Intravesical administration of highly concentrated hyaluronic acid and chondroitin sulfate as add-on therapy for chemical cystitis induced by Bacillus Calmette-Guérin (BCG) immunotherapy

PURPOSE

Intravesical (i) immunotherapy with Bacillus Calmette-Guérin (BCG) is the recommended treatment for patients with intermediate- and high-risk non-muscle-invasive bladder cancer (NMIBC) after complete tumor resection. Discontinuation or suspension of this therapy is often due to local side effects. Aim of the study was to evaluate the efficacy and safety of sequential intravesical instillations of combined hyaluronic acid (HA) and chondroitin sulfate (CS) in reducing local BCG toxicity and urinary symptoms.

METHODS

This was a prospective, multicentric study. Patients underwent BCG intravesical administration after Transurethral Resection of Bladder Tumor (TURBT) for intermediate/high-risk NMIBC. Patients underwent to HA + CS instillations after every (i) BCG (Group A) were compared with a control group (Group B) that included patient underwent only to BCG instillations, during the maintenance period. 3-day voiding diary, the International Prostate Symptom Score (IPSS), IPSS quality-of-life index (IPSS-QoL), and VAS score (to evaluate bladder pain) were evaluated at baseline and at 1-, 3-, and 6-month follow- up.

RESULTS

One hundred-eighteen patients were included (Group A: 63 patients, Group B: 55 patients). Mean value of IPSS, IPSS-QoL, and VAS score has significantly increase in Group A at 1-, 3-, and 6-month follow-up (p < 0.00). Group A showed also a significant improvement about irritative lower urinary symptoms (LUTS), which was maintained in the 6-month follow-up, as opposed to Group B that demonstrated a worsening in urinary symptoms during all follow-up (p < 0.00). No local or major side effects were reported during or after treatment.

CONCLUSION

This study demonstrated that adding (i) HA + CS significantly reduces storage symptoms, pelvic pain, and day-time urinary frequency in patients with BCG-induced chemical cystitis. This therapy could therefore improve patient adherence, ensuring better adherence and lower drop-out rates.

Total extra-peritoneal approach to radical cystectomy with ureterostomy: A novel technique for the elderly and frail

OBJECTIVES

Radical cystectomy with urinary diversion is the gold standard treatment for bladder cancer (high-risk/muscle invasive). The transperitoneal approach is associated with significant gastrointestinal complications like ileus. In the elderly and frail with a single functional kidney, we describe an extraperitoneal technique of radical cystectomy, with a ureterostomy, to be performed without general anesthesia.

MATERIALS AND METHODS

The elderly, frail, and high-risk candidates for general anesthesia, with a prior history of nephroureterectomy with a second primary muscle-invasive bladder cancer, were chosen. All patients underwent the described procedure under combined spinal and epidural anesthesia. The posterior dissection was retrograde, caudal to cranial, with the peritoneum being opened only for resection of the dome. A cutaneous ureterostomy was fashioned on the side of the functional kidney. Peri-operative parameters were assessed for early recovery in this high-risk group.

RESULTS

The mean age was 82 years (range: 73-91), with Charleson Comorbidity Index 5, and were all deemed unfit for neoadjuvant chemotherapy. With a median duration of 127.5 minutes, an average blood loss of 225ml, and no patient requiring general anesthesia; early ambulation, early return of bowel function, and a lesser hospital stay (7 days) with minimal morbidity were achieved. Negative surgical margins were achieved in all cases, with a mean harvest of 29 lymph nodes. Only 1 patient developed stomal stenosis. The cause-specific survival (CSS) is 100% at 2 years.

CONCLUSIONS

The highlighting features are the early return of bowel function (flatus passage on day 1) and the avoidance of the cardio-pulmonary complications of general anesthesia. The extraperitoneal cystectomy offers a promising alternative in this select group and warrants further studies to extrapolate this technique for bilateral urinary drainage.

Nomogram for predicting postoperative ileus after radical cystectomy and urinary diversion: a retrospective single-center study

OBJECTIVE

To predict the incidence of postoperative ileus in bladder cancer patients after radical cystectomy.

METHODS

We retrospectively analyzed the perioperative data of 452 bladder cancer patients who underwent radical cystectomy with urinary diversion at the Second Hospital of Tianjin Medical University between 2016 and 2021. Univariate and multivariate logistic regression were used to identify the risk factors for postoperative ileus. Finally, a nomogram model was established and verified based on the independent risk factors.

RESULTS

Our study revealed that 96 patients (21.2%) developed postoperative ileus. Using multivariate logistic regression analysis, we found that the independent risk factors for postoperative ileus after radical cystectomy included age > 65.0 years, high or low body mass index, constipation, hypoalbuminemia, and operative time. We established a nomogram prediction model based on these independent risk factors. Validation by calibration curves, concordance index, and decision curve analysis showed a strong correlation between predicted and actual probabilities of occurrence.

CONCLUSION

Our nomogram prediction model provides surgeons with a simple tool to predict the incidence of postoperative ileus in bladder cancer patients undergoing radical cystectomy.

The Role of Robotic Cystectomy in the Salvage and Palliative Setting: A Retrospective, Single-Center, Cohort Study

Introduction: This article compares surgical and survival outcomes of robot-assisted and open radical cystectomy with cutaneous ureterostomy for the treatment of frail bladder cancer patients with limited life expectancy. Methods: The institutional database was searched for cystectomy cases with cutaneous ureterostomy, from 1 June 2016 to 31 August 2022. The study population was split into two groups, according to the surgical approach. The baseline characteristics and surgical outcomes were compared. Logistic regression analyses identified predictors of major bleeding events (hemoglobin loss ≥ 3.5 g/dL or blood transfusion) and re-operation within 30 days from surgery. The Kaplan-Meier method estimated the impact of the robotic approach on overall survival and Cox regression analysis assessed its predictors. Results: A total of 145 patients were included: 30% (n = 43) underwent robotic cystectomy. Patients' characteristics and tumor stages distribution were comparable in the two groups but those receiving a minimally invasive treatment showed significantly reduced times to flatus, bowel and hospital discharge (all p < 0.001). Although operation times were longer in this cohort, major bleeding events (60% vs. 89%) and postoperative severe complications (0 vs. 8%) (both p < 0.001) were less frequent compared to the open approach. A logistic regression showed that robotic surgery independently predicted major bleeding events (OR: 0.26; 95%CI 0.09-0.72; p = 0.02) but not the need for re-intervention. A Kaplan-Meier analysis showed that robotic cystectomy was associated with a significant advantage in terms of overall survival (LogRank = 0.03), and this result was confirmed by Cox regression analysis (HR: 0.39; 95%CI 0.14-0.94; p = 0.04). Conclusions: Robotic cystectomy with cutaneous ureterostomy may represent a viable option to treat frail bladder cancer patients, as the minimally invasive approach reduces the risk of bleeding and serious complications and provides a prompt restoration of bowel function and a shorter hospital stay compared to open surgery.

Cutaneous ureterostomy following robot-assisted radical cystectomy: a multicenter comparative study of transperitoneal versus retroperitoneal techniques

BACKGROUND

The aim of this study was to evaluate the differences in perioperative outcomes between transperitoneal and retroperitoneal techniques in cutaneous ureterostomy (CUS).

METHODS

Between 2018 and 2023, 55 patients underwent CUS following robot-assisted radical cystectomy. Among the 55 patients, we compared 33 patients who underwent transperitoneal CUS (t-CUS) and 22 who underwent retroperitoneal CUS (r-CUS).

RESULTS

Compared with the r-CUS group, the t-CUS group had significantly shorter operative times (p < 0.001); significantly less estimated blood loss (p < 0.001); and significantly lower incidence of complications (Clavien-Dindo classification grade ≤ 2) within 30 days (p = 0.005). Unexpectedly, the incidence of ileus within 30 days was lower, though the difference was not statistically significant (p = 0.064). During the median follow-up period of 24.3 months, no ileus was observed in either group after 30 days postoperatively. There was no significant difference in the stent-free rate between the groups (p = 0.449). There were also no significant differences in the rates of change in estimated glomerular filtration rate from preoperatively at 3, 6, 12, and 24 months postoperatively between the groups (p = 0.590, p = 0.627, p = 0.741, and p = 0.778, respectively).

CONCLUSIONS

Compared with r-CUS, t-CUS was associated with a shorter operative time and lower incidence of perioperative complications, including gastrointestinal complications. We believe that t-CUS can be performed safely and effectively.

