 is professor of surgery in the division of urology at Albany Medical College in New York.

Badar M. Mian, MD

Although much of our attention in treating patients with bladder cancer (BC) is focused on cancer control, patients and their families must face other real-life issues that significantly impact survivorship. Despite being of critical importance to the patients, health-related quality of life (HRQOL) after various treatments for BC has remained underappreciated until recent years. Previous studies on HRQOL have been small and limited in scope, focusing mainly on radical cystectomy (RC) or radiation therapy (RT) for muscle-invasive bladder cancer (MIBC) and the related urinary, bowel, and sexual dysfunction. The HRQOL after non–muscle-invasive bladder cancer (NMIBC) and how BC-related QOL compares with other pelvic cancers are not well understood.

To address this gap in knowledge, Catto et al conducted a population-level study of HRQOL of patients between 1 and 10 years since BC diagnosis.

 The authors used a mail-in survey between January 2007 and December 2016 of patients diagnosed in 22 British National Health Service hospitals (representing 11% of the population). Patients with BC were identified through the National Cancer Registration and Analysis Service and were asked to participate in the survey. Several tools were used such as general HRQOL questionnaire including questions related to mobility, self-care, daily activities, pain/discomfort, and anxiety/depression. The European Organization for Research and Treatment of Cancer (EORTC) QOL questionnaire (which includes functional and symptom scales, financial impact, global QOL scale) was combined with EORTC-NMIBC QOL questionnaire to assess urologic symptoms.

Of the 3279 eligible participants, 1796 (55%) completed the survey. The average age of respondents was 75 years (11% were younger than 65 years), and only 1.0% were non-White. The nonresponders were older and lived in underserved areas. At least 1 long-term comorbid condition was reported by 76%, and 11% reported 4 or more comorbidities (hypertension, 24%; coronary artery disease, 14%; and diabetes, 11%). Of the respondents, 48% (n = 868) had treatment for NMIBC (transurethral resection of bladder tumor [TURBT]±intravesical treatment), 23% underwent RC alone, 17% received RC plus neoadjuvant chemotherapy (or prior BCG), and 7% underwent RT with curative intent.

Of the respondents, 69% reported at least 1 problem on the general HRQOL, with the most frequently reported issues including difficulty with mobility, daily activities, and pain/discomfort. The overall mean self-assessed health (SAH) score was 74 (out of 100), and it did not differ based on cancer stage (MIBC or NMIBC) or extent of treatment, eg, SAH score ranged from 75 in the RC-alone group to 71 in the RT group.

Regardless of treatment type, increasing age and number of comorbidities were associated with increasing frequency of reported problems in all general HRQOL domains (mobility, self-care, daily activities, and pain) with the exception of anxiety/depression, which was highest in the younger age groups. Also, multimodal treatment combinations (TURBT with/without intravesical treatment, RC with/without chemotherapy) did not impact HRQOL.

On the cancer-related QOL questionnaire, the mean global health score was 71 (out of 100) after RC compared with 69 after radical RT. No meaningful differences in scales or symptom scores were noted among the treatment groups (TURBT, RC, or RT) or cancer stages (I to IV). However, worse functional and symptom scores were noted with increasing age and comorbid conditions. Of note, a higher rate of financial difficulties was reported by younger patients—and especially in the younger patients undergoing RC—compared with those undergoing TURBT.

On the BC-specific QOL measures, bladder symptom scores varied considerably across different treatments and tumor stages. Worse urinary symptoms were reported following RT compared with TURBT, whereas urinary symptoms in participants following RC with neobladder were similar to those following TURBT. Also, addition of intravesical therapy to TURBT did not worsen the urinary symptoms. Worse problems with body image, sexual intimacy, sexual enjoyment, and male sexual problems were reported by those who underwent RC, which worsened with increasing age. The missing responses regarding sexual problems in women did not allow for an accurate evaluation of this domain.

