Disparities in the Use of Continent Urinary Diversions after Radical Cystectomy for Bladder Cancer

Continent cutaneous diversion: Unveiling the interplay of neuro-urology and oncological challenges

OBJECTIVES

The objective of our study is to demonstrate the practical application of continent cutaneous urinary diversion (CCUD) in oncological patients, with a focus on various aspects of the procedure: surgical challenges, functional outcomes, and quality of life.

MATERIALS AND METHODS

We studied the perioperative and follow-up data of patients who underwent cystectomy for cancer associated with CCUD (Mitrofanoff, Monti or Casale). We retrospectively analyzed complications within 30days and beyond 30days post-surgery. We evaluated oncological outcomes. Patients' quality of life was assessed using the Bladder Cancer Index (BCI) questionnaire. Results are given on an intention-to-treat basis.

RESULTS

A total of 24 patients were included in the study (July 2001 and May 2022), with a median follow-up of 62.5months. We report three deaths due to neoplasic recurrence. Forty-six percent had an early postoperative complication, two of whom required revision surgery. Overall, the medium-term complication rate was 70% and the reoperation rate was 62%. There were 8 stomal cutaneous stenoses (33%) and 3 uretero-ileal stenoses (12.5%). Overall satisfaction was rated at 9.2/10 on average, and body image was unaltered or slightly altered in 62.5% of patients. Of the patients who responded to the BCI, 75% had complete continence.

DISCUSSION

The experience gained with continent stomas in neuro-urology has allowed, in carefully selected cases, to offer patients an alternative that can improve their quality of life in a context already burdened by the shadow of cancer. CCUD can be proposed as an alternative to Bricker diversion in cases of urethral invasion or a high risk of neobladder incontinence, in selected patients.

LEVEL OF EVIDENCE: 4

The sex gap in bladder cancer survival - a missing link in bladder cancer care?

The differences in bladder cancer outcomes between the sexes has again been highlighted. Uncommon among cancers, bladder cancer outcomes are notably worse for women than for men. Furthermore, bladder cancer is three to four times more common among men than among women. Factors that might explain these sex differences include understanding the importance of haematuria as a symptom of bladder cancer by both clinicians and patients, the resultant delays in diagnosis and referral of women with haematuria, and health-care access. Notably, these factors seem to have geographical variation and are not consistent across all health-care systems. Likewise, data relating to sex-specific treatment responses for patients with non-muscle-invasive or muscle-invasive bladder cancer are inconsistent. The influence of differences in the microbiome, bladder wall thickness and urine dwell times remain to be elucidated. The interplay of hormone signalling, gene expression, immunology and the tumour microenvironment remains complex but probably underpins the sexual dimorphism in disease incidence and stage and histology at presentation. The contribution of these biological phenomena to sex-specific outcome differences is probable, albeit potentially treatment-specific, and further understanding is required. Notwithstanding these aspects, we identify opportunities to harness biological differences to improve treatment outcomes, as well as areas of fundamental and translational research to pursue. At the level of policy and health-care delivery, improvements can be made across the domains of patient awareness, clinician education, referral pathways and guideline-based care. Together, we aim to highlight opportunities to close the sex gap in bladder cancer outcomes.

Application of metagenomic next-generation sequencing in the diagnosis of urinary tract infection in patients undergoing cutaneous ureterostomy

Objective

Urinary tract infection (UTI) is an inflammatory response of the urothelium to bacterial invasion and is a common complication in patients with cutaneous ureterostomy (CU). For such patients, accurate and efficient identification of pathogens remains a challenge. The aim of this study included exploring utility of metagenomic next-generation sequencing (mNGS) in assisting microbiological diagnosis of UTI among patients undergoing CU, identifying promising cytokine or microorganism biomarkers, revealing microbiome diversity change and compare virulence factors (VFs) and antibiotic resistance genes (ARGs) after infection.

Methods

We performed a case-control study of 50 consecutive CU patients from December 2020 to January 2021. According to the clinical diagnostic criteria, samples were divided into infected group and uninfected group and difference of urine culture, cytokines, microorganism, ARGs and VFs were compared between the two groups.