3D printing and intelligent technology increase convenience, reliability, and patient acceptance of ostomy nursing: a randomized controlled trial

Traditional ostomy bags commonly cause skin allergy and inflammation around the stoma, as well as leakage. This study aimed to examine the effect of a 3D-printed ostomy bag with sensors and stimulators on stoma nursing. This is a randomized controlled trial. This trial involved 113 distinct individuals who undergo colorectal cancer surgery and intestinal obstruction surgery, with resulting stoma. The date of trial registration was January 17, 2019, and the date of first recruitment was May 1, 2019. Patients were randomized into two groups: intelligent 3D-printed ostomy bag (3D group, n = 57) and Coloplast one-piece pouching systems (control group, n = 56). The shape of ostomy and the surrounding skin of all the 57 patients of the 3D group was scanned by a handheld 3D scanner. Then, the ostomy bag chassis (also known as skin barrier) was 3D printed and an intelligent device adhered to the ostomy bag. The wearing time, leakage rate, the Discoloration, Erosion, and Tissue Overgrowth (DET) score, and the Acceptance of Illness Scale (AIS) were observed. In the 3D-printed bag group, the time to wear (0.7 ± 0.4 m) was significantly shorter than that of the control group (9.1 ± 3.5 m). The leakage rate of 3D-printed bag (1.75%) was significantly lower than that of the control group (16.1%). The DET score for the 3D-printed bag group was also lower than that of the control group, and the AIS score for the 3D-printed bag group was higher than that of the control group. The 3D-printed ostomy bags and the linked computer program can significantly reduce wearing time, leakage rate, and stoma complications. This may improve the quality of home ostomy care for patients and reduce the incidence of skin complications around the stoma.Registration number: ChiCTR1900020752.

[Urinary diversion in old patients (80+ years)]

With increasing life expectancy there is also an increased need for the management of older (≥ 80 years) patients with the diagnosis of muscle-invasive bladder cancer. Radical cystectomy with urinary diversion is the state of the art treatment (with neoadjuvant chemotherapy, as long as the patient is fit enough). Choosing the best urinary diversion with respect to morbidity compared to functionality and quality of life remains a challenge in these patients. Physical age alone is not decisive for making a decision. A thorough preoperative assessment of medical features, physical and cognitive impairments is more important. Older patients are generally provided with an ileal conduit as an incontinent urinary diversion, as the intervention involves reduced operating times and complexity compared to continent urinary diversions; however, in the case of good health status with an adequate life expectancy and sufficient compliance, continent diversions may be considered even in aged candidates. In the case of multimorbid patients with a high perioperative risk, ureterostomy with permanent ureteric stents is an important alternative. Most importantly, a thorough preoperative counselling enables patients to reach an informed decision.

Risk Factors Analysis and Pathogen Distribution of Urinary Tract Infection in Patients Undergoing Cutaneous Ureterostomy After Radical Cystectomy for Bladder Cancer

BACKGROUND

Postoperative urinary tract infection is a common complication that not only significantly prolongs the hospital stay and amplifies the economic burden on patients, but also affects their quality of life and prognosis. This study aimed to investigate risk factors and distribution of pathogenic bacteria in urinary tract infections among bladder cancer patients who underwent cutaneous ureterostomy following radical cystectomy.

METHODS

A total of 137 bladder cancer patients, who underwent cutaneous ureterostomy after radical cystectomy at our hospital from November 2018 to October 2022, were enrolled in this retrospective study. Univariate and multivariate logistic regression analyses were employed to investigate the risk factors associated with postoperative urinary tract infection and the distribution of pathogenic bacteria among the infected patients.

RESULTS

The results of both univariate and multivariate analyses confirmed that age, proficiency in ostomy knowledge, frequency of ureteral stent tube replacement, ureteral stent tube dislodgement, urine immersion at the outer end of the ureteral stent tube, and the interval of ostomy bag replacement were independent risk factors for urinary tract infection after radical cystectomy and cutaneous ureterostomy in bladder cancer patients. A total of 55 pathogenic bacteria were isolated from 52 patients with infections. Predominantly, these were gram-negative bacteria (34 strains, 61.8%), with Proteus mirabilis having the highest proportion.

CONCLUSION

Urinary tract infections after radical cystectomy and cutaneous ureterostomy predominantly involve gram-negative bacteria. This is correlated with factors such as the age of bladder cancer patients, the level of nursing education, the duration of ureteral stent tubes and ostomy bag usage, as well as issues related to impaired urine drainage.

Robotic-assisted radical cystectomy with cutaneous ureterostomies: a contemporary multicenter analysis

BACKGROUND

Robotic-assisted radical cystectomy (RARC) offers decreased blood loss during surgery, shorter hospital length of stay, and lower risk for thromboembolic events without hindering oncological outcomes. Cutaneous ureterostomies (UCS) are a seldom utilized diversion that can be a suitable alternative for a selected group of patients with competing co-morbidities and limited life expectancy.

OBJECTIVE

To describe operative and perioperative characteristics as well as oncological outcomes for patients that underwent RARC + UCS.

METHODS

Patients that underwent RARC + UCS during 2013-2023 in 3 centers (EU = 2, US = 1) were identified in a prospectively maintained database. Baseline characteristics, pathological, and oncological outcomes were analyzed. Descriptive statistics and survival analysis were performed using R language version 4.3.1.

RESULTS

Sixty-nine patients were included. The median age was 77 years (IQR 70-80) and the median follow-up time was 11 months (IQR 4-20). Ten patients were ASA 4 (14.5%). Nine patients underwent palliative cystectomy (13%). The median operation time was 241 min (IQR 202-290), and the median hospital stay was 8 days (IQR 6-11). The 30-day complication rate was 55.1% (grade ≥ 3a was 14.4%), and the 30-day readmission rate was 17.4%. Eleven patients developed metastatic recurrence (15.9%), and 14 patients (20.2%) died during the follow-up period. Overall survival at 6, 12, and 24 months was 84%, 81%, and 73%, respectively.

CONCLUSIONS

RARC + UCS may offer lower complication and readmission rates without the need to perform enteric anastomosis, it can be considered in a selected group of patients with competing co-morbidities, or limited life expectancy. Larger prospective studies are necessary to validate these results.

Comparing surgical site wound infection after laparoscopic and open radical cystectomies in patients with bladder cancer

This study comprehensively compared the effects of laparoscopic and open radical cystectomies on postoperative wound infections and complications in patients with bladder cancer. We conducted a systematic search for relevant studies in PubMed, Embase, Google Scholar, Cochrane Library, China National Knowledge Infrastructure, and Wanfang databases, from database inception to October 2023. Two researchers independently screened the literature, extracted data, and assessed the quality based on the inclusion and exclusion criteria. Data analysis was performed using Stata 17.0 software. Overall, 16 studies involving 1427 patients with bladder cancer were included. The analysis revealed that, compared with open radical cystectomy, laparoscopic radical cystectomy significantly reduced the incidence of wound infections (odds ratio [OR] = 0.38, 95% confidence interval [CI]: 0.23-0.64, p < 0.001) and complications (OR = 0.35, 95%CI: 0.26-0.47, p < 0.001) and significantly shortened the hospital stay duration (standardised mean difference [SMD] = -1.85, 95%CI: -2.34 to -1.36, p < 0.001). Thus, this study determined that laparoscopic radical cystectomy for the treatment of bladder cancer effectively reduced the occurrence of wound infections and complications, and significantly shortened the patient's hospital stay, demonstrating notable therapeutic effectiveness worthy of clinical application.

Comparison of long-term outcomes between ileal conduit and transuretero-cutaneostomy urinary diversion after radical cystectomy: a systematic review and meta-analysis

Background

Urinary diversion in bladder cancer treatment has been a distinguished topic of interest due to varying approaches available. Amongst them, ileal conduit (IC) and transuretero-ureterostomy (TUU) have been popular options in clinical practice. This study would like to compare the long-term outcomes of IC and TUU in patients undergoing RC procedures.

Materials and methods

Literature searches were conducted in MEDLINE, CENTRAL, and EMBASE. Duration of hospitalization, complication rate, quality of life, and survival rate were selected as outcomes. Risk of bias was assessed using the ROBINS-I tool. Outcome measure was pooled using forest plot in Review Manager V.5 for Macintosh. Heterogeneity was measured using the DerSimonian and Laird random-effects model.

Results

Eighteen matching interventional studies were included, 3 were prospective studies. The total number of included samples was 3,689; 1,172 patients of the TUU and 2,517 of IC group. The IC procedure associates with longer hospitalization [mean difference 3.80 [95% confidence interval (CI): 2.27-5.32), p < 0.001, I2 = 92%]. Duration of intensive care did not differ significantly. There were no differences in major complication rates [odds ratio (OR) = 1.45, 95% CI: 0.74-2.84, p = 0.27, I2 = 54%]: stone formation (OR = 1.07, 95% CI: 0.51-2.23, p = 0.48, I2 = 0%), and renal function deterioration (OR = 0.81, 95% CI: 0.39-1.68, p = 0.57, I2 = 0%) between the TUU and IC groups. Quality of life decreased in both groups, and only occurred in the early days after the stoma placement phase. Survival rates were not different among the groups.

Conclusion

TUU is a better UD option as it offers shorter time of hospitalization, with the similar major complications, quality of life, and survival rate compared to IC.

