Primary Non-muscle Invasive Bladder Cancer Research Articles

Optimal timing for the first cystoscopic follow-up using time-to-treatment initiation analysis of oncologic outcomes in primary non-muscle invasive bladder cancer

Various guidelines recommend the first follow-up cystoscopy at 3 months; however, no data exist on the optimal timing for initial follow-up cystoscopy. We tried to provide evidence on the timing of the first cystoscopy after the initial transurethral resection of bladder tumor (TUR-BT) for patients with non-muscle invasive bladder cancer (NMIBC) using big data. This was a retrospective National Health Insurance Service database analysis. The following outcomes were considered: recurrence, progression, cancer-specific mortality, and all-cause mortality. Exposure was the time-to-treatment initiation (TTI), a continuous variable representing the time to the first cystoscopy from the first TUR-BT within 1 year. Additionally, we categorized TTI (TTIc) into five levels: < 2, 2–4, 4–6, 6–8, and 8–12 months. A landmark time of 1 year after the initial TUR-BT was described to address immortal-time bias. We identified the optimal time for the first cystoscopy using Cox regression models with and without restricted cubic splines (RCS) for TTI and TTIc, respectively. Among 26,660 patients, 16,880 (63.3%) underwent cystoscopy within 2–4 months. A U-shaped trend of the lowest risks at TTI was observed in the 2–4 months group for progression, cancer-specific mortality, and all-cause mortality. TTI within 0–2 months had a higher risk of progression (aHR 1.36; 95% confidence intervals [CI] 1.15–1.60; p < 0.001) and cancer-specific mortality (aHR 1.29; 95% CI 1.05–1.58; p = 0.010). Similarly, TTI within 8–12 months had a higher risk of progression (aHR 2.09; 95% CI 1.67–2.63; p < 0.001) and cancer-specific mortality (aHR 1.96; 95% CI 1.48–2.60; p < 0.001). Based on the RCS models, the risks of progression, cancer-specific mortality, and all-cause mortality were lowest at TTI of 4 months. The timing of the first cystoscopy follow-up was associated with oncologic prognosis. In our model, undergoing cystoscopy at 4 months has shown the best outcomes in clinical course. Therefore, patients who do not receive cystoscopy at approximately 4 months for any reason need more careful follow-up to predict a poor clinical course.

The Value of Negative Urinary Dipstick Tests for Haematuria in Patients Undergoing Surveillance for Low-grade Ta Urothelial Cancer: A Two-stage Prospective Clinical Study in 524 Patients

Background and objectiveThe risk of first recurrence beyond 5 yr for patients with low-grade (LG) Ta non–muscle-invasive bladder cancer (NMIBC) is low enough to consider discontinuing cystoscopic surveillance at that point. However, a positive urinary dipstick test for haematuria (UDH) during and beyond the period of cystoscopic surveillance can disrupt plans to cease surveillance because the association between UDH positivity and recurrence in LG Ta NMIBC is unknown. In a two-stage study, we evaluated this association and explored the role of UDH negativity in predicting the absence of recurrence. MethodsBecause of previously demonstrated changes in recurrence patterns over time, two prospective cohorts were assessed: an “exploratory” cohort (January 2007–March 2008) and a “validation” cohort (November 2017–August 2018). UDH was performed before flexible cystoscopy. Patient, operative, and surveillance data have been recorded prospectively using standard pro forma sheets since 1978 in our institution. Only patients with primary LG Ta pTa NMIBC were included for analysis. Key findings and limitationsWe assessed 231 patients in the exploratory group and 293 in the validation group. The proportion of smokers (67% vs 70%; p = 0.5) and mean follow-up (72.2 vs 79.9 mo; p = 0.2) were similar between the groups. The recurrence rate was higher in the exploratory group (19% vs 11%; p = 0.009), as was the UDH positivity rate (37% vs 11%; p < 0.001). The specificity and negative predictive value were 64% and 83% in the exploratory group, and 90% and 90%, respectively, in the validation group. These values increased further for the subgroup with solitary primary tumours the subgroup without recurrence for 3 yr. Conclusions and clinical implicationsUDH negativity has a high probability of being associated with the absence of recurrence in small LG Ta NMIBC and could be an inexpensive adjunct during surveillance. Ongoing validation, which started in 2019, is being performed in a now-nationalised Scottish protocol in which UDH replaces cystoscopy in years 2 and 4 for patients in the low-risk group. Patient summaryWe investigated the accuracy of a dipstick test for blood in the urine for patients undergoing surveillance for low-grade noninvasive bladder cancer. We found that a negative dipstick test result was highly associated with the absence of tumour recurrence, particularly for patients with the lowest risk. These findings have been introduced into a national protocol designed to reduce the frequency of telescopic inspection of the bladder during surveillance to reduce the burden for patients.

Geriatric nutritional risk index as a prognostic factor in elderly patients with non-muscle-invasive bladder cancer: a propensity score-matched study.

