Delaying Radical Cystectomy After Neoadjuvant Chemotherapy for Muscle-invasive Bladder Cancer is Associated with Adverse Survival Outcomes

Efficacy and safety of dose-dense gemcitabine plus cisplatin as neoadjuvant chemotherapy for muscle-invasive bladder cancer

OBJECTIVE

The objective of this study was to evaluate the efficacy and safety of dose-dense gemcitabine and cisplatin (ddGC) as neoadjuvant chemotherapy for muscle-invasive bladder cancer (MIBC).

METHODS

Patients with locally advanced MIBC (cT2aN0M0-cT4N1M0) who received ddGC between December 2017 and December 2023 were included. Regimens of ddGC with pegfilgrastim were administered every 2 weeks for 4 cycles, followed by radical cystectomy. The pathological complete response (CR) (pT0N0) and objective response (OR) (

RESULTS

A total of 45 patients (cT2N0, 60%; cT3N0, 22%; cT4N0, 9%; and cTanyN1, 9%) were included. Of the 41 who underwent cystectomy, 38 (92.7%) completed all planned cycles, with a median RDI of 0.96 (interquartile range [IQR], 0.89-1.00). Overall, CR and OR were achieved in 12 (29.3%) and 17 (41.5%) patients, respectively, increasing to 32.4% and 45.9%, respectively, in cN0 patients. Severe AEs (grade ≥ 3) were observed in eight patients (17.8%), including four hematological toxicities. At a median follow-up of 31 months, 2-year DFS and OS were 70.8% and 89.2%, respectively.

CONCLUSION

Neoadjuvant ddGC demonstrated good tolerability, efficacy, and safety, suggesting its potential as a treatment option for MIBC.

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Key Words

• cystectomy
• drug‐related side effects and adverse reactions
• lymph node excision
• neoadjuvant therapy
• urinary bladder neoplasms

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MESH Headings

• Humans
• Urinary Bladder Neoplasms/drug therapy
• Urinary Bladder Neoplasms/pathology
• Urinary Bladder Neoplasms/surgery
• Urinary Bladder Neoplasms/mortality
• Gemcitabine
• Deoxycytidine/analogs & derivatives
• Deoxycytidine/administration & dosage
• Deoxycytidine/adverse effects
• Cisplatin/administration & dosage
• Cisplatin/adverse effects
• Male
• Female
• Aged
• Neoadjuvant Therapy/methods
• Neoadjuvant Therapy/adverse effects
• Middle Aged
• Antineoplastic Combined Chemotherapy Protocols/adverse effects
• Antineoplastic Combined Chemotherapy Protocols/therapeutic use
• Antineoplastic Combined Chemotherapy Protocols/administration & dosage
• Cystectomy
• Neoplasm Invasiveness
• Retrospective Studies
• Treatment Outcome
• Disease-Free Survival
• Chemotherapy, Adjuvant/methods
• Chemotherapy, Adjuvant/adverse effects
• Filgrastim/administration & dosage
• Filgrastim/adverse effects
• Adult
• Polyethylene Glycols

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Affiliation(s)

Yuto Hattori Department of Urology, Kobe City Medical Centre General Hospital, Kobe, Japan
Tasuku Fujiwara Department of Urology, Kobe City Medical Centre General Hospital, Kobe, Japan
Hiroki Hagimoto Department of Urology, Kobe City Medical Centre General Hospital, Kobe, Japan
Hidetoshi Kokubun Department of Urology, Kobe City Medical Centre General Hospital, Kobe, Japan
Shiori Murata Department of Urology, Kobe City Medical Centre General Hospital, Kobe, Japan
Noriyuki Makita Department of Urology, Kobe City Medical Centre General Hospital, Kobe, Japan
Yohei Abe Department of Urology, Kobe City Medical Centre General Hospital, Kobe, Japan
Masashi Kubota Department of Urology, Kobe City Medical Centre General Hospital, Kobe, Japan
Yoichiro Tohi Department of Urology, Kobe City Medical Centre General Hospital, Kobe, Japan
Naofumi Tsutsumi Department of Urology, Kobe City Medical Centre General Hospital, Kobe, Japan
Noboru Shibasaki Department of Urology, Kobe City Medical Centre General Hospital, Kobe, Japan
Koji Inoue Department of Urology, Kobe City Medical Centre General Hospital, Kobe, Japan
Mutsushi Kawakita Department of Urology, Kobe City Medical Centre General Hospital, Kobe, Japan
Toshinari Yamasaki Department of Urology, Kobe City Medical Centre General Hospital, Kobe, Japan

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Addition of neoadjuvant chemotherapy to a 'quadrifecta' composite in radical cystectomy

OBJECTIVES

To evaluate the impact of incorporating neoadjuvant chemotherapy (NAC) into the 'quadrifecta' outcomes composite for reporting outcomes of radical cystectomy (RC) creating a pentafecta score.

PATIENTS AND METHODS

This is a retrospective multicentre analysis of patients treated with RC, with or without NAC, for bladder cancer between 2002 and 2023. The primary outcome was the effect of adding NAC to a quadrifecta outcomes composite on cancer-specific (CSS) and overall survival (OS). The quadrifecta outcomes composite included a yield of ≥16 lymph nodes, negative soft tissue surgical margin, absence of major complication within 30 days from surgery, and no delay in RC.

RESULTS

A total of 590 patients were included in the analyses. A total of 233 (39.5%) patients achieved all quadrifecta outcomes and 82 (13.9%) patients were additionally treated with NAC, achieving the pentafecta. Achieving the quadrifecta outcomes composite was significantly associated with better CSS (hazard ratio [HR] 0.49, 95% confidence interval [CI] 0.32-0.75; P = 0.001) and OS (HR 0.48, 95% CI 0.34-0.69; P < 0.01). The addition of NAC to the quadrifecta composite outcomes significantly improved the discrimination of patients more likely to have better CSS (HR 0.21, 95% CI 0.08-0.57; P = 0.002) and OS (HR 0.26, 95% CI 0.12-0.55; P < 0.01).

CONCLUSION

We propose a new pentafecta that may serve as a tool for standardising outcomes reporting and measuring the quality of RC.

The impact of chemotherapy-naïve open radical cystectomy delay and perioperative transfusion on the recurrence-free survival: A perioperative parameters-based nomogram

Objective

To develop and internally validate a nomogram to predict recurrence-free survival (RFS) including the time to radical cystectomy (RC) and perioperative blood transfusion (PBT) as potential predictors.

Methods

Patients who underwent open RC and ileal conduit between January 1996 to December 2016 were split into developing (n=948) and validating (n=237) cohorts. The time to radical cystectomy (TTC) was defined as the interval between the onset of symptoms and RC. The regression coefficients of the independent predictors obtained by Cox regression were used to construct the nomogram. Discrimination, validation, and clinical usefulness in the validation cohort were assessed by the area under the curve, the calibration plot, and decision curve analysis.

Results

In the developing dataset, the 1-, 5-, and 10-year RFS were 83.0%, 47.2%, and 44.4%, respectively. On multivariate analysis, independent predictors were TTC (hazards ratio [HR] 1.07, 95% confidence interval [CI] 1.05-1.08, p<0.001), PBT (one unit: HR 1.40, 95% CI 1.03-1.90, p=0.03; two or more units: HR 1.72, 95% CI 1.29-2.29, p<0.001), bilateral hydronephrosis (HR 1.54, 95% CI 1.21-1.97, p<0.001), squamous cell carcinoma (HR 0.60, 95% CI 0.45-0.81, p=0.001), pT3-T4 (HR 1.77, 95% CI 1.41-2.22, p<0.001), lymph node status (HR 1.53, 95% CI 1.21-1.95, p<0.001), and lymphovascular invasion (HR 1.28, 95% CI 1.01-1.62, p=0.044). The areas under the curve in the validation dataset were 79.3%, 69.6%, and 76.2%, for 1-, 5-, and 10-year RFS, respectively. Calibration plots showed considerable correspondence between predicted and actual survival probabilities. The decision curve analysis revealed a better net benefit of the nomogram.

