Reduced bladder tumour recurrence rate associated with narrow‐band imaging surveillance cystoscopy

Study Type – Diagnostic (exploratory cohort)
Level of Evidence 2b What’s known on the subject? and What does the study add? Narrow‐band imaging cystoscopy is a new imaging modality developed to enhance conventional standard white‐light cystoscopy to evaluate bladder tumors. The current paper suggests that fulguration of low‐risk papillary bladder tumours using NBI cystoscopy results in fewer subsequent tumour recurrences than fulguration using standard cystoscopy. How, or if, NBI cystoscopy will become integrated into routine management of non‐invasive bladder tumours remains for further study.

OBJECTIVE

To evaluate frequency of recurrences among patients with papillary bladder tumours followed sequentially with conventional white‐light (WLI) cystoscopy and narrow‐band imaging (NBI) cystoscopy.

PATIENTS AND METHODS

A cohort of 126 patients with recurrent low‐grade papillary bladder tumours were followed every 6 months for 3 years by conventional WLI cystoscopy, and then over the next 3 consecutive years by NBI cystoscopy. Recurrent tumours detected were treated by outpatient fulguration or transurethral resection. We compared the tumour recurrence rate during follow‐up with WLI and NBI cystoscopy, using patients as their own controls.

RESULTS

Of the 126 patients, 94% had tumour recurrences during WLI cystoscopy vs 62% during NBI cystoscopy. The mean number of recurrent tumours was 5.2 with WLI cystoscopy vs 2.8 with NBI cystoscopy, and the median recurrence‐free survival time was 13 vs 29 months (P= 0.001).

CONCLUSION

Compared with follow‐up with WLI cystoscopy, NBI cystoscopy was associated with fewer patients having tumour recurrences, fewer numbers of recurrent tumours, and a longer recurrence‐free survival time.     

A comparison of white-light cystoscopy and narrow-band imaging cystoscopy to detect bladder tumour recurrences

OBJECTIVE

To determine whether narrow‐band imaging (NBI) cystoscopy enhances the detection of non‐muscle‐invasive bladder tumours over standard white‐light imaging (WLI) cystoscopy, as surveillance WLI is the standard method used to diagnose patients with recurrent bladder tumours, but they can be missed by WLI cystoscopy, possibly accounting for early recurrences.

PATIENTS AND METHODS

We evaluated 427 patients for recurrent bladder tumours by WLI cystoscopy, followed by NBI cystoscopy as a further procedure, using the same video‐cystoscope. Recurrent tumours visualized by WLI or NBI cystoscopy were mapped, imaged, biopsied and subsequently treated by transurethral resection (TUR) or fulguration. Biopsies or TUR specimens obtained by WLI and NBI were examined separately for presence of tumour.

RESULTS

In all, 103 patients (24%) had tumour recurrences; 90 (87%) were detected by both WLI and NBI and another 13 (100%) only by NBI cystoscopy. NBI detected extra papillary tumours or more extensive carcinoma in situ in 58 (56%) patients found to have recurrences. The mean number of recurrent tumours visualized on WLI cystoscopy was 2.3, vs to 3.4 seen on NBI cystoscopy (P = 0.01).

CONCLUSION

NBI cystoscopy improved the detection of recurrent non‐muscle‐invasive bladder tumours over standard WLI cystoscopy.     

Transurethral resection of bladder tumour complicated by perforation requiring open surgical repair – clinical characteristics and oncological outcomes

Study Type – Therapy (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? Evidence suggests that open repair of a bladder perforation during TURBT may increase the risk of pelvic or distant disease recurrence. The study demonstrates that while bladder violation during TURBT may carry a potential for considerable morbidity, it does not seem to substantially increase the risk of extravesical tumour seeding and disease recurrence.

OBJECTIVE

? To examine the clinical characteristics and long‐term outcomes of patients with bladder perforation requiring open surgical repair as a complication of transurethral resection of bladder tumour (TURBT).

