Low adherence to recommended use of neoadjuvant chemotherapy for muscle-invasive bladder cancer

The impact of positive surgical margins after cystectomy on oncological outcomes: a nationwide study

OBJECTIVE

To evaluate whether surgical margin status, alongside existing postoperative risk indicators, improves the identification of bladder cancer patients who may benefit from adjuvant therapy following radical cystectomy (RC).

METHODS

In this nationwide cohort study, patients aged ≥18 years diagnosed with muscle-invasive bladder cancer (MIBC) without nodal or distant metastasis (cT2-4aN0/xM0) between November 2017 and December 2020 who underwent RC were selected from the Netherlands Cancer Registry. Detailed information on surgical margin status was obtained through linkage with the Dutch central pathology database, Palga. Overall survival (OS) and progression-free survival (PFS) were assessed using the Kaplan-Meier method. Multivariable Cox regression analysis was performed to assess the independent prognostic effect of positive surgical margins (carcinoma in situ (CIS) only or invasive carcinoma) on PFS and OS.

RESULTS

We identified 1445 MIBC patients treated by RC (53% open, 47% robot-assisted), of whom 135 (9.3%) had positive surgical margins (10.7% in the open and 7.7% in the robot-assisted cohort). In the entire cohort, OS was 79% and 60% at 12 and 48 months after RC, respectively. PFS was 70% and 61% at 12 and 24 months, respectively. Multivariable Cox regression showed worse PFS (hazard ratio (HR) 2.13, 95% confidence interval (CI) 1.67-2.72) and OS (HR 2.02, 95% CI 1.58-2.58) in patients with surgical margins with invasive carcinoma vs patients with negative margins. Patients with only CIS in the margins also appeared to have worse PFS (HR 1.60, 95% CI 1.00-2.58) but these results were not statistically significant. No difference was found for OS (HR 1.30, 95% CI 0.80-2.12).

CONCLUSION

Positive margins should be considered a 'high risk feature', as they result in increased risk of disease progression and impaired survival outcomes. These findings support further investigation of the potential efficacy of adjuvant therapy (i.e., radiotherapy and systemic therapy) among patients with positive surgical margins.

Contemporary Trends and Predictors Associated with Adverse Pathological Upstaging Among Non-Metastatic Localized Clinical T2 Muscle-Invasive Bladder Cancers Undergoing Radical Cystectomy: Outcomes from a Single Tertiary Centre in the United Kingdom

Introduction: Radical cystectomy (RC) is the gold standard for urothelial cT2-4a, N0, M0 muscle-invasive bladder cancer (MIBC). However, bladder-sparing strategies (BSS) such as Trimodality Therapy (TMT) have emerged as alternative treatments for a select group of localized muscle-confined (cT2) urothelial bladder cancers. Accordingly, reliable preoperative staging and a reliable risk factor assessment linked to pathological upstaging play a key role in adequate counselling and patient selection for BSS. Patients and Methods: cT2 MIBC patients undergoing RC at our institution from 2014 to 2024 were reviewed. Preoperative staging modalities, demographics, and tumour and patient characteristics were assessed. Multivariable logistic regression was applied to explore the relative effect of confounders on any pathological upstaging from robot-assisted or open RC specimens. Subgroup analysis according to the local upstaging (>pT2) or nodal dissemination (pN+) was also performed. Results: N = 275 RCs were included (73.5% males, 26.5% females). Upstaging was documented in n = 141 (51%) cases. Of these, n = 125 (45.5%) were upstaged locally (>pT2) and n = 35 (23%) yielded pN+ disease. Preoperative parameters like gender, the number of TURBTs, previous BCG exposure, and concomitant CIS did not significantly influence the risk of any kind of upstaging (p > 0.05). At multivariable analysis, neoadjuvant chemotherapy (NAC) and multi-disciplinary team (MDT) discussion were found protective (odds ratio [OR]: 0.4, 95%CI 0.2-0.7, p = 0.001 and OR: 0.51, 95%CI 0.2-0.9, p = 0.01). Preoperative FDG-PET assessment yielded higher risk for later pN upstaging (OR: 1.8, 95%CI 1-3, p = 0.05). HG/G3 features at TURBT along with mixed/pure histology variants in RC specimens were the most relevant independent predictors for both any and pT upstaging (OR: 4.3, 95%CI 1-34, p = 0.04 and OR: 2.3, 95%CI 1.1-4.6, p = 0.02 for any upstaging and OR: 5.6, 95%CI 1.3-36, p = 0.02 and OR: 2.5, 95%CI 1.3-5, p = 0.01 for pT upstaging, respectively). Conclusions: In this study, over half of the patients undergoing RC for cT2 were upstaged at the final pathology. Therefore, adequate counselling and examining the non-conventional criteria for prognosis is mandatory in the contemporary era of bladder-preservation strategies.

