Upper Urinary Tract Recurrence Following Radical Cystectomy for Bladder Cancer: A Meta-Analysis on 13,185 Patients

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.

Cumulative incidence and risk factors for recurrence of upper tract urothelial carcinoma in patients undergoing radical cystectomy

Objectives

This study aimed to evaluate the cumulative incidence of upper tract urothelial carcinoma (UTUC) recurrence and identify its risk factors in patients who underwent radical cystectomy (RC).

Patients and methods

We performed RC on 385 patients between September 2002 and February 2020. After excluding 20 patients-13 with simultaneous nephroureterectomy, 6 with distal ureteral stump positivity and 1 with urachal cancer-365 patients were included in the analysis. To predict UTUC recurrence, we examined the cancer extension pattern in cystectomy specimens and categorized them into three types: cancer located only in the bladder (bladder-only type), cancer extending to the urethra or distal ureter (one-extension type) and cancer extending to both the urethra and distal ureter (both-extension type). We determined hazard ratios for UTUC recurrence for each covariate, including this cancer extension pattern.

Results

Of the 365 patients, 60% had the bladder-only type, 30% had the one-extension type and 10% had the both-extension type. During a median follow-up period of 72 months for survivors, UTUC recurred in 25 of the 365 patients, with cumulative incidences of 3.7% at 5 years and 8.3% at 10 years. The median interval from cystectomy to recurrence was 65 months (interquartile range: 36-92 months). In the multivariate analysis, the extension pattern was a significant predictor of UTUC recurrence. The hazard ratios for UTUC recurrence were 3.12 (95% confidence interval [CI] = 1.15-8.43, p = 0.025) for the one-extension type and 5.96 (95% CI = 1.98-17.91, p = 0.001) for the both-extension type compared with the bladder-only type.

Conclusions

The cancer extension pattern in cystectomy specimens is predictive of UTUC recurrence. A more extensive cancer extension in cystectomy specimens elevates the risk of subsequent UTUC recurrence. Intensive long-term monitoring is essential, particularly for patients with the both-extension type.

Upper Urinary Tract Urothelial Cancer After Radical Cystectomy for Bladder Cancer: Survival Outcomes After Radical Nephroureterectomy

BACKGROUND

Systemic and local recurrences of urothelial bladder cancer (UBC) significantly impair survival after radical cystectomy (RC), but little is known about the impact of the recurrence of urothelial cancer in the upper urinary tract (UTUC). This report describes survival outcomes and their predictors for patients who underwent RC followed by radical nephroureterectomy (RNU) for UTUC.

METHODS

The Surveillance, Epidemiology, and End Results database was queried to identify patients who underwent RC for UBC and subsequent RNU for UTUC. The Kaplan-Meier method and competing-risk Cox regression (CRR) were used for the survival analysis.

RESULTS

Overall, 102 patients have undergone RNU within a median of 49 months (interquartile range [IQR], 27-76 months) since RC. Muscle-invasive UTUCs were predominant at RNU (n = 58; 56.7%), but organ-confined bladder tumors were most frequent at RC (n = 42, 41.5%). After RNU, the estimated 5-year overall survival (OS) was 25.9%, the cancer-specific survival (CSS) was 35.6%, the median OS was 23 months (IQR, 11-63 months), and the CSS was 34 months (IQR, 13-132 months). In the multivariable CRR, the factors predictive for CSS after RNU included male gender (hazard ratio [HR], 2.36; 95% confidence interval [CI], 1.03-5.42; p < 0.05), muscle-invasive UTUC (HR, 2.20; 95% CI, 1.13-4.28; p < 0.05), and the presence of distant metastasis (HR,11.59; 95% CI, 5.33-25.2; p < 0.001).

CONCLUSIONS

In conclusion, the patients who underwent RNU for UTUC after RC for UBC experienced poor OS and CSS. The majority of RNUs were performed for locally advanced tumors. The independent risk factors for worse OS and CSS after RNU were UTUC T stage, presence of metastasis, and male gender.

Diagnostic Value of Urine Cytology in Pharmacologically Forced Diuresis for Upper Tract Urothelial Carcinoma Diagnosis and Follow-Up

We performed a urine cytology analysis of a pharmacologically induced diuresis for the diagnosis of upper tract urothelial carcinoma. To evaluate the diagnostic value of cytology of pharmacologically forced diuresis, an initial cohort of 77 consecutive patients with primary upper tract urothelial carcinoma treated via radical surgery was enrolled. To evaluate pharmacologically forced diuresis cytology as a follow-up procedure, a second cohort of 1250 patients who underwent a radical cystectomy for bladder cancer was selected. In the first cohort, the sensitivity of cytology of pharmacologically forced diuresis in patients with invasive, high-grade, low-grade, and concomitant carcinoma in situ was 8%, 9%, 0%, and 14%, respectively. In the second cohort, cytology of pharmacologically forced diuresis was positive in 30/689 (4.3%) patients, in whom upper urinary tract recurrence was present in 21/30 (70%) of cases, and urethral recurrence was present in 8/30 (26%) of cases. As a follow-up tool, cytology of pharmacologically forced diuresis showed a sensitivity, specificity, and positive and negative predictive values of 60%, 99%, 70%, and 98%, respectively. Overall, as a diagnostic tool, the sensitivity of cytology of pharmacologically forced diuresis is slightly better in patients with invasive upper tract urothelial carcinoma and concomitant carcinoma in situ. As a follow-up method, positive cytology of pharmacologically forced diuresis is strongly related to cancer recurrence and can reveal urethral recurrence. Cytology of pharmacologically forced diuresis might be useful in cases with contraindications for imaging or when achieving endoscopic access to the upper urinary tract is difficult.

Secondary tumours in orthotopic neobladder using isolated gut segment post radical cystectomy for urothelial carcinoma: a systematic review

BACKGROUND

Urothelial carcinoma recurrence of an orthotopic neobladder created from bowel segment is a rare occurrence. The usage of bowel segments to create neobladder following cystectomy for urinary diversion is growing yet there still remains a large gap in the literature about recurrence in neobladder. We carry out the first systematic review to outline current details of urothelial cancer recurrences in a neobladder, diagnostic approach, management and long term prognosis.

METHOD

We carried out a systematic review searching databases PubMed (MEDLINE), Scopus and Web of Science. Only studies reporting on urothelial carcinoma recurrence of the neobladder with or without multi-focal disease were reported. A quality assessment tool was utilized to ensure all studies met quality standards.

RESULTS

Fifteen studies were included in the systematic review meeting inclusion criteria. Fourteen of these studies were cases in men where pT3 disease was the most prevalent (29%). The most common symptomology was macroscopic haematuria seen in eight patients (53.33%). Management varied among cases and including adjuvant chemotherapy regimens and surgical interventions consisting of endoscopic resection to robotic neocystectomy and nephroureterectomy. Follow up period for these patients was up to 38 months and 55% of patients did not see a recurrence.