Ileal Conduit versus Cutaneous Ureterostomy after Open Radical Cystectomy: Comparison of 90-Day Morbidity and Tube Dependence at Intermediate Term Follow-Up

Background: This study aims to compare perioperative morbidity and drainage tube dependence following open radical cystectomy (ORC) with ileal conduit (IC) or cutaneous ureterostomy (CU) for bladder cancer. Methods: A single-center, retrospective cohort study of patients undergoing ORC with IC or CU urinary diversion between 2020 and 2023 was carried out. The 90-day perioperative morbidity, as per Clavien-Dindo (C.D.) complication rates (Minor C.D. I-II, Major C.D. III-V), and urinary drainage tube dependence (ureteral stent or nephrostomy tube) after tube-free trial were assessed. Results: The study included 56 patients (IC: 26, CU: 30) with a 14-month median follow-up. At 90 days after IC or CU, the frequencies of any, minor, and major C.D. complications were similar (any-69% vs. 77%; minor-61% vs. 73%; major-46% vs. 30%, respectively, p > 0.2). Tube-free trial was performed in 86% of patients with similar rates of tube replacement (19% IC vs. 32% CU, p = 0.34) and tube-free survival at 12 months was assessed (76% IC vs. 70% CU, p = 0.31). Conclusions: Compared to the ORC+IC, ORC+CU has similar rates of both 90-day perioperative complications and 12-month tube-free dependence. CU should be offered to select patients as an alternative to IC urinary diversion after RC.

Quality of life after definitive treatment for bladder cancer: A systematic review and meta-analysis

Radical cystectomy (RC) is considered the standard treatment for muscle invasive bladder cancer (MIBC). However, RC is often burdened by significant impact on quality of life (QoL); Continence preserving methods (e.g., continent cutaneous urinary diversion and orthotopic neobladder-ONB), have been proposed as alternatives to improve postoperative QoL. Trimodal therapy (TMT) emerged as alternative to surgery. To assess the impact of these treatments from the patients' perspective, we undertook a systematic review and meta-analysis of literature, focusing on studies reporting QoL data about each of the abovementioned approaches. A systematic review was carried out including all prospective and retrospective studies enrolling patientstreated with radical intent for non-metastatic MIBC from 1999 to 2021 (either RC or TMT). All studies included specifically reported QoL for one of the main treatment approaches explored (RC followed by ileal conduit urinary diversion-ICUD, ONB or TMT). Pooled analysis for EORTC QLQ-C30 and BLM-30 questionnaires showed that ONB yielded a significant advantage only for Physical Functioning (pooled mean standardized difference -0.73 SD, p-value 0.019, I 2 = 93 %) and for Emotional Functioning (pooled mean standardized difference -0.16 SD, p-value 0.029, I 2 = 0 %). A trend in favour of higher mean reported values after TMT for Global Health Score, Physical Functioning and Role Functioning was found, if compared to both RC approaches. Significant benefit for ONB if compared to ICUD was detected only for specific subdomains of QoL questionnaires. No direct comparison with TMT is available, but data suggest advantage of this approach when compared to both reconstructive scenarios.

Stent-free rates in cutaneous ureterostomy urinary diversion after radical cystectomy

PURPOSE

Cutaneous ureterostomy (CU) urinary diversion after radical cystectomy has been relegated to highly comorbid patients due to presumed rates of stenosis and drainage tube dependence. Rates of stricture as high as 70% have been reported. Though a variety of techniques have been developed to obviate the need for prolonged stenting, CU remains uncommonly performed. Herein, we present our experience with CU diversion after radical cystectomy and stent-free rates post-operatively.

MATERIALS AND METHODS

We retrospectively reviewed the records of consecutive patients undergoing radical cystectomy with single-stoma cutaneous ureterostomy from June 2020 to December 2022 at our institution. Demographic and clinical data were summarized. We recorded the presence of ureteral stent, nephrostomy, or nephroureteral catheter at the last follow-up. The primary outcome was "stent-free survival" incorporating all modalities of tube-dependent urinary drainage. Kaplan-Meier analysis was performed to determine stent-free survival at 12 months.

RESULTS AND CONCLUSIONS

We identified 28 patients meeting inclusion criteria with median age of 73 years (IQR: 66-78) and median body mass index of 25 (IQR: 22-28). Of patients that underwent stent-free trial (N = 23), the stent-free survival at 12 months was 74%. Five of 28 patients had continued tube dependence due to locally advanced disease with hydronephrosis rather than CU stenosis. These results suggest that single-stoma CU should be considered a viable option for patients undergoing radical cystectomy. Longer follow-up is needed to assess durability of stent-free rates.

Cutaneous Ureterostomy Following Radical Cystectomy for Bladder Cancer: A Contemporary Series

OBJECTIVE

To report peri-operative outcomes of a contemporary series of bladder cancer patients undergoing radical cystectomy (RC) with cutaneous ureterostomy (CU) urinary diversion at a tertiary referral center.

METHODS

We retrospectively identified patients who underwent RC with CU at Mayo Clinic between 2016 and 2021. Clinicopathologic and perioperative characteristics were analyzed using standard descriptive statistics.

RESULTS

A total of 31 patients underwent RC with CU at our institution. Median age was 72years and 21 were male. This was highly comorbid cohort (83% had an American Society of Anesthesiologists [ASA] Physical Status Classification System ≥3; median Charlson Comorbidity index= 8). Median time to flatus, tolerating regular diet, and length of stay were 3 (interquartile range [IQR] 3-3), 3 (IQR 3-4), and 4days (IQR 4-7), respectively. A total of 14 patients experienced a high-grade complication (Clavien-Dindo ≥3) within 30days of surgery, and 8 were readmitted. The most common 30-day complication was sepsis, which affected 13% (4/31) of patients. At 90days postsurgery, the readmission rate was 32% (10/31), most commonly for sepsis. Three patients required reoperation within 90days, including one patient who required CU revision due to stomal ischemia. One patient died within this time frame from causes unrelated to bladder cancer.

CONCLUSION

In a comorbid, relatively elderly bladder cancer cohort undergoing RC, the use of CU was associated with expeditious surgery and postoperative recovery. CU represents an option for urinary diversion in high-risk patients undergoing RC. Higher rate of postoperative ureteral obstruction can be pre-emptively addressed with chronic stent placement.

The effect of body mass index on quality of life in modified single stoma cutaneous ureterostomy or ileal conduit after radical cystectomy

OBJECTIVE

To explore the influence of postoperative body mass index (BMI) change on postoperative quality of life (QOL) in patients undergoing radical cystectomy (RC) plus modified single stoma cutaneous ureterostomy (MSSCU) or ileal conduit (IC).

METHODS

Patients were divided into two groups according to different BMI change patterns: patients experiencing an elevated postoperative BMI level, along with a clinically significant increase in their BMI (an increase of more than 10%) were categorized as Group 1, while patients experiencing a decrease postoperative BMI level, along with a clinically significant reduction in their BMI (a decrease of more than 5%) were categorized as Group 2. Spearman correlation analysis was used to examine the correlations between quality-of-life scores and postoperative clinical parameters.

RESULTS

Spearman correlation analysis showed that postoperative BMI, late complications and catheter-free state were significantly associated with postoperative global QoL and symptom scale in MSSCU and postoperative global QoL and physical scale in IC patients. Additionally, postoperative BMI, catheter-free state and the use of adjuvant therapy were associated with bad performance in many scales of QoL like body image, future perspective, social scale, future perspective (MSSCU), and abdominal bloating (IC) (Table 2, p<0.05). Patients in Group 2 with significant weight loss had a better Global QoL, a lower rate of stomal stricture and a higher catheter-free state compared with those in Group 1 in both IC and MSSCU patients. MSSCU patients in Group 2 could achieve a comparable Global QoL as to IC patients in Group 1.

CONCLUSION

Controlling the substantial increase in body weight after surgery contributes to improving QoL, reducing the occurrence of stomal stricture, and ensuring a postoperative catheter-free state in BCa patients undergoing MSSCU.

Comparison of trimodality therapy and neoadjuvant chemotherapy combined with radical cystectomy for the survival of muscle-invasive bladder cancer: a population-based analysis

BACKGROUND

Trimodality therapy (TMT) is a mature alternative to radical cystectomy (RC) for patients with muscle-invasive bladder cancer (MIBC) who seek to preserve their primary bladder or are inoperable due to comorbidities. To date, there has been increasing evidence of the effectiveness of TMT as an alternative to RC. In contrast, no literature has stated the effectiveness of neoadjuvant chemotherapy combined with RC (NAC + RC) compared with TMT.

OBJECTIVE

We aimed to compare the prognosis between patients receiving TMT and NAC + RC.

METHODS

The clinicopathological characteristics of patients with T2-4aN0M0 MIBC were obtained from the Surveillance, Epidemiology, and End Results (SEER) database. Univariate and multivariate Cox proportional hazards regression models and Kaplan‒Meier survival curves were used for the survival analysis. Propensity-score matching (PSM) was applied to determine the differences between the two groups. The primary outcome was cancer-specific survival (CSS), and the secondary outcome was overall survival (OS).

RESULTS

In total, 1,175 patients with MIBC who underwent TMT (n = 822) or NAC + RC (n = 353) were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. After 1:1 PSM, the final patient sample included 303 pairs. The prognosis of patients receiving NAC + RC was significantly better than that of patients receiving TMT in both unmatched and matched cohorts (5-year CSS: before PSM, 75.4% vs. 50.6%, P < 0.0001; after PSM, 76.3% vs. 49.5%, P < 0.0001; 5-year OS: before PSM, 71.7% vs. 37.4%, P < 0.0001; after PSM, 71.7% vs. 31.4%, P < 0.0001). The survival advantages of NAC + RC remained remarkable in the stratified analysis of most factors after PSM. Multivariate Cox regression analysis showed that being older than 68 years old, unmarried, grade III/IV, T3-4a stage, and undergoing TMT independently correlated with poor OS.

