Cheryl T. Lee

Postoperative nomogram predicting risk of recurrence after radical cystectomy for bladder cancer

PURPOSE Radical cystectomy and pelvic lymphadenectomy (PLND) remains the standard treatment for localized and regionally advanced invasive bladder cancers. We have constructed an international bladder cancer database from centers of excellence in the management of bladder cancer consisting of patients treated with radical cystectomy and PLND. The goal of this study was the development of a prognostic outcomes nomogram to predict the 5-year disease recurrence risk after radical cystectomy. PATIENTS AND METHODS Institutional radical cystectomy databases containing detailed information on bladder cancer patients were obtained from 12 centers of excellence worldwide. Data were collected on more than 9,000 postoperative patients and combined into a relational database formatted with patient characteristics, pathologic details of the pre- and postcystectomy specimens, and recurrence and survival status. Patients with available information for all selected study criteria were included in the formation of the final prognostic nomogram designed to predict 5-year progression-free probability. RESULTS The final nomogram included information on patient age, sex, time from diagnosis to surgery, pathologic tumor stage and grade, tumor histologic subtype, and regional lymph node status. The predictive accuracy of the constructed international nomogram (concordance index, 0.75) was significantly better than standard American Joint Committee on Cancer TNM (concordance index, 0.68; P < .001) or standard pathologic subgroupings (concordance index, 0.62; P < .001). CONCLUSION We have developed an international bladder cancer nomogram predicting recurrence risk after radical cystectomy for bladder cancer. The nomogram outperformed prognostic models that use standard pathologic subgroupings and should improve our ability to provide accurate risk assessments to patients after the surgical management of bladder cancer.

Bladder cancer in 2010: how far have we come?

Bladder cancer is the fourth most common cancer and ranks eighth as a cause of death from cancer among men in the United States. Although guidelines assist in treatment, the art of managing bladder cancer, such as the decision to use neoadjuvant chemotherapy and the timing of cystectomy, is still variable. Bladder cancer has a propensity to recur, and with recurrence, a significant number of cases progress, which makes the early detection of high‐risk patients imperative. Advances in detection, surveillance, and treatment of bladder cancer are reviewed in this article. CA Cancer J Clin 2010.

ICUD-EAU International Consultation on Bladder Cancer 2012: Urinary diversion.

CONTEXT A summary of the 2nd International Consultation on Bladder Cancer recommendations on the reconstructive options after radical cystectomy (RC), their outcomes, and their complications. OBJECTIVE To review the literature regarding indications, surgical details, postoperative care, complications, functional outcomes, as well as quality-of-life measures of patients with different forms of urinary diversion (UD). EVIDENCE ACQUISITION An English-language literature review of data published between 1970 and 2012 on patients with UD following RC for bladder cancer was undertaken. No randomized controlled studies comparing conduit diversion with neobladder or continent cutaneous diversion have been performed. Consequently, almost all studies used in this report are of level 3 evidence. Therefore, the recommendations given here are grade C only, meaning expert opinion delivered without a formal analysis. EVIDENCE SYNTHESIS Indications and patient selection criteria have significantly changed over the past 2 decades. Renal function impairment is primarily caused by obstruction. Complications such as stone formation, urine outflow, and obstruction at any level must be recognized early and treated. In patients with orthotopic bladder substitution, daytime and nocturnal continence is achieved in 85-90% and 60-80%, respectively. Continence is inferior in elderly patients with orthotopic reconstruction. Urinary retention remains significant in female patients, ranging from 7% to 50%. CONCLUSIONS RC and subsequent UD have been assessed as the most difficult surgical procedure in urology. Significant disparity on how the surgical complications were reported makes it impossible to compare postoperative morbidity results. Complications rates overall following RC and UD are significant, and when strict reporting criteria are incorporated, they are much higher than previously published. Fortunately, most complications are minor (Clavien grade 1 or 2). Complications can occur up to 20 yr after surgery, emphasizing the need for lifelong monitoring. Evidence suggests an association between surgical volume and outcome in RC; the challenge of optimum care for elderly patients with comorbidities is best mastered at high-volume hospitals by high-volume surgeons. Preoperative patient information, patient selection, surgical techniques, and careful postoperative follow-up are the cornerstones to achieve good long-term results.

