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BMJ (Clinical Research Ed.) Feb 2024Bladder cancer remains a leading cause of cancer death worldwide and is associated with substantial impacts on patient quality of life, morbidity, mortality, and cost to... (Review)
Review
Bladder cancer remains a leading cause of cancer death worldwide and is associated with substantial impacts on patient quality of life, morbidity, mortality, and cost to the healthcare system. Gross hematuria frequently precedes the diagnosis of bladder cancer. Non-muscle-invasive bladder cancer (NMIBC) is managed initially with transurethral resection of a bladder tumor (TURBT), followed by a risk stratified approach to adjuvant intravesical therapy (IVe), and is associated with an overall survival of 90%. However, cure rates remain lower for muscle invasive bladder cancer (MIBC) owing to a variety of factors. NMIBC and MIBC groupings are heterogeneous and have unique pathological and molecular characteristics. Indeed, The Cancer Genome Atlas project identified genetic drivers and luminal and basal molecular subtypes of MIBC with distinct treatment responses. For NMIBC, IVe immunotherapy (primarily BCG) is the gold standard treatment for high grade and high risk NMIBC to reduce or prevent both recurrence and progression after initial TURBT; novel trials incorporate immune checkpoint inhibitors. IVe gene therapy and combination IVe chemotherapy have recently been completed, with promising results. For localized MIBC, essential goals are improving care and reducing morbidity following cystectomy or bladder preserving strategies. In metastatic disease, advances in understanding of the genomic landscape and tumor microenvironment have led to the implementation of immune checkpoint inhibitors, targeted treatments, and antibody-drug conjugates. Defining better selection criteria to identify the patients most likely to benefit from a specific treatment is an urgent need.
Topics: Humans; Immune Checkpoint Inhibitors; Quality of Life; Non-Muscle Invasive Bladder Neoplasms; Urinary Bladder Neoplasms; Immunotherapy; Cystectomy; Neoplasm Invasiveness; BCG Vaccine; Tumor Microenvironment
PubMed: 38346808
DOI: 10.1136/bmj-2023-076743 -
European Urology Oct 2023Differences in recovery, oncological, and quality of life (QoL) outcomes between open radical cystectomy (ORC) and robot-assisted radical cystectomy (RARC) for patients... (Meta-Analysis)
Meta-Analysis Review
Robot-assisted Radical Cystectomy Versus Open Radical Cystectomy: A Systematic Review and Meta-analysis of Perioperative, Oncological, and Quality of Life Outcomes Using Randomized Controlled Trials.
CONTEXT
Differences in recovery, oncological, and quality of life (QoL) outcomes between open radical cystectomy (ORC) and robot-assisted radical cystectomy (RARC) for patients with bladder cancer are unclear.
OBJECTIVE
This review aims to compare these outcomes within randomized trials of ORC and RARC in this context. The primary outcome was the rate of 90-d perioperative events. The secondary outcomes included operative, pathological, survival, and health-related QoL (HRQoL) measures.
EVIDENCE ACQUISITION
Systematic literature searches of MEDLINE, Embase, Web of Science, and clinicaltrials.gov were performed up to May 31, 2022.
EVIDENCE SYNTHESIS
Eight trials, reporting 1024 participants, were included. RARC was associated with a shorter hospital length of stay (LOS; mean difference [MD] 0.21, 95% confidence interval [CI] 0.03-0.39, p = 0.02) than and similar complication rates to ORC. ORC was associated with higher thromboembolic events (odds ratio [OR] 1.84, 95% CI 1.02-3.31, p = 0.04). ORC was associated with more blood loss (MD 322 ml, 95% CI 193-450, p < 0.001) and transfusions (OR 2.35, 95% CI 1.65-3.36, p < 0.001), but shorter operative time (MD 76 min, 95% CI 39-112, p < 0.001) than RARC. No differences in lymph node yield (MD 1.07, 95% CI -1.73 to 3.86, p = 0.5) or positive surgical margin rates (OR 0.95, 95% CI 0.54-1.67, p = 0.9) were present. RARC was associated with better physical functioning or well-being (standardized MD 0.47, 95% CI 0.29-0.65, p < 0.001) and role functioning (MD 8.8, 95% CI 2.4-15.1, p = 0.007), but no improvement in overall HRQoL. No differences in progression-free survival or overall survival were seen. Limitations may include a lack of generalization given trial patients.