The Geriatric Nutrition Risk Index (GNRI) is a simple and validated tool used to assess the nutritional status of elderly patients and predict the risk of short-term postoperative complications, as well as the long-term prognosis, after cancer surgery. In this study, we aimed to evaluate the predictive value of GNRI for the long-term postoperative prognosis in elderly patients with primary non-muscle-invasive bladder cancer (NMIBC) who underwent transurethral resection of bladder tumor (TURBT). We retrospectively analyzed data from 292 elderly patients with primary NMIBC. Using X-tile software, we divided the cohort into two groups based on GNRI and determined the cut-off value for postoperative recurrence-free survival (RFS). Propensity score matching (PSM) with a ratio of 1:3, Kaplan-Meier analysis, log-rank test, and COX proportional hazards regression were used to assess the correlation between GNRI and prognosis and identify factors predicting recurrence and progression. In the entire cohort, the 3year recurrence group had significantly lower GNRI compared to the 3year non-recurrence group (P = 0.0109). The determined GNRI cut-off value was 93.82. After PSM, the low GNRI group had significantly lower RFS (P < 0.0001) and progression-free survival (PFS) (P = 0.0040) than the high GNRI group. Multivariate COX regression showed that GNRI independently predicted RFS (HR 2.108; 95% CI 1.266-3.512; P = 0.004) and PFS (HR 2.155; 95% CI 1.135-4.091; P = 0.019) in elderly patients with primary NMIBC. Preoperative GNRI is a prognostic marker for disease recurrence and progression in elderly patients with primary NMIBC undergoing TURBT.

Clinical impact of the intensity of follow-up cystoscopy in patients with high-risk non-muscle-invasive bladder cancer.

There is significant lack on evidence regarding the effect of non-adherence to a recommended protocol in follow-up of high-risk non-muscle-invasive bladder cancer (NMIBC), or the impact of delaying detection of recurrent lesion. Here, we aimed to investigate the optimal frequency of follow-up cystoscopy of high-risk NMIBC with respect to oncological safety in the Japanese real-world clinical practice. This retrospective single-center study included 206 patients with primary high-risk NMIBC. The intensity (%) of follow-up cystoscopy was calculated based on actual visits for cystoscopy and guideline-recommended frequency in the first 24-month follow-up period. Inverse probability of treatment weighting analyses was used to reduce the risk of bias between groups. We performed a restricted cubic spline analysis with knots at intensity of follow-up cystoscopy ≤ 100% group to examine the possible association of progression risk with the intensity of follow-up as a continuous exposure. The median intensity was 87.5% (interquartile range, 75-100). Adjusted multivariate analysis for MIBC-free and progression-free survival demonstrated no significant difference between adjusted ≤ 75% and > 75% intensity groups. A restricted cubic spline analysis suggested no significant effect of the intensity of follow-up on progression risk, and hazard ratios of patients of < 100% intensity were equivalent to those of patients of 100% intensity. Our finding suggested decreased intensity of follow-up cystoscopy did not affect oncological outcomes in patients with high-risk NMIBC. Further prospective trials directly aimed at investigating optimized follow-up schedules for NMIBC are mandatory before substantial changes to existing clinical guidelines.

Body mass index and waist circumference in relation to risk of recurrence and progression after non-muscle invasive bladder cancer.

Obesity may be associated with increased risk of recurrence and progression in patients with non-muscle invasive bladder cancer (NMIBC), but evidence is limited and inconsistent. We examined the associations of body mass index (BMI), waist circumference, and waist-to-hip ratio (WHR) with risk of recurrence and progression among patients with NMIBC. This prospective study included 1029 patients diagnosed with primary NMIBC between 2014 and 2017. Patients reported weight 2 years before diagnosis at baseline, and weight, waist and hip circumference at 3 months postdiagnosis. Associations were quantified using Cox proportional hazard analyses, adjusted for clinical and lifestyle characteristics. More than half of patients were overweight (49%) or obese (19%) after diagnosis. During a median follow-up time of 3.6 years, 371 patients developed ≥1 recurrence and 53 experienced progression. No associations with recurrence were observed for BMI (HRper 5 kg/m2 0.94; 95% CI 0.82, 1.07), waist circumference (HRper 10 cm 0.95; 95% CI 0.86, 1.05), or WHR (HRper 0.1 unit 0.90; 95% CI 0.76, 1.06). In contrast, higher BMI was associated with a 40% increased risk of progression, with only the 2-year prediagnosis association reaching statistical significance (HRper 5 kg/m2 1.42; 95% CI 1.09, 1.84). No associations for pre-to-postdiagnosis weight change were found. General and abdominal obesity were not associated with recurrence risk among patients with NMIBC, but might be associated with increased risk of progression. Studies with sufficient sample size to stratify by tumor stage and treatment are needed to better understand whether and how obesity could influence prognosis.

High-power green-light laser endoscopic submucosal dissection for non-muscle-invasive bladder cancer: A technical improvement and its initial application.

