Prostatic Urethral Involvement Research Articles

Assessing the prognostic impact of prostatic urethra involvement and developing a nomogram for T1 stage bladder cancer

PurposeTo investigate prognostic values of prostatic urethra involvement (PUI) and construct a prognostic model that estimates the probability of cancer-specific survival for T1 bladder cancer patients.Method and materialsWe investigated the national Surveillance, Epidemiology, and End Results (SEER) database (2004–2015) to get patients diagnosed with T1 bladder cancer. An external validation cohort was obtained from the First Affiliated Hospital of Nanchang University. The Kaplan–Meier method with the log-rank test was applied to assess cancer-specific survival (CSS) and overall survival (OS). Moreover, the propensity score matching (PSM) and multivariable Cox proportional hazard model were performed. All patients were randomly divided into the development cohort and validation group at the ratio of 7:3. The performance of the model was internally validated by calibration curves and the concordance index (C-index).ResultsThe PUI group had a lower survival rate of both CSS and overall survival OS before and after PSM when compared to non-involved patients (All P < 0.05). Multivariate analysis revealed a poor prognosis in the PUI group for cancer-specific mortality (CSM) and all-cause mortality (ACM) analyses before and after PSM (All P < 0.05). Seven variables, including age, surgery, radiotherapy, tumour size, PUI, and marital status, were incorporated in the final nomogram. The C-index in the development cohort was 0.715 (0.711–0.719), while it was 0.672 (0.667–0.677) in the validation group. Calibration plots for 3- and 5-year cancer-specific survival showed good concordance in the development and validation cohorts.ConclusionsPUI was an independent risk factor of ACM and CSM in T1 bladder cancer patients. In addition, a highly discriminative and precise nomogram that predicted the individualized probability of cancer-specific survival for patients with T1 bladder cancer was constructed.

Evaluation of a Natural Language Processing Model to Identify and Characterize Patients in the United States With High-Risk Non-Muscle-Invasive Bladder Cancer.

Treatment of non-muscle-invasive bladder cancer (NMIBC) is guided by risk stratification using clinical and pathologic criteria. This study aimed to develop a natural language processing (NLP) model for identifying patients with high-risk NMIBC retrospectively from unstructured electronic medical records (EMRs) and to apply the model to describe patient and tumor characteristics. We used three independent EMR-derived data sets including adult patients with a bladder cancer diagnosis in 2011-2020 for NLP model development and training (n = 140), validation (n = 697), and application for the retrospective cohort analysis (n = 4,402). Deep learning methods were used to train NLP recognition of medical chart terminology to identify seven high-risk NMIBC criteria; model performance was assessed using the F1 score, weighted across features. An algorithm was then used to classify each patient as high-risk NMIBC (yes/no). Manually reviewed records served as the gold standard. The F1 scores after model training were >0.7 for all but one uncommon feature (prostatic urethral involvement). The highest area under the receiver operating curves (AUC) was observed for Ta (0.897) and T1 (0.897); the lowest AUC was for carcinoma in situ (CIS; 0.617). For high-risk NMIBC classification, positive predictive value was 79.4%, negative predictive value was 93.2%, and false-positive rate was 8.9%. Sensitivity and specificity were 83.7% and 91.1%, respectively. Of 748 patients manually confirmed as having high-risk NMIBC, 196 (26%) had CIS (of whom 19% also had T1 and 23% also had Ta disease); 552 tumors (74%) had no associated CIS. The NLP model, combined with a rule-based algorithm, identified high-risk NMIBC with good performance and will enable future work to study real-world treatment patterns and clinical outcomes for high-risk NMIBC.

PD44-09 IMPACT OF HIGH-RISK FEATURES AND STAGING ON NEOADJUVANT CHEMOTHERAPY AMONG PATIENTS TREATED WITH RADICAL CYSTECTOMY: A SINGLE CENTER ANALYSIS OF 1700 CASES

