Management Of Invasive Bladder Cancer Research Articles

Bladder Only Radiotherapy Concurrent with Chemotherapy Outcomes in Muscle Invasive Bladder Cancer Management: Our Institute Experience

Bladder Only Radiotherapy Concurrent with Chemotherapy Outcomes in Muscle Invasive Bladder Cancer Management: Our Institute Experience

Predictive models of long-term survival outcomes following radical cystectomy.

Identifying the likelihood of life-threatening recurrence after radical cystectomy by reliable and user-friendly predictive models remains an unmet need in the clinical management of invasive bladder cancer. A total of 204 consecutive patients undergoing open radical cystectomy (ORC) for bladder cancer were retrospectively enrolled between May 2005 and August 2020. Clinicopathological and peri-ORC therapeutic data were extracted from clinical records. We explored predictive factors that significantly affected the primary endpoint of overall survival (OS) and secondary endpoints of cancer-specific survival (CSS) and recurrence-free survival (RFS). During a median follow-up of 3.9 years, 42 (20.6%) and 10 (4.9%) patients died due to bladder cancer and other causes, respectively. Five-year RFS, CSS, and OS were 66.5%, 77.6%, and 75.4%, respectively. Pathological T and N categories and lymphovascular invasion (LVI) significantly affected RFS by Cox regression analysis. Accordingly, clinical T and pathological N categories and LVI significantly affected CSS. Clinical T and pathological N categories, LVI, age, and ORC tumor grade significantly affected OS. Based on the assessment score for each independent risk factor, we developed the Gunma University Oncology Study Group (GUOSG) score, which predicts RFS, CSS, and OS. The GUOSG score classified four groups for RFS, three for CSS, and five for OS, with statistically significant distribution for nearly all comparisons. The GUOSG model is helpful to show individualized prognosis and functions as a risk-stratified historical cohort for assessing the lifelong efficacy of new salvage treatment regimens.

Radical Cystectomy in the Treatment of Invasive Bladder Cancer: Long-Term Results in 1,054 Patients.

To evaluate our long-term experience with patients treated uniformly with radical cystectomy and pelvic lymph node dissection for invasive bladder cancer and to describe the association of the primary bladder tumor stage and regional lymph node status with clinical outcomes. All patients undergoing radical cystectomy with bilateral pelvic iliac lymphadenectomy, with the intent to cure, for transitional-cell carcinoma of the bladder between July 1971 and December 1997, with or without adjuvant radiation or chemotherapy, were evaluated. The clinical course, pathologic characteristics, and long-term clinical outcomes were evaluated in this group of patients. A total of 1,054 patients (843 men [80%] and 211 women) with a median age of 66 years (range, 22 to 93 years) were uniformly treated. Median follow-up was 10.2 years (range, 0 to 28 years). There were 27 (2.5%) perioperative deaths, with a total of 292 (28%) early complications. Overall recurrence-free survival at 5 and 10 years for the entire cohort was 68% and 66%, respectively. The 5- and 10-year recurrence-free survival for patients with organ-confined, lymph node-negative tumors was 92% and 86% for P0 disease, 91% and 89% for Pis, 79% and 74% for Pa, and 83% and 78% for P1 tumors, respectively. Patients with muscle invasive (P2 and P3a), lymph node-negative tumors had 89% and 87% and 78% and 76% 5- and 10-year recurrence-free survival, respectively. Patients with nonorgan-confined (P3b, P4), lymph node-negative tumors demonstrated a significantly higher probability of recurrence compared with those with organ-confined bladder cancers (P < .001). The 5- and 10-year recurrence-free survival for P3b tumors was 62% and 61%, and for P4 tumors was 50% and 45% , respectively. A total of 246 patients (24%) had lymph node tumor involvement. The 5- and 10-year recurrence-free survival for these patients was 35%, and 34%, respectively, which was significantly lower than for patients without lymph node involvement (P < .001). Patients could also be stratified by the number of lymph nodes involved and by the extent of the primary bladder tumor (p stage). Patients with fewer than five positive lymph nodes, and whose p stage was organ-confined had significantly improved survival rates. Bladder cancer recurred in 311 patients (30%) . The median time to recurrence among those patients in whom the cancer recurred was 12 months (range, 0.04 to 11.1 years). In 234 patients (22%) there was a distant recurrence, and in 77 patients (7%) there was a local (pelvic) recurrence. These data from a large group of patients support the aggressive surgical management of invasive bladder cancer. Excellent long-term survival can be achieved with a low incidence of pelvic recurrence.

