Upper Tract Urothelial Recurrence Following Radical Cystectomy for Transitional Cell Carcinoma of the Bladder: An Analysis of 1,069 Patients With 10-Year Followup

Routine Surveillance of Upper Urinary Tract Imaging for Diagnosing Upper Urinary Tract Urothelial Cancer Recurrence in Patients with Nonmuscle Invasive Bladder Cancer

Background

Although routine surveillance imaging to examine upper urinary tract urothelial cancer recurrence during follow-up of nonmuscle invasive bladder cancer is recommended, its necessity remains invalidated. A single-institute long-term follow-up cohort study to evaluate the clinical impact of routine surveillance imaging and identify risk factors for upper urinary tract urothelial cancer recurrence after nonmuscle invasive bladder cancer treatment was conducted.

Methods and Materials

A retrospective chart review of 864 patients with primary nonmuscle invasive bladder cancer who underwent initial transurethral resection of bladder tumor between 1980 and 2020 was conducted. The opportunities to diagnose its recurrence were examined. Moreover, oncological outcomes included upper urinary tract urothelial cancer recurrence-free survival and overall survival.

Results

Of 864 patients, 19 (2.2%) experienced upper urinary tract urothelial cancer recurrence. Among 19 patients, recurrence was detected through routine imaging in 12 (63.2%), cystoscopy in 2 (10.5%), urine cytology in 2 (10.5%), and presence of gross hematuria in 1 (5.3%). All patients had high- or highest-risk NMIBC at diagnosis of primary nonmuscle invasive bladder cancer. On multivariate Fine-Gray proportional regression analyses, a tumor size of ≥30 mm and carcinoma in situ were independently associated with short upper urinary tract urothelial cancer recurrence-free survival (P=0.040 and 0.0089, respectively).

Conclusion

Most patients experiencing upper urinary tract urothelial cancer recurrence were diagnosed by routine surveillance imaging, suggesting its clinical importance, especially for patients with nonmuscle invasive bladder cancer accompanied by a tumor size of ≥30 mm and carcinoma in situ.

Trends in the incidence of urothelial carcinoma in Taiwan after the ban on aristolochic acid-containing Chinese herbal preparations, 2001-2018: a national population-based cohort study

PURPOSE

Urothelial carcinoma (UC) of the bladder (BUC) and the upper urinary tract (UTUC) are the two most common UCs. The incidence of UTUC in Taiwan is the highest worldwide. Aristolochic acid (AA) was identified as the main cause of UTUC in Taiwan. To explore trends in the incidence of UC in Taiwan after the ban on Chinese herbal preparations containing AA in 2003.

METHODS

We used data from the Taiwanese National Health Insurance Research Database-linked Taiwanese National Cancer Registry for 2001-2018. UC was defined in accordance with the International Classification of Disease for Oncology. The age-standardized incidence was calculated on the basis of the World Health Organization standard population. Trends in the incidence were calculated as the annual percent change (APC) by using the Joinpoint regression program.

RESULTS

Over the investigated period, the incidence of UC decreased at an average annual percent change (AAPC) of - 1.19% (95% CI - 1.47 ~ - 0.91, P < 0.001). However, the incidence in UTUC significantly increased, with the AAPC being 1.47% (95% CI 1.03 ~ 1.90, P < 0.001). In contrast, the incidence of BUC significantly decreased, with the overall AAPC being - 1.92% (95% CI - 2.3 ~ - 1.54, P < 0. 001). From 2001 to 2018, the overall incidence of UCs and BUC decreased in Taiwan, but the incidence of UTUC significantly increased.

CONCLUSION

We suggest to apply the same review standards of new drug development process to herbal preparations and incorporate them into the adverse drug reaction or poison surveillance system. Most importantly, raise public awareness of the potential toxicity of phytotherapy.

Management of hydronephrosis after radical cystectomy and urinary diversion for bladder cancer: A single tertiary center experience

OBJECTIVES

To clarify the incidence of postoperative hydronephrosis and verify the validity of diagnostic and therapeutic approaches for hydronephrosis after cystectomy and urinary diversion for bladder cancer.

METHODS

Totally, 290 patients receiving urinary diversion from 2005 through 2017 with complete data were enrolled, including 258 (89.0%) with an ileal conduit and 32 (11.0%) with an ileal neobladder. Postoperative radiographic images were reviewed. In patients with postoperative hydronephrosis, antegrade pyelography and ureteroscopy were performed to exclude malignant etiology. Balloon dilation and open surgical revision were performed according to the conditions.

RESULTS

Forty-six patients (58 renal units) developed postoperative hydronephrosis. The cumulative incidence was 11.4% by a median follow-up of 59.5 months. Ureteral recurrence was detected by antegrade examinations in two patients, whereas malignant strictures were subsequently revealed in three patients. Thus, malignant etiology was found in hydronephrosis in five renal units (12.8%) of five patients (16.1%). The median times to diagnosis of hydronephrosis were 0 (interquartile range [IQR] 0-4) and 14 months (IQR 9-12) for benign and malignant strictures, respectively (p = 0.003). Of them, 31 patients (39 renal units) received interventions. Balloon dilation was performed in 13 renal units with benign strictures, and was successful in two (15.4%). Open surgical revision was performed in eight patients (11 renal units), including two with failed balloon dilation, all of which was successful.

CONCLUSIONS

Postoperative hydronephrosis is potentially associated with recurrent disease. Accurate differential diagnosis is challenging although antegrade procedures may be helpful in some cases. Open surgical revision is highly effective to treat benign strictures.

