Proposal for a new Vesical Imaging-Reporting and Data System (VI-RADS)-based algorithm for the management of bladder cancer: A paradigm shift from the current transurethral resection of bladder tumor (TURBT)-dependent practice

[mpMRI of the Urinary Bladder: Significance and Clinical Use]

The diagnosis and staging of bladder cancer is challenging. TUR-B and CT diagnostics bear limitations in detecting muscle invasion and perivesical fat invasion. Thus, second TUR-B is required to ensure more reliable pathological staging. The mpMRI of the urinary bladder is a new diagnostic tool in evaluation of tumor muscle invasion. Numerous retrospective and prospective studies indicate high diagnostic accuracy of the mpMRI in this setting. Current meta-analyses show sensitivities of up to 90% with a high specificity of >85%. The "Vesical Imaging-Reporting and Data System" (VI-RADS) is a standardized and clinically easy-to-use reporting system for mpMRI of the urinary bladder. The EAU guidelines recommend the mpMRI and the VI-RADS system for local staging of urinary bladder cancer. A recently published consensus statement based on a Delphi conference of 92 international experts favors the use of the mpMRI in various clinical situations. This includes imaging before and after TUR-B when muscle invasion is possible or during neoadjuvant chemotherapy.Based on good evidence, the mpMRI of the bladder emerges as a useful imaging tool in the evaluation of urinary bladder cancer in various clinical scenarios. Availability, costs and limited experience currently stand in the way of widespread use.

Utility of MRI in NMIBC and feasibility of avoiding Re-TURB in carefully selected patients: a systematic review

OBJECTIVE

This systematic review was conducted to synthesize current research on the role of repeated transurethral resection of the bladder (re-TURB) and the emerging use of magnetic resonance imaging (MRI) in discerning patient suitability for safely foregoing this procedure.

EVIDENCE ACQUISITION

Employing a methodical literature search, we consulted several bibliographic databases including PubMed, Science Direct, Scopus, and Embase. The review process adhered strictly to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines.

EVIDENCE SYNTHESIS

We evaluated data from 667 patients (mean age 65.8 years; age range 59-75 years) who underwent MRI prior to potential re-TURB. The gap between initial TURB and MRI was reported as 42 days in one study, while the interval between MRI and subsequent cystoscopy, with or without biopsy, varied from 21 days to 3 months. Initial TURB pathology for non-muscle invasive bladder cancer (NMIBC) patients identified stage Ta in 177 (42.5%) and T1 in 246 (57.5%) patients across three studies. High-grade and low-grade pathologic classifications were reported in 377 (64.5%) and 207 (35.5%) patients respectively in two studies. The VI-RADS scoring system's sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for the detection of bladder cancer recurrence were 89%, 85.5%, 82.7%, and 96%, respectively. A total of 365 patients (54.7%) underwent re-TUR. Among NMIBC patients, re-TUR pathology revealed Ta in 22 cases (5.4%) and pT1 in 179 cases (44%) with VI-RADS 1-2, while no cases of Ta (0%) and 37 cases of T1 (9%) were reported with VI-RADS 4-5, as documented in two studies. Notably, only 69 patients (10.7%) were identified as having MIBC across all studies.

CONCLUSION

MRI is demonstrating reliability as a diagnostic tool for non-muscle invasive bladder cancers. The VI-RADS scoring system appears to be a promising approach in selecting patients for re-TURB. DW-MRI may serve as a primary diagnostic examination for patient follow-up post-TURB.

Current Status of Magnetic Resonance Imaging Use in Bladder Cancer

ABSTRACT

Bladder cancer (BC) is a significant global health concern, with over 500,000 new cases and 200,000 deaths annually, emphasizing the need for accurate staging and effective management. Traditional diagnostic techniques, such as cystoscopy and transurethral resection, are fundamental but have limitations in accurately assessing the depth of invasion. These limitations include the possibility of understaging and procedural variability, which can significantly impact treatment decisions. This review focuses on the role of multiparametric magnetic resonance imaging (mpMRI) in the diagnosis and staging of BC, particularly emphasizing the Vesical Imaging-Reporting and Data System (VI-RADS) framework. By enhancing interpretive consistency and diagnostic accuracy, mpMRI and VI-RADS offer detailed visualization of tumor characteristics and depth of invasion, while reducing the need for more invasive traditional methods. These advancements not only improve staging accuracy but also enhance treatment planning, underscoring the importance of advanced imaging in evolving BC management and positively influencing patient outcomes.