CONCLUSION

The nature of recurrence is hypothesised to be due to seeding of urothelial cells into the non-urothelial surfaces compatible for both implantation and growth. We present the first systematic review to report on recurrence rates and details of diagnosis and outcomes of various management regimes for urothelial carcinoma of the neobladder.

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

CONTEXT

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

OBJECTIVE

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

PATIENT SUMMARY

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

Application of The Paris System in neobladder washing cytology: Comparison between the original diagnosis and correlation with histopathology

BACKGROUND

In urinary diversion after radical cystectomy, the incidence of recurrent urothelial carcinoma (UC) in upper urinary tract or urethra are reported in 2%-17% of the patients. Urine cytology plays a pivotal role in detecting the recurrence of UC. However, cytologic diagnosis in urinary diversion including neobladder is often challenging due to significant degenerative changes and necro-inflammatory background. Since the proposal of The Paris System (TPS) for reporting cytology, the utility of TPS in urinary diversion specimen has not been studied yet. The objective of this study is to evaluate the diagnostic usefulness of TPS compared with the original diagnosis and correlate with the matched histopathological results.

METHODS

Urinary diversion cytology specimens with concurrent or subsequent biopsy or resection at EUMC in recent 16 years (from January 2002 to December 2018) are retrospectively reviewed and reclassified according to TPS criteria. The TPS categories and the original diagnoses were compared and correlated with follow-up histology.

RESULTS

Concurrent or subsequent biopsy or resection within a 6-month period was available in 45 cases from 28 patients. When applying TPS, the rate of atypical and suspicious categories decreased by 13.4% and 11.1%. Using TPS increased the value of sensitivity, NPV, and accuracy to 93.75%, 93.75%, and 90.91%, respectively.

CONCLUSION

Application of TPS reduced the rate of indeterminate diagnoses and moreover, improved the sensitivity and accuracy of urinary diversion cytology. Therefore, we believe that diversion urine cytology diagnosis according to TPS is useful to screen patients for detection of recurrence in routine clinical practice.

Control of bleeding from a recurrent tumor at a uretero-ileal anastomosis by electrocoagulation via an ileal conduit

Introduction

Bladder cancer is characterized by spatial and temporal recurrence in the urinary tract. We describe a case of recurrence at a uretero-ileal anastomosis after radical cystectomy and nephroureterectomy. It was difficult to control bleeding from the tumor, but hemostasis was achieved.

Case presentation

A 73-year-old man with a history of radical cystectomy and reconstruction of the ileal conduit and right nephroureterectomy was diagnosed with recurrence at the uretero-ileal anastomosis site. Bleeding from the tumor could not be controlled by flexible gastrointestinal endoscopy. The patient underwent coagulation via an ileal conduit approach using a rigid scope and bipolar electrocautery, which is usually a modality for transurethral resection.

Conclusion

This is the first report in which a modality normally used for transurethral resection was used to control bleeding in a patient with an ileal conduit. This application is useful in cases open surgery or additional irradiation might be difficult.

Subsequent Upper Urinary Tract Carcinoma Related to Worse Survival in Patients Treated with BCG

Upper urinary tract urothelial carcinoma (UTUC) after intravesical bacillus Calmette-Guerin (BCG) therapy is rare, and its incidence, clinical impact, and risk factors are not fully understood. To elucidate the clinical implications of UTUC after intravesical BCG therapy, this retrospective cohort study used data collected between January 2000 and December 2019. A total of 3226 patients diagnosed with non-muscle-invasive bladder cancer (NMIBC) and treated with intravesical BCG therapy were enrolled (JUOG-UC 1901). UTUC impact was evaluated by comparing intravesical recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) rates. The predictors of UTUC after BCG treatment were assessed. Of these patients, 2873 with a medical history that checked UTUC were analyzed. UTUC was detected in 175 patients (6.1%) during the follow-up period. Patients with UTUC had worse survival rates than those without UTUC. Multivariate analyses revealed that tumor multiplicity (odds ratio [OR], 1.681; 95% confidence interval [CI], 1.005–2.812; p = 0.048), Connaught strain (OR, 2.211; 95% CI, 1.380–3.543; p = 0.001), and intravesical recurrence (OR, 5.097; 95% CI, 3.225–8.056; p < 0.001) were associated with UTUC after BCG therapy. In conclusion, patients with subsequent UTUC had worse RFS, CSS, and OS than those without UTUC. Multiple bladder tumors, treatment for Connaught strain, and intravesical recurrence after BCG therapy may be predictive factors for subsequent UTUC diagnosis.

Oncological and Renal Function Outcomes in Patients Who Underwent Simultaneous Radical Cystectomy and Nephroureterectomy for Synchronous or Metachronous Panurothelial Carcinoma

OBJECTIVE

To assess clinical outcomes of patients who underwent simultaneous radical cystectomy (RC) and radical nephroureterectomy (RNU) for panurothelial carcinoma (PanUC).

MATERIALS AND METHODS

A retrospective analysis of 67 patients who underwent simultaneous RC and unilateral RNU for PanUC, from 1996 to 2017. Kaplan-Meier estimates for remnant urothelium recurrence-free survival, metastasis-free survival, overall survival (OS), and cancer-specific survival (CSS) were performed. Cox multivariate models were constructed.

RESULTS

The median follow-up was 38 months, 29.8% of patients had a recurrence, 34.3% had metastasis, 67.2% of patients died from any cause, and 37.3% died from urothelial carcinoma. Overall survival and CSS rates at 5 years were 44% and 61%, respectively. In multivariate analysis, progression to muscle-invasive bladder cancer before surgery, presence of muscle-invasive stages at RC and/or RNU, and prostatic urethra involvement were predictors for worse metastasis-free survival and CSS. Forty-one patients (61.2%) had an estimated glomerular filtration rate (eGFR) <60 mL/min before surgery and the number rose to 56 (83.5%) after surgery; 29.8% patients needed renal function replacement therapy after surgery (16 haemodialysis and 4 renal transplant).

CONCLUSION

Patients with PanUC who undergo simultaneous surgery have adverse oncological (only 4 out of every 10 remain alive at 5 years) and functional outcomes (1 out of 3 will need renal function replacement therapy after surgery). Up to a third of the patients had a recurrence (urethra or contralateral kidney) within 18 months, justifying close surveillance or considering prophylactic urethrectomy. These data should help in counsel on morbidity and life expectancy.

