Differential Complication Rates Following Radical Cystectomy in the Irradiated and Nonirradiated Pelvis

Ureteroenteric strictures after cystectomy: Side-specific risk factors and radiological assessment

Objective

To evaluate risk factors contributing to side-specific benign ureteroenteric strictures following radical cystectomy with an ileal conduit.

Materials and Methods

Data obtained from patients with bladder cancer who underwent radical cystectomy with ileal conduit surgery between 2015 and 2018 were retrospectively analysed. Imaging prior to surgery was analysed, regarding calcifications in the aorta, sarcopenia and postoperatively for length of remaining left ureter. Descriptive analyses were performed on preoperative and perioperative data, comparing patients who developed unilateral left- or right-sided strictures, bilateral strictures, to those who remained free of strictures. COX regression analysis was employed to calculate crude and adjusted hazard ratio for side-specific strictures.

Results

The study included 395 patients. Strictures developed in 19% (75/395) of the patients, within a median period of 9 months: 57% (43/75) unilateral left sided, 20% (15/75) unilateral right sided and 23% (17/75) bilateral. Unilateral left-sided stricture was associated with higher body mass index (p = 0.077) and hypercholesterolemia (p = 0.007). Right-sided stricture was associated with a history of prior abdominal surgery (p = 0.029) and postoperative leakage (p = 0.004). Bilateral stricture was associated with smoking (p = 0.006) and high BMI (p = 0.015). The adjusted HR comparing patients with and without previous abdominal surgery was only significantly higher for right-sided ureteroenteric strictures (HR 3.18 [95% CI: 1.11; 9.05]) compared with patients without strictures. No association was identified between strictures and preoperative aortic calcification of the abdominal aorta or sarcopenia as estimated from imaging.

Conclusion

The aetiology of ureteroenteric strictures appears multifactorial. Our findings suggest that development of left-sided stricture is influenced by factors associated with metabolic syndrome, indicating a potential role of distal ureteric ischemia. On the other hand, right-sided stricture was more frequent in patients with previous abdominal surgery and postoperative leakage.

Bladder-sparing treatment using tislelizumab combined with gemcitabine/cisplatin in selected patients with muscle-invasive bladder cancer: a real-world study

PURPOSE

To retrospectively evaluate the tislelizumab-based chemoimmunotherapy combined with gemcitabine/cisplatin for bladder-sparing in patients with muscle-invasive bladder cancer (MIBC).

METHODS

Forty-five patients who received bladder-sparing treatment or radical cystectomy (RC) for MIBC (cT2-T4a, NxM0) were retrospectively enrolled. All patients received maximal transurethral resection of bladder tumor (mTURBT), followed by four cycles of chemo-immunotherapy with tislelizumab (PD-L1 inhibitor), gemcitabine, and cisplatin. Clinical efficacy was evaluated to compare the benefit of bladder-sparing treatment on clinical CR (cCR) and RC for non-cCR patients. The primary outcomes were bladder intact disease-free survival (BIDFS) and overall survival (OS), and the secondary outcomes were adverse effects. The PD-L1 status and molecular subtypes of tumors were analyzed.

RESULTS

The overall survival rate was 88.8% (95%CI: 79.6%, 98.0%) at 12 months, 85.7% (95%CI: 74.9%, 96.5%) at 18 months, and 66.6% (95%CI: 45.2%, 88.0%) at 24 months. Twenty-nine patients (64.4%) achieved cCR and their OS rate was 96.6% (95%CI: 89.9%, 100%). Sixteen patients were in the non-cCR group, and their OS rate was 75.0% (95%CI: 53.8%, 96.2%) at 12 months, 65.6% (95%CI: 40.3%, 90.9%) at 18 months, and 52.5% (95%CI: 21.9%, 83.1%) at 24 months. The BIDFS rate for patients who received bladder-sparing treatment was 96.0% (95%CI: 88.4%, 100%) from 12 to 24 months. Four patients (8.8%) were PD-L1 positive and 41 patients (91.2%) were PD-L1 negative.

CONCLUSIONS

Our retrospective study of patients with MIBC suggests that tislelizumab-based neoadjuvant therapy was a safe and effective bladder-sparing treatment.

Definition of Benign Ureteroenteric Anastomotic Strictures in Ileal Conduits After Radical Cystectomy: Experience From a Single Center and Previously Published Literature

OBJECTIVE

To evaluate a cohort of patients diagnosed with benign ureteroenteric stricture (UES) after radical cystectomy with ileal conduits using a strict predefined definition of strictures. Additionally, we want to illustrate the UES debut, regarding symptoms and clinical findings. UES is a well-known long-term complication after radical cystectomy, affecting up to 20% of all patients. In the literature, different incidence rates are reported. However, these are based on various definitions of strictures.

METHODS

We used strict predefined criteria to evaluate UES incidence including symptoms, timing, diagnostic methods, treatment, and outcome in all patients who underwent radical cystectomy with an ileal conduit between 2012 and 2018 at a single high-volume center.

RESULTS

Of a total of 693 patients who underwent radical cystectomy with ileal conduit, we found 109 patients with 135 UES in total, corresponding to 15.7% of patients (CI: 13.2-18.6) and 10% of all included ureteroenteric anastomosis (CI: 8.5-11.6) after radical cystectomy. Median follow-up was 24months (interquartile range (IQR): 12-31), and postoperatively UES was diagnosed after a median of 6months (IQR: 3-16). A total of 56% was diagnosed with elevated creatinine. Every UES underwent a median of two (IQR: 1-2) treatment attempts and 122 UES were treated successfully.

CONCLUSION

Benign UES is a significant cause of morbidity following radical cystectomy. Our findings contribute to the knowledge of timing, incidence, and recommended treatment of strictures. We argue the importance of establishing a clear gold standard when defining UES to ensure accurate reporting in future research.

