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Current Opinion in Urology Jul 2023Bilateral pelvic lymph node dissection (PLND) at the time of radical cystectomy (RC) provides important staging information and oncologic benefit in patients with... (Review)
Review
PURPOSE OF REVIEW
Bilateral pelvic lymph node dissection (PLND) at the time of radical cystectomy (RC) provides important staging information and oncologic benefit in patients with bladder cancer. The optimal extent of the PLND remains controversial. Our aim is to highlight nodal mapping studies and the data that guides optimization of both staging and oncologic outcomes. We then review contemporary randomized trials studying the extent of PLND.
RECENT FINDINGS
A recent randomized trial (RCT) powered for a 15% improvement in recurrence-free survival (RFS) of extended (e) over limited (l)PLND was completed but failed to identify this large difference in outcome. Concerns over study design limit the ability to interpret the oncologic results. Importantly, ePLND minimally changed surgical morbidity. An ongoing, similar RCT (SWOG S1011) powered to detect a 10% difference in RFS has completed accrual, but no published outcomes are available.
SUMMARY
RC and ePLND can provide cure in 33% of LN positive bladder cancer patients. Current data support a 5% improvement in RFS if ePLND is routinely used in MIBC patients. Two randomized trials powered to identify much larger (15 and 10%) improvements in RFS are unlikely to identify such an ambitious benefit by extending the PLND.
Topics: Humans; Pelvis; Urinary Bladder Neoplasms; Lymph Node Excision; Urinary Bladder; Cystectomy; Muscles; Lymph Nodes
PubMed: 37021936
DOI: 10.1097/MOU.0000000000001096 -
International Journal of Molecular... Dec 2023Bladder cancer (BC) stands as one of the most prevalent urological malignancies, with over 500 thousand newly diagnosed cases annually. Treatment decisions in BC depend... (Review)
Review
Bladder cancer (BC) stands as one of the most prevalent urological malignancies, with over 500 thousand newly diagnosed cases annually. Treatment decisions in BC depend on factors like the risk of recurrence, the type of tumor, and the stage of the disease. While standard therapeutic approaches encompass transurethral resection of the bladder tumor, radical cystectomy, and chemo- or immunotherapy, these methods exhibit limited efficacy in mitigating the aggressive and recurrent nature of bladder tumors. To overcome this challenge, it is crucial to develop innovative methods for monitoring and predicting treatment responses among patients with BC. Metabolomics is gaining recognition as a promising approach for discovering biomarkers. It has the potential to reveal metabolic disruptions that precisely reflect how BC patients respond to particular treatments, providing a revolutionary method to improve accuracy in monitoring and predicting outcomes. In this article, we present a comprehensive review of studies employing metabolomics approaches to investigate the metabolic responses associated with different treatment modalities for BC. The review encompasses an exploration of various models, samples, and analytical techniques applied in this context. Special emphasis is placed on the reported changes in metabolite levels derived from these studies, highlighting their potential as biomarkers for personalized medicine in BC.
Topics: Humans; Urinary Bladder Neoplasms; Urinary Bladder; Cystectomy; Metabolomics; Biomarkers
PubMed: 38139377
DOI: 10.3390/ijms242417543 -
BJU International Sep 2023To assess long-term voiding and renal function (RF) changes after radical cystectomy (RC) and orthotopic neobladder (ONB) surgery in women without disease recurrence.
OBJECTIVES
To assess long-term voiding and renal function (RF) changes after radical cystectomy (RC) and orthotopic neobladder (ONB) surgery in women without disease recurrence.
MATERIAL AND METHODS
Women who underwent RC and ONB reconstruction between 1995 and 2011 were included in this study. Patients who developed disease failure or were lost to follow-up were excluded. The study outcomes were long-term voiding function and the incidence and predictors of RF deterioration (defined as >20% decline of baseline). Analysis was performed using the log-rank test and Cox regression analysis.
