Radical Cystectomy In Patients Research Articles

Oncological outcome of intraarterial chemotherapy combined with radiotherapy compared to radical cystectomy for patients with muscle invasive bladder cancer.

515 Background: Although radical cystectomy (RC) has been a standard treatment for muscle invasive bladder cancer (MIBC), some patients are unfit or refuse RC. Intraarterial chemotherapy combined with radiotherapy (IAC-RT) is one of the bladder preservation techniques, but there are a few data in patients who performed IAC-RT without salvage RC. The aim of this study was to evaluate the efficacy and tolerability of IAC-RT without RC compared to RC in patients with MIBC. Methods: We retrospectively reviewed patients with MIBC (T2-4N0M0) who had received either IAC-RT or RC in our hospital between January 1999 and December 2019. Intraarterial chemotherapy consisted of cisplatin (30mg/m2) and adriamycin (20mg/m2) on day 1 of each 1st, 2nd, 5th, 6th week. Concomitant radiotherapy (2 Gy/session, total 60 Gy) to whole pelvis was performed during chemotherapy. Salvage RC was not performed in all patients. Overall survival (OS), disease-specific survival (DSS), and metastasis-free survival (MFS) were compared between patients who received IAC-RT and RC. The prognostic factors of IAC-RT associated with OS were also investigated. Results: Forty-two and 143 patients received IAC-RT and RC, respectively. Of 42 patients who received IAC-RT, 28 (67%) and 14 (33%) were elective (refused RC) and imperative (comorbidity:7 poor PS:6 unresectable:1) cases, respectively. The patients who underwent IAC-RT were older (median; 77 vs 69 years old) and had poorer PS (≥2; 43% vs 4.9%) and shorter follow-up time (median; 21.9 vs 40.0 months) than those of RC. During follow up periods, metastasis, bladder cancer death, death of any cause was observed in 20, 19, and 27 patients with IAC-RT, 59, 55, and 49 patients with RC. In survival analyses, median OS was 38.7 months (95%CI, 16.9-74.7) with IAC-RT versus 154.0 months (95%CI, 70.6- not estimable (NE)) with RC, these OS curves were significantly different (P=0.001). There were not significant differences between two groups in DSS (median 46.5 vs not reached, P=0.06) and MFS (median 38.7 vs not reached, P=0.21). In multivariate analysis, clinical stage (≥T3; HR, 1.89; 95% CI, 1.04-3.46; P=0.04) and PS (≥2; HR, 2.24; 95% CI, 1.16-4.33; P=0.02) were suggested as risk factors associated with poor OS, however, treatment procedure (IAC-RT or RC) did not associate with OS. Forty of 42 (95%) patients with IAC-RT had any adverse events (AEs). Although grade3 AEs were observed in 21 (50%) patients, most of them were hematological AEs and Grade 4/5 AEs was not observed. Conclusions: IAC-RT was a useful and tolerable treatment option for patients with MIBC who were unfit or refused RC.

Opportunities of ICG-fluorescent imaging of lymph nodes during radical cystectomy in patients with bladder cancer: A review

Today, the "golden standard" for the treatment of aggressive forms of bladder cancer is radical cystectomy. An important stage is the pelvic lymphadenectomy. This procedure is crucial for staging the tumor process, determining the subsequent treatment tactics and improving the results of surgery. Currently, the concept of a signaling lymph node (LN) is actively developing, which allows reducing the necessary level of dissection of the pelvic LN. Reducing the number of resected LN increases the level of surgical safety of the patient. The leading method of intraoperative visualization of signal LN is the fluorescence of indocyanine green in the near infrared range of the spectrum. The prospects of this diagnostic method for radical cystectomy in patients with bladder cancer determine the vector of future scientific research in this area.