CONCLUSION

Thus, in this study, patients with MIBC receiving NAC + RC presented with a better prognosis than those receiving TMT.

Simultaneous radical cystectomy and nephroureterectomy in the treatment of panurothelial carcinoma: a systematic review and single-arm meta-analysis

Background

Panurothelial carcinoma is a rare and aggressive malignancy that requires effective treatment strategies to enhance patient outcomes.

Methods

We conducted a systematic search of English publications in databases including PubMed, Embase, Cochrane Library, and Web of Science up to May 2023. The quality of the literature was assessed using the Newcastle-Ottawa Scale (NOS) and the Methodological Quality and Synthesis of Case Series and Case Reports tool. Data statistics and analysis were performed using Stata 15.1 software (StataSE, USA).

Results

Six studies involving 339 patients were included in the analysis. Meta-analysis revealed that Simultaneous Radical Cystectomy and Nephroureterectomy had 2-year and 5-year overall survival rates of 68% (95% CI 60%-76%, I2 = 12.4%, P < 0.001) and 44% (95% CI 36%-53%, I2 = 0, P < 0.001), respectively. The 2-year and 5-year progression-free survival rates were 91% (95% CI 86%-95%, I2 = 95%, P < 0.001) and 65% (95% CI 58%-73%, I2 = 91.5%, P < 0.001), respectively. The 2-year and 5-year cancer-specific survival rates were 73% (95% CI 66%-81%, I2 = 16.7%, P < 0.001) and 57% (95% CI 49%-66%, I2 = 0, P < 0.001), respectively. Additionally, the incidence of minor complications was 19% (95% CI 15%-23%, P < 0.01), major complications was 49% (95% CI 34%-63%, P < 0.01), and the intraoperative blood transfusion rate was 53% (95% CI 44%-61%, P < 0.01).

Conclusions

Simultaneous radical cystectomy and nephroureterectomy represent feasible approaches for the treatment of Panurothelial carcinoma. Nonetheless, a comprehensive assessment of the surgical risks and benefits is imperative, and larger-scale prospective cohort studies are required to validate therapeutic efficacy.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO, identifier CRD42023426401.

Analysis of the efficacy of a single subumbilical stoma for bilateral cutaneous ureterostomy after radical cystectomy

BACKGROUND

Radical cystectomy and urinary diversion are the standard surgical treatments for patients with muscle-invasive or high-risk, or recurrent non-muscle-invasive bladder cancer. Although this approach significantly prolongs patient survival, it can lead to postoperative complications. This study aims to compare the efficacy and complications of bilateral cutaneous ureterostomy with a single subumbilical stoma to those of cutaneous ureterostomy with two stomas and an ileal conduit as a means of urinary diversion after radical cystectomy. The findings of this study will provide valuable information for healthcare providers in selecting the appropriate urinary diversion method for their patients.

METHODS

The clinical data for 108 patients who received bilateral cutaneous ureterostomy with a single subumbilical stoma (ureterostomy with a single stoma group), cutaneous ureterostomy with two stomas (ureterostomy with two stomas group), or an ileal conduit (ileal conduit group) after radical cystectomy were retrospectively analysed. The operative time, pathological stage, survival status, perioperative complication rate, rate of successful first extubation, rehospitalization rate at 6 months after surgery,ostomy-related medical costs,and postoperative quality of life were compared between the three groups of patients.

RESULTS

A significant difference in the operative time was found between the three groups (P = 0.001). No significant differences in pathological stage, survival status, perioperative complication rate, rehospitalization rate at 6 months after surgery, or bladder cancer index (BCI) score were identified among the three groups. The difference in the successful first extubation rate between the three groups of patients was significant (P = 0.001). Significant differences in ostomy-related medical costs were observed among the three groups of patients (P = 0.006).

CONCLUSION

A single subumbilical stoma for bilateral cutaneous ureterostomy after radical cystectomy may result in shorter surgery time, increased success rates for initial catheter removal, and lower medical expenses. However, to confirm these findings, further prospective randomized clinical trials are necessary.

Ileal conduit versus single stoma uretero-cutanoustomy after radical cystectomy in patients ≥ 75 years; which technique is better? a prospective randomized comparative study

PURPOSE

To compare the clinical results and patients' health-related quality of life (HR-QoL) of ileal conduit (IC) versus single stoma uretero-cutanoustomy (SSUC) after radical cystectomy in two groups of randomly selected patients ≥ 75 years.

METHODS

From January 2013 to March 2018, 100 patients ≥ 75 years with muscle invasive BCa underwent RCX and cutaneous diversion. Patients were divided in two groups; group I underwent IC (50 patients) and group II underwent SSUC (50 patients). Postoperative evaluation included clinical, laboratory, radiographic and HR-QoL. The latter was performed using the Functional Assessment of Cancer Therapy-Bladder Cancer (FACT-BL) after 12 months postoperatively.

RESULTS

Patients' characteristics were comparable between both groups. No intraoperative complications occurred. Early postoperative complications occurred in 27 patients [16 (35.5%) in group I and 11 (23.9%) in group II (p = 0.02)]. Delayed postoperative complications occurred in 26 patients [6 (13.3%) in group I and 20 (43.4%) in group II, (P = 0.002)]. No significant differences between both groups regarding the physical, social/family, emotional, functional and additional concerns scales of FACT-BL questionnaire were reported.

CONCLUSION

SSUC is a good alternative to IC in elderly frail patients  ≥ 75 years and those with multiple comorbidities who require rapid surgery in terms of perioperative complications and HR-QoL. However, the stomal complications and the possibility of a frequent stent exchange are considered its drawbacks.

Perioperative and Oncologic Outcomes Associated with Simultaneous Radical Cystectomy and Nephroureterectomy

OBJECTIVE

To compare the perioperative and oncologic outcomes associated with RCNU to a matched cohort undergoing RC alone. Simultaneous radical cystectomy and nephroureterectomy (RCNU) for synchronous upper tract and bladder urothelial carcinoma is an uncommon procedure. Sparse literature exists comparing outcomes in patients treated with radical cystectomy (RC) alone versus RCNU.

METHODS

Adults treated with RCNU for urothelial carcinoma of the bladder (UCB) and upper tract urothelial carcinoma (UTUC) between 1980 and 2020 were identified. Patients were matched 2:1 to patients undergoing RC alone for UCB based on age (+/- 5 years), gender, BMI (+/- 5), Charlson Comorbidity Index, pathologic staging (stage ≤pT2 vs >pT2), and receipt of neoadjuvant chemotherapy. Outcomes included overall survival (OS), recurrence free survival (RFS), cancer specific survival (CSS), 30-day complications, length of stay (LOS), operative time, and estimated blood loss (EBL).

RESULTS

A total of 39 patients undergoing RCNU were identified and matched to 74 patients undergoing RC. There were no significant differences in LOS, EBL, or 30-day complication rates. Operative time was significantly longer in the RC cohort. OS (HR 0.58, CI 0.35-0.97, P = .036) was significantly better for patients undergoing RC alone, while no significant difference was noted in RFS (HR 0.65, 0.34-1.24) and CSS (HR 0.58, CI 0.31-1.08, P = .08).

CONCLUSIONS

Patients undergoing RCNU had significantly lower OS compared to a matched group of patients undergoing RC alone. Perioperative outcomes between the groups did not differ significantly. This data can inform patient counseling for treatment of this rare disease state.

The influence of serum sodium concentration on prognosis in patients with urothelial carcinoma treated by radical cystectomy

Serum sodium concentration has been found to be associated with poor survival in many solid tumors. This study investigated the effect of basal serum sodium concentration on prognostic in patients with muscle-invasive bladder cancer (MIBC) undergoing radical cystectomy (RC). MIBC patients with histologically proven urothelial carcinoma treated by RC were retrospectively reviewed. According to the optimal cutoff value, we divided the patients into 2 groups: high-serum sodium concentration group (≥140 mmol/L, n = 39) and low-serum sodium concentration group (<140 mmol/L, n = 32). Overall survival (OS) was estimated with the Kaplan-Meier method and the significance was examined by the log-rank test. Multivariable Cox regression for OS was performed for lymphatic metastasis, hypertension, diabetes mellitus, and tumor size. A total of 71 MIBC patients (60 males and 11 females) were included who underwent cystectomy between 2014 and 2018. The patients' ages at the time of operation ranged from 44 to 86 years (mean, 66.66 years). Patients' serum sodium concentration <140 mmol/L had shorter median OS (1224 days (HR: 2.454 [95% CI, 1.083-5.561; P = .031]). In multivariate analysis, lower serum sodium concentration was significantly associated with worse OS after adjusted (adjusted HR: 2.422 [95% CI, 1.055-5.561; P = .037]). Serum sodium concentration <140 mmol/L was independently associated with a poorer prognosis in patients with MIBC used who underwent RC.

Real-world treatment patterns and oncological outcomes in early relapse and refractory disease after bacillus Calmette-Guérin failure in non-muscle-invasive bladder cancer

OBJECTIVE

To assess real-world oncological outcomes between the radical cystectomy (RC) group and non-RC group for early relapse and refractory disease.