Management of Primary Female Urethral Adenocarcinoma: Two Rare Case Reports and Literature Review

Primary urethral adenocarcinoma in females is an extremely rare malignancy with unclear origin and only a few retrospective cases have been reported. The controversy continues to exist over the origin of primary urethral adenocarcinoma from periurethral glands (which include the Skene's glands), urethritis glandularis or intestinal metaplasia. Herein, we report one case of a 49-year-old female with distal urethral adenocarcinoma who presented with obstructive voiding. Abdominal and pelvic CT scans and chest radiology were unremarkable. Biopsy of the mass confirmed urethral adenocarcinoma. The patient underwent partial ureterectomy and was disease-free at the 2-years follow-up period. We also present another extremely rare case of primary urethral adenocarcinoma with mucinous features in a 58-year-old female who initially complained of external urethral orifice itching with painless urethral bleeding and was treated with local excision. The patient has not received any neoadjuvant or adjuvant therapy, and experienced tumor recurrence, inguinal lymph nodes metastasis, and even local iliopsoas metastasis during over 10-years follow-up. In conclusion, our current study emphasizes the importance of imaging studies and biopsy in making an accurate preoperative diagnosis of this rare disease, and further highlights the role of multimodal therapy. A combination of radiotherapy, chemotherapy and surgery is recommended for the optimal local and distant disease control. Moreover, better medical compliance and regular follow-up are required in these patients.

A Multilayer Nanofibrous Mat for the Topical Chemotherapy of the Positive Margin in Bladder Cancer

Treatment of positive margins after solid tumor resection remains a significant challenge for clinicians. Owing to unique structural features, electrospun nanofibrous mats are promised to be an implantable antitumor system through the delivery of active agents in a controlled manner. In this study, we utilized sequential electrospinning to fabricate a multilayer mat in which gemcitabine (GEM) and cisplatin (CDDP) were electrospun individually in distinct layers. By designing the structure, the multilayer mat could deliver antitumor agents sustainedly and prolong the release of GEM, which is loaded in the inner layer. In vitro assays show that the multilayer mats effectively inhibit bladder cancer (BC) cells and elevate apoptosis. In animal models of BC, the implantable drug-loaded fibrous mat can effectively treat positive margins and prevent local recurrence. Moreover, the local delivery of GEM and CDDP significantly lowers liver toxicity compared with systemic chemotherapy. In summary, a multilayer nanofibrous mat is developed for the localized and controlled delivery of GEM, dramatically improving the treatment of residual tumors and preventing BC recurrence. Impact statement The designed multilayer nanofibrous mats can achieve two chemotherapeutic drugs (gemcitabine and cisplatin) co-loading and time-programmed sustained release, significantly improving our previous study. The antitumor effect of the drug-loaded mat in vivo and in vitro was sufficiently demonstrated. We expect to bring a new strategy of topical chemotherapy for treating positive surgical margins in bladder cancer.

A Systematic Review and Meta-Analysis of Clinicopathologic Factors Predicting Upper Urinary Tract Recurrence After Radical Cystectomy for Urothelial Bladder Cancer

To identify risk factors for upper urinary tract recurrence (UUTR) in patients treated with radical cystectomy (RC) for urothelial bladder carcinoma (UBC). The PubMed, Web of Science, and Cochrane Library were searched on March 2022 to identify relevant studies according to the Preferred Reporting Items for Systematic Review (PRISMA) statement. We included studies that provided multivariate logistic regression analyses. The pooled UUTR rate was calculated using a fixed effect model. We identified 235 papers, of which seven and 6 articles, comprising a total of 8981 and 8404 UBC patients, were selected for qualitative and quantitative analyses, respectively. Overall, 418 (4.65%) patients were diagnosed with UUTR within a median time of 1.4 to 3.1 years after RC. Risk factors for UUTR were surgical margin (hazard ratio [HR] 3.41, 95% confidence interval [CI] 2.59-4.49, P < .00001), preoperative hydronephrosis (HR: 1.74, 95% CI: 1.25-2.43, P = .001), ureteral margin (HR: 4.34, 95% CI: 2.75-6.85, P < .00001), and pT stage (HR: 2.69, 95% CI: 1.37-5.27, P < .004). Incorporation of established risk factors into a clinical prediction model might aid in the decision-making process regarding the intensity and type of surveillance protocols after RC as well as help determine the pretest probability of UUTR.

French AFU Cancer Committee Guidelines - Update 2022-2024: Non-muscle-invasive bladder cancer (NMIBC)

OBJECTIVE

To update the ccAFU recommendations for the management of bladder tumours that do not infiltrate the bladder muscle (NBMIC).

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, while evaluating the references with their levels of evidence.

RESULTS

The diagnosis of NMIBC (Ta, T1, CIS) is made after complete full-thickness tumour resection. The use of bladder fluorescence and the indication of a second look (4-6 weeks) help to improve the initial diagnosis. The EORTC score is used to assess the risk of recurrence and/or tumour progression. Through the stratification of patients in low, intermediate and high-risk categories, adjuvant treatment can be proposed: intravesical chemotherapy (immediate postoperative, initiation regimen) or BCG (initiation and maintenance regimen) instillations, or even the indication of cystectomy for BCG-resistant patients.

CONCLUSION

Updating the ccAFU recommendations should contribute to improving patient management, as well as the diagnosis and treatment of NMIBC.

Radical cystectomy, bilateral lymphadenectomy and native ureteral ligation in a patient with history of kidney transplantation

We reported radical cystectomy (RC), bilateral lymphadenectomy and orthotopic ileal neobladder reconstruction in a patient with history of kidney transplant. A 71-year-old man was referred to us with bladder tumor, elevated serum creatinine (1.9 mg/dl), hydroureteronephrosis in transplanted kidney and a 5-6-cm sessile mass in the right bladder wall with involvement of transplanted ureter orifice. The patient was candidate for RC. The native ureters were ligated permanently. Extended lymphadenectomy in left side and limited lymphadenectomy in right side were performed. The patient underwent ileal orthotopic neobladder reconstruction, and the graft ureter was reimplanted to ascending loop of the pouch with end-to-end anastomosis. In conclusion, bilateral lymphadenectomy is feasible in patients with a history of kidney transplantation during RC. Permanent ligation of native ureters is better to perform to reduce the time of surgery and prevent late probable morbidities due to uretero-intestinal reimplantation complications.

Neobladder "Function": Tips and Tricks for Surgery and Postoperative Management

Orthotopic neobladder (ONB) reconstruction is a continent urinary diversion procedure increasingly used in patients with muscle-invasive bladder cancer following radical cystectomy (RC). It represents a valid alternative to the ileal duct in suitable patients who do not prefer a stoma and are motivated to undergo adequate training of the neobladder. Careful patient selection, taking into account the absolute and relative contraindications for ONB as well as an adequate recovery protocol after surgery are integral to the success of this procedure and the oncological and functional outcomes. The objective of this review is to summarize the current data on RC with ONB in terms of patient selection, preoperative preparation, surgical techniques and functional (continence and sexual activity) and oncological outcomes, with particular attention to the management of complications and the impact on quality of life (QoL).