Approaches to Clinical Complete Response after Neoadjuvant Chemotherapy in Muscle-Invasive Bladder Cancer: Possibilities and Limitations

In the surgical oncology field, the change from a past radical surgery to an organ preserving surgery is a big trend. In muscle-invasive bladder cancer treatment, neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC) is the standard of care for muscle-invasive bladder cancer (MIBC) patients eligible for cisplatin. There is a growing interest in bladder preserving strategies after NAC because good oncologic outcome has been reported for pathologic complete response (pCR) patients after NAC, and many studies have continued to discuss whether bladder preservation treatment is possible for these patients. However, in actual clinical practice, decision-making should be determined according to clinical staging and there is a gap that cannot be ignored between clinical complete response (cCR) and pCR. Currently, there is a lack in a uniform approach to post-NAC restaging of MIBC and a standardized cCR definition. In this review, we clarify the gap between cCR and pCR at the current situation and focus on emerging strategies in bladder preservation in selected patients with MIBC who achieve cCR following NAC.

Bladder preservation in complicated invasive urothelial carcinoma following treatment with cisplatin/gemcitabine plus tislelizumab: A case report

BACKGROUND

Invasive urothelial carcinoma (UC) with squamous and glandular differentiation is a highly malignant and complicated pathological subtype, and the standard care is radical cystectomy (RC). However, urinary diversion after RC significantly reduces patient quality of life, thus bladder-sparing therapy has become a research hotspot in this field. Recently, five immune checkpoint inhibitors have been approved for systemic therapy of locally advanced or metastatic bladder cancer by the Food and Drug Administration, but the efficacy of immunotherapy combined with chemotherapy for invasive UC is still unknown, especially for pathological subtypes with squamous and glandular differentiation.

CASE SUMMARY

We report the case of a 60-year-old male who complained of repetitive painless gross hematuria and was diagnosed with muscle-invasive bladder cancer with squamous and glandular differentiation, defined as cT3N1M0 according to the American Joint Committee on Cancer, who had a strong desire to preserve the bladder. Immunohistochemical staining revealed that programmed cell death-ligand 1 (PD-L1) expression in the tumor was positive. Thus, a transurethral resection to maximize removal of the bladder tumor was performed under cystoscopy, and the patient subsequently received a combination of chemotherapy (cisplatin/gemcitabine) and immunotherapy (tislelizumab) treatment. No tumor recurrence in the bladder was observed following pathological and imaging examination after 2 cycles and 4 cycles of treatment, respectively. The patient achieved bladder preservation and has been tumor-free for more than two years.

CONCLUSION

This case shows that the combination of chemotherapy and immunotherapy might be an effective and safe treatment strategy for PD-L1 expression positive UC with divergent histologic differentiation.

Myths About Bladder Preservation in Muscle-Invasive Bladder Cancer

Radical cystectomy is long considered as the "gold standard" in the management of localized muscle-invasive bladder cancer (MIBC), and curative intent radiotherapy is relegated to those with either inoperable tumors or with multiple co-morbidities precluding surgery. This is despite a large volume of data showing equal survival between the two modalities of treatment in this setting. In this work we seek to dispel some common myths surrounding curative intent radiotherapy as part of a bladder preservation strategy in MIBC. Baseless claims of inferior outcomes and perceived contraindications for bladder preservation are debunked along with unfounded doubts relating to hypofractionation. Finally, we caution against using response to neoadjuvant chemotherapy as a predictive biomarker for treatment selection and conclude by recommending that trimodality bladder preservation be offered as a therapeutic option that is in clinical equipoise with radical cystectomy.

Current best practice for bladder cancer: a narrative review of diagnostics and treatments

This Seminar presents the current best practice for the diagnosis and management of bladder cancer. The scope of this Seminar ranges from current challenges in pathology, such as the evolving histological and molecular classification of disease, to advances in personalised medicine and novel imaging approaches. We discuss the current role of radiotherapy, surgical management of non-muscle-invasive and muscle-invasive disease, highlight the challenges of treatment of metastatic bladder cancer, and discuss the latest developments in systemic therapy. This Seminar is intended to provide physicians with knowledge of current issues in bladder cancer.

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.

[Bladder-sparing trimodal therapy for muscle invasive bladder cancer]

Organ-sparing strategies in the management of local or locally advanced cancers meet a dual objective: tumor control and preservation of the function of the involved organ. Given the morbidity and mortality of cystectomy and its impact on quality of life and bladder function, bladder-sparing strategies have emerged for the management of urothelial muscle invasive bladder cancer, mostly through trimodal treatment, which consists in maximal trans-urethral resection of bladder tumor, followed by chemo-radiotherapy. This review presents the modalities of trimodal treatment, before exposing the advantages and limitations of this strategy compared to cystectomy among operable patients. Despite the absence of comparative data from randomized trials, the two approaches seem to provide similar oncological results among appropriately selected patients. In modern series, the rate of salvage cystectomy is approximately 15% at 5 years; this delayed cystectomy does not seem to be associated with greater morbidity and mortality as compared to upfront cystectomy. Emphasis is placed in the review on quality of life data of these two approaches. In order to optimize the selection of patients eligible to trimodal therapy, the classical predictive factors of response to radio(chemo)therapy are critically analyzed, with the perspective of innovative molecular biomarkers. Finally, a close multidisciplinary collaboration is needed for the choice and the execution of the therapeutic strategy, and the patient should be fully involved in the decision-making process.

Management of Medium and Long Term Complications Following Prostate Cancer Treatment Resulting in Urinary Diversion - A Narrative Review

The purpose of this narrative review is to discuss and highlight recently published studies regarding the surgical management of patients suffering from prostate cancer treatment complications. Focus will be put on the recalcitrant and more complex cases which might lead to urinary diversion as a definite, last resort treatment. It is in the nature of every treatment, that complications will occur and be bothersome for both patients and physicians. A small percentage of patients following prostate cancer treatment (radical prostatectomy, radiation therapy, or other focal therapies) will suffer side effects and thus, will experience a loss of quality of life. These side effects can persist for months and even years. Often, conservative management strategies fail resulting in recalcitrant recurrences. Prostate cancer patients with "end-stage bladder," "devastated outlet," or a history of multiple failed interventions, are fortunately rare, but can be highly challenging for both patients and Urologists. In a state of multiple previous surgical procedures and an immense psychological strain for the patient, urinary diversion can offer a definite, last resort surgical solution for this small group of patients. Ideally, they should be transferred to centers with experience in this field and a careful patient selection is needed. As these cases are highly complex, a multidisciplinary approach is often necessary in order to guarantee an improvement of quality of life.