Estimating the Morbidity of Robot-Assisted Radical Cystectomy Using the Comprehensive Complication Index: Data from the Asian Robot-Assisted Radical Cystectomy Consortium

Background/Objectives: The Clavien-Dindo classification (CDC) grades the most severe post-operative complication and may not comprehensively reflect cumulative surgical morbidity. Our objective was to investigate the potential incremental role of the comprehensive complication index (CCI) over the CDC in defining the quality of robot-assisted radical cystectomy (RARC). Methods: Data were extracted from the Asian RARC Consortium database. Complications were classified using the CCI (CCI = 0, CCI < 75th and ≥75th percentile) and CDC. Adverse peri-operative outcomes such as length of stay >14 days (LOS > 14 days), estimated blood loss >350 mL (EBL > 350 mL), time to solid food intake >4 days (TFI > 4 days) and 30-day readmission rates were analyzed. The area under the curve (AUC) of the receiver operating characteristic (ROC) curves for CCI and CDC were compared for the various adverse outcomes. Results: The peri-operative complication rate was 44.4%, comprising 11.6% with severe complications (CDC ≥ III). The mean CCI was 10.2 (±13.5) while median CCI was 0 (IQR 0-21). There were 7.6% of patients with >one perioperative complication. On adjusted analysis, CCI ≥ 75th percentile was significantly associated with greater LOS (>14 days) (OR 2.21, 95% CI 1.47-3.31, p < 0.001) compared to when CCI = 0. There were no significant differences in the AUC between CDC and CCI in predicting LOS > 14 days, TFI > 4 days, 30-day readmission or EBL > 350 mL. Conclusions: In our multi-institutional cohort, the CCI did not provide additional discrimination over CDC, and this is likely related to the limited number of complications that occurred per individual in the Asian RARC cohort. Hence, the perceived advantages of CCI over CDC are contextual.

Outcomes of radical cystectomy in a resource-limited setting: a pilot study

BACKGROUND

Radical cystectomy is a cornerstone treatment for muscle-invasive bladder cancer, but its implementation in resource-limited settings is challenged by limited access to trained professionals and inadequate healthcare infrastructure. This pilot study aims to analyze perioperative complications and mortality associated with radical cystectomy and urinary diversion at Gezira Hospital for Renal Diseases and Surgery (GHRDS) in Sudan. These findings reflect the outcomes of an in-country training program established by the Society of International Urology (SIU) to address surgical capacity gaps in resource-limited settings.

METHODS

We conducted a retrospective analysis of patient who underwent radical cystectomy with ileal conduit urinary diversion between January 2015 and December 2019. Data were collected from medical records, including demographic details, perioperative complications classified by the modified Clavien-Dindo system, and histopathological findings.

RESULTS

A total of 30 patients were included in the study. The median age was 65 years, and 77% were male. The majority of patients (76%) had transitional cell carcinoma, followed by squamous cell carcinoma (17%) and adenocarcinoma (7%). The clinical stage at presentation were T1 N0 M0 (23%) and T2 N0 M0 (77%). A total of 32 complications were observed, with 91% classified as low-grade. Infectious complications were the most common (50%), followed by gastrointestinal and respiratory issues. Severe complications occurred in 13% of cases, and in-hospital mortality was 3%.

CONCLUSION

This study demonstrates the feasibility of performing radical cystectomy in a resource-constrained environment, supported by a collaborative training program involving international expertise and local participants. While outcomes were encouraging, key areas for improvement include infection control, critical care capacity, and early detection of bladder cancer. These findings underscore the importance of sustainable in-service training programs in building surgical capacity in resource-limited settings. Future research should focus on long-term outcomes and strategies to reduce complications.

Robotic-Assisted Radical Cystectomy: Single-Center Analysis of Factors Impacting Clavien ≥ II Complications

Despite the advent of robotics and the decreasing rate of complications after radical cystectomy, several factors are renowned to impair the early outcomes of this procedure. The aim of this paper is to provide a multivariate analysis (MVA) of patient and surgical procedure-related variables likely to affect postoperative course and 30-day complication rate. Fifty-five robotic-assisted radical cystectomies (RARCs) performed at a single center from July 2021 to March 2023 were enrolled. Baseline demographics, comorbidities, and intraoperative and postoperative data were collected. Uni- and multivariate analyses were performed to evaluate the relationship with Clavien ≥ II complications arising within 30 days of surgery. A postoperative Clavien ≥ II complication was evident in 15 patients (28%), whereas Clavien ≥ III occurred only in 5 (9%). At MVA, the only independent predictor of Clavien ≥ II complications was a prior neoadjuvant chemotherapy (OR 5.6; 95% CI 1.22-25.3, p = 0.026). Recognized the small sample size, patients who received a prior NAC should deserve special care within the postoperative course.