The technique of laser en bloc resection of bladder tumor (ERBT) has been a valuable alternative technique to transurethral resection of bladder tumor (TURBT). However, the combination of laser ERBT and endoscopic submucosal dissection (ESD) technique has not been well studied. Here, a novel technique integrating a high-power green-light laser with ESD was presented. This study aimed to evaluate the safety and efficacy of high-power green-light laser endoscopic submucosal dissection (HPL-ESD) for the treatment of primary non-muscle-invasive bladder cancer (NMIBC). From January 2015 to December 2018, a total of 56 patients with NMIBC underwent HPL-ESD. All tumors were transurethral en bloc resected in the ESD technique. Perioperative clinical data were retrospectively collected and analyzed. All operations were safely performed by the technique of HPL-ESD without blood transfusion. The mean tumor diameter was 2.04 ± 0.65 cm, ranging from 0.5 to 3.5 cm. The mean operative time was 28.39 ± 16.04 min. The average serum hemoglobin decrease was 0.88 ± 0.54 g/dL. The mean postoperative catheterization time was 2.88 ± 0.94 days. The pathologic stages included pTa (32 cases), and pT1 (24 cases). Double-J stent indwelling was not performed for four patients whose tumors were adjacent to the ureteral orifice and no postoperative hydronephrosis was observed. Only one case of ectopic bladder tumor recurred due to irregular bladder irrigation during the 36-month follow-up. HPL-ESD is a safe and effective alternative for the treatment of primary NMIBCs, especially for tumors adjacent to the ureteral orifice.

Comparison of holmium laser, bipolar and conventional monopolar transurethral resection of bladder tumour in primary non-muscle invasive bladder cancer.

To compare the efficiency and safety profile of conventional monopolar, bipolar plasmakinetic and holmium laser techniques for transurethral resection of bladder tumour. The prospective comparative study was conducted from July 2019 to May 2021 after approval from the ethicsreview committee of Kafrelsheikh University, Egypt, and comprised patients of either gender with primary non muscle invasive bladder cancer who qualified for transurethral resection of bladder tumour. The patients were stratified into low-risk group A, intermediate risk group B and high-risk group C in accordance with the guidelines of the European Association of Urology. Comprehensive cystoscopy and panendoscopy were done in all cases. Once panendoscopy was done, tumour resection was performed with monopolar resectoscope in group A, plasmakinetic resectoscope in group B and holmium laser in group C). Data was collected at preoperative, peroperative, postoperative and follow-up stages. Data was analysed using SPSS 21. Of the 84 patients, 67(79.76%) were males and 17(20.23%) were females. There were 27(32.14%) patients in group A; 21(77.8%) males and 6(22.2%) females withy mean age 60.63±11.76 years. Group B had 32(38%) patients; 26(81.2%) males and 6(18.8%) females with mean age 65.34±7.55 years. Group C had 25(29.76%) patients; 20(80%) males and 5(20%) females with mean age 59.48±12.6 years. The mean follow-up period was 12.97±2.70 months in group A, 12.81±2.75 monthsin group B and 13.48±3.3 monthsin group C. Visualised complete resection was done in 23(85.8%) group A patients, 29(90.6%) group B patients and 24(96%) group C patients(p=0.018). Visualised complete resection, tumour multiplicity, tumour size, catheter duration, and hospital stay were significant predictors (p<0.05). Survival analysis showed 26(96.3%), 30(93.75%) and 25(100%) cases in groups A, B and C, respectively. Bipolar plasmakinetic and holmium laser techniques were found to be more effective and safer than the conventional monopolar technique for transurethral resection of bladder tumour in patients with primary non-muscle invasive bladder cancer.

Can Peripheral Blood Systemic Immune Response Parameters Predict Oncological Outcomes in Patients with Non-Muscle-Invasive Bladder Cancer?

Many studies have investigated most cancer types - associations with systemic inflammatory response (SIR) parameters. Aim: This study investigated predictive values of SIR parameters in oncological outcomes and survival - to primary non-muscle-invasive bladder cancer (NMIBC) patients. We analyzed 74 primary NMIBC patients. Clinical features, laboratory results, and tumor characteristics were recorded. In addition, the neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), serum C-reactive protein, albumin-to-globulin ratio (AGR), and modified Glasgow prognostic scores (mGPS) were calculated. The - mean age of the patients was - 67.41 ± 11.31 years, and the follow-up duration was 38.77 ± 19.53 months. We - found no significant NLR, CRP, and AGR - correlations with tumor characteristics and oncological outcomes. There were significant - correlations between MLR and pathological-T-stage and the PLR, pathological-T-stage, and tumor count. Carcinoma in situ was associated with a high mGPS. Multivariate analysis revealed no significant - correlations between systemic inflammatory response parameters and oncological outcomes. Patients with a high mGPS had poor cancer-specific survival. Increased NLR was associated with reduced overall survival. This study revealed no significant correlation between SIR parameters and oncological outcomes. Therefore, we need more reliable indicators than SIR parameters in NMIBC patients in clinical practice.

