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Laukhtina E, Rajwa P, Mori K, Moschini M, D'Andrea D, Abufaraj M, Soria F, Mari A, Krajewski W, Albisinni S, Teoh JYC, Quhal F, Sari Motlagh R, Mostafaei H, Katayama S, Grossmann NC, Enikeev D, Zimmermann K, Fajkovic H, Glybochko P, Shariat SF, Pradere B. Accuracy of Frozen Section Analysis of Urethral and Ureteral Margins During Radical Cystectomy for Bladder Cancer: A Systematic Review and Diagnostic Meta-Analysis. Eur Urol Focus 2021; 8:752-760. [PMID: 34127436 DOI: 10.1016/j.euf.2021.05.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/07/2021] [Accepted: 05/25/2021] [Indexed: 11/17/2022]
Abstract
CONTEXT The question of the ability of frozen section analysis (FSA) to accurately detect malignant pathology intraoperatively has been discussed for many decades. OBJECTIVE We aimed to conduct a systematic review and meta-analysis assessing the diagnostic estimates of FSA of the urethral and ureteral margins in patients treated with radical cystectomy (RC) for bladder cancer (BCa). EVIDENCE ACQUISITION The MEDLINE and EMBASE databases were searched in February 2021 for studies analyzing the association between FSA and the final urethral and ureteral margin status in patients treated with RC for BCa. The primary endpoint was the value of pathologic detection of urethral and ureteral malignant involvement with FSA during RC compared with the final margin status. We included studies that provided true positive, true negative, false positive, and false negative values for FSA, which allowed us to calculate the diagnostic estimates. EVIDENCE SYNTHESIS Fourteen studies, comprising 8208 patients, were included in the quantitative synthesis. Forest plots revealed that the pooled sensitivity and specificity for FSA of urethral margins during RC were 0.83 (95% confidence interval [CI] 0.38-0.97) and 0.95 (95% CI 0.91-0.97), respectively. While for the FSA of ureteral margins, the pooled sensitivity and specificity were 0.77 (95% CI 0.67-0.84) and 0.97 (95% CI 0.95-0.98), respectively. Calculated diagnostic odds ratios indicated high FSA effectiveness, and patients with a positive urethral or ureteral margin at final pathology are over 100 times more likely to have positive FSA than patients without margin involvement at final pathology. Area under the curves of 96.6% and 96.7% were reached for FSA detection of urethral and ureteral tumor involvement, respectively. CONCLUSIONS Intraoperative FSA demonstrated high diagnostic performance in detecting both urethral and ureteral malignant involvement at the time of RC for BCa. FSA of both urethral and ureteral margins during RC is accurate enough to be of great value in the routine management of BCa patients treated with RC. While its specificity was great to guide intraoperative decision-making, its sensitivity remains suboptimal yet. PATIENT SUMMARY We believe that the frozen section analysis of both urethral and ureteral margins during radical cystectomy should be considered more often in urologic practice, until quality of life-based cost-effectiveness studies can identify patients within each institution who are unlikely to benefit from it.
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Affiliation(s)
- Ekaterina Laukhtina
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Pawel Rajwa
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Medical University of Silesia, Zabrze, Poland
| | - Keiichiro Mori
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Marco Moschini
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Luzerner Kantonsspital, Lucerne, Switzerland; Department of Urology and Division of Experimental Oncology, Urological Research Institute, Vita-Salute San Raffaele, Milan, Italy
| | - David D'Andrea
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Mohammad Abufaraj
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan
| | - Francesco Soria
- Division of Urology, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Studies of Torino, Turin, Italy
| | - Andrea Mari
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy
| | - Wojciech Krajewski
- Department of Urology and Oncologic Urology, Wrocław Medical University, Wroclaw, Poland
| | - Simone Albisinni
- Service d'Urologie, Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Jeremy Yuen-Chun Teoh
- S.H. Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Fahad Quhal
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Reza Sari Motlagh
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Men's Health and Reproductive Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hadi Mostafaei
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Research Center for Evidence Based Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Satoshi Katayama
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Nico C Grossmann
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Department of Urology, University Hospital Zurich, Zurich, Switzerland
| | - Dmitry Enikeev
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Kristin Zimmermann
- Department of Urology, Federal Armed Services Hospital Koblenz, Koblenz, Germany
| | - Harun Fajkovic
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria
| | - Petr Glybochko
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Shahrokh F Shariat
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria; Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia; Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman, Jordan; Karl Landsteiner Institute of Urology and Andrology, Vienna, Austria; Department of Urology, Weill Cornell Medical College, New York, NY, USA; Department of Urology, University of Texas Southwestern, Dallas, TX, USA; Department of Urology, Second Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - Benjamin Pradere
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
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Saint F, Masson-Lecomte A. Achieving disease free distal ureteral margin at the time of radical cystectomy: Why and for whom? (an overview of literature). Prog Urol 2021; 31:303-315. [PMID: 33593697 DOI: 10.1016/j.purol.2020.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/28/2020] [Accepted: 09/20/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Achieving negative status of distal ureteral margin at the time of radical cystectomy (RC), and its therapeutic benefit, remains controversial. The aim of this review was to evaluate frequency, reliability and impact of positive distal ureteral margin after radical cystectomy for bladder cancer on upper tract recurrence, cancer specific and overall survival, and to identify best candidates for intraoperative frozen section analyses. MATERIAL AND METHODS A systemic review was performed following the PRISMA guideline. PubMed/Medline (with following terms; bladder cancer or cystectomy and frozen section or ureteral margin), and Cochrane Library were searched up to April 2020, to identify all papers evaluating distal ureteral margin and discussing clinical interest. Previous reviews and single case reports were excluded. RESULTS In total, thirty-two relevant studies were identified. Mean rate of positive ureteral frozen section after RC was close to 10% [1.1-25.4%]. Frozen section (FS) achieved a very good specificity [83-100%] and reserved sensibility [45-100%]. In many cases, an initial positive margin on FS can be converted to negative. Positive FS and/or PS (permanent section) were associated with upper urinary tract recurrence (UUTR). Conversion from positive FS to negative PS was associated with low UUTR frequency and better cancer survival in large retrospective studies. The relevant prognostic factor associated with positive FS and/or PS was CIS within the bladder. CONCLUSION FS should be recommended for patients with CIS within the bladder. Achieving negative FS/PS might be associated with lower rates of UUTR and better survival, for patients with higher life expectancy. Prospective randomized controlled studies need to be performed to provide definitive recommendations in this area.