Impact of Bacillus Calmette-Guérin (BCG) vaccination on the course of COVID-19

Nowadays, Bacillus Calmette-Guérin (BCG) is the most commonly used vaccine worldwide, used typically for tuberculosis but also in non-muscle invasive bladder cancer management. Basing on previously confirmed antiviral features of BCG and first statistic data reports, BCG usage in COVID-19 prevention was claimed and its potential molecular mechanism was searched. In scientific literature there was 10 publications proving several possible mechanism of BCG interaction with SARS-CoV-2 infection immune response. The most often was cross-reactivity between various BCG and SARS-CoV-2 antigens, including those crucial for their clinical effects. In most cases, those antigens linking was shown according to bioinformatical research. According to this research, the potential role of BCG in COVID-19 management should be considered as significant, at least until the clinical trials conducted nowadays will be over.

The increasing indications of FDG-PET/CT in the staging and management of Invasive Bladder Cancer.

The management of locally advanced muscle invasive bladder cancer (MIBC) often necessitates neo-adjuvant chemotherapy (NAC) to eliminate any micro-metastatic disease prior to definitive radical cystectomy (RC) and pelvic lymph node dissection (PLND). The most common imaging techniques traditionally used during this process are computerised tomography (CT) and magnetic resonance imaging (MRI), both of which lack a high sensitivity for nodal staging. In this paper, we attempt to review the evolving indications of F-fluoro-2-deoxy-D-glucose positron emission tomography/computerised tomography (FDG-PET/CT) imaging, in the pre-clinical and post-treatment staging of bladder cancer, with a focus on its ability to evaluate response to NAC. We concluded that use of FDG-PET/CT allows for improved nodal staging and metastatic disease detection, compared to traditional imaging modalities. This enabled earlier detection of tumour response to NAC and/or residual disease, impacting factors such as duration of chemotherapy, with its associated adverse effects, and timing of surgical intervention. However, further studies are required to reliably assess its impact on both overall and disease-free survival.

MP13-15 THE ROLE OF PERITONEAL CAVITY SPARING IN THE REDUCTION OF RADICAL CYSTOPROSTATECTOMY (RCP) POSTOPERATIVE COMPLICATION RATES

