible.

The Safety and Efficacy of Vela Laser En-Bloc Endoscopic Resection versus Conventional Transurethral Resection of Bladder Tumor-A Single Center Experience

(1) Background: The current gold standard treatment of bladder cancer is conventional transurethral resection of the bladder tumor (CTURBT) using monopolar or bipolar resectoscopes. Laser en-bloc resection of the bladder tumor (LERBT) could achieve a higher quality of the specimen, reduce perioperative complications, and decrease the recurrence rate. Here, we compare the efficacy and safety of en-bloc Vela laser resection versus the conventional monopolar/bipolar resection; (2) Methods: A total of 100 clinically cT1-2 patients with bladder cancer were retrospectively reviewed in this study. Among these patients, 50 patients received LERBT, and 50 patients received CTURBT. The baseline characteristics, operation variables, and clinical outcomes were collected. The primary performance was the presence of muscle layer in the specimen. Perioperative complications and recurrence-free survival (RFS) were also compared. Independent t-test, Chi-square test, Kaplan–Meier curves, and the Cox-regression model were used in the analysis; (3) Results: The median age of the patients in the laser and resectoscope groups was 69.2 and 68.0 years old, respectively. The statistical difference in the presence of the detrusor muscle was 92.0% in the laser group and 70.0% in the CTURBT group (p = 0.005). A lower incidence of bladder perforation (p = 0.041) and major surgical complications (p = 0.046) in the LEBRT group was observed. We found no differences in operation duration, catheterization time, and hospitalization time after adjustment. Additionally, there was no statistical difference in RFS after a median follow-up time of 25 months; (4) Conclusions: Endoscopic laser en-bloc resection of bladder tumor with Vela laser is an effective method with higher muscle inclusion rate and fewer complications.

What is the impact of dynamic contrast-enhancement sequence in the Vesical Imaging, Reporting and Data System (VI-RADS)? A subgroup analysis

Background

A scoring system focusing on the risk of muscle layer invasion by Bladder cancer (BCa) has been released, Vesical Imaging - Radiological and Data System (VI-RADS), with a growing interest in evaluating its diagnostic accuracy.

Our goal was to assess the accuracy and reproducibility of the VI-RADS score for assessment of the vesical muscular layer with (multiparametric-mp) and without (biparametric-bp) a dynamic-contrast enhancement (DCE) sequence.

Methods

Retrospective study conducted from July 2018 to July 2020. All patients had suspicions of BCa and underwent Magnetic Resonance Imaging (MRI) before any intervention. MRI was interpreted by two radiologists with different levels of experience, and a VI-RADS score assigned in two different sessions (3 months apart) without and with DCE. After exclusions, 44 patients with 50 lesions were enrolled. The standard of reference was transurethral resection in 18 patients (40.9%) and cystectomy in 26 patients (59.1%).

Results

Twenty-five lesions (50%) were muscle-invasive. There was no significant difference between the two groups for gender and presence of a stalk, but mean age of NMIBCa group was significantly higher (p = 0.01). The sizes of lesions were significantly different between groups for both readers at 2.42+/− 1.58 vs. 5.70+/− 2.67 cm for reader 1 (p < 0.0001) and 2.37+/− 1.50 vs. 5.44 +/− 2.90 cm for reader 2 (p = 0.001). The area under the curve (AUC) for muscle invasion with mpVI-RADS, considering all lesions, was 0.885 +/− 0.04 (95% CI-0.79-0.98) for reader 1 and 0.924 +/− 0.04 (0.84–0.99) for reader 2, and for bpVI-RADS was 0.879+/− 0.05 and 0.916 +/− 0.04 (0.85–0.99), respectively, both differences not statistically significant (p = 0.24 and 0.07, respectively). When considering only small lesions (< 3.0 cm), the accuracy for mpVI-RADS was 0.795 +/− 0.11 (0.57–1.0) for reader1, and 0.80 +/− 0.11(0.57–1.0) for reader 2, a non-significant difference (p = 0.56) and for bpVI-RADS was 0.747 +/− 0.12 (0.50–0.99) for reader 1 and 0.80 +/− 0.11(0.57–1.0) for reader 2, a significant difference (p = 0.04). The intraclass correlation coefficient for the final score was 0.81 (0.60–1.0) for mpVI-RADS and 0.85 (0.63–1.0) for bpVI-RADS.

Conclusion

The VI-RADS system was accurate in demonstrating muscle-invasive BCa, for both experienced and less experienced reader, regardless of the use of a DCE sequence. However, when only small lesions were assessed the difference between the two readers was significant only for the biparametric analysis. The reproducibility was similar between multiparametric and biparametric approach.

Retrospective analysis of bladder cancer morphology and depth of invasion under cystoscopy

Background

The pathological diagnosis of bladder cancer workup relies on cystoscopy, however, due to sampling restriction, the depth of local invasion is often understaged.

Methods

A total of 386 patients with bladder urothelial carcinoma underwent follow-up. The data collected included age, sex, tumor size, surgical options, histologic grade, invasive depth, lymph node metastasis, and oncological outcomes, and the patients were divided into coral-like and crumb-like groups. These data were analyzed with the chi-square test, binary logistic regression, Kaplan–Meier analysis, univariable and multivariable logistic regression and Spearman correlation test.

Results

Bladder tumor morphology was moderately correlated with invasion depth (ρ = 0.492, p < 0.001; Spearman correlation), which was associated with invasion status (HR = 8.27; 95% CI 4.3–15.79, p < 0.001). Tumor morphology was not an independent factor for OS but was associated with PFS. Outer invasion depth was an independent factor that was significantly associated with inferior OS and PFS.

Conclusions

Tumor morphology (coral-like and crumb-like) under cystoscopy was related to the depth of invasion. The outer invasive depth of BC was an independent factor that was significantly associated with inferior OS and PFS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12894-022-00958-0.

