The prognostic significance of advanced age in patients with bladder cancer treated with radical cystectomy

OBJECTIVE

To evaluate the association of patient age with pathological and long‐term oncological outcomes after radical cystectomy (RC) for bladder carcinoma, as this disease, like many others, increases in incidence with age.

PATIENTS AND METHODS

We retrospectively reviewed 241 consecutive patients with invasive bladder cancer who had RC between 1990 and 2007. The age at RC was analysed both as a continuous and categorical (≤50 years, 38 patients; 51–69, 172; or ≥70, 31) variable. Survival was also analysed.

RESULTS

Increasing age, analysed as a continuous and categorical variable, was associated with advanced pathological stage (P = 0.009 and 0.006, respectively). The 5‐year cancer‐specific survival rates for patients according to the age groups were 78.5%, 44.9% and 28.1%, respectively, and Kaplan‐Meier analysis showed an increased risk of bladder cancer‐specific death with advancing age (P < 0.001). Being older at RC was an important prognostic factor for disease‐specific survival in a multivariate Cox regression model. Patients aged ≥70 years had a significantly higher risk of disease than patients aged ≤50 years (P = 0.002).

CONCLUSIONS

Higher age at RC is significantly associated with the risk of pathologically advanced disease and poorer cancer‐specific survival. More prospective work is needed to examine the impact of age on tumour biology and cancer‐specific survival.     

Clinical outcome of radical cystectomy for patients with pT4 bladder cancer

Objective:   The objective of this study was to analyze the outcomes of radical cystectomy for patients with pT4 bladder cancer.
Methods:   Between 1995 and 2003, 583 patients underwent radical cystectomy for bladder cancer at our institution and related hospitals, including 76 pathologically diagnosed as having pT4 disease. Of these 76, this study included 60 patients after excluding 16 with pT4Tis disease, and a retrospective review of their records was carried out.
Results:   Pathological examinations demonstrated that seven (11.6%) and 53 (88.4%) patients were Grades 2 and 3, respectively, and 48 (80.0%), 38 (63.4%), 10 (16.7%) and 30 (50.0%) were positive for lymphatic invasion, microvenous invasion, surgical margin and lymph node metastasis, respectively. During the observation period of this study (median, 24.5 months; range, 2–89 months), disease recurrence occurred in 38 (63.3%), and the median time to recurrence after radical cystectomy was 7.0 months (range, 1–38 months). One-, 3- and 5-year cancer-specific survival rates of the 60 patients were 68.8%, 48.5% and 23.9%, respectively. Univariate analysis identified lymph node metastasis, lymphatic invasion, microvenous invasion and positive surgical margin as significant predictors for cancer-specific survival; however, only lymph node metastasis was shown to be independently associated with cancer-specific survival by multivariate analysis.
Conclusions:   The prognosis of patients with pT4 bladder cancer is generally poor, particularly for those with nodal involvement. Therefore, it would be potentially important to carry out careful follow-up for such patients following radical cystectomy and, if necessary, to consider a multimodal therapeutic approach in an adjuvant setting.     

腹腔镜下膀胱癌根治术36例报告

目的探讨腹腔镜下全膀胱切除术治疗膀胱癌的手术方法和临床效果。方法36例患者,男性28例,女性8例;年龄56～75岁。36例病理证实为浸润性膀胱移行细胞癌Ⅱ～Ⅲ级,TNM分期：T2N2M0 22例,T3aN0M0 10例,T3bN0M0 4例。行腹腔镜下膀胱癌根治术,其中25例行原位乙状结肠代膀胱术,11例输尿管造口术,观察手术时间、术中出血量、术后肠道功能恢复、术后并发症及手术效果。站杲手术时间5～10h,术中失血200-1000mL,术后约72h肠道功能恢复,术后2周拔输尿管导管,术后3周拔尿管后腹压排尿正常,术后3个月IVU未见。肾积水,未出现腹腔并发症。结论腹腔镜下全膀胱切除术具有微创、出血少、恢复快等特点,随着技术的进步,该术式将成为治疗浸润性膀胱癌的较好方法之一。     

Prognostic significance of vascular invasion in patients with bladder cancer who underwent radical cystectomy

