Early oncologic outcomes of robotic vs. open radical cystectomy for urothelial cancer

ObjectivesOncologic outcomes of robotic cystectomy have focused on pathology and not on survival endpoints. We compared pathology, recurrence, and survival in a single surgeon series of open and robotic cystectomy since the introduction of robotic cystectomy.MethodsWe identified all patients treated by a single surgeon with radical cystectomy for urothelial cancer from June 2007 to June 2010. Clinical, demographic, and pathologic data was abstracted from chart review. Mortality was obtained from institutional cancer registry and chart review. Patients were excluded from analysis for a relative contraindication to robotic surgery. The remaining cohort of patients undergoing robotic (n = 36) vs. open (n = 29) cystectomy with median follow-up 12.2 months were evaluated.ResultsThe robotic cohort was more likely to be older and male (P < 0.05). Obesity, comorbidity, preoperative pathology, and receipt of neoadjuvant chemotherapy were not different between groups. Three patients had conversion from robotic to open cystectomy because of difficult dissection. Mean surgical time was longer in robotic cystectomy (410 vs. 345 minutes, P < 0.01). Cystectomy pathology was not different for robotic vs. open surgery for stage, margin status, or mean node count (robotic: 17.0, open: 15.5). On survival analysis robotic and open cystectomy outcomes were similar with respect to recurrence-free, disease-specific, and overall survival (all log-rank P values > 0.05). The Kaplan-Meier estimate for 2-year outcome for recurrence-free, disease-specific, and overall survival was 67% (95% CI: 41–83), 75% (95% CI: 53–88), 68% (95% CI: 47–82) for robotic cystectomy and 58% (95% CI: 29–79), 63% (95% CI: 34–82), 63% (95% CI: 34–82) for open cystectomy.ConclusionsShort-term oncologic outcomes were similar for open and robotic cystectomy. Increased sample size and further follow-up are necessary before claiming equivalent long-term survival.     

Radical cystectomy for recurrent urothelial carcinoma after prior partial cystectomy: perioperative and oncologic outcomes

Purpose

To evaluate perioperative and oncologic outcomes of patients undergoing radical cystectomy (RC) for recurrence of urothelial carcinoma (UC) after prior partial cystectomy (PC), and to compare these outcomes to patients undergoing primary RC.

Methods

Patients who underwent RC for recurrence of UC after prior PC were matched 1:3 to patients undergoing primary RC based on age, pathologic stage, and decade of surgery. Perioperative and oncologic outcomes were compared using Wilcoxon sign-rank test, McNemars test, the Kaplan–Meier method, and Cox proportional hazards regression analyses.

Results

Overall, the cohorts were well matched on clinical and pathological characteristics. No difference was noted in operative time (median 322 versus 303 min; p = 0.41), estimated blood loss (median 800 versus 700 cc, p = 0.10) or length of stay (median 9 versus 10 days; p = 0.09). Similarly, there were no differences in minor (51.7 versus 44.3%; p = 0.32) or major (10.3 versus 12.6%; p = 0.66) perioperative complications. Median follow-up after RC was 5.0 years (IQR 1.5, 13.1 years). Notably, CSS was significantly worse for patients who underwent RC after PC (10 year—46.8 versus 65.9%; p = 0.03). On multivariable analysis, prior PC remained independently associated with an increased risk of bladder cancer death (HR 2.28; 95% CI 1.17, 4.42).

Conclusions

RC after PC is feasible, without significantly adverse perioperative outcomes compared to patients undergoing primary RC. However, the risk of death from bladder cancer may be higher, suggesting the need for careful patient counseling prior to PC and the consideration of such patients for adjuvant therapy after RC.

