Transitional cell carcinoma in dialysis patients

Comparison of the risks of renal cell carcinoma or urothelial cancer between hemodialysis and peritoneal dialysis patients

PURPOSE

This study is to compare risks of developing renal cell carcinoma or urothelial cancer between hemodialysis (HD) and peritoneal dialysis (PD) patients.

METHODS

The age-, sex-, and index year-matched patients with newly diagnosed end-stage kidney disease (ESKD) undergoing dialysis [HD (N = 22,587) or PD (N = 11,547)] from 2000 to 2015 in Taiwan were identified. Patients were followed until the development of renal cell carcinoma or urothelial cancer, renal transplantation, death, or the end of follow-up (December 31, 2017). The hazard ratio (HR), and sub-hazards ratio (SHR), in which death was considered as a competing risk, of developing renal cell carcinoma or urothelial cancer were compared between the HD and PD patients.

RESULTS

The incidence rate of renal cell carcinoma was higher in the PD group than in age-, sex-, and index year-matched HD group (11.5 versus 5.52 per 10,000 person-years), with an adjusted HR of 2.15 (95% confidence interval (CI) = 1.59, 2.92), and an adjusted SHR of 1.97 (95% CI = 1.46, 2.67). The incidence rate of urothelial cancer was also higher in the PD group than in corresponding HD group (40.3 and 34.0 per 10,000 person-years), with an adjusted HR of 1.15 (95% CI = 1.00, 1.33) and an adjusted SHR of 1.08 (95% CI = 0.94, 1.25). These findings were further validated in propensity score-matched dialysis cohorts.

CONCLUSIONS

ESKD patients undergoing PD are at a higher risk of developing renal cell carcinoma than those on HD, but risks of developing urothelial cancer are similar among the two groups.

Effect of decreased renal function on poor oncological outcome after radical cystectomy

PURPOSE

To evaluate the impact of preoperative renal impairment on the oncological outcomes of patients with urothelial carcinoma who underwent radical cystectomy.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of patients with urothelial carcinoma who underwent radical cystectomy from 2004 to 2017. All patients who underwent preoperative ^99mTc-diethylenetriaminepentaacetic acid renal scintigraphy (DTPA) were identified. We divided the patients into two groups according to their glomerular filtration rates (GFRs): GFR group 1, GFR≥90 mL/min/1.73 m²; GFR group 2, 60≤GFR<90 mL/min/1.73 m². We included 89 patients in GFR group 1 and 246 patients in GFR group 2 and compared the clinicopathological characteristics and oncological outcomes between the two groups.

RESULTS

The mean time required for recurrence was 125.5±8.0 months in GFR group 1 and 85.7±7.4 months in GFR group 2 (p=0.030). The mean cancer-specific survival was 131.7±7.8 months in GFR group 1 and 95.5±6.9 months in GFR group 2 (p=0.051). The mean overall survival was 123.3±8.1 months in GFR group 1 and 79.5±6.6 months in GFR group 2 (p=0.004).

CONCLUSIONS

Preoperative GFR values in the range of 60≤GFR<90 mL/min/1.73 m² are independent prognostic factors for poor recurrence-free survival, cancer-specific survival, and overall survival in patients after radical cystectomy compared with GFR values of ≥90 mL/min/1.73 m².

New Hydronephrosis in the Native Kidney Is Associated with the Development of De Novo Urinary Bladder Urothelial Carcinoma in Patients with Post-Kidney Transplantation

Increased malignancy after kidney transplantation (KT) is by far the most troublesome issue. Among these malignancies, urothelial carcinoma (UC) incidence is uniquely high in Taiwan. We want to know whether routine sonography to detect native hydronephrosis is associated with the development of de novo urinary bladder urothelial carcinoma (UBUC) in post-KT recipients. From 2003 to 2018, we retrospectively analyzed 1005 KT patients, 58 of whom were subsequently diagnosed with UBUC. The association between new native hydronephrosis and post-KT UBUC was analyzed with univariate and multivariate logistic regression analyses and a Kaplan-Meier plot. We excluded cases of people who had upper urinary tract urothelial carcinoma (UTUC) and were diagnosed prior to UBUC. There were 612 males (60.9%) and 393 females (39.1%), with a mean age of 48.2 ± 12.0 years old at KT. The mean follow-up period was 118.6 ± 70.2 months, and the diagnosis of UBUC from KT to UBUC was 7.0 ± 5.1 years. New native kidney hydronephrosis occurred more frequently in the UBUC group (56.4% versus 6.4%, p < 0.001) than the non-UBUC group. Multivariate analysis disclosed that native hydronephrosis is the only statistically significant factor for UBUC, with an odds ratio of 16.03 (95% CI, 8.66-29.68; p < 0.001). UBUC in post-KT patients with native hydronephrosis also showed a tendency toward multifocal lesions upon presentation (47.8%). Post-KT UBUC is characterized by pathologically aggressive and multiple foci lesions. Native kidney hydronephrosis may be a deciding factor of post-KT UBUC.

Treatment Strategy for Dialysis Patient with Urothelial Carcinoma

To investigate postoperative complications and oncologic outcomes of prophylactic nephroureterectomy and/or cystectomy in dialysis patients with urothelial carcinoma (UC), we retrospectively reviewed the records of dialysis patients with UC and a final status of complete urinary tract extirpation (CUTE, i.e., the removal of both kidneys, ureters, and bladder) between January 2004 and December 2015. Patients undergoing dialysis after initial radical nephroureterectomy and/or cystectomy were excluded. Eighty-four and 27 dialysis patients, undergoing one-stage and multi-stage CUTE, were enrolled in this study, respectively. Demographic, medical, perioperative, and pathologic features were collected to determine variables associated with oncologic outcomes. Although there was no significant difference in mortality between the 2 groups (p = 0.333), all 5 (4.5%) patients with Clavien-Dindo grade 5 complications were from the one-stage CUTE group. On multivariate logistic regression analysis, advanced age (p = 0.042) and high Charlson comorbidity index (CCI) (p = 0.000) were related to postoperative major complications. Compared with multi-stage CUTE, one-stage CUTE had no overall, cancer-specific, and recurrence-free survival benefits (all p > 0.05). According to multivariate analysis with Cox regression, age > 70 years (HR 2.70, 95% CI 1.2-6.12; p = 0.017), CCI ≥ 5 (HR 2.16, 95% CI 1.01-4.63; p = 0.048), and bladder cancer stage ≥ 3 (HR 12.4, 95% CI 1.82-84.7; p = 0.010) were independent, unfavorable prognostic factors for the overall survival. One-stage CUTE is not associated with superior oncologic outcomes, and all perioperative mortalities in our series occurred in the one-stage CUTE group. Our data do not support prophylactic nephroureterectomy and/or cystectomy for uremic patients with UC.

Prognostic value of preoperative blood-based biomarkers in upper tract urothelial carcinoma treated with nephroureterectomy: A systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis assessed the prognostic value of preoperative blood-based biomarkers in patients with upper tract urothelial carcinoma (UTUC) treated with nephroureterectomy.

METHODS

PUBMED, Web of Science, Cochrane Library, and Scopus databases were searched in June 2019 according to the Preferred Reporting Items for Systematic Review and Meta-analysis statement. Studies were deemed eligible if they compared cancer-specific survival in UTUC patients with and without pretreatment laboratory abnormalities. Formal meta-analyses were performed for this outcome.

