The association of salvage intravesical therapy following BCG with pathologic outcomes and survival after radical cystectomy for patients with high-grade non-muscle invasive bladder cancer: A multi-institution analysis

Background: Radical cystectomy with pelvic lymph node dissection is the standard treatment for muscle-invasive bladder cancer. With the advent of improved surgical techniques and postoperative management, the complications and mortality rates have reduced. The present study was done to analyse the perioperative, early and late compilations following radical cystectomy for bladder tumor.Methods: This is a prospective observational study of patients who underwent radical cystectomy for invasive bladder tumor from February 2016 to November 2017. Radical cystectomy was done through midline transperitoneal approach. Urinary diversion was done by ileal conduit. All patients were followed at 6th week, 3rd month, 6th month, and at 1 year.Results: Total 21 patients underwent radical cystectomy, 17(80.95%) were males and 4 (19.04%) females. The median age was 60 years, ranging from 40 to 73 years. The most common age group was 60 to 75 years (52.3%). Thirteen (61.9%) patients were smokers and all were males. Painless haematuria alone was most common presentation (of bladder tumor) seen in 15 (71.4%) patients. Early complications were seen in 8 (38.09%) patients, most common early complication was urinary leak 2 (9.5%) patents, other early complications were bowel leak, wound dehiscence, pelvic collection, burst abdomen, prolonged ileus, subacute intestinal obstruction, acute kidney injury and sepsis seen in one (4.25%) patient each. Late complications were seen in 4 (19.04%) patients. Pelvic recurrence was the most common late complication seen in 2 (9.55%) patients. Ureteric stricture was seen in one patient (4.75%) for which percutaneous nephrostomy and antegrade DJ stenting was done. Among the histopathological variants of tumor 20 (95.25%) patients had high grade variants and only one (4.75%) had low grade papillary urothelial carcinoma. Among the high grade variants most common pathology was urothelial carcinoma in 17 (80.9%) patients.Conclusions: Radical cystectomy remains the main stay of treatment in muscle-invasive bladder cancer. This is relatively safe procedure with minimal morbidity and mortality.

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Benchmarking PASADENA Consensus along the Learning Curve of Robotic Radical Cystectomy with Intracorporeal Neobladder: CUSUM Based Assessment

Journal of Clinical Medicine ◽

10.3390/jcm10245969 ◽

2021 ◽

Vol 10 (24) ◽

pp. 5969

Author(s):

Riccardo Lombardo ◽

Riccardo Mastroianni ◽

Gabriele Tuderti ◽

Mariaconsiglia Ferriero ◽

Aldo Brassetti ◽

...

Keyword(s):

Bladder Cancer ◽

Learning Curve ◽

Radical Cystectomy ◽

Operative Time ◽

Surgical Margins ◽

Invasive Bladder Cancer ◽

High Grade ◽

Muscle Invasive Bladder Cancer ◽

Positive Surgical Margins ◽

Muscle Invasive

(1) Aim: Robot assisted radical cystectomy (RARC) with intacorporeal neobladder (iN) is a challenging procedure. There is a paucity of reports on RARC-iN, the extracorporeal approach being the most used. The aim of our study was to assess the learning curve of RARC-iN and to test its performance in benchmarking Pasadena consensus outcomes. (2) Material and methods: The single-institution learning curve of RARC-iN was retrospectively evaluated. Demographic, clinical and pathologic data of all patients were recorded. Indications to radical cystectomy included muscle invasive bladder cancer (pT ≥ 2) or recurrent high grade non muscle invasive bladder cancer. The cumulative sum (CUSUM) technique, one of the methods developed to monitor the performance and quality of the industrial sector, was adopted by the medical field in the 1970s to analyze learning curves for surgical procedures. The learning curve was evaluated using the following criteria: 1. operative time (OT) <5 h; 2. 24-h Hemoglobin (Hb) drop <2 g/dl; 3. severe complications (according to the Clavien classification system) <30%; 4. positive surgical margins <5%; and 5. complete lymph-node dissection defined as more than 16 nodes. Benchmarking of all five items on quintile analysis was tested, and a failure rate <20% for any outcome was set as threshold. (3) Results: the first 100 consecutive RARC-iN patients were included in the analysis. At CUSUM analysis, RARC required 20 cases to achieve a plateau in terms of operative time (defined as more than 3 consecutive procedures below 300 min). Hemoglobin drop, PSM and number of removed lymph-nodes did not change significantly along the learning curve. Overall, 41% of the patients presented at least one complication. Low-grade and high-grade complication rates were 30% and 17%, respectively. When assessing the benchmarks of all five Pasadena consensus outcomes on quintile analysis, a plateau was achieved after the first 60 cases. (4) Conclusions: RARC-iN is a challenging procedure. The potential impact of the learning curve on significant outcomes, such as high grade complications and positive surgical margins, has played a detrimental effect on its widespread adoption. According to this study, in tertiary referral centers, 60 procedures are sufficient to benchmark all outcomes defined in Pasadena RARC consensus.

