Woodson Smelser

Where are we with bladder preservation for muscle-invasive bladder cancer in 2017?

Introduction: In 2017, neoadjuvant, cisplatin-based chemotherapy followed by radical cystectomy (RC) is considered the gold standard therapy for muscle-invasive bladder based on randomized controlled trials. Across all tumor stages, this approach has been associated with the highest rates of disease-specific survival. However, RC is one of the most challenging procedures performed by urologic surgeons and carries with it significant risks of complications, hospital readmission, and even a small risk of mortality, in addition to lifestyle changes that can have long-term effects on well-being. For these reasons, bladder-sparing approaches are utilized in some highly selected patients. We reviewed the most recent evidence for bladder-sparing modalities for muscle-invasive urothelial bladder cancer and summarize those findings in this review article. Methods: We performed a PubMed literature review utilizing the key words “bladder preservation,” “trimodal therapy,” “muscle-invasive bladder cancer,” and “partial cystectomy” written in English, dating back to 1990. We excluded case reports. Results: Our search yielded more than 2000 articles which we screened. Some articles were then rejected due to inappropriate topic. In addition, we reviewed the most recent American Urological Association, National Comprehensive Cancer Network (NCCN), and European guidelines on muscle-invasive bladder cancer. We identified fifty relevant articles which are summarized in this text. In some rare instances, recommendations are based on expert opinion. Conclusions: Bladder preservation is often considered for quality of life considerations or in the setting of multiple medical comorbidities, and this remains oncologically appropriate even in 2016 in highly selected patients with muscle-invasive urothelial carcinoma of the bladder.

Perioperative Immunonutrition Modulates Inflammatory Response after Radical Cystectomy: Results of a Pilot Randomized Controlled Clinical Trial

Purpose: Poor preoperative nutritional status is associated with a higher complication rate after radical cystectomy in patients with bladder cancer. Given the short interval between diagnosis and radical cystectomy, we compared the effect of short‐term specialized immunonutrition to that of a standard oral nutritional supplement on the acute inflammatory response and arginine status in patients treated with radical cystectomy. Materials and Methods: In this prospective, randomized study in 29 men 14 received specialized immunonutrition and 15 received oral nutritional supplement. Each group drank 3 cartons per day for 5 days before and 5 days after radical cystectomy. The Th1‐Th2 balance, plasma interleukin‐6 and plasma amino acids were measured at baseline, intraoperatively and on postoperative days 2, 14 and 30. Body composition was measured by dual energy x‐ray absorptiometry at baseline and on postoperative days 14 and 30. Differences in outcomes were assessed using the generalized linear mixed model. Results: In the specialized immunonutrition group there was a 54.3% average increase in the Th1‐Th2 balance according to the tumor necrosis factor‐&agr;‐to‐interleukin‐13 ratio from baseline to intraoperative day, representing a shift toward a Th1 response. In the oral nutritional supplement group the Th1‐Th2 balance decreased 4.8%. The change in the Th1‐Th2 balance between the specialized immunonutrition and oral nutritional supplement groups significantly differed (p <0.027). Plasma interleukin‐6 was 42.8% lower in the specialized immunonutrition group compared to the oral nutritional supplement group on postoperative day 2 (p = 0.020). In the specialized immunonutrition group plasma arginine was maintained from baseline to postoperative day 2 and yet the oral nutritional supplement group showed a 26.3% reduction from baseline to postoperative day 2 (p = 0.0003). The change in appendicular muscle loss between the groups was not statistically significant. Conclusions: Th1‐to‐Th2 ratios, peak interleukin‐6 levels and plasma arginine suggest that consuming specialized immunonutrition counteracts the disrupted T‐helper balance, lowers the inflammatory response and prevents arginine depletion due to radical cystectomy.