CONCLUSIONS
RARC offers various perioperative benefits over ORC. It may be more suitable in patients wishing to avoid blood transfusion, those wanting a shorter LOS, or those at a high risk of thromboembolic events.
PATIENT SUMMARY
This study compares robot-assisted keyhole surgery with open surgery for bladder cancer. The robot-assisted approach offered less blood loss, shorter hospital stays, and fewer blood clots. No other differences were seen.
Topics: Humans; Cystectomy; Quality of Life; Robotics; Treatment Outcome; Postoperative Complications; Randomized Controlled Trials as Topic; Urinary Bladder Neoplasms; Robotic Surgical Procedures
PubMed: 37169638
DOI: 10.1016/j.eururo.2023.04.004 -
European Urology Jan 2024We present an overview of the updated 2023 European Association of Urology (EAU) guidelines for muscle-invasive and metastatic bladder cancer (MMIBC). (Review)
Review
CONTEXT
We present an overview of the updated 2023 European Association of Urology (EAU) guidelines for muscle-invasive and metastatic bladder cancer (MMIBC).
OBJECTIVE
To provide practical evidence-based recommendations and consensus statements on the clinical management of MMIBC with a focus on diagnosis and treatment.
EVIDENCE ACQUISITION
A broad and comprehensive scoping exercise covering all areas of the MMIBC guidelines has been performed annually since 2017. Searches cover the Medline, EMBASE, and Cochrane Libraries databases for yearly guideline updates. A level of evidence and strength of recommendation are assigned. The evidence cutoff date for the 2023 MIBC guidelines was May 4, 2022.
EVIDENCE SYNTHESIS
Patients should be counselled regarding risk factors for bladder cancer. Pathologists should describe tumour and lymph nodes in detail, including the presence of histological subtypes. The importance of the presence or absence of urothelial carcinoma (UC) in the prostatic urethra is emphasised. Magnetic resonance imaging (MRI) of the bladder is superior to computed tomography (CT) for disease staging, specifically in differentiating T1 from T2 disease, and may lead to a change in treatment approach in patients at high risk of an invasive tumour. Imaging of the upper urinary tract, lymph nodes, and distant metastasis is performed with CT or MRI; the additional value of flurodeoxyglucose positron emission tomography/CT still needs to be determined. Frail and comorbid patients should be evaluated by a multidisciplinary team. Postoperative histology remains the most important prognostic variable, while circulating tumour DNA appears to be an interesting predictive marker. Neoadjuvant systemic therapy remains cisplatin-based. In motivated and selected women and men, sexual organ-preserving cystectomy results in better functional outcomes without compromising oncological outcomes. Robotic and open cystectomy have comparable outcomes and should be combined with (extended) lymph node dissection. The diversion type is an individual choice after taking patient and tumour characteristics into account. Radical cystectomy remains a highly complex procedure with considerable morbidity and risk of mortality, although lower rates are observed for higher hospital volumes (>20 cases/yr). With proper patient selection, trimodal therapy (chemoradiation) has comparable outcomes to radical cystectomy. Adjuvant chemotherapy after surgery improves disease-specific survival and overall survival (OS) in patients with high-risk disease who did not receive neoadjuvant treatment, and is strongly recommended. There is a weak recommendation for adjuvant nivolumab, as OS data are not yet available. Health-related quality of life should be assessed using validated questionnaires at baseline and after treatment. Surveillance is needed to monitor for recurrent cancer and functional outcomes. Recurrences detected on follow-up seem to have better prognosis than symptomatic recurrences.
