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1.
Arch Esp Urol ; 73(1): 32-40, 2020 Jan.
Artigo em Espanhol | MEDLINE | ID: mdl-31950921

RESUMO

OBJECTIVE: To compare peri-operative and mid-term oncological outcomes between Open radical cystectomy (ORC) and Laparoscopic radical cystectomy (LRC). METHODS: A retrospective cohort was assembled, in which 182 patients had been subjected consecutively to Radical Cystectomy (RC) for treatment of muscle-invasive bladder cancer (MIBC) between 2000 and 2010 in a single center. Two cohorts were included: ORC (n=83) and LRC (n=99). All the RCs were performed by the same surgeon. Perioperatory complications were registered according to Clavien-Dindo classification. We evaluated recurrence-free survival, cancer-specific survival and association between the surgical technique performed and disease recurrence, with co-variable adjustment. RESULTS: Clinical and pathologic characteristics were similar for both groups. Significant differences were observed between the two groups, regarding blood loss, operative time and hospitalization days (p<0.04). The ORC group displayed 27 (32.5%) Clavien I-II cases, vs. 11 (11.1%) in the LRC group. Four Clavien≥III (4.8%) complications were reported in the ORC, vs. 7 (7%) in the LRC group (NS). Mean follow-up time for patients without recurrence was 23 months (12-48). A total of 60 patients (72.3%) showed recurrence in the ORC group, compared to 59 (59.6%) in the LRC group. Cumulative cancer-specific mortality index, stratified by surgical technique, was similar between both groups (p.-0.9). CONCLUSIONS: Based on our experience, LRC showed advantages in intraoperative bleeding and length of hospital stay with no difference in major complications between both groups. Mid-term oncological control, regarding local recurrence and cancer-specific survival, showed no significant difference between LRC and ORC in the management of MIBC.


Assuntos
Cistectomia , Laparoscopia , Neoplasias da Bexiga Urinária , Cistectomia/métodos , Humanos , Recidiva Local de Neoplasia , Estudos Retrospectivos , Resultado do Tratamento , Neoplasias da Bexiga Urinária/cirurgia
2.
Arch Esp Urol ; 73(1): 41-46, 2020 Jan.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-31950922

RESUMO

INTRODUCTION: The standard of care in muscle invasive bladder cancer is radical cystectomy; however; transurethral resection (TUR) followed by external radiotherapy and systemic chemotherapy demonstrates comparable results with radical cystectomy in terms of local control and survival rates. OBJECTIVES: To evaluate our results of multimodality bladder preservation therapy (BPT) in patients who had muscle-invasive bladder cancer and were reluctant to radical cystectomy. METHODS: The retrospective analysis of twenty-three patients with stage T2 transitional cell bladder cancer that were consecutively treated with BPT was performed. Treatment strategy included radical TUR followed by 3 cycles of cisplatin, gemcitabine combination, and radiotherapy of 64 Gy as adjuvant treatment. The Kaplan-Meier survival estimates and log rank were calculated. RESULTS: Median follow-up time was 58 (15-158) months. Disease-free survival (DFS) and five year overall survival (OS) rates for 23 patients were 55.9% and 63.9%, respectively. Cancer-specific OS was 67%. There were no grade 3 or higher complications. CONCLUSIONS: Our small patient group suggests that BPT can be safely applied in selected cases with bladder cancer or in patients that refused radical cystectomy.


Assuntos
Carcinoma de Células de Transição , Cistectomia , Tratamentos com Preservação do Órgão , Neoplasias da Bexiga Urinária , Carcinoma de Células de Transição/patologia , Carcinoma de Células de Transição/terapia , Terapia Combinada , Cistectomia/métodos , Intervalo Livre de Doença , Humanos , Invasividade Neoplásica , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do Tratamento , Bexiga Urinária/cirurgia , Neoplasias da Bexiga Urinária/patologia , Neoplasias da Bexiga Urinária/cirurgia
3.
Urology ; 135: 57-65, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31618656

