The frequency of hydronephrosis at initial diagnosis and its effect on recurrence and progression in patients with superficial bladder cancer

Risk and Prognosis of Cancer in Patients with Obstructive Uropathy Compared with the General Danish Population

BACKGROUND

To examine whether obstructive uropathy is associated with increased risk of cancer and whether mortality differs between patients with cancer with and without obstructive uropathy.

METHODS

In a nationwide population-based Danish cohort study including 37,275 adult patients with a first-time hospital-related diagnosis of obstructive uropathy in 1996 to 2022, we assessed cumulative cancer incidence (risk) and standardized incidence ratios (SIR). Furthermore, we compared the mortality of 7,485 patients diagnosed with cancer after obstructive uropathy diagnosis with that of 69,785 patients with cancer without obstructive uropathy matched by age, sex, cancer site, stage, and calendar year of cancer diagnosis.

RESULTS

The 3-month risk of cancer after an obstructive uropathy diagnosis was 9.6%. The 3-month SIR was 34.2 [95% confidence interval (CI), 33.1-35.4] while the 1 to <5 year SIR was 1.2 (95% CI, 1.1-1.3). The 3-month SIRs were 82.7 (95% CI, 79.3-86.2) for urological cancer, 88.8 (95% CI, 79.8-98.5) for gynecological cancer, and 13.9 (95% CI, 12.0-15.9) for colorectal cancer. After 1 year of follow-up, the excess number of urological cancers decreased to 0.1 per 100 person-years, whereas we observed no excess risk of gynecological and colorectal cancers. The 5-year all-cause mortality following cancer was 64.1% (95% CI, 62.9-65.2) in patients with an obstructive uropathy diagnosis before cancer diagnosis and 53.2% (95% CI, 52.9-53.6) in those without.

CONCLUSIONS

A first-time diagnosis of obstructive uropathy can be a clinical marker of underlying undiagnosed cancer and elevated mortality in relation to any cancer diagnosed after obstructive uropathy.

IMPACT

These findings can inform the follow-up recommendations for obstructive uropathy.

A Comparison of the Anesthetic Methods for Recurrence Rates of Bladder Cancer after Transurethral Resection of Bladder Tumors Using National Health Insurance Claims Data of South Korea

Bladder cancers have high recurrence rates and are usually removed via transurethral resection of bladder tumor (TURBT). Recently, some reports showed that the anesthetic method may affect the recurrence rates of bladder cancers. The purpose of this population-based study was to compare the effect of anesthetic methods with the recurrence rates of bladder cancers in South Korea. A total of 4439 patients were reviewed retrospectively using the data of the Korean National Health Insurance (NHI) claims database from January 2007 to December 2011. Patients were divided into 2 groups who received general (n = 3767) and regional anesthesia (n = 582), and were followed up until September 2017. Propensity score matching was conducted to reduce the effect of confounding factors. After using propensity score matching with a multivariable Cox regression model, age (p < 0.001), sex (p < 0.001), hypertension (p = 0.003), diabetes mellitus (p = 0.001), and renal disease (p < 0.001) were significantly associated with bladder cancer recurrence. However, there were no significant differences in the recurrence rates of bladder cancers in patients who received general anesthesia and spinal anesthesia for TURBTs. This study revealed that there is no relationship between the anesthetic method and bladder cancer recurrence. Either general anesthesia or regional anesthesia can be used depending on the situation in patients receiving TURBT. Future prospective studies are warranted to confirm the association between the anesthetic method and the recurrence rates of bladder cancer.

Impact of double J stenting or nephrostomy placement during transurethral resection of bladder tumour on the incidence of metachronous upper urinary tract urothelial cancer

Background

Whether or not double J (DJ) stenting during transurethral resection of a bladder tumour (TURBT) harms patients with regard to possible metachronous upper urinary tract urothelial cancer (UUTUC) development remains controversial. This study evaluated the impact of DJ compared to nephrostomy placement during TURBT for bladder cancer (BCa) on the incidence of metachronous UUTUCs.

Methods

We retrospectively analysed 637 patients who underwent TURBT in our department between 2008 and 2016. BCa, UUTUC and urinary drainage data (retrograde/anterograde DJ and percutaneous nephrostomy) were assessed, along with the prevalence of hydronephrosis, and mortality. Chi-square and Fisher’s exact test was performed for univariate analyses. Survival analysis was performed by the Kaplan-Meier method and log-rank tests.

