Surveillance for Nonmuscle Invasive Bladder Cancer: Identifying the Point of Diminishing Returns.

OBJECTIVE: To characterize first and second recurrence patterns using 26years of cohort-level follow-up and microsimulation modeling. METHODS: Patients diagnosed with nonmuscle-invasive bladder cancer in Stockholm County between 1995 and 1996 were included. Clinical, pathological, and longitudinal follow-up data were gathered. Logistic regressions, Kaplan Meier curves, and Cox proportional hazards models were run to generate assumptions for a microsimulation model, simulating first and second recurrence and progression for 10,000 patients. RESULTS: Three hundred eighty-six patients were included: 67.4% were male; >50% were TaLG; and 37.5% were American Urological Association high-risk. Median time to recurrence was 300days. Three patients had missing data. Cohort follow-up has been carried out for 26years. For simulated first-recurrences, low-risk patients recurred at 56.6% over 15years of follow-up, with 2.2% muscle-invasive (MI) progression; intermediate-risk patients recurred at 62.8%, with 4.3% MI progression; high-risk patients recurred at 48.7% over 15years, with MI progression at 14.3%. For second recurrences, 70.7%, 75.7%, and 84.7% of low, medium, and high-risk patients recurred. No patients were seen to have first recurrences after 9years, with low, but notable, rates beyond 5years. CONCLUSION: These data suggest that low-, intermediate-, and high-risk patients without recurrence at 5years may be potentially transitioned to less invasive monitoring.

Development of a predictive model for recurrence-free survival in pTa low-grade bladder cancer.

BACKGROUND: Data on Ta low-grade (LG) non-muscle invasive bladder cancer (NMIBC) have shown that follow-up cystoscopies are normal in 82% and 67% of patients with single and multiple tumors, respectively. OBJECTIVE: To develop a predictive model associated with recurrence-free survival (RFS) at 6, 12, 18 and 24 months in TaLG cases that consider the patients' risk aversion. MATERIALS AND METHODS: Data from a prospectively maintained database of 202 newly diagnosed TaLG NMIBC patients treated at Scandinavian institutions were used for the analysis. To identify risk groups associated with recurrence, we performed a classification tree analysis. Association between risk groups and RFS was evaluated by Kaplan Meier analysis. A Cox proportional hazard model selected significant risk factors associated with RFS using the variables defining the risk groups. The reported C index for the Cox model was 0.7. The model was internally validated and calibrated using 1000 bootstrapped samples. A nomogram to estimate RFS at 6, 12, 18, and 24 months was generated. The performance of our model was compared to EUA/AUA stratification using a decision curve analysis (DCA). RESULTS: The tree classification found that tumor number, tumor size and age were the most relevant variables associated with recurrence. The patients with the worst RFS were those with multifocal or single, ≥ 4cm tumors. All the relevant variables identified by the classification tree were significantly associated with RFS in the Cox proportional hazard model. DCA analysis showed that our model outperformed EUA/AUA stratification and the treat all/none approaches. CONCLUSION: We developed a predictive model to identify TaLG patients that benefit from less frequent follow-up cystoscopy schedule based on the estimated RFS and personal recurrence risk aversion.

Functional and Oncological Outcomes of Female Pelvic Organ-preserving Robot-assisted Radical Cystectomy.