PATIENT AND METHODS

? A search of our institutional database yielded 4144 patients who underwent TURBT from 1996 to 2008, of whom 15 (0.36%) required open surgical intervention to repair a large bladder perforation. ? In all cases, a filling cystogram was performed before laparotomy. Clinical, pathological and follow‐up data were reviewed, and the incidence and time of extravesical tumour recurrence were recorded.

RESULTS

? Median patient age was 77 years. Intraperitoneal perforation was diagnosed in 12 patients, generally involving the posterior wall. Concomitant bowel injury was identified in two patients and managed by primary repair. Two patients in whom the diagnosis and intervention were delayed died within 1 week of surgery. ? Metastatic progression was observed in two patients shortly after the perforation (median interval, 4.8 months), and local pelvic recurrence was noted in one of them. ? None of the patients with stage Ta tumours had evidence of extravesical progression. Actuarial estimates of disease‐free survival at 1, 3 and 5 years after the perforation were 83%, 71% and 41%, respectively.

CONCLUSIONS

? A significant bladder perforation during TURBT requiring open surgical repair is more likely to occur in elderly patients with large posterior wall tumours and heavily pretreated bladders. ? Despite its potential for considerable morbidity, this adverse event does not seem to substantially increase the risk of extravesical tumour seeding. Prompt diagnosis, immediate intervention and meticulous bladder and bowel inspection during laparotomy are imperative.     

Narrow‐band imaging cystoscopy to evaluate the response to bacille Calmette‐Guérin therapy: preliminary results

Study Type – Diagnostic (exploratory cohort)
Level of Evidence 2b

OBJECTIVE

To evaluate whether narrow‐band imaging cystoscopy (NBIC) can identify bladder tumour suspected on follow‐up white‐light cystoscopy (WLC) after intravesical bacille Calmette‐Guérin (BCG) therapy, as BCG causes an intense reaction in the bladder, appearing as red lesions on WLC, which might be residual tumour or BCG‐induced inflammation.

PATIENTS AND METHODS

Sixty‐one patients with high‐risk non‐muscle‐invasive bladder tumours were evaluated 3 months after starting induction BCG therapy. All patients had abnormal erythematous lesions on WLC, suspected to be residual carcinoma in situ. After WLC, they were evaluated by NBIC, urine cytology and biopsy, followed by transurethral resection of all visible lesions.

RESULTS

Of the 61 patients, 22 (36%) had residual tumour. NBIC correctly identified tumour in 21 patients, but another 10 had unnecessary biopsy (NBIC positive, negative biopsy). Only one of 30 patients who had negative NBIC findings had tumour. NBIC outperformed urine cytology in detecting residual tumour after BCG therapy.

CONCLUSION

NBIC appears to better identify patients who have suspected residual tumour on follow‐up WLC at 3 months after BCG therapy.     

Narrow‐band imaging cystoscopy to evaluate bladder tumours – individual surgeon variability

Study Type – Diagnosis (exploratory cohort)
Level of Evidence 2b

OBJECTIVE

To assess individual urologist variability using narrow‐band imaging (NBI) cystoscopy to evaluate bladder tumours.

PATIENTS AND METHODS

In all, 50 patients underwent white‐light and NBI cystoscopy to evaluate for recurrent bladder tumours. Endoscopic images in each patient were independently viewed by four urologists assessing presence or absence of tumour. Their findings were correlated with biopsy results.

RESULTS

In all, 26 patients had recurrent tumour and 24 had benign histology. There were no significant differences among urologists detecting recurrent tumour or in determining final pathology.

CONCLUSIONS

There does not appear to be a ‘learning curve’ for adapting to NBI‐surveillance cystoscopy in patients with bladder cancer.     

Transurethral endoscopic treatment of patients with upper tract urothelial carcinomas using neodymium‐YAG and/or holmium‐YAG laser ablation

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

OBJECTIVE

To report our experience of treating patients with original and recurrent upper tract urothelial carcinomas (UC) using endoscopic lasers, with holmium‐YAG and/or neodymium‐YAG laser ablation, and for whom tumour stage and grade were obtained by endoscopic biopsy.