You have accessJournal of UrologyBladder Cancer: Invasive I (MP13)1 Sep 2021MP13-15 THE ROLE OF PERITONEAL CAVITY SPARING IN THE REDUCTION OF RADICAL CYSTOPROSTATECTOMY (RCP) POSTOPERATIVE COMPLICATION RATES Guram Karazanashvili, Nika Gagoshidze, and Nino Karazanashvili Guram KarazanashviliGuram Karazanashvili More articles by this author , Nika GagoshidzeNika Gagoshidze More articles by this author , and Nino KarazanashviliNino Karazanashvili More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001994.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Radical cystectomy remains the gold standard for the management of invasive bladder cancer. However, postoperative complications of this complex surgery still remain the major problem, which ranges between 30-64%. Neobladder extra-peritonization as a method for reduction of postoperative complications was discussed by few authors, showing that it has the potential to reduce the complication rate. In 2018 a video-description of the new technique of peritoneal cavity sparing (Karazanashvili, G. (2018)) was presented at AUA annual congress. We aimed to investigate the role of this new technique in the reduction of the RCP postoperative complications. METHODS: In 2011-2016 years 98 RCP were performed using the standard transperitoneal descending approach, leaving just a partially extra-peritonized neobladder in the peritoneal cavity. In 2016-2020 years 60 patients underwent RCP using the new technique - peritoneal cavity sparing extraperitoneal RCP with extraperitoneal orthotopic neobladder formation: RCP was performed in a retrograde manner, from apex prostate to the bladder pedicles and the dome; peritoneum was detached from bladder wall and peritoneal cavity hermeticism was kept until complete removal of the specimen and until completion of extended lymphadenectomy. So the peritoneal cavity remained untouched for the most part of the operation. After the creation of the neobladder, it was completely extra-peritonized; the peritoneal cavity was closed almost hermetically (hiatus was left only for neobladder mesentery) without drains. Complication rates after the operations were calculated according to the Clavien-Dindo scale. RESULTS: The retrospective analysis of complication rates has revealed that Clavien-Dindo Grade 1 to 3 intestinal complications significantly decreased using the new RCP technique compared to the old - standard one: Postoperative ileus medical treatment rate decreased from 3% to 0%; Intra-abdominal urine leakage - from 2.2%to 1.69%; Ileus surgical intervention - from 10.8% to 5.08%; Ileal anastomosis leakage from 5.7 to 0%; Evisceration - from 2.7% to 0%. Thus Intestinal Grade 1 complications decreased from 5.2% to 1.69 and Grade 3 complications - from 18.7% to 5.08%; totally the intestinal complication rate decreased by 17.22% (from 23.9% to 6.77%), however prolonged lymphorrhea rate increased by 12.54% (from 7.8 % to 20.34%). CONCLUSIONS: Peritoneum cavity sparing extraperitoneal RCP and extraperitoneal orthotopic neobladder formation can lead to notable reduction of RCP postoperative intestinal complication rate in price of prolonged lymphorrhea. Source of Funding: No funding was available © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e249-e249 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Guram Karazanashvili More articles by this author Nika Gagoshidze More articles by this author Nino Karazanashvili More articles by this author Expand All Advertisement Loading ...

Current evidence for robotic surgery in radical cystectomy.

Robotic-assisted radical cystectomy (RARC) has been gaining momentum as an alternative to its conventional open radical cystectomy (ORC) for the management of invasive bladder cancer. Although RARC, in general, demonstrated less blood loss and shorter hospital stay than ORC, whether there is any significant difference in the overall complication rate still requires further investigation. Thus, both RARC and ORC share a similar oncology outcome, with comparable positive surgical margin rates, disease-free survival, and overall survival. Techniques of intracorporeal urinary diversion (ICUD) have not yet been standardized. ICUD may result in a lower risk of ureteroileal anastomotic stricture than extracorporeal urinary diversion (ECUD). However, ECUD is still a valid and commonly practiced option according to the available data. In general, RARC has been demonstrated to provide promising results. Long-term data and functional outcome after RARC and ICUD are needed to further validate the role of RARC in the management of bladder cancer.

Trimodal therapy in muscle invasive bladder cancer management.

Radical cystectomy (RC) is the current mainstay for muscle-invasive bladder cancer (MIBC). Concerns regarding morbidity, mortality and quality of life have favored the introduction of bladder sparing strategies. Trimodal therapy, combining transurethral resection, chemotherapy and radiotherapy is the current standard of care for bladder preservation strategies in selected patients with MIBC. A comprehensive search of the Medline and Embase databases was performed. A total of 19 studies were included in a systematic review of bladder sparing strategies in MIBC management was carried out following the preferred reporting items for systematic reviews and meta-analysis (PRISMA). The overall median complete response rate after trimodal therapy (TMT) was 77% (55-93). Salvage cystectomy rate with TMT was 17% on average (8-30). For TMT, the 5-year cancer-specific survival and overall survival rates range from 42-82% and 32-74%, respectively. Currently data supporting neoadjuvant or adjuvant chemotherapy in bladder sparing approaches are emerging, but robust definitive conclusions are still lacking. Gastrointestinal toxicity rates are low around 4% (0.5-16), whereas genitourinary toxicity rates reached 8% (1-24). Quality of life outcomes are still underreported. Published data and clinical experience strongly support trimodal therapy as an acceptable bladder sparing strategy in terms of oncological outcomes and quality of life in selected patients with MIBC. A strong need exists for specialized centers, to increase awareness among urologists, to discuss these options with patients and to stress the increased participation of patients and their families in treatment path decision-making.