You have accessJournal of UrologyCME1 Apr 2023PD44-09 IMPACT OF HIGH-RISK FEATURES AND STAGING ON NEOADJUVANT CHEMOTHERAPY AMONG PATIENTS TREATED WITH RADICAL CYSTECTOMY: A SINGLE CENTER ANALYSIS OF 1700 CASES Shreyas Naidu, Roger Li, Wenyi Fan, Kyle Rose, Heather Huelster, Aram Vosoughi, Scott Gilbert, Daniel Grass, Rohit Jain, Youngchul Kim, Brandon Manley, Michael Poch, Julio Pow-Sang, Philippe Spiess, Alice Yu, Logan Zemp, Jingsong Zhang, and Wade Sexton Shreyas NaiduShreyas Naidu More articles by this author , Roger LiRoger Li More articles by this author , Wenyi FanWenyi Fan More articles by this author , Kyle RoseKyle Rose More articles by this author , Heather HuelsterHeather Huelster More articles by this author , Aram VosoughiAram Vosoughi More articles by this author , Scott GilbertScott Gilbert More articles by this author , Daniel GrassDaniel Grass More articles by this author , Rohit JainRohit Jain More articles by this author , Youngchul KimYoungchul Kim More articles by this author , Brandon ManleyBrandon Manley More articles by this author , Michael PochMichael Poch More articles by this author , Julio Pow-SangJulio Pow-Sang More articles by this author , Philippe SpiessPhilippe Spiess More articles by this author , Alice YuAlice Yu More articles by this author , Logan ZempLogan Zemp More articles by this author , Jingsong ZhangJingsong Zhang More articles by this author , and Wade SextonWade Sexton More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003354.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Neoadjuvant chemotherapy (NAC) followed by radical cystectomy with pelvic lymph node dissection (RC) has convincingly demonstrated improvement in survival and consequently been established as the new standard-of-care for muscle invasive bladder cancer (MIBC). Due to its toxicity, multi-agent platinum-based chemotherapy has been variably adopted in the neoadjuvant setting. In this study, we report the long-term outcomes from our institutional experience with the use of NAC in MIBC patients METHODS: 1700 patients who underwent RC at Moffitt Cancer Center between July 2004 and October 2020 for bladder cancer were retrospectively reviewed. Patients received presurgical chemotherapy and radical cystectomy (PC) or underwent upfront radical cystectomy with no chemotherapy (NC). cT2 patients were sub-stratified as high-risk (HR) or low-risk (LR) using the MDACC risk criteria including the presence of hydronephrosis, LVI, prostatic urethral involvement, and variant histology. RESULTS: 761 PC and 805 NC patients were retrospectively identified with complete baseline information. Amongst 461 NC patients with ≥cT2 disease, 118 (25%) achieved pathologic downstaging<pT2N0 and 38 (8.2%) pCR. In comparison, 244 (35.8%) PC patients with ≥cT2 disease achieved pathologic downstaging (p<0.001) and 135 (19.8%) pCR (p<0.0001). Stratified by clinical T-stage, only cT2 patients derived OS (Median 62.3mo vs. 41.9mo, p<0.001) benefit. To further categorize the characteristics associated with superior chemotherapeutic response, we sub-stratified the cT2 patients according to the MDACC risk criteria. While the use of PC in low-risk (LR) cT2 patients did not significantly increase downstaging (42.7% vs. 34.4%) or pCR (23.5% vs. 11.9%) rates, dramatic increases were seen in the high risk (HR) cT2 patients undergoing PC (downstaging 41.6% vs. 19.4%, p<0.0001; pCR 23.5% vs. 6.9%, p<0.0001). CONCLUSIONS: Pathologic response rates to PC were modest compared to those previously reported in randomized controlled trials and only cT2 patients derived OS benefit among those that received PC. Upon further analysis it was found that following stratification using the MDACC risk criteria, only HR cT2 patients obtained a benefit from presurgical chemotherapy. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1128 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Shreyas Naidu More articles by this author Roger Li More articles by this author Wenyi Fan More articles by this author Kyle Rose More articles by this author Heather Huelster More articles by this author Aram Vosoughi More articles by this author Scott Gilbert More articles by this author Daniel Grass More articles by this author Rohit Jain More articles by this author Youngchul Kim More articles by this author Brandon Manley More articles by this author Michael Poch More articles by this author Julio Pow-Sang More articles by this author Philippe Spiess More articles by this author Alice Yu More articles by this author Logan Zemp More articles by this author Jingsong Zhang More articles by this author Wade Sexton More articles by this author Expand All Advertisement PDF downloadLoading ...