Upper Tract Urinary Cancer Recurrence after Radical Cystectomy: Risk Assessment of Intraoperative Frozen Section

<b><i>Introduction:</i></b> Upper tract urinary cancer recurrence (UTUCR) after radical cystectomy (RC) is outcome-limiting. Surgical recommendations on intraoperative performance of frozen section analysis (FSA) and management of positive ureteral margin (PUM) are lacking. <b><i>Methods:</i></b> 634 RC cases were identified (2010–2018). In patients with PUM, sequential ureteral resections up to a negative margin were performed. We investigated the accuracy of FSA, significance of PUM, and identified risk factors (RFs) to stratify patients for UTUCR. <b><i>Results:</i></b> FSA was performed in 355 patients, including a total of 693 ureters. FSA sensitivity was 0.93 and specificity 0.99. PUM conversion was possible in 52 (91.2%) cases. UTUCR occurred in 17 (4.8%) patients. Identified UTUCR RFs are non-muscle invasive bladder carcinoma (NMIBC) (OR 3.8, 95% confidence intervals [CI] 1.4–10.2, <i>p</i> = 0.008), multifocal bladder cancer in cystectomy specimen (OR 4.7, CI 1.1–20.8, <i>p</i> = 0.042), and recurrent NMIBC (OR 4.1, CI 1.5–10.9, <i>p</i> = 0.006). Risk-group stratification showed a six-fold increase in UTUCR risk (low-to high-risk). <b><i>Conclusion:</i></b> FSA is a sensitive and specific method to identify PUM. UTUCR occurs significantly more often in patients with recurrent, multifocal NMIBC at the time of RC. Patients can be risk stratified for UTUCR. In case of NMIBC-PUM, surgeons can safely opt for a kidney preserving strategy.

Risk factors associated with positive surgical margins' location at radical cystectomy and their impact on bladder cancer survival

PURPOSE

To evaluate the risk factors associated with positive surgical margins' (PSMs) location and their impact on disease-specific survival (DSS) in patients with bladder cancer (BCa) undergoing radical cystectomy (RC).

METHODS

We analyzed a large multi-institutional cohort of patients treated with upfront RC for non-metastatic (cT1-4aN0M0) BCa. Multivariable binomial logistic regression analyses were used to assess the risk of PSMs at RC for each location after adjusting for clinicopathological covariates. The Kaplan-Meier method was used to estimate DSS stratified by margins' status and location. Log-rank statistics and Cox' regression models were used to determine significance.

RESULTS

A total of 1058 patients were included and 108 (10.2%) patients had PSMs. PSMs were located at soft-tissue, ureter(s), and urethra in 57 (5.4%), 30 (2.8%) and 21 (2.0%) patients, respectively. At multivariable analysis, soft-tissue PSMs were independently associated with pathological stage T4 (pT4) (Odds ratio (OR) 6.20, p  <  0.001) and lymph-node metastases (OR 1.86, p  =  0.04). Concomitant carcinoma-in-situ (CIS) was an independent risk factor for ureteric PSMs (OR 6.31, p  =  0.003). Finally, urethral PSMs were independently correlated with pT4-stage (OR 5.10, p  =  0.01). The estimated 3-years DSS rates were 58.2%, 32.4%, 50.1%, and 40.3% for negative SMs, soft-tissue-, ureteric- and urethral PSMs, respectively (log-rank; p  <  0.001).

CONCLUSIONS

PSMs' location represents distinct risk factors' patterns. Concomitant CIS was associated with ureteric PSMs. Urethral and soft-tissue PSM showed worse DSS rates. Our results suggest that clinical decision-making paradigms on adjuvant treatment and surveillance might be adapted based on PSM and their location.

Prognostic value of urinary cytology for detecting urothelial carcinoma recurrence after radical cystectomy

INTRODUCTION

Urethral or upper urinary tract (UUT) recurrence of urothelial carcinoma (UC) after radical cystectomy (RC) are rare (4-6%), and their diagnosis usually occurs within the first two years. Although it is known that its early detection offers benefit in terms of survival, currently there are no clear recommendations for the detection of recurrence in the remnant urothelium (RU). Our aim is to determine the diagnostic value of urinary cytology for the detection of recurrences in the RU and to estimate its impact as an early diagnostic method on survival.

MATERIAL AND METHODS

Retrospective review of patients who underwent RC for urothelial carcinoma between 2008-2016, with a follow-up of at least 24 months.

RESULTS

The study included 142 patients. In a median follow-up of 68.5 months, nine patients (6.3%) presented recurrences in the RU (urethra: four, UUT: four, synchronous: one). The sensitivity and specificity of urinary cytology for the diagnosis of UUT recurrences were 20% and 96%, respectively. No significant differences were found between overall survival and cancer-specific survival among patients according to the urinary cytology results.

CONCLUSION

Recurrences in the RU after RC are infrequent; our study has shown that urinary cytology offers a low sensitivity for their diagnoses. For these reasons, we do not consider that urinary cytology provides useful information for surveillance of these patients.

Achieving disease free distal ureteral margin at the time of radical cystectomy: Why and for whom? (an overview of literature)

OBJECTIVE

Achieving negative status of distal ureteral margin at the time of radical cystectomy (RC), and its therapeutic benefit, remains controversial. The aim of this review was to evaluate frequency, reliability and impact of positive distal ureteral margin after radical cystectomy for bladder cancer on upper tract recurrence, cancer specific and overall survival, and to identify best candidates for intraoperative frozen section analyses.