RESUMO

OBJECTIVE: To evaluate differences in the incidence of benign ureteroenteric stricture, we compared stricture rates of robot-assisted radical cystectomy (RARC) and open radical cystectomy (ORC) using Surveillance, Epidemiology, and End Results-Medicare data. METHODS: We identified 332 RARC and 1449 ORC performed between 2009 and 2014 to determine stricture rates at 6, 12, and 24 months following surgery. We defined ureteroenteric stricture as the need for procedural intervention. Additionally, we compared the incidence of stricture diagnosis. Multivariable proportional hazards regression was performed to determine factors associated with stricture development. RESULTS: The incidence of ureteroenteric stricture at 6 and 12 months was higher for RARC vs ORC at 12.1% vs 7.0% (P < .01) and 15.0% vs 9.5% (P = .01), respectively. RARC vs ORC stricture incidence at 2 years did not differ significantly at 14.6% vs 11.4% (P = .29). Similarly, the stricture diagnosis rates were significantly lower following ORC at 6, 12, and 24 months (P < .05). In adjusted analysis, RARC (HR 1.64, 95%CI 1.23-2.19) and preoperative hydronephrosis (HR 1.51, 95% CI 1.17-1.94) were associated with the development of stricture. Higher hospital volume was associated with a lower risk of stricture (HR 0.40, 95%CI 0.26-0.63). CONCLUSION: RARC is associated with a higher rate of ureteroenteric stricture diagnosis and intervention on a population-based level that is mitigated by higher hospital volume. A significant study limitation is inability to differentiate extracorporeal vs intracorporeal diversion. However, a stricture complication compounds the financial burden of care and efforts must be pursued to improve this surgical outcome.


Assuntos
Cistectomia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Obstrução Ureteral/epidemiologia , Derivação Urinária/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Anastomose Cirúrgica/efeitos adversos , Carcinoma de Células de Transição/cirurgia , Constrição Patológica/epidemiologia , Constrição Patológica/etiologia , Constrição Patológica/cirurgia , Cistectomia/métodos , Feminino , Humanos , Incidência , Intestinos/cirurgia , Masculino , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco , Procedimentos Cirúrgicos Robóticos/métodos , Resultado do Tratamento , Ureter/cirurgia , Obstrução Ureteral/etiologia , Obstrução Ureteral/cirurgia , Neoplasias da Bexiga Urinária/cirurgia , Derivação Urinária/métodos
4.
Int Braz J Urol ; 46(1): 108-115, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31851467

RESUMO

OBJECTIVE: Cystectomy with urinary diversion is the gold standard for muscle invasive bladder cancer. It also may be performed as part of pelvic exenteration for non-urologic malignancy, neurogenic bladder dysfunction, and chronic conditions that result in a non-functional bladder (e.g., interstitial cystitis, radiation cystitis). Our objective is to describe the surgical technique of urinary diversion using large intestine as a conduit whilst creating an end colostomy, thereby avoiding a primary bowel anastomosis and to show its applicability with respect to urologic conditions. MATERIALS AND METHODS: We retrospectively reviewed five cases from a single institution that utilized the described method of urinary diversion with large intestine. We describe operative times, hospital length of stay (LOS), and describe post-operative complications. RESULTS: Five patients with a variety of urologic and oncologic pathology underwent the described procedures. Their operative times ranged from 5 hours to 11 hours and one patient experienced a Clavien III complication. CONCLUSION: We describe five patients who underwent this procedure for various medical indications, and describe their outcomes, and believe dual diversion of urinary and gastrointestinal systems with colon as a urinary conduit to be an excellent surgical option for the appropriate surgical candidate.


Assuntos
Colo Sigmoide/cirurgia , Colostomia/métodos , Derivação Urinária/métodos , Adulto , Anastomose Cirúrgica , Cistectomia/métodos , Humanos , Tempo de Internação , Masculino , Ilustração Médica , Pessoa de Meia-Idade , Duração da Cirurgia , Reprodutibilidade dos Testes , Resultado do Tratamento , Doenças da Bexiga Urinária/cirurgia
6.
Int Braz J Urol ; 45(6): 1094-1104, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31808396