Conclusion

A nomogram with good discrimination, validation, and clinical utility was constructed utilizing TTC and PBT in addition to standard pathological criteria.

Longer time to radical cystectomy in patients treated with neoadjuvant chemotherapy is associated with worse oncological outcomes

BACKGROUND

Current muscle-invasive bladder cancer (MIBC) guidelines recommend not delaying radical cystectomy (RC) >3 months after diagnosis as it decreases overall survival (OS). However, literature investigating the impact of delay in RC in patients who receive NAC is limited, especially on a population-based level.

OBJECTIVE

To investigate the association between time from diagnosis of MIBC to RC (TTRC) in patients with urothelial bladder cancer (UBC) treated with NAC and RC and 1) 2-year OS and 2) pathological lymph node status (pN+) in a population-based cohort.

METHODS

Patients were selected from the Netherlands Cancer Registry. The study included 237 patients with cT2-T4aN0M0 UBC, treated with NAC and RC between November 2017 and October 2019. Association between TTRC and OS was assessed using multivariable Cox regression analyses. Schoenfeld and Martingale residuals were used to investigate the proportional hazards assumption and whether a cut-off in the TTRC could be identified. Association between TTRC and pN+ was assessed using multivariable logistic regression analyses.

RESULTS

Median TTRC was 23 weeks (interquartile range (IQR) 19-26). 2-year OS was 67% (95%CI 59%-74%). Each week of delay in the TTRC was independently associated with 2-year OS (HR 1.06; P = 0.03) in the Cox regression analysis. The sensitivity analyses, defining TTRC as the time between last cycle of NAC and RC, revealed that each week of delay between NAC and RC was associated with 2-year OS (Hazard ratio (HR) 1.13; P < 0.0001), and with pN+ (Odds ratio (OR) 1.21; P = 0.01) in the Cox and logistic regression analyses, respectively.

CONCLUSIONS

A longer TTRC is associated with worse oncological outcomes in patients treated with NAC and RC.

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

CONTEXT

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

OBJECTIVE

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

PATIENT SUMMARY

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

Perioperative systemic therapy in muscle invasive bladder cancer: Current standard method, biomarkers and emerging strategies

Bladder cancer ranks as the 10th most common cancer type globally, and muscle-invasive disease accounts for approximately 25% of newly diagnosed bladder cancers. Despite definitive treatment, 50% of patients with muscle-invasive bladder cancer (MIBC) develop metastasis within 2 years, leading to death. Perioperative systemic therapy is generally recommended to control local relapse or distant metastasis after surgical resection for patients with MIBC. Cisplatin-based neoadjuvant chemotherapy followed by radical cystectomy is the current standard treatment to improve oncologic control and survival outcomes. Adjuvant chemotherapy is recommended for patients with pathological T3-4 or positive lymph nodes after radical cystectomy if no neoadjuvant chemotherapy was given. Nonetheless, perioperative systemic therapy is not applied widely because of its toxicity, and less than 25% of patients receive cisplatin-based neoadjuvant chemotherapy. Therefore, the development of predictive biomarkers for neoadjuvant chemotherapy efficacy and alternative effective regimens for cisplatin-ineligible patients are important. Furthermore, recently, novel anticancer agents such as immune checkpoint inhibitors and antibody-drug conjugates have proven survival benefits in the metastatic setting, thereby expanding their therapeutic applications to the perioperative setting for non-metastatic MIBC. Herein, we discuss the current status and future perspectives of perioperative systemic strategies for MIBC.

[Perioperative systemic treatment of urothelial cancer]

In 2020 the number of cases of newly diagnosed urothelial cancer in Germany was approximately 35,000, making urothelial cancer the fifth most common form of cancer in this country in terms of incidence. If systemic recurrence occurs the risk of dying from urothelial cancer is high. For this reason, perioperative concepts that improve the overall survival around curatively intended cystectomy are becoming increasingly more important as part of multimodal concepts for urothelial cancer. In the neoadjuvant setting, platinum-based chemotherapy currently remains the gold standard and can also be used in the adjuvant setting. Recently, immunotherapy has gained in importance for adjuvant treatment. Further innovations, such as the use of immunotherapy in the neoadjuvant setting or combination therapies in both situations can be expected. This article provides insights into the current recommendations and highlights possible new concepts.

Down-regulation and clinical significance of Sorbin and SH3 domain-containing protein 1 in bladder cancer tissues

Bladder cancer (BC) is a common cancer worldwide with a high prevalence. This study was conducted to elucidate the expression and clinical significance of Sorbin and SH3 domain-containing protein 1 (SORBS1) in BC as well as to explore its molecular mechanism in BC tumourigenesis. RNA-sequencing data, microarray, and Immunohistochemistry (IHC) were applied to elucidated the SORBS1 expression at multiple levels. After that, the relationship between tumour-immune infiltration and SORBS1 was also explored. Finally, SORBS1-related genes in BC were identified to perform functional enrichment analyses. The expression integration revealed that the comprehensive expression of SORBS1 at the mRNA level was -1.02 and that at the protein level was -3.73, based on 12 platforms, including 1221 BC and 187 non-BC samples. SORBS1 was negatively correlated with tumour purity (correlation = -0.342, p < 0.001) and positively correlated with macrophage (correlation = 0.358, p < 0.001). The results of enrichment analyses revealed that the most significant biological pathways of SORBS1-related genes were epithelial-mesenchymal transition. SORBS1 was significantly down-regulated in BC and may play a role as tumour suppressor. This study provides new directions and biomarkers for future BC diagnosis.

A Retrospective Analysis of the Challenges of Urothelial Cancer Management during the COVID-19 Pandemic at a Single Academic Center in Romania

The COVID-19 pandemic caused major changes in the healthcare sector due to adaptations required to hospitalize and treat an impressive number of patients. This retrospective study intended to collect reliable information on urothelial cancer patients in Romania. The primary objective was to compare the pre-pandemic and pandemic periods to observe the differences that occurred in the management of patients with urothelial carcinoma. The secondary objective was to determine the risk factors for urothelial cancer progression in the study cohort correlated with the COVID-19 pandemic. All patients that were diagnosed and treated at our clinic with a diagnosis of urothelial carcinoma (transitional cell carcinoma) during 2019-2021 were included in the current study. A total of 1122 eligible unique cases were identified during the study period. The number of patients who underwent intervention in the pre-pandemic year was 421, followed by a 22.6% decrease in 2020 to 326 cases and a 13.1% increase in 2021 to 375 cases. The proportion of muscle-invasive bladder cancer (MIBC) cases was significantly higher during the pandemic years, from 30.5% MIBC cases in 2019 to 37.4% in 2020 and 39.4% in 2021, suggesting a delay in presentations during the pandemic. Stage III and IV (TNM) cases were significantly more frequent, even though approximately 40% of all patients were operated on in stage I. The number of cystectomies increased significantly, from 5.2% in 2019 and 4.3% in 2020 to 10.1% in 2021, while the number of elective surgeries decreased, although no significant difference was observed regarding the in-hospital mortality and disease progression at six months. Patients with stage III and IV at presentation had the highest likelihood of disease progression at six months (HR = 5.61). Distant invasion was the second highest risk factor (HR = 5.13), followed by MIBC type (HR = 2.49). Nevertheless, the duration of hospitalization and year of diagnosis during the COVID-19 pandemic were not significant risk factors for cancer progression at six months. It can be concluded that there was a significant delay in patient presentations in 2020, and we advocate for increased public health awareness for urothelial cancer and increased attention toward the screening and management of these patients in the following years.