MP63-08 CLINICAL AND GENOMIC RISK FEATURES OF HIGH GRADE T1 NON-MUSCLE INVASIVE BLADDER CANCER

You have accessJournal of UrologyCME1 Apr 2023MP63-08 CLINICAL AND GENOMIC RISK FEATURES OF HIGH GRADE T1 NON-MUSCLE INVASIVE BLADDER CANCER Carissa Chu, Jessica Chen, Manuel DE Jesus Escano, Karissa Whiting, Irina Ostrovnaya, Song Jiang, Wesley Yip, Sari Khaleel, Andrew Lenis, Timothy Clinton, Goh Alvin, CHA Eugene, Timothy Donahue, Guido Dalbagni, Gopa Iyer, David Solit, Judy Sarungbam, Hikmat AL-Ahmadie, Bernard Bochner, and Eugene Pietzak Carissa ChuCarissa Chu More articles by this author , Jessica ChenJessica Chen More articles by this author , Manuel DE Jesus EscanoManuel DE Jesus Escano More articles by this author , Karissa WhitingKarissa Whiting More articles by this author , Irina OstrovnayaIrina Ostrovnaya More articles by this author , Song JiangSong Jiang More articles by this author , Wesley YipWesley Yip More articles by this author , Sari KhaleelSari Khaleel More articles by this author , Andrew LenisAndrew Lenis More articles by this author , Timothy ClintonTimothy Clinton More articles by this author , Goh AlvinGoh Alvin More articles by this author , CHA EugeneCHA Eugene More articles by this author , Timothy DonahueTimothy Donahue More articles by this author , Guido DalbagniGuido Dalbagni More articles by this author , Gopa IyerGopa Iyer More articles by this author , David SolitDavid Solit More articles by this author , Judy SarungbamJudy Sarungbam More articles by this author , Hikmat AL-AhmadieHikmat AL-Ahmadie More articles by this author , Bernard BochnerBernard Bochner More articles by this author , and Eugene PietzakEugene Pietzak More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003321.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: High grade non-muscle invasive bladder cancer invading the lamina propria (HG T1) exhibits variable clinical behavior. Existing risk stratification approaches by clinicopathologic alone are limited in determining who will benefit most from immediate radical cystectomy (RC) versus BCG. We report contemporary outcomes of patients managed with BCG or immediate RC and comparative mutational landscape across the spectrum of HG T1 disease. METHODS: This was a single-center retrospective cohort study of patients newly diagnosed with HG T1 non-muscle invasive bladder cancer between 2014 and 2020>18 months of follow up. All included patients underwent restaging TURBT with confirmed T1 by TURBT/EUA/imaging. Targeted exome sequencing with MSK-IMPACT was performed on 139 HG T1 tumors and 191 T2 tumors. RESULTS: 390 patients were included with median follow up time of 35 months (IQR 19-59 months). 308 were managed with intravesical BCG and 82 immediate RC. Patients selected for immediate RC were younger (median age 66 vs 69, p<0.001) and had higher rates of concurrent CIS (78 vs 53%, p<0.001), deep lamina propria invasion (37 vs 17%, p<0.001), lymphovascular invasion (7 vs 0.3%, p<0.001), and larger tumor size (4.3 cm vs 3.3 cm, p=0.007). Of the 82 patients who immediate radical cystectomy (BCG naïve), 32 (40%) were upstaged to pT2 and/or N+disease at RC. Persistent pT1 disease at re-resection and the presence of variant histology were associated with pathologic upstaging (p<0.01), while tumor size, concurrent CIS, bladder neck involvement, or prostatic urethra involvement were not. Compared to patients without additional risk factors, patients with CIS and at least one additional risk (e.g . “very high risk” T1 disease) harbored more TP53, ERBB2/Her2, and RB1 mutations and fewer FGFR3 mutations and a genomic profile more similar to T2 tumors than NMIBC (Figure 1). CONCLUSIONS: Very high risk T1 tumors are genomically similar to muscle-invasive tumors and are enriched in targetable alterations including ERBB2/Her2. Integration of genomic sequencing with clinical and pathologic features of HG T1 disease may improve risk stratification and treatment selection. Source of Funding: Ruth L. Kirschstein National Research Service Award T32CA082088 American Society of Clinical Oncology Young Investigator Award (YIA) Award © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e874 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Carissa Chu More articles by this author Jessica Chen More articles by this author Manuel DE Jesus Escano More articles by this author Karissa Whiting More articles by this author Irina Ostrovnaya More articles by this author Song Jiang More articles by this author Wesley Yip More articles by this author Sari Khaleel More articles by this author Andrew Lenis More articles by this author Timothy Clinton More articles by this author Goh Alvin More articles by this author CHA Eugene More articles by this author Timothy Donahue More articles by this author Guido Dalbagni More articles by this author Gopa Iyer More articles by this author David Solit More articles by this author Judy Sarungbam More articles by this author Hikmat AL-Ahmadie More articles by this author Bernard Bochner More articles by this author Eugene Pietzak More articles by this author Expand All Advertisement PDF downloadLoading ...

Oncological and Renal Function Outcomes in Patients Who Underwent Simultaneous Radical Cystectomy and Nephroureterectomy for Synchronous or Metachronous Panurothelial Carcinoma

To assess clinical outcomes of patients who underwent simultaneous radical cystectomy (RC) and radical nephroureterectomy (RNU) for panurothelial carcinoma (PanUC). A retrospective analysis of 67 patients who underwent simultaneous RC and unilateral RNU for PanUC, from 1996 to 2017. Kaplan-Meier estimates for remnant urothelium recurrence-free survival, metastasis-free survival, overall survival (OS), and cancer-specific survival (CSS) were performed. Cox multivariate models were constructed. The median follow-up was 38 months, 29.8% of patients had a recurrence, 34.3% had metastasis, 67.2% of patients died from any cause, and 37.3% died from urothelial carcinoma. Overall survival and CSS rates at 5 years were 44% and 61%, respectively. In multivariate analysis, progression to muscle-invasive bladder cancer before surgery, presence of muscle-invasive stages at RC and/or RNU, and prostatic urethra involvement were predictors for worse metastasis-free survival and CSS. Forty-one patients (61.2%) had an estimated glomerular filtration rate (eGFR) <60 mL/min beforesurgery and the number rose to 56 (83.5%) after surgery; 29.8% patients needed renal function replacement therapy after surgery (16 haemodialysis and 4 renal transplant). Patients with PanUC who undergo simultaneous surgery have adverse oncological (only 4 out of every 10 remain alive at 5 years) and functional outcomes (1 out of 3 will need renal function replacement therapy after surgery). Up to a third of the patients had a recurrence (urethra or contralateral kidney) within 18 months, justifying close surveillance or considering prophylactic urethrectomy. These data should help in counsel on morbidity and life expectancy.

Routine urethroscopic surveillance is of limited value after radical cystectomy: a single centre retrospective cohort analysis.