Because only 12% of patients underwent ileal neobladder, the comparisons of HRQOL between various urinary diversions were not informative due to mismatch in sample size, age, and health of patients. Interestingly, there were no significant differences in HRQOL scores in each questionnaire based on the time from diagnosis of BC, possibly suggesting that HRQOL may stabilize after some time.

The general HRQOL was worse after treatment for BC than for prostate or colorectal cancer treatment across all domains except anxiety/depression. The differences were greatest for problems with mobility and daily activities. For example, 48% of men with bladder cancer reported problems with mobility compared with 36% of men with colorectal cancer, 34% of men with prostate cancer, and 25% of the general male population.

Higher rates of sexual dysfunction were reported by men with bladder cancer, and significant financial toxicity was reported in younger patients. Compared with the general population and those with other common pelvic cancers, patients with BC reported lower HRQOL. The use of multimodality treatment did not appear to adversely affect the HRQOL. Participants who received TURBT alone or TURBT with intravesical therapies and those who underwent RC alone or RC with systemic chemotherapy had similar urinary symptoms and sexual function scores. “It was reassuring that overall QOL in our participants was mostly associated with their age and fitness, rather than treatment intensity or treatment received. This should reassure patients and encourage them to make the safest choice - with respect to their cancer”, remarked lead author James Catto, MBChB, PhD, professor of urological surgery at theProfessor James Catto from the University of Sheffield in the United Kingdom.

Financial toxicity reported by younger patients receiving RC or TURBT was significantly higher than that reported by older patients; this is likely related to disruption in employment due to frequent visits required for cystoscopy and/or intravesical therapy or the temporary inability to work for 2 to 3 months or longer after radical surgery. Catto pointed out, “The most frequent problems in younger men < 65 years was loss of sexual function,” and that “financial toxicity for both NMIBC and MIBC was common in younger, still employed men, both of which require consideration when planning treatment.” Knowing the expected deterioration in sexual function and financial health associated with BC treatment should prompt early and specific counseling and mitigative strategies. Although more intense treatment schedules may not have affected many of the HRQOL measures, deintensification of treatment may be necessary to reduce financial toxicity.

As the investigators pointed out, the survey was conducted among participants in a public (free) health care system, and because the nonresponders were typically older and from underserved areas (both of which contribute to poor HRQOL), the full extent of BC-related decline in HRQOL of the population is likely to be worse than reported in the study.

The variation in overall HRQOL depending upon patient age and comorbidities may not be surprising, but the lack of difference in HRQOL based on treatment type, disease stage, or time from diagnosis may be unexpected. Trimodal therapy for BC is being discussed with increasing frequency to avoid radical surgery. The patient-reported HRQOL noted in this study showed no significant differences in outcomes between RC and RT; however, the cohort undergoing RT was small and older. Could an individual with high-grade NMIBC be offered either TURBT plus intravesical BCG or radical cystectomy with sufficient equipoise? This study provides important and clinically useful information that can be used to plan the intensity of treatment and counsel our patients regarding the cancer-related and QOL-related outcomes after treatment.

Catto JWF, Downing A, Mason S, et al. Quality of life after bladder cancer: a cross-sectional survey of patient-reported outcomes. Eur Urol. 2021;79(5):621-632. doi:10.1016/j.eururo.2021.01.032

Articles

"This study provides important and clinically useful information that can be used to plan the intensity of treatment and counsel our patients regarding the cancer-related and QOL-related outcomes after treatment," writes Badar M. Mian, MD.