Short-Term and Long-Term Morbidity after Radical Cystectomy in Patients with NMIBC and Comparison with MIBC: Identifying Risk Factors for Severe Short-Term Complications

Introduction: RC represents a viable treatment option for certain NMIBC patients. However, studies investigating morbidity in the context of RC for NMIBC are scarce. The goal of the current study was to assess and compare morbidity after RC performed in patients with NMIBC and patients with MIBC and to identify risk factors for severe short-term complications. Methods: Medical records of 521 patients who underwent RC for bladder cancer were retrospectively reviewed. Patients were divided into patients with NMIBC and patients with MIBC. The groups were compared and risk factors for severe complications were identified. Results: RC for NMIBC was performed in 123 patients (23.6%). Histological upstaging was seen in 47 NMIBC patients (38.2%) and in 231 MIBC patients (58%, p < 0.001). OS was 29.8% and CSS was 15.5%. Both endpoints were higher for RC for MIBC (p < 0.001). More complications affecting the urinary diversion were seen with RC for NMIBC (p = 0.033) and more continent urinary diversions (p = 0.040) were performed in those patients. Obesity (p = 0.008), a higher ASA score (p = 0.004), and preoperative medical drug anticoagulation (p = 0.025) were risk factors for severe short-term morbidity after both, RC for NMIBC and for MIBC. Conclusion: Patients who underwent RC for NMIBC are exposed to a comparably high perioperative risk than patients with MIBC. RC seems to be a viable treatment option for certain NMIBC patients with a significant histological upstaging in both groups. In patients with obesity, a high ASA score, and with medical drug anticoagulation, the indication for surgery should be confirmed especially strict and possible treatment alternatives should be considered particularly thorough.

Hemoglobin, Albumin, Lymphocyte, and Platelet Count is a Significant Biomarker Surrogate for Nutritional Status to Predict Overall Survival in Patients Post-radical Cystectomy.

Nutritional status is an independent predictor of overall survival after radical cystectomy. Various biomarkers of nutritional status are proposed to predict postoperative outcome, including albumin, anemia, thrombocytopenia, and sarcopenia. Recently, a score comprising hemoglobin, albumin, lymphocyte, and platelet counts was postulated as an encompassing biomarker to predict overall survival post-radical cystectomy in a single-institution study. However, cutoffs for hemoglobin, albumin, lymphocyte, and platelet count are not well defined. In this study, we analyzed hemoglobin, albumin, lymphocyte, and platelet count thresholds predicting overall survival and examined the platelet-to-lymphocyte as an additional prognostic biomarker. Fifty radical cystectomy patients were retrospectively evaluated from 2010-2021. American Society of Anesthesiologists classification, pathological data, and survival were extracted from our institutional registry. Univariable and multivariable Cox regression analysis was fit to the data to predict overall survival. Median follow-up was 22 (12-54) months. Hemoglobin, albumin, lymphocyte, and platelet count (continuous) was a significant predictor of overall survival on multivariable Cox regression analysis (HR 0.95, 95% CI: 0.90-0.99, P = .03), adjusting for Charlson Comorbidity Index, lymphadenopathy (pN >N0), muscle-invasive disease, and neoadjuvant chemotherapy. Optimal hemoglobin, albumin, lymphocyte, and platelet count cutoff was 25.0. Patients with hemoglobin, albumin, lymphocyte, and platelet count <25.0 had inferior overall survival (median, 33 months) vs with those with hemoglobin, albumin, lymphocyte, and platelet count ≥25.0 (median, not reached) (P = .03). Low hemoglobin, albumin, lymphocyte, and platelet count <25.0 was an independent predictor of inferior overall survival.

Evaluation of silk fibroin-based urinary conduits in a porcine model of urinary diversion.