METHODS

We retrospectively analyzed 953 patients with recurrent non-muscle-invasive bladder cancer (NMIBC) who received bacillus Calmette-Guérin (BCG) at 31 affiliated hospitals from 2000 to 2019. Patients with missing data on the timing of failure were excluded and 871 patients remained eligible, of whom 447, 357, and 67 were classified as early relapse/refractory disease, intermediate/late relapse disease, and intolerant disease, respectively. For early relapse/refractory disease, patients were divided into two salvage treatment groups: RC and non-RC. The clinicopathological variables of each group were examined using Kaplan-Meier plots and proportional Cox hazard ratios with matched score analyses to compare oncological outcomes between the two groups.

RESULTS

Significantly worse progression-free survival and cancer-specific survival (CSS) were confirmed in the early relapse/refractory disease group compared to the intermediate/late relapse group. Of the 88 salvage patients in the RC group with early relapse/refractory disease, ≤pT1 was observed in 47, pT2 in 11, and ≥pT3 in 28 (two patients with unknown pT category). In early relapse/refractory disease, the RC group showed significantly high-risk tumor compared to the non-RC group. However, no significant difference was observed in CSS after matched score analyses (p = 0.45) between the RC and non-RC groups.

CONCLUSIONS

This study found that the RC group showed no significant superiority compared to the non-RC group in CSS for early relapse/refractory disease in terms of first salvage therapy.

Population-Based Assessment of Determining Predictors for Discharge Disposition in Patients with Bladder Cancer Undergoing Radical Cystectomy

Objective: To assess predictors of discharge disposition—either home or to a CRF—after undergoing RC for bladder cancer in the United States. Methods: In this retrospective, cohort study, patients were divided into two cohorts: those discharged home and those discharged to CRF. We examined patient, surgical, and hospital characteristics. Multivariable logistic regression models were used to control for selected variables. All statistical tests were two-sided. Patients were derived from the Premier Healthcare Database. International classification of disease (ICD)-9 (<2014), ICD-10 (≥2015), and Current Procedural Terminology (CPT) codes were used to identify patient diagnoses and encounters. The population consisted of 138,151 patients who underwent RC for bladder cancer between 1 January 2000 and 31 December 2019. Results: Of 138,151 patients, 24,922 (18.0%) were admitted to CRFs. Multivariate analysis revealed that older age, single/widowed marital status, female gender, increased Charlson Comorbidity Index, Medicaid, and Medicare insurance are associated with CRF discharge. Rural hospital location, self-pay status, increased annual surgeon case, and robotic surgical approach are associated with home discharge. Conclusions: Several specific patient, surgical, and facility characteristics were identified that may significantly impact discharge disposition after RC for bladder cancer.

A double-J stent misguided by zebra guidewire into ileum: A case report and literature review

The case is a 70-year-old man who underwent a left nephroureterectomy and cutaneous ureterostomy on the contralateral side for invasive bladder cancer had to be accepted replacement of the double-J stent because of stomal stenosis.When replacing the double-J stent, a severe complication that the double-J stent misguided into the ileum occurred. The patient underwent gastrointestinal motility drugs, and the double-J stent was excreted with the feces after 12 hours. Unfortunately，patient suffered a uretero-ileal fistula and died of septic shock finally.The diagnosis and management of Uretero-ileal fistula as an iatrogenic complication of zebra guidewire use is discussed.

Cutaneous Ureterostomy or Ileal Conduit Urinary Diversion: Can We Spare the Bowel Following Radical Cystectomy in Patients with Solitary Functioning Kidney?

To compare the outcomes between cutaneous ureterostomy and ileal conduit urinary diversion in patients with solitary functioning kidney, undergoing radical cystectomy. This study was a retrospective analysis of the patients, with solitary functioning kidney, who underwent radical cystectomy with either cutaneous ureterostomy or ileal conduit from January 2014 to May 2019. Baseline characteristics, perioperative outcomes, and follow-up renal function were evaluated and compared. For renal function outcomes, we assessed the estimated glomerular filtration rate (eGFR) and included patients with a follow-up of at least 2 years. A total of 43 patients were included in the study, 23 of them underwent cutaneous ureterostomy and 20 underwent ileal conduit urinary diversion. The two groups were similar with respect to their baseline demographic and clinical characteristics. Operative time (p < 0.001), time to drain removal (p = 0.016), postoperative length of hospital stay (p = 0.018), and bowel-related complications (p = 0.047) were significantly lower in patients who underwent cutaneous ureterostomy. The eGFR was comparable at baseline, and till 1 year of follow-up. But, there was a greater decline in eGFR over 2 years, in patients who received cutaneous ureterostomy (p = 0.039). The present study shows that cutaneous ureterostomy has better perioperative, and comparable short-term renal function outcomes over ileal conduit urinary diversion. However, over 2 years of follow-up, there was an increased likelihood, and greater degree of decline in eGFR in patients who received cutaneous ureterostomy.

Extraperitoneal cystectomy with ureterocutaneostomy derivation in fragile patients - should it be performed more often?

INTRODUCTION AND OBJECTIVES

Radical cystectomy (RC) continues to be standard of care for muscle-invasive bladder cancer and recurrent or refractory nonmuscle invasive bladder cancer. Unfortunately, it has high rates of perioperative morbidity and mortality. One of the most important predictors of postoperative outcomes is frailty, while the majority of complications are diversion related. The aim of our study was to evaluate safety of extraperitoneal cystectomy with ureterocutaneostomy in patients considered as frail.

MATERIALS AND METHODS

We retrospectively collected data of frail patients who underwent extraperitoneal cystectomy with ureterocutaneostomy from October 2018 to August 2020 in a single center. We evaluated frailty by assessing patients' age, body mass index (BMI), nutritional status by Malnutrition Universal Screening Tool, overall health by RAI (Risk Analysis Index) and ASA (American Society of Anaesthesiologists) score, and laboratory analyses. We observed intraoperative outcomes and rates of perioperative (within 30 days) and early postoperative (within 90 days) complications (Clavien-Dindo classification). We defined extraperitoneal cystectomy with ureterocutaneostomy as safe if patients did not develop Clavien Dindo IIIb, or worse, complication.

RESULTS

A total of 34 patients, 3 female and 31 male, were analyzed. The median age was 77, BMI 26, RAI 28, ASA 3 and the majority had preexisting renal insufficiency. Blood analyses revealed presence of severe preoperative hypoalbuminemia and anemia in half of our cohort. Intraoperative median blood loss was 250 cc, whilst operative time 245 min. During perioperative period 60% of our cohort developed Clavien Dindo II complication and during early postoperative period 32% of patients required readmission. One death occurred during early postoperative period (2.9%). After 12 months of follow-up, we observed stability of the renal function for most patients.

CONCLUSIONS

We believe that extraperitoneal cystectomy with ureterocutaneostomy could be considered as a treatment option for elderly and/or frail patients.

Less invasive and equivalent short-term outcomes with simultaneous en bloc robot-assisted radical cystectomy and laparoscopic nephroureterectomy: Comparison with conventional open radical cystectomy and nephroureterectomy

INTRODUCTION

To clarify the safety and efficacy of en bloc simultaneous robot-assisted radical cystectomy (RARC) and laparoscopic nephroureterectomy (LNU) for synchronous muscle-invasive bladder carcinoma and upper tract urothelial carcinoma (UTUC) or UTUC of a solitary kidney, we evaluated the perioperative and short-term outcomes of this surgical procedure compared with those of simultaneous open radical cystectomy and nephroureterectomy.

METHODS

We prospectively enrolled consecutive patients receiving en bloc simultaneous RARC and LNU between December 2018 and March 2020 at two institutes. Patients' characteristics, surgical, perioperative, and pathological outcomes and recurrence rate within 6 months were compared with a historical control receiving simultaneous open radical cystectomy and nephroureterectomy.

RESULTS

Ten patients receiving simultaneous RARC and LNU and 17 receiving simultaneous open radical cystectomy and nephroureterectomy were included in the study. Simultaneous RARC and LNU significantly reduced bleeding volume and blood transfusion (P < .0001, P < .0001, respectively) and significantly prolonged operating time (P = .035). RARC and LNU significantly shortened hospitalization after operation (P = .003) and showed reduced tendency of postoperative complications within 30 days but not significantly (P = .25). Pathological characteristics and recurrence within 6 months were not significantly different between the two groups.

CONCLUSION

Our results suggested that en bloc simultaneous RARC and LNU were safer surgical procedures with equivalent short-term oncological outcomes compared to conventional open procedures. It can be a standard minimally invasive surgical method in countries where robot-assisted radical nephroureterectomy is inaccessible.

Robot-Assisted Totally Intracorporeal Resection of Cutaneous Ureterostomy Tumor and Ileal Conduit Surgery: A Rare Case Report

BACKGROUND

Radical cystectomy (RC) is the standard treatment for muscular invasive bladder cancer (MIBC) and some high-risk non-muscular invasive bladder cancer (NMIBC). Cutaneous ureterostomy is a common form of urinary diversion. However, after radical cystectomy, recurrence of upper urinary tract malignancies is possible. There is no relevant report on how to improve this situation's management.