RESULTS

The review identified 54 studies with 23,118 patients, of these, 52 studies with 22,513 patients were eligible for the meta-analysis. Several preoperative blood-based biomarkers were significantly associated with cancer-specific survival as follows: neutrophil-lymphocyte ratio (pooled hazard ratio [HR]: 1.66, 95% confidence interval [CI]: 1.34-2.06), C-reactive protein (pooled HR: 1.17, 95% CI: 1.07-1.29), platelet-lymphocyte ratio (pooled HR: 1.68, 95% CI: 1.30-2.17), white blood cell (pooled HR: 1.58, 95% CI: 1.02-2.46), De Ritis ratio (pooled HR: 2.40, 95% CI: 1.92-2.99), fibrinogen (pooled HR: 2.23, 95% CI: 1.86-2.68), albumin-globulin ratio (pooled HR: 3.00, 95% CI: 1.87-4.84), hemoglobin (pooled HR: 1.51, 95% CI: 1.22-1.87), and estimate glomerular filtration rate (pooled HR: 1.52, 95% CI: 1.19-1.94). The Cochrane's Q test and I² test revealed significant heterogeneity for neutrophil-lymphocyte ratio, C-reactive protein, white blood cell, hemoglobin, and estimated glomerular filtration rate (P = 0.022; I² = 50.7%, P = 0.000; I² = 80.4%, P = 0.000; I² = 88.3%, P = 0.010; I² = 62.0%, P = 0.000; I² = 83.9%, respectively).

CONCLUSIONS

Several pretreatment laboratory abnormalities in patients with UTUC were associated with increased risks of cancer-specific mortality. Therefore, blood-based biomarkers may have the potential to serve as prognostic factors to assist patients and physicians in selecting appropriate treatment strategies for UTUC. However, considering the study limitations including heterogeneity and retrospective nature of the primary data, the conclusions should be interpreted with caution.

Aristolochic Acid and Immunotherapy for Urothelial Carcinoma: Directions for unmet Needs

Urothelial carcinoma of the bladder (UCB) and upper tracts (UTUC) used to share management with similar principles. However, their genetic and epigenetic differences along with different responses to immunotherapy were recently identified, which are reminiscent of their distinct etiologies. Different from the variety of environmental factors relating to UCB, UTUC is best known for its close relationship with exposure to aristolochic acid (AA). AA is believed to cause its carcinogenicity through forming DNA adducts of deoxyadenosine-aristolactam, as well as A:T → T:A transversions in the TP53 tumor suppressor gene. Since recent findings suggested that cancers with higher somatic mutations are associated with better treatment responses upon immune checkpoint blockade, UTUC and AA-related biomarkers reasonably serve as good candidates, as well as a potential prognostic predictor for the flourishing immunotherapy. This review covers the current state of the literature on the clinical response of UTUC and UCB receiving immunotherapy and points out directions for refinement regarding patient selection.

Significance of atypical urinary cytology in the evaluation of patients with end-stage renal disease for kidney transplantation - a retrospective study

To determine what percentage of renal transplant candidates have atypical urinary cytology, what proportion have urothelial carcinoma and whether cystoscopy is necessary with atypical cytology. All end-stage renal disease (ESRD) patients (703) presenting for renal transplantation at our institution were retrospectively reviewed. Individuals producing sufficient urine were screened with urine cytology and those with atypical cytology or risk factors for bladder cancer underwent cystoscopy. Four hundred and thirty patients had available urinary cytology and, of these, 151 (35%) had atypical cytology. Of patients with atypical cytology, three were identified to have urothelial carcinoma. However, three additional patients with urothelial carcinoma did not present with atypical cytology. In total, 6 of 703 (0.85%) patients had bladder cancer. All were treated with transurethral resection and eventually underwent renal transplant. One patient has had disease progression post-transplant to distant metastases. This is the largest study to date evaluating the incidence of urothelial carcinoma in ESRD patients presenting for transplant workup. We found the incidence of bladder cancer to be higher than in the general Canadian population, however, most lesions were low grade. We found atypical cytology in transplant candidates to be a poor predictor for these low-grade lesions and do not recommend routine cystoscopy for atypical cytology.

Association between urologic malignancies and end-stage renal disease: A meta-analysis

AIM

Previous studies have suggested a higher incidence of urologic malignancies in end-stage renal disease (ESRD) patients. However, incidence trends of urologic malignancies in ESRD patients remain unclear. The aims of the present study were: (i) to investigate the pooled incidence/incidence trends; and (ii) to assess the risk of urologic malignancies in ESRD patients.

METHODS

A literature search was conducted using MEDLINE, EMBASE and Cochrane Database from inception through April 2017. Studies that reported incidence or odds ratios of urologic malignancies among ESRD patients were included. Pooled odds ratios (OR) and 95%CI were calculated using a random-effect model. The protocol for this meta-analysis is registered with PROSPERO (International Prospective Register of Systematic Reviews; no. CRD42017067687).

RESULTS

Nineteen observational studies with 1 931 073 ESRD patients were enrolled. The pooled estimated incidence of kidney cancer and urothelial cancers (carcinomas of the bladder, ureters, and renal pelvis) in ESRD patients were 0.3% (95%CI: 0.2-0.5%) and 0.5% (95%CI: 0.3-0.8%), respectively. Meta-regression showed significant positive correlation between incidence of urologic malignancies in ESRD patients and year of study (slopes = +0.05 and +0.07, P < 0.001 for kidney cancer and urothelial cancers, respectively). Compared to non-ESRD status, ESRD was significantly associated with both kidney cancer (pooled OR 6.04; 95% CI 4.70-7.77) and urothelial cancers (pooled OR 4.37; 95% CI 2.40-7.96).

CONCLUSION

Our study demonstrates a significant association between ESRD and urologic malignancies. The overall estimated incidence rates of kidney cancer and urothelial cancers are 0.4% and 0.5%, respectively. There is a significant positive correlation between the incidence of urologic malignancies and year of study.

Plasma miRNA profile is a biomarker associated with urothelial carcinoma in chronic hemodialysis patients

The incidence of urothelial carcinoma (UC) is higher in patients undergoing chronic dialysis than in the general population. This study investigated plasma miRNA profiling as the ancillary diagnosis biomarker associated with UC in patients undergoing chronic hemodialysis. We successfully screened out and detected miRNA expression from plasma in eight patients undergoing dialysis through quantitative real-time PCR array analysis and identified eight candidate miRNAs. The candidate miRNAs were then validated using single quantitative RT-PCR assays from 52 plasma samples. The miRNA classifier for ancillary UC detection was developed by multiple logistic regression analyses. Moreover, we validated the classifier by testing another nine samples. Expression levels of miR-150-5p, miR-150-5p/miR-155-5p, miR-378a-3p/miR-150-5p, miR-636/miR-150-5p, miR-150-5p/miR-210-3p, and miR-19b-1-5p/miR-378a-3p were shown to be significantly different between UC and non-UC samples (P = 0.035, 0.0048, 0.016, 0.024, 0.038, and 0.048). Kaplan-Meier curve analysis also showed that low miR-19b-1-5p expression was associated with a worse prognosis (P = 0.0382). We also developed a miRNA classifier based on five miRNA expression levels to predict UC and found that the area under curve was 0.882. The classifier had a sensitivity of 80% (95% confidence interval: 0.5191% to 0.9567%) and a specificity of 83.7% (95% confidence interval: 0.6799% to 0.9381%). This classifier was tested by nine samples with 100% accuracy. The miRNA classifier offers higher sensitivity and specificity than the existing makers. Thus, this approach will improve the prospective diagnosis of UC in patients undergoing chronic hemodialysis.