Background: The primary strategy for urinary diversion in radical cystectomy patients involves incorporation of autologous gastrointestinal conduits into the urinary tract which leads to deleterious consequences including chronic infections and metabolic abnormalities. This report investigates the efficacy of an acellular, tubular bi-layer silk fibroin (BLSF) graft to function as an alternative urinary conduit in a porcine model of urinary diversion. Materials and methods: Unilateral urinary diversion with stented BLSF conduits was executed in five adult female, Yucatan mini-swine over a 3 month period. Longitudinal imaging analyses including ultrasonography, retrograde ureteropyelography and video-endoscopy were carried out monthly. Histological, immunohistochemical (IHC), and histomorphometric assessments were performed on neoconduits at harvest. Results: All animals survived until scheduled euthanasia and displayed moderate hydronephrosis (Grades 1-3) in reconstructed collecting systems over the course of the study period. Stented BLSF constructs supported formation of vascularized, retroperitoneal tubes capable of facilitating external urinary drainage. By 3months post-operative, neoconduits contained α-smooth muscle actin+ and SM22α+ smooth muscle as well as uroplakin 3A+ and pan-cytokeratin + urothelium. However, the degree of tissue regeneration in neotissues was significantly lower in comparison to ureteral controls as determined by histomorphometry. In addition, neoconduit stenting was necessary to prevent stomal occlusion. Conclusion: BLSF biomaterials represent emerging platforms for urinary conduit construction and may offer a functional replacement for conventional urinary diversion techniques following further optimization of mechanical properties and regenerative responses.

Development and validation of a survival nomogram for muscle-invasive bladder cancer in the elderly: using competing risk models and propensity matching to apply the prediction tool

Aim: Patients with muscle-invasive bladder cancer (MIBC) have a low survival rate, with a 5-year survival of approximately 45%, regardless of the treatment received. The risk of death within 5 years after radical cystectomy in patients with MIBC remains as high as 60%. Over 80% of patients with bladder cancer are over 65. Therefore, identifying prognostic correlates associated with radical cystectomy in older patients with MIBC could improve survival rates. In addition, radiotherapy and chemotherapy are particularly important as adjuvant treatments for MIBC patients undergoing radical cystectomy. Therefore, this study aimed to find risk factors for cancer-specific survival (CSS) and overall survival (OS) after radical cystectomy in elderly MIBC patients. The difference in survival between radiotherapy and chemotherapy was analyzed by Kaplan-Meier (K-M) curves to provide theoretical support for whether radiotherapy is recommended for such patients. Methods: Patients 65 or older diagnosed with MIBC with radical cystectomy between 2004-2018 were obtained from the Surveillance, Epidemiology, and End Results (SEER) database. 2004-2015 patients were subjected to column line plot production and internal validation, and 2016-2018 patients were subjected to external temporal validation. A single-factor COX regression model was first used to screen for prognostic correlates. Then a multi-factor COX regression model was used to screen for independent risk factors. A nomogram was constructed by using independent risk factors. The accuracy and reliability of the nomogram were examined using calibration curves, consistency index (C-index), and area under subjects (AUC) as operational characteristic curves. Decision curve analysis (DCA) was performed to evaluate the clinical value of the prediction model. Results: A total of 11,557 patients were included in this study, divided into training set (N = 4,712), validation set (N = 4,810) and external validation set (N = 2,035). Multivariate COX regression models showed that chemotherapy, radiotherapy, TNM stage, race, and age were independent risk factors for CSS and OS patients. We constructed a nomogram to predict CSS and OS in elderly MIBC patients undergoing radical cystectomy. The C-indexes were 0.692 (95%CI: 0.680-0.704) and 0.690 (95%CI: 0.678-0.702) for the CSS training and validation sets, respectively, and 0.674 for the OS training and validation sets (95%CI: 0.664-0.684) and 0.672 (95%CI: 0.662-0.682) for the OS training and validation sets, respectively. The C-index of the external validation set CSS was 0.731 (95%CI: 709-0.753), and that of OS was 0.721 (95%CI: 0.701-0.741), indicating that the nomogram prediction model has good discriminative power. The calibration curves and AUC also suggested that the nomogram had good accuracy and discrimination. In addition, the KM curves of propensity-matched pre- and post-radiotherapy showed that radiotherapy was detrimental to patient survival. Meanwhile, chemotherapy favored OS and short-term CSS but not long-term CSS. Conclusions: We established a nomogram to predict the CSS and OS in elderly MIBC patients undergoing radical cystectomy. After internal cross-validation and external validation, the nomogram prediction model showed good accuracy and reliability, and the DCA results showed that the nomogram has good clinical value. In addition, this study gave good suggestions on whether radiotherapy or chemotherapy is necessary for radical cystectomy in elderly MIBC patients.