VI-RADS-based Algorithm for Bladder Cancer Management Randomized Retrospective Study

OBJECTIVE

To evaluate if VI-RADS can distinguish between nonmuscle-invasive bladder cancers (NMIBC), muscle-invasive bladder cancer (MIBC), and high-risk nonmuscle-invasive bladder cancers (HR-NMIBCs). It is unclear if the Vesical Imaging-Reporting and Data System (VI-RADS) can replace repeated transurethral resection of bladder tumor (Re-TURBT) as in the new VI-RADS-based algorithm.

METHODS

Sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values of the VI-RADS score were calculated for mpMRI performance in patients undergoing TURBT and HR-NMIBC patients for only Re-TURBT.

RESULTS

Of 283 cases, when VI-RADS ≥3 lesions were considered muscle-invasive, its sensitivity was 95.7% and specificity was 92.5%. PPV and NPV were 86.6% and 97.7%, respectively. The area under the curve (AUC) was 0.942 (P <.001). Of 89 patients undergoing post-Re-TURBT, 41 (46%) were tumor-free, 47 (50.5%) showed permanent HR-NMIBC, and 3 (2.2%) were upgraded to MIBC. Per the new VI-RADS-based approach, 73 (41%) of the 178 HR-NMIBCs with VI-RADS ≤2 would not undergo Re-TURBT. Of the 75 patients with VI-RADS ≥4, 6 (6) with HR-NMIBCs (8%) would not undergo Re-TURBT. When incomplete resections were excluded, 35 (60.3%) of the patients had complete resection, 23 (39.7%) had residual disease, and complete resection would not have been performed in these patients, and 2 (100%) still had residual disease.

CONCLUSION

The new VI-RADS-based algorithm helped VI-RADS ≥4 patients by switching to radical treatment. Since the residual disease is high in cases with VI-RADS ≤2, even if incomplete resections are excluded, TURBT should be continued.

The Role of Maximal TURBT in Muscle-Invasive Bladder Cancer: Balancing Benefits in Bladder Preservation and Beyond

Radical cystectomy with lymph node dissection and urinary diversion is the gold-standard treatment for non-metastatic muscle-invasive bladder cancer (MIBC). However, in patients who refuse cystectomy, or in whom cystectomy carries a high risk, bladder-preserving therapies remain potential options. Bladder preservation therapies can include maximal debulking transurethral resection of bladder tumor (TURBT), concurrent chemoradiation therapy, followed by cystoscopy to assess response. At this time, maximal TURBT is recommended for patients prior to the initiation of chemoradiation therapy or in patients with residual bladder tumors after the completion of chemoradiation therapy. That being said, TURBT carries significant risks such as bladder perforation, bleeding, and infection, ultimately risking delayed systemic treatment. Hence, understanding its role within trimodal therapy is crucial to avoid undue suffering in patients. Herein, we review the current literature on the impact of debulking TURBT in non-metastatic MIBC.

Comparison of staging MRI to re-resection for localised bladder cancer: Narrative review

Introduction

Bladder cancer (BCa) is characterised by high prevalence, multifocality, and frequent recurrence, imposing significant clinical and economic burdens. Accurate staging, particularly distinguishing non-muscle-invasive bladder cancer (NMIBC) from muscle-invasive bladder cancer (MIBC) disease, is crucial for guiding treatment decisions. This narrative review explores the potential implications of incorporating multiparametric magnetic resonance imaging (mpMRI) and the Vesical Imaging Reporting Data System (VI-RADS) into BCa staging, focusing on repeat transurethral resection of bladder tumour (re-TURBT).

