Bladder carcinoma Results with preoperative radiation therapy and radical cystectomy

The records of 159 patients treated with preoperative radiotherapy and radical cystectomy were reviewed to ascertain the influence on survival rates and disease-free intervals of tumor stage, tumor grade, tumor appearance, lymphatic permeation, history of previous bladder tumors, and downstaging (pathologic stage < clinical stage). Knowledge of grade, tumor appearance, lymphatic invasion, and history of previous bladder tumors did not make possible an accurate prediction of response to integrated therapy. However, both downstaging and the absence of muscle invasion were associated with significantly improved survival rates and disease-free intervals.     

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.     

Bladder replacement by ileocystoplasty following radical cystectomy

Summary Between 1958 and 1985, over 402 patients underwent a radical cystoprostatectomy for bladder cancer. In 150, the bladder was replaced by a U-shape segment of ileum anastomosed midway to the urethral stump; the ureters were anastomosed to each end of the loop via an antireflux technique. Continence was achieved by an external sphincter mechanism and voiding accomplished by voluntary sphincter relaxation and abdominal straining. In the past 10 years, daytime continence has been achieved in 95% of cases. Nighttime continence was obtained in 50% by means of rehabilitation. Antireflux implantation, checked by retrograde cystogram, was proven effective in 85% of cases. The residual volume is generally moderate and 70% of patients maintain sterile urine, which is an essential factor in protecting renal function. This procedure can be performed only in patients at low risk of urethral recurrence. They must be able to undergo major surgery and be well informed and motivated. The surgical team must adhere to the rules of this long and difficult procedure.     

Intestinal strictures complicating preoperative radiation therapy followed by radical cystectomy

Between January 1975 and January 1981, 100 patients with invasive bladder cancer were evaluated for therapy. Of these patients 51 were selected for treatment with preoperative radiation therapy followed by radical cystectomy. Of 36 patients who actually completed the integrated therapy 4 (11 per cent) had clinical intestinal strictures. Three strictures occurred more than 24 months and 1 less than 6 months postoperatively. Strictures involved the colon in 3 cases and the ileum in 1. An operation was required in 2 cases. We present these 4 cases, and discuss the pathophysiology and treatment of the radiation-injured intestine. Our experience suggests that preoperative radiation therapy in conjunction with radical cystectomy may be associated with the development of clinically significant bowel injury. This factor should be considered in the decision to combine preoperative radiation therapy with radical cystectomy in the treatment of bladder cancer.     

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...     

Bladder carcinoma treated by preoperative radiotherapy followed by cystectomy

Summary In 1969 a clinical trial was started where patients with bladder carcinoma stage T2 and grade 3 were subjected to preoperative radiotherapy followed by cystectomy. The survival rate in this series was higher than in a previous series of comparable patients who were given full irradiation without cystectomy.     

Quality of life in men with localized prostate cancer treated by radical prostatectomy or radiotherapy

Radical prostatectomy and radiotherapy are the most commonly utilized modalities for managing patients with localized prostate cancer. Each has effects on quality of life that are important in decision making. Long term side effects of these treatment modalities include urinary, bowel and sexual dysfunction, and have been documented. Comparison of the side effects of these different modalities continues to be explored, emphasizing their effects on quality of life (QOL) from the patient's viewpoint. Questionnaires were mailed to 224 eligible patients and a response was elicited in 161 men (72%). The final number of patients who completed all the questionnaires was 151. Of these, 73 (48%) had radical prostatectomy and 78 (52%) had radiotherapy. General well being measures demonstrated a definite advantage favoring men treated with radical prostatectomy. Prostate cancer specific QOL measures were similar among men treated with surgery or radiotherapy. Radiotherapy treated men were slightly more likely to report bowel-related problems than surgically treated men. Urinary QOL measures were no different between treated groups. Surgically treated men reported lower level of sexual function than radiotherapy treated men.     