Chronic kidney disease and positive surgical margins as prognosticators for upper urinary tract urothelial carcinoma patients undergoing radical nephroureterectomy

Chronic kidney disease (CKD) is a common condition among elderly patients and has been reported to be a biomarker for the presence of malignant disease. In addition, unfavorable outcomes for patients with upper tract urothelial carcinoma (UTUC) undergoing radical nephroureterectomy can be due to independent clinical factors. Therefore, the present study analyzed the clinicopathological data of patients with UTUC, who underwent radical nephroureterectomy at our institution, to clarify whether preoperative CKD and other factors are independent predictors of the shorter disease-specific and/or recurrence-free survival time of these patients. A retrospective review of 187 patients who underwent radical nephroureterectomy was conducted, and patients were followed for at least 3 months postoperatively. The clinicopathological factors that are thought to have potentially significant roles in the progression and metastasis of malignant tumors and for disease-specific and recurrence-free survival were evaluated. Positive surgical margins and an estimation of the glomerular filtration rate (eGFR) of <60 were independent factors for the shorter disease-specific survival time in multivariate analysis with Cox's proportional hazards model [hazard ratio (HR), 2.401: 95% confidence interval (CI), 1.044-5.255; and HR, 2.371: 95% CI, 1.024-5.898, respectively]. Another multivariate analysis also revealed that positive surgical margins (HR, 4.477; 95% CI, 2.042-9.469), and preoperative eGFR <60 (HR, 2.362; 95% CI, 1.067-5.592) were independent factors for the worse recurrence-free survival rate in all patients. Patients with UTUC who had eGFR <60 as well as positive surgical margins had significantly shorter time to disease-specific mortality and extraurothelial recurrence. The present study demonstrated that patients with UTUC undergoing radical nephroureterectomy who have CKD as well as positive surgical margins should be carefully followed up postoperatively.

Development and validation of a nomogram for urothelial cancer in patients with chronic kidney disease

Urothelial cancer (UC) is a common kidney cancer in Taiwan and patients with chronic kidney disease (CKD) are more at risk for UC than the general population. The diagnostic value of urine analysis and urine cytology is limited, especially in CKD patients. The aim of the study is to develop a nomogram to predict the risk of UC in CKD patients. We enrolled 169 UC patients and 1383 CKD patients from 9 hospitals in Taiwan between 2012 and 2015. CA125, HE4, clinical characteristics, and medical history were analyzed using multivariable logistic regression for its association with UC. A nomogram was developed to predict the risk of UC and was validated using Bootstrap. CA125 was associated with UC in CKD patients (OR: 5.91, 95% CI: 3.24–10.77) but HE4 was not (OR: 1.29, 95% CI: 0.67–2.35). A nomogram based on patients’ age, estimated glomerular filtration rate, CA125 (log transformed), smoking, exposure of environmental toxin, use of nonsteroid anti-inflammatory drugs, and use of traditional Chinese medicine was conducted. The AUC of the nomogram was 0.90 (95% CI: 0.86–0.92, p < 0.01). Serum CA125 may identify UC patients from CKD patients but has limited diagnostic value due to low sensitivity. The diagnostic value of serum CA125 level can be improved by the combination with clinical characteristics including age, renal function, and medical history.

Higher risk of malignant neoplasms in young adults with end-stage renal disease receiving haemodialysis: A nationwide population-based study

Aim

Previous investigations have shown that end‐stage renal disease (ESRD) is associated with an increased risk of malignancies. The aim of this study was to explore the association between ESRD in patients undergoing maintenance haemodialysis (HD) and the incidence of malignancies according to age.

Methods

We analysed a nationwide cohort retrieved from Taiwan's National Health Insurance Research Database to study the incidence of malignancies in patients who were and were not receiving HD. One million beneficiaries were randomly selected and followed from 2005 to 2013. Of these 1 000 000 patients, 3055 developed ESRD and commenced maintenance HD during this period. For each HD patient, four age‐, gender‐ and diabetes‐matched controls were selected from the database (n = 12 220). We further stratified the patients according to age. The study endpoint was the occurrence of malignancy.

Results

The incidence rates of malignancy were 6.8% and 4.9% in the HD and control groups, respectively. Competing risk regression analysis indicated that age, HD, male gender and diabetes were associated with an increased risk of malignancy. When further stratified according to age, the odds ratios of developing cancer were 5.8, 1.9, 1.9 and 1.5 among the HD patients aged <40 years, 40–49 years, 50–59 years and 60–69 years, respectively.

Conclusion

The patients with ESRD who received HD had a significantly higher cumulative risk of malignancy, especially those with a young age. Therefore, specialized cancer screening protocols for young HD patients might help to prolong their lifespan.

End‐stage kidney disease is associated with an increased risk of many malignancies. This epidemiological study from Taiwan reviews the incidence rates of malignancies in a large haemodialysis cohort compared to a control group, revealing a higher cumulative risk of malignancies especially in those of a young age on dialysis.

Perioperative Complications and Mortality in Patients with Urothelial Carcinoma and End-Stage Renal Disease Undergoing One-Stage Complete Urinary Tract Extirpation

BACKGROUND

Complete urinary tract extirpation (CUTE) is a complex procedure with substantial risk for perioperative complications. The association between clinical characteristics and the risk of major postoperative complications has not been systematically investigated.

OBJECTIVE

The aim of this study was to analyze the incidence and risks for major perioperative complications after CUTE.

METHODS

Respective chart review of 81 patients with urothelial carcinoma (UC) who were treated with one-stage CUTE between January 2004 and December 2015. Fisher's exact test with Chi square and two-tailed t test were used in categorical and continuous variables, respectively. Univariable and multivariable logistic regression models were used to evaluate the probability of major complications.

RESULTS

In this population, 53 (65.4%) patients had Clavien grade 0-2 complications ('no major complications') and 28 (34.6%) patients had Clavien grade 3-5 complications ('major complications'). Compared with the major complications group, patients in the no major complications group were younger, had lower Charlson Comorbidity Index (CCI), higher preoperative serum albumin, and shorter duration of hospitalization (p < 0.05 for all). Major complications were more common in low-volume surgeons (p = 0.002). On multivariate logistic regression analyses, CCI ≥ 5 (odds ratio [OR] 6.25, 95% confidence interval [CI] 1.42-27.47; p = 0.015) and surgery by a provider who performed three or fewer cases during the study interval (OR 13.4, 95% CI 2.20-80.89; p = 0.005) were independent predictors for major complications.

CONCLUSIONS

High CCI should alert providers to increased probability of major complications, and warrant vigilant management after CUTE. Surgeon volume was inversely related to major postoperative complications.

The incidence of urinary tract cancers is related to preserved diuresis: a single-center report

PURPOSE

Residual diuresis progressively decreases with longer dialysis vintage, and higher incidence of renal and urinary tract cancers was often observed in hemodialyzed patients compared to the general population so we hypothesized that patients without preserved residual diuresis have higher risk of renal and urinary tract cancers than patients with preserved residual diuresis.

METHODS

Retrospective clinical data and pathology reports were completed for 307 uremic patients undergoing chronic hemodialysis. Patients were divided into two subgroups regarding residual diuresis: the first group with residual diuresis < 500 mL, 133 of 173 (76.8%) patients from this group were completely anuric, and the second group with 134 patients with residual diuresis > 500 mL.

RESULTS

Site- and type-specific cancers in our population of ESRD patients were all localized in estrogen-positive receptor organs. The increased risk of all types of urinary tract cancers occurred in the whole group, men and women, when compared to general population. There were a significantly higher number of patients with all types of cancers in the group with residual diuresis < 250 mL compared to patients with residual diuresis > 500 mL. Importantly, all urinary tract cancers were present in patients with residual diuresis < 500 mL.

CONCLUSION

Higher incidence of urinary tract cancers found in ESRD patients undergoing chronic hemodialysis is associated with lost residual diuresis. Residual diuresis in these patients might be considered a risk marker for future urinary tract cancers as well as already established markers.

Nephroureterectomy increase 5 year survival in patients on dialysis with upper urinary tract urothelial carcinoma

Background

There is a high incidence rate of upper tract urothelial carcinoma (UTUC) in patients on dialysis. However, the studies about nephroureterectomy (NU) in this high surgical risk group are limited. The aim of this study is to investigate the outcomes of NU in this population.

Results

There were total 931 patients enrolled and 218, 582, 131 patients were non-NU, unilateral and one-stage bilateral NU, respectively. NU provided better 5-year overall survival (66% versus 51% in non-NU, P = 0.001). 19.7% of patients with unilateral NU had successive contralateral NU with a mean interval period of 695 days. Even for the elderly, there were no significant difference in duration of hospitalization, 30- and 90-day mortality between unilateral and bilateral NU.