MATERIAL AND METHODS

A systemic review was performed following the PRISMA guideline. PubMed/Medline (with following terms; bladder cancer or cystectomy and frozen section or ureteral margin), and Cochrane Library were searched up to April 2020, to identify all papers evaluating distal ureteral margin and discussing clinical interest. Previous reviews and single case reports were excluded.

RESULTS

In total, thirty-two relevant studies were identified. Mean rate of positive ureteral frozen section after RC was close to 10% [1.1-25.4%]. Frozen section (FS) achieved a very good specificity [83-100%] and reserved sensibility [45-100%]. In many cases, an initial positive margin on FS can be converted to negative. Positive FS and/or PS (permanent section) were associated with upper urinary tract recurrence (UUTR). Conversion from positive FS to negative PS was associated with low UUTR frequency and better cancer survival in large retrospective studies. The relevant prognostic factor associated with positive FS and/or PS was CIS within the bladder.

CONCLUSION

FS should be recommended for patients with CIS within the bladder. Achieving negative FS/PS might be associated with lower rates of UUTR and better survival, for patients with higher life expectancy. Prospective randomized controlled studies need to be performed to provide definitive recommendations in this area.

Prognostic value of urinary cytology for detecting urothelial carcinoma recurrence after radical cystectomy

INTRODUCTION

Urethral or upper urinary tract (UUT) recurrence of urothelial carcinoma (UC) after radical cystectomy (RC) are rare (4-6%), and their diagnosis usually occurs within the first two years. Although it is known that its early detection offers benefit in terms of survival, currently there are no clear recommendations for the detection of recurrence in the remnant urothelium (RU). Our aim is to determine the diagnostic value of urinary cytology for the detection of recurrences in the RU and to estimate its impact as an early diagnostic method on survival.

MATERIAL AND METHODS

Retrospective review of patients who underwent RC for urothelial carcinoma between 2008-2016, with a follow-up of at least 24 months.

RESULTS

The study included 142 patients. In a median follow-up of 68.5 months, nine patients (6.3%) presented recurrences in the RU (urethra: four, UUT: four, synchronous: one). The sensitivity and specificity of urinary cytology for the diagnosis of UUT recurrences were 20% and 96%, respectively. No significant differences were found between overall survival and cancer-specific survival among patients according to the urinary cytology results.

CONCLUSION

Recurrences in the RU after RC are infrequent; our study has shown that urinary cytology offers a low sensitivity for their diagnoses. For these reasons, we do not consider that urinary cytology provides useful information for surveillance of these patients.

Ureteral and urethral recurrence after radical cystectomy: a systematic review

PURPOSE OF REVIEW

The clinical significance of ureteral and urethral recurrence in patients treated with radical cystectomy for bladder cancer is scarce and heterogeneous. The aim of the current review is to summarize the recent literature on incidence, diagnosis and oncologic outcomes of ureteral and urethral recurrences after radical cystectomy.

RECENT FINDINGS

Frozen section analysis (FSA) of ureteral margin had a sensitivity and specificity of 69-77 and 83-96%, respectively. Considering the ureteral margin, the reported sensitivity and specificity were 33-93 and 99-100%, respectively. Transurethral biopsy of the prostatic urethra might help in counseling patients' treatment, although its accuracy and prognostic role is highly questionable. In patients treated with radical cystectomy, recurrence of the urethra or ureteral are rare, occurring approximately in 5% of patients. During the follow-up, urinary cytology and cross-sectional imaging improve the early detection of recurrence in asymptomatic patients, although the majority are diagnosed for symptomatic presentation. Their use should be tailored to the patient's risk of ureteral and/or urethral recurrence. Urethrectomy is indicated in case of singular urethral recurrence, whereas no clear data exists regarding the best management of ureteral recurrence, except surgical removal.

SUMMARY

Intraoperative FSA of ureters and urethra share good specificity but poor sensitivity. Recurrence at urethra and upper tract are rare and discordant data exists regarding survival outcomes. Oncologic surveillance after radical cystectomy with the aim to detect these recurrences should be tailored to the individualized patient's risk.

Complications of Ileal Conduits after Radical Cystectomy: Interventional Radiologic Management

Since their introduction into clinical practice in the 1950s, ileal conduits have been the most common type of urinary diversion used after radical cystectomy worldwide. Although ileal conduits are technically simpler to construct than other forms of urinary diversion, a variety of complications can occur in the early and late postoperative periods. Early complications include urine leakage, urinary obstruction, postoperative fluid collection (eg, urinoma, hematoma, lymphocele, or abscess), and fistula formation. Late complications include ureteroileal anastomotic stricture, stomal stenosis, conduit stenosis, and urolithiasis. Although not directly related to ileal conduits, ureteroarterial fistula can occur in patients with an ileal conduit. Interventional radiologists can play a pivotal role in diagnosis and management of these complications by performing image-guided minimally invasive procedures. In this article, the authors review the surgical anatomy of an ileal conduit and the underlying pathophysiology of and diagnostic workup for complications related to ileal conduits. The authors also discuss and illustrate current approaches to interventional radiologic management of these complications, with emphasis on a collaborative approach with urologists or endourologists to best preserve patients' renal function and maintain their quality of life. ^©RSNA, 2020.

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 frozen-section analysis of ureteric margins at the time of radical cystectomy predict upper tract recurrence?