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Survival Outcomes of Early versus Deferred Cystectomy for High-Grade Non-Muscle-Invasive Bladder Cancer: A Systematic Review

Current Urology ◽

10.1159/000499257 ◽

2020 ◽

Vol 14 (2) ◽

pp. 66-73

Author(s):

Jonathan C. M. Wan

Keyword(s):

Systematic Review ◽

Bladder Cancer ◽

Radical Cystectomy ◽

Treatment Plan ◽

Invasive Bladder Cancer ◽

Survival Outcomes ◽

High Grade ◽

Muscle Invasive Bladder Cancer ◽

Term Survival ◽

Muscle Invasive

Background: Studies report that survival outcomes in patients with non-muscle-invasive bladder cancer (NMIBC) are worse when cystectomy is delayed. However, no systematic evidence is available. Objective: The aim of this study was to systematically review the literature to compare the long-term survival outcomes of patients with high-grade NMIBC (T1G3, including carcinoma in situ) who have early cystectomy compared to deferred radical cystectomy post-diagnosis. Materials and Methods: A systematic review was carried out by searching MEDLINE and related databases (Google Scholar, National Health Service Evidence) for all relevant studies published from 1946 to present. Additional studies were identified through following the references of relevant papers. Studies were included if they met the following criteria: inclusion of at least 30 patients having high-grade NMIBC, 2 groups treated with either early or deferred cystectomy with a clear temporal cut-off between groups and reported data on survival rate of at least 5 years. Results: Literature was systematically reviewed, and 10 studies were included, totaling 1,516 patients who underwent either primary cystectomy or deferred cystectomy. It was found that patients who underwent early cystectomy show improved 5- to 10-year cancer-specific survival (relative risk = 0.81, p = 0.029) suggesting a significant survival benefit when compared to deferred cystectomy. Conclusions: This study provides systematically gathered evidence showing benefit of early cystectomy. Despite this result, radical cystectomy greatly impairs quality of life and represents overtreatment for a significant minority. This result highlights the importance of a decisive treatment plan to minimize treatment delay.

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Utilization and Outcomes of Radical Cystectomy for High-grade Non–muscle-invasive Bladder Cancer in Elderly Patients

Clinical Genitourinary Cancer ◽

10.1016/j.clgc.2017.07.011 ◽

2018 ◽

Vol 16 (1) ◽

pp. e79-e97 ◽

Cited By ~ 3

Author(s):

William P. Parker ◽

Woodson Smelser ◽

Eugene K. Lee ◽

Elizabeth B. Habermann ◽

Prabin Thapa ◽

...

Keyword(s):

Bladder Cancer ◽

Elderly Patients ◽

Radical Cystectomy ◽

Invasive Bladder Cancer ◽

High Grade ◽

Muscle Invasive Bladder Cancer ◽

Muscle Invasive

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Emerging intravesical therapies for the management of bacillus Calmette–Guérin (BCG)-unresponsive non-muscle-invasive bladder cancer: Charting a path forward

Canadian Urological Association Journal ◽

10.5489/cuaj.6101 ◽

2020 ◽

Vol 14 (6) ◽

Author(s):

Ali Cyrus Chehroudi ◽

Peter C. Black

Keyword(s):