Cystectomy Delay More Than 3 Months From Initial Bladder Cancer Diagnosis Results in Decreased Disease Specific and Overall Survival

PURPOSE Some groups hypothesize that a delay in cystectomy may result in higher pathological stage and possibly alter survival in patients with bladder cancer. The timing of this delay has been somewhat arbitrary. We evaluated the timing from T2 bladder cancer diagnosis to cystectomy, its impact on survival and potential causes of delay. MATERIALS AND METHODS A contemporary cohort of 214 consecutive patients presented with clinical T2 bladder cancer and underwent radical cystectomy as primary therapy. Clinicopathological parameters were maintained in an institutional database. A review of time to cystectomy, pathological stage, disease specific survival and OS was performed. Variables were tested in univariate and multivariate analyses. The log rank test was used for exploratory analyses to determine meaningful delay cutoff points. RESULTS Mean followup and time to cystectomy in the entire cohort was 40 months and 60 days, respectively. A significant disease specific survival and OS advantage was observed in patients undergoing cystectomy by 93 days or less (3.1 months) compared to greater than 93 days (p = 0.05 and 0.02, respectively). Pathological staging was similar between the groups (p = 0.15). A multivariate benefit in OS was observed in patients treated with timely cystectomy. The most common factor contributing to cystectomy delay was scheduling delay, as seen in 46% of cases. CONCLUSIONS A cystectomy delay of 3.1 months undermines patient survival, likely through the development of micrometastases, since local stage progression is not apparent at this point. Most delays are avoidable and should be minimized. Despite the need for second opinions and the impact of busy surgical schedules clinicians must strive to schedule patients efficiently and complete surgical treatment within this time frame.

Mode of presentation of renal cell carcinoma provides prognostic information

PURPOSE Broadened applications of imaging modalities have increased the incidental detection of renal cell carcinoma (RCC) over the past decade. Previous small series have suggested a prognostic benefit for incidental presentation. This study utilizes a large contemporary patient cohort to examine patterns of RCC presentation and their clinical implications. MATERIALS AND METHODS Retrospective analysis was performed on 721 patients (260 women, 461 men) who underwent 750 nephrectomies for treatment of RCC between 7/1/89 and 12/31/97; 29 patients required two operations for bilateral RCC. Median age and follow-up were 63 years and 41 months, respectively. Indicators of symptomatic presentation included flank pain, flank mass, hematuria, varicocele, constitutional symptoms, paraneoplastic syndromes, and bone pain related to metastatic disease. Mode of presentation was compared with clinicopathologic parameters using Chi-square and t-test analyses. Survival analysis was performed using Kaplan-Meier estimates (log-rank test) and Cox regression modeling. RESULTS Incidental and symptomatic presentation occurred in 57% and 42% of cases, respectively. When compared to incidental cases, symptomatic presentation was predominantly detected in younger patients (mean age, 59 years; P < .001), in males (P < .04), and in tumors with conventional (clear cell) histology (P < .001), larger size (mean, 8 cm; P < .001), and non-organ confined pathology (P < .001). In univariate analysis, symptomatic cases had a more adverse disease-free (P < .0001) and disease-specific (P < .0001) survival. In multivariate analysis, mode of presentation was an independent predictor of disease-free (P < 0.0001) and disease-specific survival (P < 0.005). CONCLUSIONS Symptomatic presentation correlates with an aggressive histology and advanced disease. Incidental tumors may be frequently detected in female and elderly patients, as these groups traditionally seek general medical care more regularly. Mode of presentation can independently predict an adverse patient outcome and should be included in RCC-specific modeling systems.

Measuring Health-Related Quality of Life Outcomes in Bladder Cancer Patients Using the Bladder Cancer Index (BCI)

Health‐related quality of life (HRQOL) has not been adequately measured in bladder cancer. A recently developed reliable and disease‐specific quality of life instrument (Bladder Cancer Index, BCI) was used to measure urinary, sexual, and bowel function and bother domains in patients with bladder cancer managed with several different interventions, including cystectomy and endoscopic‐based procedures.

Alvimopan Accelerates Gastrointestinal Recovery After Radical Cystectomy: A Multicenter Randomized Placebo-Controlled Trial