Objective

To summarise the currently available literature and analyse available results of the outcome of intraoperative frozen-section analysis (FSA) on upper urinary tract recurrence (UUTR) after radical cystectomy (RC).

Materials and methods

A systematic review of the literature was performed according to the Cochrane Reviews guidelines and in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Articles discussing ureteric FSA with RC were identified.

Results

The literature search yielded 21 studies, on which the present analysis was done. The studies were published between 1997 and 2019. There were 10 010 patients with an age range between 51 and 95 years. Involvement of the ureteric margins was noted in 2–9% at RC. The sensitivity and specificity of FSA were ~75% and 99%, respectively. Adverse pathology on FSA and on permanent section, prostatic urothelial carcinoma involving the stroma but not prostatic duct, and ureteric involvement on permanent section were all more likely to develop UUTR. Neither evidence of ureteric involvement nor ureteric margin status on permanent section were significant predictors of overall survival.

Conclusion

Routine FSA is mandatory for a tumour-free uretero–enteric anastomosis and is predictive of UUTR. To lower the UUTR, FSA is not necessary if the ureters are resected at the level where they cross the common iliac vessels. FSA is indicated whenever the surgeon encounters findings suspicious of malignancy, e.g. ureteric obstruction, periureteric fibrosis, diffuse carcinoma in situ, induration or frank tumour infiltration of the distal ureter is discovered unexpectedly during surgery, and prostatic urethral involvement.

Abbreviations

CIS: carcinoma in situ; FSA: frozen-section analysis; HR: hazard ratio; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RC: radical cystectomy; (UT)UC: (upper tract) urothelial carcinoma; UUT(R): upper urinary tract (recurrence)

Radical Cystectomy in Female Patients - Improving Outcomes

PURPOSE OF REVIEW

To review the methods of improving surgical, oncological, and functional outcomes in women with bladder cancer treated with radical cystectomy.

RECENT FINDINGS

Οrthotopic urinary diversion (ONB) is a safe option for well-selected women as it combines high rates of daytime and nighttime continence with exceptional oncologic outcomes. It is considered safe even for patients with limited lymph node disease and trigone involvement, as long as a preoperative biopsy of the bladder neck or an intraoperative frozen section analysis of distal urethral margin rules out malignant disease. Nerve-sparing techniques have shown promising results. For well-selected patients with early invasive disease, sparing of internal genitalia has proven to be oncologically safe. Yet, generally accepted and evidence-based oncological and functional follow-up schemes for women after radical cystectomy are still lacking. Properly designed prospective studies are needed with adequate number of participants in order to safely conclude about a broader use of pelvic organ-sparing cystectomy.

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

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

Are there differences between de novo and secondary upper tract urothelial carcinoma tumours?

INTRODUCTION

Upper tract urothelial carcinoma (UTUC) accounts for <5% of all urothelial cancers. We aimed to ascertain the clinical differences between UTUC tumours presenting de novo (DnUTUC) and those presenting secondary (SUTUC) following a bladder cancer diagnosis.

METHODS

Our institutional database was queried for all UTUC patients who were surgically treated with radical nephroureterectomy or ureterectomy between 2003 and 2017. Bladder recurrence and cancer-specific mortality were compared. To reduce the possible bias due to confounding variables obtained from a simple comparison of outcomes, DnUTUC patients were matched (for age, gender, tumour location, type of surgery, grade, TNM staging, presence of carcinoma in situ, and lymphovascular invasion) with propensity score to SUTUC patients. Bladder recurrence and cancer-specific mortality were assessed with Cox proportional hazards model.

RESULTS

A total of 117 UTUC patients were identified: 80 with DnUTUC (68.4%) and 37 with SUTUC (31.6%). A greater proportion of males with SUTUC was demonstrated (89.2% vs. 68.8; p=0.02). In both groups, 67.5% of patients had high-grade disease, but SUTUC demonstrated a higher carcinoma in situ rate (43.2% vs. 25%; p=0.047). Univariate analysis demonstrated that the five-year bladder recurrence rate was trending to be higher in SUTUC (65.3% vs. 20.5%; p=0.099). In the Cox model, however, it was associated with increased bladder recurrence (hazard ratio [HR] 3.69; 95% confidence interval [CI] 1.68-8.09; p=0.001). Although univariate analysis demonstrated that SUTUC patients were more likely to die of their disease (30.6% vs. 9%; p=0.009), the multivariable Cox model did not demonstrate this association. The limitations of this study include its retrospective, single-centre design and relatively small cohort of patients.

CONCLUSIONS

In this hypothesis-generating study, some evidence suggests that further research is needed to delineate differences between SUTUC and DnUTUC.

Risk factors for upper tract urothelial recurrence following local excision of bladder cancer

The mechanism of upper tract recurrence after local excision of bladder cancer remains unknown. This study was designed to identify risk factors for upper tract urothelial recurrence following local tumor excision of bladder cancer. To identify 76 597 bladder cancer patients, comprising 76 537 nonrecurrence and 60 recurrence patients, the Surveillance, Epidemiology, and End Results database was used. Kaplan‐Meier analysis and univariate and multivariate Cox proportional hazards regression models were used to determine the risk factors. Compared with the nonrecurrence group, the recurrence group was associated with older age, higher grade, high T stage, and higher proportional squamous cell carcinomas. Univariate Cox proportional hazards regression model showed that age, grades III and IV, T stage, and pathology were significantly associated with worse upper tract urothelial recurrence (UTUR) survival. However, after adjusting for prognostic factors, grade was no longer an independent prognostic factor in multivariate analysis. This study demonstrates that clinical prognosis of UTUR after local bladder tumor excision has significant independent risk factors that include age ≥60 years, T1 and T2 stage, and squamous cell carcinoma, and will require more careful consideration during follow‐up.

