Clinical Panurothelial Disease in Patients with Superficial Bladder Tumors: Therapeutic Implications

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.

Tissue engineering for the oncologic urinary bladder

Urinary diversion after radical cystectomy in patients with bladder cancer normally takes the form of an ileal conduit or neobladder. However, such diversions are associated with a number of complications including increased risk of infection. A plausible alternative is the construction of a neobladder (or bladder tissue) in vitro using autologous cells harvested from the patient. Biomaterials can be used as a scaffold for naturally occurring regenerative stem cells to latch onto to regrow the bladder smooth muscle and epithelium. Such engineered tissues show great promise in urologic tissue regeneration, but are faced with a number of challenges. For example, the differentiation mesenchymal stem cells from various sources can be difficult and the smooth muscle cells formed do not precisely mimic the natural cells.

Using hair-follicle stem cells for urinary bladder-wall regeneration

There are many diseases in which autologous urothelial and muscle cells cannot be used for in vitro construction of the urinary bladder wall for augmentation (cystoplasty). These diseases are the most frequent indications for bladder augmentation. The present paper focuses on the idea of harvesting potentially multipotent stem cells out of hair follicles in order to use them for regeneration of the urinary bladder wall. Current clinical practice suggests the use of cultures enriched with progenitors. The hair follicle stem cell niche gives an opportunity to reduce the invasiveness of harvesting these cells. Both epithelial and dermal multipotent stem cells populations within hair follicles raise new possibilities for tissue engineering of the urinary bladder. The hypothesis is that hair-follicle stem cells can be used, with the guarantee of the sufficient cell number, for a construction in vitro of the urinary bladder wall replacement.

Prospective intermediate follow-up of carcinoma in situ involving the distal ureter at cystectomy: is there a role for ureteroscopy?

BACKGROUND AND PURPOSE

The presence of urothelial carcinoma in situ (CIS) at the distal ureteral margin has been identified as a risk factor for upper tract recurrence after radical cystectomy. Management of this finding is controversial. The objective of this study was to determine if follow-up with ureteroscopy could aid in early detection of recurrences in these patients.

PATIENTS AND METHODS

We collected prospective clinical-pathologic data for all patients who underwent radical cystectomy between 1999 and 2004. Patients with CIS at the distal ureteral margin were followed with endoscopy of the urinary diversion and bilateral ureteroscopy in addition to standard imaging and cytologic evaluation every 6 months. Recurrence was defined as detection of any malignant urothelial cells.

RESULTS

In 250 consecutive cystectomies, eight patients were identified with CIS that involved a ureteral margin of 12 renal units. Ureteroscopy was successful in all cases, and there were no complications. Imaging was diagnostic in one patient, all cytologic examinations from the diversion were nondiagnostic, and ureteroscopy was positive in all recurrences. Six patients had recurrences at a median follow-up of 52.7 months; five needed laparoscopic nephroureterectomy, and one had disease controlled with percutaneous mitomycin C. Five patients were disease free at last follow-up, and one patient died with brain metastasis at 30 months.

CONCLUSIONS

Patients with CIS that involves the ureteral margin are at increased risk for upper tract recurrence and progression. Aggressive follow-up with scheduled ureteroscopy may identify recurrences at an earlier stage. Development of additional markers for risk stratification and protocols for adjuvant treatment are needed.

A Comparison of Hexaminolevulinate Fluorescence Cystoscopy and White Light Cystoscopy for the Detection of Carcinoma In Situ in Patients With Bladder Cancer: A Phase III, Multicenter Study

PURPOSE

We compared hexaminolevulinate (Hexvix) fluorescence cystoscopy with white light cystoscopy for detecting carcinoma in situ.

MATERIALS AND METHODS

In this multicenter study 298 patients with known or suspected bladder cancer underwent bladder instillation with 50 ml 8 mM hexaminolevulinate for 1 hour. Cystoscopy was then performed, first using standard white light and then hexaminolevulinate fluorescence cystoscopy. Lesions or suspicious areas identified under the 2 illumination conditions were mapped and biopsied for histological examination. In addition, 1 directed biopsy was obtained from an area appearing to be normal.

RESULTS

Of 196 evaluable patients 29.6% (58 of 196) had carcinoma in situ, including 18 with carcinoma in situ alone, and 35 with carcinoma in situ and concomitant papillary disease, which was only detected on random biopsy in 5. Of the 18 patients with no concomitant papillary disease carcinoma in situ was detected only by hexaminolevulinate fluorescence in 4 and only by white light in 4. In the group with concomitant papillary disease carcinoma in situ was found only by hexaminolevulinate fluorescence in 5 patients and only by white light in 3. The proportion of patients in whom 1 or more carcinoma in situ lesions were found only by hexaminolevulinate cystoscopy was greater than the hypothesized 5% (p=0.0022). Overall more carcinoma in situ lesions were found by hexaminolevulinate than by white light cystoscopy in 22 of 58 patients (41.5%), while the converse occurred in 8 of 58 (15.1%). Biopsy results confirmed cystoscopy findings. Of a total of 113 carcinoma in situ lesions in 58 patients 104 (92%) were detected by hexaminolevulinate cystoscopy and 77 (68%) were detected by white light cystoscopy, while 5 were detected only on directed visually normal mucosal biopsy. Hexaminolevulinate instillation was well tolerated with no local or systemic side effects.

CONCLUSIONS

In patients with bladder cancer hexaminolevulinate fluorescence cystoscopy with blue light can diagnose carcinoma in situ that may be missed with white light cystoscopy. Hexaminolevulinate fluorescence cystoscopy can be used in conjunction with white light cystoscopy to aid in the diagnosis of this form of bladder cancer.