3D laparoscopic radical cystectomy in patients with urinary bladder cancer: a prospective evaluation of safety and efficacy

3D laparoscopic radical cystectomy in patients with urinary bladder cancer: a prospective evaluation of safety and efficacy

Preoperative predictors of prolonged length of stay in radical cystectomy: a retrospective study using the American College of Surgeons-National Surgical Quality Improvement Program Dataset.

Radical cystectomy (RC) is considered a complex procedure that entails significant morbidity and mortality. We aimed to determine pre-operative patient characteristics that help predict a prolonged length of hospital stay (PLOS) following RC. The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was used to select patients who underwent RC between the years 2011 and 2020. Prolonged length of stay was defined as a hospital stay ⩾9 days. We compared patient demographics, pre-operative labs, surgical characteristics, and medical history between patients with or without PLOS. Multivariable logistic regression models controlling for pre-operative characteristics and propensity score matching for post-operative complications were conducted to control for possible confounders. The analysis yielded details of 19,158 RC patients of which 6007 (31%) patients had a PLOS. Patients with PLOS were more likely to have post-operative complications that could serve as predictors for the PLOS rather than their pre-operative characteristics. Hence, we matched our cohort for these complications. After matching, patient pre-operative characteristics that predict PLOS included female gender (Odds Ratio (OR) = 5.91), 10-year increase in age (OR = 1.15), non-White race (OR = 1.98), partially or totally dependent functional health status (OR = 2.86), bleeding disorders (OR = 4.67), congestive heart failure (OR = 1.59), pre-operative transfusion (OR = 3.03), and a 20-min increase in operative time (OR = 1.01) (p < 0.046). Patient demographics and pre-operative factors can help predict PLOS in RC patients. These predictors could serve as tools for patient counseling and risk stratification.

Renal function outcome after selective bladder-preserving tetramodality therapy consisting of maximal transurethral resection, induction chemoradiotherapy and consolidative partial cystectomy in comparison with radical cystectomy for patients with muscle-invasive bladder cancer: a two-centre retrospective study.

To compare renal function (RF) outcomes after bladder-preserving tetramodal therapy against muscle-invasive bladder cancer (MIBC) to those after radical cystectomy (RC). This study included 95 patients treated with tetramodal therapy consisting of transurethral bladder tumour resection, chemoradiotherapy and partial cystectomy (PC) and 300 patients treated with RC. The annual change in the estimated glomerular filtration rate (eGFR) was compared using the linear mixed model. Renal impairment was defined as a >25% decrease from the pretreatment eGFR, and renal impairment-free survival (RIFS) was calculated. The association between treatment type and renal impairment was assessed. The number of patients who received neoadjuvant chemotherapy was 8 (8.4%) in the tetramodal therapy group and 75 (25.0%) in the RC group. After the inverse probability of treatment weighting adjustments, the baseline characteristics were balanced between the treatment groups. The mean eGFR before treatment in tetramodal therapy and RC groups was 69.4 and 69.6 mL/min/1.73 m2 and declined with a slope of -0.7 and -1.5 mL/min/1.73 m2/year, respectively. The annual deterioration rate of post-treatment eGFR in the tetramodal therapy group was milder than in the RC group. The 5-year RIFS rate in the tetramodal therapy and the RC groups was 91.2 and 85.2%, respectively. Tetramodal therapy was an independent factor of better RIFS compared with RC. RF was better preserved after tetramodal therapy than after radical therapy; however, even after tetramodal therapy, the eGFR decreased, and a non-negligible proportion of patients developed renal impairment.