BACKGROUND: The objective of this study was to determine whether vascular invasion (i.e. lymphatic and blood vessel invasion) could be a useful prognostic predictor in patients with locally invasive transitional cell carcinoma (TCC) of the bladder who underwent radical cystectomy. METHODS: This series included 114 consecutive patients undergoing radical cystectomy for primary TCC of the bladder between November 1989 and July 2003. Several clinicopathological characteristics of these patients were analyzed, focusing on the association between vascular invasion and disease recurrence after radical cystectomy. RESULTS: Lymphatic and blood vessel invasions were detected in 55 (48.2%) and 33 (29.8%) specimens, respectively. Lymphatic invasion was significantly associated with pathological stage, tumor grade, lymph node metastasis, blood vessel invasion and disease recurrence, whereas blood vessel invasion was significantly related to pathological stage, lymph node metastasis, lymphatic invasion and disease recurrence. Recurrence-free survival in patients with lymphatic invasion was significantly lower than that in those without lymphatic invasion, and a similar significant difference in recurrence-free survival was observed between patients with and without blood vessel invasion. However, multivariate analysis using the Cox proportional hazards model showed that only pathological stage and lymph node metastasis could be used as independent predictors for disease recurrence after radical cystectomy. CONCLUSIONS: Despite a significant association between several prognostic parameters, vascular invasion was not an independent predictor of disease recurrence; therefore, if there are other conventional parameters available, there might not be any additional advantage to considering the presence of vascular invasion when predicting the prognosis of patients undergoing radical cystectomy for TCC of the bladder.     

The significance of lymphovascular invasion in transurethral resection of bladder tumour and cystectomy specimens on the survival of patients with urothelial bladder cancer

OBJECTIVE

To test the hypothesis that patients with bladder cancer who had evidence of lymphovascular invasion (LVI) in their transurethral resection of bladder tumour (TURBT) and radical cystectomy (RC) specimens would have a worse prognosis and higher likelihood of clinical understaging, and to assess the effect of LVI discovered at RC on subsequent disease‐related mortality, as the prognostic significance of LVI in TURBT or RC specimens of patients treated for urothelial carcinoma of the bladder is not completely established.

PATIENTS AND METHODS

We retrospectively reviewed the records of 163 patients with urothelial carcinoma of the bladder seen at our institution, and who had TURBT (69) or RC (94) between 1995 and 2005. We compared patients with LVI on TURBT and/or RC specimens to a group of controls who did not have LVI on TURBT (34) or RC (32).

RESULTS

Patients with LVI present in their TURBT specimen had a shorter disease‐specific survival than those without LVI, with a 5‐year survival of 33.6% vs 62.9% (log‐rank test P = 0.027; hazard ratio 2.21). LVI at TURBT varied with clinical stage (P = 0.049). Patients with LVI and who were clinical stage I or II had lower survival than those without LVI (P = 0.049; hazard ratio 2.68). LVI did not affect survival among those with clinical stage III or IV (P = 0.29). There was a trend for patients with LVI at TURBT to be clinically understaged compared to those without LVI (75% vs 46%) but the difference was not significant (P = 0.086). Patients with LVI detected in their RC specimen were significantly more likely to have cancer recurrence than were those with no evidence of LVI (48% vs 19%, P = 0.006). For the RC group there was also a significant difference in survival distribution between patients with evidence of LVI vs those without (5‐year survival 45.5% vs 78.4%, P = 0.017). Those with LVI were significantly more likely to die from the disease than those without LVI (P = 0.017; hazard ratio 2.92).

CONCLUSIONS

Our findings suggest that LVI is a histological feature that might be associated with a poorer prognosis in patients with urothelial carcinoma of the bladder. The presence of LVI in TURBT specimens predicts shorter survival for patients with stage I or II disease. The presence of LVI in RC specimens predicts recurrence of disease and shorter survival. Further studies are needed to determine whether this group of patients would benefit from early RC and/or perioperative chemotherapy to improve clinical outcomes.     

Assessing the minimum number of lymph nodes needed at radical cystectomy in patients with bladder cancer

OBJECTIVE

To identify the likelihood of finding one or more positive lymph nodes (LNs) according to the number of LNs removed at radical cystectomy (RC), as the number of LNs removed affects disease progression and survival after RC.

PATIENTS AND METHODS

Between 1984 and 2003, 731 assessable patients had RC and bilateral pelvic lymphadenectomy at three different institutions. ROC curve coordinates were used to determine the probability of identifying one or more positive LNs according to the total number of removed LNs.