Results

Inflammatory responses were more serious in infected group, as evidenced by a significant increase in IFN-α (p=0.031), IL-1β (0.023) and IL-6 (p=0.018). Clinical culture shows that there is higher positive rate in infected group for most clinical pathogens like Escherichia coli, Klebsiella pneumoniae, Staphylococcus aureus, Candida auris etc. and the top three pathogens with positive frequencies were E. coli, K. pneumoniae, and Enterococcus faecalis. Benchmarking clinical culture, the total sensitivity is 91.4% and specificity is 76.3% for mNGS. As for mNGS, there was no significant difference in microbiome α- diversity between infected and uninfected group. Three species biomarkers including Citrobacter freundii, Klebsiella oxytoca, and Enterobacter cloacae are enriched in infected group based on Lefse. E. cloacae were significantly correlated with IL-6 and IL-10. K. oxytoca were significantly correlated with IL-1β. Besides, the unweighted gene number and weighted gene abundance of VFs or ARGs are significantly higher in infected group. Notablely, ARGs belonging to fluoroquinolones, betalatmas, fosfomycin, phenicol, phenolic compound abundance is significantly higher in infected group which may have bad effect on clinical treatment for patients.

Conclusion

mNGS, along with urine culture, will provide comprehensive and efficient reference for the diagnosis of UTI in patients with CU and allow us to monitor microbial changes in urine of these patients. Moreover, cytokines (IL-6, IL-1β, and IFN-a) or microorganisms like C. freundii, K. oxytoca or E. cloacae are promising biomarkers for building effective UTI diagnostic model of patients with CU and seriously the VFs and ARGs abundance increase in infected group may play bad effect on clinical treatment.

Epidemiology, Screening, and Prevention of Bladder Cancer

CONTEXT

Bladder cancer (BC) represents a significant health problem due to the potential morbidity and mortality associated with disease burden, which has remained largely unaltered over time.

OBJECTIVE

To provide an expert collaborative review and describe the incidence, prevalence, and mortality of BC and to evaluate current evidence for BC screening and prevention.

EVIDENCE ACQUISITION

Data on the estimated incidence and mortality of BC for 2020 in 185 countries were derived from the International Agency for Research on Cancer GLOBOCAN database. A review of English-language articles published over the past 5 yr was conducted using PubMed/MEDLINE to identify risk factors in addition to contemporary evidence on BC screening and prevention.

EVIDENCE SYNTHESIS

BC is the tenth most common cancer worldwide, with 573 278 cases in 2020. BC incidence is approximately fourfold higher in men than women. Tobacco smoking remains the principal risk factor, accounting for approximately 50% of cases. There is insufficient evidence to recommend routine BC screening. However, targeted screening of high-risk individuals (defined according to smoking history or occupational exposure) may reduce BC mortality and should be the focus of prospective randomized trials. In terms of disease prevention, smoking cessation represents the most important intervention, followed by a reduction in exposure to occupational and environmental carcinogens.

CONCLUSIONS

BC confers a significant disease burden. An understanding of BC epidemiology and risk factors provides an optimal foundation for disease prevention and the care of affected patients.

PATIENT SUMMARY

Bladder cancer is the tenth most common cancer worldwide and is approximately four times more common among men than among women. The main risk factors are tobacco smoking, followed by exposure to carcinogens in the workplace or the environment. Routine screening is not currently recommended, but may be beneficial in individuals at high risk, such as heavy smokers. Primary prevention is extremely important, and smoking cessation represents the most important action for reducing bladder cancer cases and deaths.

Radical cystectomy and urinary diversion in women: techniques, outcomes, and challenges-a narrative review

Background and Objective

Standard radical cystectomy (RC) in women includes the removal of the bladder, urethra, uterus with the adnexa, and the anterior vaginal wall, thereby severely affecting the urinary, sexual, and reproductive system. To limit these detrimental effects, organ-sparing, including nerve-sparing approaches, have been developed. Health-related quality of life (HRQOL) and functional outcomes are, indeed, becoming increasingly central to the shared decision-making with the patient. The objectives of this narrative review are: (I) to review the current status of RC in women, including the use of different urinary diversions (UDs); (II) to discuss organ-sparing approaches and their impact on oncological and functional outcomes in women; (III) to discuss the impact of RC on HRQOL and sexual function in women.