     

Influence of previous or synchronous bladder cancer on oncologic outcomes after radical nephroureterectomy for upper urinary tract urothelial carcinoma

ObjectiveThe objective of the study was to evaluate the effect of a history of bladder cancer (BC) or synchronous BC on the prognosis and survival of patients who have undergone radical nephroureterectomy (RNU).Methods and materialsUsing a multi-institutional, retrospective database, we identified 662 patients with upper urinary tract urothelial carcinoma (UUT-UC) treated by radical nephroureterectomy, between 1995 and 2010. We analyzed clinicopathologic characteristics and outcomes according to the history of BC or concomitant BC or both, at the time of diagnosis. BC was evaluated as a prognostic factor for bladder recurrence and survival.ResultsOverall, 83 (12.5%) patients had previous BC, 62 (9.4%) exhibited concomitant BC, and 75 (11.3%) presented with both previous and current BC. A history of BC was less seen in women and nonsmokers (P<0.0001 and P = 0.013, respectively). The patients with associated BC had more tumors located in the ureter (P<0.0001), as well as more multiple locations in the upper tract (P<0.0001). The tumors without concomitant BC were more likely to be associated with locally advanced stages (P = 0.024). At a median follow-up time of 37.3 months, 31.4% of patients experienced BC recurrence and 2.9% developed contralateral upper tract tumor. Using multivariate analyses, the previous or synchronous BC (P = 0.01) and positive surgical margins (P = 0.03) are independent prognostic factors for BC recurrence. The metastasis-free survival and cancer-specific survival rates did not significantly differ according to the associated BC status.ConclusionsIn patients without previous or concomitant BC, the upper tract tumors are more frequently localized in the renal pelvis and are associated with a more invasive status at the time of diagnosis. Nevertheless, the presence of UUT-UC without previous or synchronous BC did not significantly affect the survival rates after nephroureterectomy.     

Chronic kidney disease and radical cystectomy for bladder cancer: perioperative and oncologic outcomes in 1,214 patients

Introduction and ObjectiveTo assess the impact of chronic kidney disease (CKD) on outcomes after radical cystectomy (RC) in patients with bladder cancer treated within a high-volume tertiary referral center.MethodsWe identified 1,214 patients who underwent RC with intent to cure from 2009 to 2019. The Modification of Diet in Renal Disease (MDRD) GFR (ml/min/1.73 m²) was calculated and patients were categorized by baseline GFR: Group A = GFR > 60, Group B = GFR > 30–59 and Group C = GFR < 30. Pre-, intra- and postoperative characteristics, oncological outcomes, and 90-day perioperative outcomes were compared. Multivariable logistic regression was used to control for confounding variables.ResultsWe identified 722 (59.5%) patients in Group A, 448 (36.9%) in Group B, and 44 (3.6%) in Group C. Patients with worse CKD were older and had significantly worse overall comorbidity (all P < 0.001). Neoadjuvant chemotherapy was used in 352 patients (29%), including 182 (25.2%) in Group A, 153 in Group B (35.3%), and 12 in Group C (27.3%). On univariate analysis, worse CKD was associated with higher pathologic stage, lymph node metastases and positive soft tissue margins (all P < 0.0001). The rates of blood transfusion, 90-day complications and readmissions were higher in patients with worse CKD (P < 0.0001, P = 0.02, P = 0.04, respectively). Patients with worse CKD had worse overall survival (77% vs. 73% vs. 55%, P < 0.0001). On multivariable analysis, worse CKD was independently associated with adverse pathology (≥pT3 or node positive) (OR = 6.96, 95%CI 3.20–15.12), 90-day readmissions (OR 2.09, 95%CI 1.11–3.94) and perioperative transfusion (OR 2.08, 95%CI 1.05–4.11). Receipt of neoadjuvant chemotherapy was significantly associated with a decreased risk of adverse pathology (OR 0.51, 95%CI 0.36–0.74) and increased risk of transfusion (OR 2.24, 95%CI 1.70–2.96), but not with mortality, complications, readmissions or length or stay.ConclusionCKD is prevalent in patients undergoing radical cystectomy. We found CKD to be independently associated with a higher likelihood of adverse pathology, 90-day readmissions, and transfusion.     

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.