The incidence of urethral recurrence (UR) following radical cystectomy (RC) for transitional cell carcinoma (TCC) of the bladder varies between 1.5 and 6%. There is debate over the timing of urethrectomy for patients undergoing RC. We evaluated the requirement for a formal surveillance programme for UR in patients after RC. We retrospectively reviewed the outcomes of patients who underwent RC between 2006 and 2019. Females, non-TCC cases and patients with neo-bladder diversions were excluded. Histological prostatic urethral involvement at the time of RC was deemed high risk for UR. Carcinoma in-situ, multifocal tumours and bladder neck involvement were deemed intermediate risk and the absence of the above features was considered low risk. 417 patients underwent RC, 300 cases remained after exclusion criteria were applied. 42 patients were high-risk for UR, 102 patients were intermediate risk and 156 were low risk. Of the 300, 24 urethrectomy cases were recorded. Six cases of UR occurred. Of these, 5 presented with symptoms and only 1 case was detected by surveillance. Only 1 low-risk patient developed UR, 7years post RC. Using our risk stratification, UR rates for high, intermediate and low-risk cohorts were 25%, 10.5% and 0.8%, respectively. In our cohort, routine surveillance for all patients with annual urethroscopy was of limited value in detecting UR post RC. Staged Urethrectomy for high and intermediate-risk patients, and patient counselling in self-identification of recurrence symptoms for low-risk patients will improve the early detection of UR.

Urethrectomy at the time of radical cystectomy for non-metastatic urothelial carcinoma of the bladder: a collaborative multicenter study

IntroductionThe optimal management of the urethra in patients planned for radical cystectomy (RC) remains unclear. We sought to evaluate the impact of urethrectomy on perioperative and oncological outcomes in patients treated with RC for non-metastatic urothelial carcinoma of the bladder (UCB).Materials and methodsWe assessed the retrospective data from patients treated with RC for UCB of five European University Hospitals. Associations of urethrectomy with progression-free (PFS), cancer-free (CSS), and overall (OS) survivals were assessed in univariable and multivariable Cox regression models. We performed a subgroup analysis in patients at high risk for urethral recurrence (UR) (urethral invasion and/or bladder neck invasion and/or multifocality and/or prostatic urethra involvement).ResultsA total of 887 non-metastatic UCB patients were included. Among them, 146 patients underwent urethrectomy at the time of RC. Urethrectomy was performed more often in patients with urethral invasion, T3/4 tumor stage, CIS, positive frozen section analysis of the urethra, and those who received neoadjuvant chemotherapy, underwent robotic RC, and/or received an ileal conduit urinary diversion (all p < 0.001). Estimated blood loss and the postoperative complication rate were comparable between patients who received an urethrectomy and those who did not. Urethrectomy during RC was not associated with PFS (HR 0.83, p = 0.17), CSS (HR 0.93, p = 0.67), or OS (HR 1.08, p = 0.58). In the subgroup of 276 patients at high risk for UR, urethrectomy at the time of RC decreased the risk of progression (HR 0.58, p = 0.04).ConclusionIn our study, urethrectomy at the time of RC seems to benefit only patients at high risk for UR. Adequate risk assessment of UCB patients’ history may allow for better clinical decision-making and patient counseling.

MP23-01 URETHRECTOMY AT THE TIME OF RADICAL CYSTECTOMY FOR NON-METASTATIC UROTHELIAL CARCINOMA OF THE BLADDER: A COLLABORATIVE MULTICENTER STUDY

MP23-01 URETHRECTOMY AT THE TIME OF RADICAL CYSTECTOMY FOR NON-METASTATIC UROTHELIAL CARCINOMA OF THE BLADDER: A COLLABORATIVE MULTICENTER STUDY

Incidence, risk factors and outcomes of urethral recurrence after radical cystectomy for bladder cancer: A systematic review and meta-analysis.

We aimed to conduct a systematic review and meta-analysis assessing the incidence and risk factors of urethral recurrence (UR) as well as summarizing data on survival outcomes in patients with UR after radical cystectomy (RC) for bladder cancer. The MEDLINE and EMBASE databases were searched in February 2021 for studies of patients with UR after RC. Incidence and risk factors of UR were the primary endpoints. The secondary endpoint was survival outcomes in patients who experienced UR. Twenty-one studies, comprising 9,435 patients, were included in the quantitative synthesis. Orthotopic neobladder (ONB) diversion was associated with a decreased probability of UR compared to non-ONB (pooled OR: 0.44, 95% CI: 0.31-0.61, P < 0.001) and male patients had a significantly higher risk of UR compared to female patients (pooled OR: 3.16, 95% CI: 1.83-5.47, P < 0.001). Among risk factors, prostatic urethral or prostatic stromal involvement (pooled HR: 5.44, 95% CI: 3.58-8.26, P < 0.001; pooled HR: 5.90, 95% CI: 1.82-19.17, P = 0.003, respectively) and tumor multifocality (pooled HR: 2.97, 95% CI: 2.05-4.29, P < 0.001) were associated with worse urethral recurrence-free survival. Neither tumor stage (P = 0.63) nor CIS (P = 0.72) were associated with worse urethral recurrence-free survival. Patients with UR had a 5-year CSS that varied from 47% to 63% and an OS - from 40% to 74%; UR did not appear to be related to worse survival outcomes. Male patients treated with non-ONB diversion as well as patients with prostatic involvement and tumor multifocality seem to be at the highest risk of UR after RC. Risk-adjusted standardized surveillance protocols should be developed into clinical practice after RC.

MRI predicts prostatic urethral involvement in men undergoing radical prostatectomy: implications for cryo-ablation of localized prostate cancer.