Income Disparities in Survival and Receipt of Neoadjuvant Chemotherapy and Pelvic Lymph Node Dissection for Muscle-Invasive Bladder Cancer

Background: Muscle-invasive bladder cancer (MIBC) is a potentially fatal disease, especially in the setting of locally advanced or node-positive disease. Adverse outcomes have also primarily been associated with low-income status, as has been reported in other cancers. While the adoption of neoadjuvant cisplatin-based chemotherapy (NAC) followed by radical cystectomy (RC) and pelvic lymph node dissection (PLND) has improved outcomes, these standard-of-care treatments may be underutilized in lower-income patients. We sought to investigate the economic disparities in NAC and PLND receipt and survival outcomes in MIBC. Methods: Utilizing the National Cancer Database, a retrospective cohort analysis of cT2-4N0-3M0 BCa patients with urothelial histology who underwent RC was conducted. The impact of income level on overall survival (OS) and the likelihood of receiving NAC and PLND was evaluated. Results: A total of 25,823 patients were included. This study found that lower-income patients were less likely to receive NAC and adequate PLND (≥15 LNs). Moreover, lower-income patients exhibited worse OS (Median OS 55.9 months vs. 68.2 months, p < 0.001). Our findings also demonstrated that higher income, treatment at academic facilities, and recent years of diagnosis were associated with an increased likelihood of receiving standard-of-care modalities and improved survival. Conclusions: Even after controlling for clinicodemographic variables, income independently influenced the receipt of standard MIBC treatments and survival. Our findings identify an opportunity to improve the quality of care for lower-income MIBC patients through concerted efforts to regionalize multi-modal urologic oncology care.

Longer time to radical cystectomy in patients treated with neoadjuvant chemotherapy is associated with worse oncological outcomes

BACKGROUND

Current muscle-invasive bladder cancer (MIBC) guidelines recommend not delaying radical cystectomy (RC) >3 months after diagnosis as it decreases overall survival (OS). However, literature investigating the impact of delay in RC in patients who receive NAC is limited, especially on a population-based level.

OBJECTIVE

To investigate the association between time from diagnosis of MIBC to RC (TTRC) in patients with urothelial bladder cancer (UBC) treated with NAC and RC and 1) 2-year OS and 2) pathological lymph node status (pN+) in a population-based cohort.

METHODS

Patients were selected from the Netherlands Cancer Registry. The study included 237 patients with cT2-T4aN0M0 UBC, treated with NAC and RC between November 2017 and October 2019. Association between TTRC and OS was assessed using multivariable Cox regression analyses. Schoenfeld and Martingale residuals were used to investigate the proportional hazards assumption and whether a cut-off in the TTRC could be identified. Association between TTRC and pN+ was assessed using multivariable logistic regression analyses.

RESULTS

Median TTRC was 23 weeks (interquartile range (IQR) 19-26). 2-year OS was 67% (95%CI 59%-74%). Each week of delay in the TTRC was independently associated with 2-year OS (HR 1.06; P = 0.03) in the Cox regression analysis. The sensitivity analyses, defining TTRC as the time between last cycle of NAC and RC, revealed that each week of delay between NAC and RC was associated with 2-year OS (Hazard ratio (HR) 1.13; P < 0.0001), and with pN+ (Odds ratio (OR) 1.21; P = 0.01) in the Cox and logistic regression analyses, respectively.

CONCLUSIONS

A longer TTRC is associated with worse oncological outcomes in patients treated with NAC and RC.

An Empirical Survey on the Adaption of Neoadjuvant Chemotherapy in Bladder Cancer

INTRODUCTION

The aim of the study was to determine the adaption of neoadjuvant chemotherapy (NAC) in patients with muscle-invasive bladder cancer (MIBC) in Germany, Austria, and Switzerland and especially underlying reasons for potential low adherence to guidelines.

METHODS

We conducted a non-validated survey among 336 urologic departments in Germany, Austria, and Switzerland. RedCap questionnaires were electronically distributed and included 23 items concerning the general NAC administration standards and guideline compliance in patient counseling regarding the actual treatment.

RESULTS

The return rate of the questionnaire was 19.1% (63/336). Although 45 departments (71.4%) claim to perform NAC as the standard of care, only 49% of eligible patients actually receive NAC. An advanced disease stage (≥cT3) and a high tumor volume were mentioned to support the application of NAC, whereas 35% of responders worry about deterioration of patients' preoperative status due to NAC. Furthermore, 26.7% of respondents are concerned about the low extent of survival benefit.

CONCLUSION

Application of NAC in eligible MIBC patients in Germany, Austria, and Switzerland remains low. Although the majority of urologic departments discuss NAC and acknowledge the need for intensified treatment in advanced disease stages, not all eligible patients will actually receive NAC before radical cystectomy.