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Affiliation(s)
- F Saint
- EPROAD research laboratory (EA 4669), Amiens, France; Department of urology and transplantation, Picardie Jules-Verne university, Amiens, France.
| | - A Masson-Lecomte
- Department of urology and transplantation, Paris Diderot university, Saint-Louis hospital, Paris, France
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Soliman K, Taha DE, Aboumarzouk OM, Koraiem IO, Shokeir AA. Can frozen-section analysis of ureteric margins at the time of radical cystectomy predict upper tract recurrence? Arab J Urol 2020; 18:155-162. [PMID: 33029425 PMCID: PMC7473000 DOI: 10.1080/2090598x.2020.1751923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Objective To summarise the currently available literature and analyse available results of the outcome of intraoperative frozen-section analysis (FSA) on upper urinary tract recurrence (UUTR) after radical cystectomy (RC). Materials and methods A systematic review of the literature was performed according to the Cochrane Reviews guidelines and in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Articles discussing ureteric FSA with RC were identified. Results The literature search yielded 21 studies, on which the present analysis was done. The studies were published between 1997 and 2019. There were 10 010 patients with an age range between 51 and 95 years. Involvement of the ureteric margins was noted in 2–9% at RC. The sensitivity and specificity of FSA were ~75% and 99%, respectively. Adverse pathology on FSA and on permanent section, prostatic urothelial carcinoma involving the stroma but not prostatic duct, and ureteric involvement on permanent section were all more likely to develop UUTR. Neither evidence of ureteric involvement nor ureteric margin status on permanent section were significant predictors of overall survival. Conclusion Routine FSA is mandatory for a tumour-free uretero–enteric anastomosis and is predictive of UUTR. To lower the UUTR, FSA is not necessary if the ureters are resected at the level where they cross the common iliac vessels. FSA is indicated whenever the surgeon encounters findings suspicious of malignancy, e.g. ureteric obstruction, periureteric fibrosis, diffuse carcinoma in situ, induration or frank tumour infiltration of the distal ureter is discovered unexpectedly during surgery, and prostatic urethral involvement. Abbreviations CIS: carcinoma in situ; FSA: frozen-section analysis; HR: hazard ratio; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RC: radical cystectomy; (UT)UC: (upper tract) urothelial carcinoma; UUT(R): upper urinary tract (recurrence)
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Affiliation(s)
- Karim Soliman
- Department of Urology, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Diaa-Eldin Taha
- Department of Urology, Faculty of Medicine, Kafrelsheikh University, Kafrelsheikh, Egypt
| | - Omar M Aboumarzouk
- Glasgow Urological Research Unit, Department of Urology, Queen Elizabeth University Hospital, Glasgow, UK.,School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Islam Osama Koraiem
- Department of Urology, Damanhour International Medical Institute, Beheira, Egypt
| | - Ahmed A Shokeir
- Department of Urology, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
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Tang J, Ranasinghe W, Cheng J, Van Es S, Monsour M, Cetti R, Jensen R, Brough S. Utility of Routine Intraoperative Ureteral Frozen Section Analysis at Radical Cystectomy: Outcomes from a Regional Australian Center. Curr Urol 2019; 12:70-73. [PMID: 31114463 DOI: 10.1159/000489422] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 03/06/2018] [Indexed: 11/19/2022] Open
Abstract
Introduction The objective of this study was to look at the usefulness and cost effectiveness of intraoperative frozen section analysis (FSA) of the ureters at the time of radical cystectomy. Methods Pathology notes of patients undergoing radical cystectomy for primary bladder cancer between the years 2000-2015 at our institution were reviewed. Results A total of 196 ureteric specimens from 98 patients were reviewed. Of the 98 patients, 9% (n = 9) had positive ureteric margins, of which all were ≥ T2, with 44% (4 of 9) being T = 4. In all cases of positive FSA, preoperative clinical staging was ≥ T2. In cases where cancer staging was upgraded post-cystectomy, there were no cases of positive FSA. After adjusting for tumor stage in ≥ T2a, using Cox regression analysis, positive frozen section was associated with a 4.2 fold increase in overall mortality (95%CI 1.3-13.8; p = 0.02). Cost associated with FSA was AU$1,351.90 to obtain 1 positive result. Conclusion Patients with positive ureteric FSA are at higher risk of mortality post cystectomy, despite excision to negative tissue. However, FSA of the distal ureters at cystectomy were unlikely to be positive unless the bladder cancer stage was ≥ T2. Hence, routine ureteric FSA may not be necessary in patients undergoing cystectomy for non-muscle invasive bladder tumors.
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Affiliation(s)
| | | | - Janice Cheng
- Launceston General Hospital, Launceston, TAS, Australia
| | | | - Mike Monsour
- Launceston General Hospital, Launceston, TAS, Australia
| | - Richard Cetti
- Launceston General Hospital, Launceston, TAS, Australia
| | - Robert Jensen
- Launceston General Hospital, Launceston, TAS, Australia
| | - Steve Brough
- Launceston General Hospital, Launceston, TAS, Australia
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Positive ureteric margins at radical cystectomy: Can it be predicted at initial transurethral resection of bladder tumour? Arab J Urol 2018; 16:386-390. [PMID: 30534436 PMCID: PMC6277264 DOI: 10.1016/j.aju.2018.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 06/02/2018] [Accepted: 06/23/2018] [Indexed: 11/23/2022] Open
Abstract
Objective To identify primary tumour-related factors at transurethral resection of bladder tumour (TURBT) that may predict positive distal ureteric margins (PUM) at the time of radical cystectomy (RC). Patients and methods A retrospective, cohort study was conducted using our institution's data from June 2007 to June 2016. Patients who underwent TURBT followed by RC for non-metastatic urothelial carcinoma (UC) of the bladder were identified. In all, 211 patients underwent RC for UC during the study period. The patients were divided into two groups: Group-I (n = 17) with PUM and Group-II (n = 194) with negative ureteric margins. Univariate and multivariate analyses were performed to determine the predictors of PUM. Results On univariate analysis, multifocality, tumours involving the ureteric orifice, trigonal tumours, presence of carcinoma in situ (CIS), and lymphovascular invasion at TURBT, were significantly more common in Group-I. On multivariate analysis, tumour involvement in the ureteric orifice(s) and presence of associated CIS significantly predicted PUM. Conclusions Primary tumour-related factors on initial TURBT that predicted PUM (at RC) were involvement of the ureteric orifice(s) and presence of associated CIS. These results may help to select patients who can be selectively offered intraoperative frozen section analysis.