P0570THE INCIDENCE, RISK FACTORS OF ACUTE KIDNEY DISEASES AND DISORDERS AND ITS IMPACT ON CHRONIC KIDNEY DISEASE IN PATIENTS AFTER RADICAL CYSTECTOMY

Abstract Background and Aims Acute kidney injury (AKI) is a widely-discussed complication associated with the radical cystectomy which is the gold standard for the management of invasive bladder cancer. Until now, few studies investigate the new criteria named Acute Kidney Diseases and Disorders(AKD) as the complication of radical cystectomy. In this study, we evaluated the incidence, risk factors of AKD and evaluate its impact on chronic kidney disease (CKD) in patients after radical cystectomy. Method A total of 279 patients who underwent radical cystectomy at Sun Yat-sen Memorial Hospital, Guangzhou, China, from January 2006 to June 2019 were evaluated, including 168 patients for Robotic-assisted Laparoscopic Radical Cystectomy (RLRC) and 111 patients for Laparoscopic Radical Cystectomy(LRC). AKD was diagnosed according to the classification scheme proposed in the 2012 KDIGO guideline. Logistic regression modeling was used to explore risk factors of AKD, while risk factors associated with CKD in AKD patients were investigated using Kaplan-Meier analysis, respectively. Results The overall incidence of AKD after radical cystectomy was 34.1% (95 out of 279) ,the incidences differ significantly between the RLRC and LRC groups (67 [39.9%] vs 28 [25.2%], P=0.011). Among 279 patients, risk factors associated with postoperative AKD included RLRC (OR 2.067, 95%CI 1.188 to 3.595, P=0.010), Age (years) (OR 1.046, 95%CI 1.018 to 1.074, P=0.001), baseline eGFR&amp;lt;60(ml/(min.1.73m2) (OR 2.662, 95%CI 1.355 to 5.230, P=0.004), Further subgroup analysis identified age, operation time&amp;lt;250(min) as important risk factors of AKD in RLRC patients but not in LRC patients. Of 211 patients with a preoperative estimated glomerular filtration rate (eGFR) of &amp;gt; 60 ml/min/1.73 m2, CKD developed in 16.0% (21/ 131) of patients in the non-AKD group and 36.3% (29/ 80) of patients in the AKD group. Kaplan-Meier analysis(shown in figure 1) identified that AKD is associated with higher CKD rates in those patients (P &amp;lt;0.001). Conclusion One-third of bladder cancer patients developed AKD after after radical cystectomy. RLRC, Age, baseline eGFR &amp;lt;60(ml/(min.1.73m2) were independent risk factors for postoperative AKD in all patients. Occurance of AKD could increase the risk of new-onset CKD in the long run. Though the use of RLRC is now well established, we should be aware that it may increase the risk of postoperative AKD, especially for patients who are old and with lower eGFR .Besides, we should try to improve the management of those AKD patients with aim toward preventing further development of CKD.

Impact of 18FDG-PET CT in the management of invasive bladder cancer.