Assessment of Patient and Surgical Variables Including Residency Training Level on Adverse Events After Ureteroscopy for Ureteral Stones: A Multivariate Analysis

PURPOSE With advances in technology, ureteroscopy (URS) is increasingly utilized for the management of urolithiasis. Previous studies have attempted to characterize the post-operative complication and readmission rates relative to the technical difficulty of the procedure. There is limited data exploring the resident level of training and its effect on adverse outcomes in these cases. We review our experience with URS to create a model to predict factors, including resident experience, that affect rates of post-operative complications. MATERIALS AND METHODS We reviewed ureteroscopies performed at our academic facility from January 2009 to December 2013. Ureteral-only stones were examined for demographics, stone characteristics, operative techniques, and resident training level. Post-operative adverse events requiring urology consultation, clinic or emergency department visits, hospital admission, prolonged post-operative hospitalization, or unplanned repeat surgery within 30 days of the procedure were identified and analyzed. RESULTS Four hundred seventeen cases of URS for ureteral-only stones were included for study. We identified 53 (12.7%) involving an unexpected post-operative course. Several logistic regression models were created to make a predictive model of adverse events. One model found only lack of stone clearance to be significant for increasing the likelihood of an adverse event. A second model determined that no residency year showed higher odds of adverse outcomes. CONCLUSIONS URS has increased in prevalence in recent years, but overall complication rates are low. Resident level of experience does not appear to impact adverse event rate. Stone clearance during initial surgery appears to be the most important in avoiding adverse events. Further expansion of the database over time will improve our ability to predict adverse outcomes in this common procedure.

Utilization and Outcomes of Radical Cystectomy for High-grade Non–muscle-invasive Bladder Cancer in Elderly Patients

Background Radical cystectomy (RC) represents a treatment option for patients with high‐grade non–muscle‐invasive bladder cancer (HG‐NMIBC); however, perioperative morbidity is not insignificant, particularly in elderly patients. We sought to evaluate the associations of age with utilization and outcomes of RC for HG‐NMIBC. Patients and Methods Patients with HG‐NMIBC diagnosed between 2004 and 2013 were identified in the National Cancer Database and stratified by age: ≤ 60, 61‐70, 71‐80, and > 80 years. Association between age and treatment with RC was assessed by multivariable logistic regression. Associations between age and overall survival were assessed using the Kaplan‐Meier method. A multi‐institutional analysis was performed to evaluate the associations of age with perioperative outcomes and survival among patients managed with RC for HG‐NMIBC. Results On multivariable analysis, age was associated with RC utilization, with the lowest usage in patients > 80 years (2.1%; P < .01). Upstaging at RC occurred in 40% of patients with HG‐NMIBC, and no association of age with upstaging risk was noted. Significantly inferior overall survival was observed in the patients who were upstaged across age strata (all P < .01). In the multi‐institutional cohort, age was not associated with risks of upstaging, receipt of transfusion, 30‐/90‐day complications, or recurrence‐free or cancer‐specific survival (all P > .05), whereas upstaging was associated with inferior recurrence‐free and cancer‐specific survival regardless of age. Conclusion RC for HG‐NMIBC is used less frequently in older adults, despite similar risks of pathologic upstaging. As upstaging is associated with inferior survival regardless of age, these data suggest that elderly patients with HG‐NMIBC may be at risk for undertreatment. Micro‐Abstract The management of non–muscle‐invasive bladder cancer is complex when considering the older patient. We reviewed both the National Cancer Database and a multi‐intuitional cohort of patients with high‐grade non–muscle‐invasive bladder cancer to review associations between age and perioperative and oncologic outcomes among patients managed with radical cystectomy. We found that age was not associated with adverse perioperative outcomes, an increased risk of pathologic upstaging, or inferior survival independent of pathologic outcomes. These data support the safety and oncologic efficacy of radical cystectomy among well‐selected patients regardless of age.

Contemporary Preoperative and Intraoperative Management of the Radical Cystectomy Patient

Radical cystectomy is a morbid procedure performed on an aging and often frail population. Nonetheless, advances in preoperative and intraoperative management have significantly improved patient outcomes. Preoperative optimization includes a focus on patient education, risk factor reduction, risk stratification, nutritional optimization, and bowel motility enhancement. Intraoperative optimization focuses on maintaining normothermia, restrictive fluid administration, minimization of blood transfusions, and nonopioid pain management.