PATIENTS AND METHODS

From March 2003 to March 2007, 15 patients with upper tract UC were treated with endoscopic laser ablation as the primary management. Patients were followed up by intravenous urography, computed tomography, urine cytology and/or ureteroscopic surveillance at 3‐ to 12‐month intervals. The median (range) follow‐up was 25.5 (13–51) months.

RESULTS

Of the 15 patients, five had an upper tract recurrence during the follow‐up. Three of these were treated with total nephroureterectomy and two had a progression in tumour stage or grade. Three patients had residual tumours; they were treated with repeated endoscopic laser treatments and had no recurrence over a median (range) of 24 (13–26) months. The renal preservation rate was 12/15 and the local recurrence rate was six/15 after the initial endoscopy. The median operative duration and tumour size were 60 min and 10 mm, respectively.

CONCLUSION

Patients with low‐grade and ‐stage disease and normal contralateral kidneys also benefit from this approach, if there is an adequate endoscopic biopsy. As the operative duration tended to be associated with the maximum tumour size, this treatment is potentially available for a maximum tumour size of <4 cm; if the tumour is <4 cm surgery will require <120 min.     

The results of concurrent chemo‐radiotherapy for recurrence after treatment with bacillus Calmette‐Guérin for non‐muscle‐invasive bladder cancer: is immediate cystectomy always necessary?

OBJECTIVES

To report our original experience in patients in whom bacille Calmette‐Guérin (BCG) therapy has failed for T1 bladder cancer with subsequent progression to T2 disease treated with chemo‐radiotherapy, as the management of recurrent high‐grade T1 bladder cancer after failed BCG therapy is challenging, and radical cystectomy is the standard treatment because there are no well established second‐line bladder‐preserving therapies.

PATIENTS AND METHODS

From 1988 to 2002, 18 patients with T2 recurrence after failure of BCG therapy for T1 bladder cancer were treated with chemo‐radiotherapy at the authors’ institution. Patients received a visibly complete transurethral resection of the bladder tumour (TURBT) and concurrent chemo‐radiotherapy with a mid‐treatment evaluation after 40 Gy. Patients with less than a complete response had a prompt cystectomy; the others completed radiotherapy to 64–65 Gy. The primary treatment outcome was freedom from cystectomy due to recurrence not treatable by conservative measures; secondary outcomes included disease‐specific (DSS) and overall survival (OS).

RESULTS

With a median follow‐up of 7.0 years, only one patient had persistent tumour at re‐staging TURBT and had an immediate cystectomy. Of the remaining 17 patients, 10 (59%) were free of any bladder recurrence. The actuarial 7‐year DSS and OS were 70% and 58%, respectively. At 7 years, 54% of patients were alive with intact bladders and free of invasive recurrence.

CONCLUSIONS

In this study we specifically evaluated patients with apparently small muscle‐invasive recurrences after BCG treatment for T1 bladder cancer. Selective bladder preservation with chemo‐radiotherapy is possible, with low morbidity and a high chance of long‐term bladder control. If successful in treating T2 recurrences after BCG therapy, it now seems timely to critically evaluate chemo‐radiotherapy as an alternative to immediate cystectomy in the management of patients with T1 recurrences after BCG.     

Clinical and Cost Effectiveness of Hexaminolevulinate-guided Blue-light Cystoscopy: Evidence Review and Updated Expert Recommendations

Context

Non–muscle-invasive bladder cancer (NMIBC) is associated with a high recurrence risk, partly because of the persistence of lesions following transurethral resection of bladder tumour (TURBT) due to the presence of multiple lesions and the difficulty in identifying the exact extent and location of tumours using standard white-light cystoscopy (WLC). Hexaminolevulinate (HAL) is an optical-imaging agent used with blue-light cystoscopy (BLC) in NMIBC diagnosis. Increasing evidence from long-term follow-up confirms the benefits of BLC over WLC in terms of increased detection and reduced recurrence rates.