RESUMO

INTRODUCTION: The health-related QoL is a patient-centered evaluation covering several aspects. This evaluation seems to be particularly important in patients submitted to radical cystectomy (RC) and urinary diversion with ileal conduit (IC) or a neobladder (NB). OBJECTIVE: Review all recent data comparing QoL outcomes after radical cystectomy with NB and IC diversions. EVIDENCE ACQUISITION: A systematic search in PubMed/Medline, Embase, and Cochrane databases was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement in December 2018. All articles published from January 01, 2012 to December 31, 2018, were included. A study was considered relevant if it compared QoL outcomes using validated questionnaires (EORTC QLQ C30, FACT-G, FACT-BL, FACT-VCI, and BCI). EVIDENCE SYNTHESIS: In 11 included studies, a total of 1389 participants were accounted (730 NB and 659 IC cases). The studies were conducted in 8 different countries, two were prospective, and none was randomized. There were two studies favoring results with a neobladder, 3 with incontinent diversion and 6 with no differences. The EORTC-QLQ-C30 was the most used instrument (5 studies) followed by FACT VCI and BCI (3 studies each). Given the heterogeneity of data and lack of prospective studies, a meta-analysis was not performed. CONCLUSION: No superiority of one urinary diversion was characterized. It seems that the choice must be individualized with an extensive preoperative orientation of the patient and their relatives. That will probably infl uence how the patient accepts the new condition.


Assuntos
Cistectomia/reabilitação , Qualidade de Vida , Derivação Urinária/reabilitação , Cistectomia/métodos , Cistectomia/psicologia , Feminino , Humanos , Masculino , Qualidade de Vida/psicologia , Inquéritos e Questionários/normas , Fatores de Tempo , Resultado do Tratamento , Derivação Urinária/métodos , Derivação Urinária/psicologia
7.
Actas urol. esp ; 43(10): 568-572, dic. 2019. tab
Artigo em Espanhol | IBECS | ID: ibc-185264

RESUMO

Introducción y objetivos: El estudio se realizó con el objetivo de identificar los factores de riesgo de la formación de cálculos en el tracto urinario superior en pacientes con derivación urinaria tras cistectomía radical (CR). Materiales y métodos: Se recogieron los datos de todos los pacientes con derivación después de la CR tratados en nuestro centro desde enero del 2005 hasta diciembre del 2013. Se incluyeron 3tipos de derivaciones diferentes: neovejiga ortotópica (NO: 168 pacientes), conducto ileal (CI: 93 pacientes) o ureterostomía cutánea (UC: 104 pacientes). Se realizó análisis de regresión logística univariante y multivariante para identificar los predictores independientes de formación de cálculos en el tracto superior. Resultados: Se incluyó a 365 pacientes tratados consecutivamente (316 hombres, 49 mujeres). Con una mediana de seguimiento de 48 meses (rango 12-65 meses), 36 pacientes (9,9%) desarrollaron cálculos en el tracto superior. Entre ellos, 26 (72,2%), 5 (13,9%) y 5 (13,9%) pacientes fueron tratados mediante NO, CI y UC, respectivamente. Veinticinco pacientes presentaron cálculos renales y 11, cálculos ureterales. La cirugía mínimamente invasiva (litotricia endoscópica con láser mediante abordaje anterógrado o retrógrado en 24 casos, nefrolitotomía percutánea en 9 casos y litotricia con ondas de choque en 3 casos) se realizó con éxito en todos los casos. En el análisis uni y multivariante de regresión logística, se encontró que las variables diabetes mellitus, la hipertensión, la infección del tracto urinario (ITU), la estenosis de la anastomosis y el tipo de derivación se asocian positivamente con la formación de cálculos en el tracto urinario superior. Conclusiones: Podemos afirmar que la diabetes mellitus, la hipertensión, la ITU, la estenosis de la anastomosis y el tipo de derivación son variables predictoras de la formación de cálculos en el tracto superior