Long-term outcomes after bladder-preserving tri-modality therapy for patients with muscle-invasive bladder cancer

PURPOSE

To evaluate trimodal conservative treatment as an alternative to radical surgery for urothelial muscle-invasive bladder cancer (MIBC).

PATIENTS AND METHODS

This retrospective study reported the carcinologic and functional results of patients (pts) presenting a cT2/T3 N0M0 operable MIBC and fit for surgery, treated by a conservative strategy. Treatment consisted of a transurethral resection (TURB) followed by concomitant bi-fractionated split-course radiochemotherapy (RCT) with 5FU-Cisplatine. A control cystoscopy was performed six weeks after the induction RCT (eq45Gy) with systematic biopsies. Patients with complete histologic response achieved RCT protocol. Salvage surgery was proposed to pts with persistent tumor.

RESULTS

313 pts (83% cT2 and 17% cT3) treated between 1988 and 2013 were included, with a median follow-up of 59 months and 67-year mean age. After the induction RCT, the histologic response rate was 83%. After five years, overall, disease-free, and functional bladder-intact survival rates were respectively 69%, 61%, and 69%, significantly better for pts in complete response after induction RCT. Late urinary and digestive toxicities were limited, with respective rates of 4% and 1.5% of grade 3 toxicity.

CONCLUSION

Trimodal strategy with RCT after TURB showed interesting functional and oncologic results and should be considered as an alternative to surgery in well-selected pts.

Bladder-sparing protocols in the treatment of muscle-invasive bladder cancer

Bladder-sparing protocols (BSP) have been gaining widespread popularity as an attractive alternative to radical cystectomy (RC) for muscle-invasive bladder cancer. Unimodal therapies are inferior to multimodal regimens. The most promising regimen is trimodal therapy (TMT), which is a combination of maximal transurethral resection of bladder tumor (TURBT), radiotherapy, and chemotherapy. In appropriately selected patients (low volume unifocal T2 disease, complete TURBT, no hydronephrosis and no carcinoma-in-situ), comparable oncological outcomes to RC have been reported in large retrospective studies, with a potential improvement in overall quality of life (QOL). TMT also offers the possibility for definitive therapy for patients who are not surgically fit to undergo RC. Routine biopsy of previous tumor resection is recommended to assess response. Prompt salvage RC is required in non-responders and for recurrent muscle-invasive disease, while non-muscle-invasive recurrence can be managed conservatively with TURBT +/- intravesical BCG. Long-term follow-up consisting of routine cystoscopy, urine cytology, and cross-section imaging is required. Further studies are warranted to better define the role of neoadjuvant or adjuvant chemotherapy in the setting of TMT. Finally, future research on predictive markers of response to TMT and on the integration of immunotherapy in bladder sparing protocols is ongoing and is highly promising.

Defining postoperative ileus and associated risk factors in patients undergoing radical cystectomy with an Enhanced Recovery After Surgery (ERAS) program

INTRODUCTION

Postoperative ileus (POI) is a common complication of radical cystectomy (RC), occurring in 1.6-23.5% of cases. It is defined heterogeneously in the literature. POI increases hospital length of stay and postoperative morbidity. Factors such as age, epidural use, length of procedure, and blood loss may impact POI. In this study, we aimed to evaluate risk factors that contribute to POI in a cohort of patients managed with a comprehensive Enhanced Recovery After Surgery (ERAS) protocol.

METHODS

A retrospective review of consecutive patients who underwent RC from March 2015 to December 2016 at Vancouver General Hospital was performed. POI was defined a priori as insertion of nasogastric tube for nausea or vomiting, or failure to advance to a solid diet by the seventh postoperative day. To illustrate heterogeneity in previous studies, we also evaluated POI using other previously reported definitions in the RC literature. The influence of potential risk factors for POI, including patient comorbidities, American Society of Anesthesiologists score, gender, age, prior abdominal surgery or radiation, length of operation, diversion type, extent of lymph node dissection, removal date of analgesic catheter, blood loss, and fluid administration volume was analyzed.

RESULTS

Thirty-six (27%) of 136 patients developed POI. Using other previously reported definitions for POI, the incidence ranged from <1-51%. Node-positive status and age at surgery were associated with POI on univariate analysis but not multivariable analysis.

CONCLUSIONS

A large range of POI incidence was observed using previously published definitions of POI. We advocate for a standardized definition of POI when evaluating RC outcomes. POI occurs frequently even with a comprehensive ERAS protocol, suggesting that additional measures are needed to reduce the rate of POI.

French ccAFU guidelines – Update 2018–2020: Bladder cancer

Objective

To propose updated French guidelines for non-muscle invasive (NMIBC) and muscle-invasive (MIBC) bladder cancers.

Methods

A Medline search was achieved between 2015 and 2018, as regards 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 for NMIBC and MIBC.

Complication rate after cystectomy following pelvic radiotherapy: an international, multicenter, retrospective series of 682 cases

PURPOSE

Conflicting evidence exists on the complication rates after cystectomy following previous radiation (pRTC) with only a few available series. We aim to assess the complication rate of pRTC for abdominal-pelvic malignancies.

METHODS

Patients treated with radical cystectomy following any previous history of RT and with available information on complications for a minimum of 1 year were included. Univariable and multivariable logistic regression models were used to assess the relationship between the variable parameters and the risk of any complication.

RESULTS

682 patients underwent pRTC after a previous RT (80.5% EBRT) for prostate, bladder (BC), gynecological or other cancers in 49.1%, 27.4%, 9.8% and 12.9%, respectively. Overall, 512 (75.1%) had at least one post-surgical complication, classified as Clavien ≥ 3 in 29.6% and Clavien V in 2.9%. At least one surgical complication occurred in 350 (51.3%), including bowel leakage in 6.2% and ureteric stricture in 9.4%. A medical complication was observed in 359 (52.6%) patients, with UTI/pyelonephritis being the most common (19%), followed by renal failure (12%). The majority of patients (86%) received an incontinent urinary diversion. In multivariable analysis adjusted for age, gender and type of RT, patients treated with RT for bladder cancer had a 1.7 times increased relative risk of experiencing any complication after RC compared to those with RT for prostate cancer (p = 0.023). The type of diversion (continent vs non-continent) did not influence the risk of complications.

