Is the open cystectomy era over? An update on the available evidence

Pelvic lymph node dissection in prostate and bladder cancers

Prostate cancer and bladder cancer accounts for approximately 13.5% and 3% of all male cancers and all newly diagnosed cancers (regardless sex), respectively. Thus, these cancers represent a major health and economic burden globally. The knowledge of lymph node status is an integral part of the management of any solid tumor. In the urological field, pelvic lymph node dissection (PLND) is of paramount importance in the diagnosis, management, and prognosis of prostate and bladder cancers. However, PLND may be associated with several comorbidities. In this narrative review, the most recent updates concerning the patterns and incidence of lymph node metastasis, the role of different imaging studies and nomograms in determining patients' eligibility for PLND, and the anatomical templates of PLND in urologic patients with bladder or prostate cancer will be discussed.

Conservative treatment of urinary fistula: Case report

Radical cystectomy is the gold standard treatment for muscular invasive bladder cancer. Bricker surgery is the most common technique used for urinary diversion; however, troublesome complications such as postoperative anastomotic stenosis or fistula may occur. The case of a patient who had a urinary fistula after Bricker surgery performed at our hospital, is described. The patient was successfully treated with continuous double-cannula negative-pressure drainage and avoided a second surgery. The patient recovered well and is on regular follow-up. This case highlights the importance of timely and relevant treatment for patients with postoperative urinary fistula to avoid more invasive surgery.

Radical Cystectomy in England from 2013 to 2019 on 12,644 patients: An analysis of national trends and comparison of surgical approaches using Hospital Episode Statistics data

Introduction

We evaluate the data of 12,644 Radical Cystectomies in England (Open, Robotic and Laparoscopic) with trends in the adaption of techniques and post‐operative complications.

Methods

This analysis utilised national Hospital Episode Statistics (HES) from NHS England.

Results

There was a statistically significant increase (P < .001) in the number of Robotic assisted radical cystectomies from 10.8% in 2013‐2014 and 39.5% in 2018‐2019.The average LOS reduced from 12.3 to 10.8 days for RARC from 2013 to 2019 similarly the LOS reduced from 16.2 to 14.3 for ORC. The rate of sepsis (0‐90 days) did rise from 5% to 14.5% between 2013‐2014 and 2017‐2018 for the entire cohort (P < .001). Acute renal failure (ARF) increased over the years from 9.5% to 17% (P < .001). The rate for fever, UTI, critical care activity and ARF were higher for ORC than RARC (P < .001).The comparison of all episodes within 90 days for conduit versus non‐conduit diversions showed significantly higher rates of sepsis, infections, UTI and fever in non‐conduit group .Overall complications were significantly higher in non‐conduit group throughout the duration except was year 2016‐17(P < .001).The robotic approach has increased in last 5 years with nearly 40% of the cystectomies now being robotically in 2018‐19 from the initial percentage of 10.8% in 2013‐14.

Conclusion

This evaluation of the HES data from NHS England for 12,644 RC confirms an increase in the adoption of Robotic Cystectomy. Our data confirms the need to develop strategies with enhanced recovery protocols and post‐operative close monitoring following Radical Cystectomy in order to reduce post‐operative complications.

Prognostic significance of the Ki67 index and programmed death-ligand 1 expression after radical cystectomy in patients with muscle-invasive bladder cancer

OBJECTIVES

To investigate the association between Ki67 index and programmed death-ligand 1 (PD-L1) expression in muscle-invasive bladder cancer (MIBC) patients after RC.

MATERIALS AND METHODS

We retrospectively evaluated 262 MIBC patients treated with RC between April 2004 and April 2020. The impact of Ki67 index and PD-L1 expression on prognosis was evaluated by univariate Cox regression analysis. In addition, a pathomolecular risk score, including Ki67 and PD-L1, was developed to predict prognosis and pathological factors. We also evaluated the link between the Ki67 index and PD-L1 under the IL-6 stimulation in the bladder cancer cell lines of T24 and 5637 cells.

RESULTS

The median age and follow-up period was 69 years and 52 months, respectively. Ki67 index and PD-L1 expression were significantly associated with tumor recurrence. Univariate Cox regression analysis showed that pT3-4, mixed histology, lymphovascular invasion positive (LVI+), pN+, Ki67-high (>17%), and PD-L1+ were significantly associated with recurrence-free survival (RFS). The pathomolecular risk score was developed using resection margin+ (1 point), mixed histology (1 point), LVI+ (1 point), pN+ (1 point), and Ki67-high (1 point). RFS and overall survival were significantly shorter in patients with higher pathomolecular risk scores (>1) than in those with lower risk scores (≤1). Cell proliferation was significantly increased in the T24 and 5637 cells under the IL-6 stimulation, while PD-L1 expression was not.