Imaging Tips and Tricks in Management of Renal and Urothelial Malignancies

Management of urological malignancies has evolved significantly with continually changing guidelines and treatment options which demand more centralized involvement of radiology than ever before.

Radiologists play a pivotal role in interpreting complex cancer scans and guiding clinical teams toward the best management options in the light of clinical profile. Management of complex uro-oncology cases is often discussed in multidisciplinary meetings which are essential checkpoints to evaluate an overall picture and formulate optimal treatment plans.

The aim of this article is to provide a radiological perspective with practical guidance to fellow radiologists participating in uro-oncology multidisciplinary meetings based on commonly encountered case scenarios, updated guidelines, and cancer pathways.

Crucial imaging tips with regards to renal and urinary tract cancers, upon which therapeutic decisions are made, have been condensed in this article after reviewing several complex cases from urology multidisciplinary meetings and European Association of Urology guidelines.

Outline of various diagnostic and management strategies, key staging features, surveillance guidelines, and, above all, what the onco-urologists want to know from radiologists have been succinctly discussed in this article.

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.

Robot-Assisted Nephroureterectomy for Upper Tract Urothelial Carcinoma in a Patient with an Ileal Conduit

Background

Upper tract urothelial carcinoma remains an uncommon disease that is clinically difficult to identify early and surveil. Open nephroureterectomy is the gold standard for patients with high-grade disease, especially for patients in whom surveillance is complicated such as those with prior cystectomies/ileal conduits. This report presents a case of a patient with a history of radical cystectomy and ileal conduit construction who underwent a successful minimally invasive robotic surgery for treatment of upper tract urothelial carcinoma. Case Presentation. The patient is a 72-year-old Caucasian male with a history of recurrent superficial bladder tumors treated with cystoscopies with fulguration, Bacillus Calmette-Guerin, and a robot-assisted cystectomy with ileal conduit diversion presenting with recurrent urinary tract infections and hematuria secondary to a ureteral stricture. The patient was admitted previously for urosepsis during which time a percutaneous nephrostomy tube was inserted on the right side. Upon presentation, imaging revealed a lesion extending from the lower pole of the right kidney into the renal pelvis. The presence of a nephrostomy and urostomy allowed the surgical team to utilize a minimally invasive approach to remove the diseased kidney and ureter with visualization enhanced by indocyanine green.

Conclusion

Minimally invasive robot-assisted approaches to treating upper tract urothelial carcinomas may offer an alternative to the open cases typically employed in cases of patients with prior ileal conduit. Furthermore, utilizing indocyanine green may expand the applicability of such approaches to uro-oncologic cases with greater complexity.

SEOM-SOGUG clinical guideline for localized muscle invasive and advanced bladder cancer (2021)

Most muscle-invasive bladder cancer (BC) are urothelial carcinomas (UC) of transitional origin, although histological variants of UC have been recognized. Smoking is the most important risk factor in developed countries, and the basis for prevention. UC harbors high number of genomic aberrations that make possible targeted therapies. Based on molecular features, a consensus classification identified six different MIBC subtypes. Hematuria and irritative bladder symptoms, CT scan, cystoscopy and transurethral resection are the basis for diagnosis. Radical cystectomy with pelvic lymphadenectomy is the standard approach for muscle-invasive BC, although bladder preservation is an option for selected patients who wish to avoid or cannot tolerate surgery. Perioperative cisplatin-based neoadjuvant chemotherapy is recommended for cT2-4aN0M0 tumors, or as adjuvant in patients with pT3/4 and or pN + after radical cystectomy. Follow-up is particularly important after the availability of new salvage therapies. It should be individualized and adapted to the risk of recurrence. Cisplatin–gemcitabine is considered the standard first line for metastatic tumors. Carboplatin should replace cisplatin in cisplatin-ineligible patients. According to the EMA label, pembrolizumab or atezolizumab could be an option in cisplatin-ineligible patients with high PD-L1 expression. For patients whose disease respond or did not progress after first-line platinum chemotherapy, maintenance with avelumab prolongs survival with respect to the best supportive care. Pembrolizumab also increases survival versus vinflunine or taxanes in patients with progression after chemotherapy who have not received avelumab, as well as enfortumab vedotin in those progressing to first-line chemotherapy followed by an antiPDL1/PD1. Erdafitinib may be considered in this setting in patients with FGFR alterations. An early onset of supportive and palliative care is always strongly recommended.

Urine TERT promoter mutations-based tumor DNA detection in patients with bladder cancer: A pilot study

Telomerase reverse transcriptase (TERT) promoter mutations are the most frequent genetic events in bladder cancer (BC). The aim of the present pilot study was to evaluate the diagnostic potential of urine TERT promoter mutations-based liquid biopsy in patients with an ongoing oncological process, as well as in post-resection patients at risk of BC recurrence. A total of 60 patients were enrolled, of whom 27 patients had histologically proven BC; 23 had no signs of BC (control group); and 10 patients underwent transurethral malignancy resection 3-6 months prior to urine donation ('second look' group). Urine TERT promoter mutations were detected using Droplet Digital PCR. Receiver operating characteristic curve analysis revealed significant diagnostic power of the present approach (area under the curve: -0.768). At the cut-off value of tumor DNA fraction 0.34%, the sensitivity and specificity were 55.56 and 100%, respectively. In the positive samples, tumor DNA fraction varied significantly from 0.59 to 48.77%. In the 'second look' group, tumor DNA was detected in 4/10 patients, highlighting the possibility of BC recurrence with its fraction ranging only from 0.90 to 6.61%. Therefore, urine TERT promoter mutations-based liquid biopsy appears to be a promising tool for BC diagnosis and surveillance. The main study will include recruitment of additional patients, extension of the mutation panel, prolonged follow-up of the post-resection patients, as well as screening of industrial workers exposed to specific carcinogens.

Impact of carcinoma in situ on survival of patients treated by adjuvant chemotherapy after cystectomy

INTRODUCTION

Factors predicting response to adjuvant chemotherapy (AC) are required to identify patients who will most benefit from it. The aim of this study was to evaluate the impact of carcinoma in situ (CIS) at radical cystectomy (RC) on recurrence free survival (RFS), cancer specific survival (CSS) and overall survival (OS) of patients treated by AC.

MATERIALS AND METHODS

A single-center retrospective study was performed on patients who received AC after RC without pre-RC chemotherapy or trimodal therapy.