Results

UUTUC was noted in 28 out of 637 patients (4.4%), whereas only eight (1.3%) developed it metachronously to BCa. Out of these, four patients received DJ stents, while four patients received no urinary drainage of the upper urinary tract. Placement of urinary drainage significantly correlated with UUTUC (50.0% vs. 17.9%; p = 0.041). DJ stenting significantly correlated with UUTUC (50.0% vs. 11%; p <  0.01), while no patient with a nephrostomy tube developed UUTUC. UUTUC-free survival rates were significantly lower for patients with DJ stents than for all other patients (p = 0.001). Patients with or without DJ stents had similar overall survival (OS) rates (p = 0.73), whereas patients with nephrostomy tubes had significantly lower OS rates than all other patients (p <  0.001).

Conclusions

Patients with DJ stenting during TURBT for BCa might have an increased risk of developing metachronous UUTUC. This study indicated advantages in placing nephrostomy tubes rather than DJ stents; however, confirmation requires investigation of a larger cohort. Even so, the increased mortality rate in the nephrostomy group reflected hydronephrosis as an unfavourable prognostic factor.

Predicting recurrence of nonmuscle-invasive bladder cancer (Ta-T1): A study based on 477 patients

The aim of this study was to determine clinical recrudescent risk factors of 477 patients with newly discovered nonmuscle-invasive bladder cancer (NMIBC) (Ta-T1) in our hospital, and based on these factors, to establish a recurrence risk prediction model of each NMIBC patient.This study included 477 patients with newly discovered NMIBC (Ta-T1) from January 2012 to December 2016; all patients were treated surgically by transurethral resection of bladder tumor (TURBT). The outcomes of patients were with or without recurrence within 2 years. The nomograms were based on Cox regression analyses, and the calibration curves were founded to evaluate the agreements of the predicted probability with the actual observed probability.Of the 477 patients with NMIBC, 392 were males (82.2%) and 85 were females (17.8%), with median age 64 years. Recurrence was identified in 327 cases (68.6%). The results showed that old age, female sex, smoking history, large size of tumor, multifocal tumors, high grade, and high stage are risk factors for NMIBC recurrence, whereas no significant association was seen between tumor location and recurrence in our study. Based on the results of Cox regression analyses, several independent risk factors, including smoking history, tumor size, multifocal, immediate infusion therapy, T stage, and tumor grade, were used to establish a nomogram to calculate the recurrence probability of each NMIBC patient, and the calibration curve displayed that this nomogram had a great value of prediction.Old age, female sex, smoking history, large size of tumor, multifocal tumors, high grade, and high stage are risk factors for NMIBC recurrence, whereas immediate infusion therapy is a protective factor. And a nomogram was established as a prediction model to calculate the recurrence probability of NMIBC patients.

Clinical and prognostic value of preoperative hydronephrosis in upper tract urothelial carcinoma: a systematic review and meta-analysis

Background. Epidemiological studies have reported various results relating preoperative hydronephrosis to upper tract urothelial carcinoma (UTUC). However, the clinical significance and prognostic value of preoperative hydronephrosis in UTUC remains controversial. The aim of this study was to provide a comprehensive meta-analysis of the extent of the possible association between preoperative hydronephrosis and the risk of UTUC.

Methods. We searched PubMed, ISI Web of Knowledge, and Embase to identify eligible studies written in English. Summary odds ratios (ORs) or hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using fixed-effects or random-effects models.

Results. Nineteen relevant studies, which had a total of 5,782 UTUC patients enrolled, were selected for statistical analysis. The clinicopathological and prognostic relevance of preoperative hydronephrosis was evaluated in the UTUC patients. The results showed that all tumor stages, lymph node status and tumor location, as well as the risk of cancer-specific survival (CSS), overall survival (OS), recurrence-free survival (RFS) and metastasis-free survival (MFS) were significantly different between UTUC patients with elevated preoperative hydronephrosis and those with low preoperative hydronephrosis. High preoperative hydronephrosis indicated a poor prognosis. Additionally, significant correlations between preoperative hydronephrosis and tumor grade (high grade vs. low grade) were observed in UTUC patients; however, no significant difference was observed for tumor grading (G1 vs. G2 + G3 and G1 + G2 vs. G3). In contrast, no such correlations were evident for recurrence status or gender in UTUC patients.