CONCLUSIONS

A significant effect of Ki67-high and PD-L1 expression on poor prognosis was observed in patients with MIBC. Further studies are necessary to elucidate the precise mechanisms of cell proliferation and PD-L1 expression in patients with MIBC.

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.

Frailty is significantly associated with the type of urinary diversion in patients with muscle-invasive bladder cancer

OBJECTIVES

To investigate the effect of frailty on the type of urinary diversion after radical cystectomy in patients with muscle-invasive bladder cancer.

METHODS

Between January 2014 and January 2020, we prospectively evaluated frailty in 88 patients with localized muscle-invasive bladder cancer, who had received radical cystectomy and urinary diversion. The selection of the type of urinary diversion was determined by the operating surgeon based on performance status, comorbidities, tumor status and the patient's preference. The frailty evaluation included the Fried phenotype criteria, the modified frailty index and the frailty discriminant score. We investigated the association between frailty and type of urinary diversion, the effect of frailty on postoperative complications and the effect of frailty on overall survival.

RESULTS

The median age of the selected participants was 68 years. The number of patients with an orthotopic neobladder and any postoperative complications was 54 (61%) and 46 (52%), respectively. Of the frailty assessment tools that were used, Fried phenotype criteria and frailty discriminant score were significantly associated with the selection of non-orthotopic neobladder urinary diversion. Occurrences of postoperative complications in participants were significantly associated with modified frailty index, but not with Fried phenotype criteria and frailty discriminant score. Multivariate Cox regression analysis showed that a higher frailty discriminant score was significantly associated with poor overall survival, whereas higher Fried phenotype criteria and modified frailty index were not.

CONCLUSION

Frailty is significantly associated with the type of urinary diversion, and it should be considered for the selection of urinary diversion in muscle-invasive bladder cancer patients undergoing radical cystectomy.

Oncologic outcomes of patients with incidental prostate cancer who underwent RARC: a comparison between nerve sparing and non-nerve sparing approach

BACKGROUND

Incidental Prostate cancer (iPCa) is a relatively common finding during histopathological evaluation of radical cystectomy (RC) specimens. To reduce the high impact of RC on erectile function, several sexual-preserving techniques have been proposed. The aim of this study was to evaluate and compare the oncologic outcomes of patients with iPCa who underwent nerve spring and no-nerve sparing robot-assisted radical cystectomy (RARC).

METHODS

The clinicopathologic data of male patients who underwent RARC at our institution between 2006 and 2016 were retrospectively analysed. Patients with iPCa at definitive pathological examinations were stratified in two groups, according to the preservation of the neurovascular bundles (nerve sparing vs no nerve sparing). Significant PCa was defined as any Gleason score ≥ 3 + 4. Biochemical recurrence (BR) was defined as a sustained PSA level > 0.2 ng/mL on two or more consecutive appraisals. BR rate was assessed only in patients with incidental prostate cancer and at least 2 years of follow-up. Differences in categorical and continuous variables were analysed using the chi-squared test and the Mann-Withney U test, respectively. Biochemical recurrence curves were generated using the Kaplan-Meier method and compared with the Log-rank test.

RESULTS

Overall, 343 male patients underwent RARC for bladder cancer within the study period. Nerve-sparing surgery was performed in 143 patients (41%), of these 110 had at least 2 years of follow up after surgery. Patients who underwent nerve-sparing surgery were significantly younger (p < 0.001). Clinically significant PCa was found in 24% of patients. No significant differences regarding preoperative PSA value (p = 0.3), PCa pathological stage (p = 0.5), Gleason score (p = 0.3) and positive surgical margin rates (p = 0.3) were found between the two groups. After a median follow-up of 51 months only one patient, in the no-nerve-sparing group had developed a biochemical recurrence (p = 0.4).

CONCLUSIONS

In our series most of the iPca detected in RC specimens can be considered as insignificant with a low rate of BR (0.9%). Nerve-sparing RARC is a safe procedure which did not affect oncological outcomes of patients with iPCa.

Current status and future perspective of robot-assisted radical cystectomy for invasive bladder cancer