Gemcitabine-cisplatin versus MVAC chemotherapy for urothelial carcinoma: a nationwide cohort study

This study assessed the trends in methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC) and gemcitabine-cisplatin (GC) regimens in Korean patients with metastatic urothelial carcinoma (UC) and compared the side effects and overall survival (OS) rates of the two regimens using nationwide population-based data. The data of patients diagnosed with UC between 2004 and 2016 were collected using the National Health Insurance Service database. The overall treatment trends were assessed according to the chemotherapy regimens. The MVAC and GC groups were matched by propensity scores. Cox proportional hazard analysis and Kaplan-Meier analysis were performed to assess survival. Of 3108 patients with UC, 2,880 patients were treated with GC and 228 (7.3%) were treated with MVAC. The transfusion rate and volume were similar in both the groups, but the granulocyte colony-stimulating factor (G-CSF) usage rate and number were higher in the MVAC group than in the GC group. Both groups had similar OS. Multivariate analysis revealed that the chemotherapy regimen was not a significant factor for OS. Subgroup analysis revealed that a period of ≥ 3 months from diagnosis to systemic therapy enhanced the prognostic effects of the GC regimen. The GC regimen was widely used as the first-line chemotherapy in more than 90% of our study population with metastatic UC. The MVAC regimen showed similar OS to the GC regimen but needed greater use of G-CSF. The GC regimen could be a suitable treatment option for metastatic UC after ≥ 3 months from diagnosis.

Implementation of a comprehensive prehabilitation program for patients undergoing radical cystectomy

BACKGROUND

Coordinated preoperative optimization programs for radical cystectomy (RC) are limited and non-comprehensive. We evaluated the feasibility and acceptability of a coordinated, multi-faceted prehabilitation program for RC patients at a high-volume bladder cancer referral center.

METHODS

We performed a narrative literature review for prehabilitation in bladder cancer management as of December 1, 2020, with specific emphasis on examining higher-level evidence sources. We selected domains with the highest level of evidence and recruited a multidisciplinary team of experts to design our program. We implemented a comprehensive prehabilitation program with a pre-defined order set as standard of care for all patients undergoing RC beginning February 1, 2021. Demographic and clinicopathologic data were collected prospectively. Rates of adherence to the prehabilitation program services were analyzed using Stata version 13.

RESULTS

A total of 82 patients were enrolled between February - December 2021, of which 67 (81%) had undergone RC at data cutoff. Mean age was 68 years (SD 11) and 63 (76%) identified as male. Neoadjuvant chemotherapy (NAC) was utilized in 48 (59%) patients. The mean Charlson Comorbidity Index was 3.8 (SD 2.3). 100% of patients were screened for malnutrition, with 82% consuming nutritional supplements. Fifty-two percent of patients attended physical therapy pre-op. The 30-day and 30- to 90-day rates of complications were 56% and 40%, respectively. Resource length of stay (RLOS) declined after implementation of prehabilitation.

CONCLUSIONS

Implementation of a comprehensive prehabilitation program at a high-volume bladder cancer referral center is feasible and has a modest effect on resource consumption and complications in our early experience.

Impact of COVID-19 on Uro-Oncological Patients: A Comprehensive Review of the Literature

Background: The aim of this paper is to discuss the impact of COVID-19 on patients with urological malignancies (prostate cancer, bladder and upper tract urothelial cancer, kidney cancer, penile and testicular cancer) and to review the available recommendations reported in the literature. Methods: A review was performed, through the PubMed database, regarding available recommendations reported in the literature, to identify studies examining the impact of COVID-19 on treatment and clinical outcomes (including upstaging, recurrence, and mortality) for uro-oncological patients. Results: The COVID-19 pandemic dramatically changed the urological guidelines and patients' access to screening programs and follow-up visits. Great efforts were undertaken to guarantee treatments to high-risk patients although follow up was not always possible due to recurrent surges, and patients with lower risk cancers had to wait for therapies. Conclusions: Physically and mentally, uro-oncological patients paid a heavy price during the COVID-19 pandemic. Long term data on the "costs" of clinical decisions made during the COVID-19 pandemic are still to be revealed and analyzed.

Can We Identify Patients in Danger of Delayed Treatment? Management of COVID-19 Pandemic Backlog in Urology Care in Poland

The COVID-19 pandemic had a tremendous impact on healthcare systems around the world. This study aims to research the course of surgical treatment in urology during the pandemic in 2020, evaluate the volume of deferred treatment in urology in Poland, and indicate groups of patients that are especially vulnerable to a delay in the delivery of healthcare services. The National Health Found statistics (NHF) database was searched for information on procedures completed in urology departments from 2015 to 2020. Changes in hospital discharges of adults from 2019 to 2021 were investigated using monthly reports of NHF on patient billing groups. Statistics of PSA, testosterone, and creatinine testing were extracted from NHF reports. Annual changes in the number of surgeries were calculated. Then, the estimation of the expected quantity of procedures without the occurrence of the pandemic was performed using linear regression based on data from 2015 to 2020. The estimation was assumed reliable at R² > 0.8. The difference between collected and estimated data was analysed. In 2020, the volume of radical prostatectomies, cystectomies, and kidney surgeries noted downturns following lockdowns in March and November. All analysed procedures, except radical cystectomy, noted a reduction in the entire year. The declines reached -34% in shockwave lithotripsy, -13% in ureterorenoscopic lithotripsy, -22% in cystolithotripsy, -28% in percutaneous lithotripsy, -12% in transurethral resection of a bladder tumour (TURBT), -31% in transurethral resection of the prostate, -15% in nephrectomy and kidney tumorectomy, and -10% in radical prostatectomy. Among the analysed procedures, only radical cystectomy rates increased 5%. Prostate-specific antigen and creatinine tests fell -17%, and testosterone testing was down -18%. In conclusion, the patients most vulnerable to delayed treatment due to the post-pandemic backlog are those requiring TURBT, kidney cancer operations, and radical prostatectomies. Solving backlogs in urology should prioritise cancer patients and thus requires improved access to cystoscopy, TURBT, diagnoses and surgery of prostate and kidney tumours. Addressing the needs of patients suffering from benign diseases demands appropriate measures to increase the surgical productivity of urology departments.

French AFU Cancer Committee Guidelines - Update 2022-2024: Muscle-Invasive Bladder Cancer (MIBC)

OBJECTIVE

To update the CCAFU recommendations for the management of muscle invasive bladder carcinoma (MIBC).

METHODS

A systematic review (Medline) of the literature from 2020 to 2022 was performed taking account of the diagnosis, treatment options and surveillance of NMIBC and MIBC, while evaluating the references with their levels of evidence.

RESULTS

MIBC is diagnosed after the most complete tumour resection possible. MIBC grading is based on CTU along with chest CT. Multiparametric pelvic MRI could be an alternative. Cystectomy with extensive lymphadenectomy is the gold standard treatment for non-metastatic MIBC. It should be preceded by platinum-based neoadjuvant chemotherapy in patients in good general health with satisfactory renal function. Enterocystoplasty is proposed in men and women in the absence of contraindications and when the urethral resection is negative on extemporaneous examination. Otherwise, transileal cutaneous ureterostomy is the recommended method of urinary diversion. Inclusion of all patients in an ERAS (Enhanced Recovery After Surgery) protocol is recommended. For metastatic MIBC, first line treatment with platinum-based chemotherapy (GC or MVAC) is recommended, if general health (PS>1) and renal function (clearance>60mL/min) so allow (only 50% of the cases). Pembrolizumab immunotherapy has demonstrated an overall survival benefit in second-line treatment.

CONCLUSION

Updating the ccAFU recommendations should contribute to improving patient management, as well as the diagnosis and decision-making concerning MIBC treatment.

A systematic review and meta-analysis on delaying surgery for urothelial carcinoma of bladder and upper tract urothelial carcinoma: Implications for the COVID19 pandemic and beyond

Purpose

The COVID-19 pandemic has led to competing strains on hospital resources and healthcare personnel. Patients with newly diagnosed invasive urothelial carcinomas of bladder (UCB) upper tract (UTUC) may experience delays to definitive radical cystectomy (RC) or radical nephro-ureterectomy (RNU) respectively. We evaluate the impact of delaying definitive surgery on survival outcomes for invasive UCB and UTUC.

Methods

We searched for all studies investigating delayed urologic cancer surgery in Medline and Embase up to June 2020. A systematic review and meta-analysis was performed.