QOL after bladder cancer treatment vs other cancers

Due to the low sensitivity of imaging studies, pelvic lymph node dissection (PLND) remains the most effective method for staging of prostate cancer. Due to paucity of randomized controlled trials (RCT), the role of various PLND templates, in terms of prognostic and therapeutic benefits, has remained controversial. Some experts believe that standard or limited PLND (LPLND) is sufficient for staging whereas others strongly support the use extended PLND (EPLND) for its potential to remove more lymph nodes and micrometastases. Two recently reported RCTs within the past 6 months are now available to illuminate this subject. The RCT by Lestingi et al

 report the results of an RCT that was designed to address the questions regarding the therapeutic benefits (ie, biochemical recurrence [BCR]-free survival) of EPLND compared to LPLND. From October 2011 to March 2017, of 1477 men undergoing radical prostatectomy and bilateral PLND, 700 men were randomized to the LPLND template and 740 to the EPLND template group. Instead of individual patient randomization, a cluster randomization strategy was employed for ease of consent and logistics of trial execution. The surgeons were cluster-randomized every 3 months to perform either LPLND or EPLND. Two surgeons were removed from the study in June 2015 for poor compliance with the randomized assignments.

Of the randomized patients, no PLND was performed in 42 and 55 patients in the LPLND and EPLND groups. Thirty-seven patients were excluded either due to withdrawal of consent (8) or being lost to follow-up (29). The distribution of biopsy Gleason scores (GS) in the LPLND and EPLND groups was 18% and 22% for GS of 8 or higher, 19% and 17% for GS 4+3, 52% and 52% for GS 3+4, and 10% and 9.4% for GS 6, respectively.

In terms of lymph node yield, a median of 12 lymph nodes were removed in the LPLND group compared with 14 in the EPLND group. The rate of lymph node metastasis (pN1) was 12% in the LPLND arm and 14% in the EPLND arm (

After a median follow-up of 3.1 years, 388 (26.9%) BCR events occurred in the entire cohort. Regardless of how the data were analyzed, there was no difference in the BCR rates between the LPLND or EPLND (

=.5) groups. Overall, the rates of Clavien-Dindo grade 2 and grade 3 complications (including deep vein thrombosis or lymphocele) were similar in the LPLND and EPLND groups at 7.3% and 6.4%, respectively. There were no grade 4 or 5 complications.

Similar lack of therapeutic effect of EPLND was noted in another RCT reported by Lestingi et al a few months ago. Although these 2 trials cannot be compared directly, there are several baseline differences amongst the trials worthy of consideration. The current trial was sufficiently powered with 1477 patients, compared with 300 patients in the earlier study. One main difference among the trials was in the EPLND template. The earlier trial by Lestingi et al included the common iliac nodes in the EPLND template, which yielded median 17 lymph nodes, but not in the current trial, which yielded median 14 lymph nodes. Conversely, the median lymph node count with LPLND in the current trial was much higher than in the earlier trial (12 vs lymph nodes 3 lymph nodes, respectively), and the rate of pN1 in the LPLND group was 12% in the current trial and only 3.4% in the earlier trial. Other nonrandomized series of PLND have demonstrated different results than the current trial, showing an increased number of lymph nodes with EPLND, and increase in the rate of pN1, according to John W. Davis, MD, of The University of Texas MD Anderson Cancer Center in Houston.

Although studies have reported variability in the correlation between more lymph nodes removed and higher rate of pN1, none have demonstrated a difference in BCR rates between LPLND and EPLND groups. Further, the benefit of 

 PLND in patients with intermediate-risk prostate cancer, which comprises the majority cohort in both of the RCTs, is subject to debate. A recent report by Altok et al evaluated the impact of omitting the PLND in cases with biopsy GS of 3+4 or lower, T1-2 who are subsequently upgraded to prostatectomy GS 4+3 or lower, or stage pT3.

 They noted that omission of PLND in appropriately matched cases did not alter the rate of BCR compared with those who underwent PLND (regardless of template). The current trial did not report the outcome of 97 patients in whom a PLND was omitted.

The authors of this RCT reported that the complication rates were similar in the LPLND and EPLND groups, which is similar to what has been reported by other nonrandomized studies, and is reflective of this author’s experience. Yet a recent large, systematic review and meta-analysis of this subject suggests otherwise. A study by Cacciamani et al reviewed 176 studies (77,303 patients) undergoing PLND.