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Gakis G, Black PC, Bochner BH, Boorjian SA, Stenzl A, Thalmann GN, Kassouf W. Systematic Review on the Fate of the Remnant Urothelium after Radical Cystectomy. Eur Urol 2016; 71:545-557. [PMID: 27720534 DOI: 10.1016/j.eururo.2016.09.035] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 09/22/2016] [Indexed: 01/08/2023]
Abstract
CONTEXT Urothelial carcinoma is considered a pan-urothelial disease. As such, the remnant urothelium in the upper urinary tract and urethra following radical cystectomy (RC) remains at risk for secondary urothelial tumors (SUTs). OBJECTIVE To describe the incidence, diagnosis, treatment, and outcomes of patients with SUTs after RC. EVIDENCE ACQUISITION A systematic search was conducted using PubMed database according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to identify studies between 1970 and 2016 reporting on malignant diseases of the urothelium after RC for bladder cancer. The search strategy separated between upper and lower tract urothelial tumors. EVIDENCE SYNTHESIS Of a total of 1069 studies, 57 were considered for evidence synthesis. SUTs occured in approximately 4-10% of patients after RC. Carcinoma in situ of the bladder, a history of nonmuscle invasive bladder cancer, and tumor involvement of the distal ureter are the strongest risk factors for secondary upper tract tumors. Risk factors for secondary urethral tumors represent urothelial malignancy in the prostatic urethra/prostate and bladder neck (in women), nonorthotopic diversions, and positive findings on permanent sections. The majority of patients (84%) with SUTs, presented with urothelial recurrence without evidence of metastasis. Of those, 84.0% were treated with surgery, 10.5% with systemic chemotherapy and/or radiotherapy, and 5.6% with topical chemotherapy and/or immunotherapy. After a median follow-up of 91 mo (range: 26-155), 65.9% of patients died of disease and 21.5% died of other causes. Detection and treatment of SUTs at an asymptomatic stage can reduce the risks of cancer-specfific and overall mortality by 30%. A limitation of the study is that the available data were retrospective. CONCLUSIONS SUTs are rare oncological events and most patients have an adverse prognosis despite absence of distant disease at diagnosis. Therefore, surveillance of the remnant urothelium should be implemented for patients with histological features of panurothelial disease as it may improve timely detection and treatment. PATIENT SUMMARY Secondary tumors of the renal pelvis, ureters, and urethra occur in approximately 4-10% of patients after radical removal of the bladder for bladder cancer. These patients' prognoses are reduced, likely due to delayed diagnosis. Therefore, routine surveillance might be important to detect tumors at an early stage.
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Affiliation(s)
- Georgios Gakis
- Department of Urology, Eberhard-Karls University of Tübingen, Germany.
| | - Peter C Black
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Bernard H Bochner
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Arnulf Stenzl
- Department of Urology, Eberhard-Karls University of Tübingen, Germany
| | - George N Thalmann
- Department of Urology, Inselspital Bern, University of Bern, Switzerland
| | - Wassim Kassouf
- Division of Urology, McGill University, Montreal, QC, Canada
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Alemozaffar M, Filson CP, Master VA. The importance of surgical margins in renal cell and urothelial carcinomas. J Surg Oncol 2016; 113:316-22. [DOI: 10.1002/jso.24121] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 11/20/2015] [Indexed: 11/11/2022]
Affiliation(s)
| | - Christopher P. Filson
- Department of Urology; Emory University; Atlanta Georgia
- Atlanta Veterans Affairs Medical Center; Decatur Georgia
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Reder NP, Maxwell SP, Pambuccian SE, Barkan GA. Diagnostic accuracy of intraoperative frozen sections during radical cystectomy does not affect disease-free or overall survival: a study of 364 patients with urothelial carcinoma of the urinary bladder. Ann Diagn Pathol 2015; 19:107-12. [DOI: 10.1016/j.anndiagpath.2015.02.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 02/26/2015] [Accepted: 02/26/2015] [Indexed: 10/23/2022]
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Satkunasivam R, Hu B, Daneshmand S. Is Frozen Section Analysis of Ureteral Margins at Time of Radical Cystectomy Useful? Curr Urol Rep 2015; 16:38. [DOI: 10.1007/s11934-015-0506-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Satkunasivam R, Hu B, Metcalfe C, Ghodoussipour SB, Aron M, Cai J, Miranda G, Gill I, Daneshmand S. Utility and significance of ureteric frozen section analysis during radical cystectomy. BJU Int 2015; 117:463-8. [PMID: 25684323 DOI: 10.1111/bju.13081] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To assess the utility of routine frozen section analysis of ureters at the time of radical cystectomy (RC) for urothelial cancer (UC), and the long-term outcomes of adverse ureteric pathology. PATIENTS AND METHODS Pathological data on 2 047 patients undergoing RC for UC with routine frozen section analysis of ureters (January 1971 to December 2009) were analysed. Univariate and multivariable logistic and Cox proportional hazards models were used to determine the risk of upper tract UC (UTUC) recurrence, local recurrence and overall survival in those identified as having adverse pathology (severe atypia/carcinoma in situ [CIS] or UC) at time of frozen section analysis. RESULTS Adverse pathology was identified by frozen section analysis in 178 patients (8.6%). Frozen section analysis was found to have poor sensitivity in identifying adverse pathology (59.1%), which was improved in patients with preoperative CIS (68.0%). After a median (interquartile range) follow-up of 12.4 (1.9-10.1) years, 28 patients (1.4%) developed UTUC recurrence. There were no uretero-enteric anastomotic recurrences. Adverse pathology on frozen section analysis was associated with UTUC recurrence on univariate analysis (hazard ratio [HR] 6.2, 95% confidence interval [CI] 2.9-13.5), but 15/28 patients (54%) with UTUC recurrence had benign ureteric frozen section analysis on initial sectioning. Adverse pathology on frozen section analysis was not independently associated with the risk of local recurrence (HR 1.08, 95% CI 0.61-1.89) or overall survival (HR 1.12, 95% CI 0.94-1.35) in multivariate models. CONCLUSIONS Ureteric frozen section analysis has poor sensitivity and may be marginally improved in pre-existing CIS. UTUC recurrence is rare and can occur despite negative frozen section analysis. Our data question the utility of routine frozen section analysis of the distal ureteric margin at the time of RC.