Results

We identified a total of 30 studies with 32,591 patients. Across 13 studies (n = 12,201), a delay from diagnosis of bladder cancer/TURBT to RC was associated with poorer overall survival (HR 1.25, 95% CI: 1.09–1.45, p = 0.002). For patients who underwent neoadjuvant chemotherapy before RC, across the 5 studies (n = 4,316 patients), a delay between neoadjuvant chemotherapy and radical cystectomy was not found to be significantly associated with overall survival (pooled HR 1.37, 95% CI: 0.96–1.94, p = 0.08). For UTUC, 6 studies (n = 4,629) found that delay between diagnosis of UTUC to RNU was associated with poorer overall survival (pooled HR 1.55, 95% CI: 1.19–2.02, p = 0.001) and cancer-specific survival (pooled HR of 2.56, 95% CI: 1.50–4.37, p = 0.001). Limitations included between-study heterogeneity, particularly in the definitions of delay cut-off periods between diagnosis to surgery.

Conclusions

A delay from diagnosis of UCB or UTUC to definitive RC or RNU was associated with poorer survival outcomes. This was not the case for patients who received neoadjuvant chemotherapy.

Neoadjuvant therapy for muscle-invasive bladder cancer: Current clinical scenario, future perspectives, and unsolved questions

Cisplatin-based neoadjuvant chemotherapy (NAC) followed by radical cystectomy is the standard treatment for patients with muscle-invasive bladder cancer (MIBC). However, the implementation of NAC is lower than desirable mainly due to its limited impact on overall survival, patients' comorbidities and the lack of predictive biomarkers to select those patients most likely to benefit from NAC. In the last decade, improved molecular MIBC characterisation, the identification of potential predictive and prognostic biomarkers as well as the incorporation of new effective therapies with a better toxicity profile, such as immunotherapy, has changed the treatment paradigm for MIBC. Therefore, the main goal for the near future is to introduce these clinical and translational advances into routine clinical practice to personalise treatment for each patient and increase the opportunity to implement bladder preservation strategies. The present review focuses on the current status of NAC in MIBC, unsolved questions and future therapeutic approaches.

How Does the COVID-19 Pandemic Influence Histopathological Outcomes for Urologic Cancers?

Objective: The coronavirus disease 2019 (COVID-19) pandemic disrupted all routine health care services and resulted in a significant reconfiguration of urologic cancer services and care pathways across the globe. This study aimed to retrospectively determine the pandemic’s impact on the urologic oncological surgery outcomes at a high-volume referral center.

Materials and methods: We compared the number and histopathological outcomes of urologic oncological procedures in a referral center coded during the pandemic and data of the period before the pandemic as control. Data were extracted from patient files and hospital records. The pathological examination included a complete histopathological staging according to TNM stage.

Results: A total of 683 patients were included in the study, 424 (62%) of which were operated in the pre-pandemic period. There was a 39% decline in urologic oncological surgical activity in the pandemic, mostly in renal and prostate cancer. The mean tumor size was larger in renal cancer patients who underwent surgery during the pandemic (5.6 cm vs 4.5 cm, p=0.002). During the pandemic, more lymph node involvement was seen after radical cystectomy and prostatectomy (50% vs 27.8%, p=0.024 and 12.5% vs 4.5%, p=0.026, respectively). No differences in terms of main pathologic features were observed in patients undergoing radical orchiectomy.

Conclusion: COVID-19 appeared to adversely effect oncologic outcomes in patiens undergone surgery for prostate and bladder cancer. Tumor development induced by a delay in diagnosis may cause severe consequences for patients. Reprioritizion of non-deferrable urologic oncological seems crucial.

Photo-Enhanced Chemotherapy Performance in Bladder Cancer Treatment via Albumin Coated AIE Aggregates

The implementation of cisplatin-based neoadjuvant chemotherapy (NAC) plays a key role in conjunction with surgical resection in preventing bladder cancer progression and recurrence. However, the significant dose-dependent toxic side effects of NAC are still a major challenge. To solve this problem, we developed a photoenhanced cancer chemotherapy (PECC) strategy based on AIEgen ((E)-3-(2-(2-(5-(4-(diphenylamino)phenyl)thiophen-2-yl)vinyl)-1,1-dimethyl-1H-3λ⁴-benzo[e]indol-3-yl)propane-1-sulfonate), which is abbreviated as BITT. Multifunctional BITT@BSA-DSP nanoparticles (NPs) were employed with an albumin-based nanocarrier decorated with the cisplatin(IV) prodrug and loaded to produce strong near-infrared fluorescence imaging (NIR FLI), and they exhibited good photoenhancement performance via photodynamic therapy (PDT) and photothermal therapy (PTT). In vitro results demonstrated that BITT@BSA-DSP NPs could be efficiently taken up by bladder cancer cells and reduced to release Pt (II) under reductase, ensuring the chemotherapy effect. Furthermore, both in vitro and in vivo evaluation verified that the integration of NIR FL imaging-guided PECC efficiently promoted the sensitivity of bladder cancer to cisplatin chemotherapy with negligible side effects. This work provides a promising strategy to enhance the sensitivity of multiple cancers to chemotherapy drugs and even achieve effective treatments for drug-resistant cancers.

Effect of neoadjuvant chemotherapy on overall survival of patients with T2-4aN0M0 bladder cancer: A systematic review and meta-analysis according to EAU COVID-19 recommendation

Purpose

In the context of the COVID-19 outbreak, the European Association of Urology (EAU) guidelines Rapid Reaction Group provided recommendations to manage muscle invasive bladder cancer (MIBC) based on priority levels: neoadjuvant chemotherapy (NAC) should be avoided for patients with T2-3N0M0 MIBC. This meta-analysis aims to evaluate the efficacy of NAC compared with radical cystectomy (RC) alone in improving the overall survival (OS) of patients with T2-4aN0M0 MIBC.

Materials and methods

A systematic review was performed according to the PRISMA guidelines. The PubMed/Medline, EMBASE, and Cochrane Library databases were searched. The primary outcome was OS of patients with T2-4aN0M0 MIBC, and the secondary outcome was OS of patients with only T2N0M0 MIBC.

Results

Eight studies were included in this meta-analysis. Overall, the quality of all studies was relatively high, and little publication bias was demonstrated. The OS was significantly better in the NAC with RC group than in RC alone (HR, 0.79; 95% CI, 0.68–0.92; p = 0.002). A subgroup analysis was performed on only patients with T2N0M0 MIBC, and five studies were included. There was no difference in the OS between the NAC with RC and the RC alone groups (HR, 0.83; 95% CI, 0.69–1.01 p = 0.06).

Conclusions

As recommended by the EAU guidelines Rapid Reaction Group, patients with T2N0M0 MIBC should strongly consider omitting NAC until the end of the COVID-19 pandemic. Whether to omit NAC in T3-4aN0M0 MIBC needs further discussion, and studies targeting only T2-3N0M0 MIBC are expected to proceed further.

Triaging urological surgeries to cope with the coronavirus-19 pandemic

PURPOSE OF REVIEW

The coronavirus-19 (COVID-19) pandemic has led to strains on hospital resources and difficulties in safely and effectively triaging surgical procedures. In this article, we discuss the important considerations for triaging urologic surgeries during a global pandemic, mitigating factors on how to perform surgeries safely, and general guidelines for specific surgeries.

RECENT FINDINGS

Many urological procedures have been cut back due to the pandemic, with benign disease states being most affected whereas oncology cases affected least. Current recommendations in urology triage life-threatening conditions, or conditions that may lead to life-threatening ailments as a priority for treatment during the pandemic. Additionally, published recommendations have been put forth recommending all surgical patients be screened for COVID-19 to protect staff, prevent disease dissemination, and to educate patients on worse outcomes that can occur if infected with COVID-19 in the postoperative period.

SUMMARY

COVID-19 has caused worldwide shortages of healthcare resources and increased the need to ethically triage resources to adequately treat the urologic community. These resource limitations have led to increased wait times and cancellations of many urology surgeries that are considered 'elective'.