CONCLUSIONS
This summary of the 2023 EAU guidelines provides updated information on the diagnosis and treatment of MMIBC for incorporation into clinical practice.
PATIENT SUMMARY
The European Association of Urology guidelines panel on muscle-invasive and metastatic bladder cancer has released an updated version of the guideline containing information on diagnosis and treatment of this disease. Recommendations are based on studies published up to May 4, 2022. Surgical removal of the bladder and bladder preservation are discussed, as well as updates on the use of chemotherapy and immunotherapy in localised and metastatic disease.
Topics: Male; Humans; Female; Urinary Bladder Neoplasms; Carcinoma, Transitional Cell; Urology; Quality of Life; Cystectomy; Muscles; Neoplasm Invasiveness
PubMed: 37858453
DOI: 10.1016/j.eururo.2023.08.016 -
BMJ Case Reports Aug 2023A man in his early 70s presented with stiffness and aching in the shoulder and pelvic girdles. His C reactive protein level was elevated at 116 mg/L, leading to an...
A man in his early 70s presented with stiffness and aching in the shoulder and pelvic girdles. His C reactive protein level was elevated at 116 mg/L, leading to an initial diagnosis of polymyalgia rheumatica. Treatment with prednisone at 20 mg/day provided limited improvement and relapses recurred despite concomitant immunosuppressive agents. Extensive investigations failed to reveal an underlying aetiology.Five years later, gross painless haematuria led to the detection of an invasive papillary urothelial carcinoma. A review of the staging CT scan revealed findings compatible with bilateral erosive sacroiliitis, which had developed since his initial presentation. Radical cystoprostatectomy provided temporary relief but after a further 9 months, symptoms relapsed, and metastatic spread was discovered.Paraneoplastic sacroiliitis is a rare clinical entity; and to the best of our knowledge, this is the first reported case associated with a solid tumour.
Topics: Male; Humans; Carcinoma, Transitional Cell; Sacroiliitis; Urinary Bladder Neoplasms; Autoantibodies; Cystectomy
PubMed: 37652573
DOI: 10.1136/bcr-2022-252572 -
European Urology Focus Nov 2023Radical cystectomy is considered a procedure of high complexity with a relative high complication rate. (Meta-Analysis)
Meta-Analysis Review
CONTEXT
Radical cystectomy is considered a procedure of high complexity with a relative high complication rate.
OBJECTIVE
To systematically summarize the literature regarding the complications of radical cystectomy and the factors that contribute to them.
EVIDENCE ACQUISITION
We searched MEDLINE/PubMed, ClinicalTrials.gov, and Cochrane Library, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines for randomized controlled trials (RCTs) on complications related to radical cystectomy.
EVIDENCE SYNTHESIS
A total of 3766 studies were screened, and 44 studies were included in this systematic review and meta-analysis. Complications following radical cystectomy are quite common. The most common complications were gastrointestinal complications (20%), infectious complications (17%), and ileus (14%). The majority of complications occurring were Clavien I-II (45%). Specific measurable patient factors are related to certain complications and can be used to stratify risk and assist in preoperative counseling, while proper design of high-quality RCTs may better reflect real-life complication rates.
CONCLUSIONS
In our study, RCTs with a low risk of bias had higher complication rates than studies with a high risk of bias, underlining the need for further improvement on complication reporting in order to refine surgical outcomes.
PATIENT SUMMARY
Radical cystectomy is usually followed by high complication rates, which affect patients and are, in turn, strongly associated with patients' preoperative health status.
Topics: Humans; Cystectomy; Urinary Bladder Neoplasms; Robotic Surgical Procedures; Postoperative Complications; Treatment Outcome; Randomized Controlled Trials as Topic
PubMed: 37246124
DOI: 10.1016/j.euf.2023.05.002 -
Journal of Clinical Oncology : Official... Sep 2023Bladder-sparing trimodal therapy (TMT) is an alternative to radical cystectomy (RC) according to international guidelines. However, there are limited data to guide...