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Affiliation(s)
- Raj Satkunasivam
- USC Institute of Urology and Norris Comprehensive Cancer Center, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Brian Hu
- USC Institute of Urology and Norris Comprehensive Cancer Center, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Charles Metcalfe
- USC Institute of Urology and Norris Comprehensive Cancer Center, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Saum B Ghodoussipour
- USC Institute of Urology and Norris Comprehensive Cancer Center, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Manju Aron
- Department of Pathology, Norris Comprehensive Cancer Center, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Jie Cai
- USC Institute of Urology and Norris Comprehensive Cancer Center, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Gus Miranda
- USC Institute of Urology and Norris Comprehensive Cancer Center, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Inderbir Gill
- USC Institute of Urology and Norris Comprehensive Cancer Center, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Siamak Daneshmand
- USC Institute of Urology and Norris Comprehensive Cancer Center, Keck School of Medicine of USC, Los Angeles, CA, USA
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Gordetsky J, Bivalacqua T, Schoenberg M, Epstein JI. Ureteral and Urethral Frozen Sections During Radical Cystectomy or Cystoprostatectomy: An Analysis of Denudation and Atypia. Urology 2014; 84:619-23. [DOI: 10.1016/j.urology.2014.05.037] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 05/06/2014] [Accepted: 05/28/2014] [Indexed: 12/01/2022]
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Kim HS, Moon KC, Jeong CW, Kwak C, Kim HH, Ku JH. The clinical significance of intra-operative ureteral frozen section analysis at radical cystectomy for urothelial carcinoma of the bladder. World J Urol 2014; 33:359-65. [PMID: 24825471 DOI: 10.1007/s00345-014-1306-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 04/17/2014] [Indexed: 12/01/2022] Open
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Hoang AN, Agarwal PK, Walton-Diaz A, Wood CG, Metwalli AR, Kassouf W, Brown GA, Black PC, Urbauer DL, Grossman HB, Dinney CPN, Kamat AM. Clinical significance of ureteric 'skip lesions' at the time of radical cystectomy: the M.D. Anderson experience and literature review. BJU Int 2014; 113:E28-33. [PMID: 24053608 DOI: 10.1111/bju.12344] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess the incidence and clinical significance of 'skip lesions' that are present in proximal but not in distal ureteric sections, which are occasionally found during the pathological examination of ureteric margins during radical cystectomy (RC). PATIENTS AND METHODS We identified 660 patients who underwent a RC and had at least two permanent margins for a given ureter. In all, 1173 ureters were analysed and classified as follows: 'normal' (no tumour, reactive atypia, mild or moderate dysplasia) or 'abnormal' (severe dysplasia, carcinoma in situ (CIS), or tumour). Transitions from 'normal' distal pathology to 'abnormal' on proximal section(s) determined frequency of skip lesions. Fisher's exact test and the log-rank test were used to study correlations. RESULTS Ureteric skip lesions were found in 4.8% patients (2.9% ureters). Pathology of skip lesions was CIS in 55.9%, transitional cell carcinoma in 23.5% and severe dysplasia in 20.6%. Skip lesions were associated with lymphovascular invasion (34.4% vs 13.7%, P = 0.004) and advanced pT stage (P = 0.007). On multivariate analysis, skip lesions correlated with lower median overall survival (OS) (inestimable vs 8.2 years, P = 0.014) in patients with pT0 or pTa disease and a trend towards lower OS (2.7 vs 8.8 years, P = 0.066) in pTis disease. Concordance between frozen distal margin and permanent proximal margin varied; sensitivity was 80% in those without and 20% in those with skip lesions. CONCLUSIONS The presence of a ureteric skip lesion may be associated with lower survival in patients with pT0, pTa or pTis urothelial carcinoma. Thus, while uncommon, ureteric skip lesions should be reported in pathological findings.
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Affiliation(s)
- Anthony N Hoang
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
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Loeser A, Katzenberger T, Vergho DC, Kocot A, Burger M, Riedmiller H. Frozen Section Analysis of Ureteral Margins in Patients Undergoing Radical Cystectomy for Bladder Cancer: Differential Impact of Carcinoma in situ in the Bladder on Reliability and Impact on Tumour Recurrence in the Upper Urinary Tract. Urol Int 2014; 92:50-4. [DOI: 10.1159/000353230] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Accepted: 05/20/2013] [Indexed: 11/19/2022]
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Gondo T, Nakashima J, Ohno Y, Hashimoto T, Takizawa I, Sakamoto N, Horiguchi Y, Aoyagi T, Ohori M, Tachibana M. Preoperative prediction of malignant involvement of resected ureters in patients undergoing radical cystectomy for bladder cancer. Int J Urol 2012; 20:501-6. [PMID: 23106193 DOI: 10.1111/j.1442-2042.2012.03203.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Accepted: 09/23/2012] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate preoperative predictors of ureteral involvement of bladder malignancy and to develop a novel preoperative model for the prediction of ureteral involvement in bladder cancer patients undergoing radical cystectomy. METHODS This study included 197 consecutive bladder cancer patients treated with radical cystectomy. The correlations of preoperative factors with ureteral involvement were analyzed by univariate analysis with Pearson's χ(2-) test and multivariate logistic regression analysis with a stepwise selection procedure. RESULTS Positive ureteral involvement was observed in 38 (19.3%) patients. Tumor location (involvement of the vesical trigone), clinical T stage (≥ cT3) and the number of tumors (≥ 3), but not sex, tumor grade and histological features determined by transurethral resection of bladder tumor, tumor size, shape of tumor, concomitant presence of carcinoma in situ, preoperative intravesical therapy, number of transurethral resection of bladder tumor procedures or the presence of hydronephrosis were significantly associated with ureteral involvement in the univariate analysis. Multivariate logistic regression analysis confirmed that the aforementioned three significant factors identified in the univariate analysis were significant independent predictors of ureteral involvement. The probability of ureteral involvement estimated by a combination of these three parameters was well correlated with the real incidence (R = 0.904, P = 0.0021). CONCLUSIONS Tumor location (involvement of vesical trigone), clinical T stage (≥ cT3) and the number of tumors (≥ 3) are significant independent preoperative predictors of ureteral involvement of malignancy in bladder cancer patients undergoing radical cystectomy. Our predictive model might be useful for preoperative prediction of ureteral tumor involvement.