Treatment Outcomes of High-Risk Non-Muscle Invasive Bladder Cancer (HR-NMIBC) in Real-World Evidence (RWE) Studies: Systematic Literature Review (SLR)

Background

To date, there has been limited synthesis of RWE studies in high-risk non-muscle invasive bladder cancer (HR-NMIBC). The objective of this research was to conduct a systematic review of published real-world evidence to better understand the real-world burden and treatment patterns in HR-NMIBC.

Methods

An SLR was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines with the scope defined by the Population, Intervention Comparators, Outcomes, and Study design (PICOS) criteria. EMBASE, MEDLINE, and Cochrane databases (Jan 2015–Jul 2020) were searched, and relevant congress abstracts (Jan 2018–Jul 2020) identified. The final analysis only included studies that enrolled ≥100 patients with HR-NMIBC from the US, Europe, Canada, and Australia.

Results

The SLR identified 634 RWE publications in NMIBC, of which 160 studies reported data in HR-NMIBC. The average age of patients in the studies was 71 years, and 79% were males. The rates of BCG intravesical instillations ranged from 3% to 86% (29–95% for induction and 8–83% for maintenance treatment). Five-year outcomes were 17–89% recurrence-free survival (longest survival in patients completing BCG maintenance), 58–89% progression-free survival, 71–96% cancer-specific survival (lowest survival in BCG-unresponsive patients), and 28–90% overall survival (lowest survival in patients who did not receive BCG or instillation therapy).

Conclusion

BCG treatment rates and survival outcomes in patients with HR-NMIBC vary in the real world, with better survival seen in patients completing maintenance BCG, responding to treatment, and not progressing to muscle-invasive disease. There is a need to better understand the factors associated with BCG use and discontinuation and for an effective treatment that improves outcomes in HR-NMIBC. Generalization of these results is limited by variations in data collection, reporting, and methodologies used across RWE studies.

Restaging transurethral resection in ta high-grade nonmuscle invasive bladder cancer: a systematic review

PURPOSE OF REVIEW

The role of a re-transurethral resection (TUR) is clearly demonstrated in T1 high-grade nonmuscle invasive bladder cancer. However, its role remains controversial for Ta high-risk tumors and the recent European guidelines stated that the second look procedure could be avoided for these patients despite harboring a high-risk of both disease recurrence and progression. We aimed to evaluate the added benefit on staging, response to bacillus Calmette-Guérin and oncological outcomes of re-TUR in patients with Ta high-grade nonmuscle invasive bladder cancer.

RECENT FINDINGS

Overall, we identified 15 studies, including 3912 patients from which 743 harbored Ta high-grade disease. Delay between first and second TUR was ranging from 2 to 12 weeks (median 5.6 weeks). The rate of residual disease was 52.8% (range 17-67%). The rate of overall upstaging to T1 and muscle-invasive disease were 10.9 and 4.7%, respectively. Although there was a trend toward improvement of recurrence-free survival outcomes, no definitive conclusions can be drawn due to the retrospective design of the studies included.

SUMMARY

Residual tumor is common after initial TUR for Ta high-grade. Re-TUR is useful in reducing the rates of residual disease, may improve staging, response to bacillus Calmette-Guérin and oncological outcomes.

Role of Vesical Imaging-Reporting and Data System in predicting muscle-invasive bladder cancer: A diagnostic meta-analysis

The objective of this study is to systematically evaluate the diagnostic performance of the Vesical Imaging-Reporting and Data System for predicting muscle-invasive bladder cancer. Embase, PubMed and Web of Science were systematically searched from 1 September 2018 to 30 July 2021 to include proper studies. We included studies that included data on Vesical Imaging-Reporting and Data System and their associated pathological findings, and we assessed their quality using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. The pooled sensitivity and specificity were calculated and plotted using hierarchical summary receiver operating characterisijutic modeling. Meta-regression analysis was carried out to detect heterogeneity. A total of 20 studies with 2725 patients were included. When the cut-off point was 3, the pooled sensitivity and specificity were 0.92 (0.89-0.94) and 0.85 (0.78-0.90), respectively, and 0.82 (0.75-0.88) and 0.95 (0.91-0.97), respectively, when the cut-off point was 4. The area under the curve was 0.95 and 0.95, respectively. Heterogeneity was substantially considerable in sensitivity and specificity. All subgroup variables, including patient number, study design, magnetic resonance imaging field strength, number of radiologists, surgery pattern, diffusion-weighted imaging, and dynamic contrast-enhanced magnetic resonance imaging, contributed to sensitivity heterogeneity when the cut-off point was 3 and specificity heterogeneity when the cut-off point was 4. Multiple image acquisition plane of diffusion-weighted imaging achieved a higher sensitivity than single image acquisition plane of diffusion-weighted imaging in both the Vesical Imaging-Reporting and Data System 3 and 4 groups, and higher specificity in the Vesical Imaging-Reporting and Data System 4 group. Another significant source of heterogeneity was the cut-off point. The diagnostic performance of the Vesical Imaging-Reporting and Data System for predicting muscle-invasive bladder cancer was excellent in both cut-off points of the Vesical Imaging-Reporting and Data System 3 and 4. Multiple image acquisition planes of diffusion-weighted imaging should be given more attention in the Vesical Imaging-Reporting and Data System.

Outcomes of bacillus Calmette-Guérin therapy without a maintenance schedule for high-risk non-muscle-invasive bladder cancer in the second transurethral resection era

Objectives

We examined the outcomes of eight weekly bacillus Calmette–Guérin induction therapy after second transurethral resection, and investigated risk factors for intravesical recurrence or disease progression in high‐risk non‐muscle‐invasive bladder cancer patients.

Methods

This retrospective study included 146 high‐risk non‐muscle‐invasive bladder cancer patients who received eight weekly bacillus Calmette–Guérin instillations without a maintenance schedule between 2000 and 2019. Intravesical recurrence‐free and progression‐free survival rates were evaluated using the Kaplan–Meier method. The Cox proportional hazards model was used to identify risk factors.

