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Current Opinion in Urology Sep 2023Radical cystectomy is the standard of care for patients with localized muscle-invasive bladder cancer (MIBC). In this context, bladder-sparing strategies (BSS) have been... (Review)
Review
PURPOSE OF REVIEW
Radical cystectomy is the standard of care for patients with localized muscle-invasive bladder cancer (MIBC). In this context, bladder-sparing strategies (BSS) have been investigated as viable alternatives for patients who are unfit for radical cystectomy or aim to preserve their bladder without compromising oncological outcomes. This review aims to provide the most up-to-date evidence on BSSs as an alternative treatment for patients with MIBC.
RECENT FINDINGS
Different studies have highlighted the long-term efficacy of trimodal therapy or chemoradiation protocols. However, due to the lack of randomized controlled trials, there is still a lack of high-level evidence on BSS efficacy as compared to radical cystectomy. Consequently, the adoption of these approaches is still limited. A possible turning point could be represented by the introduction of immunotherapy, as several studies are investigating the potential combination with chemoradiotherapy or radiotherapy alone. Patient selection, together with the implementation of new predictive biomarkers and imaging tools, may improve the efficacy of BSS in the near future.
SUMMARY
Radical cystectomy with perioperative chemotherapy remains the gold standard treatment for MIBC patients. Nevertheless, BSS can be considered a viable option in selected patients who desire to preserve their bladder. Further evidence is needed to clearly state the role of BSS in MIBC.
Topics: Humans; Urinary Bladder; Urinary Bladder Neoplasms; Cystectomy; Combined Modality Therapy; Neoplasm Invasiveness; Muscles
PubMed: 37395512
DOI: 10.1097/MOU.0000000000001113 -
BMC Cancer Nov 2023In muscle-invasive bladder cancer (MIBC), neoadjuvant chemotherapy (NAC) combined with radical cystectomy (RC) is critical in reducing disease recurrence, with GC... (Meta-Analysis)
Meta-Analysis
BACKGROUND
In muscle-invasive bladder cancer (MIBC), neoadjuvant chemotherapy (NAC) combined with radical cystectomy (RC) is critical in reducing disease recurrence, with GC (gemcitabine and cisplatin) being one of the most commonly used NACs. Different GC schedules have been used, but the best neoadjuvant regimen is still unknown. The clinical outcomes of 3 and 4 cycles of neoadjuvant GC are compared in this systematic review and meta-analysis to determine which is best for patients with MIBC.
METHODS
We searched PubMed, Embase, Web of Science, Cochrane Library, CBM, CNKI, WAN FANG DATA, and meeting abstracts to identify relevant studies up to March 2023. Studies that compared 3 and 4 cycles of neoadjuvant GC for MIBC were included. The primary outcomes were pCR, pDS, OS, and CSS. The secondary outcome was recurrence and SAEs.
RESULTS
A total of 3 studies, with 1091 patients, were included in the final analysis. Patients that received 4 cycles of GC had a higher pCR (OR = 0.66; 95% CI, 0.50-0.87; p = 0.003) and pDS (OR = 0.63; 95% CI, 0.48-0.84; p = 0.002) than those who received 3 cycles. Regarding recurrence rate (OR = 1.23; 95% CI, 0.91-1.65; p = 0.18), there were no appreciable differences between the 3 and 4 cycles of GC. Survival parameters such as OS (HR, 1.35; 95% CI, 0.86-2.12; p = 0.19) and CSS (HR, 1.06; 95% CI, 0.82-1.38; p = 0.20) were similar. Only one trial reported on the outcomes of SAEs. And there were no statistically significant differences in thrombocytopenia, infection rate, neutropenic fever, anemia, or decreased renal function between patients. The neutropenia of patients was statistically different (OR = 0.72; 95% CI, 0.52-0.99; p = 0.04).
CONCLUSION
The 4-cycle GC regimen was superior to the 3-cycle regimen in only the pCR and pDS results. Survival and recurrence rates were similar between the two regimens. In both treatment regimes, the toxicity profile was manageable. However, due to the inherent drawbacks of retrospective research, this should be regarded with caution.