Materials and Methods

Patients on dialysis with UTUC between January 1998 and December 2012 were assessed from the nationwide cohort of Taiwan National Health Insurance Research Database. We classified these patients into non-NU and NU groups. In NU group, we analyzed clinical outcomes of patient groups between different NU types and surgical methods.

Conclusions

Although the high surgical risk in patients on dialysis with UTUC, NU provided better 5-year overall survival. One-stage bilateral NU both provides comparable safety profile and avoids 19.7% of successive contralateral NU in less than two years. Even in the elderly, one-stage bilateral NU is safe and feasible.

The Risk of Tumour Recurrence in Patients Undergoing Renal Transplantation for End-stage Renal Disease after Previous Treatment for a Urological Cancer: A Systematic Review

CONTEXT

Renal transplantation is the gold standard renal replacement therapy in end-stage renal disease owing to its superior survival and quality of life compared with dialysis. When the potential recipient has a history of cancer, the waiting period before renal transplantation is usually based on the Cincinnati Registry.

OBJECTIVE

To systematically review all available evidence on the risk of cancer recurrence in end-stage renal disease patients with a history of urological cancer.

EVIDENCE ACQUISITION

Medline, Embase, and the Cochrane Library were searched up to March 2017 for all relevant publications reporting oncologic outcomes of urological cancer in patients who subsequently received a transplantation or remained on dialysis. The primary outcome was time to tumour recurrence. Secondary outcomes included cancer-specific and overall survival. Data were narratively synthesised in light of methodological and clinical heterogeneity. The risk of bias of each included study was assessed.

EVIDENCE SYNTHESIS

Thirty-two retrospective studies enrolling 2519 patients (1733 dialysed, 786 renal transplantation) were included. For renal cell carcinomas, the risks of recurrence, cancer-specific, and overall survival were similar between transplantation and dialysis. For prostate cancer, most of the tumours had favourable prognoses consistent with nomograms. Studies dealing with urothelial carcinomas (UCs) mainly included upper urinary tract UC in the context of aristolochic acid nephropathy, for which the risks of synchronous bilateral tumour and recurrence were high. Data on testicular cancer were scarce.

CONCLUSIONS

Immunosuppression after renal transplantation does not affect the outcomes and natural history of low-risk renal cell carcinomas and prostate cancer. Therefore, the waiting time from successful treatment for these cancers to transplantation could be reduced. Except in the particular situation of aristolochic acid nephropathy, more studies are needed to standardise the waiting period after UC owing to the paucity of data.

PATIENT SUMMARY

Renal transplantation does not appear to increase the risk of recurrence of renal carcinoma or the recurrence of low-risk prostate cancer compared with dialysis. More reliable evidence is required to recommend a standard waiting period especially for urothelial and testicular carcinomas.

Long-term outcomes of complete urinary tract exenteration for dialysis patients with urothelial cancer

PURPOSE

To survey long-term outcomes of dialysis patients with urothelial cancers who have undergone complete urinary tract exenteration (bilateral nephroureterectomy and cystectomy).

METHODS

We retrospectively reviewed our patients with urinary tract urothelial cancer. Forty-two dialysis patients who underwent complete urinary tract exenteration were enrolled in our study. Seventeen patients had undergone one-stage complete urinary tract exenteration, and twenty-five patients had undergone multi-stage surgery. We reviewed the demographic, clinical, surgical, and pathological data to determine the clinical and pathologic variables that affected the survival between the two groups.

RESULTS

Baseline demographics were comparable in both groups. There was no significant difference in age, American Society of Anesthesiologists class, Charlson index, or body mass index between the two groups. Furthermore, there was no statistically significant difference in estimated blood loss (1280 vs. 1440 ml) or total hospital stay (31 vs. 21 days). Simultaneous upper and lower tract tumors were noted in one-stage CUTE group In comparison with multi-stage surgery, one-stage surgery was associated with a higher complication rate (58.8 vs. 28%). Twenty-two patients were still alive at the end of the study, and 20 had died. The median survival period after confirmation of complete urinary tract exenteration status was 27.5 months. The overall survival was the same between the two groups. The Charlson comorbidity index was a mandatory indicator to predict long-term survival outcome.

CONCLUSIONS

In dialysis patients with urothelial cancers who have undergone complete urinary tract exenteration, one-stage complete urinary tract exenteration had a high perioperative complication rate. The Charlson comorbidity index was a mandatory indicator to predict long-term survival outcome.

Areca Nut Chewing and an Impaired Estimated Glomerular Filtration Rate as Significant Risk Factors for Non-Muscle-Invasive Bladder Cancer Recurrence

The present study sought to investigate the predictive value of preoperative clinicopathological variables, with a special focus on areca nut chewing, on disease recurrence and progression in patients with non-muscle-invasive bladder cancer (NMIBC). Data from 242 patients diagnosed with NMIBC between 2008 and 2013 were analyzed retrospectively. Fifteen clinicopathological variables were analyzed to evaluate their prognostic value. During a mean observation period of 21 months, disease recurrence occurred in 140 patients (57.9%). On multivariate analysis, heavy-areca nut chewing (HR = 2.18, 95% CI: 1.37-3.47), current smoking (HR = 3.09, 95% CI: 1.99-4.80), moderately impaired estimated glomerular filtration rate (eGFR) (HR = 1.76, 95% CI: 1.09-2.83), severely impaired eGFR (HR = 3.32, 95% CI: 1.70-6.48) and tumor grade (HR = 1.94, 95% CI: 1.36-2.77) were independent factors for recurrence, based on which a risk factor model was developed to stratify patients into high, medium and low risk groups. In conclusion, our study suggests that in addition to quitting smoking, quitting areca nut chewing may also reduce the risk of first recurrence in NMBIC patients, monitoring and preserving their renal function may be beneficial as well. Further prospective studies are needed to verify the prognostic significance of these factors and the risk stratification model in this population.

Metachronous urothelial carcinoma of whole urinary tract in a dialysis-dependent patient: A case report

Numerous studies have reported an association between end-stage renal disease (ESRD) and malignancy. The predominant malignant tumor that occurs in patients with ESRD in Asian countries is urothelial carcinoma (UC). According to recent research, cases of UC in dialysis-dependent patients are associated with higher recurrence rates and more aggressive biological behavior compared with patients without ESRD. The necessity of 1-step total urinary tract exenteration for dialysis-dependent patients with UC is advocated by certain studies. The current study reports a case of metachronous bladder cancer and bilateral upper urinary tract tumor in a dialysis-dependent patient. Three separate surgeries were performed to remove the bladder, and left and right urinary tract, respectively. The question of whether the stepwise strategy or the 1-step surgery should be selected for such special cases remains in debate.

Upper urinary tract urothelial carcinoma behaviors in patients with end-stage renal disease after kidney transplantation in Taiwan

PURPOSE

To determine upper urinary tract urothelial carcinoma (UT-UC) behavior in patients with end-stage renal disease (ESRD) after kidney transplantation (KT).

METHODS

From 2005 to 2012, 117 ESRD patients with localized UT-UC underwent nephroureterectomy at our institution. We divide these patients into two groups according to having had KT or not. Kaplan-Meier survival plot and multivariate analysis were used to evaluate whether kidney transplantation interfered with the UT-UC outcome.

RESULTS

The mean age was younger in ESRD with KT group (p = 0.001), but there was no difference in gender, smoking, or previous bladder cancer history between these two groups. The pathological features were more aggressive in ESRD with KT group compared to those without KT in regard to incidence of carcinoma in situ (p = 0.025) and multifocality (p = 0.001). Kidney transplantation did not interfere with the oncological outcome of UT-UC in ESRD patients. There were no differences in oncological outcome. Five-year metastasis-free survival rate was comparable.