CONCLUSION

pRTC carries a high rate of major complications that dramatically exceeds the rates reported in RT-naïve RCs.

[Organ preservation by chemoradiation for bladder cancer]

When localized, the reference treatment of urothelial, muscle-invasive bladder tumours relies on radical cystectomy with reconstruction by enterocystoplasty if possible or Bricker bypass. Trimodal therapy combining transurethral resection of the tumour followed by concomitant chemotherapy may be considered as a therapeutic alternative to radical cystectomy in well-selected patients with unifocal tumours, stage T2, non-diverticular location, without in situ carcinoma or hydronephrosis and with macroscopically complete transurethral resection. The functional prognosis of the bladder and quality of life should be discussed with the patient as well as the need for salvage surgery for persistent tumour at a 45-Gy dose level, the latter being a highly unfavourable prognosis factor. On the other hand, this trimodal treatment is the reference in case of surgical contraindication. This article details the methods and results of the main series available in the literature in terms of local control, survival, bladder preservation rates and complications, as well as study prospects.

MRE11 as a Predictive Biomarker of Outcome After Radiation Therapy in Bladder Cancer

PURPOSE

Organ-confined muscle-invasive bladder cancer is treated with cystectomy or bladder preservation techniques, including radiation therapy. There are currently no biomarkers to inform management decisions and aid patient choice. Previously we showed high levels of MRE11 protein, assessed by immunohistochemistry (IHC), predicted outcome after radiation therapy, but not cystectomy. Therefore, we sought to develop the MRE11 IHC assay for clinical use and define its relationship to clinical outcome in samples from 2 major clinical trials.

METHODS AND MATERIALS

Samples from the BCON and BC2001 randomized controlled trials and a cystectomy cohort were stained using automated IHC methods and scored for MRE11 in 3 centers in the United Kingdom.

RESULTS

Despite step-wise creation of scoring cards and standard operating procedures for staining and interpretation, there was poor intercenter scoring agreement (kappa, 0.32; 95% confidence interval, 0.17-0.47). No significant associations between MRE11 scores and cause-specific survival were identified in BCON (n = 132) and BC2001 (n = 221) samples. Reoptimized staining improved agreement between scores from BCON tissue microarrays (n = 116), but MRE11 expression was not prognostic for cause-specific survival.

CONCLUSIONS

Manual IHC scoring of MRE11 was not validated as a reproducible biomarker of radiation-based bladder preservation success. There is a need for automated quantitative methods or a reassessment of how DNA-damage response relates to clinical outcomes.

Bladder Preservation Therapy: Review of Literature and Future Directions of Trimodal Therapy

PURPOSE OF THE REVIEW

This review targets the latest literature on bladder preservation therapy with emphasis on trimodal therapy (TMT), highlighting its role in the management of muscle invasive bladder cancer (MIBC) and outlining future directions in bladder preservation research.

RECENT FINDINGS

TMT is the most promising bladder preservation treatment modality. Comparable results to contemporary radical cystectomy series are seen in properly selected patients. A multidisciplinary team approach is critical in the management of these patients. Future research is directed at the integration of immunotherapy into the treatment protocol. TMT, involving maximal transurethral resection followed by chemoradiation, is an attractive alternative to radical cystectomy with urinary diversion in carefully selected patients with muscle invasive disease. In the absence of randomized trial (RCT), comparison between TMT and cystectomy, based on retrospective data from large centers, suggests comparable oncological outcomes, with a favorable impact on quality of life.

RETRACTED: Recommandations françaises du Comité de Cancérologie de l’AFU — Actualisation 2018—2020 : tumeurs de la vessie French ccAFU guidelines — Update 2018—2020: Bladder cancer

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations. Le nouvel article est disponible à cette adresse: doi:10.1016/j.purol.2019.01.006. C’est cette nouvelle version qui doit être utilisée pour citer l’article. This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published. The replacement has been published at the doi:10.1016/j.purol.2019.01.006. That newer version of the text should be used when citing the article.

Muscle-invasive bladder cancer organ-preserving therapy: systematic review and meta-analysis

PURPOSE

To determine the effectiveness and harms of bladder-preserving trimodal therapy (TMT) as a first-line treatment versus radical cystectomy (RC) plus radical pelvic lymphadenectomy in the treatment of muscle-invasive bladder cancer in terms of overall survival.

METHODS

We included parallel clinical trials and prospective and retrospective cohort studies that included patients older than 18 years old, diagnosed with muscle-invasive bladder cancer, who underwent TMT compared with RC. The planned comparison was TMT versus RC plus pelvic lymphadenectomy as first-line treatment. The primary outcome was overall survival (OS) and secondary outcomes were salvage cystectomy and cancer-specific survival and progression-free survival. A search strategy was designed for MEDLINE, CENTRAL, Embase, and LILACS. We saturated information with conference abstracts, in progress clinical trials, literature published in non-indexed journals, and other sources of gray literature. Standardized tools assessed the risk of bias independently. We performed the statistical analysis in R v3.4.1 and effect sizes were reported in terms of hazard ratios (HR) and the corresponding 95% confidence intervals (95%CI). Accordingly, we used a random effect model due to the statistical heterogeneity found in included studies.

RESULTS

We found 2682 records with the search strategies and, finally, 11 studies were included in the quantitative analysis. The summary HR for OS was 1.06 95%CI (0.85-1.31) I² = 77%, showing no statistical difference. Regarding cancer-specific survival, the summary HR was 1.23 95%CI (1.04-1.46) I² = 14%. On the other side, for the progression-free survival, the summary HR was 1.11 95%CI (0.63-1.95) I² = 78%. Only one study described HR for adverse events (1.37 95%CI 1.16-1.59).

CONCLUSION

We found no differences in overall survival and progression-free survival between these two interventions. Nonetheless, we found that cancer-specific survival favored patients who received radical cystectomy.