Urothelial carcinoma in COVID-19: lessons from a pandemic and their impact on clinical practice

The COVID-19 pandemic has modified the management of urothelial carcinoma (UC). Eighteen months after the onset of the pandemic, a scoping narrative review was able to state that radical cystectomy for UC should not be delayed beyond 10 weeks when neoadjuvant chemotherapy (NAC) was administered and 12 weeks when it was not. NAC should be considered when imminent chemotherapy cannot be performed. Early cystectomy should not be delayed when indicated for patients with high-risk non-MIBC. Patients with non-MIBC should still receive their induction doses of intravesical instillations. Diagnostic cystoscopy should not be deferred in symptomatic patients. Surgical management of upper tract urothelial carcinoma (UTUC) allows for a wider deferral interval.

Impact of COVID-19 on endourology surgical practice in Saudi Arabia: A national multicenter study

OBJECTIVE

To identify the impact of COVID-19 on endourology surgical practice in Saudi Arabia.

METHODS

A retrospective study of seven tertiary hospitals from January 2019 to April 2019, and from January 2020 to April 2020 was performed. Records of urology outpatient department (OPD) visits and endourology procedures in the first third of 2020 were analyzed and compared with those in the first third of 2019, as well as, during the full curfew time, i.e. April 2020 versus April 2019.

RESULTS

Number of OPD visits in the first third of 2020 and 2019 were 19 499 and 26 594, respectively (p<0.001). Number of OPD visits in April 2020 was 1512, with a 78.6% decrease compared to that in April 2019, and among them 1373 (90.8%) were teleclinics. Number of elective procedures in the first third of 2020 has decreased by 34.3% (from 3025 to 1988) compared to that in the first third of 2019 (p<0.001). There were 120 elective procedures in April 2020, 84.1% lower than that in April 2019. Percutaneous nephrolithotomy, shockwave lithotripsy, and transurethral resection of prostate procedures declined by 94.2%, 98.5%, and 93.8%, respectively. Most procedures were performed as day surgery (85.0%). Number of emergency procedures in 2020 have fallen by 9.3% compared to 2019 (p=0.286). Urolithiasis was the commonest pathology (52.6%) presented to the emergency room (52.6%).

CONCLUSION

During COVID-19 pandemic, urology services slashed by >75%, including OPD visits and elective endourology procedures. Most hospitals have changed their strategic preventive measures by increasing the rate of teleclinics and day surgeries.

The Evolving Clinical Management of Genitourinary Cancers Amid the COVID-19 Pandemic

Coronavirus disease-2019 (COVID-19), a disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection, has become an unprecedented global health emergency, with fatal outcomes among adults of all ages throughout the world. There is a high incidence of infection and mortality among cancer patients with evidence to support that patients diagnosed with cancer and SARS-CoV-2 have an increased likelihood of a poor outcome. Clinically relevant changes imposed as a result of the pandemic, are either primary, due to changes in timing or therapeutic modality; or secondary, due to altered cooperative effects on disease progression or therapeutic outcomes. However, studies on the clinical management of patients with genitourinary cancers during the COVID-19 pandemic are limited and do little to differentiate primary or secondary impacts of COVID-19. Here, we provide a review of the epidemiology and biological consequences of SARS-CoV-2 infection in GU cancer patients as well as the impact of COVID-19 on the diagnosis and management of these patients, and the use and development of novel and innovative diagnostic tests, therapies, and technology. This article also discusses the biomedical advances to control the virus and evolving challenges in the management of prostate, bladder, kidney, testicular, and penile cancers at all stages of the patient journey during the first year of the COVID-19 pandemic.

[French ccAFU guidelines - update 2020-2022: bladder cancer]

OBJECTIVE

- To update French guidelines for the management of bladder cancer specifically non-muscle invasive (NMIBC) and muscle-invasive bladder cancers (MIBC).

METHODS

- A Medline search was achieved between 2018 and 2020, notably regarding diagnosis, options of treatment and follow-up of bladder cancer, to evaluate different references with levels of evidence.

RESULTS

- Diagnosis of NMIBC (Ta, T1, CIS) is based on a complete deep resection of the tumor. The use of fluorescence and a second-look indication are essential to improve initial diagnosis. Risks of both recurrence and progression can be estimated using the EORTC score. A stratification of patients into low, intermediate and high risk groups is pivotal for recommending adjuvant treatment: instillation of chemotherapy (immediate post-operative, standard schedule) or intravesical BCG (standard schedule and maintenance). Cystectomy is recommended in BCG-refractory patients. Extension evaluation of MIBC is based on contrast-enhanced pelvic-abdominal and thoracic CT-scan. Multiparametric MRI can be an alternative. Cystectomy associated with extended lymph nodes dissection is considered the gold standard for non-metastatic MIBC. It should be preceded by cisplatin-based neoadjuvant chemotherapy in eligible patients. An orthotopic bladder substitution should be proposed to both male and female patients with no contraindication and in cases of negative frozen urethral samples; otherwise transileal ureterostomy is recommended as urinary diversion. All patients should be included in an Early Recovery After Surgery (ERAS) protocol. For metastatic MIBC, first-line chemotherapy using platin is recommended (GC or MVAC), when performans status (PS <1) and renal function (creatinine clearance >60 mL/min) allow it (only in 50% of cases). In second line treatment, immunotherapy with pembrolizumab demonstrated a significant improvement in overall survival.

CONCLUSION

- These updated French guidelines will contribute to increase the level of urological care for the diagnosis and treatment of patients diagnosed with NMIBC and MIBC.

The "COVID-19 Pandemic Gap" and Its Influence on Oncologic Outcomes of Bladder Cancer

Simple Summary

The COVID-19 pandemic has had a major impact on the entire healthcare system, resulting in severe restrictions of nonemergency clinical services, as well as in the clinical practice of uro-oncology. We performed a retrospective analysis to evaluate outcomes of the COVID-19 pandemic resulting from delayed diagnosis, staging, and treatment of bladder cancer. We showed that the COVID-19 pandemic led to a deferred oncological diagnosis and treatment of bladder cancer. More attention is required to avoid adverse outcomes, with increased rates of advanced and aggressive tumors in patients with primary bladder cancer. Moreover, timely treatment is compulsory in those patients.

Abstract

Coronavirus-19 (COVID-19)-induced effects on deferred diagnosis and treatment of bladder cancer (BC) patients are currently not clarified. The aim of this study was to evaluate outcomes of the COVID-19 pandemic by considering its effects on tumor stage and grade, and to create feasible clinical triage decisions. A retrospective single-center analysis of all patients who underwent diagnostic and surgical procedures due to BC, during January 2019 and December 2020, was performed. Due to COVID-19 lockdowns, significantly fewer (diagnostic and therapeutic) endoscopic procedures were performed in the first 6 months of 2020 compared to 2019 (p = 0.002). In patients with a primary diagnosis of BC, a significant increase of high-grade tumors (p < 0.001), as well as advanced tumor stages (p = 0.014), were noticed during 2020 in comparison to 2019. On the contrary, patients with recurrent BC undergoing risk-adapted surveillance, depending on previous tumor histology, showed no adverse outcomes regarding tumor stage and grade when comparing the pre COVID-19 era with 2020. Thus, more awareness in clinical urologic practice is mandatory to avoid adverse consequences, with increased rates of advanced and aggressive tumors in patients with primary BC. In recurrent BC, an individual risk stratification in order to avoid worse outcomes during the COVID-19 pandemic seems to be justified.

Impact of COVID-19 outbreak on urology surgical waiting lists and waiting lists prioritization strategies in the post-COVID-19 era

Introduction

Methods

Results

Conclusions

[Impact of COVID-19 outbreak on urology surgical waiting lists and waiting lists prioritization strategies in the Post-COVID-19 era]

Introduction

The suspension of most elective surgeries during COVID-19 pandemic caused the lengthening of urology surgical waiting lists. The objective of this study is to evaluate the impact of COVID-19 pandemic on urology surgical waiting list in a high-volume hospital.