Risk groups in bladder cancer patients treated with radical cystectomy

Objective

To stratify patients with bladder cancer into homogeneous risk groups according to statistically significant differences found in PFS (progression-free survival). To identify those patients at increased risk of progression and to provide oncological follow-up according to patient risk group.

Materials and Methods

A retrospective study of 563 patients treated with radical cystectomy (RC). In order to determine which factors might predict bladder tumour progression and death, uni- and multivariate analyses were performed. The risk groups were identified according to “inter-category” differences found in PFS and lack of differences, thus revealing intra-category homogeneity.

Results

Median follow up time was 37.8 months. Recurrence occurred in a total of 219 patients (38, 9%). In 63% of cases this was distant recurrence. Only two variables retained independent prognostic value in the multivariate analysis for PFS: pathological organ confinement and lymph node involvement. By combining these two variables, we created a new “risk group” variable. In this second model it was found that the new variable behaved as an independent predictor associated with PFS.Four risk groups were identified: very low, low, intermediate and high risk:• Very low risk: pT0 N0• Low risk: pTa, pTis, pT1, pT2 and pN0• Intermediate risk: pT3 and pN0• High risk: pT4 N0 or pN1-3.

Conclusions

We retrospectively identified 4 risk groups with an independent prognostic value for progression-free survival following RC. Differences in recurrence patterns after RC between risk groups have led us to set different intervals in monitoring for cancer.     

Health-related quality of life and satisfaction with care among older men treated for prostate cancer with either radical prostatectomy or external beam radiation therapy

OBJECTIVE: To analyse health-related quality of life (HRQoL) and satisfaction with care across potential curative treatments for older patients newly diagnosed with prostate cancer. PATIENTS AND METHODS: In a prospective cohort study we recruited 115 older patients (> or =65 years) newly diagnosed with prostate cancer from the urology clinics of an urban academic and a Veterans' Administration (VA) hospital. Patients completed generic (Short Form-36), prostate-specific (University of California Los Angeles Prostate Cancer Index) HRQoL, and Client Satisfaction with Care (CSQ-8) surveys before treatment with either radical prostatectomy (RP) or external beam irradiation (EBRT) and at 3, 6 and 12 months afterward. Clinical and demographic data were obtained via medical chart review. A repeated-measures analysis of variance was used to examine changes in generic and prostate cancer-specific HRQoL between treatments. Log-linear regression was used to analyse the factors associated with 12-month HRQoL scores, and Kaplan-Meier survival curves were used to compare the return to baseline values for HRQoL. RESULTS: The RP group had significantly higher income, education and better general health than the EBRT group. Age (odds ratio 0.5, 95% confidence interval 0.32-0.82), non-VA hospital (28.8, 2-402) and prostate-specific antigen level at diagnosis (2.8, 1.05-7.5) were associated with RP. The analysis results indicated that the RP group had higher scores for generic HRQoL subscales of physical function (P = 0.019), role emotional (P = 0.037), vitality (P = 0.033) and general health (P = 0.05) than the EBRT group. A log-linear regression model for predicting the 12-month scores showed that RP was associated with higher scores for most of the generic HRQoL and bowel function (odds ratio 1.12, P = 0.03), urinary bother (1.6, P = 0.014) and bowel bother (1.5, P = 0.013). Being older was associated with a lower score on bowel function (0.98, P = 0.05) and sexual function (0.92, P = 0.05). Satisfaction with care was comparable between treatment groups at baseline and at the follow-up. CONCLUSIONS: Older patients tolerate RP well from the HRQoL perspective and thus decisions for therapy in this age cohort should not be based primarily on age.     