Adherence to lifestyle recommendations after non-muscle invasive bladder cancer diagnosis and risk of recurrence

BackgroundPatients with non-muscle invasive bladder cancer (NMIBC) are at a high risk of tumor recurrence. It has not been previously investigated if adherence to cancer prevention recommendations lowers the risk of recurrence. ObjectivesWe examined whether the standardized lifestyle score measuring adherence to the 2018 World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) cancer prevention recommendations was associated with the risk of recurrence and progression among patients with NMIBC. MethodsThe study population included patients diagnosed with primary NMIBC between 2014 and 2017 from the prospective cohort UroLife. Lifestyle was assessed at baseline (n = 979; reflecting the prediagnosis period) and 3-mo postdiagnosis (n = 885). The standardized 2018 WCRF/AICR score was constructed based on recommendations for body weight, physical activity, diet, and alcohol intake. We computed multivariable-adjusted HRs and 95% CIs using Cox proportional hazard regression models. ResultsDuring a median follow-up time of 3.7 y, 320 patients developed ≥1 recurrence(s) and 49 experienced progression. Patients in the highest compared with the lowest tertile of postdiagnosis WCRF/AICR scores had a lower risk of first bladder cancer recurrence (HR: 0.74; 95% CI: 0.56, 0.98). No associations were observed for multiple recurrences (HR: 0.90; 95% CI: 0.70, 1.15) or for the baseline score with either first (HR: 1.07; 95% CI: 0.82, 1.40) or multiple recurrences (HR: 1.04; 95% CI: 0.82, 1.31). Improving lifestyle after diagnosis (per 1-point increase) was not significantly associated with the risk of first or multiple recurrence(s) (HR: 0.87; 95% CI: 0.74, 1.02; HR: 0.93; 95% CI: 0.80, 1.08, respectively). No associations were observed for bladder cancer progression, but the power was limited. ConclusionsBetter adherence to the WCRF/AICR cancer prevention recommendations 3 mo after NMIBC diagnosis, but not before diagnosis, is associated with a decreased risk of first bladder cancer recurrence. More studies evaluating postdiagnosis lifestyles are needed to provide solid support for lifestyle recommendations for cancer survivors.

Impact of an optimized surveillance protocol based on the European Association of Urology substratification on surveillance costs in patients with primary high-risk non-muscle-invasive bladder cancer.

The optimal frequency and duration of surveillance in patients with high-risk non-muscle-invasive bladder cancer (NMIBC) remain unclear. The aim of the present study is to develop an optimal surveillance protocol based on the European Association of Urology (EAU) substratification in order to improve surveillance costs after transurethral resection of bladder tumor (TURBT) in patients with primary high-risk NMIBC. We retrospectively evaluated 428 patients with primary high-risk NMIBC who underwent TURBT from November 1993 to April 2019. Patients were substratified into the highest-risk and high-risk without highest-risk groups based on the EAU guidelines. An optimized surveillance protocol that enhances cost-effectiveness was then developed using real incidences of recurrence after TURBT. A recurrence detection rate ([number of patients with recurrence / number of patients with surveillance] × 100) of ≥ 1% during a certain period indicated that routine surveillance was necessary in this period. The 10-year total surveillance cost was compared between the EAU guidelines-based protocol and the optimized surveillance protocol developed herein. Among the 428 patients with primary high-risk NMIBC, 97 (23%) were substratified into the highest-risk group. Patients in the highest-risk group had a significantly shorter recurrence-free survival than those in the high-risk without highest-risk group. The optimized surveillance protocol promoted a 40% reduction ($394,990) in the 10-year total surveillance cost compared to the EAU guidelines-based surveillance protocol. The optimized surveillance protocol based on the EAU substratification could potentially reduce over investigation during follow-up and improve surveillance costs after TURBT in patients with primary high-risk NMIBC.

Additional oncological benefit of photodynamic diagnosis with blue light cystoscopy in transurethral resection for primary non-muscle-invasive bladder cancer: A comparative study from experienced institutes.

The objective of this work is to evaluate the additional oncological benefit of photodynamic diagnosis (PDD) using blue-light cystoscopy in transurethral resection (TURBT) for primary non-muscle-invasive bladder cancer (NMIBC) based on the International Bladder Cancer Group (IBCG)-defined progression and the subsequent pathological pathways. We reviewed 1578 consecutive primary NMIBC patients undergoing white-light TURBT (WL-TURBT) or PDD-TURBT during 2006-2020. One-to-one propensity score-matching was performed using multivariable logistic regression to obtain balanced groups. IBCG-defined progression of NMIBC included stage-up and grade-up as well as conventional definitions such as the development of muscle-invasive BC or metastatic disease. Nine oncological endpoints were evaluated. Sankey diagrams were generated to visualize follow-up pathological pathways after the initial TURBT. Comparison of event-free survival between the matched groups revealed that PDD use decreased the bladder cancer recurrence risk and IBCG-defined progression risk, whereas no significant difference was noted in conventionally defined progression. This was attributable to a reduced risk of stage-up, from Ta to T1, and grade-up. Sankey diagrams of the matched groups showed that patients with primary Ta low-grade tumour and first-recurrence Ta low-grade tumour did not have bladder recurrence or progression, while some of those in the WL-TURBT group developed recurrence after treatment. The multiple survival analysis demonstrated that the risk of IBCG-defined progression was significantly decreased by PDD use in NMIBC patients. Sankey diagrams revealed possible differences in pathological pathways after the initial TURBT between the two groups, demonstrating that repeated recurrence could be prevented by PDD use.