Postoperative Outcomes After Radical Cystectomy in Patients With Prior Pelvic Radiation

OBJECTIVE

To compare complication rates, perioperative outcomes, and survival after radical cystectomy (RC) in patients with prior abdominal or pelvic radiation therapy (RT) vs those without an RT history.

MATERIALS AND METHODS

We retrospectively reviewed patients undergoing RC for urothelial carcinoma between January 2008 and January 2016. Patients were stratified by receipt of RT, and differences in complications (any, minor, and major) at 30 and 90 days, as well as estimated blood loss, length of surgery, length of hospital stay, and pathologic stage, were compared. Recurrence-free, cancer-specific, and overall survival were compared using the Kaplan-Meier method and log-rank test.

RESULTS

We identified 518 patients who underwent RC between 2008 and 2016. Of these patients, 55 (11%) had a history of RT. There were no significant differences in complication rates (66% vs 69%, P= .80) between patients who did not and patients who did have a history of RT. Similarly, there were no differences in any perioperative or pathologic outcome by receipt of prior RT (all P>.05). Meanwhile, at a median follow-up of 26 (interquartile range 13-46) months among patients alive at last follow-up, no differences in survival were observed by prior RT (P= .08).

CONCLUSION

Among patients with a history of prior abdominal or pelvic RT treated at a tertiary referral center, there was no difference in complication rates, perioperative, or pathologic outcomes. Importantly, no differences in survival were noted by prior RT receipt. Therefore, our data support the use of RC, when indicated, in patients with a prior history of abdominal or pelvic RT.

Lymph node dissection during radical cystectomy following prior radiation therapy: results from the SEER database

PURPOSE

Population studies of patients undergoing radical cystectomy (RC) for bladder cancer (BC) suggest that a more extended lymph node dissection (LND) increases survival. However, information regarding LNDs of patients undergoing RC with a history of radiation therapy for BC is largely unknown. This study aims to define the lymph node yield (LNY) in patients undergoing RC for BC following radiation of the bladder using the surveillance epidemiology and end results (SEER) database.

METHODS

Data were collected using SEER 18 registries from 1988 to 2013 to identify patients undergoing RC for BC. Data on extent and yield of LND were obtained. Logistic regression and multivariate Cox proportional hazard regression were done to identify predictors of adequate LND and all-cause mortality, respectively.

RESULTS

In total, 27,451 patients were identified, of which, 27,362 (99.7%) were radiation naïve and 89 (0.3%) had prior radiation therapy for BC. The average LNY in radiation naïve patients (15, SD [13.5]) was slightly higher than the LNY in patients with prior radiation (12.3 SD [9.2], p = 0.157). Prior radiation was not an independent predictor of overall mortality (HR = 1.3, 95% CI [0.98-1.7]; p = 0.076).

CONCLUSIONS

A lower proportion of patients with a history of radiation underwent a LND. The LNYs of radiation naïve patients, and those with a history of radiation, were not statistically different; however, the proportion of irradiated patients was small. Further investigation will be required to elucidate the patient and provider characteristics that contribute to the similar LNYs.

Clinical and patient-reported outcomes of SPARE - a randomised feasibility study of selective bladder preservation versus radical cystectomy

OBJECTIVES

To test the feasibility of a randomised trial in muscle-invasive bladder cancer (MIBC) and compare outcomes in patients who receive neoadjuvant chemotherapy followed by radical cystectomy (RC) or selective bladder preservation (SBP), where definitive treatment [RC or radiotherapy (RT)] is determined by response to chemotherapy.

PATIENTS AND METHODS

SPARE is a multicentre randomised controlled trial comparing RC and SBP in patients with MIBC staged T2-3 N0 M0, fit for both treatment strategies and receiving three cycles of neoadjuvant chemotherapy. Patients were randomised between RC and SBP before a cystoscopy after cycle three of neoadjuvant chemotherapy. Patients with ≤T1 residual tumour received a fourth cycle of neoadjuvant chemotherapy in both groups, followed by radical RT in the SBP group and RC in in the RC group; non-responders in both groups proceeded immediately to RC following cycle three. Feasibility study primary endpoints were accrual rate and compliance with assigned treatment strategy. The phase III trial was designed to demonstrate non-inferiority of SBP in terms of overall survival (OS) in patients whose tumours responded to neoadjuvant chemotherapy. Secondary endpoints included patient-reported quality of life, clinician assessed toxicity, loco-regional recurrence-free survival, and rate of salvage RC after SBP.

RESULTS

Trial recruitment was challenging and below the predefined target with 45 patients recruited in 30 months (25 RC; 20 SBP). Non-compliance with assigned treatment strategy was frequent, six of the 25 patients (24%) randomised to RC received RT. Long-term bladder preservation rate was 11/15 (73%) in those who received RT per protocol. OS survival was not significantly different between groups.

CONCLUSIONS

Randomising patients with MIBC between RC and SBP based on response to neoadjuvant chemotherapy was not feasible in the UK health system. Strong clinician and patient preferences for treatments impacted willingness to undergo randomisation and acceptance of treatment allocation. Due to the few participants, firm conclusions about disease and toxicity outcomes cannot be drawn.

Long-term Outcomes After Bladder-preserving Tri-modality Therapy for Patients with Muscle-invasive Bladder Cancer: An Updated Analysis of the Massachusetts General Hospital Experience

BACKGROUND

Tri-modality therapy (TMT) is a recognized treatment strategy for selected patients with muscle-invasive bladder cancer (MIBC).

OBJECTIVE

Report long-term outcomes of patients with MIBC treated by TMT.

DESIGN, SETTING, AND PARTICIPANTS

Four hundred and seventy-five patients with cT2-T4a MIBC were enrolled on protocols or treated as per protocol at the Massachusetts General Hospital between 1986 and 2013.

INTERVENTION

Patients underwent transurethral resection of bladder tumor followed by concurrent radiation and chemotherapy. Patients with less than a complete response (CR) to chemoradiation or with an invasive recurrence were recommended to undergo salvage radical cystectomy.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Disease-specific survival (DSS) and overall survival (OS) were calculated using the Kaplan-Meier method.