To determine whether multi-parametric magnetic resonance imaging (mpMRI) can reliably predict proximity of prostate cancer to the prostatic urethra in a contemporary series of men undergoing radical prostatectomy (RP) at two academic centers. Clinical characteristics of consecutive men undergoing pre-operative mpMRI prior to RP and whole-mount axial serial step-sectioned pathology examination at two academic centers between Jun 2016 and Oct 2018 were analyzed retrospectively. Every tumor was characterized by its pathologic minimum distance to the prostatic urethral lumen (pMDUL). Only the cancer closest to the urethra represented the prostatic urethral index lesion. The radiologic minimum distance of the index lesion to the prostatic urethral lumen was measured and noted as ≤ 5mm versus > 5mm. The sensitivity, specificity, positive and negative predicting values (PPV and NPV) and area under the receivers operating characteristics curve (AUC) were calculated for performance of mpMRI for predicting pMDUL ≤ 5mm. Of the 163 surgical specimens examined, 112 (69%) exhibited a pMDUL ≤ 5mm. These men had significantly higher grade group (GG) and advanced pathological and clinical stage. The rates of high PI-RADS score and presence of gross extracapsular extension were also significantly greater for the group with pMDUL ≤ 5mm. The AUC, sensitivity, specificity, PPV, and NPV were 0.641, 51.8, 76.5, 82.9, and 42.4%, respectively, for mpMRI to predict pMDUL < 5mm. Nearly 70% of men undergoing RP present with tumor within 5mm of the prostatic urethra. These tumors present higher risk characteristics, and mpMRI exhibited moderate performance and high PPV in their pre-operative detection. Physicians performing partial gland ablation should take these results into consideration during treatment selection and planning.

Urethral recurrence following radical cystectomy: Risk factors and outcomes.

416 Background: Urethral recurrence (UR) has been reported to occur in up to 5% of patients following radical cystectomy (RC). Debate continues regarding the utility of screening for UR after RC. Moreover, oncologic outcomes of patients with UR remain incompletely described, and reports have been limited by small cohort sizes. Herein, we evaluated risk factors for UR as well as cancer-specific survival (CSS) and overall survival (OS) among patients with UR. Methods: We reviewed our institutional RC registry to identify patients with UR following RC. Logistic regression was used to assess risk factors for UR. Kaplan-Meier and Cox proportional hazard regression were used to compare outcomes in those with UR diagnosis prompted by symptoms versus those with asymptomatic UR diagnosed on surveillance cytology. Results: Overall, 2930 patients underwent RC from 1980-2018, with a median post-operative follow-up of 4.9 years (IQR 1.6-11.0), of whom 144 (4.9%) were subsequently diagnosed with UR. Prostatic urethral involvement at RC (odds ratio [OR] 5.75 [3.67-9.01], p &lt; 0.0001) and higher pT-stage (OR 3.57 [2.07-6.14], p &lt; 0.0001) were associated with an increased risk of UR, whereas receipt of continent urinary diversion (OR 0.34 [0.20-0.58], p &lt; 0.0001) was associated with a decreased risk of UR. A total of 72/144 (50%) patients were diagnosed with UR based on symptoms, and 104/144 (72.2%) patients with UR underwent subsequent urethrectomy. Patients with symptomatic recurrence had higher tumor stage on urethrectomy than those with asymptomatic recurrence (≥pT2 in 13.1% vs 3.1%, p = 0.007). At a median follow-up of 2.6 years (IQR 1.0-7.1) after UR, 68 of the patients with UR died of urothelial carcinoma. Kaplan-Meier analyses suggest longer median overall and cancer-specific survival for patients with UR detected by cytology than those presenting with symptoms (p = 0.05 for both). On multivariable analyses, patients who experienced UR had significantly increased risk of cancer-specific (hazard ratio [HR] 1.93 [95% confidence interval 1.50-2.50), p &lt; 0.0001) and all-cause mortality (HR 1.34 [1.13-1.65], p = 0.001). Conclusions: Approximately 5% of patient undergoing RC experience UR, with higher pT-stage and prostatic urethral involvement increasing the risk of UR. Asymptomatic detection of UR was associated with lower pathologic stage at urethrectomy as well as longer cancer-specific and overall survival, supporting urethral surveillance after RC.

Impact of UTUC on Outcomes of Non-Muscle Invasive Bladder Cancer Treated with Intravesical Bacillus Calmette-Guerin