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Affiliation(s)
- Tatsuo Gondo
- Department of Urology, Tokyo Medical University, Tokyo, Japan.
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Canda AE, Dogan B, Atmaca AF, Akbulut Z, Balbay MD. Ureteric duplication is not a contraindication for robot-assisted laparoscopic radical cystoprostatectomy and intracorporeal Studer pouch formation. JSLS 2012; 15:575-9. [PMID: 22643522 PMCID: PMC3340976 DOI: 10.4293/108680811x13176785204751] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The authors found that duplicated ureters was not a contraindication to robot-assisted laparoscopic radical cystoprostatectomy in this case. Objectives: Ureteric duplication is a rarely seen malformation of the urinary tract more commonly seen in females. Materials and Methods: We report 2 cases of robot-assisted laparoscopic radical cystoprostatectomy (RALRCP) with bilateral extended pelvic lymph node dissection and intracorporeal Studer pouch formation in patients with duplicated right ureters. Results: Two male patients (53 and 68 years old) underwent transurethral resection of a bladder tumor that revealed high-grade muscle invasive transitional cell carcinoma, with no metastases. We performed RALRCP and intracorporeal Studer pouch formation. A duplicated right ureter was observed during the procedures in both patients. Left ureter distal segment was spatulated 2cm long and anastomosed using running 4/0 Vicryl to the right ureter at its bifurcation where it forms a single lumen without spatulation. All 3 ureters were catheterized individually. A Wallace type uretero-ileal anastomosis was performed between the ureters and the proximal part of the Studer pouch chimney. Although ureteric frozen section analysis suggested ureteric carcinoma in situ in patient 1, postoperative pathologic evaluation was normal. Frozen section and final postoperative pathologic evaluations were normal in patient 2. Conclusions: Duplicated ureters might be underdiagnosed on CT. The presence of a duplicated ureter is not a contraindication to RALRCP and intracorporeal Studer pouch formation. The da Vinci-S surgical robot is very safe for performing this complicated procedure. Frozen section analysis of ureters during radical cystectomy for bladder cancer might not reliably diagnose the pathologic condition and might overestimate the disease in the ureters.
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Touma N, Izawa JI, Abdelhady M, Moussa M, Chin JL. Ureteral frozen sections at the time of radical cystectomy: reliability and clinical implications. Can Urol Assoc J 2011; 4:28-32. [PMID: 20165574 DOI: 10.5489/cuaj.08107] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND We hypothesized that the incidence of ureteral abnormalities on frozen section analysis (FS) at the time of radical cystectomy is much lower than historical values and that FS has minimal impact on outcomes. We also sought to determine the accuracy of FS and the associated costs. METHODS We reviewed the records of 301 patients who underwent a radical cystectomy for urothelial carcinoma of the bladder (UC) between March 2000 and January 2007. The ureteral margins were sent for FS and subsequent permanent hematoxyllin and eosin (H&E) sections and results were compared. Analyses were performed to determine the costs of FS and if any association was present with the pathological stage of the primary bladder tumour and regional lymph nodes, the presence of urothelial carcinoma in situ of the bladder (CIS) and survival outcomes with the FS. RESULTS We identified 602 ureters for this study. The incidence of CIS or solid urothelial carcinoma in the ureter was 2.8%. The presence of CIS of the bladder and prostatic urethra was significantly associated with a positive FS (p = 0.02). The FS were not associated with survival outcomes. The cost to pick up 1 patient with any abnormality on FS was $2080. The cost to pick up 1 patient with CIS or solid urothelial carcinoma of the ureter on FS was $6471. CONCLUSION The incidence of CIS and tumour on FS during radical cystectomy for UC is low. The costs associated with FS are substantial. Frozen section analysis should only be performed in select patients undergoing radical cystectomy.