RESULTS AND LIMITATIONS

Median follow-up for surviving patients was 7.21 yr. Five- and 10-yr DSS rates were 66% and 59%, respectively. Five- and 10-yr OS rates were 57% and 39%, respectively. The risk of salvage cystectomy at 5 yr was 29%. In multivariate analyses, T2 disease (OS hazard ratio [HR]: 0.57, 95% confidence interval [CI]: 0.44-0.75, DSS HR: 0.51, 95% CI: 0.36-0.73), CR to chemoradiation (OS HR: 0.61, 95% CI: 0.46-0.81, DSS HR: 0.49, 95% CI: 0.34-0.71), and presence of tumor-associated carcinoma in situ (OS HR: 1.56, 95% CI: 1.17-2.08, DSS HR: 1.50, 95% CI: 1.03-2.17) were significant predictors for OS and DSS. When evaluating our cohort over treatment eras, rates of CR improved from 66% to 88% and 5-yr DSS improved from 60% to 84% during the eras of 1986-1995 to 2005-2013, while the 5-yr risk of salvage radical cystectomy rate decreased from 42% to 16%.

CONCLUSIONS

These data demonstrate high rates of CR and bladder preservation in patients receiving TMT, and confirm DSS rates similar to modern cystectomy series. Contemporary results are particularly encouraging, and therefore TMT should be discussed and offered as a treatment option for selected patients.

PATIENT SUMMARY

Tri-modality therapy is an alternative to radical cystectomy for patients with muscle-invasive bladder cancer, and is associated with comparable long-term survival and high rates of bladder preservation.

Urothelial-based reconstructive surgery for upper- and mid-ureteral defects: Long-term results

INTRODUCTION

Ureteral strictures can result in obstructive nephropathy and renal function deterioration. Surgical management of ureteral defects, especially in the proximal- and mid-ureter, is particularly challenging. Our purpose was to analyze the long-term outcomes of urothelial-based reconstructive surgery for upper- and mid-ureteral defects.

METHODS

We conducted a retrospective analysis of a single tertiary centre's database, including 149 patients treated for ureteral defects between 2001 and 2011. Thirty-one patients (21%) underwent complex urothelial-based surgical repairs for upper- and mid-ureter defects. Patients' median age was 61 years. The mean length of the ureteral strictures was 2.5 cm, located in upper-, mid-ureter, or in between in 19 (61%), 10 (32%), and two (6%) patients, respectively. All patients were treated with a primary urothelial-based repair. Median followup time was 26 months. The primary outcome of the study was the long-term preservation of renal function and lack of clinical obstruction. The secondary endpoint of the study was the assessment of the intra- and postoperative complication rates.

RESULTS

Most of the lesions were benign (22, 71%), while nine strictures (29%) were malignant. Seven patients (23%) suffered from postoperative complications, five of which were infectious. The median pre- and postoperative calculated glomerular filtration rates were 66 ml/min/1.72m2 and 64ml/min/1.72m2, respectively. Success rate was 84%, defined as lack of need for re-operation or kidney drainage at the last followup.

CONCLUSIONS

Upper- and mid-ureteral defects present a complex pathology necessitating experienced reconstructive surgical skills. Our data suggest good long-term results for primary urothelial-based reconstructions for these pathologies.

Bladder Preservation Therapy: A Review of the Literature and Future Directions

Trimodal bladder preservation therapy (ie, transurethral resection followed by chemoradiotherapy) may be an acceptable treatment alternative to radical cystectomy with urinary diversion in the carefully selected patient with muscle invasive bladder cancer. Although no head-to-head randomized controlled trials have been performed, large retrospective cohort reviews and observational data analyses suggest comparable oncologic outcomes in select patients with the additional benefit of maximizing quality of life and maintaining the patient's native bladder. In this review, we discuss the evolution and clinical outcomes of bladder preservation therapy, highlighting its role in the contemporary management of muscle invasive bladder cancer.

Obstruction of an ileal urinary conduit in an incarcerated right inguinal hernia

We present the case of a 72-year-old man with a history of anuria from his ileal conduit 15 months following its formation. That conduit had become incarcerated in a right-sided ingunial hernia. The patient presented with anuria and an acute kidney injury. A clincal diagnosis of an incarcerated hernia was made, and he was taken to theatre for reduction and repair of the hernia. On removal of the conduit from the hernial sac, it began to drain immediately. He made a full recovery, with normalisation of his renal function.

Comparison of the short-term efficacy of sequential treatment with intravesical single-port laparoscopic partial cystectomy with bladder preservation or open partial cystectomy in combination with cisplatin plus gemcitabine chemotherapy

This study aimed to assess the short-term efficacy of sequential therapy for T2/T3a bladder cancer with intravesical single-port laparoscopic partial cystectomy or open partial cystectomy combined with cisplatin plus gemcitabine (GC) chemotherapy in a prospective randomized controlled study. Thirty patients with bladder cancer who underwent open partial cystectomy (group A) or single-port laparoscopic partial cystectomy (group B) and received standard GC chemotherapy were analyzed. Perioperative functional indicators and tumor recurrence during a 1-year postoperative follow-up were compared between the two groups. The baseline characteristics were comparable between the two groups. The mean operative time, amount of blood loss and duration of hospital stay were 90.3 min, 182.0 ml and 7.3 days, respectively, for group A, and 105.3 min, 49.3 ml and 5.8 days, respectively, for group B. No secondary postoperative bleeding, urine leakage, wound infection or other complications were observed in the two groups. Postoperative scarring was not evident in group B. The overall incidence of surgical complications, tumor recurrence rate and complications during chemotherapy in the postoperative follow-up period of 12 months were similar between the two groups. Single-port laparoscopic partial cystectomy surgery is an idea surgical method for the treatment of invasive bladder cancer, with good surgical effect, minimal invasiveness, rapid recovery and short hospital stay. The data from 1-year postoperative follow-up showed that laparoscopic surgery was superior with regard to perioperative bleeding, postoperative recovery and duration of indwelling urinary catheter use. However, regarding the tumor recurrence rate, long-term comparative details are required to determine the effect of laparoscopic surgery.