Results

Pathological T staging in the first transurethral resection was pTa in 56 patients (38.4%), pT1 in 75 (51.4%) and primary carcinoma in situ in 15 (10.2%). A total of 109 (83.2%) with pTa–1 disease underwent second transurethral resection before bacillus Calmette–Guérin induction therapy, and residual disease was detected in 54 (49.5%). The completion rate of eight instillations was 82.2%. The 2‐ and 5‐year intravesical recurrence‐free survival rates were 80.7% and 75.2%, whereas the 2‐ and 5‐year progression‐free survival rates were 85.7% and 82.0%. Recurrent tumors (hazard ratio 6.5830, P = 0.0007) and residual tumors at the second transurethral resection (hazard ratio 4.0337, P = 0.0021) were risk factors for intravesical recurrence. Multiple tumors (hazard ratio 5.8056, P = 0.0302), pT1 disease (hazard ratio 3.7351, P = 0.0447) and residual tumors at second transurethral resection (hazard ratio 3.2552, P = 0.0448) were associated with disease progression.

Conclusions

Accurate disease staging and disease elimination by second transurethral resection followed by eight weekly bacillus Calmette–Guérin instillations achieved good disease control. Our protocol (without a maintenance schedule) after thorough surgical resection has potential as a treatment option in the current bacillus Calmette–Guérin shortage.

Diagnostic benefit of multiparametric MRI over contrast-enhanced CT in patients with bladder cancer: A single-center 1-year experience

PURPOSE

To assess the clinical applicability of local tumor staging in urinary bladder cancer (BC) with preoperative multiparametric MRI (mpMRI) using the five-point Vesical Imaging-Reporting and Data System (VI-RADS) scoring system and to compare it to dual-phase contrast-enhanced computed tomography (CECT).

METHODS

33 patients with primary untreated bladder cancer underwent CECT followed by preoperative multiparametric 3.0 T MRI between July 2019 and August 2020 and were enrolled in this retrospective study. Two radiologists initially performed staging on the CECT image data sets and - blinded to CT results - on subsequent mpMRI. BCs were staged according to the VI-RADS scoring system. Postoperative pathology was correlated to the VI-RADS score and the CECT results. The performance of VI-RADS in determining detrusor muscle invasion was analyzed using a receiver operating characteristic curve. Based on the histopathology, sensitivity, specificity and accuracy for muscle invasiveness between both image modalities were compared using the Chi square test.

RESULTS

A total of 33 patients (29 male, median age 70 years, IQR: 59-81 years) were included. 10 tumors were categorized as non-muscle invasive (30%) and 23 as muscle invasive BC (70%) in final histology. Tumor stages were correctly assigned as being either muscle invasive or non-muscle invasive on both CECT and mpMRI with regard to both early and late stages of BC (Ta-Tis and T3a-T4b). T-stages bordering the histopathologic limits of muscle invasiveness (T1-T2a-b) resulted in overestimation of muscle invasion in 43% of cases (VI-RADS 3-4) for the mpMRI image data sets and in an underestimation of muscle invasion in up to 55.5% of cases analysing the CECT data. Sensitivity and specificity for the determination of muscle invasion in CECT and mpMRI were 80%/80% and 74%/61% for Radiologist#1 and 70%/90% and 83%/70% for Radiologist#2, respectively.

CONCLUSIONS

There are advantages and disadvantages of both CECT and mpMRI when used in the clinical assessment of BC muscular tumor invasion. In borderline cases, only the combination of cross-sectional imaging and histopathological staging may help in making the optimal treatment decisions.

European Association of Urology Guidelines on Non-muscle-invasive Bladder Cancer (Ta, T1, and Carcinoma in Situ)

CONTEXT

The European Association of Urology (EAU) has released an updated version of the guidelines on non-muscle-invasive bladder cancer (NMIBC).

OBJECTIVE

To present the 2021 EAU guidelines on NMIBC.

EVIDENCE ACQUISITION

A broad and comprehensive scoping exercise covering all areas of the NMIBC guidelines since the 2020 version was performed. Databases covered by the search included Medline, EMBASE, and the Cochrane Libraries. Previous guidelines were updated, and the level of evidence and grade of recommendation were assigned.

EVIDENCE SYNTHESIS

Tumours staged as Ta, T1 and carcinoma in situ (CIS) are grouped under the heading of NMIBC. Diagnosis depends on cystoscopy and histological evaluation of tissue obtained via transurethral resection of the bladder (TURB) for papillary tumours or via multiple bladder biopsies for CIS. For papillary lesions, a complete TURB is essential for the patient's prognosis and correct diagnosis. In cases for which the initial resection is incomplete, there is no muscle in the specimen, or a T1 tumour is detected, a second TURB should be performed within 2-6 wk. The risk of progression may be estimated for individual patients using the 2021 EAU scoring model. On the basis of their individual risk of progression, patients are stratified as having low, intermediate, high, or very high risk, which is pivotal to recommending adjuvant treatment. For patients with tumours presumed to be at low risk and for small papillary recurrences detected more than 1 yr after a previous TURB, one immediate chemotherapy instillation is recommended. Patients with an intermediate-risk tumour should receive 1 yr of full-dose intravesical bacillus Calmette-Guérin (BCG) immunotherapy or instillations of chemotherapy for a maximum of 1 yr. For patients with high-risk tumours, full-dose intravesical BCG for 1-3 yr is indicated. For patients at very high risk of tumour progression, immediate radical cystectomy should be considered. Cystectomy is also recommended for BCG-unresponsive tumours. The extended version of the guidelines is available on the EAU website at https://uroweb.org/guideline/non-muscle-invasive-bladder-cancer/.

CONCLUSIONS

These abridged EAU guidelines present updated information on the diagnosis and treatment of NMIBC for incorporation into clinical practice.

PATIENT SUMMARY

The European Association of Urology has released updated guidelines on the classification, risk factors, diagnosis, prognostic factors, and treatment of non-muscle-invasive bladder cancer. The recommendations are based on the literature up to 2020, with emphasis on the highest level of evidence. Classification of patients as having low, intermediate, or and high risk is essential in deciding on suitable treatment. Surgical removal of the bladder should be considered for tumours that do not respond to bacillus Calmette-Guérin (BCG) treatment and tumours with the highest risk of progression.