444 Background: Guidelines do not recommend FDG-Positron Emission Tomography (PET) Computed Tomography (CT) for the staging of Muscle Invasive Bladder Cancer (MIBC), but rather CT scan for lymph node (LN) and metastatic staging, despite its low accuracy. We performed a retrospective analysis of patients (pts) with MIBC who had a FDG-PET CT for staging, indicated by multidisciplinary team, in two centers, and analyzed its utility in this setting. Methods: All pts who had a FDG-PET CT performed at the time of diagnosis of MIBC from 01/2005 to 12/2017 in Bordeaux (Bergonie Institute and University Hospital) were retrospectively reviewed. Nodal and metastatic staging on CT and FDG-PET CT were done independently according to the 8th TNM classification. The aims of the study were to evaluate the accuracy of the FDG-PET CT for LN staging and to determine the rate of treatment modification (neoadjuvant chemotherapy for curative intent, no surgery for metastatic disease), according to FDG-PET CT results. Results: Among the 130 pts included, with a median age of 65 years, 74% were considered free from nodal metastasis (N0) by CT whereas only 44% were N0 from FDG-PET CT. Based on CT results, 88% of pts were free from distant metastasis (M0) but only 75% were classified M0, on FDG-PET CT. Accuracy of LN staging for CT and FDG-PET CT at initial diagnosis were analyzed for 85 pts (including 70 pts treated with neoadjuvant chemotherapy) and compared to pathological examination of resected LN. Sensitivity of FDG-PET CT was better than CT (respectively 80.8% versus 26.9%) but the specificity was low (respectively 54.2% versus 83.1%). Youden index was better for FDG-PET CT (0.35; 0.1 for CT), being more accurate for determining LN staging of MIBC. FDG-PET CT findings allowed a treatment decision modification in 34/130 pts (26.1%): therapeutic intensification in 12 pts (9.2%), including surgery not previously indicated, modified radiotherapy; or de-escalation in 22 pts (16.9%), mostly avoiding surgery. Conclusions: FDG-PET CT is more sensitive to detect LN involvement at initial diagnosis of MIBC than standard CT scan. Moreover, in the present study, treatment decisions were modified, according to FDG-PET CT results, in a quarter of pts according to LN and distant metastatic staging.

The role of Narrow-band Imaging Cystoscopy in Non-muscular Invasive Bladder Cancer Management

Cystoscopy is the most common assessment method for the lower urinary tract, with the primary goal of establishing pathology management that can occur at this level. The most used method of performing cystoscopy is with white light, but it can lead to omission of lesions, especially when considering millimetric tumor formations. New light source technologies are under development, such as narrow-band cystoscopy. Overall, we examined a total of 416 patients, known with tumoral lesions, in WLI followed by reassessment in NBI at the same time and transurethral resection of tumor biopsy specimens. In 37.5% of the cases, NBI highlighted 1 to 3 tumors in addition to WLI. In 178 cases, tumor formations were newly discovered, and in 238 patients these were recurrent. Histopathological diagnosis indicated the pTa stage in 67.3% of cases, in 27.64% patients presented with pT1 stage and in 5.04% of cases CIS was identified. In terms of grading, G1 was identified in 205 of the cases, 124 patients presenting G2 and G3 occurred in 87 of the cases.

Management of Recurrent Non-Muscle Invasive Bladder Cancer.

Management of Recurrent Non-Muscle Invasive Bladder Cancer.

Radical cystectomy with pelvic lymphadenectomy: pathologic, operative and morbidity outcomes in a Brazilian cohort.

ABSTRACTIntroduction and Objective Radical cystectomy (RC) with pelvic lymph node dissection is the standard treatment for muscle invasive bladder cancer and the oncologic outcomes following it are directly related to disease pathology and surgical technique. Therefore, we sought to analyze these features in a cohort from a Brazilian tertiary oncologic center and try to identify those who could negatively impact on the disease control. Patients and Methods We identified 128 patients submitted to radical cystectomy, for bladder cancer treatment, from January 2009 to July 2012 in one oncology tertiary referral public center (Mario Penna Institute, Belo Horizonte, Brazil). We retrospectively analyzed the findings obtained from their pathologic report and assessed the complications within 30 days of surgery.Results We showed similar pathologic and surgical findings compared to other large series from the literature, however our patients presented with a slightly higher rate of pT4 disease. Positive surgical margins were found in 2/128 patients (1.5%). The medium number of lymph nodes dissected were 15. Major complications (Clavien 3 to 5) within 30 days of cystectomy occurred in 33/128 (25.7%) patients.Conclusions In the management of invasive bladder cancer, efforts should focus on proper disease diagnosis and staging, and, thereafter, correct treatment based on pathologic findings. Furthermore, extended LND should be performed in all patients with RC indication. A critical analysis of our complications in a future study will help us to identify and modify some of the factors associated with surgical morbidity.