There is a paucity of information regarding impact of upper tract urothelial carcinoma (UTUC) on the patterns of BCG response in patients with NMIBC treated with BCG. We present the clinicopathological characteristics of patients with a history of NMIBC and UTUC treated with intravesical BCG and evaluate the impact of UTUC on BCG response and progression. An IRB approved review of patients with NMIBC patients treated with at least induction BCG at our institution between 2000 and 2018 was performed. Patients were then stratified by (1) presence of UTUC and (2) time of UTUC onset (prior to NMIBC diagnosis vs synchronous or metachronous disease). Outcomes were calculated from date of index transurethral resection. Of 577 patients who received BCG induction for NMIBC, 63 (11%) patients were diagnosed with UTUC. Of these, 36 patients had a history of UTUC prior to NMIBC (median 344 days prior, IQR 211 – 821 days), while 27 developed UTUC after diagnosis of NMIBC (8 synchronous and 19 metachronous, median 350 days after, IQR 25-833 days). There was no difference between the UTUC and no UTUC groups, except that the UTUC group had more multifocal bladder tumors (71% vs 50%, P=0.002) and prostatic urethral involvement (12% vs 5%, P=0.023). The UTUC group had more non-responders to BCG with respect to recurrence (60% vs. 36%, P=0.0002), any stage/grade progression (25% vs 11%, P=0.005), and progression to muscle invasive or metastatic disease (18% vs 8%, P=0.016). There was no significant difference in rates of recurrence or progression based on timing of UTUC with respect to bladder tumor, albeit this analysis is limited by small numbers. Presence of UTUC – whether prior to or after diagnosis of bladder cancer - was associated with an almost 2-fold increased recurrence and progression rate following BCG. This should be factored in when counselling patients and designing cohorts for clinical trials.

Risk Factors for Urethral Recurrence in Men After Radical Cystectomy with Orthotopic Urinary Diversion for Urothelial Carcinoma: A Retrospective Cohort Study.

PurposeTo evaluate the risk factors affecting urethral recurrence (UR) in men after radical cystectomy (RC) with ileal orthotopic neobladder (IONB).Materials and MethodsWe retrospectively reviewed 348 men who underwent RC with IONB for bladder cancer between January 2010 and December 2017. Clinicopathologic characteristics, including tumor location (trigone and/or bladder neck), prostatic urethral and/or stromal involvement, presence of carcinoma in situ (CIS), pathologic T and N stage, and urethral resection margin status, were identified. Kaplan–Meier survival analysis was used to illustrate urethral recurrence-free survival (URFS), and Cox proportional hazard models were applied to identify factors predicting UR.ResultsOf the 348 patients, UR was identified in 7 (2.0%) patients during the mean follow-up of 33.3 months. The 2-, 3-, and 5-year URFS rates were 97.6%, 96.3%, and 93.8%, respectively. On multivariable analysis, prostatic urethral involvement (P = 0.033, hazard ratio: 6.25, 95% confidence interval: 1.06–36.96) was an independent predictor of UR. When patients were divided according to prostatic urethral involvement (negative vs positive), the 2- and 3-year URFS rates were significantly different (93.8% and 96.8%, respectively, vs 92.0% and 92.0%, respectively; P = 0.020). All 7 patients with UR underwent transurethral surgery and maintained their IONB.ConclusionIn this series, UR occurred in approximately 2% of men after RC with IONB. Prostatic urethral involvement was the only significant prognostic factor for UR. Follow-up strategies considering UR risk should be adopted to facilitate early detection in those at high risk of UR.

Can frozen-section analysis of ureteric margins at the time of radical cystectomy predict upper tract recurrence?

ABSTRACT Objective To summarise the currently available literature and analyse available results of the outcome of intraoperative frozen-section analysis (FSA) on upper urinary tract recurrence (UUTR) after radical cystectomy (RC). Materials and methods A systematic review of the literature was performed according to the Cochrane Reviews guidelines and in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Articles discussing ureteric FSA with RC were identified. Results The literature search yielded 21 studies, on which the present analysis was done. The studies were published between 1997 and 2019. There were 10 010 patients with an age range between 51 and 95 years. Involvement of the ureteric margins was noted in 2–9% at RC. The sensitivity and specificity of FSA were ~75% and 99%, respectively. Adverse pathology on FSA and on permanent section, prostatic urothelial carcinoma involving the stroma but not prostatic duct, and ureteric involvement on permanent section were all more likely to develop UUTR. Neither evidence of ureteric involvement nor ureteric margin status on permanent section were significant predictors of overall survival. Conclusion Routine FSA is mandatory for a tumour-free uretero–enteric anastomosis and is predictive of UUTR. To lower the UUTR, FSA is not necessary if the ureters are resected at the level where they cross the common iliac vessels. FSA is indicated whenever the surgeon encounters findings suspicious of malignancy, e.g. ureteric obstruction, periureteric fibrosis, diffuse carcinoma in situ, induration or frank tumour infiltration of the distal ureter is discovered unexpectedly during surgery, and prostatic urethral involvement. Abbreviations CIS: carcinoma in situ; FSA: frozen-section analysis; HR: hazard ratio; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RC: radical cystectomy; (UT)UC: (upper tract) urothelial carcinoma; UUT(R): upper urinary tract (recurrence)

Prognostic implications of prostatic urethral involvement in non-muscle-invasive bladder cancer.