BACKGROUND: For females undergoing cystectomy and urinary diversion, decreases in sexual and urinary functions can have a significant impact on quality of life. Pelvic organ-preserving (POP) radical cystectomy (RC) has been proposed as an approach to improve postoperative functional outcomes. OBJECTIVE: To evaluate postoperative functional outcomes of a robotic approach for female POP RC with intracorporeal urinary diversion. DESIGN SETTING AND PARTICIPANTS: This was a multicenter retrospective study evaluating sexual, urinary, and oncological outcomes for sexually active females undergoing POP robot-assisted RC for ≤T2 bladder cancer. Exclusion criteria included multifocal, trigonal, or locally advanced tumors. SURGICAL PROCEDURE: We describe a step-by-step technique for POP robot-assisted RC with intracorporeal urinary diversion. MEASUREMENTS: The primary outcome of the study was evaluation of sexual and urinary functions following surgery. Oncological outcomes were evaluated as a secondary endpoint. RESULTS AND LIMITATIONS: Our study included 23 females who underwent POP robot-assisted RC between 2008 and 2020 with intracorporeal neobladder (87%) or ileal conduit (13%) reconstruction. The median follow-up was 20 mo. A postoperative sexual function questionnaire was completed by 15 patients (65%). Of those, 13 (87%) resumed sexual activity at a median of 6 mo after surgery. Of the patients with a neobladder, 14 (70%) achieved daytime continence and 16 (80%) achieved nighttime continence. Cancer-specific and overall survival were both 91%. The results are limited by their retrospective nature. CONCLUSIONS: POP robot-assisted RC with orthotopic neobladder allows a majority of female patients to return to sexual activity after surgery. This approach should be considered for selected sexually active women. PATIENT SUMMARY: We evaluated 23 women with bladder cancer who underwent surgical removal of the bladder with preservation of their reproductive organs. Following this surgery, a majority of patients resumed sexual activity. For selected patients, this technique can be performed without compromising cancer control.

Bladder Cancer (NMIBC) in a population-based cohort from Stockholm County with long-term follow-up; A comparative analysis of prediction models for recurrence and progression, including external validation of the updated 2021 E.A.U. model.

INTRODUCTION: Non muscle invasive bladder cancer (NMIBC) has recurrence and progression rates of approximately 55-75% and 5-45% respectively. After diagnosis, risk stratification guides management decisions regarding surveillance, intravesical therapy or surgery. This prospective cohort of patients from Stockholm County is ideal for external validation of the current risk stratification models used in clinical practice. PATIENTS & METHODS: The cohort consisted of 395 patients diagnosed with bladder cancer across all the hospitals in Stockholm County between the years 1995-96, with up to 25 years follow up. All patients with pathologic Ta or T1 disease were included. Patients with muscle invasive disease (MIBC) referred for radical treatment at diagnosis were excluded. External validation of EORTC, CUETO and updated EAU Sylvester et al. (2021) models was done and multivariate Cox regression analysis was performed to generate hazard ratios for covariables of interest using both WHO '73 and WHO '04/16 pathological grade classifications. RESULTS: Overall Harrel's C-indices (CIs) for EORTC and CUETO models for recurrence were 0.66 and 0.63 respectively. The CIs for the EORTC, CUETO and EAU Sylvester et al. (2021) WHO '73 and '04/16 models for progression were higher at 0.82, 0.84, 0.83 and 0.83 respectively. All models tended to underestimate both recurrence and progression rates at 1 and 5 yrs. A simplified model devised to include only multifocality, tumor stage, size and grade performed with similar accuracy to all models for both recurrence and progression. CONCLUSION: Current risk stratification models are clinically useful but only moderately accurate across different patient populations, and the results of this study suggest a model using fewer variables is of similar accuracy to all models tested. In the future, research into the use of genomic classifiers will hopefully contribute to more accurate, modern risk stratification models.

Ureteric stricture rates and management after robot-assisted radical cystectomy: a single-centre observational study.