Methods

An observational descriptive study was designed. All patients included in the urology surgical waiting list of our high-volume center on May 1st 2020 (46 days after the suspension of elective surgery) were analyzed. Baseline variables, priority on the waiting list, main urological disease, type of scheduled surgery, and waiting time were recorded. Other variables recorded were the presence of a urinary catheter, number of accesses to the emergency department, evidence of COVID-19 infection, number of deaths and their cause. The waiting time for each disease was compared with the time to surgery in 2019.

Results

A total of 350 patients were included. The mean (SD) time on the waiting list was 97.33 (55.47) days. Priority 1 patients, who normally should undergo surgery within 30 days, were on the waiting list for a mean (SD) time of 60.51 (20.14) days. They were mainly patients with ureteral lithiasis (25.6%), high-risk or muscle-invasive bladder cancer (20.9%) and high-risk prostate cancer (13.9%). The mean waiting time had already significantly exceeded the mean time to surgery in 2019 for radical cystectomy (p = 0.04) and URS (p = 0.003).

Conclusions

The suspension of most elective surgeries due to COVID-19 had a significant impact on urology surgical waiting list of our high-volume center, especially in priority 1 group.

Nation-wide analysis of the impact of Covid-19 pandemic on daily urology practice in Turkey

OBJECTIVE

To present a nation-wide analysis of the workload of urology departments in Turkey week-by-week during Covid-19 pandemic.

METHODOLOGY

The centres participating in the study were divided into three groups as tertiary referral centres, state hospitals and private practice hospitals. The number of outpatients, inpatients, daily interventions and urological surgeries were recorded prospectively between 9-March-2020 and 31-May-2020. All these variables were recorded for the same time interval of 2019 as well. The weekly change of the workload of urology during pandemic period was evaluated, also the workload of urology and the distributions of certain urological surgeries were compared between the pandemic period and the same time interval of the year 2019.

RESULTS

A total of 51 centres participated in the study. The number of outpatients, inpatients, urological surgeries and daily interventions were found to be dramatically decreased by the 3rd week of pandemics in state hospitals and tertiary referral centres; however, the daily urological practice were similar in private practice hospitals throughout the pandemic period. When the workload of urology in pandemic period and the same time interval of the year 2019 were compared, a huge decrease was observed in all variables during pandemic period. However, temporary measures like ureteral stenting, nephrostomy placement and percutaneous cystostomy have been found to increase during Covid-19 pandemic compared with normal life.

CONCLUSIONS

Covid-19 pandemic significantly affected the routine daily urological practice likewise other subspecialties and priority was given to emergent and non-deferrable surgeries by urologists in concordance with published clinical guidelines.

Population-based analysis of perioperative chemotherapy use, interventions requiring hospitalization and atheroembolic events among patients with non-metastatic muscle-invasive bladder cancer

Introduction

Utilization of neoadjuvant chemotherapy (NC) in muscle invasive bladder cancer (MIBC) is increasingly recognized as standard of care but trends of use in Ontario remain unknown. Currently, there remains knowledge gaps regarding the effects of perioperative chemotherapy on the rates of interventions requiring hospitalization (IRH) and atheroembolic events (ATEs).

Methods

We conducted a population‐based retrospective study within the province of Ontario over 16 years. Patients with non‐metastatic MIBC receiving surgery only or planned for perioperative chemotherapy were included. Primary outcomes included 2‐year IRH and ATE rates. Univariate/multivariate analysis was used to identify predictors associated with IRHs and ATEs. Cochrane‐Armitage was used to assess treatment trends over time.

Results

Our study included 3281 patients. RC alone occurred in 2030 (60.9%), NC in 974 (29.6%) and adjuvant chemotherapy in 8.4% (n = 277). A total of 490/974 (50.3%) patients whom initiated NC with RC intent failed to undergo RC. This improved to 20.5% by 2015 (p < 0.001). Use of NC increased by an absolute value of 33% (p < 0.001). Overall, 4.2% of patients experienced IRHs and 11.5% ATEs. On multivariate analysis, advanced age and Charlson index score (CI) were strong predictors of outcomes, not timing of perioperative chemotherapy (p < 0.05.)

Conclusion

A total of 29.6% of MIBC patients are planned for NC with 20.5% not progressing to their surgery. Use of NC has substantially increased over time. IRHs and ATEs remain stubbornly high at 4.2% and 11.5% respectively. Older age and higher CI scores are the strongest predictors of IRHs and ATEs (p < 0.05), not perioperative chemotherapy.

Current Management of Localized Muscle-Invasive Bladder Cancer: A Consensus Guideline from the Genitourinary Medical Oncologists of Canada

BACKGROUND: Despite recent advances in the management of muscle-invasive bladder cancer (MIBC), treatment outcomes remain suboptimal, and variability exists across current practice patterns. OBJECTIVE: To promote standardization of care for MIBC in Canada by developing a consensus guidelines using a multidisciplinary, evidence-based, patient-centered approach who specialize in bladder cancer. METHODS: A comprehensive literature search of PubMed, Medline, and Embase was performed; and most recent guidelines from national and international organizations were reviewed. Recommendations were made based on best available evidence, and strength of recommendations were graded based on quality of the evidence. RESULTS: Overall, 17 recommendations were made covering a broad range of topics including pathology review, staging investigations, systemic therapy, local definitive therapy and surveillance. Of these, 10 (59% ) were level 1 or 2, 7 (41% ) were level 3 or 4 recommendations. There were 2 recommendations which did not reach full consensus, and were based on majority opinion. This guideline also provides guidance for the management of cisplatin-ineligible patients, variant histologies, and bladder-sparing trimodality therapy. Potential biomarkers, ongoing clinical trials, and future directions are highlighted. CONCLUSIONS: This guideline embodies the collaborative expertise from all disciplines involved, and provides guidance to further optimize and standardize the management of MIBC.

Can we perform frozen section instead of repeat transurethral resection in bladder cancer?

OBJECTIVE

To confirm frozen section (FS) method for muscularis propria (MP) sampling and to compare the FS method with the ReTUR section (RS) procedure to reduce needing for second resection that can cause waste of time for definitive treatment of muscle-invasive bladder cancer.

METHODS

A total of 27 patients who admitted to our clinic and was performed transurethral resection of bladder tumor (TUR-BT) due to bladder tumor and had an indication of ReTUR were evaluated prospectively in the study. During the first TUR-BT procedure (as permanent section), FS examination was also performed to the patients. ReTUR was performed 2-6 weeks after the first TUR-BT procedure.

RESULTS

Presences of MP were observed in 51.8% and 77.7% of FS and permanent section examinations. In the comparing of the presence of residual tumor in the methods, although 12 of 27 patients were found to have a residual tumor in FS, it was found to be in only 6 of 12 patients in RS. There was no statistical significance between FS and RS methods for MP sampling and detecting of residual tumor.

CONCLUSIONS

FS was found to be a comparable method with the RS method (ReTUR procedure) for the sampling of MP and detecting of residual tumor, despite the limitations in the pathological examination FS. Especially in patients with detected residual tumor after the pathological consultation of FS during the procedure, re-resection can be a choice at the end of the first TUR-BT instead of ReTUR.

Impact of noninvasive down-staging after transurethral resection of bladder tumor plus systemic chemotherapy on bladder-sparing strategy in patients with muscle-invasive bladder cancer

OBJECTIVE

To identify the optimal selection criteria for bladder sparing strategy with transurethral resection of bladder tumor (TURBT) and systemic chemotherapy in patients with muscle-invasive bladder cancer (MIBC).

METHODS

We conducted a retrospective cohort study in 71 patients with MIBC (T2-4aN0M0) who desire to bladder preservation received neoadjuvant chemotherapy (NAC) after maximal TURBT, followed by clinical restaging and second-TURBT. Fifty-eight of 71 patients with no residual tumor on the second-TURBT were placed on conservative management for bladder sparing (BS). Noninvasive down-staging (NID) was defined as cT0/Ta/Tis/T1N0 at first-TURBT after NAC and no residual tumor on second-TURBT. Overall survival (OS) and cystectomy-free survival (CFS) were assessed according to the response of NAC in the BS group by using Kaplan-Meier methods. Cox proportional hazards regression model was used to identify independent variables predicting OS.