The current status of robot-assisted radical cystectomy was reviewed 16 years after the initial robot-assisted radical cystectomy for the treatment of invasive bladder cancer. Articles associated with robot-assisted radical cystectomy and written in English were selected from the PubMed database from January 2003 to February 2019. The present review article focused on the distribution of robot-assisted radical cystectomy, patient selection, preoperative management, surgical technique, lymph node dissection, urinary diversion, recurrence pattern, oncological outcomes, cost, learning curve, complications and educational programs. A total of 400 articles were divided according to the country of the first author's affiliation. The USA was the most dominant at 198 (50%), whereas the number of articles from the countries belonging to the Urological Association of Asia was 15 (3.8%) for China, 17 (4.3%) for South Korea, 10 (2.5%) for Japan, eight (2%) for Taiwan, eight (2%) for Turkey and one (0.2%) for Iran. The percentage of robot-assisted radical cystectomy carried out is increasing, and intracorporeal urinary diversion and ileal neobladder are also frequently carried out. With a refined technique being performed in high-volume centers, robot-assisted radical cystectomy has contributed to the reduction in transfusion rate, length of stay and severe complications; however, it has not yet shown any cancer-specific survival benefits. Robot-assisted radical cystectomy is not fully spread throughout the Urological Association of Asia. Further investigation with respect to worldwide results is needed to prove the real benefit of robot-assisted radical cystectomy regarding low morbidity, reduced total medical cost, and survival benefit. In the era of precision medicine, appropriate drug and surgery will be given based on each genetic profile.

Robot-assisted radical cystectomy in a patient with muscle-invasive bladder cancer following radiotherapy for prostate cancer

INTRODUCTION

Muscle-invasive bladder cancer following radiotherapy for prostate cancer is rare. We reported a case of muscle-invasive bladder cancer who underwent robot-assisted radical cystectomy following radiotherapy for prostate cancer.

CASE PRESENTATION

A 72-year-old man was referred to our division with a muscle-invasive bladder cancer. He had a history of intensity-modulated radiation therapy for localized prostate cancer. After three courses of platinum-based neoadjuvant chemotherapy, he obtained a radiologic complete response. He elected for robot-assisted radical cystectomy, standard lymph node dissection, and intracorporeal ileal conduit urinary diversion. Pathological findings revealed no residual tumor within the bladder and residual tumor in the prostate. He had discharged without any complications; and quality of life had improved.

CONCLUSION

A robot-assisted approach might be a potential option for well-selected patients with muscle-invasive bladder cancer who have previously received radiotherapy for localized prostate cancer.

Postoperative weight loss followed by radical cystectomy predicts poor prognosis in patients with muscle-invasive bladder cancer

We aimed to investigate the impact of postoperative weight loss following radical cystectomy (RC) on patients' prognoses. RC and urinary diversion were performed in 512 consecutive patients with muscle-invasive bladder cancer at our hospitals between May 1996 and July 2018. Demographic clinical information, pre- and postoperative serum albumin, hemoglobin, and weight were evaluated retrospectively at 1 month. We also evaluated the association of weight loss with complications and overall survival (OS) as estimated using the Kaplan-Meier method and compared using the log-rank test. Risk factors for poor OS were determined by Inverse Probability of Treatment Weighted (IPTW)-adjusted Cox regression analysis. In 385 patients who met the study search criteria, median postoperative weight loss from baseline at 1 week and 1 month was 1.1 (- 1.8%) and 3.2 (- 5.4%) kg, respectively. Patients with significant weight loss (defined as ≥ 7.5% at 1 month) had higher-grade complications within 1 month and had significantly shorter OS than those with weight loss of < 7.5%. Type of urinary diversion, loss of serum albumin, and loss of hemoglobin were not significantly associated with weight loss. IPTW-adjusted Cox regression analysis showed that such significant weight loss was an independent risk factor for poor OS. Weight loss followed by radical cystectomy was significantly associated with poor prognosis in patients with muscle-invasive bladder cancer.

[Radical cystectomy and urinary diversion-what is important ?]

BACKGROUND

In Germany, radical cystectomy with urinary diversion is the primary therapeutic option for localized muscle invasive urothelial bladder cancer. Modifications in the pre-, peri-, and postoperative phase have significantly improved outcomes.

OBJECTIVES

Different factors and parameters are directly associated with patients' outcome. An overview on how to best approach this procedure is provided in this article.

MATERIALS AND METHODS

The data regarding preparation and the procedure for the radical cystectomy followed by urinary diversion are separately analyzed.

RESULTS

During the preoperative phase, Fast Track and ERAS (Enhanced Recovery after Surgery) concepts should be an integral part of therapeutic management. Different aspects of such models are presented and discussed. Comorbidities such as diabetes mellitus, hypertension, malnutrition or anemia should also be treated early. In the perioperative phase, optimized fluid management and close interaction with the anesthesiologist are needed. Use of vasopressors during surgery and controlled hypotension (about 80 mm Hg) help reduce perioperative blood loss. Blood product use should be minimized. The use of epidural anesthesia to improve the stress reaction of the body improves pain management and functional recovery. Radical cystectomy is associated with the best oncological outcome, preserving functional structures to maintain a good quality of life. Nerve-sparing procedures in men and women should be used where appropriate. The use of robotic assisted radical cystectomy (RARC) is also discussed.

CONCLUSION

The ileum conduit is still the most common urinary diversion worldwide. However, numerous other urinary diversions to provide patients with the highest quality of life are available. Centers with a high case load seem to be associated with an improved outcome.