Bladder Cancer ◽

High Risk ◽

Radical Cystectomy ◽

Clinical Trial Design ◽

Standard Of Care ◽

Invasive Bladder Cancer ◽

Intravesical Therapy ◽

Muscle Invasive Bladder Cancer ◽

Bcg Failure ◽

Muscle Invasive

Management of patients with cacillus Calmette–Guérin (BCG)-unresponsive, high-risk, non-muscle-invasive bladder cancer (NMIBC) presents a formidable clinical challenge that requires urologists to weigh the competing risks of progression during further intravesical therapy vs. the morbidity of radical cystectomy. The prognosis of high-risk NMIBC recurring after BCG depends on the adequacy of prior BCG, the timing of recurrence, and tumor histology. The standard of care is currently radical cystectomy, as effective salvage intravesical therapy has not been established. The development of bladder-sparing treatments has been hampered to date by inconsistent definitions of BCG failure and difficulties in identifying appropriate control treatments in clinical trials. Despite these limitations, the spectrum of salvage therapy is expanding to include enhanced intravesical chemo-, gene, and immuno-therapies. In this review, we provide an overview of these emerging agents in the context of our current understanding of BCG failure and the unique considerations for clinical trial design in this disease state.

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Bladder preservation approach versus radical cystectomy for high-grade non-muscle-invasive bladder cancer: a meta-analysis of cohort studies

World Journal of Surgical Oncology ◽

10.1186/s12957-018-1497-0 ◽

2018 ◽

Vol 16 (1) ◽

Cited By ~ 5

Author(s):

Pei-lin Shen ◽

Ming-en lin ◽

Ying-kai Hong ◽

Xue-jun He

Keyword(s):

Bladder Cancer ◽

Cohort Studies ◽

Radical Cystectomy ◽

Meta Analysis ◽

Invasive Bladder Cancer ◽

High Grade ◽

Muscle Invasive Bladder Cancer ◽

Bladder Preservation ◽

Muscle Invasive

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Optimum Management Of The T1 High Grade Bladder Cancer

Bangladesh Journal of Urology ◽

10.3329/bju.v16i1.45932 ◽

2020 ◽

Vol 16 (1) ◽

pp. 26-32

Author(s):

Md Abul Hossain ◽

Md Waliul Islam ◽

Md Nurul Hooda ◽

Md Fazal Naser ◽

Md Shafiqul Azam

Keyword(s):

Bladder Cancer ◽

Cancer Treatment ◽

Treatment Option ◽

Conservative Therapy ◽

Invasive Bladder Cancer ◽

Intravesical Therapy ◽

High Grade ◽

Muscle Invasive Bladder Cancer ◽

Optimum Treatment ◽

Muscle Invasive

Objectives: To determine the optimum treatment option for patients with superficial high grade (T1Hg) bladder cancer. Introduction: Controversy exists about the most appropriate treatment for superficial high grade (T1Hg) bladder cancer. Immediate cystectomy offers the best chance for survival but associated with an impaired quality of life compared with conservative therapy. In case of conservative therapy lifelong surveillance is required and there is a high rate of recurrence and risk of disease progression. So optimum treatment option should be determined to treat the disease optimistically. Methods: A comprehensive and systemic search of the pubmed database for English Language articles was performed using the following medical subject Heading (MeSH): Bladder cancer, treatment of superficial high grade (T1Hg) bladder cancer, treatment options for bladder cancer, natural history of T1Hg bladder cancer, newer Intravesical agents, cystectomy and in addition reference of relevant articles were searched for additional references. Results: Approximately 70% of all newly diagnosed bladder tumors are non-muscle invasive bladder cancer. The management of these patients entails transurethral resection with or without adjuvant intravesical therapy. After review of obtained articles it is evident that the conservative treatment of T1Hg bladder cancer should be ended when there is systemic or local toxicity from intravesical therapy or patient is not complaint or persistence of tumor or tumor progression despite therapy. Conclusion : The management of T1Hg is highly variable due to several factors including divergence in treatment related evidence. The efficacy of treatments must be balanced with their toxicity, so that single treatment option cannot be considered superior across all Non-Muscle Invasive Bladder Cancer (NMIBC). Immediate radical cystectomy may be offered upfront in patients with T1Hg tumors with concomitant CIS or multiple recurrent high grade tumors. Bangladesh Journal of Urology, Vol. 16, No. 1, Jan 2013 p.26-32

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