CONCLUSION

In our sample, for patients with ESRD after kidney transplantation, the postoperative onset of UT-UC was younger and the pathological features were more aggressive. Standard surgical intervention resulted in satisfactory and similar outcome as did ESRD.

Chronic Kidney Disease is Associated With Upper Tract Urothelial Carcinoma: A Nationwide Population-Based Cohort Study in Taiwan

Increased urinary tract malignancy has been reported in end-stage renal disease (ESRD). However, little is known about chronic kidney disease (CKD). This study is designed to explore the association between CKD and upper tract urothelial carcinoma (UTUC).Using Taiwan's Longitudinal Health Insurance Database, we studied CKD patients between January 2000 and December 2011. The non-CKD controls were selected at a ratio of 4:1 and frequency matched by gender, age group, and index date. We used the chi-square test and t test to analyze the sociodemographic information and comorbidities. Cox regression analysis was used to calculate the hazard ratio (HR) and 95% confidence interval (CI).The selected cases included 45,321 CKD cases and 181,284 controls. A significantly higher incidence of UTUC was noted in the CKD group (0.22% vs 0.07%, P < 0.001). In univariate analysis, CKD, female gender, age, hypertension, hematuria, repeated urinary tract infection, bladder cancer, and ESRD were all associated with UTUC. In multivariate analysis, only CKD, female gender, age, hematuria, bladder cancer, and ESRD were significantly associated. The HR for CKD was 1.63 (95% CI: 1.26-2.13). Females had a higher HR of 1.38 (95% CI: 1.11-1.71). After excluding those patients who progressed to dialysis or kidney transplantation, the risk for CKD was still high, with an HR of 1.72 (95% CI: 1.33-2.33).CKD is a significant factor associated with UTUC. We should pay attention to the possibility of UTUC for CKD patients before they progress to ESRD.

Shorter hemodialysis duration is a risk factor for the recurrence of urothelial carcinoma of the bladder in patients on maintenance hemodialysis

PURPOSE

To investigate the association of hemodialysis duration with the recurrence of urothelial carcinoma (UC) of the bladder and overall survival in patients undergoing maintenance hemodialysis (MHD).

PATIENTS AND METHODS

52 bladder cancer patients who underwent MHD at the Xiangya Hospital of The Central South University between 2001 and 2011 were enrolled in the study. The patients were divided into three groups according to hemodialysis duration, and patient mortality and tumor recurrence rates were analyzed. The association of hemodialysis duration with occurrence and recurrence of UC of the bladder was analyzed by Cox regression analysis. Survival was evaluated by the Kaplan-Meier method.

RESULTS

Out of 6266 chronic hemodialysis patients, 52 patients had UC of the bladder after the initiation of hemodialysis for 6 months. The mean age at hemodialysis onset was 55 years (IQR 36, 71). The major complaints were painless gross hematuria and urethral bloody discharge. Tumors were generally large and multifocal. The standardized incidence ratio of UC of the bladder was 43.9 compared with general population, and it was higher in women (76.7) and in the age group 61-65 years (186.6). The mean hemodialysis duration before the diagnosis of bladder cancer was 32 months. 30 (57.7 %) patients received hemodialysis no more than 3 years, 10 (19.2 %) patients received hemodialysis between 3 and 6 years, and 12 (23.1 %) patients received hemodialysis for more than 6 years.

CONCLUSION

Preoperative shorter hemodialysis duration is a risk factor for the occurrence and recurrence of UC of the bladder in patients undergoing MHD.

Upper tract urothelial carcinomas in patients with chronic kidney disease: relationship with diagnostic challenge

Chronic kidney disease and upper tract urothelial carcinomas display a bidirectional relationship. Review of the literature indicates that early diagnosis and correct localization of upper tract urothelial carcinomas in dialysis patients and kidney transplant recipients are important but problematic. Urine cytology and cystoscopy have limited sensitivity for the diagnosis of upper tract urothelial carcinomas in dialysis patients. Enhanced computed tomography and magnetic resonance imaging could prove useful for the detection and staging of upper tract urothelial carcinomas in dialysis patients. Renal ultrasound can detect hydronephrosis caused by upper tract urothelial carcinomas in kidney transplant recipients but cannot visualize the carcinomas themselves. High detection rates for upper tract urothelial carcinomas in kidney transplant recipients have recently been demonstrated using computed tomography urography, which appears to be a promising tool. To detect carcinomas in dialysis patients and kidney transplant recipients as early as possible, regular screening in asymptomatic patients and diagnostic work-up in symptomatic patients should be performed using a combination of urological and imaging methods. Careful assessment of subsequent recurrence within the contralateral upper urinary tract and the urinary bladder is necessary for dialysis patients and kidney transplant recipients with upper tract urothelial carcinomas.

Increased risk of urinary tract cancer in ESRD patients associated with usage of Chinese herbal products suspected of containing aristolochic acid

Introduction

Both end-stage renal disease (ESRD) and urothelial cancer (UC) are associated with the consumption of Chinese herbal products containing aristolochic acid (AA) by the general population. The objective of this study was to determine the risk of UC associated with AA-related Chinese herbal products among ESRD patients.

Methods

We conducted a cohort study using the National Health Insurance reimbursement database to enroll all ESRD patients in Taiwan from 1998–2002. Cox regression models were constructed and hazard ratios and confidence intervals were estimated after controlling for potential confounders, including age, sex, residence in region with endemic black foot disease, urinary tract infection, and use of non-steroidal anti-inflammatory drugs and acetaminophen.

Results

A total of 38,995 ESRD patients were included in the final analysis, and 320 patients developed UC after ESRD. Having been prescribed Mu Tong that was adulterated with Guan Mu Tong (Aristolochia manshuriensis) before 2004, or an estimated consumption of more than 1–100 mg of aristolochic acid, were both associated with an increased risk of UC in the multivariable analyses. Analgesic consumption of more than 150 pills was also associated with an increased risk of UC, although there was little correlation between the two risk factors.

Conclusion

Consumption of aristolochic acid-related Chinese herbal products was associated with an increased risk of developing UC in ESRD patients. Regular follow-up screening for UC in ESRD patients who have consumed Chinese herbal products is thus necessary.

Increased risk of urothelial cancer in young and middle aged patients with end-stage renal disease

BACKGROUND/PURPOSE

End-stage renal disease (ESRD) may increase the likelihood of malignancy. The aim of this study is to evaluate the characteristics of increased urothelial cancer (UC) risk in patients with ESRD in Taiwan by a population-based study.

METHODS

The standardized incidence ratios (SIRs) for UC among a registered cohort of ESRD in Taiwan during 1997-2002 were calculated using reimbursement data obtained from the Bureau of National Health Insurance (NHI), with the incidence rates of UC in the general population as the reference.

RESULTS

During the study period we identified 58,739 patients with ESRD, 20,939 patients with UC, and 1305 patients with ERSD and UC. Among the 1305 patients with both diseases, 687 developed UC after ESRD had been diagnosed. Using the general population as the reference group, SIRs were 12.9 [95% confidence interval (CI)]: 12.0-13.9) for all UC cases, 13.9 (95% CI: 12.4-15.0) for bladder cancer, 11.9 (95% CI: 8.6-16.0) for renal cell carcinoma, and 11.6 (95% CI: 10.1-13.1) for upper tract urothelial cancer.

CONCLUSION

Patients with ESRD are at increased risk for UC in Taiwan, especially women age 50 years and younger. Early and lifelong surveillance of UC is recommended after diagnosis of ESRD.

Segmental ureterectomy does not compromise the oncologic outcome compared with nephroureterectomy for pure ureter cancer

PURPOSE

Pure ureter cancers are rare and account for only 1-3 % of urothelial carcinomas with limited data. Nowadays, nephron-sparing methods are reserved mainly for imperative cases. This study intends to assess the oncologic outcome between segmental ureterectomy (SU) and radical nephroureterectomy (RNU) for pure ureteral urothelial carcinoma.