Radical Cystectomy for Bladder Cancer in Patients With and Without a History of Pelvic Irradiation: Survival Outcomes and Diversion-related Complications

OBJECTIVE

To compare survival outcomes and diversion-related complications of patients with and without a history of pelvic irradiation who underwent radical cystectomy.

PATIENTS AND METHODS

Three hundred sixty-four patients underwent radical cystectomy for bladder cancer (BCa) from July 2001 to September 2013. Thirty-seven patients (10%) had a history of pelvic irradiation, and 327 (90%) did not. The Kaplan-Meier method and Cox regression models were applied to evaluate survival outcomes. Diversion-related complications were tabulated.

RESULTS

The proportion of non-organ-confined disease was numerically higher in irradiated than in nonirradiated patients (18 of 37 [49%] vs 117 of 327 [36%] patients, P = .1). The difference in the proportion of T4 disease between the 2 groups was statistically significant (13 of 37 [35%] irradiated vs 37 of 327 [11%] nonirradiated patients, P = .005). Pelvic lymph node dissection could not be performed in 7 of 37 irradiated patients. A nonurothelial carcinoma histology was more frequent in irradiated than in nonirradiated patients (5 of 37 [14%] vs 19 of 327 [6%], P = .003). At 3 years, BCa recurrence-free survival estimates were 70 ± 9% and 77 ± 3% (log-rank P = .5), and BCa-specific survival estimates were 64 ± 9% and 69 ± 3% (log-rank P = .4), for irradiated and nonirradiated patients, respectively. In multivariate analysis, a history of pelvic irradiation was not predictive of BCa recurrence or BCa-specific death. Rates of diversion-related complications did not differ between the 2 groups.

CONCLUSION

BCa patients with a history of pelvic irradiation present with more advanced disease. Surgery remains difficult in this group of patients as pelvic lymph node dissection is omitted in approximately 1 of 5 patients. Within limitations, prior pelvic irradiation is not predictive of survival outcomes.

Selective organ preservation for the treatment of muscle-invasive transitional cell carcinoma of the bladder: a review of current and future perspectives

Radical treatment remains underutilized for those with muscle-invasive bladder cancer. Radical radiotherapy, in particular, continues to be perceived by many as reserved only for patients unfit for cystectomy. However, with concurrent use of radiosensitizers, radiotherapy can achieve excellent local control and survival comparable to modern surgical series, thus presenting a real alternative to surgery. The possibility of further enhancing patient outcome is likely to come from both advances in radiotherapy treatment delivery and appropriate candidate selection. Growing evidence from selective bladder preservation trials demonstrate long term survival with functional organ preservation. In the era of personalized medicine, we review the evidence supporting an individualized treatment approach, in particular case selection for radical radiotherapy.

Radical Cystectomy after BCG Immunotherapy for High-Risk Nonmuscle-Invasive Bladder Cancer in Patients with Previous Prostate Radiotherapy

Purpose. Intravesical Bacillus Calmette-Guerin (BCG) immunotherapy is indicated for high-grade nonmuscle-invasive bladder cancer (NMIBC). The efficacy of BCG in patients with a history of previous pelvic radiotherapy (RT) may be diminished. We evaluated the outcomes of radical cystectomy for BCG-treated recurrent bladder cancer in patients with a history of RT for prostate cancer (PC). Methods. A retrospective chart review was performed to identify patients with primary NMIBC. We compared the outcomes of three groups of patients who underwent radical cystectomy for BCG-refractory NMIBC: those with a history of RT for PC, those who previously underwent radical prostatectomy (RP), and a cohort without PC or RT exposure. Results. From 1996 to 2008, 53 patients underwent radical cystectomy for recurrent NMIBC despite BCG. Those with previous pelvic RT were more likely to have a higher pathologic stage and decreased recurrence-free survival compared to the groups without prior RT exposure. Conclusion. Response rates for intravesical BCG therapy may be impaired in those with prior prostate radiotherapy. Patients with a history of RT who undergo radical cystectomy after failed BCG are more likely to be pathologically upstaged and have decreased recurrence-free survival. Earlier consideration of radical cystectomy may be warranted for those with NMIBC who previously received RT for PC.

Definition, incidence, risk factors, and prevention of paralytic ileus following radical cystectomy: a systematic review

CONTEXT

Postoperative paralytic ileus (POI) has profound clinical consequences because it represents a substantial burden on both patients and health care resources.

OBJECTIVE

To determine the knowledge base regarding POI in the radical cystectomy (RC) population with an emphasis on preventive measures and risk factors.

EVIDENCE ACQUISITION

A systematic literature search of Medline (1966 to February 2011) and a study review were conducted. Eligible studies explicitly reported the incidence of POI and/or at least two quantitative measures of gastrointestinal recovery.

EVIDENCE SYNTHESIS

The search identified 727 relevant articles; 77 met eligibility criteria, comprising 13 793 patients. Of these, 21 used explicit definitions of POI, and they varied widely. Across studies, the incidence of POI ranged from 1.58% to 23.5%. Possible risk factors for POI included increasing age and body mass index. Seventeen studies reported effects of an intervention on POI: 3 randomized controlled studies, 11 observational cohort studies with concurrent comparison, and 3 observational cohort studies with nonconcurrent comparison. Gum chewing was associated with shortened times to flatus (2.4 vs 2.9 d; p<0.0001) and bowel movement (BM) (3.2 vs 3.9 d; p<0.001) in one observational cohort study (n=102); omission of a postoperative nasogastric tube (NGT) was associated with shorter time to flatus (4.21 vs 5.33 d; p=0.0001) and shorter length of stay (14.4 vs 19.1 d; p=0.001) in one observational cohort study (n=430); and the routine use of bowel preparation was associated with an increased incidence of POI (5% vs 19%) in another series (n=86). Additionally, readaptation of the dorsolateral peritoneal layer was shown to shorten times to flatus (p=0.016) and times to BM (p=0.011) in one randomized controlled study (n=200).

CONCLUSIONS

The incidence/definition of POI after RC is highly variable. An improved reporting strategy is needed to identify true incidence and risk factors, and to guide future research for both potential preventive and therapeutic interventions.