Neoadjuvant chemotherapy and radical cystectomy in patients with bladder cancer

Background. Bladder cancer is the ninth most common malignant neoplasm worldwide. Hidden metastases at the time of diagnosis are the main reason muscle-invasive bladder cancer has poor prognosis. Even after radical cystectomy, muscleinvasive bladder cancer mostly progresses within 2 years with a recurrence rate of over 50 %. At stages II–IV of the disease, drug treatment is indicated before radical cystectomy. The main goal of neoadjuvant chemotherapy is to affect micrometastases, which may be present at the beginning of disease development. The response to ongoing chemotherapy can serve as a predictor of long-term survival.Aim. To increase effectiveness of bladder cancer treatment.Materials and methods. A total of 231 patients with bladder cancer were included in the study. The main contingent consisted of men over 60 years old with locally advanced tumors at stage Т2–Т4. Drug therapy was carried out in neoadjuvant mode before surgical treatment. Standard regimens were used: cisplatin + gemcitabine and MVAC (methotrexate, vinblastine, adriamycin, cisplatin). After four courses of neoadjuvant chemotherapy, the results were evaluated. With complete normalization of a patient’s condition, the issue of surgical treatment – radical cystectomy with one of the types of urinary diversion – was decided.Results and conclusion. The follow-up period for patients after treatment was 62 months. In patients who underwent neoadjuvant chemotherapy, the median overall survival was 44.9 months, in patients without neoadjuvant treatment – 36.8 months with improvement in recurrence-free survival from 32.5 to 39.8 months (p = 0.08). Overall survival after neoadjuvant chemotherapy improved by 8.1 months (p = 0.09).

Quality of Life after Radical Cystectomy for Patients with Bladder Cancer

Quality of Life after Radical Cystectomy for Patients with Bladder Cancer

EE563 Evaluating the Cost-Utility of Intravesical Bacillus Calmette-Guérin Versus Radical Cystectomy in Patients With High-Risk Non-Muscle-Invasive Bladder Cancer in the UK

EE563 Evaluating the Cost-Utility of Intravesical Bacillus Calmette-Guérin Versus Radical Cystectomy in Patients With High-Risk Non-Muscle-Invasive Bladder Cancer in the UK

Intraoperative Blood Transfusion is Associated With Increased Risk of Venous Thromboembolism After Radical Cystectomy.

Our objective was to examine whether perioperative blood transfusion is associated with venous thromboembolism following radical cystectomy adjusting for both patient- and disease-related factors. Patients who underwent radical cystectomy for bladder cancer from 1980-2020 were identified in the Mayo Clinic cystectomy registry. Blood transfusion during the initial postoperative hospitalization was analyzed as a 3-tiered variable: no transfusion, postoperative transfusion alone, or intraoperative with or without postoperative transfusion. The primary outcome was venous thromboembolism within 90 days of radical cystectomy. Associations between clinicopathological variables and 90-day venous thromboembolism were assessed using multivariable logistic regression, with transfusion analyzed as both a categorical and a continuous variable. A total of 3,755 radical cystectomy patients were identified, of whom 162 (4.3%) experienced a venous thromboembolism within 90 days of radical cystectomy. Overall, 2,112 patients (56%) received a median of 1 (IQR: 0-3) unit of blood transfusion, including 811 (38%) with intraoperative transfusion only, 572 (27%) with postoperative transfusion only, and 729 (35%) with intraoperative and postoperative transfusion. On multivariable analysis, intraoperative with or without postoperative blood transfusion was associated with a significantly increased risk of venous thromboembolism (adjusted OR 1.73, 95% CI 1.17-2.56, P = .002). Moreover, when analyzed as a continuous variable, each unit of blood transfused intraoperatively was associated with 7% higher odds of venous thromboembolism (adjusted OR 1.07, 95% CI 1.01-1.13, P = .03). Intraoperative blood transfusion was significantly associated with venous thromboembolism within 90 days of radical cystectomy. To ensure optimal perioperative outcomes, continued effort to limit blood transfusion in radical cystectomy patients is warranted.