Introduction and objectives: The study was conducted to identify the risk factors of upper tract stone formation in patients with diversions after radical cystectomy (RC). Materials and methods: All patients with diversion after RC were collected in our center from January 2005 to December 2013. Three different common diversions were included: Orthotopic neobladder (ON: 168 patients), Ileal Conduit (IC: 93 patients) or Ureterocutaneostomy (UC: 104 patients). Univariable and multivariable logistic regression analysis were conducted to identify the independent predictors of stone formation in the upper tract. Results: A total of 365 consecutive patients (316 males, 49 females) were included. At a median follow-up of 48 months (range 12-65 months), 36 patients (9.9%) developed upper tract stone. Among them, 26 (72.2%), 5 (13.9%) and 5 (13.9%) patients underwent ON, IC and UC, respectively. 25 patients had renal stone and 11 ureter stone. Minimally invasive operations (endoscopic laser lithotripsy via the anterograde or retrograde approach in 24 cases, percutaneous nephrolithotomy in 9 cases and shock wave lithotripsy in 3 cases) were carried out successfully in all stone cases. On univariable and multivariable logistic regression analysis, diabetes mellitus, hypertension, urinary tract infection (UTI), anastomotic stenosis and types of diversions (P < .05) were positively associated with upper tract stone formation. Conclusion: The variable predictors of upper tract stone may contain diabetes mellitus, hypertension, UTI, anastomotic stenosis and types of diversión


Assuntos
Humanos , Masculino , Feminino , Idoso , Cálculos Urinários/complicações , Fatores de Risco , Cistectomia/métodos , Derivação Urinária/métodos , Cistectomia/efeitos adversos , Análise de Regressão , Ureterostomia/métodos , Cálculos Urinários/diagnóstico por imagem , Tomografia por Emissão de Pósitrons
8.
Medicine (Baltimore) ; 98(48): e18000, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31770212

RESUMO

RATIONALE: Bladder cancer (BC) is commonly diagnosed in the urinary system and the most common subtype is transitional urothelial carcinoma (TCC). Even with the best treatment, tumor recurrence and metastases always occur. While clinicians commonly observe the metastases to pelvic lymph nodes, liver, lung, and bone, it may infrequently spread to some uncommon locations. PATIENT CONCERNS: The patient was a 67-year-old man with a diagnosis of high-grade TCC with squamous differentiation in the bladder and prostate. Subsequently, radical cystoprostatectomy, adjuvant radiotherapy, and chemotherapy were performed. However, he felt intermittent right scrotal pain about 1 year later. DIAGNOSIS: Ultrasound strongly suggested a testicular neoplasm of right testis, but the left was normal. INTERVENTIONS: The patient underwent a right radical orchiectomy and histopathology confirmed testicular metastatic neoplasm from bladder. Moreover, further examination with positron emission tomography revealed no visible distant spread of the urothelial carcinoma. OUTCOMES: No signs of tumor recurrence or distant metastasis were visible under follow-up 1 year after radical orchiectomy. LESSONS: Testicular mass may be metastatic tumor during follow-up for patients who were diagnosed as BC, especially for TCC with variant histology. The reason of this could be explained of residual micrometastases after surgery and need more examination to discover local micrometastases to apply more aggressive treatment.


Assuntos
Carcinoma de Células de Transição/secundário , Cistectomia/efeitos adversos , Prostatectomia/efeitos adversos , Neoplasias da Próstata/patologia , Neoplasias Testiculares/secundário , Neoplasias da Bexiga Urinária/patologia , Idoso , Carcinoma de Células de Transição/cirurgia , Cistectomia/métodos , Humanos , Masculino , Período Pós-Operatório , Prostatectomia/métodos , Neoplasias da Próstata/cirurgia , Neoplasias da Bexiga Urinária/cirurgia , Urotélio/patologia
10.
Pan Afr Med J ; 33: 184, 2019.
Artigo em Francês | MEDLINE | ID: mdl-31565144

RESUMO

We here report a case of bladder urothelial carcinoma, a rare tumor in subjects less than 40 years, as well as our therapeutic experience. The study involved a 37-year old patient with a history of urinary tract infection and of staying at a riparian area (bilharzia) presenting with hypogastralgia and total macroscopic hematuria. Clinical and paraclinical assessment showed voluminous bladder mass suggesting infiltrative tumor without local or distant lymph node or organic involvement. Surgical management was based on resection of bladder tumor and biopsy followed by total cystectomy with substitutive ileal enterocystoplasty. The postoperative course was uneventful. The patient also underwent adjuvant chemotherapy and vitamin B-12 therapy. Clinical and paraclinical assessment, performed after 6 and 12 months, showed no recurrence.