Bladder-Sparing Treatment With Radical Dose Radiotherapy Is an Effective Alternative to Radical Cystectomy in Patients With Clinically Node-Positive Nonmetastatic Bladder Cancer.
PURPOSE
Bladder-sparing trimodal therapy (TMT) is an alternative to radical cystectomy (RC) according to international guidelines. However, there are limited data to guide management of nonmetastatic clinically node-positive bladder cancer (cN+ M0 BCa). We performed a multicenter retrospective analysis of survival outcomes in node-positive patients to inform practice.
METHODS
Data from patients diagnosed with cN+ M0 BCa were collected from participating UK Oncology centers offering both TMT and RC. Overall survival (OS) and progression-free survival (PFS) outcomes were collected with details of treatment and clinical factors.
RESULTS
A total of 287 patients with cN+ M0 BCa were included in the survival analysis. Median OS across all patients was 1.55 years (95% CI, 1.35 to 1.82 years). Receiving radical treatments was associated with improved OS (hazard ratio [HR], 0.32; 95% CI, 0.23 to 0.44; < .001) compared with receiving palliative treatment. Radically treated patients (n = 163) received RC (n = 76) or radical dose radiotherapy (RT, n = 87); choice of radical treatment showed no association with OS (HR, 0.94; 95% CI, 0.63 to 1.41; = .76) or PFS (HR, 0.74; 95% CI, 0.50 to 1.08; = .12) on multivariable analysis.
CONCLUSION
Patient cohorts with cN+ M0 BCa had equivalent survival outcomes whether treated with surgery or radical RT. Given the known morbidities of RC-in a patient group with poor survival-this study confirms that bladder-sparing TMT treatment should be a treatment option available to all patients with cN+ M0 BCa.
Topics: Humans; Urinary Bladder; Cystectomy; Retrospective Studies; Treatment Outcome; Urinary Bladder Neoplasms
PubMed: 37478391
DOI: 10.1200/JCO.23.00725 -
Aktuelle Urologie Apr 2024
Topics: Humans; BCG Vaccine; Cystectomy; Non-Muscle Invasive Bladder Neoplasms; Antibodies, Monoclonal; Immunologic Factors; Urinary Bladder Neoplasms
PubMed: 38537657
DOI: 10.1055/a-2175-3560 -
Aktuelle Urologie Feb 2024
Topics: Adult; Humans; Urinary Bladder; Cystectomy; Urinary Bladder Neoplasms; Muscles
PubMed: 38330953
DOI: 10.1055/a-2223-3380 -
Clinical Genitourinary Cancer Apr 2024Many patients with muscle-invasive bladder cancer are poor candidates for radical cystectomy or trimodality therapy with maximal transurethral resection of bladder tumor...
INTRODUCTION
Many patients with muscle-invasive bladder cancer are poor candidates for radical cystectomy or trimodality therapy with maximal transurethral resection of bladder tumor (TURBT) and chemoradiotherapy with cisplatin or mitomycin C. Given the benefit of chemotherapy in bladder-preserving therapy, less-intense concurrent chemotherapy regimens are needed. This study reports on efficacy and toxicity for patients treated with trimodality therapy using single-agent concurrent capecitabine.
MATERIALS AND METHODS
Patients deemed ineligible for radical cystectomy or standard chemoradiotherapy by a multidisciplinary tumor board and patients who refused cystectomy were included. Following TURBT, patients received twice-daily capecitabine (goal dose 825 mg/m) concurrent with radiotherapy to the bladder +/- pelvis depending on nodal staging and patient risk factors. Toxicity was evaluated prospectively in weekly on-treatment visits and follow-up visits by the treating physicians. Descriptive statistics are provided. Overall, progression-free, cancer-specific, distant metastasis-free, and bladder recurrence-free survival were estimated using the Kaplan-Meier method.