METHODS

From July 2004 to August 2010, 112 patients at a single tertiary referral center were included. Perioperative data were obtained from our institutional database. Postoperative CT scan, cystoscopy, and contralateral renal echo were performed regularly for survey of disease recurrence.

RESULTS

The mean length of follow-up was 43.8 and 48.3 months for the RNU and SU group, respectively. The bladder recurrences, local recurrences, distant metastasis, and cancer-specific survival rates showed no significant differences between RNU and SU (36.4 vs. 34.2 %, p = 0.83; 23.4 vs. 14.3 %, p = 0.27; and 16.9 vs. 8.6 %, p = 0.244, and 13.0 vs. 5.7 %, p = 0.249, respectively).

CONCLUSION

The study suggested that SU is not inferior to RNU for ureter cancer in oncologic outcomes and is less invasive and better nephron preservation.

Reduction of cystometric bladder capacity and bladder compliance with time in patients with end-stage renal disease

BACKGROUND/PURPOSE

Reduced bladder capacity and compliance in patients with end-stage renal disease (ESRD) may affect storage and voiding function after kidney transplantation. This study evaluated the bladder capacity, compliance, and lower urinary tract dysfunction in ESRD patients with duration after dialysis and anuria.

MATERIALS AND METHODS

Adults with ESRD on kidney transplantation waiting list were consecutively enrolled. The survey items included videourodynamic study (VUDS), renal ultrasound, and cystoscopy. The analytical variables assessed included the duration of dialysis, the duration of anuria, cystometric bladder capacity and bladder compliance, voiding phases in VUDS, and cystoscopic findings.

RESULTS

A total of 62 patients with a mean dialysis duration of 58.9 ± 6.3 months were enrolled. The mean cystometric bladder capacity was 178 ± 14 mL and decreased significantly with duration of dialysis (p < 0.001). Anuria was diagnosed in 26 patients, and the mean cystometric bladder capacity decreased significantly with the duration of anuria (p = 0.002). Among the 26 patients with anuria, 16 had a poor bladder compliance. VUDS revealed abnormal storage function in 44 (71.0%) patients and bladder outlet obstruction due to bladder neck dysfunction or urethral narrowing in the voiding phase in 32 (51.6%). Abnormal cystoscopic findings were also noted in 30 (48.4%) patients.

CONCLUSION

Cystometric bladder capacity and bladder compliance decreased with longer duration of dialysis, and the presence of anuria contributed to further decreases in cystometric bladder capacity and bladder compliance. More than two-thirds of patients with ESRD had abnormal findings on VUDS.

Urothelial carcinoma of the bladder in patients on hemodialysis: clinical characteristics and oncological outcomes

PURPOSE

We characterized the clinical presentation and outcome of patients on hemodialysis diagnosed with urothelial carcinoma of the bladder.

MATERIALS AND METHODS

Patients treated for bladder cancer while undergoing maintenance hemodialysis were identified by querying the medical registry of a university affiliated hospital between 1999 and 2010. Clinical, pathological and treatment related data were retrieved and characterized. The study end points were recurrence-free, progression-free and overall survival.

RESULTS

A total of 15 patients met study criteria. Median age at hemodialysis onset was 67 years (IQR 62, 74). Median dialysis duration before the bladder cancer diagnosis was 36 months (IQR 12, 60). Hematuria and bloody urethral discharge were the most common clinical manifestations. Tumors were generally large and multifocal. Of the patients 66% had invasive disease (T1 or greater) at presentation and 73% had high grade tumors. There were no adverse sequelae after transurethral resection or intravesical therapy. Two of the 4 patients treated with total urinary exenteration died soon after surgery and 1 had a grade IV complication. At a median followup of 18 months the estimated recurrence-free survival rate was 54% at 1 year, and 43% each at 2 and 3 years. The progression-free survival rate was 78%, 56% and 42%, and the overall survival rate was 66%, 45% and 23% at 1 to 3 years, respectively.

CONCLUSIONS

Bladder cancer diagnosed in patients on hemodialysis often harbors aggressive histological features at presentation. Conservative therapy in patients with noninvasive tumors appears to be well tolerated while urinary tract exenteration is associated with high morbidity and mortality. The prognosis of patients with invasive cancer is generally dismal.

Urothelial carcinoma in patients with advanced kidney disease: a 12-year retrospective cohort survey

INTRODUCTION

The goal of this study was to compare the clinical and pathological features of urothelial carcinoma (UC) identified in patients with end-stage renal disease (ESRD) and advanced-stage chronic kidney disease (CKD). The predictive value of CKD on patient mortality in these UC patients was also analyzed.

METHODS

From January 1997 to December 2008, 141 patients with pathologically proven UC with stage 4/5 CKD (predialysis) and patients with ESRD receiving long-term dialysis were identified under an institutional review board approval protocol. The medical records and survival outcome of these patients were reviewed.

RESULTS

A total of 141 UC patients with renal diseases (n = 97, 68.8%, of stage 4/5 CKD; n = 44, 31.2%, at dialysis) were enrolled. Patients with stage 4/5 CKD were significantly older, male gender, less anemic and more likely to have higher prevalence of diabetes mellitus (P < 0.05). We noticed a more significant increase in the frequency of high-stage UC (24.7% and 6.8%) and a larger tumor size (50.5% and 27.3%) in patients with stage 4/5 CKD, compared with patients with ESRD (P < 0.05). Old age at the time of dialysis initiation in patients with ESRD [hazard ratio (HR) = 1.121, P = 0.039], male gender (HR = 6.822, P = 0.016) and high-stage tumors (HR = 5.012, P = 0.008) in patients with stage 4/5 CKD were independent predictors of mortality from UC.

CONCLUSIONS

Patients with stage 4/5 CKD had more aggressive histological UC patterns than did patients with ESRD.

Increased risk of cancer in chronic dialysis patients: a population-based cohort study in Taiwan

BACKGROUND

An increased incidence of cancer in chronic dialysis patients has not been confirmed in the Chinese population. The aim of this population-based study was to examine the risk of various types of cancers in chronic dialysis patients in Taiwan.

METHODS

Data of 92 348 chronic dialysis patients extracted from the National Health Institutes Research Database during 1997-2008 were analyzed. Patients newly diagnosed with end-stage renal disease, free of cancer and receiving dialysis for >3 months were eligible for inclusion in the study.

RESULTS

After a mean follow-up of 4.4 years, a new cancer was diagnosed in 4328 chronic dialysis patients. The standardized incidence ratio (SIR) of chronic dialysis patients was 1.4 [95% confidence interval (CI): 1.3-1.4] and annual incidence of cancer was 1.1%. A trend of an increased SIR of cancer was observed in young patients and within the first year of dialysis. Bladder cancer carried the highest SIR (SIR: 8.2, 95% CI: 6.7-9.9) and had the highest frequency (21.2%). Importantly, the frequency (15.3%) of liver cancer was the second highest and the SIR (SIR: 1.4, 95% CI: 1.2-1.5) of liver cancer in chronic dialysis patients was higher than that of their healthy counterparts. Unexpectedly, chronic dialysis patients had a significantly reduced risk of developing lung cancer.

CONCLUSION

Increased risk of cancer in chronic dialysis patients is confirmed in the Taiwanese population and it is necessary to develop different strategies for cancer screening in chronic dialysis patients among different ethnicities.

High incidence and recurrence of transitional cell carcinoma in Taiwanese patients with end-stage renal disease

AIM

This study examines the epidemiology of transitional cell carcinoma (TCC) in end-stage renal disease (ESRD) population from Taiwan, the area with the highest incidence and prevalence of ESRD.

METHODS

A total of 98 out of 10,890 ESRD patients were referred for management of TCC between 2000 and 2008. Demographic, clinical and laboratory data were collected and patient mortality and tumour recurrence rates were analyzed.