Assuntos
Carcinoma de Células de Transição/cirurgia , Cistectomia/métodos , Neoplasias da Bexiga Urinária/cirurgia , Procedimentos Cirúrgicos Urológicos/métodos , Adulto , Carcinoma de Células de Transição/diagnóstico , Carcinoma de Células de Transição/patologia , Quimioterapia Adjuvante/métodos , Seguimentos , Humanos , Íleo/cirurgia , Masculino , Recidiva Local de Neoplasia , Resultado do Tratamento , Neoplasias da Bexiga Urinária/diagnóstico , Neoplasias da Bexiga Urinária/patologia , Vitamina B 12/administração & dosagem
11.
Urology ; 134: e1-e2, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31586569
12.
Medicine (Baltimore) ; 98(41): e17222, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31593079

RESUMO

RATIONALE: Radical cystectomy and urinary diversion remains the definite management for muscle invasive bladder urothelial cancer. Internal herniation caused by ureteral adhesion is an extremely rare complication after the procedure. To the best of our knowledge, this is the first case report of small bowel obstruction and internal herniation occurring between bilateral ureters and urinary diversion after robot-assisted radical cystectomy (RARC). PATIENT CONCERNS: A 64-year-old woman presented with symptom of small bowel obstruction such as nausea, vomiting, and abdominal fullness after RARC and Indiana pouch. Another 61-year-old man presented with left obstructive hydronephrosis and recurrent pyelonephritis after RARC and ileal conduit. DIAGNOSIS: Both patients received computed tomography scans and the results were suggestive of small bowel herniation between bilateral ureters and urinary diversion. INTERVENTIONS: The 2 patients underwent open ureterolysis and internal hernia reduction. During the operation, bowel loop herniation between the interureteral spaces were found. OUTCOMES: Both patients recovered smoothly after second operation. LESSONS: The incidence of internal herniation may increase by the growing use of RARC. Suitable stoma position, appropriate length of ureter dissection, and retroperitonealization can help prevent this complication.


Assuntos
Cistectomia/efeitos adversos , Hérnia/etiologia , Complicações Pós-Operatórias/etiologia , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Doenças Ureterais/etiologia , Derivação Urinária/efeitos adversos , Cistectomia/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Robóticos/métodos , Derivação Urinária/métodos
13.
Urology ; 134: 124-134, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31542459

RESUMO

OBJECTIVE: To assess the success of robot-assisted holmium laser debridement of the pubic symphysis for osteomyelitis of the pubic symphysis with associated urosymphyseal fistula. Traditionally, excision of the fistulous tract and concomitant cystectomy with urinary diversion and pubic symphyseal debridement has been done using an open approach. This paper presents patients who were successfully managed with this approach. METHODS AND MATERIALS: Between January 2007 and January 2018, all patients who underwent pubic symphyseal debridement with or without cystectomy were identified. We reviewed patients who underwent planned robot-assisted cystectomy with holmium laser debridement for osteomyelitis of the pubic symphysis as a result of urinary fistula. Data on clinical presentation, perioperative outcomes, and recurrence of urinary tract fistula and symptoms were collected. RESULTS: Twelve patients underwent holmium laser debridement of the pubic symphysis during robot-assisted cystectomy for urinary fistula. Eleven patients had prior radiation treatments for prostate cancer with all having failed prior conservative management. Median operative time was 270 minutes with median length of stay of 5 days. At last follow-up, 11 (91.7%) of patients had complete resolution of their urinary fistula at median follow-up of 29 months. No patients developed osteonecrosis of the bone or complications from their urinary diversion at last follow-up. CONCLUSION: Definitive surgical treatment with holmium laser debridement of the pubic symphysis with concomitant robot-assisted cystectomy and urinary diversion is a safe and durable approach to the complex problem of urinary fistula with pubic symphysis osteomyelitis.