RESULTS
The study included 195 patients with a median (interquartile range) follow-up of 98 (53-151) months, of whom 95 had >10 years of follow-up. Daytime continence, night-time continence and chronic urine retention (CUR) were identified in 170 (87%), 134 (69%) and 52 patients (27%), respectively. Among patients with >10 years of follow-up, 82 (86%), 66 (70%) and 31 (33%) had daytime continence, night-time continence and CUR at the last follow-up visit, respectively. RF deterioration events occurred in 74 patients throughout the follow-up and chronic kidney disease (CKD) stage III-V developed in 80 patients. Patients' age (hazard ratio [HR] 1.41, 95% confidence interval [CI]1.06-1.89; P = 0.02) and serous-lined extramural tunnel diversion (HR 0.43, 95% CI 0.19-0.86; P = 0.02) were the independent predictors of RF deterioration. Among patients with >10 years of follow-up, RF deteriorated in 46 patients (49%) and CKD stage III-V developed in 40 (42%).
CONCLUSION
Women surviving more than 10 years after RC and ONB maintained acceptable continence status, apart from having a higher CUR rate, compared to those followed for <10 years. However, RF deterioration developed in nearly half of them.
Topics: Humans; Female; Cystectomy; Urinary Diversion; Urinary Bladder Neoplasms; Treatment Outcome; Neoplasm Recurrence, Local; Urinary Retention; Kidney; Renal Insufficiency, Chronic
PubMed: 36961256
DOI: 10.1111/bju.16011 -
Urology Sep 2023To evaluate financial toxicity in Urologic surgery using the Comprehensive Score for financial Toxicity (COST) as well as validate a single item measure of toxicity.
OBJECTIVE
To evaluate financial toxicity in Urologic surgery using the Comprehensive Score for financial Toxicity (COST) as well as validate a single item measure of toxicity.
METHODS
A cross-sectional study of 182 patients undergoing oncologic and benign urologic procedures at a single academic medical center. Oncologic procedures included robotic assisted laparoscopic prostatectomy, transurethral resection of bladder tumor, and radical cystectomy. Benign procedures included holmium laser enucleation of the prostate, intravesical chemodenervation, ureteroscopy laser lithotripsy, and ureteral stent exchange. Retrospective review, patient interviews, and the previously validated COST survey, as well as a novel single item measure of toxicity were used pre and post-op. Descriptive statistics and logistic regression models compared COST scores by type of urologic procedure.
RESULTS
Eighty (44%) patients underwent oncologic procedures and 102 (56%) benign procedures. Benign patients were most likely to have lower income and be younger than oncologic patients, with a median age of 56.7 vs 64.9. One in 4 patients undergoing urologic procedures experienced moderate to severe financial toxicity, without a statistically significant difference between the benign and the oncology groups pre- or post-operatively. Single item measure strongly correlated with COST (r = -0.80) pre- and post-operative.
CONCLUSION
The COST survey and a single-item financial toxicity measure are both valid tools that can be used to measure financial toxicity in urology. Further research is needed to elicit the exact cause of financial toxicity in the heterogenous urologic patient population.
Topics: Male; Humans; Urology; Cross-Sectional Studies; Financial Stress; Urologic Surgical Procedures; Cystectomy
PubMed: 37353088
DOI: 10.1016/j.urology.2023.04.040 -
Aktuelle Urologie Jun 2024
Topics: Humans; Antibiotic Prophylaxis; Cystectomy; Surgical Wound Infection; Urinary Tract Infections; Urinary Bladder Neoplasms; Anti-Bacterial Agents; Postoperative Complications; Risk Factors
PubMed: 38806028
DOI: 10.1055/a-2188-9583 -
Aktuelle Urologie Apr 2024
Topics: Humans; Cystectomy; Quality of Life; Urinary Bladder
PubMed: 38537653
DOI: 10.1055/a-2082-3877 -
European Urology Sep 2023The COXEN gene expression model was evaluated for prediction of response to neoadjuvant chemotherapy for muscle-invasive bladder cancer (MIBC). (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
The COXEN gene expression model was evaluated for prediction of response to neoadjuvant chemotherapy for muscle-invasive bladder cancer (MIBC).
OBJECTIVE
To conduct a secondary analysis of the association of each COXEN score with event-free survival (EFS) and overall survival (OS) and by treatment arm.