Clinicopathological patterns of bladder carcinoma over 1 year: experience from University Hospital of Nepal

PURPOSE

To define the clinical and pathological patterns of urinary bladder carcinoma from the University Hospital of Nepal.

METHODS

This is a retrospective analytical study. Patients with bladder mass who underwent surgery over 1 year and who had data record were included in the study. Demographic profile, type of surgery, findings on clinical examination, cystoscopy findings, histopathological report, tumor stage, and post-surgery adjuvant therapy were analyzed.

RESULTS

Out of 86 patients who underwent transurethral resection of bladder tumor, 77 patients had biopsy-proven malignant bladder tumor. Urothelial cancer was present in 96.1%. Male were 78.6%. The mean age of diagnosis was 65.5 ± 11.8 years. Non-muscle-invasive bladder cancer (NMIBC) was 3.7 times more common than muscle-invasive bladder cancer (MIBC). High-grade tumors (58.6%) were more common than low grade (41.4%). The detrusor muscle was present inthe biopsy specimen of 48 patients (64%). Re-TURBT within 2-6 weeks was considered based on histopathology reports for about half of the patients (45.3%). Upstaging and upgrading of the tumor was present in 5.8 and 5.8% of the patients, respectively. Residual tumor without upstaging and upgrading was present in 23.5%. One patient (1.3%) had Clavien-Dindo grade 1, three (4%) patients had grade 2 and two patients (2.7%) had grade 3b.

CONCLUSION

In the present study, patients with bladder cancer are younger than reported in other studies. Smokers are strongly predisposed. The histological pattern is similar to the Western and Asian populations. NMIBC and MIBC occur in proportion to that described as in other studies. We had a lower rate of recurrence, upstaging and upgrading. We had a lesser rate of acceptance for radical cystectomy in our patients.

Clinical outcomes of reresection in patients with high-risk nonmuscle-invasive bladder cancer treated with en bloc transurethral resection: a retrospective study with a 1-year follow-up

Purpose To evaluate the impact of reresection on the clinical outcome in patients with primary high-risk nonmuscle-invasive bladder cancer (NMIBC) who initially received en bloc transurethral resection. Methods A retrospective analysis of data on eligible high-risk NMIBC with en bloc resection from June 2015 to June 2019 was performed. Patients were divided into two groups based on the presence or absence of reresection after the initial en bloc resection. The primary study endpoint was recurrence-free survival. The secondary outcomes were the residual rate of the tumor after initial en bloc resection, tumor upstaging rate and progression-free survival. Results We identified 115 eligible patients, including 51 (44.3%) who underwent reresection within 6 weeks of the initial en bloc resection and 64 (55.7%) who did not undergo en bloc reresection after the initial en bloc resection. The clinicopathological features were similar in patients with or without reresection. On finding tumor residues after the first en bloc resection, there were 3 cases (5.9%) in the reresection group compared to 2 cases (3.1%) in the non-reresection group (P=0.473). Two patients (3.9%) in the reresection group had tumor progression to muscle-invasive bladder cancer, whereas one patient (1.6%) in the non-reresection group exhibited tumor progression (P=0.430). The 1-year recurrence-free survival rate was 94.1% in the reresection group and 90.6% in the non-reresection group (P=0.269). In multivariate analysis, multifocality and T1 staging were independent prognostic factors for recurrence in patients with high-risk NMIBC who underwent en bloc resection. Conclusion In patients with high-risk NMIBC not exceeding 4 cm in diameter with no more than 4 lesions and not in the anterior bladder wall, reresection after en bloc resection seems to have failed to improve the patient's prognosis. However, a randomized controlled clinical study is required to confirm this hypothesis.

Validation of vesical imaging reporting and data system score for the diagnosis of muscle invasive bladder cancer: A prospective cross-sectional study

Objective

Vesical Imaging Reporting and Data System (VIRADS) score was developed to standardize the reporting and staging of bladder tumors on pre-operative multiparametric magnetic resonance imaging. It helps in avoiding unnecessary repeat transurethral resection of bladder tumor in high-risk non-muscle-invasive bladder cancer patients. This study was done to determine the validity of VIRADS score prospectively for the diagnosis of muscle-invasive bladder cancer.

Methods

This study was conducted from March 2019 to March 2020 at Sawai Man Singh Medical College and Hospital, Jaipur, Rajasthan, India. Patients admitted with the provisional diagnosis of bladder tumor were included as participants. All these patients underwent a 3 Tesla mpMRI to obtain a VIRADS score before they underwent transurethral resection of bladder tumor and these data were analyzed to evaluate the correlation of pre-operative VIRADS score with muscle invasiveness of the tumor in final biopsy report.

Results

A cut-off of VIRADS ≥4 for prediction of detrusor muscle invasion yielded a sensitivity of 79.4%, specificity of 94.2%, positive predictive value of 90.0%, negative predictive value of 87.5%, and diagnostic accuracy of 86.4%. A cut off of VIRADS ≥3 for prediction of detrusor muscle invasion yielded a sensitivity of 91.2%, specificity of 78.8%, positive predictive value of 73.8%, negative predictive value of 93.2%, and accuracy of 83.7%. The receiver operating curve showed the area under the curve to be 0.922 (95% confidence interval: 0.862–0.983).

Conclusion

VIRADS score appears to be an excellent and effective pre-operative radiological tool for the prediction of detrusor muscle invasion in bladder cancer.

Detecting Muscle Invasion of Bladder Cancer Using a Proposed Magnetic Resonance Imaging Strategy

BACKGROUND

Accurate evaluation of the invasion depth of tumors with a Vesical Imaging-Reporting and Data System (VI-RADS) score of 3 is difficult.