Health related quality of life in Japanese men after radical prostatectomy or radiation therapy for localized prostate cancer

BACKGROUND: We performed a retrospective survey of general and disease specific health-related quality of life (HRQOL) after radical prostatectomy (RP) and external beam radiotherapy (XRT) in Japanese men. METHODS: A total of 186 patients underwent RP and 78 underwent XRT for clinically localized prostate cancer between 2000 and 2002. We measured the general and disease specific HRQOL with the MOS 36-Item Health Survey and the University of California, Los Angeles Prostate Cancer Index, respectively. Each treatment group was further divided into four subgroups according to the time scale. RESULTS: Patients from the RP group were significantly younger than those from the XRT group. The tumor characteristics differed significantly in their distributions among the treatment groups. Patients undergoing XRT had low scores in most of the general measures of HRQOL just after treatment, but after 6 months there were no differences between the treatment groups, except for the physical domains. The RP group was associated with worse urinary function, whereas the XRT group had worse bowel function and bother during the first 6 months after treatment. Thereafter, however, urinary and bowel domain did not differ between the groups. Both groups reported poor sexual function, although the RP group scored lower sexual bother. CONCLUSION: The patients who underwent RP had significantly worse urinary and better bowel function than those treated with XRT. Both treatment groups had decrements in sexual function throughout the post-treatment period; careful attention should be paid to this side-effect in preoperative counselling, especially in younger patients, regardless of the primary treatments.     

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.

     

Sexual function in men after radical cystectomy with or without urethrectomy.

Sexual function was evaluated in 21 patients with bladder carcinoma who had undergone radical cystectomy either with (n = 9) or without (n = 12) excision of the urethra. All patients received preoperative radiotherapy, and the cystectomy was done by a nerve-sparing surgical technique. At follow-up all patients reported normal sexual desire and tactile sexual activity. Eight of the 12 patients in whom the urethra was preserved could achieve penile erection and orgasm to tactile stimulation, and five of them had sufficient strength and duration of erection for sexual intercourse. Two of the nine patients in whom the urethra was removed-had weak erections insufficient for intercourse; three could experience orgasm. These results show that when cystectomy is done by a nerve-sparing technique and without urethrectomy there is more chance of preserving sexual function than when simultaneous urethrectomy is done.     

Hyperbaric oxygen therapy for radiation induced proctopathy in men treated for prostate cancer

PURPOSE: Radiation proctitis is a common complication following external beam radiation therapy and brachytherapy for prostate cancer. While 95% percent of radiation induced proctitis is temporary and self-limiting, up to 5% of patients experience toxicities that are refractory to conservative management. Hyperbaric oxygen has a well-defined role in treating chronic wounds, osteomyelitis, hemorrhagic cystitis and necrotizing fasciitis. We reviewed our experience with hyperbaric oxygen therapy for radiation induced proctitis in patients undergoing radiation treatment for prostate cancer. MATERIALS AND METHODS: From October 1998 to December 2003, 27 patients with radiation induced proctitis secondary to brachytherapy (4), external beam radiation therapy (16) or combined modality (7) for prostate cancer were treated with hyperbaric oxygen therapy at Virginia Mason Medical Center in Seattle, Washington. In all patients primary medical or endoscopic management had failed. Patients received 100% oxygen in a multiplace hyperbaric chamber at a pressure of 2.4 atmospheres absolute for 90 minutes 5 to 7 days weekly for an average of 36 sessions (range 29 to 60). Data were collected from a retrospective review of medical records following approval by the Institutional Review Board at Virginia Mason Medical Center. RESULTS: All 27 men completed the planned course of therapy. Of patients with bleeding 48% showed complete resolution after therapy, while 28% reported significantly fewer bleeding episodes. Of patients 50% noted complete resolution of fecal urgency. Six of the 8 patients (75%) with pain noticed some improvement after therapy, although no patients reported complete resolution of rectal pain. Of patients with rectal ulceration 21% showed complete resolution of the ulcer on posttreatment endoscopy, while 29% showed evidence of improvement. Six patients (43%) had no change or worsening of rectal ulcers. Overall 67% of patients had a partial to good response, while 33% showed no response or disease progression. CONCLUSIONS: This series of patients showed a good overall response rate to hyperbaric oxygen for radiation induced proctopathy after other attempts at management had failed. Hyperbaric oxygen is generally well tolerated and it remains an important treatment option for managing this common and difficult disease.     