RESULTS

Among the 150 patients analyzed, 52,7% had CIS on the RC specimens. Baseline characteristics were not significantly different between the CIS negative and positive groups. Most patients received a cisplatin-based AC (74%). The median follow-up of the cohort was 36,4 months. The presence of CIS was not significantly associated to disease-recurrence (OR=0.67; 95%CI=0.35-1.29; P=0.23), cancer related death (OR=0.70; 95%CI=0.36-1.33; P=0.27) or death by any cause (OR=0.80; 95%CI=0.42-1.52; P=0.50). The presence of CIS had no significant impact on RFS (HR=0.86; 95%CI=0.56-1.33; P=0.49), CSS (HR=0.85; 95%CI=0.53-1.36; P=0.50) or OS (HR=0.93; 95%CI=0.60-1.45; P=0.74).

CONCLUSION

The presence of CIS on RC specimens did not have an impact on survival of patients treated by AC. CIS could be evaluated as a prognostic factor of response to novel adjuvant regimens such as immunotherapy.

Stereotactic Ablative Radiation Therapy for the Treatment of Upper Urinary Tract Urothelial Carcinoma

PURPOSE

Urothelial carcinomas (UCs), also known as transitional cell carcinomas, account for the majority of upper urinary tract tumors. The gold-standard therapy for operable patients with localized disease is radical nephroureterectomy. However, some patients are not surgical candidates. Data on the use of modern radiation therapy for upper urinary tract UC (UTUC) are scarce. The purpose of this study was to assess the safety and efficacy of SABR in UTUC.

METHODS AND MATERIALS

This retrospective study included all patients with UTUC treated with SABR at one institution. Charts were reviewed to evaluate renal function and the development of toxicity using Common Terminology Criteria for Adverse Events, version 3.0. Tumor response on follow-up imaging with computed tomography or magnetic resonance imaging scans was assessed using the Response Evaluation Criteria in Solid Tumors, version 1.1.

RESULTS

A total of 16 patients (7 patients with UC at the ureter and 9 at the renal pelvis) were identified as treated with SABR. Of the 9 patients with renal pelvis UC, 4 had a previous history of bladder cancer. At the time of treatment, the median age was 85 years (range, 67-95 years). Most patients received 40 Gy in 8 fractions every second day. The median followup was 21 months (range, 3-110 months). Most patients maintained stable renal function, and only 2 patients developed worsening chronic kidney disease, but none required dialysis. Acutely, 4 patients developed grade 1 diarrhea, and 1 patient had new grade 1 hematuria. No chronic side effects were observed. One patient did not have follow-up imaging and was excluded from the tumor-response analysis. Two patients had a complete response of the treated lesion, 9 had a partial response, 2 had stable disease, and 2 had disease progression within the treatment field.

CONCLUSIONS

This small case series suggests that SABR for UTUC is safe and well-tolerated, with good radiographic tumor response to ablative doses of radiation therapy.

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.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Management of upper urinary tract problems after radical cystectomy for urothelial carcinoma: tips and tricks

PURPOSE OF REVIEW

After radical cystectomy (RC) patients are at risk for both benign and malignant problems regarding the upper urinary tract (UUT). This review summarizes the recent literature and provides tips on how to manage problems of the UUT after RC.

RECENT FINDINGS

Disease recurrence, kidney stones and ureteroenteric strictures (UES) are common after RC. Endourological techniques can be used to treat low-grade disease recurrence, either with a retrograde or antegrade approach. Treatment success depends on getting access to the UUT and on tumor characteristics; selecting the right approach is key. Kidney stones can be treated endourologically with good results. With use of minimal invasive techniques such as robot cystectomy, a higher incidence of UES is observed. The use of indocyanine green could help to prevent this complication. In case of a stricture, primary reconstruction should be the treatment strategy of choice.

SUMMARY

After RC, recurrence of the UUT remains a complicated problem. Choice of treatment method should be tailored to the patient and tumor characteristics. Kidney stones after cystectomy can be successfully managed endourological. Robot assisted RC introduced a higher rate of UES, which should be managed by primary revision.

Female primary urethral carcinoma: A rare case report

Introduction

Primary tumors of the female urethra are exceedingly rare and account for <0.02% of the malignant disease occurring in women. This disease usually presents late and, hence, has a poor outcome. Early diagnosis is necessary to prevent further metastasis and prevent urinary catheter-dependant. Tumors arising from the distal urethra tend to be early stage and cure rates are high, however lack of knowledge about this disease is notorious, the transmission of knowledge is made only by case reports.

Case presentation

A 76-years-old woman presented with the chief complaint of lower pelvic pain. The complaintas also accompanied by a burning sensation in the urethra and stranguria, urinary retention, and hematuria. Macroscopic observation revealed the lesion was whitish with vegetative aspect at the urethral meatus, involving the entire urethra. The fragile mass was palpable in distal urethra and external meatus urethra per vaginally and easily bleedings. Laboratory examination of blood chemistry results within normal limit. Urinalysis showed pyuria and hematuria. Urethrocystoscopy findings were whitish lesion with vegetative aspect also fragile mass along the urethra, abnormal bladder neck, and bladder mucous was hyperemis. The histopathological result showed metaplasia squamous cell carcinoma, clear cell carcinoma. She is planned on getting cystouretherectomy (anterior exenteration) later.

Clinical discussion

The female urethral carcinoma is a disease with low prevalence with urothelial carcinoma (transitional cell) is the most common histological type (Leão et al., 2016; Adolfsson et al., 2012). Symptoms of urethral carcinoma are varied. The carcinoma spreads initially by local invasion into the periurethral tissue, vagina, and vulva and proximally spread to the bladder neck (Leão et al., 2016; Mittal et al., 2020). Distant metastasis is uncommon (Mittal et al., 2020). The most suitable method for collecting material for biopsy is the urethrocystoscopy. MRI is commonly used for staging. For post-surgical staging, the best investigation is the excretory urography (Gourtsoyianni et al., 2011; Picozzi et al., 2012). The management in vogue are surgical such as tumor excision, radical nephro-ureterectomy or anterior pelvic exenteration with radiotherapy or chemotherapy complementary. This cancer is associated with poor outcomes. Therefore, prognostic factors are important to be known.

Conclusion

Although female urethral carcinoma is a rare disease entity, clinicians should have strong suspicion of malignancies in patients to make an exact diagnosis. Early radical surgery can achieve better outcomes, although the standard therapy remains controversial.