Methods

We performed a non-systematic literature review of the available publications in the PubMed database.

Key Content and Findings

Over the past years, gender differences in oncological and functional outcomes after RC have received increased attention. According to the currently available literature, organ-sparing approaches can be safely performed in well-selected women without negatively impacting oncological outcomes. The orthotopic neobladder is feasible and oncologically safe in well-selected and informed women. The choice of the UD should be based on comprehensive counseling and the patient's comorbidities and preferences. There still is a lack of data on sexual recovery after the different surgical approaches aimed to mitigate sexual dysfunction in women undergoing RC.

Conclusions

Pre-and post-operative counseling and support of females undergoing RC regarding their expectations and experiences in terms of quality of life and functional and sexual outcomes are currently insufficient. Well-designed studies in this field are necessary to further improve outcomes of women treated with RC with an overarching aim to close the gender gap in managing women with bladder cancer.

Ileal Conduit versus Continent Urinary Diversion in Radical Cystectomy: A Retrospective Cohort Study of 30-day Complications, Readmissions, and Mortality

OBJECTIVES

To quantify the short-term burden associated with continent diversion relative to ileal conduit creation.

METHODS

Bladder cancer patients who underwent radical cystectomy in 2019 and 2020 were identified in the American College of Surgeons National Surgical Improvement Program database using current procedural terminology codes and pathology reports. Patients were grouped by urinary diversion performed: ileal conduit versus continent diversion (neobladder or cutaneous reservoir). Multiple logistic regression was used to examine the association between type of urinary diversion and 30-day outcomes, including postoperative complications, all-cause readmissions, and mortality, adjusting for baseline differences.

RESULTS

Of 4,755 patients who underwent radical cystectomy, 677 underwent continent diversion (14.2%). These patients were significantly younger (median 62 vs. 71 years, p< 0.01) and less likely to have diabetes (13.6% vs. 20.1%, p<0.01), COPD (3.7% vs. 7.1%, p<0.01), and prior pelvic radiation (5.5% vs. 13.1%, p<0.01). A greater proportion of continent diversion patients experienced a postoperative complication (56.0% vs. 48.9%, p<0.01) and all-cause readmission (30.3% vs. 20.4%, p<0.0). After adjustment, continent diversion patients had 1.4 (95% CI: 1.1 - 1.7) and 1.7 (95% CI: 1.4 - 2.1) times the odds of experiencing a postoperative complication or all-cause readmission, respectively. There was no statistically significant difference in mortality (OR 1.2, 95% CI: 0.5 - 2.9).

CONCLUSIONS

Compared to ileal conduit creation, continent urinary diversion is associated with increased odds of postoperative complications and readmission to the hospital within 30 days of surgery. Bladder cancer patients undergoing cystectomy and seeking continent diversion should be counseled on the increased short-term morbidity associated with this specific type of diversion.

Prophylactic parastomal mesh sublay at the time of ileal conduit: surgical technique

OBJECTIVE

To demonstrate the surgical technique for prophylactic mesh placement in the sublay position during ileal conduit creation because literature suggests that prophylactic mesh placement at the time of cystectomy may reduce the risk of parastomal hernias with low risk of mesh-related complications. Parastomal hernias are one of the most common complications following ileal conduit construction and occur in 17-65% of patients undergoing cystectomy with urinary diversion. Review of our institutions data demonstrated a high incidence of hernias associated with ileal conduits, which have substantial burden to patients, surgeons, and the healthcare system.

METHODS

This is a retrospective chart review of data from a single surgeon who performed cystectomy with ileal conduit for 12 patients with bladder cancer between 1/2021-3/2022 at our institution. These dates were chosen based on the timing of availability of literature suggesting a benefit from prophylactic mesh placement. Preliminary data was analyzed determine the incidence of parastomal hernia and mesh-related complications.