CASE PRESENTATION

This case is a 56-year-old male patient hospitalized due to the development of a new tumor in the ureteral cutaneous stoma following radical cystectomy for more than five years. A biopsy of the tumor revealed high-grade urothelial carcinoma. Computed tomography (CT) revealed that the local soft tissue around the cutaneous stoma was thickened, but no other lesions were visible. After evaluating the case, we chose robot-assisted completely intracorporeal resection of cutaneous ureterostomy tumor and ileal conduit surgery. The total time for the operation and the blood loss were 400 minutes and 150 ml, respectively. Following surgery, the patient got standard chemotherapy in combination with immunotherapy. Additionally, ten months following the surgery, the patient did not experience disease progression or complications.

CONCLUSION

The robot-assisted operation is safe and feasible for upper urinary tract tumor recurrence following radical cystectomy with cutaneous ureterostomy.

Bricker ileal conduit vs. Cutaneous ureterostomy after radical cystectomy for bladder cancer: a systematic review

PURPOSE

A systematic review of the literature with available published literature to compare ileal conduit (IC) and cutaneous ureterostomy (CU) urinary diversions (UD) in terms of perioperative, functional, and oncological outcomes of high-risk elderly patients treated with radical cystectomy (RC). Protocol Registration: PROSPERO ID CRD42020168851.

MATERIALS AND METHODS

A systematic review, according to the PRISMA Statement, was performed. Search through the Medline, Embase, Scopus, Scielo, Lilacs, and Cochrane Database until July 2020.

RESULTS

The literature search yielded 2,883 citations and were selected eight studies, including 1096 patients. A total of 707 patients underwent IC and 389 CU. Surgical procedures and outcomes, complications, mortality, and quality of life were analyzed.

CONCLUSIONS

CU seems to be a safe alternative for the elderly and more frail patients. It is associated with faster surgery, less blood loss, lower transfusion rates, a lower necessity of intensive care, and shorter hospital stay. According to most studies, complications are less frequent after CU, even though mortality rates are similar. Studies with long-term follow up are awaited.

Evaluation of Functional Outcomes and Quality of Life in Elderly Patients (>75 y.o.) Undergoing Minimally Invasive Radical Cystectomy with Single Stoma Ureterocutaneostomy vs. Bricker Intracorporeal Ileal Conduit Urinary Diversion

Background: Diversion after radical cystectomy (RC) is crucial when considering elderly subjects. Data on the quality of life (QoL) impact with different diversions is scarce. This study aims to compare complications and QoL in patients aged > 75 y.o., who underwent minimally invasive (MI) RC with Bricker intracorporeal urinary derivation and single stoma ureterocutaneostomy. Methods: We conducted a retrospective analysis of elderly patients who underwent MIRC and intracorporeal diversion. The 78 subjects were divided into two groups: group A, ileal conduit, and group B, single stoma ureterocutaneostomy. We evaluated the bowel’s recovery time and complications rate. We investigated QoL 3 and 6 months after surgery using the Stoma-QoL questionnaire. Results: Mean age was 77.2 in group A and 82.4 in group B. The mean ASA score and Charlson Comorbidity index were comparable between the two groups. Rates of complications were 57.6% and 37.4% in groups A and B, respectively. The mean postoperative Stoma-QoL score 3 months after surgery was 52.2 and 52.4 in groups A and B, respectively. At 6 months of follow-up the Stoma QoL mean score was 63.4, showing homogeneity between the groups. Conclusion: MIRC with single stoma ureterocutaneostomy represents an alternative to ileal conduit, with comparable QoL and ostomy management 6 months after surgery, reporting fewer complications.

Age and risk of major complications in patients undergoing radical cystectomy for muscle invasive bladder cancer

Introduction

Radical cystectomy is the treatment of choice for patients with muscle invasive bladder cancer (MIBC), but it may be unsafe in older patients.

Aim

In this study, we investigated whether age and selected clinical characteristics were associated with outcomes of radical cystectomy.

Material and methods

We enrolled 434 patients with MIBC who underwent radical cystectomy between 2012 and 2016, and we classified them into three age groups: < 65, 66–74, and ≥ 75 years. Postoperative complications were classified on the Clavien-Dindo scale. Regression models were used to find predictors of major postoperative complications (Clavien-Dindo score of 3 or more), long hospital stay (> 7 days), blood loss, and operating time. The models included American Society of Anesthesiologists scores, age group, sex, body mass index, Tumor Nodes Metastasis scores, type of urine derivation (ileal conduit or orthotopic bladder vs. ureterocutaneostomy), and operation type (open vs. laparoscopic).

Results

In the regression models, age was not a significant predictor of major complications, long hospital stay, or blood loss (p ≥ 0.206). Older age was associated with shorter surgery times (p = 0.002). Higher preoperative American Society of Anesthesiologists scores tended to be associated with a greater risk of major complications (odds ratio, 1.47; p = 0.092).

Conclusions

Older age was not associated with an increased risk of major complications in patients who undergo radical cystectomy because of MIBC. Therefore, older age alone should not be a contraindication to this operation.

Treating Elderly Patients With Muscle-Invasive Bladder Cancer

Bladder cancer is an extremely common cancer that primarily affects individuals aged >65 years. In caring for patients with bladder cancer, clinicians must also consider care of older persons in general. Management of muscle-invasive bladder cancer (MIBC) involves multidisciplinary treatment planning, because curative-intent therapy includes either surgery or radiation, with consideration of the role of systemic therapy. As clinicians develop a treatment plan, considering a geriatric oncology perspective may enhance patient care and influence outcomes for this large and growing population. Similarly, treatment plan development must also consider aspects unique to an older patient population, such as altered organ function, increased comorbidity, decreased functional reserve, and perhaps altered goals of treatment. Thus a thorough evaluation inclusive of disease assessment and geriatric assessment is essential to care planning. Population-based data show that as patients with MIBC age, use of standard therapies declines. Given the complexities of coordinating a multidisciplinary care plan, as well the complexities of treating a heterogeneous and potentially vulnerable older patient population, clinicians may benefit from upfront assessments to inform and guide the process. This review highlights the unique treatment planning considerations for elderly patients diagnosed with MIBC.

A comparative study of perioperative and survival outcomes of robot-assisted radical cystectomy in patients over 80 and under 80 years old

Background

Radical cystectomy (RC) is the standard treatment for bladder cancer, but the safety and efficacy of this treatment for elderly people need to be considered. We compare perioperative data and survival outcomes between elderly (≥80 years) and younger (<80 years) patients undergoing robot-assisted radical cystectomy (RARC).

Methods

We reviewed demographic, perioperative clinical and follow-up data of 190 consecutive patients with urothelial carcinoma of bladder who received RARC from May 2015 to December 2018 in Nanjing Drum Tower Hospital. The patients were divided into 2 groups by age: ≥80 years and <80 years. Perioperative outcomes were compared between 2 groups. Logistic regression method was used to analyze the factors that may affect preoperative complications. Cox regression model was employed to analyze the factors affecting 3-year overall survival (OS), recurrence-free survival (RFS), and cancer-specific survival (CSS).

Results

Of the 190 patients, 44 (23.2%) were octogenarians. The elderly patients did not statistically differ from younger patients in most of the demographic, perioperative, and pathological information. American Society of Anesthesiologists (ASA) score (p=0.045) and Charlson comorbidity index (CCI) (p=0.035) could predict high-grade and any grade complications, respectively. Positive lymph node and pT≥3 were main factors affecting OS, RFS, and CSS. ASA score (p=0.048) and CCI (p=0.003) could predict OS and RFS, respectively. Elderly group had worse OS (p=0.007) and CSS (p=0.027) but similar RFS (p=0.147) compared with younger group.

Conclusion

The elderly who received RARC had similar risk of perioperative complications and RFS compared with younger patients. RARC could be an alternative treatment for selected octogenarians.

[How do patients manage their urostomy in everyday life? A questionnaire survey]

INTRODUCTION

The complications of stoma and peristomal are encountered by nearly 80% of patients within two years of surgery. The objective of this study was to evaluate the practical modalities of daily management of stoma and possible skin complications in a series of patients with non-continent urinary stoma.

METHODS

Monocentric study by questionnaires including all patients with non-continent urinary stoma between 2007 and 2019 in a French university center. The STOMA-QOL and a self-report questionnaire with 15 specific questions were used.

RESULTS

Among the 87 patients included in the analysis whose median age was 71 years, 57.5% used a 2-piece system, 69% used leg or thigh pockets, 74.7% were self-sufficient in emptying their stoma pockets. Autonomy on cutaneous support change was 38%. 62.1% of patients reported a peristomal skin event and 74.7% reported leaking stoma. In multivariate analysis, BMI>30, the presence of leaks and physical activity were significantly associated with the onset of peristomal skin events.

CONCLUSION

This study sheds light on the practical modalities of management of urinary stoma and the occurrence of skin complications related to stoma in terms of frequency and predisposing factors. The results obtained are likely to guide practitioners in the information of future operations and in the management of complications of urinary stoma.

LEVEL OF EVIDENCE

III.

Surgery for Bladder and Upper Tract Urothelial Cancer

The cornerstone for diagnosis and treatment of bladder and upper tract urothelial carcinoma involves surgery. Transurethral resection of bladder tumors forms the basis of further management. Radical cystectomy for invasive bladder carcinoma provides good oncologic outcomes. However, it can be a morbid procedure, and advances such as minimally invasive surgery and early recovery after surgery need to be incorporated into routine practice. Diagnostic ureteroscopy for upper tract carcinoma is needed in cases of doubt after cytology and imaging studies. Low-risk cancers can be managed with conservative endoscopic surgery without compromising oncological outcomes; however, high-risk disease necessitates radical nephroureterectomy.