MP54-13 MALNUTRITION STATUS AND AN INTERVENTION FOR MALNUTRITION IN PATIENTS UNDERGOING RADICAL CYSTECTOMY

INTRODUCTION AND OBJECTIVES: Underdiagnosing malnutrition in high-risk surgical patients is problematic. Rapid skeletal muscle wasting is a serious and common complication following radical cystectomy (RC) to treat muscle-invasive bladder cancer. Specialized immunonutrition (SIM) intake before and after RC may help counteract muscle wasting in the post-operative period. METHODS: Men with muscle-invasive cancer scheduled for radical cystectomy were randomly assigned to oral SIM providing supplemental L-arginine, fish oil, vitamin A, and nucleotides (n 1⁄4 14) or a calorieand nitrogen-matched oral nutrition supplement [ONS (n 1⁄4 15)] for 5 days before and 5 days after RC. Malnutrition was assessed by a trained research team using the Patient-Generated Subjective Global Assessment (PG-SGA) tool. Dual Energy X-Ray Absorptiometry scans were obtained at baseline, 14 days, and 30 days after surgery to calculate relative skeletal muscle index (RSMI). Discrepancies between the malnutrition diagnoses using the PG-SGA tool and the UHC Billing database on the same patients were compared. RESULTS: Using the PG-SGA tool, 21% of patients were identified as well nourished, 66% were moderately malnourished, and 14% were severely malnourished prior to RC. Billed and coded data showed 86% of patients were well nourished, 7% were moderately malnourished, and 7% were severely malnourished prior to RC. Relative Skeletal Muscle Index (RSMI) was better preserved in the SIM group at 14 days (7% vs. 17% in the ONS group). CONCLUSIONS: The large discrepancy between patients identified as malnourished using the PG-SGA as compared to the billing data suggests a problem of underdiagnosing malnutrition in this population. Improving nutrition status through specialized immunonutrition could be a low risk, high-impact means of counteracting muscle wasting after RC for bladder cancer.

MP15-16 THE ASSOCIATION OF AGE WITH PERIOPERATIVE AND CLINICOPATHOLOGIC OUTCOMES FOLLOWING RADICAL CYSTECTOMY FOR NON-MUSCLE INVASIVE BLADDER CANCER

INTRODUCTION AND OBJECTIVES: Non muscle invasive bladder cancer is a recurrent and progressive disease; currently we are unable to forecast recurrence in the individual patient. Recently we developed a mathematical model that found NLR as a good prognostic tool. The model was tested retrospectively in an additional study and found accurate too. The aim of the current study is to assess its accuracy to forecast recurrence prospectively in patients with NMIBC METHODS: All patients admitted to bladder tumor resection (TURBT) and agreed to participate in the study had blood drawn for blood count 24 hours prior to surgery. Patients with non-muscle invasive tumor were recruited and prospectively followed. Patients had urine cytology and cystoscopy every 3 months for 2 years following resection. Time to recurrence and recurrence free of tumor were recorded. Statistical analysis was done with X2 test for categorical parameters and T test for serial parameters. Logistic regression was performed to forecast prognosis. RESULTS: 123 patients were recruited, mean age was 71 years, all patients had at least 1 year follow up. Twenty nine patients (23.6%) experienced biopsy proven tumor recurrence. The mean time for recurrence was 7.38 months.Neutrophil to Lymphocyte rate > 2 showed direct statistically significant correlation with tumor recurrence (p1⁄40.038), tumor stage showed the same correlation (p1⁄40.048). The specificity of our recurrence forecasting model was 96.8%. EORTC score did not demonstrate significance between the recurrent and nonrecurrent groups. CONCLUSIONS: Our mathematical model that found NLR as a prognostic tool in patients with NMIBC was tested for the first time prospectively. The model demonstrated its ability to forecast recurrence more accurately then tumor stage grade and EORT score in the individual patient with NMIBC.The main limitation of this work is the relatively low number of patients.