Objective

To provide updated expert guidance on the optimal use of HAL-guided cystoscopy in clinical practice to improve management of patients with NMIBC, based on a review of the most recent data on clinical and cost effectiveness and expert input.

Evidence acquisition

PubMed and conference searches, supplemented by personal experience.

Evidence synthesis

Based on published data, it is recommended that BLC be used for all patients at initial TURBT to increase lesion detection and improve resection quality, thereby reducing recurrence and improving outcomes for patients. BLC is particularly useful in patients with abnormal urine cytology but no evidence of lesions on WLC, as it can detect carcinoma in situ that is difficult to visualise on WLC. In addition, personal experience of the authors indicates that HAL-guided BLC can be used as part of routine inpatient cystoscopic assessment following initial TURBT to confirm the efficacy of treatment and to identify any previously missed or recurrent tumours. Health economic modelling indicates that the use of HAL to assist primary TURBT is no more expensive than WLC alone and will result in improved quality-adjusted life-years and reduced costs over time.

Conclusions

HAL-guided BLC is a clinically effective and cost-effective tool for improving NMIBC detection and management, thereby reducing the burden of disease for patients and the health care system.

Patient summary

Blue-light cystoscopy (BLC) helps the urologist identify bladder tumours that may be difficult to see using standard white-light cystoscopy (WLC). As a result, the amount of tumour that is surgically removed is increased, and the risk of tumour recurrence is reduced. Although use of BLC means that the initial operation costs more than it would if only WLC were used, over time the total costs of managing bladder cancer are reduced because patients do not need as many additional operations for recurrent tumours.     

Bladder preservation multimodality therapy as an alternative to radical cystectomy for treatment of muscle invasive bladder cancer

Study Type – Therapy (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? The subject of bladder preservation multimodality protocols in muscle invasive bladder TCC is not new. In our study, even in a highly selected group of patients, multimodality protocol with M‐VAC and radiation therapy achieved suboptimal results at 1 year. This emphasized the role of radical cystectomy as the gold standard treatment for invasive bladder TCC.

OBJECTIVE

• ? To evaluate the efficacy of a bladder preservation multimodality protocol for patients with operable carcinoma invading bladder muscle.

MATERIALS AND METHODS

• ? In this prospective study, we included 33 patients with transitional cell carcinoma (TCC) (T2 and T3, Nx, M0) who were amenable to complete transurethral resection.
• ? These patients refused radical cystectomy as their first treatment option. After maximum transurethral resection of bladder tumour (TURBT), all patients received three cycles of adjuvant chemotherapy in the form of methotrexate, vinblastin, adriamycin and cisplatin (MVAC) followed by radical radiotherapy.
• ? Four weeks later, all cases had radiological and cystoscopical re‐evaluation.
• ? Complete responders were considered to be those patients who had no evidence of residual tumour. All patients were subjected to a regular follow‐up by cystoscopy and tumour site biopsy conducted every 3 months. Abdomino‐pelvic computed tomography and chest X‐ray were conducted every 6 months.
• ? The study endpoint was the response to treatment after completion of the first year of follow‐up after therapy.

RESULTS

• ? Out of 33 eligible patients, a total of 28 patients completed the study treatment protocol. Their mean ± SD age was 56.7 ± 6 years. Trimodal therapy was well tolerated in most of cases, with no severe acute toxicities. After 12 months of follow‐up, a complete response was achieved in 39.3% and a partial response in 7.1%, with an overall response rate of 46.4%.
• ? By the end of the first year, disease‐free survival was reported in 39.3%, whereas 25% were still alive with their disease, giving an overall survival of 64.3% for all patients who maintained their intact, well functioning bladders.
• ? Tumour stage and completeness of transurethral resection of bladder tumour were the most important predictors of response and survival. T2 lesions had complete and partial response rates of 69.2% and 23%, respectively, whereas T3 lesions had rates of 40% and 13.3%, respectively (P= 0.001).
• ? The response rate in patients who had complete TURBT was 82.6% vs 20% in those with cystoscopic biopsy only (P= 0.001). In addition, disease‐free survival was 72.7% in T2 patients and 27.3% in T3 patients (P= 0.001).