The Role of Chemotherapy and Radiotherapy in the Surgical Management of Muscle Invasive Bladder Cancer

The management of muscle invasive bladder cancer represents an unresolved clinical challenge. Invasive urothelial carcinomas are associated with high mortality rates and early metastatic disease. Radical cystectomy is a recognized standard of care, although disease-free survival outcomes remain suboptimal. The limitations of pre-operative clinical staging, as well as the complex natural history of the disease, precludes the introduction of simple management protocols. To what degree chemotherapy and radiotherapy may be useful in the surgical management of invasive bladder cancer remains contentious. This literature review critically examines the benefits, risks and difficulties of each approach, with an emphasis on individually tailored therapy.

International Robotic Radical Cystectomy Consortium: A way forward.

Robot-assisted radical cystectomy (RARC) is an emerging operative alternative to open surgery for the management of invasive bladder cancer. Studies from single institutions provide limited data due to the small number of patients. In order to better understand the related outcomes, a world-wide consortium was established in 2006 of patients undergoing RARC, called the International Robotic Cystectomy Consortium (IRCC). Thus far, the IRCC has reported its findings on various areas of operative interest and continues to expand its capacity to include other operative modalities and transform it into the International Radical Cystectomy Consortium. This article summarizes the findings of the IRCC and highlights the future direction of the consortium.

Role of Systemic Chemotherapy in Urothelial Urinary Bladder Cancer

Radical cystectomy is the standard of care for patients with localized muscle-invasive bladder cancer; however, 50 percent of patients still relapse in distant sites following surgery. A systemic approach is needed to improve outcomes in bladder cancer in the metastatic and perioperative settings. We reviewed the literature for use of systemic chemotherapy in bladder cancer and its role in metastatic, neoadjuvant, and adjuvant settings, including patients with comorbidities and renal dysfunction. Current controversies on the role of chemotherapy in neoadjuvant and adjuvant settings as well as the role of novel agents are discussed. First-line cisplatin-based polychemotherapy improves survival in the metastatic setting and is the standard of care. Approved regimens for subsequent-line therapy do not exist. Chemotherapy has a modest benefit in the neoadjuvant setting, but evidence is insufficient to justify its role in the adjuvant setting despite a possible benefit. Carboplatin cannot be substituted for cisplatin in fit patients, and the addition of taxane to a standard regimen cannot be recommended. Systemic chemotherapy plays a central role in the management of invasive bladder cancer in the metastatic and neoadjuvant settings, but its role in the adjuvant setting remains undefined. Neoadjuvant chemotherapy is underutilized and should be routinely used. Pathological downstaging strongly correlates with improved outcomes and may serve as a surrogate end point for survival. An urgent need exists for the development of novel therapeutic agents to improve outcomes.

Pure Laparoscopic Radical Cystectomy with Ileal Conduit: A Single Surgeon's Mid-Term Outcomes

PurposeThe use of laparoscopic radical cystectomy (LRC) for muscle-invasive bladder cancer is not yet widespread because of the technical difficulties of the procedure and the lengthy operating time. In this study, we report a single surgeon's experience with LRC.Materials and MethodsThirty patients (25 men and 5 women) with bladder cancer underwent LRC and ileal conduit by a single surgeon between November 2007 and May 2011. An extracorporeal urinary diversion was performed through 5-6 cm midline incision for specimen extraction.ResultsThe median operating time and estimated blood loss were 527.5 minutes and 275 mL, respectively. There was no conversion to open surgery. The median time to oral intake and postoperative hospital stay were 5 days and 12 days, respectively. The rates of immediate, early postoperative and late postoperative complication were 3.3%, 20% and 20%, respectively. With 16 months of median follow-up, the overall and recurrence-free survival rates were 70% and 56.7%, respectively.ConclusionLRC is feasible for the management of invasive bladder cancer and, with appropriate patient selection, can be a good alternative to open or robot-assisted radical cystectomy in the era of robot-assisted surgery.

