Treatment and outcomes of urethral recurrence after orthotopic neobladder replacement in patients with bladder cancer - practice in a single centre

Early and late post-procedural complications in different orthotopic neobladder surgical approaches: A systematic review

Bladder cancer (BCa) represents the second most common malignancy of the genitourinary tract. The major risk factors include age, gender, smoking attitude, and occupational exposure, while the exact etiopathogenesis is still uncertain. Patients diagnosed with a BCa showing invasion of the muscle layer below the submucosa must undergo radical cystectomy (RC) with urinary diversion (UD). Many different surgical approaches to UD have been developed. Packaging an orthotopic neobladder (ON) with a bowel tract represents the gold standard when certain patient selection criteria are satisfied. Using PRISMA guidelines, we performed a systematic review assessing early (within 90 days) and late (beyond 90 days) post-procedural complications of different ON surgical approaches. A comprehensive systematic search was conducted in PubMed, Scopus, and Google Scholar databases to identify papers starting from 2012 using dedicated keywords ("neobladder", "orthotopic neobladder", "complications'' and "outcomes"). A total of 27 articles were found to satisfy the inclusion criteria and selected. Although the ON is a safe procedure that guarantees the patient the best quality of life (QoL), it is not free from risks. Many complications could occur during and after the surgical time which imposes the necessity of strict follow-up and careful checks over time, which should be properly discussed with patients before.

Impact of Urethra-Preserving Surgery During Radical Cystectomy: An Optimal Urethral Management in the Robotic Era

OBJECTIVES

The optimal indication and survival benefits of prophylactic urethrectomy (PU) during radical cystectomy remain unclear. Therefore, this study aims to evaluate the impact of urethra-preserving surgery (UPS) on oncological outcome including its recurrence patterns, and to establish an optimal urethral management strategy with a novel UPS technique in the robotic era.

PATIENTS AND METHODS

We retrospectively analyzed 281 male patients with bladder cancer who received radical cystectomy (RC) (115 with and 166 without PU) at our institutions between 2010 and 2023. Subsequently, perioperative and oncological outcomes were assessed between propensity score-matched cohorts.

RESULTS

Urethral recurrence (UR) occurred in 5 patients (5/166, 3.0%), all of whom underwent open-RC. Three among those (1.8%) with concomitant metastasis were died of cancer. There were no statistically significant differences between the PU and UPS groups in urethral-recurrence free survival (urethral-RFS) (P = .14), local-RFS (P = .59) and overall survival (OS) (P = .84) in the entire cohort. However, the UPS group showed significantly worse urethral-RFS (P = .008), local-RFS (P = .005) and OS (P = .03) in patients with high-risk of UR. Analysis of recurrence patterns revealed that UPS in high-risk patients significantly increased local recurrence (25.8% vs. 5.0%, P = .02). Conversely, a novel robotic-UPS technique demonstrated significantly favorable perioperative outcomes, comparable local-RFS (P = .79) and OS (P = .16) without UR (0/134, 0%) when compared to robotic-PU. Robotic-UPS also exhibited significantly better local-RFS (P =.007) and OS (P < .001) than open-UPS.

CONCLUSIONS

UR-related death was rare and PU did not show a survival benefit for the entire cohort. However, inappropriate UPS in patients at high-risk of UR may increase local recurrence which might be responsible for poor survival after UPS rather than disease progression derived from UR. The robotic-UPS has the potential to reduce unnecessary PU, urethral and local recurrence without compromising survival.

Follow-up of the Urethra and Management of Urethral Recurrence After Radical Cystectomy: A Systematic Review and Proposal of Management Algorithm by the European Association of Urology-Young Academic Urologists: Urothelial Carcinoma Working Group

CONTEXT

Surveillance of the urethra and management of urethral recurrence (UR) after radical cystectomy (RC) is an area with poor evidence.

OBJECTIVE

We aimed to summarize the available evidence and provide clinicians with practical recommendations on how to prevent and manage UR after RC for bladder cancer.

EVIDENCE ACQUISITION

The MEDLINE and EMBASE databases were searched during September 2021 for studies evaluating UR after RC. The primary endpoint was oncologic outcomes for patients who experienced UR depending on different surveillance and management approaches.

EVIDENCE SYNTHESIS

Forty-three studies were included in the quantitative synthesis. According to the currently available literature, a tight-knitted surveillance protocol should be implemented for males treated with RC and nonorthotopic neobladder diversion as well as patients with prostatic involvement, tumor multifocality, bladder neck involvement, and concomitant carcinoma in situ. A survival benefit of a prophylactic urethrectomy has been reported only in patients at very high risk for UR based on clinical factors. Surveillance protocols were highly heterogeneous and poorly documented among included studies. Patients whose UR was diagnosed based on clinical symptoms had a poor prognosis. Only limited data were available on the comparative effectiveness of watchful waiting after RC versus clinical symptom screening as part of a follow-up strategy. However, the use of regular cytology and/or urethroscopy seems useful in select patients at high risk for UR. Despite limited data on the optimal management of UR, urethra-sparing approaches (transurethral resection of UR) seem to be an option for Ta (only) recurrences; a salvage urethrectomy with or without chemotherapy should be the standard for all others.