RESULTS

A total of 12 patients underwent cystectomy with ileal conduit between 1/2021-3/2022 at our institution. Eleven patients (92%) had prophylactic mesh placed during their procedure. Median follow up was 5.4 months (0.8-8 months). Two patients (17%) developed a parastomal hernia which was detected clinically and/or radiographically. The hernias occurred in patients with mesh and within 6 months of cystectomy. One patient had stomal stenosis eventually requiring surgical revision. There were no mesh infections or mesh removals.

CONCLUSIONS

Parastomal hernias are a common and morbid complication of ileal conduit urinary diversion. Our early experience demonstrates that the procedure is straightforward, adds little time to the surgical procedure, and is associated with a low complication rate. Our experience is too small and follow up too short to confirm that the results of the randomized trial can be matched at our center.

Screening Biomarkers and Constructing a Predictive Model for Symptomatic Urinary Tract Infection and Asymptomatic Bacteriuria in Patients Undergoing Cutaneous Ureterostomy: A Metagenomic Next-Generation Sequencing Study

Objectives. To investigate the clinical diagnostic value of differential flora as biomarkers in patients with symptomatic urinary tract infection (UTI) and asymptomatic bacteriuria (ASB) undergoing cutaneous ureterostomy based on metagenomic next-generation sequencing and construct predictive models to provide a scientific reference for clinical diagnosis and treatment. Material and Methods. According to standard procedures, samples were taken from each patient for routine tests (urine, ureteral stent, and skin swab around the stoma). Cytokine levels in the blood were also detected. Urinary microflora were measured by mNGS, and potential biomarkers for distinguishing UTI and ASB were identified by differential flora. Finally, we generated the predictive models for ASB and UTI using the Lasso method and cytokine levels. Results. Urine culture was performed for 50 patients with cutaneous ureterostomy; 44 of these patients developed bacteriuria. The incidence of symptomatic bacteriuria was 54.55%. Biomarker analysis showed that Propionimicrobium lymphophilum, Staphylococcus haemolyticus, Stenotrophomonas maltophilia, Ralstonia insidiosa, and Aspergillus sydowii all had good predictive performance and were combined in a single model. The predictive model exhibited good prediction performance (area under the curve $\left(\text{AUC}\right)=0.8729$ , $\text{sensitivity}=80\%$ , $\text{specificity}=83.3\%$ , and $\text{cutoff}=1.855$ ). We also identified a significant negative correlation between the weight sum of the abundance for these five characteristic pathogens (Sum_weighted_Reads) and levels of the cytokine IL-6 and IL-1β ( $P<0.05$ ). Conclusion. mNGS had a higher positive detection rate for pathogens in urine samples. The selected differential bacteria can be used as biomarkers of ASB and UTI, and the prediction model has good predictive performance. Analysis also showed that the occurrence of symptoms was related to individual immunity. Combined with the Sum_weighted_Reads cutoff and cytokine levels (IL-6 and IL-1β) of differential flora, it was possible to judge the severity of symptoms in cutaneous ureterostomy patients with bacteriuria and provide new insights for the treatment and intervention of ASB and UTI.

Removing Race from eGFR calculations: Implications for Urologic Care

Equations estimating the glomerular filtration rate are important clinical tools in detecting and managing kidney disease. Urologists extensively use these equations in clinical decision making. For example, the estimated glomerular function rate is used when considering the type of urinary diversion following cystectomy, selecting systemic chemotherapy in managing urologic cancers, and deciding the type of cross-sectional imaging in diagnosing or staging urologic conditions. However, these equations, while widely accepted, are imprecise and adjust for race which is a social, not a biologic construct. The recent killings of unarmed Black Americans in the US have amplified the discussion of racism in healthcare and has prompted institutions to reconsider the role of race in estimation of glomerular filtration rate equations and raced-based medicine. Urologist should be aware of the consequences of removing race from these equations, potential alternatives, and how these changes may affect Black patients receiving urologic care.

The Pull-through Anastomosis of Ureter to Enteric Conduit (PAUTEC): A Novel Technique for Urinary Diversion

OBJECTIVE

To describe and illustrate a novel technique of uretero-ileal anastomosis for use in urinary diversion - the Pull-through Anastomosis of Ureter To Enteric Conduit (PAUTEC). A second objective was to evaluate the surgical outcomes of the PAUTEC anastomosis.