Role of the Combined Regimen with Local Chemotherapy and Mw-Induced Hyperthermia for Non-Muscle Invasive Bladder Cancer Management. A Systematic Review

To give an updated review concerning the role of combined regimen (CT) based on microwave-induced hyperthermia (MwHT, CT-MwHT) with intravesical chemotherapy (ICT) as a treatment for non-muscle invasive bladder cancer (NMIBC). The review process followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. An electronic search of the Medline, Embase, Cochrane Library, CancerLit, and ClinicalTrials.gov databases was undertaken. Relevant conference abstracts and urology journals were also included. The primary end-point was the time to recurrence. Secondary end-points included time to progression, bladder preservation rate, and adverse event (AE) rate. A total of 24 studies met inclusion criteria and underwent data extraction. When feasible, data were combined using random-effects meta-analytic techniques. Recurrence was seen 59% less after CT-MwHT than after MMC alone, however, due to the short follow-up, no definitive conclusions can be drawn about the impact on the time to recurrence and progression. The overall bladder preservation rate after CT-MwHT was 87.6%. This rate appeared higher than after MMC alone, but valid comparison studies could not be drawn due to the absence of randomized trials in neo-adjuvant settings. AEs were higher with CT-MwHT than with MMC alone, but this difference was not statistically significant. Published data suggest that recurrence rates for chemo-hyperthermia are substantially reduced compared with chemotherapy alone in adjuvant settings. Patients with refractory disease fare worse than those being treated with chemo-hyperthermia for their first tumor. Progression rates to muscle-invasive disease are markedly lower after combination treatment than after chemotherapy alone, with very high rates of bladder preservation. Tolerability is good, with few dropouts in the clinical trials. The results support CT-MwHT in the future as a standard procedure for high-risk recurrent patients, for subjects in whom the treatment with Bacillus Calmette-Guérin is contraindicated, and those unsuitable for radical cystectomy.

Update on the management of invasive bladder cancer 2012

Muscle-invasive bladder cancer is a deadly disease for which a number of new approaches have become available to improve prognosis. A recent review emphasized the importance of timely indication of surgery and highlighted current views regarding the adequate extent of the surgery and the importance of lymph node dissection. Furthermore, treatment using neoadjuvant and adjuvant systemic chemotherapy has become more prominent, while cystectomy and diversion should be conducted only in experienced centers. Optimal methods of urinary diversion and the use of robot-assisted laparoscopic cystectomy require further study.

Super Extended Versus Extended Pelvic Lymph Node Dissection in Patients Undergoing Radical Cystectomy for Bladder Cancer: A Comparative Study

There is evidence from retrospective studies that radical cystectomy with extended pelvic lymph node dissection provides better staging and outcomes than limited lymph node dissection. However, the optimal limits of extended lymph node dissection remain unclear. We compared oncological outcomes at 2 cystectomy centers where 2 different extended lymph node dissection templates are practiced to determine whether removing lymphatic tissue up to the inferior mesenteric artery confers an additional survival advantage. Patients undergoing radical cystectomy and extended lymph node dissection with curative intent from 1985 to 2005 were included in analysis if they met certain criteria, including clinically organ confined urothelial bladder carcinoma (cN0M0), pathological stage pT2-pT3, negative surgical margins and no neoadjuvant therapy. Survival and recurrence data were analyzed. Demographic data and pathological subgroup distribution (pT2 and pT3) were similar in the 554 University of Southern California and 405 University of Bern patients. University of Southern California patients had higher median number of lymph nodes removed than University of Bern patients (38 vs 22, p <0.0001) and a higher incidence of lymph node metastasis (35% vs 28%, p = 0.02). However, the University of Southern California and University of Bern groups had similar 5-year recurrence-free survival for pT2pN0-2 (57% vs 67%) and pT3pN0-2 (32% vs 34%) disease (p = 0.55 and 0.44, respectively). The overall recurrence rate was equal at the 2 institutions (38%). Meticulous extended lymph node dissection up to the mid-upper third of the common iliac vessels appears to provide survival and recurrence outcomes similar to those of a super extended template up to the inferior mesenteric artery. Complete skeletonization in the extended lymph node dissection template is more important than nodal yield. This does not exclude the possibility that certain patient subgroups with suspicious nodes or after neoadjuvant chemotherapy may benefit from more extensive lymph node dissection.