Updates for the radiologist in non-muscle-invasive, muscle-invasive, and metastatic bladder cancer

Urothelial bladder cancer is a common malignancy requiring a multidisciplinary approach to treatment. Significant recent advances have been made in terms of the genetic and molecular characterization of bladder cancer subtypes, and novel treatment approaches are being investigated and approved. Given the important role of imaging in the diagnosis, staging, and follow-up of this disease, it is necessary for radiologists to remain up-to-date in terms of nomenclature and standards of care. In this review, recent developments in bladder cancer characterization and treatment will be discussed, with reference to the contributions of imaging in non-muscle-invasive, muscle-invasive, and metastatic settings.

Systematic Review on the Fate of the Remnant Urothelium after Radical Cystectomy

CONTEXT

Urothelial carcinoma is considered a pan-urothelial disease. As such, the remnant urothelium in the upper urinary tract and urethra following radical cystectomy (RC) remains at risk for secondary urothelial tumors (SUTs).

OBJECTIVE

To describe the incidence, diagnosis, treatment, and outcomes of patients with SUTs after RC.

EVIDENCE ACQUISITION

A systematic search was conducted using PubMed database according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to identify studies between 1970 and 2016 reporting on malignant diseases of the urothelium after RC for bladder cancer. The search strategy separated between upper and lower tract urothelial tumors.

EVIDENCE SYNTHESIS

Of a total of 1069 studies, 57 were considered for evidence synthesis. SUTs occured in approximately 4-10% of patients after RC. Carcinoma in situ of the bladder, a history of nonmuscle invasive bladder cancer, and tumor involvement of the distal ureter are the strongest risk factors for secondary upper tract tumors. Risk factors for secondary urethral tumors represent urothelial malignancy in the prostatic urethra/prostate and bladder neck (in women), nonorthotopic diversions, and positive findings on permanent sections. The majority of patients (84%) with SUTs, presented with urothelial recurrence without evidence of metastasis. Of those, 84.0% were treated with surgery, 10.5% with systemic chemotherapy and/or radiotherapy, and 5.6% with topical chemotherapy and/or immunotherapy. After a median follow-up of 91 mo (range: 26-155), 65.9% of patients died of disease and 21.5% died of other causes. Detection and treatment of SUTs at an asymptomatic stage can reduce the risks of cancer-specfific and overall mortality by 30%. A limitation of the study is that the available data were retrospective.

CONCLUSIONS

SUTs are rare oncological events and most patients have an adverse prognosis despite absence of distant disease at diagnosis. Therefore, surveillance of the remnant urothelium should be implemented for patients with histological features of panurothelial disease as it may improve timely detection and treatment.

PATIENT SUMMARY

Secondary tumors of the renal pelvis, ureters, and urethra occur in approximately 4-10% of patients after radical removal of the bladder for bladder cancer. These patients' prognoses are reduced, likely due to delayed diagnosis. Therefore, routine surveillance might be important to detect tumors at an early stage.

The neutrophil-to-lymphocyte ratio as a predictor of intravesical recurrence in patients with upper urinary tract urothelial carcinoma treated with radical nephroureterectomy

BACKGROUND

The neutrophil-to-lymphocyte ratio (NLR) is a marker of systemic inflammation associated with recurrence and poor prognosis in numerous cancer types. The aim of this study was to evaluate the use of the NLR as a biomarker for intravesical recurrence (IVR) in patients undergoing radical nephroureterectomy (RNU) for upper urinary tract urothelial carcinoma (UTUC) for the first time.

METHODS

We retrospectively analyzed the records of 100 patients with UTUC who had undergone RNU between 1999 and 2015 at our institution. The association between the preoperative NLR and IVR were assessed using multivariate models.

RESULTS

Among the 100 patients enrolled in the study, 33 developed IVR during a median follow-up of 34 months. The receiver operating characteristic analysis revealed that the optimum cut-off value for the preoperative NLR was >3.8. A high preoperative NLR (n = 21) was associated with a significantly increased risk of lymph node involvement (p = 0.036) and IVR (p = 0.034) compared with a low preoperative NLR (n = 79). IVR-free survival in patients with a high preoperative NLR was significantly worse than that of patients with a low preoperative NLR (p = 0.018). On multivariate analysis, the preoperative NLR [hazard ratio (HR) 2.49; p = 0.015] and tumor multifocality (HR 2.96; p = 0.024) were independent risk factors predictive of IVR.

CONCLUSION

In our study population of patients with UTUC who had undergone RNU the preoperative NLR was associated with a significantly increased risk of IVR, suggesting that the NRL could be a useful biomarker for predicting IVR.