RESULTS

TCC patients were aged 61.4 ± 10.2 years and 66.3% were female. The average time from initiation of dialysis to tumour detection was 51.2 ± 36.4 months. Hypertensive nephrosclerosis, diabetes mellitus, chronic glomerulonephritis and unknown aetiology accounted for 25.5%, 20.4%, 22.4% and 31.6% of the causes of renal failure, respectively. The aetiology of renal failure for the 31.6% of patients was unclear, but chronic tubulointerstitial nephritis following long-term consumption of Chinese herbs (19.4%) or analgesic compounds (3.1%) was considered in some patients. Almost all (98.0%) patients presented with gross haematuria. Most TCC were in early stage (stage 0, 3.1%; stage I, 56.1%) during diagnosis. At the end of this study, 17 of 98 (17.3%) patients died. Multivariate Cox regression analysis found that age (odds ratio =1.140, 95% confidence interval = 1.049-1.239, P = 0.002) and tumour pain (odds ratio = 0.234, 95% confidence interval = 0.057-0.961, P = 0.044) were significant risk factors for all-cause mortality. Furthermore, 35.7% of TCC recurred during follow up. The 5 year patient and tumour-free survival rates were 72.4% and 14.4%, respectively.

CONCLUSION

The data shows that Taiwanese patients with ESRD had high incidence (0.9%) and recurrence (35.7%) of TCC.

Malignancies after renal transplantation in Taiwan: a nationwide population-based study

BACKGROUND

Renal transplantation has been regarded as the treatment of choice for end-stage renal disease. Renal transplantation increases the risk of cancers due to long-term immunosuppression. The types of post-transplantation malignancies may vary among different geographic regions and ethnic populations. To date, large population-based studies of post-transplantation malignancies in Asian renal transplant recipients (RTRs) have rarely been reported.

METHODS

To investigate the patterns of post-transplantation malignancies in Chinese RTRs, we performed a nationwide population-based cohort study between 1997 and 2008 based on data from the National Health Insurance Database in Taiwan. Patterns of cancer incidence in RTRs were compared with those of the general population using standardized incidence ratios (SIRs).

RESULTS

Among the 4716 RTRs (2475 males and 2241 females; mean age 44.1 ± 12.4 years) and 22 556 person-years of observation, 320 post-transplant cancers were diagnosed. The SIR of all cancers was 3.75 (95% confidence interval 3.36-4.18). Women had a higher risk than men for the development of malignancies (SIR 5.04 for women and SIR 2.88 for men). Renal, bladder and liver cancers were the most common cancers, with SIRs of 44.29, 42.89 and 5.07, respectively. When stratified by age, RTRs of young age at transplant (<20 years) had the highest risk of post-transplantation malignancies.

CONCLUSIONS

This study demonstrates different patterns of malignancies after renal transplantation in Chinese RTRs, with higher incidences of kidney and bladder cancers. Physicians should be more vigilant in examining RTRs for post-transplantation malignancies especially in younger patients.

Simultaneous robot-assisted nephroureterectomy and cystectomy in patients with uremia and multifocal urothelial carcinoma

BACKGROUND AND PURPOSE

In Taiwan, patients with uremia have a high risk of the development of multifocal urothelial carcinoma. We report on eight patients with uremia and urothelial carcinoma who underwent simultaneous robot-assisted laparoscopic nephroureterectomy and radical cystectomy (RANUC).

PATIENTS AND METHODS

Between April 2006 and August 2010, eight patients with uremia (five women, three men; mean age 66.9  y) who were receiving dialysis underwent RANUC. Patients were classified into two groups: Group I, cases 1 to 4 occurring between April 2006 and June 2009; and group II, cases 5 to 8 occurring between July 2009 and August 2010.

RESULTS

The mean operative time was significantly shorter in group II (252.5±35.0  min vs 360±25.8  min; P=0.029). The estimated blood loss was also significantly less in group II (332.5±53.8  mL vs 660±137.4  mL; P=0.029). The blood transfusion rate was 75% in group I and 0% in group II. The postoperative stay was reduced from 8.5 days for group I to 7 days for group II. No perioperative morbidity and mortality were noted in either group. None of the patients had died at the short- and intermediate-term mean follow-up of 28.1 months (range 2-54  mos).

CONCLUSIONS

Simultaneous RANUC are feasible and can be performed safely. Long-term oncologic data are awaited; however, at intermediate-term oncologic follow-up, results are satisfactory. RANUC for uremic patients with multifocal urothelial carcinoma necessitating complete urinary tract exenteration is a viable option and patients experience a rapid convalescence.

Complete urinary tract exenteration for a dialysis patient with urothelial cancer: lower midline and extraperitoneal approach in a supine position

OBJECTIVES

To report a novel technique of extraperitoneal complete urinary tract exenteration (CUTE) for dialysis patients with multifocal urothelial cancer via a lower midline approach in a supine position (the spread-eagle position [SEP]).

MATERIALS AND METHODS

From October 2006 to May 2009, extraperitoneal CUTE was performed in 10 dialysis patients with multifocal urothelial cancer. Patients were placed supine with both legs extended and abducted at 45 to 60 degrees and both arms stretched out to the sides (SEP). CUTE involves simultaneous bilateral hand-assisted retroperitoneoscopic nephroureterectomy (HARN) and cystectomy or cystoprostatectomy. Bilateral HARN was completed via a 7- to 8-cm lower midline incision and 4 laparoscopic ports (2 on each side). Infraumbilical incision was extended to 12 cm and then extraperitoneal cystectomy was performed under direct vision using standard open surgical techniques.

RESULTS

All procedures were successful. The mean operation time of extraperitoneal CUTE was 328 minutes. The time to oral intake was 2.6 days and to ambulation was 4.6 days. The mean parenteral narcotic requirement (morphine) was 43.6 mg (range, 12-88.6). No patient had recurrent transitional cell carcinoma at a mean follow-up of 29.8 months.

CONCLUSIONS

Extraperitoneal CUTE via a lower midline incision in a completely supine position is feasible and safe. This technique has the benefit of easy supine positioning, eliminates the need for interprocedural repositioning, avoids bowel interference of the visual field, and reduces the risk of possible mechanical bowel injury of a retroperitoneal approach. This approach is a rational option when CUTE is considered.

Single-session laparoscopic total urinary tract exenteration without repositioning for multifocal urothelial carcinoma in dialysis-dependent patients

OBJECTIVES

To report our experience of single-session, en bloc, laparoscopic total urinary tract exenteration in dialysis-dependent patients with multifocal urothelial carcinoma.

METHODS

From June 2005 to April 2008, 5 dialysis-dependent patients (4 women and 1 man) diagnosed with synchronous upper urinary tract and bladder urothelial carcinoma underwent single-session, en bloc, laparoscopic total urinary tract exenteration. Bilateral nephroureterectomy was facilitated by rotating the operating table with or without alternative inflation of the tourniquet cuffs on either side of the patient's back to allow adequate spontaneous bowel displacement by gravity, thereby avoiding the need to reposition the patient. After completing bilateral nephroureterectomy, we performed radical cystectomy with the patient in the Trendelenburg position. All specimens, including the 2 kidneys, ureters, and bladder, were collected in an endobag and were intended to be retrieved using the Pfannenstiel incision in male patients and the vaginal route in the female patients. The demographic and perioperative information were collected and analyzed.

RESULTS

All the laparoscopic procedures were completed successfully without major complications. Although 1 patient developed a minor complication owing to paralytic ileus, she recovered after conservative treatment. The continuity of all the urothelial epithelium was maintained intact throughout the procedure to avoid tumor spillage.

CONCLUSIONS

In our experience, laparoscopic total urinary tract exenteration is a technically feasible and safe alternative modality to the open counterpart to treat dialysis-dependent patients with end-stage renal disease with multifocal urothelial carcinoma for experienced surgeons with advanced laparoscopic skills. Furthermore, it can be performed successfully without the need for repositioning the patient, and this probably decreased the incidence of associated complication in the high-risk patients.