RESULTS

Of the 731 patients, 174 (23.8%) had LNs metastases. The mean (median, range) number of LNs removed was 18.7 (17, 1–80). The ROC coordinate‐based plots of the number of removed LNs and the probability of finding one or more LNs metastases indicated that removing 45 LNs yielded a 90% probability. Conversely, removing either 15 or 25 LNs indicated, respectively, 50% and 75% probability of detecting one or more LNs metastases.

CONCLUSIONS

These data indicate that removing 25 LNs might represent the lowest threshold for the extent of lymphadenectomy at RC. Our findings confirm the importance of an extended lymph node dissection.     

Upper urinary tract recurrence following radical cystectomy for bladder cancer

AIM: The objective of this study was to analyze the clinicopathological features of upper urinary tract recurrence following radical cystectomy for bladder cancer. METHODS: Between 1995 and 2003, 583 patients underwent radical cystectomy and urinary diversion for bladder cancer at the authors' institution and the related hospitals. A retrospective review of patient records was carried out to evaluate characteristics of patients who underwent upper urinary tract recurrence after radical cystectomy. RESULTS: During the observation period (median, 41.5 months), 12 (2.1%) of the 583 patients had upper urinary tract recurrence. Of the 12 patients with upper urinary tract recurrence, there were multiple tumors in eight at the initial diagnosis of bladder cancer, and eight received transurethral resections two or more times before radical cystectomy. The median time to diagnosis of an upper urinary tract cancer after radical cystectomy was 29.5 months. When upper urinary tract recurrence was detected, five patients had metastatic diseases simultaneously, and two had bilateral upper urinary tract cancers. The cancer-specific survival in patients with upper urinary tract recurrence was significantly poorer than that in those without upper urinary tract recurrence. In addition, eight of the 12 patients (66.7%) died of disease progression within 3 years after the diagnosis of upper urinary tract cancer. CONCLUSIONS: These findings suggest that despite the low incidence of upper urinary tract recurrence following radical cystectomy, the prognosis of such patients was markedly poorer compared with that of those without upper urinary tract recurrence. Accordingly, intensive therapies should be considered when upper urinary tract recurrence is detected after radical cystectomy.     

Minimal incisions for laparoscopic radical cystectomy with extracorporeal-assisted urinary diversion

ObjectiveLaparoscopic radical cystectomy (LRC) had been used for >10 years. However, longer wound incisions for extracorporeal-assisted urinary diversion decrease the benefits of a laparoscopic approach. In this study, we describe our experience of modified LRC with extracorporeal-assisted urinary diversion using minimal wound incisions.Materials and methodsFrom January 2011 to January 2013, 22 consecutive patients underwent radical cystectomy by a single surgeon. Seven patients underwent open radical cystectomy (ORC), and 15 patients underwent LRC with four-port incisions.ResultsThe LRC group had a significantly lower estimated blood loss (p = 0.005), lower blood transfusion rate (p = 0.004), and lower ileus rate (p = 0.031) than the ORC group. No significant differences were noted in operative time, time to flatus, pain score, overall complication rate, pathological stage, positive surgical margin rate, or lymph node yield (27.6 for LRC and 29.1 for ORC). The 1-year disease free survival rate was 86.7% in the LRC group and 71.4% in the ORC group, and the 1-year overall survival rates were both 100%.ConclusionOur experience shows that LRC with extracorporeal-assisted urinary diversion using minimal incisions is a safe and feasible surgical technique with less blood loss. Further reports with a longer follow-up period and large number of cases are necessary to validate our findings.     

膀胱癌合并上尿路积水患者行根治术的预后分析

目的 探讨术前合并上尿路积水对根治性膀胱切除患者预后的影响.方法 回顾性分析从2003年1月至2010年5月期间126例行根治性膀胱切除术患者的资料,上尿路积水39例(31.0%),单因素分析上尿路积水对膀胱癌患者术后无复发生存率的影响,多因素分析上尿路积水、病理T分期和盆腔淋巴结转移情况等因素对膀胱癌根治术患者术后预...     