Conclusions. The results of this meta-analysis suggest that preoperative hydronephrosis is associated with increased risk and poor survival in UTUC patients. The presence of preoperative hydronephrosis plays an important role in the carcinogenesis and prognosis of UTUC.

Predictive role of preoperative hydronephrosis on poor pathological outcomes and prognosis in upper tract urothelial carcinoma patients: Experience from a nationwide high-volume center in China

To validate the predictive value of preoperative hydronephrosis (HN) with regard to clinicopathological outcome and prognosis in a large cohort of upper tract urothelial carcinoma (UTUC) patients, a retrospective analysis was conducted using the clinicopathological data of 520 consecutive patients treated between 2000 and 2010 at a nationwide high-volume center in China. Preoperative computed tomography or magnetic resonance imaging scans were evaluated for the presence of ipsilateral HN, and the associations between HN and pathological outcomes, patient survival and urinary tract recurrences were assessed. Ipsilateral HN was present in 271 patients (52.1%). Preoperative HN was associated with advanced age (P=0.007), sessile tumor architecture (P<0.001), ureteral location (P<0.001), higher tumor stage (P<0.001) and higher histological grade (P=0.002). Univariate and multivariate analyses revealed that poorer cancer-specific survival (CSS) and overall survival (OS) times were correlated with preoperative HN (P=0.004 and P=0.009, respectively). The 5-year CSS and OS rates for patients with HN were 86.9 and 86.2%, respectively, compared to 93.3 and 91.9% for patients without HN. For patients with muscle-invasive disease, HN remained a risk factor for poor CSS and OS (P=0.009 and P=0.012, respectively). No association was identified between HN and bladder recurrence (P=0.552) or the development of contralateral upper tract carcinoma (P=0.164). The findings indicated that preoperative HN is prevalent in UTUC. The presence of preoperative HN predicted poorer pathological outcomes and was a significant risk factor affecting survival. The evaluation of HN may be informative for decisions concerning surgical options, and the presence of HN should raise the possibility of employing an aggressive treatment approach.

Tumour stage on re-staging transurethral resection predicts recurrence and progression-free survival of patients with high-risk non-muscle invasive bladder cancer

INTRODUCTION

To identify patients who should be considered for early radical cystectomy, we evaluated the clinical and pathological variables affecting the outcome of patients with high-risk non-muscle invasive bladder cancer (NMIBC) who underwent re-staging transurethral resection (re-TUR).

METHODS

We reviewed the clinical data of 453 patients treated for urothelial carcinoma between 2006 and 2010. In total, 94 patients underwent re-TUR after their initial TUR. Of these, 72 were not upstaged to muscle invasive disease and were therefore included in our study.

RESULTS

On re-TUR, 31 patients had no residual tumour (T0) and 41 patients had residual NMIBC. A statistically significant difference was noted between patients with pT0 and patients with residual NMIBC on re-TUR in regard to tumour recurrence and progression (39% vs. 83%, p < 0.001) (6% vs. 34%, p = 0.005), respectively. On multivariate analysis, tumour stage on re-TUR and the regimen of intravesical bacillus Calmette-Guérin (BCG) therapy (induction vs. maintenance) remained independent predicting factors for recurrence-free survival (RFS) (p = 0.001, hazard ratio [HR]: 1.77), (p < 0.001 HR: 0.16) and progression-free survival (PFS) (p = 0.014, HR: 2.11), (p = 0.008, HR: 0.097), respectively.

CONCLUSIONS

The presence of T0 on re-TUR is associated with better RFS and PFS and could be a predictive factor for candidates for conservative management. Patients with persistent NMIBC on re-TUR require close follow-up and, in some cases, could be considered for early cystectomy. Maintenance intravesical BCG therapy can improve RFS and PFS in patients with high-risk NMIBC. This study is limited by its retrospective nature and the relatively small number of patients in the cohort.

Upper urinary tract urothelial carcinoma: what have we learned in the last 4 years?