PURPOSE

To evaluate the diagnostic performance of a new magnetic resonance imaging (MRI) strategy based on the integration of the VI-RADS and tumor contact length (TCL) for the diagnosis of muscle-invasive bladder cancer (MIBC).

STUDY TYPE

Single center, retrospective.

SUBJECTS

A group of 179 patients with a mean age of 67 years (range, 24.0-96.0) underwent multiparametric MRI (mpMRI) before surgery, including 147 (82.1%) males and 32 (17.9%) females. Twenty-four (13.4%), 90 (50.3%), 43 (24.0%), 15 (8.4%), and 7 (3.9%) cases were Ta, T1, T2, T3, and T4, respectively.

FIELD STRENGTH/SEQUENCE

A 1.5 T and 3.0 T, T2-weighted turbo spin-echo (TSE), single-shot echo-planar (SS-EPI), diffusion-weighted imaging (DWI), and T1-weighted volumetric interpolated breath-hold examination (T1-VIBE).

ASSESSMENT

Three radiologists independently graded the VI-RADS score and measured the TCL on index lesion images. A proposed MRI strategy called VI-RADS_TCL was introduced by modifying the VI-RADS score, which was downgraded to VI-RADS 3F (equal to a VI-RADS score of 2) if VI-RADS = 3 and TCL < 3 cm.

STATISTICAL TESTS

Intraclass correlation coefficients (ICCs), Mann-Whitney U test, chi-square tests, receiver operating characteristic (ROC) curves, and 2 × 2 contingency tables were applied.

RESULTS

Inter-reader agreement values were 0.941 (95% CI, 0.924-0.955) and 0.934 (95% CI, 0.916-0.948) for the TCL and VI-RADS score. The TCL was significantly increased in the MIBC group (6.40-6.85 cm) compared with the NMIBC group (1.98-2.45 cm) (P < 0.05). The specificity and positive predictive values (PPV) of VI-RADS_TCL were 82.46%-87.72% and 90.91%-91.59%, which were significantly greater than VI-RADS score (P < 0.05). Additionally, 52.17%-55.88% NMIBC lesions with VI-RADS 3 were downgraded to 3F by using VI-RADS_TCL.

DATA CONCLUSION

The proposed MRI strategy could reduce the false-positive rate of lesions with a VI-RADS score of 3 while retaining sensitivity.

EVIDENCE LEVEL

4 TECHNICAL EFFICACY: 2.

Effects of targeted Notch1 silencing on the biological processes of the T24 and 5637 cells in vitro

The present study aimed to investigate the roles of Notch1 in the biological processes of bladder cancer cells (BCCs) in vitro. Short hairpin (sh)RNA targeting Notch1 was designed and constructed, and the T24 and 5637 BCCs were selected for transfection. The cells were classified into two groups: shRNA negative control (NC) and Notch1 shRNA. MTT and Transwell assays, and flow cytometry were performed to examine the changes in cell proliferation, invasiveness, and apoptosis, respectively. In addition, reverse transcription-quantitative PCR and western blot analysis was used to detect the mRNA and protein expression levels of apoptosis-related proteins (Bax, Bid and Bcl2) and epithelial-mesenchymal transition factors (vimentin and E- and N-cadherin). Compared with that in the shRNA NC group, the Notch1 shRNA group showed significantly decreased cell proliferation rate and invasiveness; increased apoptotic rate; elevated mRNA expression levels of Bad, Bid and E-cadherin; and reduced mRNA expression levels of Bcl2, N-cadherin and vimentin. The trends for protein expression levels were the same as those for mRNA levels. Notch1 silencing inhibited invasion and promoted apoptosis of BCCs.

Transurethral resection of bladder tumour (TURBT)

The goals of transurethral resection of bladder tumour (TURBT) are to identify and eradicate visualized bladder tumour if technically safe and feasible and to obtain a specimen of satisfactory quality to enable accurate histological diagnosis. In the setting of high grade bladder tumour this generally entails the inclusion of detrusor muscle and assessment for the presence of associated carcinoma in situ (CIS), lymphovascular involvement or any variant form of bladder cancer. This will assist in determining risk stratification and prognostication of the bladder cancer and guides further treatment planning. Conversely, if suboptimal TURBT is performed there will be detrimental consequences on patient outcomes in regards to undergrading or understaging, increased recurrence or progression, and subsequently need for further treatments including more invasive interventions. This review article firstly summarises the key principles and complications of TURBT, as well as significance of re-TURBT. We also discuss a number of modifications and advances in detection technology and resection techniques that have shown to improve perioperative as well as pathological and oncological outcomes of bladder cancer. They include enhanced cystoscopy such as blue light cystoscopy (BLC), narrow band imaging (NBI) and en bloc resection of bladder tumour (ERBT) technique using various types of energy source.

Endoscopic Molecular Imaging plus Photoimmunotherapy: A New Strategy for Monitoring and Treatment of Bladder Cancer

Due to the high recurrence and progression rate of non-muscle invasive bladder cancer after transurethral resection of bladder tumor, some new optical imaging technologies have arisen as auxiliary imaging modes for white light cystoscopy to improve the detection rate of small or occult tumor lesions, such as photodynamic diagnosis, narrow-band imaging, and molecular imaging. White light cystoscopy is inadequate and imperfect for bladder cancer detection, and thus residual tumors or coexisting flat malignant lesions, especially carcinoma in situ, would be ignored during conventional resection. The bladder, a hollow organ with high compliance, provides an ideal closed operation darkroom for endoscopic molecular imaging free from interference of external light sources. Also, intravesical instillation of a molecular fluorescent tracer is simple and convenient before surgery through the urethra. Molecular fluorescent tracer has high sensitivity and specificity to tumor cells, and its mediated molecular imaging allows small or occult tumor lesion detection while minimizing false-positive results. Meanwhile, endoscopic molecular imaging provides a real-time and dynamic image during surgery, which helps urologists to perform high-quality and complete tumor resection through accurate judgment of tumor boundaries and depth of invasion. Photoimmunotherapy is a novel molecular targeted therapeutic pattern of photodynamic therapy that kills malignant cells selectively and minimizes the cytotoxicity to normal tissues. The combination of endoscopic molecular imaging and photoimmunotherapy used in initial treatment may avoid the need of repeat transurethral resection in strictly selected patients and improve oncological outcomes such as recurrence-free survival and overall survival after operation.