•

Primary tumors of the female urethra are exceedingly rare

•

The carcinoma spreads by local invasion into the periurethral tissue, vagina, vulva and proximally to the bladder neck

•

Distant metastasis is uncommon

•

Early diagnosis is necessary to prevent further metastasis and prevent urinary catheter-dependant

•

This cancer is associated with poor outcome, prognostic factors are important to be known

Surgical benchmarks, mid-term oncological outcomes, and impact of surgical team composition on simultaneous enbloc robot-assisted radical cystectomy and nephroureterectomy

Background

Simultaneous urothelial cancer manifestation in the lower and upper urinary tract affects approximately 2% of patients. Data on the surgical benchmarks and mid-term oncological outcomes of enbloc robot-assisted radical cystectomy and nephro-ureterectomy are scarce.

Methods

After written informed consent was obtained, we prospectively enrolled consecutive patients undergoing enbloc radical cystectomy and nephro-ureterectomy with robotic assistance from the DaVinci Si-HD® system in a prospective institutional database and collected surgical benchmarks and oncological outcomes. Furthermore, as one console surgeon conducted all the procedures, whereas the team providing bedside assistance was composed ad hoc, we assessed the impact of this approach on the operative duration.

Results

Nineteen patients (9 women), with a mean age of 73 (SD: 7.5) years, underwent simultaneous enbloc robot-assisted radical cystectomy and nephro-ureterectomy. There were no cases of conversion to open surgery. In the postoperative period, we registered 2 Clavien-Dindo class 2 complications (transfusions) and 1 Clavien-Dindo class 3b complication (port hernia). After a median follow-up of 23 months, there were 3 cases of mortality and 1 case of metachronous urothelial cancer (contralateral kidney).The total operative duration did not decrease with increasing experience (r = 0.174, p = 0.534). In contrast, there was a significant, inverse, strong correlation between the console time relative to the total operative duration and the number of conducted procedures after adjusting for the degree of adhesions and the type of urinary diversion(r = -0.593, p = 0.02).

Conclusions

These data suggest that en bloc simultaneous robot-assisted radical cystectomy and nephro-ureterectomy can be safely conducted with satisfactory mid-term oncological outcomes. With increasing experience, improved performance was detectable for the console surgeon but not in terms of the total operative duration. Simulation training of all team members for highly complex procedures might be a suitable approach for improving team performance.

Trial registration: Not applicable.

Endoscopic exploration directly impacts clinical decision making in the management of patients with suspected upper tract urothelial carcinoma following radical cystectomy

OBJECTIVES

To assess whether the use of endoscopic exploration (EE) as a routine diagnostic tool in patients with clinical suspicion of upper tract urothelial carcinoma (UTUC) following radical cystectomy (RC) significantly impacts management decision-making and to describe the oncological outcomes of patients with UTUC after RC.

MATERIALS AND METHODS

We performed a retrospective review of medical records of patients with suspicion of UTUC after RC between 2000 and 2019. Patient demographics, clinicopathological features, treatments, and outcomes were analyzed.

RESULTS

We identified 60 patients with suspicion of UTUC. After diagnostic work-up, 16 were submitted to radical nephroureterectomy (RNU) and 44 underwent diagnostic EE. After EE, a further 18/44 (40.9%) were submitted to RNU, while no evidence of tumor was found in 12 (27.3%) and the remaining 12 (27.3%) underwent endoscopic treatment (ET). Thus, in 24/44 (54.5%) patients the primary treatment strategy, i.e., RNU, was altered. Twenty-nine (85.3%) of the 34 patients who underwent RNU had high-grade tumors and 16 (47%) had the muscle-invasive disease. In the ET group, 6 (50%) had high-grade tumors and 10 (83.4%) had tumors less than 2 cm. The 5-year estimated recurrence-free survival and cancer-specific survival were, respectively, 58.4% and 45.6% in the RNU group and 25% and 80.8% in the ET group.

CONCLUSION

EE significantly impacts clinical decision-making in patients with suspicion of UTUC after RC, resulting in a change in treatment strategy in approximately half of the patients. UTUC following RC has a poor prognosis and although RNU is the gold standard, ET could be considered in a selected group of patients.

The impact of carcinoma in situ in ureteral margins during radical cystectomy: A case-controlled study

BACKGROUND AND OBJECTIVE

The presence of carcinoma in situ (Cis) in association with bladder cancer is associated with a poor prognosis. However, the prognosis associated with the presence of Cis in ureteral margins (CUM) during radical cystectomy has been poorly defined. To assess the prognosis associated with the presence of Cis in ureteral margins in patients with pM0 bladder cancer who have not undergone neoadjuvant chemotherapy.

MATERIALS AND METHODS

A retrospective case-control study was conducted between 2001 and 2016 using data from one academic center in France. From 1,450 radical cystectomies, 122 patients (case) who had CUM were matched according to age, sex, pTNM stage and urinary diversion method with a population sample of 122 patients (controls) who did not have Cis in ureteral margins during radical cystectomy. The survival analysis was performed by Kaplan-Meier using a (95%) CI. Multivariate Cox regression analysis was used to test the effect of CUM on cancer-specific survival. Recurrence-free survival was defined as a recurrence of urothelial carcinoma in the upper urinary tract.

RESULTS AND LIMITATIONS

The mean follow-up period was 55.43 ± 39.6 months. The rate of Cis in the bladder in the CUM cases group was evaluated at 11.47%. The median overall and specific survival was inferior in the CUM cases group estimated at 43.3 [35.33-56.93] months, 52.43 [42.16-68.93] months respectively compared to the control group with a significant difference (P= 0.001, P= 0.0039). The cumulative probability of urothelial recurrence-free survival was decreased in the case group compared with the control group (63.9% vs. 92.6%, P = 0.0001). Multivariate analysis shown that urothelial recurrence was associated with CUM [(P <0.001), (HR adjusted =11.31), (95% CI): (3.38-37.77)] and the macroscopic appearance of the ureter (thickened, dilated) [(P= 0.003), (HR adjusted =4.62), (95% CI): (3.31-8.84)].

CONCLUSION

CUM is a poor prognostic factor that impacts cancer-specific survival and Recurrence-free survival. The presence of CUM has been independently associated with a significant increase in the risk of urothelial recurrence, and a decrease in both overall and specific survival. This supports the use of frozen section analysis to complete radical cystectomy without CUM.

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.

Preoperative positive voided urine cytology predicts poor clinical outcomes in patients with upper tract urothelial carcinoma undergoing nephroureterectomy

BACKGROUND

Performance of urinary cytology is recommended as the part of a standard diagnostic workup and base surveillance regimens in upper tract urothelial carcinoma (UTUC). However, the effect of positive voided urine cytology (VUC) on UTUC prognosis, compared with negative VUC, has not been fully demonstrated. This study aimed to evaluate the impact of preoperative VUC on predicting intravesical recurrence, disease recurrence, and mortality in patients with UTUC who underwent nephroureterectomy (RNU).