RESULTS

At a median follow-up of 40 months 5-year OS and CFS in patients with NID and non-NID were 89.1% versus 20.8% and 84.8% versus 16.7%, respectively. Multivariate analysis showed that the ≥3 cycles of NAC (hazard ratio [HR] 0.14, 95% confidential index [CI] 0.03-0.7; P = 0.017) and achievement of NID (HR 0.11, 95% CI 0.03-0.46, P = 0.002) favorably associated with OS.

CONCLUSIONS

Patients who achieved NID might be optimal candidates for the bladder sparing strategy with maximum TURBT plus NAC followed by second-TURBT.

Nomogram Predicting Bladder Cancer-specific Mortality After Neoadjuvant Chemotherapy and Radical Cystectomy for Muscle-invasive Bladder Cancer: Results of an International Consortium

BACKGROUND

Cisplatin-based neoadjuvant chemotherapy (NAC) for muscle-invasive bladder cancer (MIBC) is associated with improved overall and cancer-specific survival. The post-NAC pathological stage has previously been reported to be a major determinant of outcome.

OBJECTIVE

To develop a postoperative nomogram for survival based on pathological and clinical parameters from an international consortium.

DESIGN, SETTING, AND PARTICIPANTS

Between 2000 and 2015, 1866 patients with MIBC were treated at 19 institutions in the USA, Canada, and Europe. Analysis was limited to 640 patients with adequate follow-up who had received three or more cycles of NAC.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

A nomogram for bladder cancer-specific mortality (BCSM) was developed by multivariable Cox regression analysis. Decision curve analysis was used to assess the model's clinical utility.

RESULTS AND LIMITATIONS

A total of 640 patients were identified. Downstaging to non-MIBC (ypT1, ypTa, and ypTis) occurred in 271 patients (42 %), and 113 (17 %) achieved a complete response (ypT0N0). The 5-yr BCSM was 47.2 % (95 % confidence interval [CI]: 41.2-52.6 %). On multivariable analysis, covariates with a statistically significant association with BCSM were lymph node metastasis (hazard ratio [HR] 1.90 [95% CI: 1.4-2.6]; p < 0.001), positive surgical margins (HR 2.01 [95 % CI: 1.3-2.9]; p < 0.001), and pathological stage (with ypT0/Tis/Ta/T1 as reference: ypT2 [HR 2.77 {95 % CI: 1.7-4.6}; p < 0.001] and ypT3-4 [HR 5.9 {95 % CI: 3.8-9.3}; p < 0.001]). The area under the curve of the model predicting 5-yr BCSM after cross validation with 300 bootstraps was 75.4 % (95 % CI: 68.1-82.6 %). Decision curve analyses showed a modest net benefit for the use of the BCSM nomogram in the current cohort compared with the use of American Joint Committee on Cancer staging alone. Limitations include the retrospective study design and the lack of central pathology.

CONCLUSIONS

We have developed and internally validated a nomogram predicting BCSM after NAC and radical cystectomy for MIBC. The nomogram will be useful for patient counseling and in the identification of patients at high risk for BCSM suitable for enrollment in clinical trials of adjuvant therapy.

PATIENT SUMMARY

In this report, we looked at the outcomes of patients with muscle-invasive bladder cancer in a large multi-institutional population. We found that we can accurately predict death after radical surgical treatment in patients treated with chemotherapy before surgery. We conclude that the pathological report provides key factors for determining survival probability.

Global change of surgical and oncological clinical practice in urology during early COVID-19 pandemic

Objectives

While the coronavirus disease 2019 (COVID-19) pandemic captures healthcare resources worldwide, data on the impact of prioritization strategies in urology during pandemic are absent. We aimed to quantitatively assess the global change in surgical and oncological clinical practice in the early COVID-19 pandemic.

Methods

In this cross-sectional observational study, we designed a 12-item online survey on the global effects of the COVID-19 pandemic on clinical practice in urology. Demographic survey data, change of clinical practice, current performance of procedures, and current commencement of treatment for 5 conditions in medical urological oncology were evaluated.

Results

235 urologists from 44 countries responded. Out of them, 93% indicated a change of clinical practice due to COVID-19. In a 4-tiered surgery down-escalation scheme, 44% reported to make first cancellations, 23% secondary cancellations, 20% last cancellations and 13% emergency cases only. Oncological surgeries had low cancellation rates (%): transurethral resection of bladder tumor (27%), radical cystectomy (21–24%), nephroureterectomy (21%), radical nephrectomy (18%), and radical orchiectomy (8%). (Neo)adjuvant/palliative treatment is currently not started by more than half of the urologists. COVID-19 high-risk-countries had higher total cancellation rates for non-oncological procedures (78% vs. 68%, p = 0.01) and were performing oncological treatment for metastatic diseases at a lower rate (35% vs. 48%, p = 0.02).

Conclusion

The COVID-19 pandemic has affected clinical practice of 93% of urologists worldwide. The impact of implementing surgical prioritization protocols with moderate cancellation rates for oncological surgeries and delay or reduction in (neo)adjuvant/palliative treatment will have to be evaluated after the pandemic.

Electronic supplementary material

The online version of this article (10.1007/s00345-020-03333-6) contains supplementary material, which is available to authorized users.

Impact of the COVID-19 Pandemic on the Urologist's clinical practice in Brazil: a management guideline proposal for low- and middle-income countries during the crisis period

This letter to the Editor aims to provide suggestions and recommendations for the management of urological conditions in times of COVID-19 crisis in Brazil and other low- and middle-income countries. It is important to highlight that one of the main characteristics of this pandemic is the oversaturation of the health system capacity, mostly due to a high demand for personal protective equipment (PPE), Hospital/ICU beds, as well as ventilators. In places with limited resources and where the health care systems are already saturated, such consideration is even more worrisome. Therefore, most worldwide authorities are recommending to avoid, as much as possible, patient's elective visits to hospitals, as well as a judicious use of the operating room in order to mitigate the strain put on the health system. While efforts should be directed to the care of COVID-19 patients, other conditions (especially urgencies and oncological cases) must continue to be assisted. Thus, through a panel of experts, we have prepared a practical guide for Thus, through a panel of experts, we have prepared a practical guide for urologists based on the recommendations from the main Urologic Associations, as well as data from the literature to support the suggested management. We will try to follow the standard guideline recommendations from the American Urological Association (AUA) and European Association of Urology (EAU), with the aim of pursuing the best outcomes possible. However, some recommendations were based on the consensus of the panel, taking into consideration the reality of developing countries and the unprecedented situation caused by the COVID-19 crisis. Most importantly, all recommendations on this manuscript are based on the expectancy of a maximum 3-month duration of the crisis. If this period shall extended, these recommendations will be revised and updated.

Bladder Cancer at the time of COVID-19 Outbreak

The COVID-19 outbreak has led to the deferral of a great number of surgeries in an attempt to reduce transmission of infection, free up hospital beds, intensive care and anaesthetists, and limit aerosol-generating procedures. Guidelines and suggestions have been provided to categorize Urological diseases into risk groups and recommendations are available on procedures that can be or cannot be deferred. We aim to summarise updates on diagnosis, treatment and follow up of bladder cancer during the COVID-19 outbreaks.

Where do urologists stand in the era of novel coronavirus-2019 disease

PURPOSE OF REVIEW

The novel coronavirus-2019 disease (COVID-19) pandemic has had devastating consequences on healthcare systems globally. The effect this has on urologists and the patients they care for is not fully understood and presents the challenge of prioritizing the most urgent cases. We aim to review the impact on urology services and evaluate strategies to minimize disruption.

RECENT FINDINGS

Various healthcare systems have been forced to postpone treatment for many urological conditions as resources are dedicated to the treatment of COVID-19. Training has been postponed as staff are reallocated to areas of need. Face-to-face contact is largely minimized and innovative, virtual communication methods are used in the outpatient setting and multidisciplinary team meetings. Surgical practice is changing because of the risks posed by COVID-19 and procedures can be prioritized in a nonurgent, low priority, high priority or emergency category.