MATERIALS AND METHODS

Our novel anastomotic technique was described step-by-step and visually depicted with illustrations and the accompanying narrated video. Additionally, to evaluate safety and efficacy, a retrospective review of a prospectively maintained database was performed. Patients who underwent radical cystectomy alone or during pelvic exenteration, with ileal conduit diversion incorporating PAUTEC, 2016-2020 with ≥6 months follow-up were included. Surgical outcomes and renal function were analysed.

RESULTS

PAUTEC anastomosis was performed on 43 ureters in 23 patients. Mean age was 66 years [50-80] and 21 of 23 patients were male. One patient had a conservatively-managed small urine leak. No ureteric strictures have been identified to date. Mean serum creatinine was 1.15 mg/dL [0.69-2.08] (102umol/L, range 61-184 umol/L) preoperatively, and 1.09 mg/dL [0.61-2.59] (96.3 umol/L, range 54-229 umol/L) at follow-up, demonstrating no significant change (P= .26, paired t-test). Mean follow-up was 15 months [6-44].

CONCLUSION

A PAUTEC technique of uretero-ileal anastomosis is feasible and technically straightforward, with satisfactory outcomes observed to date.

Orthotopic urinary diversions after radical cystectomy for bladder cancer: lessons learned last decade

PURPOSE OF REVIEW

Orthotopic urinary diversion (OUD), or neobladder, is believed to be the gold standard for surgical bladder reconstruction following radical cystectomy though it is performed far less often than ileal conduits. As both a continent and intracavitary diversion, OUDs offer unique advantages for patients. Their utilization has decreased overall though, especially with the advent of robotic surgery. In this review, we will cover patient selection for OUD, functional outcomes (i.e., continence, sexual activity, quality of life [QoL]), and robotic orthotopic diversions.

RECENT FINDINGS

OUDs have seen a proportionally greater decline in utilization compared with ileal conduits as the number of robotic radical cystectomies being performed with intracorporeal diversions increases. Multiple robotic series have demonstrated less perioperative blood loss and shorter hospital stays when compared with the open approach though operative times are longer, the learning curve is steeper, and overall costs may be higher in some settings. Perioperative safety and short-term oncological outcomes appear comparable. Since robotic OUDs are relatively new, functional outcomes are not yet well established. Patient satisfaction with urinary diversion is associated with informed decision-making tailored to the patient. A thorough understanding of expected short- and long-term functional outcomes and the care required to maintain an OUD improves QoL and satisfaction with diversion choice.

SUMMARY

Given the potential advantages of OUD, its decreasing use is a remarkable trend. Shared decision-making and a patient-centered approach should be used when selecting the type of urinary diversion.

Contemporary Outcomes of Open Radical Cystectomy: a 5-Year Experience from a Tertiary Care Center

To evaluate the perioperative outcomes of patients undergoing open radical cystectomy for carcinoma bladder in a tertiary care center. A retrospective analysis of a prospectively maintained database of all patients undergoing open radical cystectomy with a urinary diversion from July 2014 to August 2019 was done. A total of 195 patients were included. A total of 172 patients (88.2%) underwent radical cystectomy with ileal or sigmoid conduit, 6 patients underwent orthotopic neobladder, and 17 patients underwent cutaneous ureterostomy. The mean American Society of Anaesthesiology (ASA) score was 1.4. On preoperative histopathology, 125 patients had the muscle-invasive disease. The mean operative time (± SD) was 303.6 ± 53.4 min and the operative time was significantly longer for neobladder (p = 0.033). The mean blood loss (± SD) was 977.5 ± 346.5 ml. Among the complications, a total of 350 events occurred in 96 patients (49.3%). Thirty-nine patients (20%) suffered grade I complications, 12 patients (6.2%) suffered grade II complications, 26 patients (13.3%) suffered grade III complications, and 9 patients (4.6%) suffered grade IV complications. Grade III, IV, and V complications were considered major complications and 46 patients (23.5%) had major complications. Among the grade III complications, the majority included fascial dehiscence (burst abdomen), i.e., 13.3%, and uretero-ileal leak, i.e., 2.6%. The overall 30-day mortality rate was 5.2% (10/195). On multivariate analysis, the presence of diabetes mellitus (p = 0.047), operative time (p = 0.003), and low preoperative albumin (p = 0.009) were significant predictors for major preoperative complications. Diabetes mellitus, serum albumin, and operative time are significant predictors of postoperative complications. The ASA score, low preoperative hemoglobin, and blood loss are significant predictors of perioperative mortality. Though radical cystectomy has been associated with significant perioperative morbidity and mortality, the advancements in surgical techniques and intensive care tools have led to a significant decrease in morbidity and mortality in the contemporary era.