Assuntos
Desbridamento/instrumentação , Lasers de Estado Sólido , Osteomielite/cirurgia , Sínfise Pubiana/cirurgia , Procedimentos Cirúrgicos Robóticos , Fístula Urinária/cirurgia , Idoso , Idoso de 80 Anos ou mais , Perda Sanguínea Cirúrgica , Cistectomia/métodos , Seguimentos , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Osteomielite/microbiologia , Sínfise Pubiana/diagnóstico por imagem , Sínfise Pubiana/microbiologia , Estudos Retrospectivos , Tomografia Computadorizada por Raios X
14.
Urology ; 134: 90-96, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31560917

RESUMO

OBJECTIVE: To describe a rare complication in 5 women who had vaginal prolapse, dehiscence, and/or evisceration after having undergone robotic-assisted radical cystectomy with creation of ileal conduit urinary diversion. Radical cystectomy is the standard of care in the extirpative treatment for muscle invasive urothelial carcinoma. Anterior exenteration in the female patient requires removal of the anterior vaginal wall, urethra, uterus, and adnexa which results in significant changes to the pelvic floor. METHODS: Retrospective identification of all women having undergone robotic-assisted radical cystectomy for urothelial carcinoma who ultimately represented with vaginal prolapse, dehiscence, and/or evisceration between January 2012 and April 2019. We identified patient characteristics detailing their presentation. A review of the available literature highlighted the lack of available information in this uncommon cohort. RESULTS: Five women with vaginal dehiscence and/or evisceration who had previously undergone robotic-assisted radical cystectomy, anterior vaginectomy with urethrectomy, pelvic lymph node dissection, and creation of ileal conduit by 4 surgeons were identified. Mean interval time to initial presentation of prolapse or dehiscence was 44.4 weeks (range 11-120). In the 2 patients that eviscerated prior to repair, this occurred at 5 and 25 weeks after initial outpatient consultation. All reconstructive efforts were approached transvaginally. Two patients underwent 2 or more repairs. Management options included expectant management, pessary, and immediate vs delayed transvaginal surgical repair. CONCLUSION: Our case series describes the unique and potentially devastating complication of vaginal dehiscence and bowel evisceration in women with history of robotic-assisted radical cystectomy.


Assuntos
Carcinoma/cirurgia , Doenças do Colo , Cistectomia , Herniorrafia/métodos , Distúrbios do Assoalho Pélvico , Complicações Pós-Operatórias/cirurgia , Deiscência da Ferida Operatória , Neoplasias da Bexiga Urinária/cirurgia , Prolapso Uterino , Idoso , Carcinoma/patologia , Doenças do Colo/etiologia , Doenças do Colo/cirurgia , Cistectomia/efeitos adversos , Cistectomia/métodos , Feminino , Humanos , Pessoa de Meia-Idade , Invasividade Neoplásica , Distúrbios do Assoalho Pélvico/diagnóstico , Distúrbios do Assoalho Pélvico/etiologia , Distúrbios do Assoalho Pélvico/cirurgia , Reoperação/métodos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Procedimentos Cirúrgicos Robóticos/métodos , Deiscência da Ferida Operatória/etiologia , Deiscência da Ferida Operatória/cirurgia , Resultado do Tratamento , Neoplasias da Bexiga Urinária/patologia , Derivação Urinária/efeitos adversos , Derivação Urinária/métodos , Prolapso Uterino/etiologia , Prolapso Uterino/cirurgia
15.
Cancer Radiother ; 23(6-7): 732-736, 2019 Oct.
Artigo em Francês | MEDLINE | ID: mdl-31400955

RESUMO

When localized, the reference treatment of urothelial, muscle-invasive bladder tumours relies on radical cystectomy with reconstruction by enterocystoplasty if possible or Bricker bypass. Trimodal therapy combining transurethral resection of the tumour followed by concomitant chemotherapy may be considered as a therapeutic alternative to radical cystectomy in well-selected patients with unifocal tumours, stage T2, non-diverticular location, without in situ carcinoma or hydronephrosis and with macroscopically complete transurethral resection. The functional prognosis of the bladder and quality of life should be discussed with the patient as well as the need for salvage surgery for persistent tumour at a 45-Gy dose level, the latter being a highly unfavourable prognosis factor. On the other hand, this trimodal treatment is the reference in case of surgical contraindication. This article details the methods and results of the main series available in the literature in terms of local control, survival, bladder preservation rates and complications, as well as study prospects.