CONCLUSION

• ? In the present study, bladder preservation protocol with MVAC and radical radiotherapy achieved suboptimal response rates at 1 year in patients with localized TCC invading bladder muscle. Patients with solitary T2 lesions that are amenable to complete TURBT achieved the best response rates. Longer follow‐up is needed to verify these results. Patients with localized disease should be encouraged for radical cystectomy, which achieved better results.

     

Maintenance therapy with bacillus Calmette-Guérin Connaught strain clearly prolongs recurrence-free survival following transurethral resection of bladder tumour for non-muscle-invasive bladder cancer

Study Type – Therapy (RCT) Level of Evidence 1b

OBJECTIVE

• ? To confirm the recurrence‐preventing efficacy and safety of 18‐month bacillus Calmette‐Guérin (BCG) maintenance therapy for non‐muscle‐invasive bladder cancer.

PATIENTS AND METHODS

• ? The enrolled patients had been diagnosed with recurrent or multiple non‐muscle‐invasive bladder cancer (stage Ta or T1) after complete transurethral resection of bladder tumours (TURBT).
• ? The patients were randomized into three treatment groups: a maintenance group (BCG, 81 mg, intravesically instilled once weekly for 6 weeks as induction therapy, followed by three once‐weekly instillations at 3, 6, 12 and 18 months after initiation of the induction therapy), a non‐maintenance group (BCG, 81 mg, intravesically instilled once weekly for 6 weeks) and an epirubicin group (epirubicin, 40 mg, intravesically instilled nine times). The primary endpoint was recurrence‐free survival (RFS).

RESULTS

• ? Efficacy analysis was performed for 115 of the full‐analysis‐set population of 116 eligible patients, including 41 maintenance group patients, 42 non‐maintenance group patients and 32 epirubicin group patients.
• ? At the 2‐year median point of the overall actual follow‐up period, the final cumulative RFS rates in the maintenance, non‐maintenance and epirubicin groups were 84.6%, 65.4% and 27.7%, respectively.
• ? The RFS following TURBT was significantly prolonged in the maintenance group compared with the non‐maintenance group (generalized Wilcoxon test, P= 0.0190).

CONCLUSION

• ? BCG maintenance therapy significantly prolonged the post‐TURBT RFS compared with BCG induction therapy alone or epirubicin intravesical therapy.

     

Bipolar energy for transurethral resection of bladder tumours at low-power settings: initial experience

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

OBJECTIVE

To evaluate the efficacy and safety of using bipolar energy at low‐power setting for transurethral resection (TUR) of bladder tumours.

MATERIALS AND METHODS

In total, 108 patients (100 males and eight females) with superficial bladder carcinoma undergoing bipolar TUR of bladder tumours (B‐TURBT) with the Gyrus^TM Plasma kinetic Tissue Management System (Gyrus Medical Ltd, Cardiff, UK) were studied. The initial ten patients were operated at a default setting of 160 W cutting and 80 W coagulation. Subsequently, the current settings were modified to 50 W cutting and 40 W coagulation. The present study reports on the 98 patients who underwent TURBT with low‐power settings. Tumour number, size, shape, location, operating time, hospital stay, blood loss, as well as intraoperative and postoperative complications, were all recorded .The resected tissues were examined by a pathologist who recorded grade, invasion of the muscularis propria and the presence of muscular invasion.