Comparing the outcome of ileal conduit and transuretero-cutaneostomy urinary diversion after radical cystectomy: a retrospective cohort study

Background

Most of the outcomes after radical cystectomy (RC) are directly associated with the type of urinary diversion. This study sets out to evaluate the outcomes of ileal conduit (IC) and transuretero-cutaneostomy (TUC) urinary diversion after RC.

Methods

This retrospective study included 52 patients (IC, n = 30; TUC, n = 22) at Dr. Sardjito Hospital between January 2014 and December 2019. The clinical outcomes were compared using Chi-squared tests and independent t tests. Multivariable logistic regression analysis was performed to determine the odds of developing related complications.

Results

Demographically, both groups were similar in terms of age, gender, ASA score, staging, body mass index, and comorbidities. IC was associated with a high incidence of postoperative complications than TUC (56.7% vs. 27.3%; p = 0.035). Long-term postoperative complications stoma stenosis was more common in the TUC than IC (p = 0.010). Multivariate analysis showed TUC was a significant predictor for stoma stenotic with odds ratio of 1.29 (95% confidence interval, 1.03–1.62; p = 0.006). Meanwhile, metabolic change was found higher in IC (p = 0.047). No difference between the rate of required blood transfusion, postoperative ileus, re-operation, and anastomotic stricture in both groups. Operative time (p = 0.000) and length of stay (p = 0.002) were lower in patients who underwent TUC. The hospitalized cost was also lower in TUC ($ 2311.8 ± 1448 for IC vs. $ 1844.2 ± 948.8 for TUC; p = 0.005). Nonetheless, the follow-up cost was higher in the TUC but not statistically significant. Additionally, there was no difference between the overall satisfaction and diversion-related symptoms scores in both groups. The psychological score was better in IC groups.

Conclusions

Both of these techniques can be an option in a urinary diversion after RC with various advantages and disadvantages. TUC provides reduced complication rates, operative time, shorter length of stay, and hospitalized costs, but IC may reduce postoperative stoma stenosis complications and better psychological function.

Inhibition of Androgen Signalling Improves the Outcomes of Therapies for Bladder Cancer: Results from a Systematic Review of Preclinical and Clinical Evidence and Meta-Analysis of Clinical Studies

Bladder cancer (BCa) is an endocrine-related tumour and the activation of androgen signalling pathways may promote bladder tumorigenesis. We summarized the available preclinical and clinical evidence on the implications of the manipulation of androgen signalling pathways on the outcomes of BCa therapies. A systematic review was performed in December 2020. We included papers that met the following criteria: original preclinical and clinical research; evaluating the impact of androgen signalling modulation on the outcomes of BCa therapies. Six preclinical and eight clinical studies were identified. The preclinical evidence demonstrates that the modulation of androgen receptor-related pathways has the potential to interfere with the activity of the Bacillus Calmette Guerin, doxorubicin, cisplatin, gemcitabine, and radiotherapy. The relative risk of BCa recurrence after transurethral resection of the bladder tumour (TURBT) is significantly lower in patients undergoing therapy with 5 alpha reductase inhibitors (5-ARIs) or androgen deprivation therapy (ADT) (Relative risk: 0.50, 95% CI: 0.30–0.82; p = 0.006). Subgroup analysis in patients receiving 5-ARIs revealed a relative risk of BCa recurrence of 0.46 (95% CI: 0.22–0.95; p = 0.040). A significant negative association between the ratio of T1 BCa patients in treated/control groups and the relative risk of BCa recurrence was observed. Therapy with 5-ARIs may represent a potential strategy aimed at reducing BCa recurrence rate, mainly in patients with low stage disease. Further studies are needed to confirm these preliminary data.

Conservative management of primary malignant melanoma of the bladder: a case report

Background

Primary malignant melanoma (PMM) of the bladder represents a very rare clinic-pathologic entity. Given the rarity of the disease, the best treatment option is not well recognized.

Case presentation

We describe a case of neoplasm of the bladder in a 74 years-old Caucasian man presenting with massive hematuria. Based on clinical, instrumental and histological findings a diagnosis of PMM was made. The patient underwent trans urethral resection of bladder tumor plus intravesical Bacillus Calmette–Guérin.

Conclusions

To make a correct diagnosis, clinical history, endoscopic evaluation, histopathological examination and immunohistochemistry, are necessary. Multidisciplinary evaluation is required to discriminate primary from metastatic malignant melanoma.

Treatment of muscle-invasive bladder cancer in patients without comorbidities and fit for surgery: Trimodality therapy vs radical cystectomy. Development of GRADE (Grades of Recommendation, Assessment, Development and Evaluation) recommendation by the Italian Association of Radiotherapy and Clinical Oncology (AIRO)

AIM

To compare trimodality therapy (TMT) versus radical cystectomy (RC) and develop GRADE (Grades of Recommendation, Assessment, Development and Evaluation) Recommendation by the Italian Association of Radiotherapy and Clinical Oncology (AIRO) for treatment of muscle-invasive bladder cancer (MIBC).

MATERIAL AND METHODS

Prospective and retrospective studies comparing TMT and RC for MIBC patients were included. Qualitative and quantitative evaluation of evidence was made.

RESULTS

Ten studies were included in the analysis. Pooled analysis showed salvage cystectomy and pathological complete response rates after TMT of 12 % and 72-77.5 %, respectively. Pooled rates of G3-G4 GU toxicity and serious toxicity rate were 18 vs 3% and 45 vs 29 % for patients undergoing TMT vs RC, respectively. The panel assessed a substantial equivalence in terms of OS and CSS at 5 years between TMT and RC.

CONCLUSIONS

TMT could be suggested as an alternative treatment to RC in non-metastatic MIBC patients, deemed fit for surgery.

Comparison of survival in elderly patients treated with uretero-cutaneostomy or ileal conduit after radical cystectomy

Background

In bladder cancer patients with age ≥ 80 years old, there have been controversies in performing uretero-cutaneostomy or ileal conduit as urinary diversion after radical cystectomy. Limited study evaluated overall survival (OS) and cancer-specific survival (CSS) between the two urinary diversions in elderly patients. This study is to compare OS and CSS between uretero-cutaneostomy and ileal conduit after radical cystectomy in bladder cancer patients with age ≥ 80 years old.

Patients and methods

Data were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Bladder cancer patients diagnosed between 2004 and 2016 with age ≥ 80 years old who underwent radical cystectomy with either UC or IC were selected. After propensity score matching, Cox regression and Kaplan-Meier analysis were used to analyze the survival. We calculated statistical power for survival.

Results

Of 1394 patients who met the inclusion criteria, 1093 underwent ileal conduit and 301 underwent uretero-cutaneostomy. After propensity score matching, 285 patients were included in each group. Multivariable Cox analysis showed urinary diversion was not a risk factor of OS and CSS (HR 1.044, [95% CI 0.867–1.257] and 1.012 [0.748–1.368], respectively). Both OS and CSS were not significantly different, with median survival of ileal conduit and uretero-cutaneostomy were 19 [16–24] months and 19 [15–26] months respectively. Additionally, We found OS had the following risk factors: tumor stage (distant vs regional vs localized, 5.332 [3.610–7.875] vs 1.730 [1.375–2.176] vs 1), node density (>0.2 vs ≤0.2 vs none, 1.410 [1.047–1.898] vs 0.941 [0.658–1.344] vs 1) and age (1.067 [1.032–1.103] for each year). While CSS had the following risk factors: tumor stage (distant vs regional vs localized, 4.035 [2.046–7.959] vs 2.476 [1.651–3.713] vs 1), node density (>0.2 vs ≤0.2 vs none, 2.501 [1.645–3.804] vs 1.062 [0.590–1.914] vs 1) and tumor size (greater than 3 cm vs less than 3 cm, 1.596 [1.057–2.412] vs 1). Our analysis obtained 0.707 power for overall survival.

Conclusion

Urinary diversion by uretero-cutaneostomy or by ileal conduit was not associated with overall and cancer-specific survival. It is reasonable to consider uretero-cutaneostomy as a regular procedure of urinary diversion in elderly bladder cancer patients after radical cystectomy to avoid associate complications.

Radical cystectomy: a review of techniques, developments and controversies

Radical cystectomy (RC) with urinary diversion is considered the standard treatment for muscle invasive bladder cancer (MIBC). As one of the most challenging surgical techniques performed by urologists, RC was described many decades ago, and yet patient morbidity rates have remained stagnant over the years. This review outlines the most recent indications and techniques for RC and analyses the current landscape of complications after cystectomy. There is significant room for improvement with respect to both oncologic and functional outcomes after RC. Future efforts will need to focus on unifying reporting methodology, optimal patient selection criteria, enhanced surgical techniques and peri-operative care pathways, and technological advances to improve patient outcomes.