Assuntos
Quimiorradioterapia/métodos , Tratamentos com Preservação do Órgão/métodos , Neoplasias da Bexiga Urinária/terapia , Bexiga Urinária , Antineoplásicos/uso terapêutico , Terapia Combinada/métodos , Cistectomia/métodos , Humanos , Qualidade de Vida , Bexiga Urinária/cirurgia , Neoplasias da Bexiga Urinária/patologia
16.
Urology ; 133: 164-174, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31401220

RESUMO

OBJECTIVE: To address the overarching question whether chemoradiation therapy (CMT) offers overall survival (OS) similar to that of radical cystectomy (RC) in muscle-invasive bladder cancer (MIBC), we performed analyses using the National Cancer Database. MATERIALS AND METHODS: Patients diagnosed with MIBC in 2004-2014 who underwent RC or received primary CMT were identified in the National Cancer Database. Survival was estimated using the weighted Kaplan-Meier method, and propensity score-weighted Cox proportional hazards model were used to evaluate association of clinicopathologic features with outcome. RESULTS: Of 484,367 patients with a diagnosis of bladder cancer, 35,856 underwent RC and 4050 received CMT. After applying the exclusion/inclusion criteria, data for 15,854 patients who underwent RC and 2083 who received CMT were available for analysis. Five-year OS was 40.4% in the RC group and 29.4% in the CMT group (P <.001). OS was significantly shorter in the CMT group than in the RC group in both multivariate analysis (hazards ratio [HR] 1.15, 95% CI 1.08-1.22; P <.001) and propensity score-weighted analysis (HR 1.18, 95% CI 1.07-1.30; P <.001). Interaction terms indicated better survival after RC in patients younger than 70 years (HR 1.61, 95% CI 1.34-1.93; P <.001); subgroup analyses identified a survival benefit in patients with N0/N1 disease who underwent RC (HR 1.21, 95% CI 1.09-1.33; P <.001). CONCLUSION AND RELEVANCE: OS after 1 year of treatment was increased in RC group compared to CMT group in patient with MIBC. Further studies are required to identify optimal treatment for specific patients.


Assuntos
Quimiorradioterapia , Cistectomia , Neoplasias da Bexiga Urinária/mortalidade , Neoplasias da Bexiga Urinária/terapia , Idoso , Idoso de 80 Anos ou mais , Cistectomia/métodos , Bases de Dados Factuais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica , Pontuação de Propensão , Taxa de Sobrevida , Estados Unidos , Neoplasias da Bexiga Urinária/patologia
17.
Expert Opin Investig Drugs ; 28(9): 757-770, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31412742

RESUMO

Introduction: The current first line therapy for high grade (HG) non-muscle invasive bladder cancer (NMIBC) is intravesical Bacillus Calmette-Guerin (BCG). Patients who recur or progress despite BCG are recommended to undergo radical cystectomy or participate in clinical trials. There is an urgent need for alternative therapies in the BCG-unresponsive NMIBC realm. Areas covered: We queried clinicaltrials.gov and pubmed.gov for current and recently completed early clinical trials pertaining to investigational agents used for the treatment of BCG-unresponsive NMIBC. These included intravesical chemotherapy, immunotherapy, vaccines, gene therapy, viruses, and agents used with novel drug delivery methods. In this article, we discuss the treatment guidelines for non-muscle invasive bladder cancer and therapeutic approaches under investigation in clinical trials. Expert opinion: The FDA is currently allowing single-arm studies as a pathway for approval in BCG-refractory patients with CIS. Although many agents are currently undergoing testing, none have been approved since Valrubicin. Hopefully, we will identify therapies sufficiently effective and durable to achieve FDA approval. Other considerations in this realm include the use of biomarkers in NMIBC to identify patients who will most likely respond to specific interventions. In addition, as systemic agents such as checkpoint inhibitors, are studied further, a multidisciplinary approach may be needed to treat this subset of patients.