DESIGN, SETTING, AND PARTICIPANTS
This was a randomized phase 2 trial of neoadjuvant gemcitabine-cisplatin (GC) or dose-dense methotrexate-vinblastine-adriamycin-cisplatin (ddMVAC) in MIBC.
INTERVENTION
Patients were randomized to ddMVAC (every 14 d) or GC (every 21 d), both for four cycles.
OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS
EFS events were defined as progression or death before scheduled surgery, a decision to not undergo surgery, recurrence, or death due to any cause after surgery. Cox regression was used to evaluate the COXEN score or treatment arm association with EFS and OS.
RESULTS AND LIMITATIONS
A total of 167 evaluable patients were included in the COXEN analysis. The COXEN scores were not significantly prognostic for OS or EFS in the respective arms, but the GC COXEN score had a hazard ratio (HR) of 0.45 (95% confidence interval [CI] 0.20-0.99; p = 0.047) when the arms were pooled. In the intent-to-treat analysis (n = 227), there was no significant difference between ddMVAC and GC for OS (HR 0.87, 95% CI 0.54-1.40; p = 0.57) or EFS (HR 0.86, 95% CI 0.59-1.26; p = 0.45). Among the 192 patients who underwent surgery, pathologic response (pT0 vs downstaging vs no response) was strongly correlated with superior postsurgical survival (5-yr OS 90%, 89% and 52%, respectively).
CONCLUSIONS
The COXEN GC score has prognostic value for patients receiving cisplatin-based neoadjuvant treatment. The randomized, prospective design provides estimates of OS and EFS for GC and ddMVAC in this population. Pathologic response (
PATIENT SUMMARY
In this study, we evaluated a biomarker to predict the response to chemotherapy. The results did not meet the preset study parameters, but our study provides information on clinical outcomes with the use of chemotherapy before surgery for bladder cancer.
Topics: Humans; Cisplatin; Cystectomy; Deoxycytidine; Muscles; Neoadjuvant Therapy; Neoplasm Invasiveness; Retrospective Studies; Treatment Outcome; Urinary Bladder Neoplasms
PubMed: 37414705
DOI: 10.1016/j.eururo.2023.06.014 -
Annals of Surgical Oncology Apr 2024Genitourinary malignancies have a substantial impact on men and women in the USA as they include three of the ten most common cancers (prostate, renal, and bladder).... (Review)
Review
BACKGROUND
Genitourinary malignancies have a substantial impact on men and women in the USA as they include three of the ten most common cancers (prostate, renal, and bladder). Other urinary tract cancers are less common (testis and penile) but still have profound treatment implications related to potential deficits in sexual, urinary, and reproductive function. Evidenced-based practice remains the cornerstone of treatment for urologic malignancies.
METHODS
The authors reviewed the literature in consideration of the four top articles influencing clinical practice in the prior calendar year, 2022.
RESULTS
The PROTECT trial demonstrates favorable 15-years outcomes for active monitoring of localized prostate cancer. The SEMS trial establishes retroperitoneal lymph node dissection as a viable option for patients with seminoma of the testis with limited retroperitoneal lymph node metastases. CheckMate 274 supports adjuvant immunotherapy following radical cystectomy for muscle-invasive bladder cancer with a high risk of recurrence. Data reported from the IROCK consortium reinforce stereotactic ablative radiotherapy as an option for localized renal cell carcinoma.
CONCLUSION
The care for patients with urologic cancers has been greatly improved through advances in surgical, medical, and radiation oncologic treatments realized through prospective randomized clinical trials and large multicenter collaborative groups.
Topics: Female; Humans; Male; Cystectomy; Kidney Neoplasms; Lymph Node Excision; Prospective Studies; Urinary Bladder Neoplasms; Urologic Neoplasms; Urology
PubMed: 38300402
DOI: 10.1245/s10434-023-14838-w -
World Journal of Surgical Oncology Aug 2023Even though there isn't enough clinical evidence to demonstrate that robot-assisted radical cystectomy (RARC) is preferable to open radical cystectomy (ORC), RARC has... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Even though there isn't enough clinical evidence to demonstrate that robot-assisted radical cystectomy (RARC) is preferable to open radical cystectomy (ORC), RARC has become a widely used alternative. We performed the present study of RARC vs ORC with a focus on oncologic, pathological, perioperative, and complication-related outcomes and health-related quality of life (QOL).