Penile length changes in men treated with androgen suppression plus radiation therapy for local or locally advanced prostate cancer

PURPOSE: We determined penile length alterations in men treated with androgen suppression plus radiation therapy for local or locally advanced prostate cancer. MATERIALS AND METHODS: From November 2000 to November 2005, 47 patients were enrolled in this prospective study. After clinical staging all patients received hormonal therapy (luteinizing hormone releasing agonist, leuprolide acetate or goserelin every 3 months for a total of 3 injections) and at month 7 of hormonal therapy radiation therapy was begun (total 70 Gy) for 7 weeks. Stretched penile length measurements were performed before starting androgen suppression therapy and every 3 months thereafter with a paper ruler. RESULTS: With the initiation of therapy a gradual decrease in stretched penile length was observed. Penile shortening was statistically significant at a mean followup of 18 months (mean 14.2 to 8.6 cm, p <0.001). CONCLUSIONS: Our findings support observations of decreased penile length after neoadjuvant hormonal therapy plus external beam radiation therapy for local or locally advanced prostate cancer. Patients should be counseled before therapy that penile shortening may occur.     

Characterization of perioperative androgen profiles in men with bladder cancer undergoing radical cystectomy

BackgroundPrior studies have demonstrated declines in androgen levels in men with cancer and patients undergoing anesthesia and surgery. In this study, we hypothesized that decreased serum androgen levels are prevalent in male patients undergoing radical cystectomy (RC) for bladder cancer and that it persists in the postoperative period. We characterized perioperative androgen hormonal profiles and examined for associated changes indicative of sarcopenia on computed tomography scans in men undergoing RC.MethodsWe implemented a prospective observational trial in men with newly diagnosed non-metastatic bladder cancer undergoing RC. Baseline pre-operative total testosterone (TT), free testosterone (FT), and luteinizing hormone (LH) were obtained on morning lab draws with 30 days of surgery. TT and FT were then repeated on postoperative days (POD) 2, 3, 30, and 90. The threshold for normal TT was defined as >300 ng/dl, consistent with the AUA Guidelines for Evaluation and Management of Testosterone Deficiency. We evaluated postoperative changes in weight and psoas muscle cross-sectional area using computed tomography scans to assess for sarcopenic changes.ResultsUnivariable statistical analysis was performed. 25 patients were enrolled. The mean patient age was 68.9 years. The mean pre-operative TT was 308 ng/dl, and 12/23 (52.5%) patients had low testosterone. Mean TT onPOD 2 and 3 were 166 ng/dl and 161 ng/dl, respectively (range 24–345). 19/20 (95%) of men who had morning lab draws had decreased TT. The mean TT at 30 days was 253 ng/dl with 37.5% of men having low TT. Mean TT at 90 days was 306 ng/dl. The mean FT levels were 43 ng/dl, 29.25 ng/dl, 28.2 ng/dl, 40.89 ng/dl, and 42.62 ng/dl at baseline, POD 2, POD 3, POD 30, and POD 90, respectively. Mean LH at baseline was 9.9 IU/L. Average weight loss at 30- and 90- days postop was -4.29 and -4.38 kilograms, respectively. Weight loss was persistent with only 3/23 (13%) returning to their presurgery weight by 90 days. Despite significant declines in weight and perioperative TT, no significant differences in psoas muscle cross-sectional area were observed (net change -92 mm², P= 0.13)ConclusionsPerioperative disruption of androgen levels is prevalent in men undergoing RC. Our trial demonstrates a pre-op, immediate postop, 30- and 90-day postoperative prevalence of low TT of 52%, 95%, 63%, and 37.5%, respectively. Significant changes in baseline weight were noted, although no significant changes in psoas muscle cross-sectional area were observed, limiting conclusions regarding a link between changes in androgens and sarcopenia in this setting.     