Topics: Humans; Antineoplastic Combined Chemotherapy Protocols; Cisplatin; Cystectomy; Gemcitabine; Muscles; Neoadjuvant Therapy; Neoplasm Invasiveness; Neoplasm Recurrence, Local; Retrospective Studies; Urinary Bladder Neoplasms
PubMed: 37932689
DOI: 10.1186/s12885-023-11572-0 -
Nutrients May 2024Nutrition is a key element of the prehabilitation process prior to surgery. The aim of this study was to identify the clinical pathways of nutritional prehabilitation... (Review)
Review
BACKGROUND/AIM
Nutrition is a key element of the prehabilitation process prior to surgery. The aim of this study was to identify the clinical pathways of nutritional prehabilitation before cystectomy.
METHODS
A systematic literature review was conducted in PubMed, the Cochrane Library, CINAHL, Scopus and the Web of Science databases. Quality and risk of bias assessment was conducted adhering to the JBI framework and evidence was evaluated according to the Oxford Centre for Evidence Based Medicine levels of evidence.
RESULTS
Out of 586 records identified, six studies were included. Among them, only two were randomized controlled trials. Immunonutrition has been shown to improve postoperative bowel function (3.12 vs. 3.74 days; RR 0.82; CI, 0.73-0.93; = 0.0029) and decrease postoperative complications (-36.7%; = 0.008) and readmission rates (-15.38%; = 0.03). Furthermore, oral nutritional supplements combined with nutritional counseling demonstrated an accelerated recovery of bowel function (-1 day; < 0.01), a reduction in the length of hospital stay (-1.75 days; = 0.01), an improvement in handgrip strength (+6.8%, < 0.001), an increase in bone mass (+0.3 kg, = 0.04), and a better BMI value (+2.3%, = 0.001).
CONCLUSIONS
Nutritional prehabilitation demonstrates potential in enhancing postoperative outcomes following radical cystectomy. Oral supplements, immunonutrition, and counseling exhibit efficacy in improving postoperative results.
Topics: Humans; Cystectomy; Postoperative Complications; Preoperative Care; Length of Stay; Preoperative Exercise; Nutritional Status; Dietary Supplements; Randomized Controlled Trials as Topic; Recovery of Function
PubMed: 38892615
DOI: 10.3390/nu16111682 -
Acta Oncologica (Stockholm, Sweden) Aug 2023Population-based survival results after radical cystectomy (RC) are limited. Our objective was to report short and long-term survival results after RC for bladder cancer...
BACKGROUND
Population-based survival results after radical cystectomy (RC) are limited. Our objective was to report short and long-term survival results after RC for bladder cancer from Finland in a population-based setting.
MATERIALS AND METHODS
The Finnish National Cystectomy Database containing retrospectively collected essential RC data covering the years 2005-2017 was combined with the survival data from the Finnish Cancer Registry. Kaplan-Meier plots were used to estimate survival and the survival graphs were illustrated according to the final pathological staging. Centers were divided according to operational volume, and the results were then compared using Pearsons's Chi-squared test.
RESULTS
A total of 2047 patients were included in the study. 30-, and 90-day mortality was 1.3%, and 3.8%, respectively. The OS of the entire RC population at 5- and 10 years was 66% and 55%, and CSS was 74% and 72%, respectively. Center volume did not significantly associate with surgical mortality or long-term survival. The 5- and 10-year OS according to pT-category was 87% and 74% for pT0, 85% and 69% for pTa-pTis-pT1, 70% and 58% for pT2, 50% and 42% for pT3 and 41% and 30% for pT4. The corresponding 5- and 10-year CSS rates were 96% and 93% for pT0, 91% and 90% for pTa-pTis-pT1, 78% and 75% for pT2, 56% and 55% for pT3 and 47% and 44% for pT4. The 5- and 10-year OS rates in patients with no lymph node metastases (pN-) were 74% and 62%, and CSS 82% and 80%, respectively. If lymph nodes were positive (pN+), the corresponding OS rates were 44% and 34% and CSS 49% and 48%, respectively.