Non-muscle-invasive bladder cancer involving the prostatic urethra is associated with pathologic upstaging and shorter survival. We investigated the survival impact of prostatic urethral involvement in non-muscle-invasive patients who are not upstaged at cystectomy. From 2000 to 2016, 177 male patients underwent cystectomy for high-risk non-muscle-invasive bladder cancer and remained pT1, pTis, or pTa, and N0 on final pathology; 63 (35.6%) patients had prostatic urethral involvement and 114 (64.4%) did not. Prostatic involvement was non-invasive (Ta or Tis) in 56 (88.9%) patients and superficially invasive (T1) in 7 (11.1%) patients. No patient had stromal invasion. Log-rank and Cox regression analyses were used to evaluate survival. Compared to patients without prostatic urethral involvement, patients with involvement were more likely to have received intravesical therapy (84.6% vs. 64.4%, p < 0.01), have multifocal tumor (90.8% vs. 51.7%, p < 0.01), and have positive urethral margins (7.7% vs. 0%, p < 0.01) and ureteral margins (18.5% vs. 5.1%, p < 0.01). Log-rank comparison showed inferior recurrence-free, cancer-specific, and overall survival in patients with prostatic involvement (p = 0.01, p = 0.03, p < 0.01). Patients with prostatic urethral involvement were more likely to experience recurrence in the urinary tract (p < 0.01). On Cox regression, prostatic urethral involvement was an independent predictor of overall mortality (HR=2.08, p < 0.01). Prostatic urethral involvement is associated with inferior survival in patients who undergo cystectomy for non-muscle-invasive bladder cancer and remain pT1, pTis, or pTa on final pathology. Prostatic urethral involvement is thus an adverse pathologic feature independent of its association with upstaging.

ICUD-SIU International Consultation on Bladder Cancer 2017: management of non-muscle invasive bladder cancer.

To provide a summary of the Third International Consultation on Bladder Cancer recommendations for the management of non-muscle invasive bladder cancer (NMIBC). A detailed review of the literature was performed focusing on original articles for the management of NMIBC. An international committee assessed and graded the articles based on the Oxford Centre for Evidence-based Medicine system. The entire spectrum of NMIBC was covered such as prognostic factors of recurrence and progression, risk stratification, staging, management of positive urine cytology with negative white light cystoscopy, indications of bladder and prostatic urethral biopsies, management of Ta low grade (LG) and high risk tumors (Ta high grade [HG], T1, carcinoma in situ [CIS]), impact of BCG strain and host on outcomes, management of complications of intravesical therapy, role of alternative therapies, indications for early cystectomy, surveillance strategies, and new treatments. The working group provides several recommendations on the management of NMIBC. Recommendations were summarized with regard to staging; management of primary and recurrent LG Ta and high risk disease, positive urine cytology with negative white light cystoscopy and prostatic urethral involvement; indications for timely cystectomy; and surveillance strategies. NMIBC remains a common and challenging malignancy to manage. Accurate staging, grading, and risk stratification are critical determinants of the management and outcomes of these patients. Current tools for risk stratification are limited but informative, and should be used in clinical practice when determining diagnosis, surveillance, and treatment of NMIBC.

Incidence of Stress Urinary Incontinence After Posterior Urethroplasty for Radiation-induced Urethral Strictures

To identify the frequency of de novo stress urinary incontinence (SUI) after posterior excision and primary anastomotic (EPA) urethroplasty in patients with radiation-induced urethral strictures (RIUS) and compare with patients with pelvic fracture urethral injuries (PFUIs). A retrospective review was conducted among patients who underwent successful posterior EPA urethroplasty between 2008 and 2016 for RIUS from prostate cancer or PFUI from blunt trauma. Only patients with an intact bladder neck on imaging were included. SUI was defined by patient-reported outcomes and daily pad use. Inclusion criteria were met by 36 patients with RIUS and 33 patients with PFUI. Among the RIUS cohort, mean follow-up was 18 months, mean stricture length was 2.5 cm, and surgical dissection extended to the prostatic urethra in 67% (n = 24). The overall frequency of de novo SUI among patients with RIUS was 33% (n = 12), of which 75% (9 of 12) had prostatic urethral involvement. Two patients with RIUS (17%, n = 12) proceeded with artificial urinary sphincter (AUS) placement, whereas the remaining 10 patients required pads. SUI after urethroplasty in patients with PFUI was less common (12%, n = 4) and the prostatic urethra was involved in only 3% (n = 1) of all patients with PFUI. One patient with PFUI underwent AUS placement, whereas the remaining 3 patients did not require pads. Among RIUS patients with an intact bladder neck, SUI impacts one-third of patients. Subsequent AUS placement is uncommon. Prostatic urethral involvement increases risk of SUI. SUI is less common among patients with PFUI, likely related to a more limited involvement of the proximal bulbomembranous urethra and lack of radiation.

PD29-04 INCIDENCE OF STRESS INCONTINENCE FOLLOWING POSTERIOR URETHROPLASTY AMONG RADIATION-INDUCED POSTERIOR URETHRAL STENOSES