OBJECTIVE: Benign ureterointestinal anastomosis (BUIA) stricture is a recognized complication after open radical cystectomy. The evidence for stricture rates following robot-assisted radical cystectomy (RARC) is limited. This article reports stricture rates from a single high-volume RARC centre. MATERIALS AND METHODS: Between December 2003 and December 2015, 371 patients underwent RARC with a totally intracorporeal urinary diversion. All patients received a ureteric anastomosis utilizing the 'Wallace plate' with a running suture technique. Monofilament suture was used in the first 81 patients (22%) and a barbed suture (Quill™) in the remaining 290 patients (78%). RESULTS: Median follow-up was 33 months and minimum follow-up was 7.9 months. The median time to stricture formation was 165 days (range 10-495 days). Twenty-four patients (6.5%) developed BUIA strictures. Six of 81 patients (7.4%) in the monofilament group and 18 of 290 (6.2%) in the barbed suture group developed strictures (p = .22). Fifteen patients (63%) had a stricture on the left side, seven (29%) on the right side and two patients (8%) developed bilateral ureteric strictures (p = .002). Strictures occurred in 11 of 131 patients (8.3%) with an orthotopic neobladder and 13 of 240 (5.4%) with an ileal-conduit urinary diversion (p = .17). CONCLUSIONS: The overall incidence of ureteric strictures is low in patients undergoing RARC with totally intracorporeal urinary diversion. Strictures were more common on the left side, which has been described in open series and is probably related to the increased mobilization on the left side required to cross the ureter to the right side.

Does Coronary Angiography and Percutaneous Coronary Intervention Affect Cognitive Function?

Cerebral microemboli are frequently observed during coronary angiography (CA) and percutaneous coronary intervention (PCI), and their numbers have been related to the vascular access site used. Although cerebral microemboli can cause silent cerebral lesions, their clinical impact is debated. To study this, 93 patients referred for CA or PCI underwent serial cognitive testing using the Montreal Cognitive Assessment (MoCA) test to detect postprocedural cognitive impairment. Patients were randomized to radial or femoral access. In a subgroup of 35 patients, the number of cerebral microemboli was monitored with transcranial Doppler technique. We found the median precatheterization result of the MoCA test to be 27, and it did not change significantly 4 and 31 days, respectively, after the procedure. There was no significant correlation between the number of cerebral microemboli and the difference between preprocedural and postprocedural MoCA tests. The test results did not differ between vascular access sites. One-third of the patients had a precatheterization median MoCA test result <26 corresponding to mild cognitive impairment. In conclusion, using the MoCA test, we could not detect any cognitive impairment after CA or PCI, and no significant correlations were found between the results of the MoCA test and cerebral microemboli or vascular access site, respectively. In patients with suspected coronary heart disease, mild cognitive impairment was common.

Introducing an enhanced recovery programme to an established totally intracorporeal robot-assisted radical cystectomy service.

OBJECTIVE: The aim of this study was to assess the effect of introducing an enhanced recovery programme (ERP) to an established robot-assisted radical cystectomy (RARC) service. MATERIALS AND METHODS: Data were prospectively collected on 221 consecutive patients undergoing totally intracorporeal RARC between December 2003 and May 2014. The ERP was specifically designed to support an evolving RARC service, where increasing proportions of patients requiring radical cystectomy underwent RARC. Patient demographics and outcomes before and after implementation of the ERP were compared. The primary endpoint was length of stay (LOS). Secondary outcomes included age, American Society of Anesthesiologists (ASA) score, preoperative staging, operative time, complications and readmissions. Differences in outcomes between patients before and after implementation of ERP were tested with the Jonckheere-Terpstra trend test and quantile regression with backward selection. RESULTS: Following implementation of the ERP, the demographics of the patients (n = 135) changed, with median age increasing from 66 to 70 years (p < 0.01), higher ASA grade (p < 0.001), higher preoperative stage cancer (pT ≥ 2, p < 0.05) and increased likelihood of undergoing an ileal conduit diversion (p < 0.001). Median LOS before ERP was 9 days [interquartile range (IQR) 8-13 days] and after ERP was 8 days (IQR 6-10 days) (p < 0.001). ASA grade and neoadjuvant chemotherapy also affected LOS (p < 0.05 and p < 0.01, respectively). There was no significant difference in 30 day complication rates, readmission rates or 90 day mortality, with 59% experiencing complications before ERP implementation and 57% after implementation. The majority of complications were low grade. CONCLUSIONS: Patient demographics changed as the RARC service evolved from selected patients to a general service. Despite worsening demographics, LOS decreased following ERP implementation. This evidence-based ERP safely standardized perioperative care, resulting in decreased LOS and decreased variability in LOS.