Best of AUA 2014: Bladder Cancer

July 10, 2014

Wassim Kassouf, MD, CM, presents the take home messages on bladder cancer from the AUA annual meeting in Orlando, FL.

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• Both men and women experience significant delays between presentation with microhematuria and bladder cancer diagnosis, but longer delays are seen in women, which may partly explain the gender-based discrepancies published in recent years.

• Risk of urinary tract malignancy in over 7,000 patients with asymptomatic microhematuria was 2.4%-useful information for counseling patients regarding a hematuria workup.

• Screening men aged 60 to 80 years with a smoking history of more than 30 pack-years yielded a bladder cancer incidence rate of 2/1,000 person years.

• In nonmuscle-invasive disease, a study comparing Hexvix transurethral resection of bladder tumor (TURBT) plus mitomycin with white-light TURBT plus mitomycin found no impact on recurrence nor progression in patients undergoing Hexvix TURBT plus mitomycin at 3 years.

• The combination of bacillus Calmette-Guérin (BCG) plus interferon showed significantly lower recurrence rates and significantly less toxicity compared to patients treated with BCG in a randomized, prospective trial.

• Sequential BCG/electromotive mitomycin for high-risk disease showed an 84% complete response rate at 1 year, but 29% of patients did not tolerate the nine-dose full-induction course.

• Upper tract and/or urethral cancer was detected during long-term follow-up in more than 50% of patients with high-risk nonmuscle-invasive disease failing at least two courses of BCG. In the stratification of T1 disease, both the a/b classification and the extensive versus microinvasive stratification were validated to significantly predict progression.

• In invasive bladder cancer, sarcopenia is associated with increased complications, increased mortality, and decreased cancer-specific survival after radical cystectomy, and is prognostic in patients with metastatic disease.

• Neutrophil-to-lymphocyte ratio was an independent prognostic factor in patients treated with radical cystectomies in multiple abstracts.

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• Gender did not impact on outcomes following radical cystectomy, in contrast with previously published literature. Body mass index >30 was independently associated with improved survival after radical cystectomy. And ASA classification was found to be superior to the Charlson score in predicting mortality.

• Intraoperative blood transfusion but not postoperative transfusion was associated with worse bladder cancer-specific survival.

• The majority of readmissions after radical cystectomy are non-modifiable and attributable to the inherent morbidity of the procedure. Significant predictors of readmission were African-American race, multiple comorbidities, discharge to post-acute care facility, and use of neoadjuvant chemotherapy.

• The majority of radical cystectomies in the U.S. are done by urologists who performed only one radical cystectomy, concerning in light of the recent volume-outcome associations with this procedure.

• A report on the enhanced recovery after surgery (ERAS) protocol in patients undergoing an open radical cystectomy showed impressive decreased length of stay from 8 days historically to 4 days in those undergoing the ERAS protocol without an increased risk of readmission or complications.

• The use of alvimopam (Entereg) was associated with reduced time to bowel movement and length of stay in patients undergoing robotic cystectomy.

• Prophylactic anticoagulation remains underutilized in patients undergoing radical cystectomy; only 39% of patients receive prophylaxis at day of surgery, and vascular/thrombotic events is significant at 5.5%, half of which occurred after discharge.

• The most common adverse events after radical cystectomy are transfusion-related and infectious complications.

• Radical cystectomy provides excellent local control of disease and importantly, pelvic recurrence is ominous, with median post-recurrence survival of 7 months.

• Up to 14% of patients develop late recurrence following radical cystectomy. Predictive factors are young age, nonmuscle-invasive disease, prostatic urethral involvement, or the presence of concomitant carcinoma in situ.

• Radical cystectomy in octogenarians is feasible and can be performed with acceptable outcomes, but complications and perioperative mortality could be significant. Highly selected patients with muscle-invasive disease can undergo a partial cystectomy following adjuvant therapy with acceptable outcomes.

• The cancer-specific survival of robotic radical cystectomy is comparable to that of the open published series. Early oncologic failure occurred in .5% to 2% of patients and an additional .2% had port-site metastasis.

• Real-world pT0 after neoadjuvant chemotherapy seems to be lower than previously reported; a large cohort showed 24% pT0 rates. Separately, mixed variant histology did not affect downstaging and outcome following neoadjuvant chemotherapy, and neoadjuvant chemotherapy was not associated with worse short-term outcomes in patients undergoing cystectomy.

• The absence of tumor on repeat TURBT did not predict pT0 in muscle-invasive disease at radical cystectomy. In fact, two-thirds of patients with clinical T0 had residual disease and half of those had muscle-invasive disease.

• Examination under anesthesia is still necessary and has added value for staging of bladder cancer, even in the modern era of computed tomography, adding above and beyond what the CT showed to predict T3 disease.UT

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