Older patients suffer from adverse histopathological features after radical cystectomy

Objectives: Radical cystectomy (RC) remains a complex procedure in older patients. Perioperative morbidity can be significant and it can represent a limitation for its indication in this population. The aim of the present study was to evaluate the outcomes of RC in elderly patients from a large single‐center cohort. Methods: A total of 447 patients who underwent RC between 1996 and 2009 at our institution were considered. Patients were stratified by age (≤70 vs >70 years). Logistic regression analyses were carried out comparing both groups regarding clinical, perioperative and histopathological findings, as well as complications according to the modified Clavien system and survival. Results: Data of 390 patients were available for the analysis. Of these, 265 (67.9%) versus 125 (32.1%) patients were <70 versus ≥70 years‐of‐age. The median age was 61 and 75 years, respectively. In the elderly, ASA score (P < 0.001), delay between transurethral resection of the bladder (TURBT) and RC (P = 0.004), and number of perioperative blood transfusions (P = 0.002) were significantly higher. Additionally, a clear trend towards higher stages (pT3–4) was observed (P = 0.04). However, complications, and overall and cancer‐specific mortality were not increased in older patients. Finally, age was identified as a significant risk factor for upstaging (P = 0.04). Upstaging between TURBT and final histopathology in patients <70 versus ≥70 years occurred in 45% versus 58%, respectively (P = 0.03). Conclusions: RC is equally feasible in older patients without increasing morbidity or mortality. On the contrary, older patients have a higher risk of significant upstaging and advanced stages at final histopathology. These findings suggest that RC should neither be delayed in nor withheld from elderly patients.     

Early oncological outcomes for bladder urothelial carcinoma patients treated with robotic-assisted radical cystectomy

Study Type – Therapy (case series) Level of Evidence 4

OBJECTIVE

• ? To determine oncological outcomes including early survival rates among unselected bladder urothelial carcinoma (BUC) patients treated with robotic‐assisted radical cystectomy (RRC).

PATIENTS AND METHODS

• ? Clinicopathologic and survival data were prospectively gathered for 85 consecutive BUC patients treated with RRC.
• ? The decision to undergo a robotic rather than open approach was made without regard to tumor volume or surgical candidacy.
• ? Kaplan–Meier survival rates were determined and stratified by tumor stage and LN positivity, and multivariate analysis was performed to identify independent predictors of survival.

RESULTS

• ? Patients were relatively old (25% >80 years; median 73.5 years), with frequent comorbidities (46% with ASA class ≥3). Of these patients 28% had undergone previous pelvic radiation or pelvic surgery, and 20% had received neoadjuvant chemotherapy.
• ? Extended pelvic lymphadenectomy was performed in 98% of patients, with on average 19.1 LN retrieved.
• ? On final pathology, extravesical disease was common (36.5%).
• ? Positive surgicalmargins were detected in five (6%) patients, all of whom had extravesical tumors with perineural and/or lymphovascular invasion, and most of whom were >80 years old.
• ? At a mean postoperative interval of 18 months, 20 (24%) patients had developed recurrent disease, but only three (4%) patients had recurrence locally. Disease‐free, cancer‐specific and overall survival rates at 2 years were 74%, 85% and 79%, respectively. Patients with low‐stage/LN(?) cancers had significantly better survival than extravesical/LN(?) or any‐stage/LN(+) patients, with stage being the most important predictor on multivariate analysis.

CONCLUSION

• ? RRC can achieve adequately high LN yields with a low positive margin rate among unselected BUC patients.
• ? Early survival outcomes are similar to those reported in contemporary open series, with an encouragingly low incidence of local recurrence, however long‐term follow‐up and head‐to‐head comparison with the open approach are still needed.

     

Evaluating the utility of a preoperative nomogram for predicting 90-day mortality following radical cystectomy for bladder cancer

Study Type – Prognosis (individual cohort) Level of Evidence 2b What's known on the subject? and What does the study add? We know that patient fitness for surgery is a major predictor of morbidity and mortality after surgery. We found the published nomogram did not incorporate several known clinical risk factors and its predictive value was only slightly better than using the patient's age and Charlson score to predict perioperative morality. This limitation may be related to the lack of availability of these factors in national databases for inclusion when creating a nomogram. In addition, there are elements that factor into postoperative patient care that are not easily measured, such as hospital‐stay pathways, ancillary staff expertise, supportive medical care, and surgeon ability.

OBJECTIVE

• ? To evaluate the performance of the Isbarn nomogram for predicting 90‐day mortality following radical cystectomy in a contemporary series.

PATIENTS AND METHODS

• ? We identified 1141 consecutive radical cystectomy patients treated at our institution between 1995 and 2005 with at least 90 days of follow‐up.
• ? We applied the published nomogram to our cohort, determining its discrimination, with the area under the receiver operating characteristic curve (AUC), and calibration.
• ? We further compared it with a simple model using age and the Charlson comorbidity score.