Identification of genetic alterations in upper urinary tract urothelial carcinoma in end-stage renal disease patients

Clinical presentations of end-stage renal disease (ESRD) patients on dialysis with upper urinary tract urothelial carcinoma (UUT-UC) are different from those with normal renal function. The pathogenesis remains unknown. We investigated the pathogenetic influence of chromosomal aberrations in patient on dialysis with UUT-UC. The chromosomal aberrations of UUT-UC specimens from seven dialysis patients were assessed by conventional comparative genomic hybridization (cCGH). Subsequently, we further investigated 20 cases by whole genome and fine-tiling oligonucleotide array-based CGH to demonstrate gains and losses, and compared with the clinicopathologic background. The chromosomal aberrations in UUT-UC specimens from dialysis patients were more complex than in bladder urothelial carcinoma (B-UC). Our data showed that gains at 5p, 7, 19q, and losses at 4q, 9p, and 15q are common in UUT-UC of ESRD patients. Gains in regions associated with DNA repair genes were noted in this study. High-stage and high-grade tumors displayed more copy number variants. In addition, female ESRD patients with UUT-UC had more frequent chromosomal aberrations than their male counterparts. In conclusion, unique chromosomal aberrations were indentified in UUT-UC in ESRD patients.

Bilateral hand-assisted retroperitoneoscopic nephroureterectomy (HARN) in the spread-eagle position for dialysis patients-low midline HARN in a completely supine position

OBJECTIVES

To evaluate the feasibility of hand-assisted bilateral retroperitoneoscopic nephroureterectomy (HARN) in a completely supine position (spread-eagle position [SEP]) for dialysis patients with bilateral upper urinary tract tumors.

METHODS

From October 2006 to May 2009, bilateral HARN with open bladder cuff excisions were performed in 13 dialysis patients with upper urinary tract tumors. The patient was placed supine with both legs extended and abducted at 45-60 degrees and both arms stretched out to the sides in a SEP. The operation was completed via a 7- to 8-cm lower midline incision and 4 laparoscopic ports (2 on each side).

RESULTS

All procedures were successful. The mean operation time of bilateral HARN and open bladder cuff resection was 215 minutes, and the mean estimated blood loss was 216 mL. The time to oral intake was 2.5 days and to ambulation was 4.3 days. All patients recovered uneventfully to normal daily activity. No specific complication was related to the position.

CONCLUSIONS

Bilateral HARN in a completely supine, SEP position is feasible and safe. SEP has several advantages, including ease in patient positioning, and the feasibility to perform simultaneous bilateral nephroureterectomy without repositioning of the patient. It also avoids potential risks associated with the lateral decubitus position. Bowel interference of the visual field and mechanical bowel injury are not concerns in this approach. Our experience shows that a completely supine position is not only possible but also advantageous to bilateral HARN.

Urinary fluorescence in situ hybridization assay for detecting urothelial carcinoma in Taiwanese patients

OBJECTIVES

To investigate the cytogenetic marker detected by fluorescence in situ hybridization (FISH; UroVysion, Vysis, Inc., Abbott Laboratories, Des Plaines, IL, USA) in the diagnosis of bladder cancer and upper tract urothelial carcinoma (UC) in Taiwanese patients, as FISH has been used in Western countries for detecting UC, but there are limited results in Asian populations.

PATIENTS AND METHODS

We analysed polyploidy of chromosome 3, 7, 17 and aneuploidy of chromosome 21, using uroepithelial cells collected at the first void or by instrumental extraction of urine, for bladder cancer, and shedding cells from the upper tract flushed by normal saline via ureteric catheterization or ureterorenoscopy. The criteria for positive tumour cells included three or more positive staining in two or more chromosomes showing polyploidy or <50% staining of the chromosome 9p21.

RESULTS

In all, 32 patients with bladder UC and 12 with upper tract UC were assessed. The overall sensitivity for bladder cancer by UroVysion was 96.8%. The sensitivity of the cytology test was 36% for UC of the bladder. The sensitivity for UroVysion in upper tract UC was 12/12 but the specificity was three of nine.

CONCLUSIONS

This preliminary report shows that UroVysion was a sensitive screening method for UC of the bladder and upper urinary tract.

Intermediate-term oncological outcomes of hand-assisted laparoscopic versus open bilateral nephroureterectomy for dialysis and kidney transplant patients with upper urinary tract urothelial carcinoma

PURPOSE

To compare the outcomes of hand-assisted laparoscopic bilateral nephroureterectomy (HALBNU) for dialysis and kidney transplant patients with clinically localized upper urinary tract urothelial carcinoma (UUT-UC) with those achieved by open bilateral nephroureterectomy (OBNU).

MATERIALS AND METHODS

Between 1995 and 2006, 49 patients under dialysis or after kidney transplantation underwent simultaneous bilateral nephroureterectomy for clinically presumed localized UUT-UC at our institute. Of those, 33 underwent HALBNU and 16 received conventional open surgery. Perioperative and pathological data and oncological outcomes were collected by chart review. Bladder recurrence, metastasis, and cancer-specific and overall survival were analyzed and compared between both groups.

RESULTS

The median follow-up for HALBNU and OBNU group was 35 and 46 months, respectively. Totally, 40 patients were identified to have pathologically confirmed urothelial carcinoma of upper urinary tract. HALBNU group was associated with less blood loss, earlier bowel recovery, less narcotic use, shorter hospital stay, and earlier convalescence. The operative time and complication rate were comparable between the two groups. There was no open conversion in the HALBNU group. The two groups were similar in regard to bladder recurrence rate. The overall, cancer-specific, and bladder-recurrence-free survival were also equivalent between the HALBNU and OBNU group (all p > 0.05).

CONCLUSION

In dialysis and kidney transplant patients with localized UUT-UC, simultaneous bilateral nephroureterectomy with hand-assisted laparoscopic approach offered less perioperative morbidity and, most importantly, comparable intermediate-term oncological and survival results when compared with its open counterpart. A longer follow-up is required to demonstrate the oncological efficacy of this minimally invasive procedure.

The aggressiveness of urinary tract urothelial carcinoma increases with the severity of chronic kidney disease

OBJECTIVE

To assess, in a retrospective cohort, urinary tract urothelial carcinoma (UT-UC) in patients with various stages of chronic kidney disease (CKD) and their clinicopathological features, as patients with end-stage renal disease (ESRD) have a higher incidence of UT-UC, but the relationship between early stages of CKD and characteristics of UT-UC are less well known.

PATIENTS AND METHODS

The study included 267 patients with pathologically confirmed UT-UC from January 1994 to December 2006; all had a physical examination (blood pressure), and measurements of laboratory data (serum creatinine, serum haemoglobin) and pathological data. The glomerular filtration rate (GFR) was calculated using the Modification of Diet in Renal Disease equation. Patients were divided into three groups by individual GFR (mL/min), i.e. >60 (no/mild CKD), 30-60 (CKD stage 3) and <30 (CKD stage 4/5).

RESULTS

The CKD stages included 81 (30.3%) patients with none/mild CKD, 121 (45.3%) with CKD stage 3 and 65 (24.3%) with CKD stage 4/5. There was a significant and parallel increase in the frequency of UT-UC as CKD severity increased from none/mild CKD to stage 3 (11% vs 55%), and from CKD stage 3 to 4/5 (55% vs 71%; P < 0.05). Pathologically, the frequency of high-grade and high T stage UT-UC in patients with CKD stage 3 (90% and 35%, respectively) and CKD stage 4/5 (91% and 29%, respectively) were significantly greater than in the group with none/mild CKD (P < 0.001). Advanced age and more distant metastasis were independent risk factors for patient survival.

CONCLUSION

The aggressiveness of UT-UC increased with the severity of CKD, and this might have important clinical consequences.