     

Predicting survival after radical cystectomy for bladder cancer

Accurate prediction is essential for patient counselling, appropriate selection of treatments and determination of eligibility for clinical trials. In this review we assess the available determinants of oncological outcome after radical cystectomy (RC) for transitional cell carcinoma of the urinary bladder. We reviewed previous publications to provide guidelines in terms of criteria, limitations and clinical value of available tools for predicting patient outcome after RC. Our findings suggest that while individual surgical, patient and pathological features provide useful estimates of survival outcome, the inherent heterogeneity of tumour biology and patient characteristics leads to significant variation in outcome. By incorporating all relevant continuous predictive factors for individual patients, integrative predictive models, such as nomograms or artificial neural networks, provide more accurate predictions and generally surpass clinical experts at predicting outcomes. Nonetheless, there is a clear need for the development and validation of molecular biomarkers and their incorporation into multivariable predictive tools. Significant progress has been made in identifying important molecular markers of disease and the development of multifactorial tools for predicting the outcome after RC.     

Improving outcomes with radical cystectomy for high-grade invasive bladder cancer

It is clear that the optimal clinical outcomes in bladder cancer patients requiring radical cystectomy are related to standard histopathologic variables of tumor grade, stage and lymph node status. However, other less well defined variables are also critical to the successful outcomes of these patients. Patients with muscle invasive bladder cancer and treating physicians should avoid unnecessary and significant treatment delays. In addition, hospital and surgeon-volume/experience are thought to be factors that may too be important components that relate to the clinical outcomes of patients following surgery. Lastly, there is a growing body of literature to support the concept of an appropriate lymphadenectomy at the time of surgery, for both node-positive and node-negative bladder cancer patients. It is becoming more obvious that there are multiple variables involved in the clinical success and outcomes of patients with bladder cancer following radical cystectomy. As treating physicians and surgeons we must be aware of these components to ensure the best outcomes for our patients.     

Impact of preoperative systemic immune-inflammation Index on oncologic outcomes in bladder cancer patients treated with radical cystectomy

PurposeTo investigate the predictive and prognostic value of the preoperative systemic immune-inflammation index (SII) in patients undergoing radical cystectomy (RC) for clinically non-metastatic urothelial cancer of the bladder (UCB).MethodsOverall, 4,335 patients were included, and the cohort was stratified in two groups according to SII using an optimal cut-off determined by the Youden index. Uni- and multivariable logistic and Cox regression analyses were performed, and the discriminatory ability by adding SII to a reference model based on available clinicopathologic variables was assessed by area under receiver operating characteristics curves (AUC) and concordance-indices. The additional clinical net-benefit was assessed using decision curve analysis (DCA).ResultsHigh SII was observed in 1879 (43%) patients. On multivariable preoperative logistic regression, high SII was associated with lymph node involvement (LNI; P = 0.004), pT3/4 disease (P <0.001), and non-organ confined disease (NOCD; P <0.001) with improvement of AUCs for predicting LNI (P = 0.01) and pT3/4 disease (P = 0.01). On multivariable Cox regression including preoperative available clinicopathologic values, high SII was associated with recurrence-free survival (P = 0.028), cancer-specific survival (P = 0.005), and overall survival (P = 0.006), without improvement of concordance-indices. On DCAs, the inclusion of SII did not meaningfully improve the net-benefit for clinical decision-making in all models.ConclusionHigh preoperative SII is independently associated with pathologic features of aggressive disease and worse survival outcomes. However, it did not improve the discriminatory margin of a prediction model beyond established clinicopathologic features and failed to add clinical benefit for decision making. The implementation of SII as a part of a panel of biomarkers in future studies might improve decision-making.     

Urethrogluteal fistula occurring after radical cystectomy for bladder cancer

We report on a patient who developed a urethrogluteal fistula 11 years following cystectomy performed for carcinoma of the bladder. The diagnosis was established by retrograde urethrography and fistulography. To the best of our knowledge, no previous case has been reported in the literature.     