Total Pelvic Exenteration, Cytoreductive Surgery, and Hyperthermic Intraperitoneal Chemotherapy for Rectal Cancer with Associate Peritoneal Metastases: Surgical Strategies to Optimize Safety

Simple Summary

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a curative treatment for patients with peritoneal carcinomatosis. Pelvic exenteration is an established treatment option for locally advanced pelvic malignancy. Based on the argument that high-risk complications arise from each procedure, the majority of researchers do not recommend performing a CRS/HIPEC with pelvis exenteration. Herein, we critically analyzed the data from 16 patients treated by these two procedures for 15 rectal and one appendiceal adenocarcinomas. Clear resection (R0) margins were achieved in 81.2% of cases. The median hospital stay was 46 days (26–129), and nine patients (56.2%) experienced severe complications that led to death in two cases (12.5%). Survival rates were not clarified, since the follow-up is ongoing. Pelvis exenteration associated with CRS/HIPEC may be a reasonable procedure in selected patients at expert centers. Pelvic involvement should not be considered a definitive contraindication for CRS/HIPEC if a R0 resection could be achieved. However, the morbidity and the mortality are high with this combination of treatment, and further research is needed to assess the oncologic benefit and quality of life before such a radical approach can be recommended.

Abstract

Background: Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a curative treatment option for patients with peritoneal carcinomatosis. Total pelvic exenteration (TPE) is an established treatment option for locally advanced pelvic malignancy. These two procedures have high mortality and morbidity, and therefore, their combination is not currently recommended. Herein, we reported our experience on TPE associated with CRS/HIPEC with a critical analysis for rectal cancer with associate peritoneal metastases. Methods: From March 2006 to August 2020, 319 patients underwent a CRS/HIPEC in our hospital. Among them, 16 (12 men and four women) underwent an associated TPE. The primary endpoints were perioperative morbidity and mortality. Results: There was locally recurrent rectal cancer in nine cases, six locally advanced primary rectal cancer, and a recurrent appendiceal adenocarcinoma. The median Peritoneal Cancer Index (PCI) was 8. (4–16). Mean duration of the surgical procedure was 596 min (420–840). Complete cytoreduction (CC0) was achieved in all patients, while clear resection (R0) margins on the resected pelvic organs were achieved in 81.2% of cases. The median hospital stay was 46 days (26–129), and nine patients (56.2%) experienced severe complications (grade III to V) that led to death in two cases (12.5%). The total reoperation rate for patients was 6/16 (37.5%) and 3/16 (18.75%) with percutaneous radiological-guided drainage. Conclusions: In summary, TPE/extended TPE (ETPE) associated with CRS/HIPEC may be a reasonable procedure in selected patients at expert centers. Pelvic involvement should not be considered a definitive contraindication for CRS/HIPEC in patients with resectable peritoneal surface diseases if a R0 resection could be achieved on all sites. However, the morbidity and the mortality are high with this combination of treatment, and further research is needed to assess the oncologic benefit and quality of life before such a radical approach can be recommended.

Health-related quality of life in Japanese patients with bladder cancer measured by a newly developed Japanese version of the Bladder Cancer Index

Introduction

We validated a Japanese version of the Bladder Cancer Index (BCI) as a tool for measuring health-related quality of life (HRQOL) in bladder cancer patients treated with various surgical procedures.

Methods

The reliability and validity of the Japanese BCI were examined in 397 Japanese patients with bladder cancer via cross-sectional analysis. The patients simultaneously completed the Short Form (SF)-12, EQ-5D, and the Functional Assessment of Cancer Therapy-General and Bladder (FACT-G and FACT-BL). The differences in BCI subscales among various treatment groups were analyzed.

Results

This study involved 397 patients (301 males and 96 females), with a mean age of 70 years and a median disease duration of 29 months (IQR: 12–66 months). Of these patients, 221 underwent transurethral resection of a bladder tumor, and 176 patients underwent radical cystectomy (ileal conduit: 101 patients, ileal neobladder: 49, and ureterostomy: 26). Cronbach’s alpha coefficient was ≥ 0.78 for all subscales, except the bowel bother subscale. Despite moderate correlations being detected between the function and bother score in urinary and bowel domains, the sexual function score was inversely correlated with the sexual bother score (r = − 0.19). A missing value percentage of > 15% was associated with old age (p < 0.05). The mean domain scores differed significantly among distinct clinically relevant treatment groups.

Conclusions

Although revisions are needed to make it easier for elderly patients to comprehend, we confirmed the reliability and validity of the Japanese BCI. The Japanese BCI could be used for cross-cultural assessments of HRQOL in bladder cancer patients.

Electronic supplementary material

The online version of this article (10.1007/s10147-020-01770-2) contains supplementary material, which is available to authorized users.

Assessment of health-related quality of life of male patients with ileal orthotopic neobladder compared to cutaneous ureterostomy

Introduction

The aim of this article was to compare patients' health-related quality of life (HR-QoL) outcomes between ileal orthotopic neobladder (IONB) and standard bilateral cutaneous ureterostomy (CU) using validated diversion-specific HR-QoL questionnaires.

Material and methods

This study utilized a retrospective cohort design, including all male patients who underwent open radical cystectomy with either IONB or CU from January 2010 until December 2017. In total, 69 and 57 male patients with a minimum of 12 months of follow-up were included in each group respectively, after applying the following exclusion criteria: female, pre- and postoperative radio- and chemotherapy and palliative surgery. For every patient, HR-QoL was evaluated using the European Association of Research and Treatment of Cancer Quality of Life Core (EORTC-QLQ-C30) and Functional Assessment of Cancer Therapy for patients undergoing radical cystectomy (FACT-Bl-Cys) validated questionnaires.

Results

In multivariable analysis, the type of the urinary diversion, and the occurrence of early and late postoperative complications were independently associated with the change of scores of HR-QoL domains. When comparing the 2 surgical methods (IONB vs. CU), after adjusting for confounders, such EORTC-QLQ-C30 domains as physical functioning (66.5 vs. 57.9, p = 0.011) and global health status (58.1 vs. 42.6, p <0.001) were superior in the IONB arm which was statistically significant. Similarly, functional health (15.3 vs. 11.9, p <0.001) and total score (110.1 vs. 101.7, p = 0.009) from the FACT-Bl-Cys questionnaire were superior in the IONB arm.

Conclusions

In our study, patients with IONB possessed statistically significant, better scores of HR-QoL domains assessed with EORTC-QLQ-C30 and FACT-Bl-Cys questionnaires compared to those with CU. The occurrence of early major and late complications negatively affected patients' HR-QOL.

Complications and quality of life of ileal conduit, orthotopic neobladder and ureterocutaneostomy: systematic review of reports using the Clavien-Dindo Classification

INTRODUCTION

Radical cystectomy (RC) and urinary diversion (UD) are two steps of the same surgical procedure involving likely complications and important impact on quality of life (QoL). The literature was reviewed to identify recent studies reporting UDs complications occurred 90 days after surgery and graded by Clavien-Dindo Classification System (CCS).

EVIDENCE ACQUISITION

A comprehensive systematic Medline search was performed in PubMed/Medline, Embase and Scopus databases to identify reports published in English starting from 2013 using key words related to review outcome (i.e. neobladder, ileal conduct, ureterocutaneostomy, cystectomy, QoL). Complications were defined as minor or major whether the CCS grade was ≤2 or ≥3, respectively. Then, manuscripts references were screened to identify unfounded studies. Only studies using CCS to report surgical complications were considered.

EVIDENCE SYNTHESIS

Retrieved studies were reported according to two main items of complications and QoL. About UDs complications, fourteen studies were identified incorporating overall 4436 patients. Up to 50% of patients experienced at least one low-grade complications (CCS≤2) requiring pharmacological treatment to be healed. On the other hand, high-grade complications (CCS≥3) occurred in 0.7-42% of cases and required surgical interventions (CCS 3a and 3b) or life support (CCS=4). Finally, mortality (CCS=5) rated between 0.4-7%. Regarding QoL, six studies were analyzed with overall 445 patients. Most of them were retrospective and showed conflicting results whether the external UDs were better than neobladder in term of impact on QoL.

CONCLUSIONS

The use of a standardized system such as CCS improves analyses of literature. However, rigorous patient selection for UD type makes unable a randomized comparison between UDs in terms of complications and QoL impact.

Short- and Long-Term Evaluation of Renal Function after Radical Cystectomy and Cutaneous Ureterostomy in High-Risk Patients

Deterioration of renal function has been reported after radical cystectomy (RC) with urinary diversion. We investigated renal function changes in elderly bladder cancer (BCa) patients who underwent RC with cutaneous ureterostomy (CU) urinary diversion. We performed a retrospective, observational study. BCa patients aged ≥75 with an American Society of Anesthesiologists (ASA) class greater than II were included. Glomerular filtration rate (GFR) was the main outcome measure. GFR values were recorded preoperatively, at discharge, at 6-month follow-up, and yearly up to 60 months. A total of 70 patients with a median age of 78.0 years were identified. Median preoperative GFR was 74.3 mL/min/1.73 m2 and declined significantly to 54.6 mL/min/1.73 m2 after 6 months (p < 0.001). A gradual GFR decline was observed thereafter, reaching a median value of 46.2 after 60 months. Preoperative GFR and acute kidney injury were significant predictors of fast deterioration of GFR and of 25% deterioration of GFR after 12 months. Elderly BCa patients with high comorbidity rates undergoing RC with CU should be carefully informed about the risk of GFR deterioration and the need for adequate monitoring.

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.