Significance of dorsal bladder neck involvement in predicting the progression of non-muscle-invasive bladder cancer.

Accurately predicting of progression is important for patients with non-muscle-invasive bladder cancer (NMIBC). We previously reported that bladder neck involvement (BNI) was significantly associated with progression of NMIBC. In this study, we evaluated the prognostic significance of the detailed BNI location in NMIBC patients. We retrospectively reviewed 651 patients diagnosed with primary NMIBC at a single center between 2000 and 2018. Using the detailed BNI location, patients were divided into the following three groups: dorsal BNI (BNId; 4 to 8 o'clock position), ventral BNI (BNIv; 8 to 4 o'clock but not 4 to 8 o'clock position), and non-BNI group. Both time to progression to muscle-invasive disease and distant metastasis was compared among the three groups. A prognostic model was developed and its discriminative ability was evaluated. Dorsal bladder neck involvement and BNIv were observed in 43 (6.6%) and 36 (5.5%) patients, respectively. During a median follow-up of 61months, 35 (5.4%) patients progressed. The cumulative incidence at 5 years was 12%, 0%, and 5.0% in BNId, BNIv, and non-BNI groups, respectively. On multivariate analysis, BNId was a significant and independent risk factor for progression, tumor stage pT1, and histologic grade G3. One point was assigned to each factor, and patients were classified into four well-stratified prognostic groups based on the total score. Dorsal bladder neck involvement was an independent and significant risk factor for progression in primary NMIBC. Our simple and practical prognostic model including BNId is easy to use and may help selecting the optimal treatment and its timing.

Resección transuretral en bloque vs. resección transuretral convencional para el cáncer de vejiga primario no músculo-infiltrante: metaanálisis

IntroductionWe performed a meta-analysis to evaluate the effect of en-bloc transurethral resection vs. conventional transurethral resection for primary non-muscle invasive bladder cancer. MethodsA systematic literature search up to January 2022 was done and 28 studies included 3714 primary non-muscle invasive bladder cancer subjects at the start of the study; 1870 of them were en-bloc transurethral resection, and 1844 were conventional transurethral resection for primary non-muscle invasive bladder cancer. We calculated the odds-ratio (OR) and mean-difference (MD) with 95% confidence-intervals (CIs) to evaluate the effect of en-bloc transurethral resection compared with conventional transurethral resection for primary non-muscle invasive bladder cancer by the dichotomous or continuous methods with random or fixed-effects models. ResultsEn-bloc transurethral resection had significantly lower twenty-four-month recurrence (OR: 0.63; 95%CI: 0.50-0.78; P<0.001), catheterization-time (MD: –0.66; 95%CI: –1.02-[–0.29]; P<0.001), length of hospital stay (MD: –0.95; 95%CI: –1.55-[–0.34]; P=0.002), postoperative bladder irrigation duration (MD: –6.06; 95%CI: –9.45-[–2.67]; P<0.001), obturator nerve reflex (OR: 0.08; 95%CI: 0.02-0.34; P=0.03), and bladder perforation (OR: 0.14; 95%CI: 0.06-0.36: P<0.001) and no significant difference in the 12-month-recurrence (OR: 0.79; 95%CI: 0.61-1.04; P=0.09), the operation time (MD: 0.67; 95%CI: –1.92-3.25; P=0.61), and urethral stricture (OR: 0.46; 95%CI: 0.14-1.47; P=0.19) compared with conventional transurethral resection for primary non-muscle invasive bladder cancer subjects. ConclusionsEn-bloc transurethral resection had a significantly lower twenty-four-month recurrence, catheterization time, length of hospital stay, postoperative bladder irrigation duration, obturator nerve reflex, bladder perforation, and no significant difference in the twelve-month recurrence, operation time, and urethral stricture compared with conventional transurethral resection for primary non-muscle invasive bladder cancer subjects. Further studies are required.

Immediate post-operative intravesical instillation of a single dose chemotherapy is not superior to continuous saline irrigation