 Intraoperative complications were noted in 1.8% and postoperative complications in 14.1%. The limited or standard PLND group experienced fewer complications (risk ratio, 0.55; 

=.01), especially lymphoceles and thromboembolic events, when compared with EPLND. EPLND was an independent predictor of increased complications, especially lymphocele formation (risk ratio, 1.77; 

When comparing this trial with other studies, the median lymph node count in the LPLND cohort were higher, and in the EPLND cohort was lower than expected. The lymphatic and fibrofatty tissue removed during PLND are contiguous and not anatomically compartmentalized based on the arbitrary template boundaries assigned by surgeons. The surgical technique and tissue handling by various surgeons can easily result in variations in lymph node count within the same template.

The lack of difference in the lymph node yield between the LPLND and EPLND templated noted in this RCT raises interesting questions about surgical technique, trial design, compliance with instructions, and surgical bias. This is illustrated by the fact that surgeons retrieved more lymph nodes from patients with high-risk prostate cancer even when they were assigned to perform LPLND. Knowledge of tumor characteristics and the awareness that their work is being reviewed may have influenced the surgical technique, resulting in higher-than-expected lymph node counts in the LPLND group and thus obscuring any potential differences in node count, pN1, or BCR rates.

It is common practice in uro-oncology to perform EPLND for high-risk prostate cancer. It remains unclear whether the increased lymph node yield or increased pN1 rates have any therapeutic effect on BCR. Neither the current nor the previous RCTs (and several nonrandomized studies) have reported any improvement in BCR rates with the use of EPLND. However, the median follow-up in both RCTs was relatively short and most patients harbored low- or intermediate-risk disease, which makes it difficult to draw firm conclusions.

Three decades into prostate-specific antigen screening–detected prostate cancer, the prognostic and therapeutic impacts of various types of pelvic lymph node dissection remain unclear. The role of PLND will be further challenged when more sensitive imaging and staging modalities (such as prostate-specific membrane antigen PET scan) become readily available. Although it’s likely that the urologists will continue to utilize EPLND despite unclear prognostic value, this will have to be balanced with the lack of therapeutic advantage, additional surgical time and cost, and possible increase in complications associated with EPLND.

1. Lestingi JFP, Guglielmetti GB, Trinh Q-D, et al. Extended versus limited pelvic lymph node dissection during radical prostatectomy for intermediate- and high-risk prostate cancer: early oncological outcomes from a randomized phase 3 trial. 

2021;79(5):595-604. doi:10.1016/j.eururo.2020.11.040

2. Mian BM. Extended pelvic lymph node dissection during RP does not appear beneficial. 

January 8, 2021. Accessed April 26, 2021. 

3. Touijer KA, Sjoberg DD, Benfante N, et al. Limited versus extended pelvic lymph node dissection for prostate cancer: a randomized clinical trial. 

Published online April 14, 2021. doi:10.1016/j.euo.2021.03.006

3. Altok M, Chapin BF, Matin SF, Achim MF, Gregg JR, Davis JW. Therapeutic consequences of omitting a pelvic lymph node dissection at radical prostatectomy when grade and/or stage increase. 

Published online March 4, 2021. doi:10.1016/j.urology.2021.01.064

4. Cacciamani GE, Maas M, Nassiri N, et al. Impact of pelvic lymph node dissection and its extent on perioperative morbidity in patients undergoing radical prostatectomy for prostate cancer: a comprehensive systematic review and meta-analysis. 

2021;4(2):134-149. doi:10.1016/j.euo.2021.02.001

"Three decades into prostate-specific antigen screening–detected prostate cancer, the prognostic and therapeutic impacts of various types of pelvic lymph node dissection remain unclear," writes Badar M. Mian, MD.