CONCLUSION
RC survival results have improved in contemporary series and are associated with the pTNM-status. The nationwide results from Finland demonstrate outcome comparable to high volume single-center series.
Topics: Humans; Cystectomy; Finland; Retrospective Studies; Urinary Bladder Neoplasms; Urinary Bladder; Neoplasm Staging; Treatment Outcome; Survival Rate
PubMed: 37377029
DOI: 10.1080/0284186X.2023.2228446 -
European Urology Focus Nov 2023Given the morbidity associated with radical cystectomy (RC) and the significant survival benefit for patients who experience tumor downstaging after neoadjuvant... (Review)
Review
Given the morbidity associated with radical cystectomy (RC) and the significant survival benefit for patients who experience tumor downstaging after neoadjuvant chemotherapy (NAC), there is growing interest in bladder preservation strategies for select patients who have a complete response (CR) to NAC. In this mini-review we discuss the concept of avoiding RC as an alternative option for patients who experience a clinical CR following NAC. Several studies support this concept, with comparable long-term survival outcomes observed for patients with cT0 disease after NAC and patients undergoing RC. However, the definitive approach and the optimal surveillance strategy for patients with a clinical CR who choose bladder preservation are lacking. A dynamic response-driven bladder preservation strategy is a highly anticipated option for patients and is needed to avoid debilitating overtreatment. PATIENT SUMMARY: For selected patients with bladder cancer who experience a complete response to chemotherapy before any surgery, close follow-up might be an alternative option to surgical removal of the bladder without compromising cancer control.
Topics: Humans; Urinary Bladder; Neoadjuvant Therapy; Urinary Bladder Neoplasms; Cystectomy; Pathologic Complete Response
PubMed: 37150628
DOI: 10.1016/j.euf.2023.04.009 -
European Urology Oncology Dec 2023European Urology Association (EAU) guidelines recommend immediate radical cystectomy (early RC) for patients with very high-risk (VHR) non-muscle invasive bladder cancer...
Oncological Outcomes for Patients with European Association of Urology Very High-risk Non-muscle-Invasive Bladder Cancer Treated with Bacillus Calmette-Guérin or Early Radical Cystectomy.
BACKGROUND
European Urology Association (EAU) guidelines recommend immediate radical cystectomy (early RC) for patients with very high-risk (VHR) non-muscle invasive bladder cancer (NMIBC), with bacillus Calmette-Guérin (BCG) recommended only for those who refuse or are unfit for RC.
OBJECTIVE
To describe oncological outcomes following BCG or early RC in a contemporary cohort of patients with VHR NMIBC (EAU criteria).
DESIGN, SETTING, AND PARTICIPANTS
Patients diagnosed with VHR NMIBC between 2000 and 2020 were identified from our institutional NMIBC registry.
OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS
The primary outcomes were overall survival (OS) and cancer-specific mortality (CSM). Secondary outcomes were the progression rate and high-grade recurrence (HGR) rate for patients receiving BCG.
RESULTS AND LIMITATIONS
We identified 235 patients with VHR NMIBC, of whom 157 (67%) received BCG and 78 (33%) underwent early RC. The median follow-up was 52.8 mo. OS and CSM rates were 80.2% and 5.3% in the BCG group, and 88.1% and 4.9% in the early RC group, respectively with no significant difference in OS (p = 0.6) or CSM (p = 0.8) between the two groups. Among the patients treated with BCG, 5-yr HGR and progression rates were 41.9% and 17.4%, respectively; 39 patients (25%) underwent delayed RC after BCG. No significant difference in CSM emerged when comparing patients treated with delayed RC (after BCG) with those undergoing early RC (p = 0.86).
CONCLUSIONS
Our findings suggest that intravesical BCG can be offered to patients as a resonable alternative to early RC for selected patients with VHR NMIBC.