Transurethral needle electrode resection and transurethral holmium laser resection of bladder cancer

Purpose

The aim of the present study was to explore the efficacy and safety of transurethral needle electrode resection and transurethral holmium laser resection of non-muscular invasive bladder cancer (NMIBC).

Patients and methods

In this prospective, case-control study, patients from the Urinary Surgery or Oncology Department who met the inclusion and exclusion criteria received transurethral needle electrode resection (n = 52) or transurethral holmium laser resection (n = 51).

Results

A total of 103 patients with NMIBC were included in the present study, with 68 males and 35 females. Their mean age was 57.3 years. Sixty-two patients had Ta, 15 patients had T1, and 26 patients had Tis. Operative time, intraoperative blood loss, postoperative gross hematuria time, bladder irrigation time, and postoperative hospitalization time were all significantly lower in the transurethral holmium laser resection group than the transurethral needle electrode resection group. After resection, transurethral holmium laser resection significantly decreased the value of HGF, TSH, and TNF-α versus the transurethral needle electrode resection group. The incidence of obturator reflex was significantly lower in the transurethral holmium laser resection group than the transurethral needle electrode resection group. There was no significant difference in disease-free survival rate and progression-free survival rate between the two groups.

Conclusions

Transurethral holmium laser resection has clinical advantages in the treatment of NMIBC.

Quality Indicators for Bladder Cancer Services: A Collaborative Review

CONTEXT

There is a lack of accepted consensus on what should constitute appropriate quality-of-care indicators for bladder cancer.

OBJECTIVE

To evaluate the optimal management of bladder cancer and propose quality indicators (QIs).

EVIDENCE ACQUISITION

A systematic review was performed to identify literature on current optimal management and potential quality indicators for both non-muscle-invasive (NMIBC) and muscle-invasive (MIBC) bladder cancer. A panel of experts was convened to select a recommended list of QIs.

EVIDENCE SYNTHESIS

For NMIBC, preoperative QIs include tobacco cessation counselling and appropriate imaging before initial transurethral resection of bladder tumour (TURBT). Intraoperative QIs include administration of antibiotics, proper safe conduct of TURBT using a checklist, and performing restaging TURBT with biopsy of the prostatic urethra in appropriate cases. Postoperative QIs include appropriate receipt of perioperative adjuvant therapy, risk-stratified surveillance, and appropriate decision to change therapy when indicated (eg, bacillus Calmette-Guerin [BCG] unresponsive). For MIBC, preoperative QIs include multidisciplinary care, selection for candidates for continent urinary diversion, receipt of neoadjuvant cisplatin-based chemotherapy, time to commencing radical treatment, consideration of trimodal therapy as a bladder-sparing alternative in select patients, preoperative counselling with stoma marking, surgical volume of radical cystectomy, and enhanced recovery after surgery protocols. Intraoperative QIs include adequacy of lymphadenectomy, blood loss, and operative time. Postoperative QIs include prospective standardised monitoring of morbidity and mortality, negative surgical margins for pT2 disease, appropriate surveillance after primary treatment, and adjuvant cisplatin-based chemotherapy in appropriate cases. Participation in clinical trials was highlighted as an important component indicating high quality of care.

CONCLUSIONS

We propose a set of QIs for both NMIBC and MIBC based on established clinical guidelines and the available literature. Although there is currently a lack of level 1 evidence for the benefit of implementing these QIs, we believe that the measurement of these QIs could aid in the improvement and benchmarking of optimal care for bladder cancer.

PATIENT SUMMARY

After a systematic review of existing guidelines and literature, a panel of experts has recommended a set of quality indicators that can help providers and patients measure and strive towards optimal outcomes for bladder cancer care.

The Impact of Centralised Services on Metric Reflecting High-quality Performance: Outcomes from 1110 Consecutive Radical Cystectomies at a Single Centre

BACKGROUND

The 2002 National Institute for Health and Care Excellence guidance on centralisation of radical cystectomy (RC) coincided with changes in practice: use of neoadjuvant chemotherapy (NAC) and pelvic lymph node dissection (PLND), and RC for high-risk non-muscle-invasive bladder cancer (HR-NMIBC).

OBJECTIVE

To report the outcomes of RC at a single centre and to compare trends in survival with respect to centralisation and change in RC practice.

DESIGN, SETTING, AND PARTICIPANTS

Data were collected retrospectively between 1 January 1994 and 31 December 2016. Patients with urothelial cell carcinoma (UCC) were selected. Outcomes from 1994 to 2007 (before centralisation, era 1) were compared with those from 2008 to 2016 (after centralisation, era 2).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcome was disease-specific mortality. Secondary outcomes were survival and use of NAC and PLND.

RESULTS AND LIMITATIONS

Overall, 1100 RCs (era 1, 316; era 2, 794) were performed for UCC. Median (interquartile range [IQR]) follow-up was 28.5 (11.9-57.4) mo. RC for NMIBC was 36.2% versus 51.3% (p<0.001), NAC use was 2.2% versus 31.6% (p<0.001), and PLND use was 59.7% versus 76.4% (p<0.001) in era 1 versus era 2. The 30-d (1.6% [era 1] vs 0.8% [era 2], p=0.21) and 90-d (4.1% vs 2.6%, p=0.2) mortality rates did not differ with respect to RC year. Five-year disease-specific survival (DSS) was 56.0% in era 1 versus 79.0% in era 2 (p<0.001). RC for patients aged ≥75 yr was 13.9% versus 28.1% (p<0.001) and 30-d mortality in this group was 4.5% versus 0% (p=0.001) in era 1 versus era 2. The study is limited by its retrospective design.