BACKGROUND Radical cystectomy (RC) for bladder cancer is frequently associated with delayed gastrointestinal (GI) recovery that prolongs hospital length of stay (LOS). OBJECTIVE To assess the efficacy of alvimopan to accelerate GI recovery after RC. DESIGN, SETTING, AND PARTICIPANTS We conducted a randomized double-blind placebo-controlled trial in patients undergoing RC and receiving postoperative intravenous patient-controlled opioid analgesics. INTERVENTION Oral alvimopan 12 mg (maximum: 15 inpatient doses) versus placebo. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The two-component primary end point was time to upper (first tolerance of solid food) and lower (first bowel movement) GI recovery (GI-2). Time to discharge order written, postoperative LOS, postoperative ileus (POI)-related morbidity, opioid consumption, and adverse events (AEs) were evaluated. An independent adjudication of cardiovascular AEs was performed. RESULTS AND LIMITATIONS Patients were randomized to alvimopan (n=143) or placebo (n=137); 277 patients were included in the modified intention-to-treat population. The alvimopan cohort experienced quicker GI-2 recovery (5.5 vs 6.8 d; hazard ratio: 1.8; p<0.0001), shorter mean LOS (7.4 vs 10.1 d; p=0.0051), and fewer episodes of POI-related morbidity (8.4% vs 29.1%; p<0.001). The incidence of opioid consumption and AEs or serious AEs (SAEs) was comparable except for POI, which was lower in the alvimopan group (AEs: 7% vs 26%; SAEs: 5% vs 20%, respectively). Cardiovascular AEs occurred in 8.4% (alvimopan) and 15.3% (placebo) of patients (p=0.09). Generalizability may be limited due to the exclusion of epidural analgesia and the inclusion of mostly high-volume centers utilizing open laparotomy. CONCLUSIONS Alvimopan is a useful addition to a standardized care pathway in patients undergoing RC by accelerating GI recovery and shortening LOS, with a safety profile similar to placebo. PATIENT SUMMARY This study examined the effects of alvimopan on bowel recovery in patients undergoing radical cystectomy for bladder cancer. Patients receiving alvimopan experienced quicker bowel recovery and had a shorter hospital stay compared with those who received placebo, with comparable safety. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT00708201.

Urinary diversion after radical cystectomy for bladder cancer: options, patient selection, and outcomes

The urinary reconstructive options available after radical cystectomy (RC) for bladder cancer are discussed, as are the criteria for selection of the most appropriate diversion, and the outcomes and complications associated with different diversion options.

Matched Comparison of Robotic-assisted and Open Radical Cystectomy

OBJECTIVE To evaluate our initial robotic-assisted radical cystectomy (RARC) experience compared with a robust open radical cystectomy (ORC) series performed at a single institution using a matched-pair analysis. Although early results suggest that RARC is safe, with favorable perioperative and early oncologic outcomes, limited data exist comparing ORC and RARC. METHODS RARC and ORC patients were identified through a prospectively maintained institutional review board-approved bladder cancer database. RARC and ORC cases performed from September 2007 to November 2010 were matched 1:2 by age, sex, urinary diversion, and clinical stage. The perioperative, complication, and pathologic outcomes were compared. RESULTS A total of 50 RARC and 100 ORC cases were reviewed, with a median follow-up of 8 and 13.5 months, respectively. No differences in the demographic parameters were present between the 2 groups. RARC was associated with a significantly decreased median estimated blood loss (350 vs 475 mL) and 30-day transfusion rate (2% vs 24%) but with longer operative times (454.9 vs 349.1 minutes). No difference was found in the rate of 30-day minor or major Clavien complications, length of stay, or 30-day readmissions between groups. The 90-day mortality rate was 3% versus 0% for ORC and RARC, respectively. No difference in the final pathologic findings, number of lymph nodes removed, or margin status was identified. CONCLUSION Early experience with RARC compared with a robust ORC experience demonstrated similar perioperative and pathologic outcomes. Continued experience with RARC has the potential to bring improved perioperative results.

Patterns of Hematuria Referral to Urologists: Does a Gender Disparity Exist?

OBJECTIVES To examine the referral patterns of hematuria within a nonprofit healthcare organization to determine the factors that influence referral. Hematuria continues to be an important sign of urologic disease, including urothelial malignancy. An increasing awareness of gender differences in tumor stage at bladder cancer presentation has led to speculation about delayed referral and diagnosis in women. However, little is known about the referral patterns of hematuria and whether gender differences exist. METHODS The insurance records were examined from 926 consecutive adult health plan participants (559 men and 367 women) with newly diagnosed hematuria from 1998 to 2002. The patterns of urologic referral were evaluated. A Cox multivariate regression model was used to examine the relationship between urologic referral and the relevant variables. RESULTS Overall, 263 men (47%) and 102 women (28%) were referred for urologic evaluation of hematuria, with a median follow-up of 27 and 26 months, respectively. Referral was initiated by the primary care physician in 80% of the cohort. Increased urologic referral was associated with advancing age, repeated hematuria, provider type, and male gender. The adjusted hazard ratio of male referral was 1.65 (95% confidence interval 1.31-2.08) compared with female referral. CONCLUSIONS Primary care physicians practicing in a managed care setting are less likely to refer women for a urologic evaluation of new or first recurrent episodes of hematuria than to refer men in all patient age categories, except for 40-49 years. This apparent gender disparity could result in unequal access of specialty evaluation and could potentially delay the diagnosis of important urologic conditions.