Metastasis-directed radiation therapy after radical cystectomy for bladder cancer

PurposeMetastasis-directed radiation therapy (MDRT) may improve oncologic and quality of life outcomes in patients with metastatic cancer, but data on its use in metastatic bladder cancer is severely limited. We sought to review our institutional experience with MDRT in patients with metastatic bladder cancer following radical cystectomy.Materials and MethodsWe reviewed records of patients who underwent radical cystectomy and subsequent MDRT at our institution between 2009 and 2020. Baseline demographic and clinical/pathologic factors were collected, as were details of treatment including systemic therapy and MDRT. Cases were categorized by treatment intent as consolidative (intended to prolong survival) and palliative (intended only to relieve symptoms). Response to treatment, survival, and toxicity outcomes were reviewed.ResultsA total of 52 patients underwent MDRT following radical cystectomy. MDRT was categorized as consolidative in 40% of cases and palliative in 60%. Toxicity (CTCAE Grade ≥ 2) was reported in 15% of patients, none of which exceeded Grade 3. Most patients undergoing consolidative MDRT were treated with SBRT techniques (76%) and a majority (67%) received concurrent treatment with an immuno-oncology agent. Among patients treated with consolidative intent, 2-year progression-free and overall survival were 19% and 60%, respectively.ConclusionMDRT is safe and well-tolerated by a majority of patients. A majority of patients treated with consolidative intent survived ≥ 2 years from treatment.     

Upper urinary tract transitional cell cancer after radical cystectomy for bladder cancer

We studied 425 patients who had undergone radical cystectomy for transitional cell cancer of the bladder and were followed for 5 years or more, or until death. Upper urinary tract urothelial cancer developed in 14 patients (3.3 per cent), 3 of whom had bilateral disease: 2 synchronous and 1 asynchronous. The interval between cystectomy and emergence of the upper tract tumor ranged from 8 to 100 months (mean 40 months). There was a declining incidence of upper tract cancer relative to cystectomy P stage for carcinoma in situ (9.1 per cent), papillary stages O and A (3.6 per cent), stages B1, C and D1 (2.6 per cent) and no residual cancer (0 per cent). Of the 14 patients 8 (57 per cent) had features of multifocal carcinoma in situ in the cystectomy specimens. In 4 of the 14 patients (29 per cent) ipsilateral disease developed when the distal ureteral margins were involved with cancer at cystectomy. Only 3 of the 14 patients (21.4 per cent), all with stage I disease, were alive at the time of this report.     

Development of a nomogram to predict non-organ-confined bladder urothelial cancer before radical cystectomy

Purpose

To create a preoperative prediction model for estimating the risk of non-organ-confined (pT3-4 or pN+) bladder urothelial cancer (NOC?CBUC) in patients with clinically OC?CBUC (cT1-2N0M0).

Methods

The study involved 248 consecutive patients who had undergone radical surgery for clinically OC?CBUC at a tertiary cancer center between 2003 and 2011. Logistic regression analysis was used to develop a prediction model for estimating the risk of pathological NOC disease. Prespecified predictors included age, gender, recurrent frequency, tumor size and number, hydronephrosis, and pathological characteristics at transurethral resection (T-stage, tumor grade, lymphovascular invasion (LVI), and carcinoma in situ). Discrimination ability was measured by the area under the receiver operating characteristic curve (AUC).

Results

Overall, 39.1?% of the patients with clinically OC?CBUC had NOC disease at the time of radical surgery. In multivariate analysis, recurrent frequency, tumor size, hydronephrosis, and three pathological features at transurethral resection (T-stage, tumor grade, and LVI) were significantly associated with disease extent. The final prediction model included seven variables after backward elimination and achieved a bootstrap-corrected AUC of 0.79. Internal validation showed good calibration and clinical usefulness of the nomogram.

Conclusions

Based on readily available clinicopathological parameters, we developed a nomogram for predicting NOC tumor in clinically OC?CBUC. Despite reasonable performance in internal validation, the prediction model should be assessed in external dataset before applied in clinical setting.