RESULTS

Out of the ten patients who were operated at the recommended default settings of 160 W cutting and 80 W coagulation, three patients had obturator jerks leading to two‐bladder perforation. The results of 98 patients operated on at the low‐power settings of 50 W cutting and 40 W coagulation are reported. Mean ± SD age was 56.34 ± 13.51 years. Tumours were multiple in 62 (63%) patients and single in 36 (37%) patients, with 68 (69%) in the lateral wall and six (6%) involving the ureteric orifice. Mean ± SD tumour size was 2.5 ± 0.81 cm with a mean ± SD resection time of 36.64 ± 16.5 min. The mean drop in haemoglobin was 0.94 ± 0.71 (0.20–4.0), with a mean ± SD (range) drop in haematocrit of 1.33 ± 1.29 (1–7). Five (5%) patients required blood transfusion as a result of preoperative low haemoglobin. Mean ± SD drop in sodium was 2.06 ± 0.66 mEq/L, with no patient developing TUR syndrome. None of the 98 patients developed obturator jerks and perforation at low‐power settings. Complete resection was achieved in 94 (96%) patients. Mean postoperative hospital stay was 3 days.

CONCLUSIONS

TURBT using bipolar energy is safe and effective in the treatment of bladder tumours at power settings lower than the conventionally recommended settings. Lower power settings reduce the number of obturator jerks and perforations.     

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.     

Does photodynamic transurethral resection of bladder tumour improve the outcome of initial T1 high‐grade bladder cancer? A long‐term follow‐up of a randomized study

OBJECTIVE

To evaluate, in a long‐term follow‐up of T1 high‐grade bladder cancer treated in a prospective, randomized trial, whether fluorescence diagnosis (FD) increases recurrence‐free survival (RFS) or reduces progression to muscle‐invasive stages.

PATIENTS AND METHODS

In all, 191 patients with suspected superficial bladder cancer were treated with transurethral resection under white light (WL) or with FD; 46 presented with initial T1 high‐grade BC (WL, 25; FD, 21). There were no differences in multifocality of tumours, concomitant carcinoma in situ or tumour size in either group.

RESULTS

Patients were followed for a median of 7.3 (WL) and 7.5 (FD) years to evaluate RFS. In the WL group there were 11, and in the FD group three, recurrent tumours of the same stage and grade. The RFS at 4 and 8 years was 69% and 52% in the WL, and 91% and 80% in FD group, respectively. With FD, the RFS was significantly longer according to Kaplan‐Meier analysis (P = 0.025). In the WL group, three (12%), and in the FD group four (19%) patients progressed to muscle‐invasive stages (≥ T2).

CONCLUSION

In initial T1 high‐grade bladder cancer, FD is significantly better than conventional WL transurethral resection for RFS. However, the progression rate to muscle‐invasive disease was not reduced by FD. Thus the clinical course (progression) of T1 high‐grade bladder cancer remains unaffected by FD.     

Longitudinal evaluation of the concordance and prognostic value of lymphovascular invasion in transurethral resection and radical cystectomy specimens

THIS IS A COMMENT MODERATED PAPER
available at http://www.bjui.org/commentary Study Type – Therapy (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? Lymphovascular invasion (LVI) is a prognostic marker for biologically aggressive disease in numerous tumour types. Indeed, numerous studies have documented the negative prognostic value of LVI in bladder cancer patients who have undergone radical cystectomy, however few studies have evaluated the prognostic value of LVI at TURBT. The current study examines both the concordance between the presence of LVI at TURBT and radical cystectomy specimens and furthermore examines the survival implications of the presence of LVI at both TURBT and radical cystectomy.

OBJECTIVE

To evaluate the concordance transurethral resection of bladder tumour (TURBT) and radical cystectomy (RC) specimens with regard to the presence of lymphovascular invasion (LVI). Additionally, to evaluate the prognostic value of LVI in the prediction of lymph node metastases, overall survival, disease‐specific survival and recurrence‐free survival following RC.

PATIENTS AND METHODS

The records of 487 patients who underwent RC at our institution between 1987 and 2008 were retrospectively reviewed and evaluated for the presence or absence of LVI as determined by pathological evaluation. The presence or absence of LVI was then evaluated on previous transrectal resection specimens of this cohort of patients undergoing RC. Cox regression and Kaplan–Meier analysis were undertaken to evaluate the contribution of LVI to various outcomes.