Introduction and objectivesTo evaluate whether there is any difference between immediate postoperative instillation of intravesical chemotherapy (IPOIC) and continuous saline bladder irrigation (CSBI) in terms of bladder cancer (BC) recurrence in patients with primary low- or intermediate-risk non-muscle-invasive BC (NMIBC). Materials and methodsMedical records of 1482 patients who underwent transurethral resection of bladder tumor between March 1994 and August 2020 were reviewed retrospectively. Patients were divided into two groups according to IPOIC and/or CSBI administration status [Group-1 = CSBI alone; Group-2 = CSBI following IPOIC]. Low- and intermediate-risk NMIBC patients were also divided into subgroups according to IPOIC and/or CSBI administration status. ResultsA total of 594 patients with primary NMIBC were included. Of the patients, 86 (14.5%) were female and 508 (85.5%) were male with a median age of 69 (60–78) years. The frequency of patients in Group-1 and Group-2 were 361 (60.8%) and 233 (39.2%), respectively. Recurrent disease was observed in 213 (35.9%) patients. There was no difference between the groups when they were compared for recurrent disease frequency, median time to first recurrence and frequency of recurrence within first 12 months (P = .064, P = .671, and P = .145, respectively). Disease recurrence rates in low-risk NMIBC patients was lower when they were treated with “CSBI following IPOIC” when compared to “CSBI alone” (P = .042). However, no difference was observed in low-risk NMIBC subgroups when they were compared for pathological features of recurrent tumors such as number, size, grade, stage, and presence of carcinoma in situ (P > .05, for each). Conclusions“CSBI following IPOIC” combination was not superior to “CSBI alone” for preventing adverse pathological outcomes in recurrent low- and intermediate-risk NMIBC.

Risk score-based substratification improves surveillance costs after transurethral resection of bladder tumor in patients with primary high-risk non-muscle-invasive bladder cancer

High-risk non-muscle-invasive bladder cancer (NMIBC) has a heterogeneity and intensive surveillances after transurethral resection of bladder tumor (TURBT) are major factors of increased costs. Therefore, we aimed to develop optimized surveillance protocols based on the risk score-based substratifications to improve surveillance costs. We retrospectively evaluated 428 patients with primary high-risk NMIBC who underwent TURBT. Patients were substratified into intra-lower, intra-intermediate, and intra-higher groups or UUT-lower, UUT-intermediate, and UUT-higher groups by summing each of the independent risk factors of intravesical and UUT recurrences, respectively. The optimized surveillance protocols that enhance cost-effectiveness were then developed using real incidences of recurrence after TURBT. The 10-year total surveillance costs were compared between the European Association of Urology (EAU) guidelines-based and optimized surveillance protocols. The Kaplan–Meier curves of intravesical and UUT recurrence-free survivals were clearly separated among the substratified groups. The optimized surveillance protocols promoted a 43% reduction ($487,599) in the 10-year total surveillance cost compared to the EAU guidelines-based surveillance protocol. These results suggest that the optimized surveillance protocols based on risk score-based substratifications could potentially reduce over investigation and improve surveillance costs after TURBT in patients with primary high-risk NMIBC.

En-bloc transurethral resection vs. conventional transurethral resection for primary non-muscle invasive bladder cancer: A meta-analysis

IntroductionWe performed a meta-analysis to evaluate the effect of en-bloc transurethral resection vs. conventional transurethral resection for primary non-muscle invasive bladder cancer. MethodsA systematic literature search up to January 2022 was done and 28 studies included 3714 primary non-muscle invasive bladder cancer subjects at the start of the study; 1870 of them were en-bloc transurethral resection, and 1844 were conventional transurethral resection for primary non-muscle invasive bladder cancer. We calculated the odds-ratio (OR) and mean-difference (MD) with 95% confidence-intervals (CIs) to evaluate the effect of en-bloc transurethral resection compared with conventional transurethral resection for primary non-muscle invasive bladder cancer by the dichotomous or continuous methods with random or fixed-effects models. ResultsEn-bloc transurethral resection had significantly lower twenty-four-month recurrence (OR: 0.63; 95%CI: 0.50–0.78; p < 0.001), catheterization-time (MD: –0.66; 95%CI: –1.02–[–0.29]; p < 0.001), length of hospital stay (MD: –0.95; 95%CI: –1.55–[–0.34]; p = 0.002), postoperative bladder irrigation duration (MD: –6.06; 95%CI: –9.45–[–2.67]; p < 0.001), obturator nerve reflex (OR: 0.08; 95%CI: 0.02–0.34; p = 0.03), and bladder perforation (OR: 0.14; 95%CI: 0.06–0.36: p < 0.001) and no significant difference in the 12-month-recurrence (OR: 0.79; 95%CI: 0.61–1.04; p = 0.09), the operation time (MD: 0.67; 95%CI: –1.92 to 3.25; p = 0.61), and urethral stricture (OR: 0.46; 95%CI: 0.14–1.47; p = 0.0.19) compared with conventional transurethral resection for primary non-muscle invasive bladder cancer subjects. ConclusionsEn-bloc transurethral resection had a significantly lower twenty-four-month recurrence, catheterization time, length of hospital stay, postoperative bladder irrigation duration, obturator nerve reflex, bladder perforation, and no significant difference in the twelve-month recurrence, operation time, and urethral stricture compared with conventional transurethral resection for primary non-muscle invasive bladder cancer subjects. Further studies are required.