METHODS

Clinicopathological information was collected from 315 UTUC patients treated with RNU. The association between VUC and oncological outcomes was analyzed using the Kaplan-Meier method with log-rank test and Cox proportional hazards regression models. Multiple logistic regression analysis was performed to identify the influence of VUC on tumor grade.

RESULTS

Preoperative positive VUC, presenting in 101 patients (32%), was significantly associated with tumor multifocality (P = 0.017) and higher tumor grade (P = 0.010). On multivariable Cox regression analyses, preoperative positive VUC was an independent prognostic factor of intravesical recurrence-free survival (RFS) (hazard ratio [HR] = 2.21, 95% confidence interval [CI] 1.06-4.64; P = 0.035), RFS (HR = 1.80, 95% CI 1.08-2.99; P = 0.023), and cancer-specific survival (CSS) (HR = 1.87, 95% CI 1.10-3.18; P = 0.020), but not overall survival (HR = 1.32, 95% CI 0.80-2.18; P = 0.28). Logistic regression analysis revealed that VUC was related to high tumor grade in UTUC (odds ratio = 2.23, 95%CI 1.15-4.52).

CONCLUSION

Preoperative positive VUC significantly increases the risk of intravesical recurrence in UTUC patients undergoing RNU. In addition, positive VUC is an adverse predictor of RFS and CSS, which might be due to the association between positive VUC and high tumor grade.

Outcomes of endoscopic management of upper tract urothelial carcinoma

While radical nephroureterectomy (RNU) remains the gold-standard treatment for upper tract urothelial carcinoma (UTUC), a growing volume of literature surrounding endoscopic, organ-sparing procedures has developed over the past few decades. Based on this, endoscopic management of UTUC has gained acceptance as a standard of care approach, particularly among those with low-risk disease or with imperative indications for organ preservation. As a rare disease, however, data is mostly restricted to retrospective single institution series with relatively small numbers. Therefore, comparative outcomes of endoscopic management to RNU remain incompletely defined. Furthermore, the comparative utility of endoscopic approaches (ureteroscopy versus percutaneous resection) and topical therapy following resection lacks prospective analysis. In this article we review the available literature on endoscopic management of UTUC.

Guar bean in urinary cytology: a morphologic pitfall

INTRODUCTION

Various types of contaminants can be encountered in cytologic specimens. This study describes a vegetable material that we encountered in ileal conduit urine specimens. We aim to describe the cytomorphology and the source of origin of this vegetable material.

MATERIAL AND METHODS

The cytology database for the past 5 years (January 2015-April 2020) was searched for ileal conduit urine cytology specimens with a reported vegetable contaminant. The details of the ostomy procedure and device used were recorded. Histologic sections were prepared from the ostomy devices as well as from guar beans and seeds.

RESULTS

A total of 17 urinary specimens from 8 patients were identified that showed the presence of a vegetable contaminant. All the patients were using Coloplast (Minneapolis, MN) SenSura Mio ostomy device. The urine cytology showed presence of polygonal thick-walled cells with a dark brown/orange core with irregular outlines. Similar cells were also seen in the histologic sections prepared from the ostomy adhesive and the guar seed and bean.

CONCLUSIONS

Guar gum is a naturally occurring hydrocolloid that is used in ostomy wafer adhesives. Correct identification and familiarity with the cytomorphology of the guar cells in samples of ileal conduit urine is essential to avoid a potential diagnostic pitfall when evaluating urine cytology specimens from these diversion specimens.

Survival nomogram for patients with upper tract recurrence after resection for localized bladder urothelial carcinoma

Aim: To develop a survival nomogram for patients with upper tract recurrence (UTR) after resection for localized bladder urothelial carcinoma (BUC). Methods: The data of 361 patients with UTR after resection for BUC registered in the Surveillance, Epidemiology, and End Results database were retrospectively analyzed. The nomogram was established using the Fine and Gray method and its predictive accuracy was assessed using the concordance index. The nomogram was calibrated by comparing the predicted and actual survival. Results: The concordance index of the nomogram was 0.746 (95% CI: 0.733-0.759). Excellent agreement was observed between the predicted and actual survival in all calibration plots. Conclusion: This study describes the first survival nomogram for patients experienced UTR after resection for BUC.

Does Ureteral Stent Drainage Prior to Cystectomy Increase the Risk of Subsequent Upper Tract Urothelial Carcinoma and Ureteral Complications?

OBJECTIVE

To guide management of preoperative hydronephrosis prior to radical cystectomy (RC), we compared post-RC risks of upper tract urothelial carcinoma (UTUC) and ureteroenteric anastomotic complications between ureteral stent and percutaneous nephrostomy tube drainage.

METHODS

Patients who underwent RC for urothelial carcinoma without a prior diagnosis of UTUC at our institution between 2000 and 2015 were included and divided into 4 patient groups: (1) no hydronephrosis (75%, N = 787); (2) hydronephrosis without preoperative upper tract drainage (13%, N = 132); (3) hydronephrosis treated with nephrostomy tube (3%, N = 36); (4) hydronephrosis treated with ureteral stent (9%, N = 94). The incidence of post-RC UTUC and ureteral complications was compared using Kaplan-Meier analyses and multivariable Cox proportional hazard modeling.

RESULTS

We identified a total of 1049 patients who underwent RC (median postoperative follow-up 4.3 years). Five-year post-RC UTUC incidence was 6.6%, 10.2%, 17%, 18.7% for groups 1-4, respectively (P= .13). On multivariable analysis, nephrostomy tube drainage (hazard ratio [HR] 4.10, P = .02) and preoperative ureteral stenting (HR 2.35, P = .04) were both associated with UTUC after RC, but ureteral stenting did not have a significantly higher association with UTUC than nephrostomy tube drainage. Severe hydronephrosis was also associated with development of UTUC (HR 4.03, P = .02). The incidence of ureteroenteric anastomotic complications did not vary by drainage modality.

CONCLUSION

Preoperative hydronephrosis was associated with UTUC after RC, but ureteral stent placement did not increase the risk of UTUC or ureteral complications relative to nephrostomy tube placement. The choice of hydronephrosis drainage pre-RC should not be guided by concern for UTUC risk.

Epidemiology, clinical presentation, and evaluation of upper-tract urothelial carcinoma

An overview of epidemiological pattern of upper tract urothelial carcinoma (UTUC), including outcome of UTUC over past decades as well as factors responsible for observed epidemiological changes was performed. Gender and racial disparities influencing incidence of UTUC were reviewed. The incidence of multifocal urothelial carcinoma and relation of UTUC to urothelial carcinoma of bladder were examined.