Selective bladder preservation with curative intent for muscle-invasive bladder cancer: a contemporary review

Radical cystectomy plus urinary diversion, the reference standard treatment for muscle-invasive bladder cancer, associates with high complication rates and compromises quality of life as a result of long-term effects on urinary, gastrointestinal and sexual function, and changes in body image. As a society ages, the number of elderly patients unfit for radical cystectomy as a result of comorbidity will increase, and thus the demand for bladder-sparing approaches for muscle-invasive bladder cancer will also inevitably increase. Trimodality bladder-sparing approaches consisting of transurethral resection, chemotherapy and radiotherapy (Σ 55-65 Gy) yield overall survival rates comparable with those of radical cystectomy series (50-70% at 5 years), while preserving the native bladder in 40-60% of muscle-invasive bladder cancer patients, contributing to an improvement in quality of life for such patients. Limitations of the trimodality therapy include (i) muscle-invasive bladder cancer recurrence in the preserved bladder, which most often arises in the original muscle-invasive bladder cancer site; (ii) potential lack of curative intervention for regional lymph nodes; and (iii) increased morbidity in the event of salvage radical cystectomy for remaining or recurrent disease as a result of high-dose pelvic irradiation. Consolidative partial cystectomy with pelvic lymph node dissection followed by induction chemoradiotherapy at lower dose (e.g. 40 Gy) is a rational strategy for overcoming such limitations by strengthening locoregional control and reducing radiation dosage. Molecular profiling of the tumor and functional imaging might play important roles in optimal patient selection for bladder preservation. Refinement of radiation techniques, intensified concurrent or adjuvant chemotherapy, and novel sensitizers, including molecular targeting agent, are also expected to improve outcomes and consequently provide more muscle-invasive bladder cancer patients with favorable quality of life.

Perioperative complications of radical cystectomy after induction chemoradiotherapy in bladder-sparing protocol against muscle-invasive bladder cancer: a single institutional retrospective comparative study with primary radical cystectomy

OBJECTIVE

To compare rates of early morbidity after radical cystectomy in patients treated with or without induction chemoradiotherapy (CRT) using a standardized reporting methodology.

METHODS

All 193 consecutive patients undergoing radical cystectomy for bladder cancer between 1989 and 2010 were retrospectively reviewed. Induction chemoradiotherapy consists of radiation at 40 Gy to the small pelvis and two cycles of concurrent cisplatin at 20 mg/day for 5 days. Deaths within 90 days after radical cystectomy and complications arising within 30 days were recorded and graded according to the Clavien-Dindo classification. Grades 1-2 were considered minor; Grades 3-5 were considered major.

RESULTS

Eighty-seven patients underwent radical cystectomy following chemoradiotherapy (chemoradiotherapy group) while the remaining 106 primarily underwent radical cystectomy (no chemoradiotherapy group). No Grade 4-5 complication was observed. Overall, 118 patients (61%) experienced 36 major and 122 minor complications. There was no significant difference in the incidence of overall complications between the chemoradiotherapy and no chemoradiotherapy groups (67 vs. 57%). Overall urinary anastomosis-related complications and major gastrointestinal complications, most of which were Grade 3 ileus, were more frequent in the chemoradiotherapy group than the no chemoradiotherapy group (11 vs. 2%, P = 0.007; and 14 vs. 4%, P = 0.02; respectively). Multivariate analysis identified induction chemoradiotherapy as an independent risk factor for overall urinary anastomosis-related complications (relative risk 6.0, P = 0.01) but not for major gastrointestinal complications.

CONCLUSIONS

Induction chemoradiotherapy at 40 Gy in bladder-sparing protocols against MIBC is unlikely to increase the rate of severe complications of radical cystectomy.

Selective bladder-sparing protocol consisting of induction low-dose chemoradiotherapy plus partial cystectomy with pelvic lymph node dissection against muscle-invasive bladder cancer: oncological outcomes of the initial 46 patients

OBJECTIVE

To evaluate oncological outcomes of muscle-invasive bladder cancer (MIBC) patients who were treated with a selective bladder-sparing protocol consisting of induction low-dose chemoradiotherapy (LCRT) plus partial cystectomy (PC) with pelvic lymph node dissection.

PATIENTS AND METHODS

From 1997-2010, 183 consecutive patients with cT2-4aN0M0 bladder cancer (median age 70 years, women/men = 46/137, T2/3/4a = 100/69/14) underwent debulking transurethral resection followed by LCRT (radiation at 40 Gy to the small pelvis concurrently with two cycles of i.v. cisplatin at 20mg/day for 5 days). Criteria for PC include: (i) essentially solitary MIBC or intravesically circumscribed tumours (≈25% or less of the bladder in area, excluding the bladder neck and trigone); (ii) no involvement of bladder neck or trigone; and (iii) clinically, no residual disease or minimal amounts of non-invasive disease in the original MIBC site after LCRT; otherwise, radical cystectomy (RC) is recommended. Primary and secondary endpoints were cancer-specific survival (CSS) and intravesical MIBC recurrence-free survival (MRFS) for bladder-preserved patients, respectively.

RESULTS

Of the 183 patients, 87 (48%) achieved a clinical complete response after LCRT and 65 (36%) met the PC criteria; 46 (25%) patients actually underwent PC, 86 (47%) had RC, and the remaining 51 (28%) had neither PC, nor RC. Histological examination of the 46 PC specimens showed residual muscle-invasive disease in three (7%). Overall, 5-year overall survival and CSS rates were 64% and 71%, respectively (median follow-up for survivors of 45 months). In the 46 PC patients, neither MIBC, nor pelvic recurrence was observed; 5-year CSS and MRFS rates were both 100%. In 13 non-PC patients who achieved a complete response after LCRT and who met PC criteria but declined PC, 5-year CSS and MRFS rates were 74% and 81%, respectively; CSS and MRFS were significantly better in the PC group than in the non-PC group (P= 0.025 and 0.002, respectively).

CONCLUSIONS

In the current selective bladder-sparing protocol, one-third of MIBC patients met the PC criteria; when patients from this group underwent PC with pelvic lymph node dissection, their oncological outcomes were excellent. Consolidative PC potentially reduces MIBC recurrence in the preserved bladder, eventually improving survival in properly selected MIBC patients.