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Affiliation(s)
- Naji Touma
- Departments of Surgery & Oncology, Divisions of Urology & Surgical Oncology
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Mukha R, Kumar S, Kekre NS. Ureteral frozen section analysis during radical cystectomy: Do margins matter? Indian J Urol 2011; 23:211-2. [PMID: 19675808 PMCID: PMC2721540 DOI: 10.4103/0970-1591.32082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Rajiv Mukha
- Department of Urology, Christian Medical College, Vellore, Tamilnadu, India
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Sequential resection of malignant ureteral margins at radical cystectomy: a critical assessment of the value of frozen section analysis. World J Urol 2010; 29:451-6. [DOI: 10.1007/s00345-010-0581-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2010] [Accepted: 06/28/2010] [Indexed: 10/19/2022] Open
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Tollefson MK, Blute ML, Farmer SA, Frank I. Significance of Distal Ureteral Margin at Radical Cystectomy for Urothelial Carcinoma. J Urol 2010; 183:81-6. [DOI: 10.1016/j.juro.2009.08.158] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Indexed: 11/15/2022]
Affiliation(s)
- Matthew K. Tollefson
- Departments of Urology and Health Sciences Research (SAF), Mayo Medical School and Mayo Clinic, Rochester, Minnesota
| | - Michael L. Blute
- Departments of Urology and Health Sciences Research (SAF), Mayo Medical School and Mayo Clinic, Rochester, Minnesota
| | - Sara A. Farmer
- Departments of Urology and Health Sciences Research (SAF), Mayo Medical School and Mayo Clinic, Rochester, Minnesota
| | - Igor Frank
- Departments of Urology and Health Sciences Research (SAF), Mayo Medical School and Mayo Clinic, Rochester, Minnesota
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Lee SE, Byun SS, Hong SK, Chang IH, Kim YJ, Gill MC, Song SH, Kim KT. Significance of Cancer Involvement at the Ureteral Margin Detected on Routine Frozen Section Analysis during Radical Cystectomy. Urol Int 2009; 77:13-7. [PMID: 16825809 DOI: 10.1159/000092928] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2005] [Accepted: 12/21/2005] [Indexed: 11/19/2022]
Abstract
INTRODUCTION We investigated the clinical significance of preoperatively-unsuspected ureteral involvement of cancer detected on intraoperative frozen section analysis of ureteral margins during radical cystectomy. PATIENTS AND METHODS We performed a retrospective study of 115 patients who received radical cystectomy for locally-advanced but node-negative transitional cell carcinoma of the bladder between 1995 and 2002 by reviewing their records. RESULTS Of 115 total patients, 5 (4.3%) demonstrated carcinoma in situ at the ureteral margin with 2 of 5 having a positive margin on final pathologic analysis. Meanwhile, only 3 of 115 total patients (2.6%) later showed upper urinary tract recurrence at a median interval of 30 months after cystectomy. And all 3 patients had intramural or juxtavesical ureter involvement of disease (p = 0.006), while not demonstrating carcinoma in situ in ureteral margins resected during cystectomy. On multivariate analysis, only the stage and grade of bladder cancer along with pathologic feature of vascular invasion were observed to be independent prognostic predictors of disease-specific survival. CONCLUSIONS Cancer involvement of the distal ureteral margin detected through intraoperative frozen section analysis may not be a significant factor regarding upper tract recurrence and survival of patients with locally-advanced bladder cancer after radical cystectomy. Upper tract recurrence may be more prone to occur in patients with cancer involvement at the intramural or juxtavesical ureter.
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Affiliation(s)
- Sang Eun Lee
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, Kyunggi-do, Korea
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Wagner KR, Schoenberg MP, Bianco FJ, Jarrett TW. Prospective intermediate follow-up of carcinoma in situ involving the distal ureter at cystectomy: is there a role for ureteroscopy? J Endourol 2008; 22:1241-6. [PMID: 18578657 DOI: 10.1089/end.2008.0074] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND PURPOSE The presence of urothelial carcinoma in situ (CIS) at the distal ureteral margin has been identified as a risk factor for upper tract recurrence after radical cystectomy. Management of this finding is controversial. The objective of this study was to determine if follow-up with ureteroscopy could aid in early detection of recurrences in these patients. PATIENTS AND METHODS We collected prospective clinical-pathologic data for all patients who underwent radical cystectomy between 1999 and 2004. Patients with CIS at the distal ureteral margin were followed with endoscopy of the urinary diversion and bilateral ureteroscopy in addition to standard imaging and cytologic evaluation every 6 months. Recurrence was defined as detection of any malignant urothelial cells. RESULTS In 250 consecutive cystectomies, eight patients were identified with CIS that involved a ureteral margin of 12 renal units. Ureteroscopy was successful in all cases, and there were no complications. Imaging was diagnostic in one patient, all cytologic examinations from the diversion were nondiagnostic, and ureteroscopy was positive in all recurrences. Six patients had recurrences at a median follow-up of 52.7 months; five needed laparoscopic nephroureterectomy, and one had disease controlled with percutaneous mitomycin C. Five patients were disease free at last follow-up, and one patient died with brain metastasis at 30 months. CONCLUSIONS Patients with CIS that involves the ureteral margin are at increased risk for upper tract recurrence and progression. Aggressive follow-up with scheduled ureteroscopy may identify recurrences at an earlier stage. Development of additional markers for risk stratification and protocols for adjuvant treatment are needed.
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Affiliation(s)
- Kristofer R Wagner
- Department of Urology, George Washington University, Washington, District of Columbia, USA
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Donat SM. Argument against frozen section analysis of distal ureters in transitional cell bladder cancer. ACTA ACUST UNITED AC 2008; 5:538-9. [DOI: 10.1038/ncpuro1210] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2008] [Accepted: 07/29/2008] [Indexed: 11/09/2022]
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Irani J, Bernardini S, Bonnal JL, Chauvet B, Colombel M, Davin JL, Laurent G, Lebret T, Maidenberg M, Mazerolles C, Pfister C, Roupret M, Roy C, Rozet F, Saint F, Theodore C. [Urothelial tumors]. Prog Urol 2008; 17:1065-98. [PMID: 18153988 DOI: 10.1016/s1166-7087(07)74781-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Malkowicz SB, van Poppel H, Mickisch G, Pansadoro V, Thüroff J, Soloway MS, Chang S, Benson M, Fukui I. Muscle-Invasive Urothelial Carcinoma of the Bladder. Urology 2007; 69:3-16. [PMID: 17280906 DOI: 10.1016/j.urology.2006.10.040] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2006] [Revised: 09/04/2006] [Accepted: 10/23/2006] [Indexed: 11/20/2022]
Abstract
Muscle-invasive urothelial (transitional cell) carcinoma is a potentially lethal condition for which an attempt at curative surgery is required. Clinical staging does not allow for accurate determination of eventual pathologic status. Muscle-invasive urothelial carcinoma is a highly progressive disease, and initiation of definitive therapy within 3 months of diagnosis is worthwhile. Age is not a contraindication for aggressive surgical care, and surgical candidates should be evaluated in the context of overall medical comorbidity. In those patients who undergo surgery, clinical pathways may streamline care. Radical cystectomy remains the "gold standard" of therapy, providing 5-year survival rates of 75% to 80% in patients with organ-confined disease, yet organ-sparing procedures demonstrate clinical effectiveness as well. Cystectomy should be undertaken with the intent of performing complete pelvic lymph node dissection and attaining surgically negative margins. In younger female patients, the preservation of reproductive organs may be achieved in many cases. Prostate- and seminal vesicle-preserving cystectomy has been performed, yet the long-term safety and efficacy of such a procedure remains to be determined. Laparoscopic and robotic cystectomy procedures continue to be explored by several investigators. The role of "radical transurethral resection" in muscle-invasive disease is limited to a small cohort of patients, and, when it is performed, cystectomy may be required to consolidate therapy. Postoperative follow-up after cystectomy should occur over short intervals during the first 2 years and can be extended, but not discontinued, beyond that time. Currently, no tumor markers have been prospectively validated to help guide clinical decision making, and prospective trials incorporating marker data should be encouraged.