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

CONTEXT

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

OBJECTIVE

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

PATIENT SUMMARY

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

Recommendations for the improvement of bladder cancer quality of care in Canada: A consensus document reviewed and endorsed by Bladder Cancer Canada (BCC), Canadian Urologic Oncology Group (CUOG), and Canadian Urological Association (CUA), December 2015

This initiative was undertaken in response to concerns regarding the variation in management and in outcomes of patients with bladder cancer throughout centres and geographical areas in Canada. Population-based data have also revealed that real-life survival is lower than expected based on data from clinical trials and/or academic centres. To address these perceived shortcomings and attempt to streamline and unify treatment approaches to bladder cancer in Canada, a multidisciplinary panel of expert clinicians was convened last fall for a two-day working group consensus meeting. The panelists included urologic oncologists, medical oncologists, radiation oncologists, patient representatives, a genitourinary pathologist, and an enterostomal therapy nurse. The following recommendations and summaries of supporting evidence represent the results of the presentations, debates, and discussions. Methodology

Segmental ureteroileal conduit resection for the treatment of distal upper urinary tract recurrence of bladder cancer following cystectomy

Segmental ureterectomy is less invasive than radical nephroureterectomy and results in nephron preservation and satisfactory tumor control. This study was to determine the feasibility of segmental ureteroileal conduit resection (SUICR) for patients with distal upper urinary tract recurrence of bladder cancer following radical cystectomy. Four patients with high-grade distal upper urinary tract recurrence underwent SUICR 15–108 months after radical cystectomy. The surgical technique details of SUICR, operative results, and follow-up outcomes are reported. The median operation time was 280 min, and estimated blood loss was less than 100 mL. One patient suffered from ileus 5 days after surgery and was managed conservatively. Histopathologic evaluation showed high-grade stages pTa-pT1 diseases for these patients, and ureteral margins were all negative. No patient suffered from tumor recurrence, with a median follow-up of 39 months. SUICR preserved the ipsilateral renal unit and conformed to oncological principles during surgery. The oncological outcome was satisfactory for these properly selected patients. This technique provides a valid alternative to nephroureterectomy for patients with imperative indications and high-grade upper urinary tract recurrence of bladder cancer following radical cystectomy.

Sources of variation in follow-up expenditure after radical cystectomy

BACKGROUND

Follow-up care after radical cystectomy is poorly defined, with extensive variation in practice patterns. We sought to determine sources of these variations in care as well as examine the economic effect of standardization of care to guideline-recommended care.

METHODS

Using linked Surveillance, Epidemiology, and End Results (SEER)-Medicare data from 1992 to 2007, we determined follow-up care expenditures (time and geography standardized) for 24 months after surgery. Accounted expenditures included office visits, imaging studies, urine tests, and blood work. A multilevel model was implemented to determine the effect of region, surgeon, and patient factors on care delivery. We then compared the actual expenditures on care in the Medicare system (interquartile range) with the expenditures if patients received care recommended by current clinical guidelines.

RESULTS

Expenditures over 24 months of follow-up were calculated per month and per patient. The mean and median total expenditures per patient were $1108 and $805 respectively (minimum $0, maximum $9,805; 25th-75th percentile $344-$1503). Variations in expenditures were most explained at the patient level. After accounting for surgeon and patient levels, we found no regional-level variations in care. Adherence to guidelines would lead to an increase in expenditures by 0.80 to 10.6 times the expenditures exist in current practice.

CONCLUSION

Although some regional-level and surgeon-level variations in care were found, the most variation in expenditure on follow-up care was at the patient level, largely based on node positivity, chemotherapy status, and final cancer stage. Standardization of care to current established guidelines would create higher expenditures on follow-up care than current practice patterns.

Recurrence patterns after open and robot-assisted radical cystectomy for bladder cancer

BACKGROUND

Concerns remain whether robot-assisted radical cystectomy (RARC) compromises survival because of inadequate oncologic resection or alteration of recurrence patterns.

OBJECTIVE

To describe recurrence patterns following open radical cystectomy (ORC) and RARC.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective review of 383 consecutive patients who underwent ORC (n=120) or RARC (n=263) at an academic institution from July 2001 to February 2014.

INTERVENTION

ORC and RARC.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Recurrence-free survival estimates were illustrated using the Kaplan-Meier method. Recurrence patterns (local vs distant and anatomic locations) within 2 yr of surgery were tabulated. Cox regression models were built to evaluate the effect of surgical technique on the risk of recurrence.

RESULTS AND LIMITATIONS

The median follow-up time for patients without recurrence was 30 mo (interquartile range [IQR] 5-72) for ORC and 23 mo (IQR 9-48) for RARC (p=0.6). Within 2 yr of surgery, there was no large difference in the number of local recurrences between ORC and RARC patients (15/65 [23%] vs 24/136 [18%]), and the distribution of local recurrences was similar between the two groups. Similarly, the number of distant recurrences did not differ between the groups (26/73 [36%] vs 43/147 [29%]). However, there were distinct patterns of distant recurrence. Extrapelvic lymph node locations were more frequent for RARC than ORC (10/43 [23%] vs 4/26 [15%]). Furthermore, peritoneal carcinomatosis was found in 9/43 (21%) RARC patients compared to 2/26 (8%) ORC patients. In multivariable analyses, RARC was not a predictor of recurrence. Limitations of the study include selection bias and a limited sample size.

CONCLUSIONS

Within limitations, we found that RARC is not an independent predictor of recurrence after surgery. Interestingly, extrapelvic lymph node locations and peritoneal carcinomatosis were more frequent in RARC than in ORC patients. Further validation is warranted to better understand the oncologic implications of RARC.

PATIENT SUMMARY

In this study, the locations of bladder cancer recurrences following conventional and robotic techniques for removal of the bladder are described. Although the numbers are small, the results show that the distribution of distant recurrences differs between the two techniques.

Comparative effectiveness research in urologic cancers

Controversies abound in urologic cancers. While some work in comparative effectiveness research has been performed, most controversies remain unresolved. In this chapter, we examine the three most common urologic malignancies: Prostate cancer, kidney cancer, and bladder cancer. We will review progress made in comparative effectiveness research for each cancer and outline important topics where future research is needed.