A tale of 2 lymph node dissections for prostate cancer

For men undergoing surgery for localized prostate cancer, which is often diagnosed at an early, curable stage, functional outcomes as important as oncological outcomes. Patient and tumor characteristics are often the subject of post-surgical outcomes studies. But, despite the commonly held belief that surgeon-related factors are an important determinant of surgical outcomes, the studies evaluating the effect of surgeon-related factors are infrequent and opaque.

In a recent update of a previously reported trial,

 Nyberg et al examine the effect of heterogeneity in surgeon experience and caseload on the outcomes after radical prostatectomy.1 A previous report on the Laparoscopic Prostatectomy Robot Open (LAPPRO) trial (a prospective, non-randomized, multicenter trial) comparing open radical prostatectomy (ORP) and robot-assisted laparoscopic prostatectomy (RALP) procedures demonstrated that there was no difference in the rate of urinary incontinence or oncological outcomes, and modestly improved erectile function after RALP.

The trial was conducted at 14 Swedish centers by 68 surgeons; however, the previous report only included surgeons who had performed at least 100 RPs before participating in the trial. In the current report, the authors included all participating surgeons to determine the influence of surgeon-related factors (including previous experience and current caseload) on the outcomes and to determine whether surgeon heterogeneity affected the comparative outcomes of ORP and RALP. The outcome measures included urinary incontinence, erectile dysfunction (ED), and cancer recurrence (prostate-specific antigen > 0.25 ng/mL) at 24 months after surgery.

Of the 3443 evaluable patients for this analysis, 826 underwent ORP and 2617 underwent RALP. A model including surgeons with at least 20 procedures during the study was developed that adjusted for the baseline patient and tumor characteristics to account for any differences in the case mix. Additional analyses included the subgroup of experienced surgeons (> 250 cases) and the annual caseload of surgeons during the study.

Amongst the main cohort of surgeons with 20 or more cases during the study period (n = 25), significant heterogeneity was noted in the incontinence rates, ranging from 5% to 30% (

 =.001). The rate of ED also varied significantly, ranging from 61% to 93% (

 <.001). Similarly, wide variation was noted in the recurrence rate from 4% to 35% (

 <.001). In the subgroup of surgeons with prior experience with more than 250 RPs (n = 12), significant heterogeneity in outcomes during the trial was noted in the rate of incontinence (P = .008), rate of ED (

 = .03). Despite adjusting for annual caseload, statistically significant heterogeneity of outcomes persisted for incontinence rate (

The authors analyzed the effect of prior experience, annual caseload, and extent of nerve sparing to determine the role of these surgeon-related factors on the heterogeneity in outcomes noted amongst the surgeons. It was noted that surgeons’ prior experience accounted for 42% of observed heterogeneity regarding incontinence (

 =.03), but did not affect the recurrence rate. The caseload during the trial accounted for 19% of heterogeneity in the rate of recurrence (

 =.01), but it did not significantly influence the rate of incontinence or ED. The extent of nerve-sparing explained only 5% of heterogeneity in both incontinence and ED (

The authors also evaluated whether the baseline patient/tumor characteristics and surgeon-related factors could explain the difference in the outcomes of ORP and RALP. After adjusting for baseline patient and tumor characteristics only, the difference in incontinence rate was significantly lower after ORP than after RALP.

Adjusting for the annual caseload increased the difference in favor of ORP whereas adjustments for previous experience reduced the difference in incontinence rate. Regarding ED, there was no statistically significant difference between ORP and RALP at baseline, but adjusting for surgeons’ experience alone, or in combination with current caseload resulted in improvement (less ED) in favor of RALP. In terms of recurrence rates, there was no significant difference between ORP and RALP at baseline, and additional adjustments for surgeons’ caseload or experience did not change this outcome.