RESULTS

• ? Our cohort was similar to that used to develop the Isbarn nomogram in terms of age, gender, grade and histology; however, we observed a higher organ‐confined (≤pT2, N0) rate (52% vs 24%) and a lower overall 90‐day mortality rate [2.8% (95% confidence interval 1.9%, 3.9%) vs 3.9%].
• ? The Isbarn nomogram predicted individual 90‐day mortality in our cohort with moderate discrimination [AUC 73.8% (95% confidence interval 64.4%, 83.2%)].
• ? In comparison, a model using age and Charlson score alone had a bootstrap‐corrected AUC of 70.2% (95% confidence interval 67.2%, 75.4%).

CONCLUSIONS

• ? The Isbarn nomogram showed moderate discrimination in our cohort; however, the exclusion of important preoperative comorbidity variables and the use of postoperative pathological stage limit its utility in the preoperative setting.
• ? The use of a simple model combining age and Charlson score yielded similar discriminatory ability and underscores the significance of individual patient variables in predicting outcomes.
• ? An accurate tool for predicting postoperative morbidity/mortality following radical cystectomy would be valuable for treatment planning and counselling. Future nomogram design should be based on preoperative variables including individual risk factors, such as comorbidities.

     

Upper urinary tract recurrence after radical cystectomy for bladder cancer: incidence and risk factors

Objectives: To examine the incidence of and the risk factors for upper urinary tract recurrence in patients undergoing a radical cystectomy for bladder cancer, and to examine the clinical course of patients harboring upper urinary tract recurrence. Methods: This retrospective study included 362 patients who underwent radical cystectomy for bladder cancer. Patients with a history of upper urinary tract recurrence and concomitant upper urinary tract recurrence at cystectomy were excluded. Results: After a median follow up of 48 months (range 0–214) after radical cystectomy, 11 patients (3.0%) developed upper urinary tract recurrence. The median time to upper urinary tract recurrence was 48.4 months (range 11.6–78.6). The overall probability of upper urinary tract recurrence was 3.3% at 5 years. The median overall survival period after upper urinary tract recurrence was 23.5 months (range 4.3–53.9), with a better overall survival for patients who received a radical operation than for those who did not (38.6 months vs 11.9 months, respectively; P = 0.03). At multivariable analysis, the presence of carcinoma in situ (P < 0.01) and invasion of the urethra (P = 0.02) were independent risk factors for upper urinary tract recurrence. The 5‐year upper urinary tract recurrence was significantly higher for patients positive for either of these risk factors than for those without risk factors (12.0% vs 0.9%, respectively; P < 0.001). Conclusions: This study shows that the presence of carcinoma in situ and cancer invading the urethra are risk factors for upper urinary tract recurrence. Close follow up is needed for early detection of upper urinary tract recurrence in patients at higher risk.     

高危非肌层浸润性膀胱癌患者早期与延迟行膀胱全切术的疗效比较

目的:通过高危非肌层浸润性膀胱癌患者早期与延迟行膀胱全切术的疗效比较,探讨高危非肌层浸润性膀胱癌患者的适用治疗方法。方法:回顾性分析2000年1月~2008年12月我院收治的70例非肌层浸润性膀胱癌患者的临床资料:均首次行TURBT联合卡介苗(BCG)治疗,术后均复发,再行膀胱全切术。根据肿瘤复发情况及再手术时间,分为早期膀胱全切组28例,延迟膀胱全切组42例。结果:早期膀胱全切组中,5例死亡,其中3例死亡原因与肿瘤相关,2例死于心脑血管等其他疾病;延迟膀胱全切组中,9例死亡,其中5例死亡原因与肿瘤相关,1例死于意外伤,3例死于心脑血管等其他疾病。早期全切组5年总体生存率为82.1%,延迟全切组为79.6%,两组差异无统计学意义(P=0.803)。早期全切组5年肿瘤特异性生存率为90.9%,延迟全切组为75.0%,两组差异无统计学意义(P=0.125)。延迟全切组较早期全切组患者生活质量满意程度高,其中生理得分延迟与早期全切组分别为87.94分和58.95分,心理得分延迟与早期全切组分别为93.08分和70.12分,社会关系得分延迟与早期全切组分别为85.82分和60.67分。以上各项得分差异均有统计学意义(P0.05)。环境因素得分延迟与早期全切组分别为83.51分和91.18分,差异无统计学意义(P0.05)。结论:对高危非肌层浸润性膀胱癌患者尽可能行TURBT联合BCG灌注治疗,确保患者的生活质量,直到肿瘤出现进展或浸润时再行膀胱全切术。