Effect of Levofloxacin on the Efficacy and Adverse Events in Intravesical Bacillus Calmette-Guerin Treatment for Bladder Cancer: Results of a Randomized, Prospective, Multicenter Study

BackgroundAlthough bacillus Calmette-Guerin (BCG) is a standard treatment for high-risk non–muscle-invasive bladder cancer (NMIBC), a high rate of adverse events with a variety of grades remains a difficulty. ObjectiveIn this randomized, prospective, multicenter study, we examined whether levofloxacin, given after each intravesical instillation of BCG, could improve its tolerance in patients with intermediate- to high-risk urothelial carcinoma of the bladder without compromising its efficacy. Design, setting, and participantsOverall, 106 Japanese patients (85 men and 21 women; age: median, 69.5 yr) with primary or recurrent NMIBC were randomized after transurethral resection to induce treatment with intravesical BCG plus levofloxacin (group 1) or BCG alone (group 2). InterventionPatients who underwent intravesical instillation of BCG were randomized with or without levofloxacin administration. Outcome measurements and statistical analysisAdverse events were assessed using the National Cancer Institute-Common Toxicity Criteria version 3.0. Cumulative incidence functions and Kaplan-Meier methods were applied to estimate survival outcomes. Results and limitationsThere was no significant difference in baseline characteristics between the groups. The completion rate of group 1 (85.5%) was not significantly lower than that of group 2 (76.5%; p = 0.321). There was no significant difference in the completion rate of patients with pollakisuria, painful micturition, gross hematuria, fever elevation, and others between the groups. The incidence of adverse events in patients with high-grade pollakisuria (7.3% vs 25.4%, p = 0.041) and fever (0% vs 9.1%, p = 0.034) was significantly lower in group 1. The 5-yr progression-free and cancer-specific survival rates were significantly better in group 1. ConclusionsProphylactic levofloxacin administration may reduce the severity of adverse events and contribute to better outcomes from BCG intravesical therapy in patients with NMIBC. Patient summaryLevofloxacin administration seems to be a safe and effective therapy for non–muscle-invasive bladder cancer patients treated with bacillus Calmette-Guerin intravesical therapy.

La dosis única de instilación intravesical postoperatoria inmediata de quimioterapia no es superior al lavado continuo con suero

Introduction and objectivesTo evaluate whether there is any difference between immediate postoperative instillation of intravesical chemotherapy (IPOIC) and continuous saline bladder irrigation(CSBI) in terms of bladder cancer(BC) recurrence in patients with primary low- or intermediate-risk non-muscle-invasive BC (NMIBC). Materials and methodsMedical records of 1482 patients who underwent transurethral resection of bladder tumor between March 1994 and August 2020 were reviewed retrospectively. Patients were divided into two groups according to IPOIC and/or CSBI administration status (Group 1: CSBI alone; Group 2: CSBI following IPOIC). Low- and intermediate-risk NMIBC patients were also divided into subgroups according to IPOIC and/or CSBI administration status. ResultsA total of 594 patients with primary NMIBC were included. Of the patients, 86 (14.5%) were female and 508 (85.5%) were male with a median age of 69 (60-78) years. The frequency of patients in group 1 and group 2 were 361 (60.8%) and 233 (39.2%), respectively. Recurrent disease was observed in 213 (35.9%) patients. There was no difference between the groups when they were compared for recurrent disease frequency, median time to first recurrence and frequency of recurrence within first 12 months (P=.064, P=.671, and P=.145, respectively). Disease recurrence rates in low-risk NMIBC patients was lower when they were treated with “CSBI following IPOIC” when compared to “CSBI alone” (P=.042). However, no difference was observed in low-risk NMIBC subgroups when they were compared for pathological features of recurrent tumors such as number, size, grade, stage, and presence of carcinoma in situ (P>.05, for each). Conclusions“CSBI following IPOIC” combination was not superior to “CSBI alone” for preventing adverse pathological outcomes in recurrent low- and intermediate-risk NMIBC.

PD26-05 HOW LONG SHOULD WE FOLLOW LOW GRADE TA NON-MUSCLE INVASIVE BLADDER CANCER (NMIBC)? A LARGE RETROSPECTIVE SINGLE INSTITUTION ANALYSIS