Implementation of a comprehensive prehabilitation program for patients undergoing radical cystectomy

BackgroundCoordinated preoperative optimization programs for radical cystectomy (RC) are limited and non-comprehensive. We evaluated the feasibility and acceptability of a coordinated, multi-faceted prehabilitation program for RC patients at a high-volume bladder cancer referral center. MethodsWe performed a narrative literature review for prehabilitation in bladder cancer management as of December 1, 2020, with specific emphasis on examining higher-level evidence sources. We selected domains with the highest level of evidence and recruited a multidisciplinary team of experts to design our program. We implemented a comprehensive prehabilitation program with a pre-defined order set as standard of care for all patients undergoing RC beginning February 1, 2021. Demographic and clinicopathologic data were collected prospectively. Rates of adherence to the prehabilitation program services were analyzed using Stata version 13. ResultsA total of 82 patients were enrolled between February – December 2021, of which 67 (81%) had undergone RC at data cutoff. Mean age was 68 years (SD 11) and 63 (76%) identified as male. Neoadjuvant chemotherapy (NAC) was utilized in 48 (59%) patients. The mean Charlson Comorbidity Index was 3.8 (SD 2.3). 100% of patients were screened for malnutrition, with 82% consuming nutritional supplements. Fifty-two percent of patients attended physical therapy pre-op. The 30-day and 30- to 90-day rates of complications were 56% and 40%, respectively. Resource length of stay (RLOS) declined after implementation of prehabilitation. ConclusionsImplementation of a comprehensive prehabilitation program at a high-volume bladder cancer referral center is feasible and has a modest effect on resource consumption and complications in our early experience.

EP028 - Beneficial effects of intraoperative cell salvage on allogenic blood transfusion and recurrence free survival in radical cystectomy patients

EP028 - Beneficial effects of intraoperative cell salvage on allogenic blood transfusion and recurrence free survival in radical cystectomy patients

Intensive preoperative ostomy education for the radical cystectomy patient.

Patients undergoing radical cystectomy with ileal conduit formation usually receive training on the use of their stoma during their initial hospitalization - while actively recovering from surgery - often with little follow-up or reinforcement. Many of these patients are not equipped to deal with these significant body changes, which can lead to additional clinic visits, stoma-related complications, and decreased patient satisfaction/health-related quality of life (HRQOL). In an effort to improve patient education, we sought to evaluate the feasibility of implementing a preoperative comprehensive stoma education session termed the "stoma bootcamp" for patients scheduled for a radical cystectomy and ileal conduit (RCIC). We tracked patient related outcomes to determine its impact. We performed a longitudinal, quality-improvement feasibility study at the University of Kansas Health System. All patients who were scheduled to undergo a RCIC for bladder cancer were offered enrollment into the study at their preoperative clinic visit. The "stoma boot camp" consisted of a 3-hour group session within 2 weeks of the surgery date. Patients were given a short presentation by residents and advanced practice providers regarding the operation, recovery, and expectations for their post-operative care. Ostomy nurses then demonstrated basic urostomy care - pouching, sizing, emptying - along with trouble-shooting tips for common ostomy problems. Measurements of HRQOL questionnaires were completed at the initial visit, after "boot camp," and at defined time points after surgery for 12 weeks. This included using an ostomy adjustment score. Length of stay, unplanned stoma-related interventions, and re-admissions within 30 days were also tracked. In this initial pilot program, 51 patients participated in the stoma bootcamp. The patients had an average ostomy adjustment score (OAS) of 150.4 (95% CI 142.0, 158.8) at discharge from the hospital, and these high OAS levels persisted throughout the 12 weeks of follow-up data without any significant decline. Short-form 36 (SF-36) scores demonstrated numerical improvements in each individual category at the 6-week mark above baseline. These improvements persisted at the 12-week mark. In this study we were able to establish the feasibility of implementing a preoperative comprehensive stoma education session for patients scheduled for a RCIC. Additionally, we were able to document favorable HRQOL data and improved ostomy adjustment scores surrounding the education session.

Complications after neoadjuvant chemotherapy and radical cystectomy for patients with bladder cancer: A propensity score matched analysis.