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) II1 Apr 2017PD29-04 INCIDENCE OF STRESS INCONTINENCE FOLLOWING POSTERIOR URETHROPLASTY AMONG RADIATION-INDUCED POSTERIOR URETHRAL STENOSES Paul H Chung, Paige Esposito, Hunter Wessells, and Bryan B Voelzke Paul H ChungPaul H Chung More articles by this author , Paige EspositoPaige Esposito More articles by this author , Hunter WessellsHunter Wessells More articles by this author , and Bryan B VoelzkeBryan B Voelzke More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1356AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES No data exists regarding the frequency of de novo stress urinary incontinence (SUI) in patients with an intact bladder neck who undergo excision and primary anastomotic (EPA) urethroplasty for radiation-induced urethral stenoses (RIUS). We identified the risk for SUI in RIUS patients with urethral stenoses between the membranous and mid-prostatic urethra. A secondary aim was to compare the incidence of SIU to patients with pelvic fracture urethral injuries (PFUI) following EPA urethroplasty. METHODS Patients who underwent successful EPA urethroplasty between 2008-2016 were reviewed. Only patients with a history of RIUS from prostate cancer or PFUI from blunt trauma were included. Patients at risk for developing SUI were excluded: open bladder neck on pre-operative fluoroscopy, bladder neck dissection during urethroplasty, prior bladder neck surgery (robotic, open, or endoscopic prostate surgery), urinary tract fistula, failed prior posterior urethroplasty, or SUI at baseline. SUI was defined by patient reported outcome measures and subjective complaints. Cystoscopy was performed to assess for anatomic success of urethroplasty. RESULTS Of the total 135 patients, 47% (36/77) of RIUS and 57% (33/58) of PFUI met the inclusion criteria. Among the RIUS cohort, mean follow up was 18 months and mean stricture length was 2.5 cm. Radiated urethral strictures involved the prostatic urethra in 67% (24/36), and surgical scar excision beyond the prostate apex was necessary in 56% (20/36). The overall incidence of de novo SUI among RIUS patients was 33% (12/36). Among those with de novo SUI, 75% (9/12) had prostatic urethral involvement and 50% (6/12) required dissection beyond the prostate apex. For RIUS patients, 2/12 (17%) underwent artificial urinary sphincter (AUS) placement while the remaining 10 patients reported a mean use of 2.3 pads per day (range 1-4). SUI following urethroplasty in PFUI patients was less common (12%, 4/33). One PFUI patient underwent AUS placement while the remaining 3 patients did not report use of pads. CONCLUSIONS Among RIUS patients with an intact bladder neck, SUI is common following excision of scar in the prostatic urethra, affecting a third of the patients. SUI is less common among PFUI patients, likely related to more a reliable stricture location at the bulbomembranous urethra. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e573 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Paul H Chung More articles by this author Paige Esposito More articles by this author Hunter Wessells More articles by this author Bryan B Voelzke More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The role of prostatic urethral biopsies as a staging tool for bladder cancer

Objective: To determine the incidence of prostatic urethral involvement in our patient population and how prostatic urethral biopsy correlates with final cystectomy pathology. Patients and methods: We conducted a retrospective review of prostatic urethral biopsies (PUB) performed between February 2008 and April 2012 in a single centre. PUB pathology was correlated with cystectomy pathology. Results: PUB was undergone by 172 patients with a median age of 70 years (range: 37–84 years): There were 35 (20%) patients having a positive PUB and 137 (80%) who were negative. Of the 94 patients who underwent cystectomy, we found that when the entire prostatic urethra was sectioned, 20 (21%) patients had cancer in the prostatic urethra. Cancer was found in 17 (77%) of 22 patients with a positive PUB and in three (4%) out of the 72 with a negative PUB (positive predictive value (PPV) 77%, negative predictive value (NPV) 96%, sensitivity 85% and specificity 93%). In all 94 patients, the prostatic apical margin was negative. Conclusion: Disease in the prostatic urethra affected 20% of patients, consistent with published data. Prostatic urethral apical margins were all negative. Intra-operative frozen section would have missed cancer in the 20 patients with prostatic urethral cancer, whereas PUB identified 17 (85%) of the 20 patients. These data confirm the value of using PUB before cystectomy, in our UK population.

Risk factors of urethral recurrences following radical cystectomy for bladder cancer

Objective To evaluated the risk factors of urethral recurrence (UR) following radical cystectomy (RC)in patients with bladder urothelial carcinoma. Methods The clinical data of 350 male patients who underwent RC between January 2005 and January 2013 were retrospectively analyzed. The mean age was 63 years (rang 46-76) years. 176 cases had the history of non-muscle-invasive bladder cancer.15 cases were were found the tumor invasion into the prostatic urethral. The way of urinary diversion after RC included 172 cases were orthotopic neobladder, 90 cases were cutaneous diversion and 88 cases were ileal couduitin. 331 cases underwent preoperation intravesical instillation.36 cases underwent systemic chemotherapy after operation.148 cases were found the multiple tumor lesions, which was more than 2 sites. The pathological stage was more than T2 satge in 189 cases. And 177 cases were diagnosed as high-grade urothelial carcinoma. Multivariate Cox regression analyses were used to evaluate the risk factors associated with the UR. Results There were 350 cases in this study, UR was observed in 28 cases (8%). On multivariate Cox regression analyses, previous history of NMIBC (HR=15.205, 95%CI 3.718-62.180, P<0.001), prostate urethral involvement(HR=5.233, 95%CI 1.106-24.754, P=0.037) and Non-orthotopic neobladder(HR=6.656, 95%CI 1.840-24.077, P=0.004)which the operation of cutaneous diversion and ileal couduit , were independent risk factors of UR following RC. Intravesical instillation before operation (HR=0.470, 95%CI 0.010-0.217, P<0.001) was the protective factor of the UR. Conclusions Previous history of NMIBC, prostatic urethral involvement and Non-orthotopic neobladder were independent risk factors of UR. Intravesical instillation before operation was protective factor of UR. Urethrectomy for patients with high risk factors and intravesical instillation before operation were important. Key words: Bladder cancer; Urothelial carcinoma; Radical Cystectomy; Risk factors