Impact of Surgical Technique on Surgical Margin Status Following Partial Cystectomy

Transurethral Resection of Bladder Tumor: Novel Techniques in a New Era

Transurethral resection of bladder tumor (TURBT) serves both diagnostic and therapeutic purposes in the management of bladder cancer. Attaining a high-quality TURBT is not always guaranteed due to various factors. En-bloc resection of bladder tumors (ERBT) holds promise to be a primary technique for removing bladder tumors in most non-muscle invasive bladder cancers. However, so far, no conclusive evidence indicates the superiority of any specific energy source used for ERBT. While laser energy can prevent the activation of obturator nerve reflex during ERBT, it poses challenges such as thermal injury and imprecise controllability. Needle-shaped electrodes offer high-level precision and controllability, without causing tissue deterioration or vaporization. The primary limitation of ERBT at present is the extraction/harvesting of large en-bloc specimens. Effective tools have been developed to overcome this limitation. Enhanced cystoscopy improves the detection of flat and small bladder tumors, allowing for better removal of cancerous tissues and significantly reducing recurrence rates. Advances in medical technology have brought forth a multitude of strategies to address the shortcomings of traditional TURBT. Appliances with large operating channel provide a platform for conducting laparoscopic procedures within the context of pneumocystoscopy, facilitating the execution of super TURBT and conferring comparable advantages to en-bloc resection. Moreover, the utilization of pneumocystoscopy enables the safe and effective performance of transurethral partial cystectomy for localized muscle-invasive bladder cancer. Novel techniques significantly improve the precision of the transurethral surgery and lower the risk of complications.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Current Management of Urachal Carcinoma: An Evidence-based Guide for Clinical Practice

Urachal carcinoma is a rare urological disease. The shortage of data about diagnosis and surgical treatment in literature makes it hard for clinicians to make a decision. Indeed, urachal carcinoma is an aggressive disease that requires prompt staging and treatment to ensure the best outcome for patients. We reviewed the last evidence about the management of urachal carcinoma to provide an easy-to-use guide for clinical practice.

Patient summary

Urachal carcinoma is a rare malignancy. The literature on this challenging disease remains limited. Herein, we provide a practical guide for its management from diagnosis to treatment, which in most cases requires surgical intervention or chemotherapy.

Efficacy and safety of transurethral resection of bladder tumor for superficial bladder cancer

The purpose of this study was to explore the efficacy and safety of transurethral resection of bladder tumor (TURBT) in the treatment of superficial bladder cancer (SBC). In this retrospective study, we included 103 patients with SBC who were admitted to the Hebei Yanda Hospital from March 2015 to May 2019. Among them, 53 patients were treated by TURBT and assigned to the research group. The rest, 50 patients, were treated by partial cystectomy (PC) and were included in the control group. The two groups were compared in terms of curative efficacy, complications, operation-related indexes, 2-year recurrence and survival, quality of life, and serum tumor markers. The operation-related indexes mainly included intraoperative blood loss, the time of operation, bladder flushing, catheter indwelling, and hospitalization. The quality of life of patients was assessed by the 36-Item Short-Form Health Survey (SF-36). The data revealed that compared with the control group, the overall response rate and the scores of various dimensions of the SF-36 were significantly higher in the research group. The complication rate, surgical indicators, and 2-year recurrence were significantly lower in the research group, with a better survival. Serum levels of tumor marker cancer antigen 125 (CA125), carcinoembryonic antigen (CEA), and neuron specific enolase (NSE) in the research group were significantly lower than those in the control group after treatment. TURBT is effective and safe in the treatment of patients with SBC.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The impact of routine frozen section analysis during partial cystectomy for bladder cancer on surgical margin status and long-term oncologic outcome

OBJECTIVES

The utility of frozen section analysis (FSA) during partial cystectomy has not been established. We assessed the impact of intraoperative FSA in partial cystectomy cases on surgical margin (SM) status and patient outcome.

SUBJECTS AND METHODS

A retrospective review identified 76 consecutive patients who underwent partial cystectomy for bladder carcinoma with (n = 66; 87%) or without (n = 10; 13%) FSA for SMs at our institution from 2004 to 2018. FSA was correlated with the diagnosis of the frozen section control, the status of final SM, and the prognosis.

RESULTS

Final SM was positive in 9 (12%) cystectomies, including 6 (9%) FSA vs. 3 (30%) non-FSA cases (P = 0.091). There were no significant differences in tumor size, histology, or tumor grade/stage between the 2 cohorts. FSAs were reported as positive (n = 7; 11%), atypical (n = 10; 15%), and negative (n = 49; 74%). All of the positive and negative FSA diagnoses were confirmed accurate on the frozen section controls, whereas atypical diagnoses were revised to benign (n = 4), atypical (n = 4), and carcinoma (n = 2) on the controls. Ten (77%) of 13 initial FSA-positive (6 of 7)/atypical (4 of 6; excluding benign diagnoses on the controls) cases achieved negative conversion by excision of additional tissue. Thus, final SM was positive in 1 (14%) FSA-positive case, 3 (30%) FSA-atypical cases (including one at the SM where FSA was not sampled), and 2 (4%) FSA-negative cases (at the SM where FSA was not sampled). Kaplan-Meier analysis and log-rank test revealed an association of performing FSA with the risk of disease progression (P = 0.021), but not intravesical recurrence (P = 0.434) or cancer-specific mortality (P = 0.560). Initial positive/atypical FSA, as an independent prognosticator, was associated with reduced progression-free (P = 0.002) and cancer-specific (P = 0.004) survival rates, compared with initial negative FSA. Positive SM was also associated with a larger tumor size (P < 0.05) and a higher risk of intravesical recurrence (P = 0.070) or disease progression (P = 0.096).

CONCLUSIONS

Performing FSA during partial cystectomy may contribute to preventing positive SM and disease progression. Additionally, as seen in most of initial FSA-positive/atypical cases that achieved negative conversion, select patients may benefit from the routine FSA. Meanwhile, positive or atypical FSA was associated with significantly poorer prognosis.