The role of neoadjuvant chemotherapy for patients with variant histology muscle invasive bladder cancer undergoing robotic cystectomy: Data from the International Robotic Cystectomy Consortium.

OBJECTIVE: To assess the role of neoadjuvant chemotherapy (NAC) before robot-assisted radical cystectomy (RARC) for patients with variant histology (VH) muscle-invasive bladder cancer (MIBC). METHODS: Retrospective review of 988 patients who underwent RARC (2004-2023) for MIBC. Primary outcomes included the utilization of NAC among this cohort of patients, frequency of downstaging, and discordance between preoperative and final pathology in terms of the presence of VH. Secondary outcomes included disease-specific (DSS), recurrence-free (RFS), and overall survival (OS). RESULTS: A total of 349 (35%) had VH on transurethral resection or at RARC. The 4 most common VH subgroups were squamous (n = 94), adenocarcinoma (n = 64), micropapillary (n = 34), and sarcomatoid (n = 21). There was no difference in OS (log-rank: P = 0.43 for adenocarcinoma, P = 0.12 for micropapillary, P = 0.55 for sarcomatoid, P = 0.29 for squamous), RFS (log-rank: P = 0.25 for adenocarcinoma, P = 0.35 for micropapillary, P = 0.83 for sarcomatoid, P = 0.79 for squamous), or DSS (log-rank P = 0.91 for adenocarcinoma, P = 0.15 for micropapillary, 0.28 for sarcomatoid, P = 0.92 for squamous) among any of the VH based on receipt of NAC. Patients with squamous histology who received NAC were more likely to be downstaged on final pathology compared to those who did not (P < 0.01). CONCLUSION: Our data showed no significant difference in OS, RFS, or DSS for patients with VH MIBC cancer who received NAC before RARC. Patients with the squamous variant who received NAC had more pathologic downstaging compared to those who did not. The role of NAC among patients with VH is yet to be defined. Results were limited by small number in each individual group and lack of exact proportion of VH.

World social impact of assisted reproductive

In considering the uptake of ART around the world and in particular regions, it is crucial to consider outcome and what is considered to be successful treatment. Standardisation of reporting for comparability between clinics and countries is essential. This will be affected by multiple pregnancy and efforts to minimize them and the anxiety relating to possible problems such as imprinting abnormalities. General access is influenced by ethical by ethical and religious value systems, which in turn impinge on the political nature of discussions about provision. Of primary importance is the extent of access to treatment; the need for ART in the first instance is related to the prevalence of STDs and the quality of reproductive health services in the community. Access is critically determined by whether ART is provided by the public health system, otherwise it is the preserve of the better off. However, the public health system does not usually accord ART high priority. Even in the UK where there has been a positive analysis of the evidence base by the public health service, funding remains a major issue. ART is not explicitly included in the UN Millennium Development Goals, however they could be interpreted as including it. Of importance was the WHO Ministerial Summit on Health Research held in Mexico last November. Its recommendations and timetable were aimed at overcoming health system constraints to the delivery of all health care, in particular promoting access in low income settings. Successful implementation of any recommendations will likely have a long term impact on the provision of all health care. Perhaps 50% of all infertility can be treated by ART. It should no longer be seen as the high tech end of provision, only required by a few. It should be widely available and included in public health provision. The technical challenge is to reduce the cost and increase the efficacy. But the greater challenge for the medical scientific communities is to educate the public and the politicians to understand the techniques and their implications. Cost-benefit analyses will be required to demonstrate appropriate and wise spending and to show a rational case for the public health expenditure. The development of trusted regulatory system will also be necessary, ideally with legal flexibility to encompass scientific advances. Only then can public health provision of ART be envisaged; funding allocation must follow for it to become readily available. Although ART births are now contributing significantly to national data in some countries, the social impact on the world community will continue to be minimal until these changes have taken place.