European Association of Urology Guidelines on Muscle-invasive and Metastatic Bladder Cancer: Summary of the 2020 Guidelines

CONTEXT

This overview presents the updated European Association of Urology (EAU) guidelines for muscle-invasive and metastatic bladder cancer (MMIBC).

OBJECTIVE

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

EVIDENCE ACQUISITION

A broad and comprehensive scoping exercise covering all areas of the MMIBC guideline has been performed annually since its 2017 publication (based on the 2016 guideline). Databases covered by the search included Medline, EMBASE, and the Cochrane Libraries, resulting in yearly guideline updates. A level of evidence and a grade of recommendation were assigned. Additionally, the results of a collaborative multistakeholder consensus project on advanced bladder cancer (BC) have been incorporated in the 2020 guidelines, addressing those areas where it is unlikely that prospective comparative studies will be conducted.

EVIDENCE SYNTHESIS

Variant histologies are increasingly reported in invasive BC and are relevant for treatment and prognosis. Staging is preferably done with (enhanced) computerised tomography scanning. Treatment decisions are still largely based on clinical factors. Radical cystectomy (RC) with lymph node dissection remains the recommended treatment in highest-risk non-muscle-invasive and muscle-invasive nonmetastatic BC, preceded by cisplatin-based neoadjuvant chemotherapy (NAC) for invasive tumours in "fit" patients. Selected men and women benefit from sexuality sparing RC, although this is not recommended as standard therapy. Open and robotic RC show comparable outcomes, provided the procedure is performed in experienced centres. For open RC 10, the minimum selected case load is 10 procedures per year. If bladder preservation is considered, chemoradiation is an alternative in well-selected patients without carcinoma in situ and after maximal resection. Adjuvant chemotherapy should be considered if no NAC was given. Perioperative immunotherapy can be offered in clinical trial setting. For fit metastatic patients, cisplatin-based chemotherapy remains the first choice. In cisplatin-ineligible patients, immunotherapy in Programmed Death Ligand 1 (PD-L1)-positive patients or carboplatin in PD-L1-negative patients is recommended. For second-line treatment in metastatic disease, pembrolizumab is recommended. Postchemotherapy surgery may prolong survival in responders. Quality of life should be monitored in all phases of treatment and follow-up. The extended version of the guidelines is available at the EAU website: https://uroweb.org/guideline/bladder-cancer-muscle-invasive-and-metastatic/.

CONCLUSIONS

This summary of the 2020 EAU MMIBC guideline provides updated information on the diagnosis and treatment of MMIBC for incorporation into clinical practice.

PATIENT SUMMARY

The European Association of Urology Muscle-invasive and Metastatic Bladder Cancer (MMIBC) Panel has released an updated version of their guideline, which contains information on histology, staging, prognostic factors, and treatment of MMIBC. The recommendations are based on the current literature (until the end of 2019), with emphasis on high-level data from randomised clinical trials and meta-analyses and on the findings of an international consensus meeting. Surgical removal of the bladder and bladder preservation are discussed, as well as the use of chemotherapy and immunotherapy in localised and metastatic disease.

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)

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.

Dataset for the reporting of carcinoma of the bladder-cystectomy, cystoprostatectomy and diverticulectomy specimens: recommendations from the International Collaboration on Cancer Reporting (ICCR)

The International Collaboration on Cancer Reporting (ICCR) is a not for profit organisation whose goal is to produce standardised internationally agreed and evidence-based datasets for pathology reporting. With input from pathologists worldwide, the datasets are intended to be uniform and structured. They include all items necessary for an objective and accurate pathology report which enables clinicians to apply the best treatment for the patient. This dataset has had input from a multidisciplinary ICCR expert panel. The rationale for some items being required and others recommended is explained, based on the latest literature. The dataset incorporates data from the World Health Organization (WHO) 2016, and also from the latest (8th edition) TNM staging system of the American Joint Committee on Cancer (AJCC). Fifteen required elements and eight recommended items are described. This dataset provides all the details for a precise and valuable pathology report required for patient management and prognostication. This dataset is intended for worldwide use, and should facilitate the collection of standardised comparable data on bladder carcinoma at an international level.

[Usefulness of frozen section exams during radical cystectomy for urothelial carcinoma]

AIM

To determine the usefulness of the frozen section exams of lymph nodes dissection, ureteral and urethral section during radical cystectomy for urothelial carcinoma and define the impact on the surgical procedure.

METHOD

A retrospective, single-center study of data collected from 182 patients who underwent radical cystectomy for an cT=3bN0M0 urothelial bladder cancer between 2016 and 2018. Bladder cancer extension was determined by thoracoabdominal CT with contrast enhancement and urography and an 18-FDG PET scanner. No patient received neoadjuvant chemotherapy. The diagnostic performance of the frozen section exams was related to final examinations. The impact of the result on the initial intervention was determined.

RESULTS

The frozen section were positive in 29 lymph nodes dissections (15.9 %), 59 (16.6 %) ureteral and 20 (10.9 %) ureteral recessions. With lymph nodes exams, sensitivity, specificity and positive and negative predictive values were 93.5 %, 100 %, 100 %, and 98.7 %, respectively. With ureteral sections exams the same values were 91.5 %, 100 %, 100 %, and 98.4 % respectively. With urethral section exams, all the values were of 100 %. Finally, all the procedure has been modified for all patients with positive frozen section exam except one positive urethral section that did not give rise to radical urethrectomy.

CONCLUSION

Frozen section exams were useful to the urologist during radical cystectomy for urothelial carcinoma. The performances of the frozen section exams carried out were excellent. The information of the urologist of the positive frozen section leeds to modify its management during the intervention in all the studied cases with the exception of one case.

[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.

Urothelial Carcinoma Recurrence in an Orthotopic Neobladder without Urethral or Upper Urinary Tract Involvement

We describe a case of a 71-year-old male with an isolated recurrence of urothelial carcinoma in an ileal neobladder without involvement of the upper urinary tract or urethra. He was diagnosed with high grade urothelial carcinoma involving a bladder diverticulum with associated carcinoma in situ. He underwent a radical cystectomy and orthotopic Studer ileal neobladder. On routine follow-up, 11 years following cystectomy, voided urine cytology was positive for high grade urothelial carcinoma. Further workup revealed normal upper urinary tracts, normal urethra, and a solitary lesion at the left anteroinferior wall of the neobladder. He subsequently underwent resection of the neobladder and conversion to an ileal conduit with pathology confirming the diagnosis of high grade urothelial carcinoma. Isolated recurrence of urothelial carcinoma within a neobladder without involvement of the upper urinary tract or urethra is rare. No guidelines exist regarding its management. Herein we present our management as well as the current literature published on this topic.