RESULTS

Of 474 patients with complete LVI data, 60 (12.3%) were found to have LVI at TURBT compared to 161 (33.1%) at RC. Although the presence of LVI at TURBT was more significantly associated with the presence of LVI at RC, only 42.9% of patients in whom LVI was documented at TURBT were found to harbour LVI at RC. The risk of nodal disease was higher in those patients with LVI at TURBT than in those with no evidence of LVI at TURBT (48.3% vs 25.0%, P < 0.001). Additionally, LVI at TURBT was associated with an increasing risk of pathological upstaging and the receipt of adjuvant chemotherapy. Survival analysis showed a significant decrement in overall and recurrence‐free survival among those with LVI at TURBT compared to those with no evidence of LVI.

CONCLUSIONS

Lymphovascular invasion at TURBT provides useful prognostic information that should be incorporated into clinical decision‐making, particularly with regard to cystectomy for nonmuscle‐invasive carcinoma and the administration of neoadjuvant chemotherapy.     

Bladder carcinoma among live-donor renal transplant recipients: a single-centre experience and a review of the literature

OBJECTIVES

To present our experience with bladder cancer among a renal transplant population and to review critically the relevant literature.

PATIENTS AND METHODS

In all, 1865 renal graft recipients were followed for a mean (sd ) of 6.5 (5) years. Seven recipients (all men) developed a urothelial bladder tumour. The stage and grade of the tumours were determined. The method of the treatment was selected on the basis of the tumour characteristics and graft function. Patients were regularly followed; the endpoints were cancer‐specific survival, recurrence or metastasis.

RESULTS

All patients presented with gross haematuria. There was non‐muscle‐invasive disease in two patients who were treated by transurethral resection and adjuvant intravesical bacille Calmette‐Guérin immunotherapy. One patient died 24 months later due to complications of end‐stage renal disease. To date the second patient is alive and free of the recurrence. Five recipients with muscle‐invasive disease had a radical cystectomy and orthotopic bladder substitution. The mean (sd ) time to the last follow‐up or death was 14.6 (3.1) months. Three patients died with stable graft function; two from distant metastasis and one from a cerebrovascular stroke. The remaining two patients are still alive, free of disease and with good graft function.

CONCLUSIONS

Urothelial bladder tumours are generally uncommon. The presence of haematuria in renal allograft recipients should be thoroughly investigated. Early diagnosis and prompt treatment are required for managing such tumours, because they are aggressive. Orthotopic bladder substitution is feasible with a good functional outcome for patients in whom cystectomy is indicated.     

Organ‐preserving neodymium‐yttrium‐aluminium‐garnet laser therapy for penile carcinoma: a long‐term follow‐up

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

OBJECTIVE

To retrospectively analyse the long‐term follow‐up of 54 patients treated with organ‐preserving laser therapy for penile carcinoma, as such therapy provides excellent cosmetic and functional results, but recurrence rates are high, which might impair the oncological outcome and worsen tumour‐related survival.

PATIENTS AND METHODS

Between 1979 and 2008, 54 patients with penile carcinoma were treated with the neodymium‐doped yttrium‐aluminium‐garnet (Nd:YAG) laser at our institution; 11 were classified as having carcinoma in situ (Tis), 39 as T1 and four as T2.

RESULTS

There was local recurrence in 16 patients (42%); the mean (range) time to local recurrence was 53 (9–132) months. In half the patients the time to local recurrence was >53 months, with the latest recurrence at 132 months after initial therapy of primary tumour. There was no statistically significant difference in recurrence rates with Tis or invasive penile carcinoma. In lymph‐node‐negative patients at initial presentation, there were no newly developed positive lymph nodes during the follow‐up.

CONCLUSIONS

Organ‐preserving laser therapy showed a relatively high recurrence rate in patients with a long‐term follow up, but the oncological outcome and survival were not compromised by local recurrence. Therefore, laser therapy appears to be appropriate for treating premalignant lesions and early stages of penile carcinoma. Patients should be informed about the potential for late recurrence.     