CONCLUSIONS

Based on the currently available literature, we have proposed an algorithm to guide the decision-making process to help identify and treat UR after RC. Given the lack of evidence on how to deal with UR and surveil patients at risk for UR, this study may invigorate research in this area of unmet need.

PATIENT SUMMARY

Early diagnosis and tailored management of urethral recurrence could help improve oncologic outcomes in these patients.

Spectrum of imaging manifestations of tumour recurrences in orthotopic neobladder

Continent diversion with orthotopic neobladder is the most upcoming form of urinary diversion postradical cystectomy. This allows patients to void through the native urethra preserving the maximal quality of life. These patients with greater life expectancies increasingly present with a wide range of late complications, which also include local recurrences involving neobladder. Such presentations on surveillance scans can be challenging for radiologists unfamiliar with expected post-surgical anatomy and usual sites of local recurrences. Tumour in neobladder, although rare, has predilection concerning specific sites of involvement and few distinct histological types. Major subtypes of such recurrences with corresponding radiological features on multimodality imaging have been discussed in this article. Management of such cases with revision of diversions is challenging, and surgeons expect a meticulous read of such scans before contemplating pelvic clearance and secondary diversions. This pictorial review aims to appraise the literature related to various primary and secondary types of tumours involving reservoir and anastomotic sites in an orthotopic neobladder, their relative incidences and illustrate salient imaging points with case examples.

Incidence, risk factors and outcomes of urethral recurrence after radical cystectomy for bladder cancer: A systematic review and meta-analysis

We aimed to conduct a systematic review and meta-analysis assessing the incidence and risk factors of urethral recurrence (UR) as well as summarizing data on survival outcomes in patients with UR after radical cystectomy (RC) for bladder cancer. The MEDLINE and EMBASE databases were searched in February 2021 for studies of patients with UR after RC. Incidence and risk factors of UR were the primary endpoints. The secondary endpoint was survival outcomes in patients who experienced UR. Twenty-one studies, comprising 9,435 patients, were included in the quantitative synthesis. Orthotopic neobladder (ONB) diversion was associated with a decreased probability of UR compared to non-ONB (pooled OR: 0.44, 95% CI: 0.31-0.61, P < 0.001) and male patients had a significantly higher risk of UR compared to female patients (pooled OR: 3.16, 95% CI: 1.83-5.47, P < 0.001). Among risk factors, prostatic urethral or prostatic stromal involvement (pooled HR: 5.44, 95% CI: 3.58-8.26, P < 0.001; pooled HR: 5.90, 95% CI: 1.82-19.17, P = 0.003, respectively) and tumor multifocality (pooled HR: 2.97, 95% CI: 2.05-4.29, P < 0.001) were associated with worse urethral recurrence-free survival. Neither tumor stage (P = 0.63) nor CIS (P = 0.72) were associated with worse urethral recurrence-free survival. Patients with UR had a 5-year CSS that varied from 47% to 63% and an OS - from 40% to 74%; UR did not appear to be related to worse survival outcomes. Male patients treated with non-ONB diversion as well as patients with prostatic involvement and tumor multifocality seem to be at the highest risk of UR after RC. Risk-adjusted standardized surveillance protocols should be developed into clinical practice after RC.

Ureteral and urethral recurrence after radical cystectomy: a systematic review

PURPOSE OF REVIEW

The clinical significance of ureteral and urethral recurrence in patients treated with radical cystectomy for bladder cancer is scarce and heterogeneous. The aim of the current review is to summarize the recent literature on incidence, diagnosis and oncologic outcomes of ureteral and urethral recurrences after radical cystectomy.

RECENT FINDINGS

Frozen section analysis (FSA) of ureteral margin had a sensitivity and specificity of 69-77 and 83-96%, respectively. Considering the ureteral margin, the reported sensitivity and specificity were 33-93 and 99-100%, respectively. Transurethral biopsy of the prostatic urethra might help in counseling patients' treatment, although its accuracy and prognostic role is highly questionable. In patients treated with radical cystectomy, recurrence of the urethra or ureteral are rare, occurring approximately in 5% of patients. During the follow-up, urinary cytology and cross-sectional imaging improve the early detection of recurrence in asymptomatic patients, although the majority are diagnosed for symptomatic presentation. Their use should be tailored to the patient's risk of ureteral and/or urethral recurrence. Urethrectomy is indicated in case of singular urethral recurrence, whereas no clear data exists regarding the best management of ureteral recurrence, except surgical removal.

SUMMARY

Intraoperative FSA of ureters and urethra share good specificity but poor sensitivity. Recurrence at urethra and upper tract are rare and discordant data exists regarding survival outcomes. Oncologic surveillance after radical cystectomy with the aim to detect these recurrences should be tailored to the individualized patient's risk.