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Affiliation(s)
- S Bruce Malkowicz
- Department of Urology, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
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Osman Y, El-Tabey N, Abdel-Latif M, Mosbah A, Moustafa N, Shaaban A. The value of frozen-section analysis of ureteric margins on surgical decision-making in patients undergoing radical cystectomy for bladder cancer. BJU Int 2007; 99:81-4. [PMID: 17026592 DOI: 10.1111/j.1464-410x.2006.06567.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To prospectively investigate the value of routine frozen-section analysis (FSA) of the ureteric margin for detecting distal ureteric malignancy in patients undergoing cystectomy for bladder transitional cell carcinoma (TCC). PATIENTS AND METHODS In all, 100 consecutive patients had a radical cystectomy for TCC of the bladder; routine FS biopsies were obtained from the lower ureters of all. Definitive pathology with step-sectioning of the lower ureters was reviewed, and the results of paraffin-wax embedded sections and FSA were compared. The true incidence of distal ureteric malignancy was identified and correlated with different clinical and pathological variables. RESULTS There were 193 ureteric specimens examined; 16 ureters (8.3%) in 14 patients showed evidence of malignancy by FSA. True distal ureteric malignancy was diagnosed in 29 ureteric specimens (15%) in 24 patients. The sensitivity and specificity of the FSA were 45% and 98%, respectively, while the positive and negative predictive values were 81% and 91%, respectively. There was no significant correlation between distal ureteric malignancy and: patient age, tumour site or morphology, clinical or pathological staging, ipsilateral hydronephrosis, suspicious intraoperative ureter, biopsy or tumour grade, associated carcinoma in situ or nodal involvement. Male gender and positive intraoperative FSA were the only predictors significantly associated with distal ureteric malignancy by univariate analysis (P = 0.01 and <0.01, respectively). Both predictors remained significant on multivariate analysis. CONCLUSION A positive ureteric FSA during cystectomy has a high predictive value in the diagnosis of distal ureteric malignancy, and is justified as an independent predictor in male patients with bladder TCC.
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Affiliation(s)
- Yasser Osman
- Urology and Nephrology Center, Mansoura University, Mansoura, Egypt.
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Schumacher MC, Scholz M, Weise ES, Fleischmann A, Thalmann GN, Studer UE. Is There an Indication for Frozen Section Examination of the Ureteral Margins During Cystectomy for Transitional Cell Carcinoma of the Bladder? J Urol 2006; 176:2409-13; discussion 2413. [PMID: 17085117 DOI: 10.1016/j.juro.2006.07.162] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2005] [Indexed: 11/24/2022]
Abstract
PURPOSE We evaluated the incidence of pathological findings of the ureter at cystectomy for transitional cell carcinoma of the bladder and assessed the usefulness of intraoperative frozen section examination of the ureter. MATERIALS AND METHODS Histopathological findings of ureteral frozen section examination were compared to the corresponding permanent sections and the diagnostic accuracy of frozen section examination was evaluated. These segments were then compared to the more proximal ureteral segments resected at the level where they cross over the common iliac arteries. The histopathological findings of the ureteral segments were then correlated for upper urinary tract recurrence and overall survival. RESULTS Transitional cell carcinoma or carcinoma in situ was found on frozen section examination of the distal ureter in 39 of 805 patients (4.8%) and on permanent sections in 29 (3.6%). In 755 patients the false-negative rate of frozen section examination of the ureters was 0.8%. Of the patients with carcinoma in situ diagnosed on the first frozen section examination 80% also had carcinoma in situ in the bladder. Transitional cell carcinoma or carcinoma in situ in the most proximally resected ureteral segments was found in 1.2% of patients. After radical cystectomy there was tumor recurrence in the upper urinary tract in 3% of patients with negative ureteral frozen section examination and in 17% with carcinoma in situ on frozen section examination. CONCLUSIONS Routine frozen section examination of the ureters at radical cystectomy is only recommended for patients with carcinoma in situ of the bladder, provided the ureters are resected where they cross the common iliac arteries.
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Affiliation(s)
- Martin C Schumacher
- Department of Urology, Institute of Pathology, University Hospital Bern, 3010 Bern, Switzerland
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Brooks JD. Editorial Comment. J Urol 2006. [DOI: 10.1016/j.juro.2006.07.175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- James D. Brooks
- Department of Urology, Stanford University School of Medicine, Stanford, California
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Nakanishi S, Nishiyama H, Ito M, Yoshimura K, Kamoto T, Ogawa O. Management of concomitant ureteral carcinoma in situ at radical cystectomy. Int J Urol 2006; 13:524-8. [PMID: 16771720 DOI: 10.1111/j.1442-2042.2006.01349.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We conducted a retrospective study to evaluate and define the management of concomitant ureteral carcinoma in situ (CIS) at radical cystectomy. METHODS For 158 consecutive patients, who underwent radical cystectomy for invasive bladder cancer, ureteral CIS missed by preoperative examinations were evaluated by intraoperative analysis of frozen sections or postoperative histological analysis. The median follow-up period was 3.4 years. RESULTS In total, 15 concomitant ureteral CIS were diagnosed by intraoperative (n=9) or postoperative analysis (n=6). Additional ureteral resection achieved no malignancies in the final ureteral margins of eight patients. During the follow-up period, five patients (3.6%) suffered from tumor recurrence in the upper urinary tract in total, as did three (20%) among the 15 patients with ureteral CIS missed by preoperative examinations. No recurrence was identified in the eight patients with no malignancy in the final ureteral margins after additional resection. Furthermore, multivariate analysis indicated that the presence of bladder CIS was a risk factor for the presence of concomitant ureteral CIS. CONCLUSIONS Detection of concomitant ureteral CIS by intraoperative studies, in combination with complete resection of ureteral CIS, might be beneficial for patients with risk factors such as bladder CIS.