CONCLUSIONS

Centralisation was associated with higher rates of NAC and PLND use, and increased RC performed for older patients and patients with HR-NMIBC. DSS was higher and RC appeared to be safer for older patients (fewer postoperative mortalities) after centralisation.

PATIENT SUMMARY

We looked at outcomes from bladder removal for bladder cancer. Survival outcomes improved following centralisation of services. Surgery appeared to be safer for older patients, as there were fewer postoperative mortalities after centralisation. Centralisation of radical cystectomy (RC) services was associated with higher rates of neoadjuvant chemotherapy and pelvic lymph node dissection use, and increased usage of RC for older patients with high-risk non-muscle-invasive bladder cancer. Survival outcomes from RC were superior after centralisation and safer for older patients undergoing RC (fewer postoperative mortalities).

Risks from Deferring Treatment for Genitourinary Cancers: A Collaborative Review to Aid Triage and Management During the COVID-19 Pandemic

Context

The coronavirus disease 2019 (COVID-19) pandemic is leading to delays in the treatment of many urologic cancers.

Objective

To provide a contemporary picture of the risks from delayed treatment for urologic cancers to assist with triage.

Evidence acquisition

A collaborative review using literature published as of April 2, 2020.

Evidence synthesis

Patients with low-grade non–muscle-invasive bladder cancer are unlikely to suffer from a 3–6-month delay. Patients with muscle-invasive bladder cancer are at risk of disease progression, with radical cystectomy delays beyond 12 wk from diagnosis or completion of neoadjuvant chemotherapy. Prioritization of these patients for surgery or management with radiochemotherapy is encouraged. Active surveillance should be used for low-risk prostate cancer (PCa). Treatment of most patients with intermediate- and high-risk PCa can be deferred 3–6 mo without change in outcomes. The same may be true for cancers with the highest risk of progression. With radiotherapy, neoadjuvant androgen deprivation therapy (ADT) is the standard of care. For surgery, although the added value of neoadjuvant ADT is questionable, it may be considered if a patient is interested in such an approach. Intervention may be safely deferred for T1/T2 renal masses, while locally advanced renal tumors (≥T3) should be treated expeditiously. Patients with metastatic renal cancer may consider vascular endothelial growth factor targeted therapy over immunotherapy. Risks for delay in the treatment of upper tract urothelial cancer depend on grade and stage. For patients with high-grade disease, delays of 12 wk in nephroureterectomy are not associated with adverse survival outcomes. Expert guidance recommends expedient local treatment of testis cancer. In penile cancer, adverse outcomes have been observed with delays of ≥3 mo before inguinal lymphadenectomy. Limitations include a paucity of data and methodologic variations for many cancers.

Conclusions

Patients and clinicians should consider the oncologic risk of delayed cancer intervention versus the risks of COVID-19 to the patient, treating health care professionals, and the health care system.

Patient summary

The coronavirus disease 2019 pandemic has led to delays in the treatment of patients with urologic malignancies. Based on a review of the literature, patients with high-grade urothelial carcinoma, advanced kidney cancer, testicular cancer, and penile cancer should be prioritized for treatment during these challenging times.

MRI of Bladder Cancer: Local and Nodal Staging

Accurate staging of bladder cancer (BC) is critical, with local tumor staging directly influencing management decisions and affecting prognosis. However, clinical staging based on clinical examination, including cystoscopy and transurethral resection of bladder tumor (TURBT), often understages patients compared to final pathology at radical cystectomy and lymph node (LN) dissection, mainly due to underestimation of the depth of local invasion and the presence of LN metastasis. MRI has now become established as the modality of choice for the local staging of BC and can be additionally utilized for the assessment of regional LN involvement and tumor spread to the pelvic bones and upper urinary tract (UUT). The recent development of the Vesical Imaging-Reporting and Data System (VI-RADS) recommendations has led to further improvements in bladder MRI, enabling standardization of image acquisition and reporting. Multiparametric magnetic resonance imaging (mpMRI) incorporating morphological and functional imaging has been proven to further improve the accuracy of primary and recurrent tumor detection and local staging, and has shown promise in predicting tumor aggressiveness and monitoring response to therapy. These sequences can also be utilized to perform radiomics, which has shown encouraging initial results in predicting BC grade and local stage. In this article, the current state of evidence supporting MRI in local, regional, and distant staging in patients with BC is reviewed. LEVEL OF EVIDENCE: 3 TECHNICAL EFFICACY STAGE: 2 J. Magn. Reson. Imaging 2020;52:649-667.

The rational and benefits of the second look transurethral resection of the bladder for T1 high grade bladder cancer

The second look transurethral resection of the bladder (TURB) represents a fundamental step in the treatment of papillary non-muscle invasive bladder cancer (NMIBC); it is therefore recommended by all guidelines. However, not all the literature agrees on its staging value and its ability to improve oncological outcomes of patients. Therefore, the purpose of this review is to evaluate the strengths and weaknesses of second look TURB, trying to depict its evolving role in the management of high grade NMIBC. Using Medline, a non-systematic review was performed including articles between January 2000 and June 2018. English language original articles, reviews and editorials were selected based on their clinical relevance. To date, TURB seems to be largely inadequate in retrieving a correct diagnosis and in removing all tumor tissue. Second look TURB maximizes staging accuracy, allows to clear residual cancer and yields prognostic advantages allowing key information to identify possible candidates for immediate radical cystectomy for very high risk T1HG tumors. Moreover, it seems to have a therapeutic benefit by improving recurrence- and progression-free survivals. However, few recent large studies showed that these advantages seem to be limited to patients without detrusor muscle present at first resection. Similarly, the presence of residual disease and the risk of upstaging are related to the presence of detrusor muscle in specimen. It could well be that in the future the presence of detrusor muscle would be a quality criteria to avoid an unnecessary second look TURB as shown by recent studies using the en-bloc resection technique. Finally, it has to be underlined that this is a surgical procedure not free of risks and complications and with a non-negligible impact on patients’ quality of life, waiting lists and healthcare costs. Therefore, future studies trying to identify the criteria that may better allow which patients to select for a second look TURB while avoiding an unnecessary intervention with possible risks and associated cost are needed to allow a personalized approach to even this one size fits all strategy.