Prognostic significance of pathologic nodal positivity in non-metastatic patients with renal cell carcinoma who underwent radical or partial nephrectomy

This retrospective, five-multicenter study was aimed to evaluate the prognostic impact of pathologic nodal positivity on recurrence-free (RFS), metastasis-free (MFS), overall (OS), and cancer-specific (CSS) survivals in patients with non-metastatic renal cell carcinoma (nmRCC) who underwent either radical or partial nephrectomy with/without LN dissection. A total of 4236 nmRCC patients was enrolled between 2000 and 2012, and followed up through the end of 2017. Survival measures were compared between 52 (1.2%) stage pT1-4N1 (LN+) patients and 4184 (98.8%) stage pT1-4N0 (LN-) patients using Kaplan-Meier analysis with the log-rank test and Cox regression analysis to determine the prognostic risk factors for each survival measure. During the median 43.8-month follow-up, 410 (9.7%) recurrences, 141 (3.3%) metastases, and 351 (8.3%) deaths, including 212 (5.0%) cancer-specific deaths, were reported. The risk factor analyses showed that predictive factors for RFS, CSS, and OS were similar, whereas those of MFS were not. After adjusting for significant clinical factors affecting survival outcomes considering the hazard ratios (HR) of each group, the LN+ group, even those with low pT stage, had similar to or worse survival outcomes than the pT3N0 (LN-) group in multivariable analysis and had significantly more relationship with RFS than MFS. All survival measures were significantly worse in pT1-2N1 patients (MFS/RFS/OS/CSS; HR 4.12/HR 3.19/HR 4.41/HR 7.22) than in pT3-4N0 patients (HR 3.08/HR 2.92/HR 2.09/HR 3.73). Therefore, LN+ had an impact on survival outcomes worse than pT3-4N0 and significantly affected local recurrence rather than distant metastasis compared to LN- in nmRCC after radical or partial nephrectomy.

Urinary Diversion Disparity Following Radical Cystectomy for Bladder Cancer in the Hispanic Population

OBJECTIVE

To determine if disparities in quality of surgical care exist between Hispanics and non-Hispanics undergoing radical cystectomy for bladder cancer.

MATERIALS AND METHODS

An observational cohort study was conducted retrospectively on patients who underwent radical cystectomy for urothelial carcinoma of the bladder at our institution between January 2005 and July 2018. Data was collected on demographic, clinical, and pathological characteristics of patients, including self-reported ethnicity. Univariable and multivariable logistic or linear regression analyses were used to evaluate the association of ethnicity with receipt of neoadjuvant chemotherapy, utilization of laparoscopic surgery, number of lymph nodes removed, and continent urinary diversion.

RESULTS

We identified 507 patients in our database out of which, 136 (27%) were Hispanic and 371 (73%) were non-Hispanic. Compared to non-Hispanics, Hispanics had a higher body mass index (26.9 kg/m2 vs 28.2 kg/m2, P = .006) and lived further away from site of surgery (34 vs 96 miles, P = .02). No significant differences were observed in receipt of neoadjuvant chemotherapy, laparoscopic surgery, or number of lymph nodes removed during cystectomy between ethnicity groups. However, Hispanics were less likely than non-Hispanics to receive a continent urinary diversion on multivariable analysis (odds ratio 0.30, 95% confidence interval 0.10 - 0.92, P = .03).

CONCLUSION

Disparity exists in the delivery of continent urinary diversions for Hispanic patients undergoing radical cystectomy for bladder cancer. Further investigation is needed to determine the potential causes for this disparity in care delivered.