In the last 4 years many studies have been published on the topic of upper urinary tract urothelial carcinoma (UTUC). This is a recent review of the available literature of the last 3 years. A systematic Medline/PubMed search on UTUC including limits for clinical trials and randomized, controlled trials was performed for English-language articles using the keywords 'upper urinary tract carcinoma', 'nephroureterectomy', 'laparoscopic', 'ureteroscopy', 'percutaneous', 'renal pelvis', 'ureter' and their combinations from January 2008 to December 2010. Additional selected reports from 2007 were included. Case reports and non-English literature were excluded. Publications were mostly retrospective, including some large, multicentre studies from the Upper Tract Urothelial Carcinoma Collaboration (UTUCC). The authors of this article are members of the UTUCC. Altogether, 92 original articles dealing with UTUC were identified and summarized. The vast majority of the available literature has a low level of evidence (level IV), although many multicentre studies tried to overcome the problem of low numbers by pooling data. It was concluded that in the last 3 years our knowledge regarding UTUC has increased dramatically, although new study concepts allowing us to increase the level of evidence are needed.

Urothelial carcinoma of the bladder: definition, treatment and future efforts

The identification of patients with high-risk bladder cancer is important for the timely and appropriate treatment of this lethal disease. The understanding of the natural history of bladder cancer has improved; however, the criteria used to define high-risk disease and the relevant treatment strategies have remained the same for the past several decades, despite multiple large, randomized, prospective clinical trials that have evaluated the use of intravesical, surgical and systemic therapies. The genetic signature of high-risk bladder cancer has been a focus of investigation and has led to the discovery of potential molecular targets for disease identification, risk stratification and therapy. These advances, combined with a comprehensive risk assessment profile that incorporates available pathological and clinical characteristics, might improve the diagnosis and treatment of patients with bladder cancer.

Radical cystectomy for the treatment of T1 bladder cancer: the Canadian Bladder Cancer Network experience

BACKGROUND

Radical cystectomy may provide optimal survival outcomes in the management of clinical T1 bladder cancer. We present our data from a large, multi-institutional, contemporary Canadian series of patients who underwent radical cystectomy for clinical T1 bladder cancer in a single-payer health care system.

METHODS

We collected a pooled database of 2287 patients who underwent radical cystectomy between 1993 and 2008 in 8 different centres across Canada; 306 of these patients had clinical T1 bladder cancer. Survival data were analyzed using Kaplan-Meier method and Cox regression analysis.

RESULTS

The median age of patients was 67 years with a mean follow-up time of 35 months. The 5-year overall, disease-specific and disease-free survival was 71%, 77% and 59%, respectively. The 10-year overall and disease-specific survival were 60% and 67%, respectively. Pathologic stage distribution was p0: 32 (11%), pT1: 78 (26%), pT2: 55 (19%), pT3: 60 (20%), pT4: 27 (9%), pTa: 16 (5%), pTis: 28 (10%), pN0: 215 (74%) and pN1-3: 78 (26%). Only 12% of patients were given adjuvant chemotherapy. On multivariate analysis, only margin status and pN stage were independently associated with overall, disease-specific and disease-free survival.

INTERPRETATION

These results indicate that clinical T1 bladder cancer may be significantly understaged. Identifying factors associated with understaged and/or disease destined to progress (despite any prior intravesical or repeat transurethral therapies prior to radical cystectomy) will be critical to improve survival outcomes without over-treating clinical T1 disease that can be successfully managed with bladder preservation strategies.

Preoperative hydronephrosis grade independently predicts worse pathological outcomes in patients undergoing nephroureterectomy for upper tract urothelial carcinoma

PURPOSE

We analyzed the prognostic impact of hydronephrosis grade on disease specific survival and evaluated whether hydronephrosis grade could preoperatively predict worse pathological outcomes in cases of upper tract urothelial carcinoma treated surgically.

MATERIALS AND METHODS

We identified and retrospectively reviewed the records of 91 patients who were evaluated by multidetector computerized tomography and/or magnetic resonance imaging preoperatively, and treated with nephroureterectomy at our institution from 2000 to 2009. Ipsilateral hydronephrosis was graded 0 to 4 by 2 urological radiologists blinded to clinical outcomes. We analyzed the associations between hydronephrosis grade, and pathological findings and patient outcomes.