Neoadjuvant chemotherapy (NAC) in combination with radical cystectomy (RC) is the standard of care for muscle-invasive bladder cancer (MIBC). We investigated the impact of NAC on postoperative complications after RC in patients with bladder cancer (BCa). Using the recently available American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Targeted Cystectomy database, we identified adult (>18 years old) patients who underwent RC for the treatment of BCa. Patients were then dichotomized based on whether they received NAC. We performed a 1:1 propensity score matched (PSM) analysis based on demographic and perioperative covariates. Postoperative outcomes were then compared between the two matched groups. A multivariable analysis was also performed to identify if NAC was associated with any complication. We identified 1582 eligible patients: 913 (57.7%) in the group that did not receive NAC and 669 (42.3%) in the group that did receive NAC. Before PSM, patients in the NAC group were younger, had lower American Society of Anesthesiology (ASA) scores, had higher rates of preoperative anemia, and were more likely to undergo continent urinary diversion. Similarly, before PSM patients in the NAC group had significantly higher rates of major complications, sepsis, urinary leak/fistula, and intraoperative/postoperative blood transfusion compared to the group that did not receive NAC; however, after 1:1 PSM, we did not find any significant difference postoperative complication rates. Multivariable analysis confirmed that NAC was not associated with any complications. We demonstrated that NAC does not impact 30-day postoperative complications in patients undergoing RC for BCa.

Survival Outcome of Partial Cystectomy versus Transurethral Bladder Tumor Resection in T1 High-Grade Bladder Cancer Patients: A Propensity Score Matching Study.

Partial cystectomy was investigated as a method of bladder preservation with better disease outcomes than transurethral bladder tumor resection in T1 high-grade bladder cancer patients. Method and materials. The national Surveillance, Epidemiology, and End Results database (SEER) (2004-2015) were used to obtain patients diagnosed with T1 high-grade bladder cancer, and finally, 25263 patients were enrolled in our study. The Kaplan-Meier method with the log-rank test was performed to analyze the outcome of overall survival (OS) and cancer-specific survival (CSS) between patients undergoing partial cystectomy (PC), transurethral resection of bladder tumor (TURBT), or radical cystectomy (RC). Moreover, the propensity score matching (PSM) and multivariable Cox proportional hazard model were also utilized in the study. Ultimately, 24635 patients were undergoing TURBT, while 190 and 438 patients were, respectively, assigned to the PC and RC groups. Compared with patients with TURBT, a tendency of a higher proportion of higher older and male patients was observed in the PC group. When matching with RC patients, patients in the PC group were commonly older and had bigger tumor sizes and single tumors (All P < 0.05). After 1 : 1 PSM, 190 patients with TURBT and 160 patients receiving PC were selected. In survival analysis, the patients in the PC group had a higher survival probability of both OS and CSS before and after PSM compared with those in the TURBT group. Meanwhile, no significant differences were observed between the RC and PC groups in OS and CSS analysis. Moreover, multivariable Cox regression showed that PC was a protective factor for overall mortality (ACM) and cancer-specific mortality (CSM) compared with TURBT in T1 high-grade patients (All P < 0.05). Patients undergoing partial cystectomy were shown to have a better outcome compared with those with transurethral bladder tumor resection in T1 high-grade bladder cancer patients. Partial cystectomy could be the more worthwhile choice for bladder preservation in T1 high-grade bladder cancer patients.

Multi-Institutional Matched Comparison of Radical Cystectomy to Trimodality Therapy for Muscle Invasive Bladder Cancer (MIBC)