The role of surveillance in the treatment of patients with muscle‐invasive bladder cancer after chemotherapy

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

OBJECTIVE

To determine the survival of patients at our institution who were clinically tumour‐free (cT0) on re‐staging transurethral resection (TUR) after treatment with chemotherapy for muscle‐invasive bladder cancer.

PATIENTS AND METHODS

In all, 55 patients with muscle‐invasive, organ‐confined transitional cell carcinoma of the bladder were treated with TUR followed by systemic chemotherapy, over a 10‐year period. Patients were separated into two groups, those who were clinically T0 and those who showed persistent disease (>cT0) on re‐biopsy after chemotherapy. Overall and disease‐specific survival rates were calculated for the two groups. The cT0 group was further followed for tumour recurrence and clinical outcomes.

RESULTS

Thirty‐one patients (56%) were clinically T0 on TUR after chemotherapy; of these patients, 22 (71%) either died from other causes (with no disease recurrence) or are alive and with no evidence of disease at a mean follow‐up of 53 months. Twenty of the 31 patients (65%) have retained their bladder with no evidence of cancer recurrence at a mean follow‐up of 46 months. Disease‐free status (cT0) at the time of TUR after chemotherapy was associated with significantly higher overall and cancer‐specific survival (hazard ratio 3.40, P = 0.003; and 8.63, P = 0.001, respectively).

CONCLUSION

Previous studies suggest that surveillance can be a reasonable option for patients with muscle‐invasive transitional cell carcinoma of the bladder who show no evidence of disease on TUR after chemotherapy. Patients with persistent bladder cancer on re‐biopsy after chemotherapy tend to fare poorly even with immediate cystectomy.     

A chemosensitivity test to individualize intravesical treatment for non‐muscle‐invasive bladder cancer

OBJECTIVE

To describe the design of a new chemosensitivity assay based on the expression of genes involved in the resistance to standard intravesical regimens, to allow individualization of therapy for high‐risk non‐muscle‐invasive bladder cancer.

PATIENTS AND METHODS

To date, 35 patients with high‐risk no‐nmuscle‐invasive bladder cancer have been enrolled, all candidates for transurethral resection of the bladder (TURB) followed by intravesical treatment. The intravesical regimen was chosen according to the risk profile of each patient. All patients were evaluated by cystoscopy 3 and 6 months after TURB. According to the molecular characterization of each tumour, our team of molecular oncologists determined for each patient a molecular profile of chemosensitivity to BCG, mitomycin c, anthracyclines and gemcitabine. This profile was then correlated to the response to intravesical therapy 6 months after TURB.

RESULTS

This chemosensitivity test was able to predict response to treatment in 96% of patients. The assay is easy to perform, inexpensive and quick.

CONCLUSION

Our results, although preliminary, are encouraging for the future of an individualized therapeutic approach, with the aim to provide a higher treatment success rate while sparing patients unnecessary toxicity from drugs that are not suited for their tumours.     

The effectiveness of the Nd-YAG laser in destroying superficial bladder tumours

Fifty-five bladder tumours, in 12 patients, were treated by coagulation using the neodymium-yttrium aluminium garnet (Nd-YAG) laser. All the tumours were superficial, grade I or II, and varied in size from 5 to 30 mm. Laser energy was applied using a quartz-fibre delivery system via a rigid cystoscope under general anaesthesia. Up to ten tumours were treated at any one cystoscopy. One patient underwent transurethral resection of tumours larger than 30 mm combined with laser coagulation of smaller lesions. Fifty-four tumours were completely destroyed by the laser. Six patients (50%) had recurrent tumours on review cystoscopies performed one to eight months after the initial treatment. However, only one tumour was found at the site of previous laser coagulation, indicating incomplete tumour destruction. This was successfully eradicated by a further laser coagulation. Coagulation of superficial bladder tumours with Nd-YAG laser energy during rigid cystoscopy under general anaesthesia is therefore an effective treatment for superficial non-invasive bladder tumours, although the recurrence rate is unaffected.