SUMMARY

Although the COVID-19 pandemic will inevitably affect urological services, steps can be taken to mitigate the impact and prioritize the patients most in need of urgent care. Similarly, in future; simulation, e-learning and webinars will allow interaction to share, discuss and debate focused training and education.

Urologic oncology surgery during COVID-19: a rapid review of current triage guidance documents

The Coronavirus Disease 2019 pandemic placed urologic surgeons, and especially urologic oncologists, in an unprecedented situation. Providers and healthcare systems were forced to rapidly create triage schemas in order to preserve resources and reduce potential viral transmission while continuing to provide care for patients. We reviewed United States and international triage proposals from professional societies, peer-reviewed publications, and publicly available institutional guidelines to identify common themes and critical differences. To date, there are varying levels of agreement on the optimal triaging of urologic oncology cases. As the need to preserve resources and prevent viral transmission grows, prioritizing only high priority surgical cases is paramount. A similar approach to prioritization will also be needed as nonemergent cases are allowed to proceed in the coming weeks. While these decisions will often be made on a case-by-case basis, more nuanced surgeon-driven consensus guidelines are needed for the near future.

Radical cystectomy plus chemotherapy in patients with pure squamous cell bladder carcinoma: a population-based study

PURPOSE

To test the effect of perioperative chemotherapy (CHT) on overall mortality (OM) and cancer-specific mortality (CSM) in patients with locally advanced or metastatic squamous cell carcinoma of the urinary bladder (SCC UB).

METHODS

Within the Surveillance, Epidemiology and End Results database (1988-2016), we identified 1,018 SCC UB patients (664 T_3-4aN₀M₀, 197 TanyN_1-3M₀ and 156 T_4bN_0-3 or M₁), who underwent radical cystectomy with or without perioperative chemotherapy administration. Inverse probability of treatment-weighting (IPTW), Kaplan-Meier plots and Cox-regression models (CRMs) were used.

RESULTS

CHT was administrated in 116 (17.5%) T_3-4aN₀M₀, 77 (39.1%) TanyN_1-3M₀ and 47 (30.1%) T_4bN_0-3 or M₁ patients. IPTW-adjusted 2-year cancer-specific survival (CSS) was 66.5 vs. 71.5% (p = 0.19), 60.9 vs. 29.5% (p < 0.001) and IPTW-adjusted 1-year CSS was 46.2 vs. 31.1% (p = 0.03) for CHT vs. no CHT administration in T_3-4aN₀M₀, TanyN_1-3M₀ and T_4bN_0-3 or M₁, respectively. In multivariable IPTW-adjusted CRMs, chemotherapy was an independent predictor of lower CSM in TanyN_1-3M₀ (HR 0.44) and in T_4bN_0-3 or M₁ (HR 0.60), but not in T_3-4aN₀M₀ (p = 0.6) patients. Virtually the same results were obtained on OM, as well as without IPTW-adjustment and after stratification according to age and gender.

CONCLUSIONS

The use of perioperative CHT in patients with SCC UB confers survival benefit in the presence of T4b disease, lymph node or distant metastases. Conversely, patients with locally advanced disease but negative lymph node invasion do not benefit from its use. Pending higher quality data from prospective trials, these data should encourage the use of perioperative CHT in those high-risk patient groups.

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.

Rates of other-cause mortality after radical cystectomy are decreasing over time-A population-based analysis over two decades

BACKGROUND AND OBJECTIVES

To investigate other-cause mortality (OCM) rates over time according to several baseline characteristics in bladder cancer (BCa) patients treated with radical cystectomy (RC).

METHODS

Within the Surveillance, Epidemiology, and End Results database (1988-2011), we identified 7702 T_1-2 N₀ M₀ urothelial BCa patients treated with RC. Temporal trends and multivariable Cox regression (MCR) analyses assessed 5-year OCM. Data were stratified according to the year of diagnosis (1988-1995 vs 1996-2000 vs 2001-2004 vs 2005-2008 vs 2009-2011), age group (<60 vs 60-75 vs >75 years), sex, race, marital status, and socioeconomic status.

RESULTS

Overall, OCM rates decreased from 13.9% in 1988-1995 to 8.6% in 2009-2011. The greatest decrease was recorded in elderly (>75) patients (32%-16%, slope: -0.55% per year; P = .01), followed by patients aged 60 to 75 (21%-5%, slope: -0.35% per year; P = .01), unmarried patients (16%-10%, slope: -0.26% per year; P < .001), male patients (14%-8.9%, slope: -0.23% per year), and African Americans (16%-11%, slope: -0.27% per year; P < .001). MCR models corroborated these results.

CONCLUSIONS

Most important decrease in OCM after RC over the last decades was recorded in the elderly, unmarried, and male patients. Nonetheless, these three patient groups still represent ideal targets for efforts aimed at minimizing the morbidity and mortality after RC, as their risk of OCM is higher than in others.

[Recommendations CCAFU on the management of cancers of the urogenital system during an epidemic with Coronavirus COVID-19]

Objectif

La population française est confrontée à la pandémie de COVID-19 et le système de santé a été réorienté en urgence pour la prise en charge des patients atteints du coronavirus. La prise en charge des cancers de l’appareil urinaire et génital masculin doit être adaptée à ce contexte.

Matériel et méthode

Un avis d’experts documenté par une revue de la littérature a été formulé par le Comité de Cancérologie de l’Association Française d’Urologie (CCAFU).

Résultats

La prise en charge médicale et chirurgicale des patients atteints de cancers de l’appareil urinaire et génital masculin doit être adaptée en modifiant les modalités de consultation, en priorisant les interventions en fonction du pronostic intrinsèque des cancers en tenant compte des comorbidités du patient. La protection des urologues vis-à-vis du COVID-19 doit être prise en considération.

Conclusion

Le CCAFU émet un avis d’experts quant aux mesures à prendre pour adapter la prise en charge des cancers de l’appareil urinaire et génital masculin au contexte de pandémie par COVID-19.

Increasing Rates of Perioperative Chemotherapy are Associated With Improved Survival in Men With Urothelial Bladder Cancer With Prostatic Stromal Invasion

BACKGROUND

Our objective was to test whether the rates of perioperative chemotherapy (CHT) administration in patients with urothelial bladder cancer (UCUB) with prostatic stromal invasion (pT4a) changed over time. Moreover, we tested the effect of CHT on overall mortality (OM), as well as on cancer-specific mortality (CSM) in this patient population.

MATERIALS AND METHODS

Within the Surveillance, Epidemiology, and End Results database (2004-2016), we identified 1513 men with non-metastatic UCUB with prostatic stromal invasion who underwent radical cystectomy with lymph node dissection, with or without CHT administration. Estimated annual percentage change analyses, inverse probability of treatment-weighting (IPTW), Kaplan-Meier plots, Cox regression models, and landmark analyses were performed.

RESULTS

Overall, 732 (48.4%) patients with pT4a UCUB disease underwent radical cystectomy with perioperative CHT administration between 2004 and 2016. The CHT administration rate increased from 29.0% in 2004 to 64.8% in 2016 (P < .001). In IPTW-adjusted analyses, the 5-year overall survival was 47.7% versus 39.8%, and cancer-specific survival was 53.6 versus 50.1%, for with versus without CHT administration, respectively. After multivariable and IPTW-adjusted Cox regression models, administration of CHT independently predicted lower OM (hazard ratio [HR], 0.62; 95% confidence interval [CI], 0.52-0.73), as well as lower CSM (HR, 0.66; 95% CI, 0.55-0.80). even after 3-month landmark analyses (OM HR, 0.64; 95% CI 0.54-0.76; CSM HR, 0.70; 95% CI, 0.58-0.85).

CONCLUSIONS

The use of CHT in patients with pT4a UCUB increased from low to moderate in the most contemporary era. However, based on its impressive reduction in OM, as well as in CSM, further increases in CHT administration rates should be highly encouraged in this patient population.