RESULTS

Preoperatively 67 patients (73.6%) had ipsilateral hydronephrosis. Grade was 1 to 4 in 3 (3.3%), 17 (18.7%), 23 (25.3%) and 24 cases (26.4%), respectively. Higher hydronephrosis grade was significantly associated with a ureteral tumor (p = 0.0307), higher pT stage (p = 0.0002) and lymphovascular invasion (p = 0.0014). Higher hydronephrosis grade was not associated with disease specific or metastasis-free survival. On preoperative multivariate analysis high hydronephrosis grade predicted pathological T stage (T3 or greater) (HR 4.98, p = 0.0228), positive lymphovascular invasion (HR 6.37, p = 0.0022) and grade 3 (HR 2.98, p = 0.0311).

CONCLUSIONS

On image analysis preoperative hydronephrosis grade was associated with features of aggressive disease and predicted an advanced pathological outcome in patients with upper tract urothelial carcinoma. This information could prove useful to select candidates for neoadjuvant chemotherapy and make decisions concerning surgical options.

Optimal timing of radical cystectomy in T1 high-grade bladder cancer

T1 high-grade (formerly T1G3) bladder cancer is a challenging clinical entity representing approximately 10-15% of all new bladder cancer cases. The variable natural history of the disease and possible impairment in quality of life associated with radical treatment makes T1 high-grade one of the most challenging uro-oncological patient groups to manage. In particular, the risk of clinical understaging and not recognizing muscle-invasive disease may have detrimental effects on patient outcome. The cornerstone of contemporary staging is restaging transurethral resection (TUR), which helps in defining further management. In patients with restaging TUR stage less than T1, induction bacillus Calmette-Guérin combined with maintenance offers good results. The option of radical cystectomy should be discussed with patients with restaging TUR stage T1 or higher and it is highly recommended to all patients with recurrent T1 of carcinoma in situ during bacillus Calmette-Guérin maintenance. In addition to restaging TUR stage, several other clinicopathological factors, such T1 substaging, associated carcinoma in situ, tumor size and appearance, lymphovascular invasion, and hydronephrosis, aid in the decision making between radical and conservative treatment. Future prospects include improved staging and molecular markers that may guide toward conservative therapy or allow more cT1 patients to be offered nerve-sparing cystectomies and neobladders and, thus, improving quality of life for patients undergoing radical surgery.

Does the presence of hydronephrosis on preoperative axial CT imaging predict worse outcomes for patients undergoing nephroureterectomy for upper-tract urothelial carcinoma?

OBJECTIVES

Hydronephrosis at the time of diagnosis of bladder cancer is associated with advanced disease and is a predictor of poorer outcomes. There is, however, limited information addressing whether a similar relationship exists for upper-tract urothelial carcinoma (UTUC). We investigate the prognostic impact of hydronephrosis on preoperative axial imaging on clinical outcomes after radical nephroureterectomy.

MATERIALS AND METHODS

The records for 106 patients with UTUC who underwent radical nephroureterectomy at 2 medical centers were reviewed. Preoperative computed tomography (CT) images were evaluated for ipsilateral hydronephrosis by radiologists blinded to clinical outcomes. Association of hydronephrosis with pathologic features and oncologic outcomes after surgery was assessed.

RESULTS

Sixty-seven men and 39 women with a median age of 69 years (range, 36 to 90) were evaluated. One-third of these patients had muscle invasive disease or greater (≥T2), 44% had high grade tumors, and 3% had lymph node (LN) metastases. At a median follow-up of 47 months (range, 1 to 164), 43% of patients experienced disease recurrence, 18% developed metastasis, and 12% died of their cancer. Thirty-nine patients (37%) had hydronephrosis on preoperative axial imaging; 35% of these patients had ureteral tumors, and 27% had multifocal disease. The presence of hydronephrosis was associated with advanced pathologic stage (P = 0.03) and disease in the ureter (vs. renal pelvis) (P = 0.007). Hydronephrosis was a predictor of non-organ confined disease on final pathology (hazard ratio [HR] 3.7, P = 0.01). On preoperative multivariable analysis controlling for age, gender, tumor location, ureteroscopic biopsy grade, and urinary cytology, hydronephrosis was independently associated with cancer metastasis (HR 8.2, P = 0.02) and cancer-specific death (HR 12.1, P = 0.03).

CONCLUSIONS

Preoperative hydronephrosis on axial imaging is associated with features of aggressive disease and predicts advanced pathologic stage for UTUC. Hydronephrosis can be a valuable prognostic tool for preoperative planning and counseling regarding disease outcomes.