Follow up of patients with bladder cancer treated with radical cystectomy

Radical cystectomy provides excellent local control of the disease in cancer patients, although specific 5-year mortality is about 50%. Additionally, nearly half the patients show complications after surgery usually due to urinary by-pass. Patients should undergo periodical monitoring for life. For rescue treatment to be as effective as possible, follow-up schemes should allow for early detection of relapsing-recurrent tumours, metastasis and complications. Knowledge of the "natural evolution" in these patients allows to optimise the frequency of visits and complementary examinations based on each patient's risk at specific time-points. Cost-efficacy relationship will also be optimised. We analyze here the current literature and our own experience of what we know as "natural evolution" of these patients and propose a follow-up scheme for patients with cancer of the bladder treated with radical cystectomy and urinary by-pass.     

Sigmoid neobladder in women after radical cystectomy

PURPOSE: Neobladder reconstruction using an intestinal segment is the common procedure of choice in men after cystectomy. Recently this procedure has been extended to women. We present our surgical and functional experience with the sigmoid neobladder in women. MATERIALS AND METHODS: A total of 11 women 49 to 74 years old (mean age plus or minus standard deviation 60 +/- 8.5) with transitional cell carcinoma of the bladder underwent lower urinary tract reconstruction with a modified sigmoid neobladder after nerve and urethral support sparing cystectomy. After at least 3 months voiding pattern and continence status were evaluated. Pressure flow studies and uroflowmetry were performed, the urethral pressure profile and neocystourethral angle were measured, and blood chemistry was analyzed. RESULTS: After at least 3 months complete daytime continence was achieved in 2 patients, while 8 had mild stress incontinence. At night 8 of the 11 women (72.7%) were continent with or without voiding at regular intervals. All except 1 patient voided to completion. Of the 2 patients with complete continence 1 needed clean intermittent catheterization 4 months postoperatively. Mean maximal urinary flow was 19.9 +/- 10.5 ml. per second. Excluding the woman who required catheterization mean residual urine volume was 15 +/- 13.7 ml. Postoperatively maximal urethral pressure was slightly lower and functional urethral length was about 10 mm. shorter than preoperatively. The mean neocystourethral angle was 131.9 +/- 21.7 degrees. Mean pH, bicarbonate and base excess were 7.38 +/- 0.03, 23. 48 +/- 2.34 mmol./l. and -0.92 +/- 2.50, respectively. CONCLUSIONS: After nerve and urethral support sparing cystectomy a modified sigmoid neobladder may be constructed in women to obtain satisfactory continence and voiding results.     

Palliative care use among bladder cancer patients treated with radical cystectomy

IntroductionPractice guidelines recommend early consideration for palliative care for patients with advanced malignancies, and there has been limited research regarding the use of palliative care for patients with advanced bladder cancer. Our aim is to describe the rate and determinants of the use of palliative care consultation for patients treated with radical cystectomy at our institution.MethodsA retrospective review was performed to identify patients who underwent cystectomy for bladder cancer between September 2014 and June 2019 at our institution. Our primary outcome was receipt of palliative care, defined as receiving a palliative care consult. We tested for associations between factors and our outcome of interest, and then estimated the impact on various determinants of palliative care use by fitting a multivariable logistic regression model.ResultsOver the study period, 294 patients underwent radical cystectomy. Of those patients, 29 (9.9%) received palliative care. Mean time from surgery to palliative care consult was 11.4 months. Palliative care consults were initiated by urologists in 32.1% of cases. On multivariable analysis, patients were more likely to receive palliative care if they had pT3+ disease (P < 0.001), were readmitted after surgery (P = 0.028), or had any major complication after surgery (P = 0.025).ConclusionRates of palliative care consults in patients with advanced bladder cancer at our institution are higher than other population-based estimates nationally. The majority of palliative care consults were requested by medical oncologists, highlighting an opportunity for educational initiatives for urologic oncologists to promote earlier consideration of palliative care referrals.