RESULTS
Twenty-seven consecutive patients met criteria for inclusion from 2013 to 2023. The median age was 79 with 9 patients staged cT3-4a and 7 staged cN1-3. The rate of complete response in the bladder and pelvis was 93%. Overall, progression-free, cancer-specific, distant metastasis-free, and bladder recurrence-free survival at 2 years were estimated as 81%, 65%, 91%, 75%, and 92%, respectively. There were 2 bladder recurrences, both noninvasive. There were 7 grade 3 acute hematologic or metabolic events but no other grade 3+ toxicities.
CONCLUSION
Maximal TURBT followed by radiotherapy with concurrent capecitabine offers a high rate of bladder control and low rates of acute and late toxicity.
Topics: Humans; Aged; Capecitabine; Combined Modality Therapy; Urinary Bladder; Urinary Bladder Neoplasms; Cisplatin; Cystectomy; Neoplasm Invasiveness
PubMed: 38228414
DOI: 10.1016/j.clgc.2024.01.002 -
European Urology Nov 2023Little is known regarding functional outcomes after robot-assisted radical cystectomy (RARC) and intracorporeal neobladder (ICNB) reconstruction.
BACKGROUND
Little is known regarding functional outcomes after robot-assisted radical cystectomy (RARC) and intracorporeal neobladder (ICNB) reconstruction.
OBJECTIVE
To report on urinary continence (UC) and erectile function (EF) at 12 mo after RARC and ICNB reconstruction and investigate predictors of these outcomes.
DESIGN, SETTING, AND PARTICIPANTS
We used data from a multi-institutional database of patients who underwent RARC and ICNB reconstruction for bladder cancer.
SURGICAL PROCEDURE
The cystoprostatectomy sensu stricto followed the conventional steps. ICNB reconstruction was performed at the physician's discretion according to the Studer/Wiklund, S pouch, Gaston, vescica ileale Padovana, or Hautmann technique. The techniques are detailed in the video accompanying the article.
MEASUREMENTS
The outcomes measured were UC and EF at 12 mo.
RESULTS AND LIMITATIONS
A total of 732 male patients were identified with a median age at diagnosis of 64 yr (interquartile range 58-70). The ICNB reconstruction technique was Studer/Wiklund in 74%, S pouch in 1.5%, Gaston in 19%, vescica ileale Padovana in 1.5%, and Hautmann in 4% of cases. The 12-mo UC rate was 86% for daytime and 66% for nighttime continence, including patients who reported the use of a safety pad (20% and 32%, respectively). The 12-mo EF rate was 55%, including men who reported potency with the aid of phosphodiesterase type 5 inhibitors (24%). After adjusting for potential confounders, neobladder type was not associated with UC. Unilateral nerve-sparing (odds ratio [OR] 3.85, 95% confidence interval [CI] 1.88-7.85; p < 0.001) and bilateral nerve-sparing (OR 6.25, 95% CI 3.55-11.0; p < 0.001), were positively associated with EF, whereas age (OR 0.93, 95% CI 0.91-0.95; p < 0.001) and an American Society of Anesthesiologists score of 3 (OR 0.46, 95% CI 0.25-0.89; p < 0.02) were inversely associated with EF.
CONCLUSIONS
RARC and ICNB reconstruction are generally associated with good functional outcomes in terms of UC. EF is highly affected by the degree of nerve preservation, age, and comorbidities.
PATIENT SUMMARY
We investigated functional outcomes after robot-assisted removal of the bladder in terms of urinary continence and erectile function. We found that, in general, patients have relatively good functional outcomes at 12 months after surgery.
Topics: Humans; Male; Urinary Bladder; Cystectomy; Robotics; Erectile Dysfunction; Treatment Outcome; Urinary Bladder Neoplasms; Robotic Surgical Procedures; Urinary Diversion
PubMed: 37117109
DOI: 10.1016/j.eururo.2023.04.009