Assuntos
Antineoplásicos/farmacologia , Drogas em Investigação/farmacologia , Neoplasias da Bexiga Urinária/terapia , Animais , Antineoplásicos/administração & dosagem , Vacina BCG/administração & dosagem , Biomarcadores Tumorais/metabolismo , Cistectomia/métodos , Sistemas de Liberação de Medicamentos , Drogas em Investigação/administração & dosagem , Humanos , Imunoterapia/métodos , Invasividade Neoplásica , Recidiva Local de Neoplasia , Neoplasias da Bexiga Urinária/patologia
19.
Urology ; 133: 157-163, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31421144

RESUMO

OBJECTIVE: To determine if the timing of radical cystectomy for variant histology of urothelial carcinoma has an impact on survival. Variant histology has been associated with aberrant behavior compared to pure urothelial carcinoma, however the timing of surgery for these patients has not been studied. MATERIALS AND METHODS: We identified 363 patients with cT2-T4N0M0 urothelial carcinoma who underwent radical cystectomy without perioperative intravesical and/or systemic therapy from 2003 to 2014. Clinicopathologic data were compared between pure urothelial carcinoma and variant histology. The time from diagnosis to radical cystectomy was analyzed as a continuous variable and dichotomized at 4-, 8-, and 12-weeks to determine impact on oncologic outcomes. RESULTS: Patients with variant histology, when compared to those with pure urothelial carcinoma, were more likely to present with extravesical disease (P <.01), be upstaged (P <.01), have lymphovascular invasion (P <.01) and have lymph node metastasis at radical cystectomy (P = .02). The median days to radical cystectomy did not differ between pure urothelial and variant histology. On multivariable analysis controlling for age, comorbidities, tumor stage, lymph node status, lymphovascular invasion, and surgical margins, every month in delay was associated with a worse overall survival for variants (HR = 1.36, P = .003). At an 8-week delay or longer, those with variant histology had a statistically worse survival (P = .03). CONCLUSION: For patients with variant histology, delays in surgery were associated with an increased risk of death.


Assuntos
Carcinoma de Células de Transição/patologia , Carcinoma de Células de Transição/cirurgia , Cistectomia/métodos , Tempo para o Tratamento , Neoplasias da Bexiga Urinária/patologia , Neoplasias da Bexiga Urinária/cirurgia , Idoso , Carcinoma de Células de Transição/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida , Tempo para o Tratamento/estatística & dados numéricos , Neoplasias da Bexiga Urinária/mortalidade
20.
Med Care ; 57(9): 728-733, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31313685

RESUMO

BACKGROUND: Regionalization to higher volume centers has been proposed as a mechanism to improve short-term outcomes following complex surgery. OBJECTIVE: The objective of this study was to assess trends in regionalization and mortality for patients undergoing radical cystectomy (RC). RESEARCH DESIGN: An observational study of patients receiving RC in the United States from 2004 to 2013. SUBJECTS: Data for patients receiving RC were extracted from the National Cancer Database. MEASURES: The primary exposure was hospital volume; low-volume hospitals (LVH) included those with <5 RC/year and high-volume hospitals (HVH) were those with ≥30 RC/year. Trends in the volume were assessed, as were 30- and 90-day mortality. Cochrane-Armitage tests were performed for volume, and propensity score-weighted proportional hazard regression was used to assess mortality. RESULTS: A total of 47,028 RC were performed in 1162 hospitals from 2004 to 2013. The proportion of RC at LVH declined from 29% to 17% (P<0.01), whereas that of HVH increased from 16% to 33% (P<0.01). Unadjusted 30- (P=0.02) and 90-day (P<0.001) mortality decreased, and the absolute decrease was greatest at LVH (4.8% vs. 2.6%, P=0.03), whereas rates for HVH remained stable (1.9% vs. 1.4%, P=0.34). Following risk-adjustment, relative to treatment at HVH, treatment at LVH was associated with increased 30-day (hazard ratio: 1.66, 95% CI: 1.53-1.80) and 90-day mortality (hazard ratio: 1.37, 95% confidence interval: 1.30-1.44). CONCLUSIONS: Regionalization of RC to HVH was observed from 2004 to 2013. Treatment at LVH was associated with 66% and 33% relative increases in hazard of death at 30 and 90 days, respectively. These findings support the selective referral of complex cases to higher volume centers.


Assuntos
Cistectomia/mortalidade , Mortalidade Hospitalar/tendências , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Adolescente , Adulto , Idoso , Cistectomia/métodos , Bases de Dados Factuais , Feminino , Geografia , Humanos , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estados Unidos , Adulto Jovem
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