METHODS
We conducted a literature review up to August 2022. The search included PubMed, EMBASE and Cochrane controlled trials register databases. We classified the studies according to version 2 of the Cochrane risk-of-bias tool for randomized trials (RoB 2). The data was assessed by Review Manager 5.4.0.
RESULTS
8 RCTs comparing 1024 patients were analyzed in our study. RARC was related to lower estimated blood loss (weighted mean difference (WMD): -328.2; 95% CI -463.49--192.92; p < 0.00001), lower blood transfusion rates (OR: 0.45; 95% CI 0.32 - 0.65; p < 0.0001) but longer operation time (WMD: 84.21; 95% CI 46.20 -121.72; p < 0.0001). And we found no significant difference in terms of positive surgical margins (P = 0.97), lymph node yield (P = 0.30) and length of stay (P = 0.99). Moreover, no significant difference was found between the two groups in terms of survival outcomes, pathological outcomes, postoperative complication outcomes and health-related QOL.
CONCLUSION
Based on the present evidence, we demonstrated that RARC and ORC have similar cancer control results. RARC is related to less blood loss and lower transfusion rate. We found no difference in postoperative complications and health-related QOL between robotic and open approaches. RARC procedures could be used as an alternate treatment for bladder cancer patients. Additional RCTs with long-term follow-up are needed to validate this observation.
Topics: Humans; Cystectomy; Quality of Life; Robotics; Treatment Outcome; Robotic Surgical Procedures; Randomized Controlled Trials as Topic; Urinary Bladder Neoplasms; Postoperative Complications
PubMed: 37542288
DOI: 10.1186/s12957-023-03132-4 -
Clinical Genitourinary Cancer Dec 2023Squamous cell carcinoma of the bladder (SqCC) is a rare disease with limited management data. Thus, we sought to characterize the clinicopathologic and survival outcomes...
BACKGROUND
Squamous cell carcinoma of the bladder (SqCC) is a rare disease with limited management data. Thus, we sought to characterize the clinicopathologic and survival outcomes amongst patients with SqCC and explore the association of squamous differentiation within urothelial carcinoma (UC w/Squam), as compared to muscle invasive pure UC.
METHODS
We conducted a single-center retrospective cohort study of patients, stratified by histology, who underwent cystectomy for MIBC. Baseline clinicopathologic characteristics were compared, and overall survival was assessed using Kaplan-Meier method.
RESULTS
We identified 1,034 patients; 37 (3.58%) with SqCC histology, 908 (87.81%) with UC histology, and 89 (8.61%) with UC w/ Squam histology. Among SqCC patients, a higher proportion were Black and similarly a higher proportion were women; amongst patients with UC w/ Squam a higher proportion had lower BMI; and amongst patients with UC a higher proportion had lower clinical (c) T, cN, pathological (p) T, and pN stages. Patients presenting with UC were more likely to receive intravesical therapy; patients presenting with SqCC were less likely to receive neoadjuvant chemotherapy (NAC). Adjuvant chemotherapy rates were similar. With post-hoc Bonferroni analysis, overall survival, cancer-specific survival, and recurrence-free survival were significantly worse for the UC w/ Squam cohort.
CONCLUSIONS
UC w/ Squam histology was associated with worse survival outcomes after cystectomy for muscle invasive bladder cancer compared to UC. Our results suggest that UC w/ Squam is associated with more advanced disease compared to UC, warranting further prospective work on consideration of combination therapies for patients with this disease state.
Topics: Humans; Female; Male; Urinary Bladder Neoplasms; Carcinoma, Transitional Cell; Urinary Bladder; Cystectomy; Retrospective Studies; Carcinoma, Squamous Cell; Neoadjuvant Therapy
PubMed: 37336703
DOI: 10.1016/j.clgc.2023.05.019