PATIENT SUMMARY
We evaluated outcomes for patients with very high-risk non-muscle-invasive bladder cancer (NMIBC) treated with BCG (bacillus Calmette-Guérin) versus early surgical removal of the bladder and found no differences in survival. We conclude that BCG could be offered to selected patients with this type of bladder cancer as a reasonable alternative to early bladder removal.
Topics: Humans; Urinary Bladder; BCG Vaccine; Cystectomy; Urology; Non-Muscle Invasive Bladder Neoplasms; Adjuvants, Immunologic; Urinary Bladder Neoplasms
PubMed: 37558542
DOI: 10.1016/j.euo.2023.07.012 -
BJU International Mar 2024To determine and summarize the available data on urinary, sexual, and health-related quality-of-life (HRQOL) outcomes after traditional radical cystectomy (RC),... (Review)
Review
OBJECTIVES
To determine and summarize the available data on urinary, sexual, and health-related quality-of-life (HRQOL) outcomes after traditional radical cystectomy (RC), reproductive organ-preserving RC (ROPRC) and nerve-sparing RC (NSRC) for bladder cancer (BCa) in female patients.
METHODS
The PubMed, SCOPUS and Web of Science databases were searched to identify studies reporting functional outcomes in female patients undergoing RC and urinary diversion for the treatment of BCa. The outcomes of interest were voiding function (for orthotopic neobladder [ONB]), sexual function and HRQOL. The following independent variables were derived and included in the meta-analysis: pooled rate of daytime and nighttime continence/incontinence, and intermittent self-catheterization (ISC) rates. Analyses were performed separately for traditional, organ- and/or nerve-sparing surgical approaches.
RESULTS
Fifty-three studies comprising 2740 female patients (1201 traditional RC and 1539 organ-/nerve-sparing RC, and 264 nerve-sparing-alone RC) were eligible for qualitative synthesis; 44 studies comprising 2418 female patients were included in the quantitative synthesis. In women with ONB diversion, the pooled rates of daytime continence after traditional RC, ROPRC and NSRC were 75.2%, 79.3% and 71.2%, respectively. The pooled rate of nighttime continence after traditional RC was 59.5%; this rate increased to 70.7% and 71.7% in women who underwent ROPRC and NSRC, respectively. The pooled rate of ISC after traditional RC with ONB diversion in female patients was 27.6% and decreased to 20.6% and 16.8% in patients undergoing ROPRC and NSRC, respectively. The use of different definitions and questionnaires in the assessment of postoperative sexual and HRQOL outcomes did not allow a systematic comparison.
CONCLUSIONS
Female organ- and nerve-sparing surgical approaches during RC seem to result in improved voiding function. There is a significant need for well-designed studies exploring sexual and HRQOL outcomes to establish evidence-based management strategies to support a shared decision-making process tailored towards patient expectations and satisfaction. Understanding expected functional, sexual and quality-of-life outcomes is necessary to allow individualized pre- and postoperative counselling and care delivery in female patients planned to undergo RC.
Topics: Humans; Female; Cystectomy; Urinary Bladder; Urinary Bladder Neoplasms; Urinary Incontinence; Urination; Urinary Diversion; Treatment Outcome
PubMed: 37562831
DOI: 10.1111/bju.16152 -
Frontiers in Oncology 2024This study compares the clinical efficacy of partial cystectomy (PC) versus radical cystectomy (RC) in the treatment of muscle-invasive bladder urothelial carcinoma...
OBJECTIVE
This study compares the clinical efficacy of partial cystectomy (PC) versus radical cystectomy (RC) in the treatment of muscle-invasive bladder urothelial carcinoma (SCUB) through a retrospective analysis.
METHODS
We retrospectively analyzed the clinical data of 20 patients diagnosed with muscle-invasive SCUB from July 2015 to August 2023 at Ganzhou People's Hospital. All patients underwent surgical treatment followed by chemotherapy, with 9 receiving PC and 11 undergoing RC. We compared the average survival time of deceased patients for both treatments and conducted survival and multivariate analyses using the Kaplan-Meier method and Cox proportional hazards model, respectively.