Multiparametric Magnetic Resonance Imaging for Bladder Cancer: Development of VI-RADS (Vesical Imaging-Reporting And Data System)

CONTEXT

Management of bladder cancer (BC) is primarily driven by stage, grade, and biological potential. Knowledge of each is derived using clinical, histopathological, and radiological investigations. This multimodal approach reduces the risk of error from one particular test, but may present a staging dilemma when results conflict. Multiparametric magnetic resonance imaging (mpMRI) may improve patient care through imaging of the bladder with better resolution of the tissue planes than computed tomography and without radiation exposure.

OBJECTIVE

To define a standardized approach to imaging and reporting mpMRI for BC, by developing a VI-RADS score.

EVIDENCE ACQUISITION

We created VI-RADS (Vesical Imaging-Reporting And Data System) through consensus using existing literature.

EVIDENCE SYNTHESIS

We describe standard imaging protocols and reporting criteria (including size, location, multiplicity, and morphology) for bladder mpMRI. We propose a five-point VI-RADS score, derived using T2-weighted MRI, diffusion-weighted imaging, and dynamic contrast enhancement, which suggests the risks of muscle invasion. We include sample images used to understand VI-RADS.

CONCLUSIONS

We hope that VI-RADS will standardize reporting, facilitate comparisons between patients, and in future years, will be tested and refined if necessary. While we do not advocate mpMRI for all patients with BC, this imaging may compliment pathology or reduce radiation-based imaging. Bladder mpMRI may be most useful in patients with non-muscle-invasive cancers, in expediting radical treatment or for determining response to bladder-sparing approaches.

PATIENT SUMMARY

Magnetic resonance imaging (MRI) scans for bladder cancer are becoming more common and may provide accurate information that helps improve patient care. Here, we describe a standardized reporting criterion for bladder MRI. This should improve communication between doctors and allow better comparisons between patients.

Recurrence, progression and cancer-specific mortality according to stage at re-TUR in T1G3 bladder cancer patients treated with BCG: not as bad as previously thought

PURPOSE

The goals of transurethral resection of a bladder tumor (TUR) are to completely resect the lesions and to make a correct diagnosis to adequately stage and treat the patient. Persistent disease after TUR is not uncommon and is why re-TUR is recommended in T1G3 patients. When there is T1 tumor in the re-TUR specimen, very high risks of progression (82%) have been reported. We analyze the risks of recurrence, progression to muscle-invasive disease and cancer-specific mortality (CSM) according to tumor stage at re-TUR in T1G3 patients treated with BCG.

METHODS

In our retrospective cohort of 2451 T1G3 patients, 934 patients (38.1%) underwent re-TUR. 667 patients had residual disease (71.4%): Ta in 378 (40.5%), T1 in 289 (30.9%) patients. Times to recurrence, progression and CSM in the three groups were estimated using cumulative incidence functions and compared using the Cox regression model.

RESULTS

During a median follow-up of 5.2 years, 512 patients recurred. The recurrence rate was significantly higher in patients with a T1 at re-TUR (P < 0.001). Progression rates differed according to the pathology at re-TUR, 25.3% in T1, 14.6% in Ta and 14.2% in case of no residual tumor (P < 0.001). Similar trends were seen in both patients with and without muscle in the original TUR specimen.

CONCLUSIONS

Patients with T1G3 tumors and no residual disease or Ta at re-TUR have better recurrence, progression and CSM rates than previously reported, with a CSM rate of 13.1 and a 25.3% progression rate in re-TUR T1 disease.

Repeat Transurethral Resection in Non-muscle-invasive Bladder Cancer: A Systematic Review

CONTEXT

Initial treatment for most bladder cancers (BCs) involves transurethral resection (TUR) or tumours. Often more cancer is found after the initial treatment in around half of patients, requiring a second resection. Repeat transurethral resection (reTUR) is recommended for high-risk, non-muscle-invasive bladder cancer (NMIBC) to remove any residual disease and improve cancer outcomes.

OBJECTIVE

To systematically review the practice and therapeutic benefit of an early reTUR for high-risk NMIBC.

EVIDENCE ACQUISITION

A systematic review of original articles was performed using PubMed/Medline and Web of Science databases in December 2016 (initial) and October 2017 (final). We searched the references of included papers.

EVIDENCE SYNTHESIS

We screened 15 209 manuscripts and selected 31 detailing 8409 persons with high-grade Ta and T1BC for inclusion. Detrusor muscle was found at initial TUR histology in 30-100% of cases. Residual tumour at reTUR was found in 17-67% of patients following Ta and in 20-71% following T1 cancer. Most residual tumours (36-86%) were found at the original resection site. Upstaging occurred in 0-8% (Ta to ≥T1) and 0-32% (T1 to ≥T2) of cases. Conflicting data report the impact of reTUR on subsequent recurrence and cancer-specific mortality. Recurrence for Ta was 16% in the reTUR group versus 58% in the non-reTUR group. For T1, recurrence ranged from 18% to 56%, but no clear trend was identified between reTUR and control. No clear relationship between reTUR and progression was found for Ta, although for T1 rates were higher in the non-reTUR group in series with control populations (5/6 studies). Overall mortality was slightly reduced in the reTUR group in two studies with controls (22-30% vs 26-36% [no reTUR]).

CONCLUSIONS

Residual tumour is common after TUR for high-risk NMIBC. The reTUR helps in the diagnosis of this residual cancer and may improve outcomes for cancers initially staged as T1.

PATIENT SUMMARY

Some bladder cancers (BCs) are aggressive but confined to the bladder surface. Initial treatment includes endoscopic resection. More cancer is found after the initial treatment in approximately half of patients. In the aggressive but confined group of BC, a second resection, a few weeks after the first, may help find this residual cancer and improve outcomes, although the evidence quality for this is weak.