<h3>Purpose/Objective(s)</h3> Prior randomized controlled trials (RCT) comparing bladder preservation to radical cystectomy (RC) for muscle invasive bladder cancer (MIBC) closed early due to lack of accrual. Given that no future RCTs are foreseen, and in the absence of level 1 data, we aimed to provide the best evidence possible on outcomes of matched cohorts comparing trimodality therapy (TMT, maximal transurethral resection of bladder tumor followed by concurrent chemoradiation) to RC in order to guide management. <h3>Materials/Methods</h3> This retrospective analysis included 703 patients with MIBC clinical stage T2-T3/4aN0M0 MIBC urothelial carcinoma of the bladder, 421 RC and 282 TMT who would have been eligible for both TMT or RC, treated at three tertiary referral academic institutions between 2005-2017. To compare homogeneous cohorts, all patients included in this analysis had solitary tumors <7 cm, no or unilateral hydronephrosis, and no extensive carcinoma in situ. Treatment propensity scores were estimated using logistic regression, and patients were matched 3:1 with replacement. Covariates included age, sex, clinical T stage, hydronephrosis, (neo)adjuvant chemotherapy, body mass index, smoking history, and ECOG status. Overall survival (OS) was estimated with adjusted Cox models; cancer-specific survival (CSS), distant failure-free survival, pelvic nodal failure-free survival and metastasis-free survival (combined distant and pelvic nodal failure) were estimated with adjusted competing risk models. Our primary endpoint of interest was metastasis-free survival. The analysis was performed as intent-to-treat. <h3>Results</h3> The 3:1 matched cohort comprised of 1,116 patients (834 RC vs 282 TMT). After matching, age (71.3 vs 71.6), cT2 clinical stage (88 vs 90%), presence of hydronephrosis (12 vs 10%), and use of (neo)adjuvant chemotherapy (60 vs 65%) was similar between RC and TMT cohorts. Salvage cystectomy was performed in 38 patients (13%) treated by TMT. At 5 years, metastasis-free (73 vs 78%, p=0.07), distant failure-free (78 vs 82%, p=0.14), and pelvic nodal failure-free (96 vs 94%, p=0.33) survival were not statistically different between RC and TMT, whereas CSS and OS favored TMT (78 vs 85%, p=0.02; 66 vs 78%, p<0.001). Outcomes for RC and TMT were not different among centers. Final pT stage in the RC patients was: pT0 14%, pT1 7%, pT2 29%, pT3/4 42% and N+ 24%. Peri RC mortality was 2.1% and median number of nodes removed was 40. NMIBC recurrence occurred in 57/282 (20.2%) TMT patients. <h3>Conclusion</h3> This large multi-institutional contemporary study provides the best evidence to date, in the absence of randomized trials, supporting TMT for select patients with MIBC. Oncologic outcomes seem to be equivalent between TMT and RC, affirming the position that TMT should be offered as an effective alternative.

Twenty-Four-Month Efficacy of Ureteroureterostomy Combined With Unilateral Nephrostomy Following Radical Cystectomy

Introduction The purpose of this study was to evaluate the 24-month outcomes of ureteroureterostomy combined with unilateral nephrostomy following radical cystectomy in patients with muscle-invasive bladder cancer (BC). Materials and methods This single-center study with prospectively collected data with retrospective data analysis was carried out between December 2018 and November 2021 and enrolled 36 patients, who underwent radical cystectomy combined with ureteroureterostomy and unilateral nephrostomy. Regular renal function assessment was carried out using serum creatinine and estimated glomerular filtration rate (eGFR), and postoperative complications, endoscopic, ultrasound, and other radiological study findings were evaluated. The follow-up of the patients was carried out over a period of 24 months. Results After completion of the 24-month follow-up, the renal function proved to be slightly improved (mean serum creatinine and eGFR values of 1.38±0.72 mg/dL and 55.9±21.87 mL/min) compared to the first-year results (1.41±0.54 mg/dL and 52.10±19.64 mL/min). However, this improvement is statistically not significant (p=0.44, p=0.30). The 24-month follow-up imaging findings remained stable in 97.22% of patients compared to the first-year results, with preservation of bilateral ureteric dilatation and grade 1 dilatation of the non-drained kidney. No case of acute pyelonephritis was recorded after the completion of the second year of follow-up, in comparison to the eight patients (22.22%) of the 12-month follow-up, who sufferedacute pyelonephritis. After completing of the 24-month follow-up, one patient was excluded from further analysis, due to the placement of a second permanent percutaneous nephrostomy in the non-drained kidney, due to ureteroureterostomy stenosis with consecutive hydronephrosis in the contralateral kidney and acute renal failure. No case of anastomotic leak was observed. Conclusions The function of the ureteroureterostomy combined with unilateral nephrostomy is proven to be a safe method of urinary diversion (UD) at 24 months, with minimal and easily manageable complications. Only one case of stenosis of the ureteroureterostomy with consecutive acute renal failure due to hydronephrosis in the non-drained kidney was observed. The renal function remained stable.