Prognostic value of prior history of urothelial carcinoma of the bladder in patients with upper urinary tract urothelial carcinoma: results from a retrospective multicenter study

BACKGROUND

Patients with urothelial carcinoma (UC) often develop multifocal metachronous tumors throughout the genitourinary tract. In the present study, we evaluated the prognostic value of prior history of UC of the bladder (UCB) in patients with upper tract urothelial carcinoma (UTUC) in an international multi-institutional cohort.

PATIENTS AND METHODS

Data from 785 patients who underwent radical nephroureterectomy (RNU) with ipsilateral bladder cuff resection at nine academic institutions in Europe and the USA between 1987 and 2008 were reviewed. Log-rank tests and Cox proportional hazards regression models were used for univariable and multivariable analyses.

RESULTS

The median follow-up of the whole cohort was 34 months (interquartile range 15-66 months). Five hundred and fifty-eight (72 %) patients had no UCB before the diagnosis of UTUC; a prior history of non-muscle-invasive and muscle-invasive UCB before the UTUC was found in 179 (23 %) and 36 (5 %), respectively. History of UCB before RNU was an independent predictor of both recurrence-free survival (p = 0.012; no UCB vs. non-muscle-invasive UCB: hazard ratio (HR) 1.4, p = 0.082; no UCB vs. muscle-invasive UCB: HR 2.1, p = 0.007) and cancer-specific survival (p = 0.008; no UCB vs. non-muscle-invasive UCB: HR 1.2, p = 0.279; no UCB vs. muscle-invasive UCB: HR 2.3, p = 0.008) on multivariable Cox regression analyses that included age, gender, surgical type, stage, grade, presence of concomitant carcinoma in situ, presence of lymphovascular invasion, and lymph node status.

CONCLUSIONS

Prior history of muscle-invasive UCB was significantly associated with an increased risk of disease recurrence and cancer-specific death in patients with UTUC.

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

Objective

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

Materials and Methods

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

Results

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

Conclusion

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

Survival impact of followup care after radical cystectomy for bladder cancer

PURPOSE

Due to substantial variation in patient followup after radical cystectomy for bladder cancer, we sought to understand the effect of urine and laboratory tests, physician visits and imaging on overall survival.

MATERIALS AND METHODS

We analyzed a cohort of patients treated in the fee for service Medicare population from 1992 through 2007 using Surveillance Epidemiology and End Results (SEER)-Medicare data. Using propensity score analysis, we assessed the relationship between time and geography standardized expenditures on followup care and overall survival during 3 postoperative periods, including perioperative (0 to 3 months), early followup (4 to 6 months) and later followup (7 to 24 months). Using instrumental variable analysis, we assessed the overall survival impact of the quantity of followup care by category, including physician visits, imaging, and laboratory and urine tests.

RESULTS

We found no improvement in survival due to followup care in the perioperative and early followup periods. Receiving followup care during later followup was associated with improved survival in the low, middle and high expenditure tertiles (HR 0.23, 95% CI 0.15-0.35, HR 0.27, 95% CI 0.18-0.40 and HR 0.47, 95% CI 0.31-0.71, respectively). Instrumental variable analysis suggested that only physician visits and urine testing improved survival (HR 0.96, 0.93-0.99 and 0.95, 0.91-0.99, respectively).

CONCLUSIONS

Followup care after radical cystectomy in the later followup period was associated with improved survival. Physician visits and urine tests were associated with this improved survival. Our results suggest that aspects of followup care significantly improve patient outcomes but imaging could be done more judiciously after cystectomy.

Surveillance of patients with bladder cancer following cystectomy: yield of CT urography

PURPOSE

To determine the yield of CT urography (CTU) in the surveillance of patients with bladder cancer following cystectomy.

MATERIALS AND METHODS

In this IRB-approved, HIPAA-compliant, retrospective study of 5,404 CT urograms performed at our institution between March 2000 and February 2011, 225 CT urograms were performed in 105 patients [79 men, 26 women; mean age 65 years (43-85)] following cystectomy for bladder cancer. Median follow-up after cystectomy was 63 months (range 1-234), median time between cystectomy and CTU was 39 months (range 0-229), median follow-up after CTU was 34 months (range 1-111). CTU examinations were reviewed by two radiologists in consensus and findings were categorized into those related to surgery, locoregional recurrence, metastases, or metachronous upper tract urothelial tumor (UTT).

FINDINGS

Findings were present in 69 (65.7 %) of 105 patients, including findings related to surgery in 60 (57.1 %) patients, locoregional recurrence or metastatic disease in 21 (20 %) patients, and UTT in 3 (2.9 %) patients. Of surgery-related findings, hydronephrosis (23/105, 21.9 %) and parastomal hernia (17/105, 16.2 %) were the most common findings. Visceral metastases (16/105, 15.2 %) and lymph node metastases (13/105, 12.4 %) were the most common manifestations of recurrent disease.

CONCLUSION

CTU findings in the surveillance of patients with bladder cancer after cystectomy are common and include those related to surgery, spread of the disease, and metachronous tumors. Our study supports current published guidelines on the use of CTU in these patients.

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

CONTEXT

Following cystectomy, approximately 50% of patients will present tumour recurrence. A recurrence may be local, systemic or occur in the urethra or upper urinary tract.