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Affiliation(s)
- Shinichi Nakanishi
- Department of Urology, Kyoto University, Graduate School of Medicine, Kyoto, Japan
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Raj GV, Tal R, Vickers A, Bochner BH, Serio A, Donat SM, Herr H, Olgac S, Dalbagni G. Significance of intraoperative ureteral evaluation at radical cystectomy for urothelial cancer. Cancer 2006; 107:2167-72. [PMID: 16991149 DOI: 10.1002/cncr.22238] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Patients undergoing radical cystectomy (RC) for urothelial cancer are at increased risk for upper tract recurrence and anastomotic recurrence. In an attempt to reduce this recurrence risk, urologists employ intraoperative frozen sections to achieve an uninvolved ureteral margin. The utility of this surgical approach was examined. METHODS A retrospective review identified 1330 bladder cancer patients from 1990 to 2004 with pathologic evaluation of their ureters. Using pathologic findings on permanent section as the reference standard, the accuracy of ureteral frozen sections was examined. Ureteral involvement and margin status were examined as risk factors for upper tract and anastomotic recurrence and overall survival. RESULTS Of 2579 ureteral margins evaluated in 1330 patients, ureteral involvement was noted in 9% of ureters (13% of patients). The sensitivity and specificity of frozen section analyses were approximately 75% and 99%, respectively. The 5-year probability of anastomotic and upper tract recurrences was low: 2% and 13%, respectively. Evidence of involvement of the ureter or at the ureteral anastomotic margin was associated with higher likelihood of upper tract recurrence but not anastomotic recurrence or overall survival. Furthermore, sequential resection of ureters to reach a negative anastomotic ureteral margin did not eliminate the risk of anastomotic or upper tract recurrence. CONCLUSIONS Patients with involved ureters and/or ureteral anastomotic margins have a higher risk of upper tract recurrence. However, the overall risk of recurrence is low and is not clearly associated with overall survival. The data do not support routine intraoperative frozen sections to assess ureteral involvement.
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Affiliation(s)
- Ganesh V Raj
- Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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Abstract
Radical cystectomy remains one of the mainstay treatments for organ-confined invasive bladder cancer. Components of this surgery including the extent of pelvic lymph node dissection, the assessment of ureteric margins and the indications for bladder reconstruction as opposed to the simpler ileal conduit urinary diversion continue to provoke debate. This review provides a broad overview of radical cystectomy and summarises the options for bladder reconstruction. Special emphasis is given to data concerning the role of pelvic lymphadenectomy in the patient staged pre-operatively as N0M0.
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Affiliation(s)
- Ashok G Bhojwani
- Division of Urology, University of Leicester, Clinical Sciences Unit, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK
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THE EFFICACY OF TRANSURETHRAL BIOPSY FOR PREDICTING THE LONG-TERM CLINICAL IMPACT OF PROSTATIC INVASIVE BLADDER CANCER. J Urol 2001. [DOI: 10.1097/00005392-200105000-00039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Carney KJ, Schellhammer PF. Separated pyelocolocutaneous diversion after bilateral ureterectomy and radical cystectomy for transitional cell carcinoma. Urology 1997; 50:449-52. [PMID: 9301717 DOI: 10.1016/s0090-4295(97)00222-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To report a technique for excision of bilateral ureteral transitional cell carcinoma which preserves renal function and provides ready access for endoscopic follow-up and therapy of the renal pelvis. METHODS The operative procedure of bilateral ureterectomy with construction of a separated pyelocolocutaneous diversion utilizing transverse colon is described and the clinical course of 4 patients is reported. RESULTS All 4 patients maintained excellent renal function and normal electrolytes. Conduit urine cytologic studies and renal pelvis endoscopic examinations have remained normal. Parastomal herniation was the most frequently observed postoperative complication. CONCLUSIONS This approach is well suited for the treatment of bilateral ureteral transitional cell carcinoma. Long-term complications are minimal and renal function is preserved. Periodic endoscopic visualization of each renal pelvis with resection and fulguration and/or instillation of immunotherapeutic or chemotherapeutic agents for recurrent renal pelvic lesions is readily accomplished.
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Affiliation(s)
- K J Carney
- Department of Urology, Sentara Cancer Institute, Norfolk, Virginia, USA
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Silver DA, Stroumbakis N, Russo P, Fair WR, Herr HW. Ureteral carcinoma in situ at radical cystectomy: does the margin matter? J Urol 1997; 158:768-71. [PMID: 9258077 DOI: 10.1097/00005392-199709000-00020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE The clinical impact of ureteral carcinoma in situ identified at the time of radical cystectomy for bladder cancer has been poorly studied. We discuss our experience with this clinical problem in the context of published reports. MATERIALS AND METHODS A total of 31 patients with concomitant ureteral carcinoma in situ was retrospectively identified among 401 consecutive radical cystectomies. End points analyzed included positive urinary cytology, upper tract recurrence of carcinoma and cancer specific survival. RESULTS Ureteral margins were positive in 21 patients and negative in 10. Among 30 patients in whom it was performed frozen section failed to detect carcinoma in situ in 5 (16.6%) and sequential ureteral resection did not result in a negative margin in 15 (50%). In 3 patients upper tract carcinoma recurred at the anastomosis (1) and renal pelvis/ureter (2) at a median of 51 months (mean 49, range 36 to 59) following cystectomy. Positive cytology and upper tract carcinoma recurrence were not significantly associated with ureteral margin status, clinical or pathological bladder tumor stage or prior bacillus Calmette Guerin treatment. Median followup was 22.9 months (mean 31.8, range 2.0 to 74.2), during which 7 of the 31 patients died of metastatic bladder cancer. CONCLUSIONS Concomitant ureteral carcinoma in situ is uncommon, and is rarely associated with local morbidity. It appears to confer increased risk for upper tract carcinoma recurrence, irrespective of margin status. In our experience upper tract carcinoma recurrence is heralded by positive cytology and generally appears only with protracted followup. Prognosis appears to be determined by the bladder tumor. Given the lack of morbidity and mortality attributable to concomitant ureteral carcinoma in situ, and the limited ability of frozen section examination to assist in its extirpation, the value of intraoperative identification of concomitant ureteral carcinoma in situ is questionable and expectant management is advised.
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Affiliation(s)
- D A Silver
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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