This report demonstrates a large and significant variability of functional and oncological outcomes amongst individual surgeons, without clearly demonstrating the superiority of either ORP and RALP. The most important factor affecting the heterogeneity of functional outcomes appears to be the surgeon’s prior experience, whereas current caseload had a significant impact on oncological outcomes. This raises other questions that are of importance to the surgical specialties, our patients, and the health care systems in general. How do we identify surgeons with clearly better outcomes and train the ones in need of improvement? Who should have the responsibility or authority (the department or the hospital) to collect such data? If the surgeons’ outcomes data are to be placed in the public domain, what necessary steps would be required to ensure that the data are robust and the public is sufficiently educated to use that information properly?

It is important to note that the variability in functional and oncologic outcomes in this study persisted even after adjusting for surgical volume and experience. This clearly suggests that surgical volume alone is insufficient to promise improved outcomes after RP. There must be some other unmeasured or intangible factors that influence the functional and oncologic outcomes such as advanced training, hand-eye coordination, and tissue handling.

In a patient-centric approach, monitoring and reporting surgical outcomes, albeit challenging, may become necessary. Further efforts such as anonymous review of surgical videos, and intervention such as additional training, peer review, and feedback may be warranted to reduce the significant heterogeneity in outcomes noted amongst surgeons.

 is professor of surgery in the division of urology at Albany Medical College, Albany, New York.

1. Nyberg M, Hugosson J, Wiklund P, et al. Functional and oncologic outcomes between open and robotic radical prostatectomy at 24-month follow-up in the Swedish LAPPRO trial. 

2018;1(5)353-360. doi:10.1016/j.euo.2018.04.012

2. Nyberg M, Sjoberg DD, Carlsson SV, et al. Surgeon heterogeneity significantly affects functional and oncological outcomes after radical prostatectomy in the Swedish LAPPRO trial. 

. 2021;127(3):361-368. doi:10.1111/bju.15238

The trend persists even after adjusting for surgical volume and experience.

Prostate cancer functional and oncological outcomes vary among surgeons

Intravesical instillation of BCG remains the most frequently utilized therapy against high-grade non–muscle-invasive urothelial bladder cancer (NMIBC). Treating urologists are quite familiar with the identification and management of early urinary and systemic adverse effects of BCG instillation. However, the spread of BCG infection to other organs is less well appreciated, likely due to the low incidence of such complications. Further, the published literature mostly consists of single-case reports. To increase awareness of these complications, Cabas et al performed a systematic review of the published literature demonstrating the frequency and timing of potentially serious post-BCG infections involving genitourinary (GU) and non-GU sites.

To identify all case reports of post-BCG infections, the investigators systematically reviewed 401 publications through Medline and other searches. Of these, 271 case reports, including 307 patients, met the inclusion criteria for the review. From these reports, the authors compiled data including demographics, tumor grade/stage, number of intravesical instillations, number of organs with BCG infection, time from last BCG instillation to signs of infection, type of imaging utilized, microbiological confirmation, type and duration of surgical and nonsurgical treatment, and patient outcomes.

Of the 307 cases of post-BCG infection, only 4 (1.3%) occurred in female patients. The average number of intravesical BCG instillations prior to developing symptoms of infection was 8 plus or minus 5.3 instillations. A single organ/site was infected in 72.0%, 2 organs were affected 20.2%, and 3 or more organs were affected 7.8% of the cases. Of all the cases identified by the authors, including those with multiple organs involved, BCG-related infection of GU organs occurred in 23.7% and non-GU organs were involved in 76.2% of cases. Most frequently involved sites included non-GU organs such as lungs, vascular system, and liver, whereas the various GU organs (testis, penis, prostate, and kidneys) were involved equally and infrequently.

The median time from last BCG instillation to clinical signs of infection varied and depended on the organs involved. The granulomatous infection of the liver and lungs (such as miliary pulmonary infection) occurred earlier, at a median time of 1 week from the last instillation. In contrast, vascular lesions (endograft graft infection or mycotic aneurysm), bone/joint involvement (prosthetics infection or spondylodiscitis), and muscular involvement (psoas abscesses) occurred late, at a median of 52, 68, and 93 weeks, respectively. Amongst the GU organs, penile lesions (erythema, ulcer, granulomatous lesions) appeared at a median of 1 week, prostatitis or abscess at 3 weeks, renal granulomatous disease at a median of 8 weeks, and epididymo-orchitis at a median of 56 weeks.