You have accessJournal of UrologyCME1 May 2022PD26-05 HOW LONG SHOULD WE FOLLOW LOW GRADE TA NON-MUSCLE INVASIVE BLADDER CANCER (NMIBC)? A LARGE RETROSPECTIVE SINGLE INSTITUTION ANALYSIS Eunice Villegas, Christian Vitug, Katherine Lajkosz, Cynthia Kuk, Bruce Gao, Otto Hemminiki, Dhiral Kot, Shayan Din, Jimmy Misurka, Girish S. Kulkarni, Michael Jewett, Neil E. Fleshner, Theodorus H. van der Kwast, and Alexandre R. Zlotta Eunice VillegasEunice Villegas More articles by this author , Christian VitugChristian Vitug More articles by this author , Katherine LajkoszKatherine Lajkosz More articles by this author , Cynthia KukCynthia Kuk More articles by this author , Bruce GaoBruce Gao More articles by this author , Otto HemminikiOtto Hemminiki More articles by this author , Dhiral KotDhiral Kot More articles by this author , Shayan DinShayan Din More articles by this author , Jimmy MisurkaJimmy Misurka More articles by this author , Girish S. KulkarniGirish S. Kulkarni More articles by this author , Michael JewettMichael Jewett More articles by this author , Neil E. FleshnerNeil E. Fleshner More articles by this author , Theodorus H. van der KwastTheodorus H. van der Kwast More articles by this author , and Alexandre R. ZlottaAlexandre R. Zlotta More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002574.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Over 50% of Ta low grade (LG) NMIBC will recur during long-term follow up but only a few percent will experience stage progression, metastases and death due to BC. For patients with TaLG NMIBC free of recurrence for 10 years, discontinuation of routine cystoscopic surveillance or replacement with urinary markers and/or ultrasonography has been considered as the recurrence rate drops after 5 years. We investigated the long-term follow-up of TaLG NMIBC to further define the length of monitoring. METHODS: We retrospectively analyzed 529 patients with primary TaLG NMIBC diagnosed between 1989-2019 and followed until 2021 using patient records and the Bladder Cancer Informatics System at the University Health Network, Canada. We assessed the risk of progression to high grade Ta/T1 NMIBC, progression to muscle-invasive disease, metastasis and risk of death due to BC at 5, 10 and 15 years using cumulative incidence functions. Non-BC death served as a competing risk for death due to BC, and all-cause death served as a competing risk for all other outcomes. RESULTS: Among 529 patients (73% men, median age 67.5 years), 360 (68%) recurred, 50(9%) progressed in stage, 20 (4%) developed metastases and 15 (3%) died from BC. Median follow-up was 9.4 years. 312/360 (87%) patients recurred within the first 5 years. Of the 217 patients who did not recur within the first 5 years, 11 died due to non BC related causes. Of the remaining patients, 48 (9% of the entire cohort) recurred. 36 patients (free of recurrence in the first 5 years) recurred within 10 years of their diagnosis, 9 recurred between 10-15 years and 3 between 15-20 years. Of the 15 patients who succumbed to BC (median 9.6 years; IQR3.6-14.8 years) despite presenting initially with TaLG disease, 80% were men, 10% had associated CIS, 67% had multiple tumors and 80% had tumors <3 cm. The actuarial CSS were 99%, 97% and 96% at 5, 10 and 15 years, respectively, whereas the progression to MIBC or metastases was 3, 5 and 6% at 5, 10 and 15 years. Limitations include the retrospective analysis and results obtained in a tertiary referral center might not be generalizable. CONCLUSIONS: Surveillance of patients with TaLG NMIBC should definitely be continued beyond 5 years of follow-up and probably even beyond 10 years. Even after being free of recurrence for 5 years, about 10% of patients will recur. Although the risk is low, about 3% of patients presenting with TaLG NMIBC will eventually die from the disease, most in the intermediate risk category. The term “cancer” for TLGa NMIBC should therefore be kept in our opinion. Source of Funding: N/A © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e489 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Eunice Villegas More articles by this author Christian Vitug More articles by this author Katherine Lajkosz More articles by this author Cynthia Kuk More articles by this author Bruce Gao More articles by this author Otto Hemminiki More articles by this author Dhiral Kot More articles by this author Shayan Din More articles by this author Jimmy Misurka More articles by this author Girish S. Kulkarni More articles by this author Michael Jewett More articles by this author Neil E. Fleshner More articles by this author Theodorus H. van der Kwast More articles by this author Alexandre R. Zlotta More articles by this author Expand All Advertisement PDF DownloadLoading ...

Patients with Non-Muscle-Invasive Bladder Cancer Previously Treated with Nephroureterectomy Have a High Risk of Recurrence after Bacillus Calmette-Guérin Intravesical Instillation Therapy

Background: There is a high incidence of intravesical recurrence after transurethral resection of bladder tumor for non-muscle-invasive bladder cancer (NMIBC). Intravesical instillation of bacillus Calmette-Guérin (BCG) is widely used to prevent recurrence and progression. There are two types of NMIBC: primary NMIBC and subsequent NMIBC after radical nephroureterectomy (RNU). We compared the clinical outcomes of BCG intravesical instillation therapy between the two types of NMIBC. Patients and Methods: This study included a total of 357 patients, who received BCG intravesical instillation therapy to prevent recurrence of NMIBC (pTa/pT1) between 1991 and 2019. Among them, 34 patients had subsequent NMIBC after RNU, and the remaining 323 patients had primary NMIBC. This retrospective study analyzed 68 patients extracted by propensity score matching. Survival curves were estimated using the Kaplan-Meier method, and independent prognostic factors for survival were examined by the Cox proportional hazards model. Results: The 3-year recurrence-free survival (RFS) rates in patients with primary NMIBC and subsequent NMIBC after RNU were 70.7% and 54.8%, respectively (p = 0.036). However, there were no significant differences between the two groups in progression-free survival and cancer-specific survival. Multivariate analysis of RFS showed that only a previous history of upper tract urothelial carcinoma was an independent prognostic and predictive factor. Conclusion: Patients with subsequent NMIBC after RNU treated with BCG intravesical instillation therapy have a higher risk of recurrence than those with primary NMIBC. Thus, stringent follow-up is necessary for patients with subsequent NMIBC after RNU.