RESULTS
All 20 patients were postoperatively diagnosed with muscle-invasive SCUB and were followed up for 4 to 60 months. The average survival time for patients undergoing PC was 11.5 months, with survival rates at 1 year, 2 years, and 5 years of 55.56%, 22.22%, and 11.11%, respectively. In contrast, patients receiving RC had an extended average survival time of 22.5 months, and their 1-year, 2-year, and 5-year survival rates increased to 63.64%, 36.36%, and 18.18%, respectively. Survival analysis revealed statistically significant differences in prognosis between PC and RC for the treatment of muscle-invasive SCUB (P<0.05).
CONCLUSION
SCUB is a rare malignant tumor with unique biological characteristics often associated with poor prognosis. Upon diagnosis, RC should be considered as an early treatment approach when the patient's overall condition permits.
PubMed: 38371629
DOI: 10.3389/fonc.2024.1324487 -
European Urology Jan 2024
Topics: Humans; Urology; Urinary Bladder Neoplasms; Cystectomy; Muscles; Neoplasm Invasiveness
PubMed: 37919189
DOI: 10.1016/j.eururo.2023.10.010 -
Urologic Oncology Oct 2023Opioid use, misuse, and diversion is of paramount concern in the United States. Radical cystectomy is typically managed with some component of opioid pain control. We...
OBJECTIVES
Opioid use, misuse, and diversion is of paramount concern in the United States. Radical cystectomy is typically managed with some component of opioid pain control. We evaluated persistent opioid and benzodiazepine use after radical cystectomy and assessed the impact of their preoperative use on this outcome. We also explored associations between preoperative use and perioperative outcomes.
METHODS AND MATERIALS
We used prospectively maintained data from our enhanced recovery after surgery (ERAS) cystectomy database and the Prescription Reporting with Immediate Medication Utilization Mapping (PRIMUM) database to identify controlled substance prescriptions for radical cystectomy patients. We separated patients by frequency of preoperative opioid and/or benzodiazepine prescriptions (0, 1, 2+) and used these cohorts to explore persistent use (prescription 3-12 months after surgery) alongside perioperative outcomes.
RESULTS
Our cohort included 257 patients undergoing cystectomy at a single institution from 2017 to 2021. Preoperative opioid and benzodiazepine prescriptions were documented for 120 (46.7%) and 26 (10.1%) patients, respectively. Persistent opioid use was observed in 20 (14.6%) of opioid-naive patients (no prescriptions in 9 months prior to surgery) while 13 (19.7%) patients with 1 preoperative prescription and 28 (51.9%) patients with 2 or more preoperative prescriptions demonstrated persistent use. New persistent benzodiazepine use occurred in 6 (2.6%) patients. Overall persistent benzodiazepine use was present in 11 (4.3%) patients. In a multivariable model, preoperative opioid and benzodiazepine prescriptions were associated with persistent opioid use (P < 0.001; P = 0.027 respectively). No association was identified between preoperative opioid or benzodiazepine usage and perioperative outcomes including length of stay, return of bowel function, inpatient opioid usage, inpatient or discharge complications, readmissions, or emergency department visits. Inpatient pain scores were noted to be higher in patients with ≥ 2 preoperative opioid prescriptions (P = 0.037).
CONCLUSIONS
Persistent opioid use was present in 23.7% of patients, with a new persistent use rate of 14.6%. Benzodiazepine use was less frequent than opioids, with a small number demonstrating new persistent use. Preoperative opioid and benzodiazepine use is associated with persistent opioid use postoperatively. Preoperative opioid and benzodiazepine use did not affect perioperative outcomes in our cohort.
Topics: Humans; Cystectomy; Analgesics, Opioid; Enhanced Recovery After Surgery; Benzodiazepines; Pain; Retrospective Studies
PubMed: 37455232
DOI: 10.1016/j.urolonc.2023.05.022