Overall, microbiological diagnosis was made in 55.6% of cases through acid-fast stain, culture, or polymerase chain reaction test. The rate of isolation and mycobacteria identification at the affected sites also appears to be related to the organs involved. Microbiological detection was noted in 28.6% of penile lesions, 35.2% of lung lesions, and nearly 60% of prostate/epididymis/testis lesions. The highest rates of microbiological detection of the mycobacteria were noted in vascular (83.6%), bone/joint (91.7%), and muscle lesions (100%). In evaluating concomitant infections at various sites, the investigators observed a strong association (

 < .001) between lungs and liver complications, bone marrow and liver complications, bones/joints and muscles, and lungs and bone marrow complications. No significant associations between concomitant infections and various GU organ sites were identified.

The reported duration of antimycobacterial therapy ranged from a median of 6 weeks for penile or testicular lesions, 8 weeks for lungs or liver lesions, and 12 weeks for bone/joint infections. Surgical intervention was most frequently required for cases of infections involving vascular (83%), bone/joint (85.4%), and muscular systems (90.5%), whereas surgical intervention was relatively infrequent for lung (6.8%) and liver (8.9%) infections.

Of the GU organs involved with post-BCG infection, a majority (55%-90%) of the penile, prostate, and kidney infections manifested within 1 month of the last BCG instillation, whereas testicular cases appeared after 12 months or longer. For the non-GU organs, there appears to be a biphasic distribution of the time to post-BCG infection. A majority (50%-75%) of the lung, liver, and bone marrow infections became apparent within 1 month. More than 50% of the infections involving vascular, muscular, and bone/joint systems appeared 12-24 months after the last BCG instillation.

An interesting observation from this compilation of 307 case reports is that only 1.3% of post-BCG systemic infections occurred in female patients. One may speculate that the male anatomy (bulbar urethra, prostate) is more prone to catheter-related trauma during instillation, followed by increased exposure of traumatized area to the BCG when voiding. Both of these would result in potential intravasation of BCG resulting in systemic spread of BCG. Thus, strict adherence to the protocol for canceling the BCG in the presence of infection, and aborting the instillation in the setting of trauma and/or any degree of gross hematuria, is required. Although systemic infections involving non-GU organs are uncommon, these infections are associated with significant morbidity, and mortality. Of the 65 cases of vascular involvement, 10 (15.4%) died of BCG-related complications. The mortality rate for the post-BCG infections involving lungs, liver, and muscles was reported to be 4.1%, 3.6%, and 4.8%, respectively.

This study provides clinically useful data on the frequency and timing of BCG-related infection of various organ systems. Urologists play a pivotal, long-term role in the diagnosis and treatment of NMIBC, and essentially serve as the primary oncologists for patients with NMIBC. It is essential for us to be vigilant about all the complications, whether local or systemic, associated with intravesical BCG. A high index of suspicion is required for early identification of these infrequent, but potentially lethal, post-BCG systemic infections.

1. Cabas P, Rizzo M, Giuffrè M, et al. BCG infection (BCGitis) following intravesical instillation for bladder cancer and time interval between treatment and presentation: a systematic review. 

2021;39(2):85-92. doi:10.1016/j.urolonc.2020.11.037

"It is essential for us to be vigilant about all the complications, whether local or systemic, associated with intravesical BCG," writes Badar M. Mian, MD.

Badar M. Mian, MD

Articles

QOL after bladder cancer treatment vs other cancers

A tale of 2 lymph node dissections for prostate cancer

Prostate cancer functional and oncological outcomes vary among surgeons

Urologists must remain vigilant regarding post-BCG infection