OBJECTIVE

To analyse the characteristics, risk factors and outcomes of patients with tumour recurrence following cystectomy so as to subsequently propose a cancer follow-up protocol.

ACQUISITION OF EVIDENCE

Analysis of original articles and reviews related to tumour recurrence and follow-up after radical cystectomy for urothelial tumour. Articles were obtained from Pubmed searches.

SUMMARY OF THE EVIDENCE

Systemic and local recurrences following cystectomy appear in 20%-35% and 5%-15% of cases, respectively. Some 80%-90% are diagnosed in the first 3 years, with the majority concentrated in the first 24 months. Common factors related to an increased risk of local and systemic recurrence are a pathologic stage ≥pT3, the presence of positive margins and the extension of the lymphadenectomy. The incidence of recurrence in the upper urinary tract and urethra is 2%-6% and 4%-6%, respectively. Both types of recurrence may appear late and share risk factors such as signs of multifocal disease, a history of non-muscle-invasive bladder cancer, multiplicity, presence of ISC, urinary tract tumours and prostatic urethral tumours. Tumours in the distal ureteral cystectomy specimen and tumours in the prostatic urethra are also risk factors related to the appearance of tumours in the urinary tract and urethra, respectively.

CONCLUSION

Understanding the natural history of urothelial bladder carcinoma and the risk factors related to the appearance of tumour recurrence following cystectomy are essential for designing an appropriate follow-up protocol. The follow-up of patients with risk factors for local or systemic recurrence will achieve maximum efficiency during the first 3 years. The follow-up should be extended for patients with risk factors for presenting upper urinary tract or urethral tumours.

The expression and actions of androgen receptor in upper urinary tract urothelial carcinoma (UUTUC) tissues and the primary cultured cells

Sex hormone receptors, androgen receptor (AR) and estrogen receptors (ERs) including both ERα and ERβ, mediate the actions of sex hormones. In this study, we aimed to evaluate sex hormone receptors expression in upper urinary tract urothelial carcinomas (UUTUCs) of ureter and renal pelvis with different tumor stages and grades as well as their possible roles in tumor progression. Immunohistochemistry was used to assay the expression of AR and ERs in the primary UUTUCs. XTT viability test was applied to evaluate cell responses for anticancer drug treatment. Wound healing assay was performed to determine cell migration abilities. AR and ERβ immunoreactivities were observed in both UUTUCs, but ERα was not detected in either UUTUCs. In UUTUC of ureter specimens, higher AR expression was found in superficial or lower grade tumors. In contrast, little difference of ERβ expression was found in superficial versus muscle-invasive tumor stages or low grades versus high grades in UUTUCs of ureter specimens. Furthermore in the primary cultured cells from UUTUC specimens, the addition of functional AR reduced cell chemosensitivity, but increased cell migration. These results provide the first data showing the expression patterns of sex hormone receptors in both renal pelvis and ureter UUTUCs. From results, we concluded that there is a positive correlation for higher AR expression found in superficial or low-grade UUTUCs of ureter and identified the functional roles of AR in UUTUC progression.

Androgen receptor decreases the cytotoxic effects of chemotherapeutic drugs in upper urinary tract urothelial carcinoma cells

Upper urinary tract urothelial carcinomas (UUTUCs) represent relatively uncommon yet devastating tumors that affect more males than females. However, the correlation between gender difference and disease progression remains unclear. Androgen and the androgen receptor (AR) were previously hypothesized to account for the gender difference in the incidence of urothelial carcinomas; however, the role of AR in the development and progression of UUTUCs is not well understood. In addition, although UUTUCs are responsive to chemotherapy, various responses are presented among patients. Therefore, the aim of the present study was to determine the role of AR in the response of UUTUC cells to chemotherapeutic drugs. In this study, AR overexpression in UUTUC cells (BFTC 909) was identified to reduce the cytotoxic effect of chemotherapeutic drugs, including doxorubicin, cisplatin and mitomycin C and protected cells from drug-induced death. The expression of ABCG2, an ATP-binding cassette half-transporter associated with multidrug resistance, was increased in AR-overexpressing BFTC cells. In addition, use of the AR degradation enhancer, ASC-J9^®, repressed the AR effect on increasing cell viability under drug treatment. In summary, results of the present study indicate that the status of AR expression levels in UUTUCs may be a significant factor in affecting the efficacy of chemotherapy and classic chemotherapeutic drugs and AR targeted therapy may provide a novel potential therapeutic approach to improve treatment of UUTUCs.

The Treatment of Recurrent Urothelial Tumors of the Upper Urinary System and at Urostomy Site following Radical Cystectomy with Intraureteral Bacillus Calmette-Guérin and Cryotherapy

Urinary bladder carcinoma is the second most common cancer of the urinary system. The recurrence rate in the upper urinary system (UUS) for urothelial cancers is around 3% following radical cystectomy. The followup generally consists of imaging studies and urinary cytology, although there are no prospective data on the frequency, the mode, and the duration of followup. In patients carefully selected according to risk factors, kidney-sparing minimally invasive methods (ureteroscopic procedures, percutaneous approach, and local drug instillation) appear as contemporary alternatives for low-grade and low-stage primary UUS. In this paper, we present the patient who underwent radical cystectomy with urinary diversion ureterocutaneostomy, was diagnosed with widespread bilateral UUS tumors and recurrent tumor at the urostomy site at active followup, for which he was given local Bacillus Calmette-Guérin (BCG) and cryotherapy, and was followed by disease-free for 2 years thereafter.