Multidetector-row computed tomography (MDCT) in patients with a history of previous urothelial cancer or painless macroscopic haematuria

The sensitivity and specificity of MDCT for depiction and localization of urothelial carcinoma (UC) was determined retrospectively. Axial and coronal four-row MDCT of the urinary tract (unenhanced, contrast-enhanced nephrographic, CT urography) was independently reviewed for UC by a radiologist (R1) and a urologist (R2), without other patient information, in 27 patients (22 male, five female; age, 72 +/- 11 years) with previous UC and/or painless macroscopic haematuria. Urinary tract segments included bladder, right and left upper, middle, and lower caliceal groups, renal pelvis, uretero-pelvic junction, upper, middle, and lower ureter. MDCT findings were corroborated by surgery, other invasive procedures, and 1-year follow-up, including MDCT, intravenous urography, and cystoscopy. Receiver-operating characteristic analysis was undertaken and the the area under the curve (AUC) calculated. Eighteen of 27 patients had evidence of UC (pTa, n = 3; pT1-pT3, n = 15; TNM 2002). Tumor was correctly located by both R1 and R2 in 17 patients (sensitivity, 94%; 95% confidence interval, 84-100%) and ruled out in seven (specificity, 78%; 95% confidence interval, 51-100%), with complete agreement. Each detected ten of 11 upper urinary tracts affected by UC. For 35 urinary tract segments with UC and 308 without, the AUC was 0.910 +/- 0.035 (R1) and 0.74 +/- 0.055 (R2), z = 2.4772, Bonferroni-corrected P = 0.022. MDCT depicts urinary tracts affected by UC with high sensitivity and substantial agreement between readers with different training.

Management of panurothelial disease in superficial bladder cancer

BACKGROUND

A 59-year-old female presented with a history of recurrent superficial bladder cancer. Since the initial diagnosis 12 years earlier, she had had 12 recurrences, all treated with transurethral resection with adjuvant bacillus Calmette-Guérin and mitomycin C. Pathology samples had always shown Ta grade 1 transitional-cell carcinoma. At the last recurrence, she presented with several papillary lesions throughout the bladder, discovered on control cystoscopy. Transurethral resection revealed a papillary grade 3 transitional-cell carcinoma of the bladder.

INVESTIGATIONS

Intravenous urography and ureteroscopy.

DIAGNOSIS

Panurothelial superficial transitional-cell carcinoma.

MANAGEMENT

Radical cystectomy with total right ureterectomy and distal left ureterectomy. Reconstruction of the urinary tract was performed with the distal ileum detubulized and rearranged in a U shape. A pyeloileal anastomosis and a proximal ureteroileal anastomosis were performed at the right and left sides respectively.

Improved Detection of Urothelial Carcinoma In Situ With Hexaminolevulinate Fluorescence Cystoscopy

PURPOSE

In this European multicenter study we compared hexaminolevulinate (HAL) fluorescence cystoscopy and standard white light cystoscopy for the detection of carcinoma in situ (CIS) in patients suspected of having high risk bladder cancer.

MATERIALS AND METHODS

This study was a prospective controlled, within-patient comparison of standard and HAL fluorescence cystoscopy. Eligible patients received an intravesical instillation of 50 ml HAL 8 mM solution. Cystoscopy was performed using a D light system, which provided white and blue light at 375 to 440 nm. The bladder wall was inspected and mapped, first under white light, followed by blue light. All tumors and suspicious areas identified under white light and by red fluorescence were resected or biopsied. Histological findings were assessed by an independent central pathologist blinded to the identity of the biopsies.

RESULTS

Of 211 evaluable patients 83 (39%) had CIS, of whom 18 (22%) were detected by HAL cystoscopy only, 62 (75%) were detected by standard and HAL cystoscopy, 2 (2%) were detected by standard cystoscopy only and 1 (1%) was detected by nonguided biopsy. Therefore, HAL cystoscopy identified 28% more patients with CIS than standard cystoscopy. The side effects of HAL instillation were negligible and no unexpected events were reported.

CONCLUSIONS

HAL fluorescence cystoscopy improves the detection of bladder CIS significantly, which has consequences for clinical management and may improve the patient prognosis. The procedure is easily implemented as an adjunct to standard cystoscopy and it adds no significant risk of complications.

[Cystectomy in superficial bladder tumours. Analysis of criterion include and prediction factors]

INTRODUCTION

Though usually the treatment of a superficial bladder tumour consists in transurethral resection, exceptionally because of several clinical conditions, in this kind of patients a radical cystectomy may be suitable.

PATIENTS AND METHOD

From june 1986 through december 2001, 127 radical cystectomies were performed. A series of 25 patients with a radical cystectomy performed in superficial bladder tumours were analysed. Indications, anatomo-pathological correlation and clinical evolution with survival curves are analysed.

RESULTS

The mean time of follow-up was 47 months. Extensive GIIIpT1 tumours (40%) were the chief indication. The remaining of the series consisted in carcinoma uncontrollable by endoscopy and refractory to chemotherapy. Anatomo-pathological correlation coincided in 48% of patients, existing supra and understaging in 25% and 28% respectively. A period of 54 months was without relapse. Seven patients died during the evolution (28%), and 18 patients are alive without disease. 128,48 months were the mean actuarial survival.

CONCLUSIONS

GIIIpT1 tumours were the chief indication of our series. The significant percentage of understaging, poor morbidity and good survival curves are emphasized. Because of these results we consider that radical cystectomies are a viable choice for selected patients with superficial vesical tumour.