Methods

A comprehensive search of PubMed, EMBASE, and MEDLINE databases identified studies published from 2018 to 2023 discussing mpMRI or VI-RADS in the context of re-TURBT for BCa staging. Studies meeting inclusion criteria underwent qualitative analysis.

Results

Six recent studies met inclusion criteria. VI-RADS scoring, accurately predicted muscle invasion, aiding in NMIBC/MIBC differentiation. VI-RADS scores of ≥3 indicated MIBC with high sensitivity and specificity. VI-RADS potentially identified patients benefiting from re-TURBT and those for whom it could be safely omitted.

Discussion

mpMRI and VI-RADS offer promising prospects for BCa staging, potentially correlating more closely with re-TURBT and radical cystectomy histopathology than initial TURBT. However, validation and careful evaluation of clinical integration are needed. Future research should refine patient selection and optimise mpMRI's role in BCa management.

Conclusion

VI-RADS scoring could revolutionise BCa staging, especially regarding re-TURBT. There is potential that VI-RADS correlates more with the histopathology of re-TURBT and radical cystectomy than initial TURBT. While promising, ongoing research is essential to validate utility, refine selection criteria, and address economic considerations. Integration of VI-RADS into BCa staging holds potential benefits for patients and health care systems.

MRI evaluation of vesical imaging reporting and data system for bladder cancer after neoadjuvant chemotherapy

BACKGROUND

The Vesical Imaging-Reporting and Data System (VI-RADS) has demonstrated effectiveness in predicting muscle invasion in bladder cancer before treatment. The urgent need currently is to evaluate the muscle invasion status after neoadjuvant chemotherapy (NAC) for bladder cancer. This study aims to ascertain the accuracy of VI-RADS in detecting muscle invasion post-NAC treatment and assess its diagnostic performance across readers with varying experience levels.

METHODS

In this retrospective study, patients with muscle-invasive bladder cancer who underwent magnetic resonance imaging (MRI) after NAC from September 2015 to September 2018 were included. VI-RADS scores were independently assessed by five radiologists, consisting of three experienced in bladder MRI and two inexperienced radiologists. Comparison of VI-RADS scores was made with postoperative histopathological diagnosis. Receiver operating characteristic curve analysis (ROC) was used for evaluating diagnostic performance, calculating sensitivity, specificity, and area under ROC (AUC)). Interobserver agreement was assessed using the weighted kappa statistic.

RESULTS

The final analysis included 46 patients (mean age: 61 years ± 9 [standard deviation]; age range: 39-70 years; 42 men). The pooled AUC for predicting muscle invasion was 0.945 (95% confidence interval (CI): 0.893-0.977) for experienced readers, and 0.910 (95% CI: 0.831-0.959) for inexperienced readers, and 0.932 (95% CI: 0.892-0.961) for all readers. At an optimal cut-off value ≥ 4, pooled sensitivity and specificity were 74.1% (range: 66.0-80.9%) and 94.1% (range: 88.6-97.7%) for experienced readers, and 63.9% (range: 59.6-68.1%) and 86.4% (range: 84.1-88.6%) for inexperienced readers. Interobserver agreement ranged from substantial to excellent between all readers (k = 0.79-0.92).

CONCLUSIONS

VI-RADS accurately assesses muscle invasion in bladder cancer patients after NAC and exhibits good diagnostic performance across readers with different experience levels.

Artificial Intelligence in Urology: Current Status and Future Perspectives

Surgical fields, especially urology, have shifted increasingly toward the use of artificial intelligence (AI). Advancements in AI have created massive improvements in diagnostics, outcome predictions, and robotic surgery. For robotic surgery to progress from assisting surgeons to eventually reaching autonomous procedures, there must be advancements in machine learning, natural language processing, and computer vision. Moreover, barriers such as data availability, interpretability of autonomous decision-making, Internet connection and security, and ethical concerns must be overcome.

Diagnostic validity of the vesical imaging-reporting and data system (VI-RADS): a real-world study

OBJECTIVES

Preoperative Vesical Imaging-Reporting and Data System (VI-RADS) becomes widespread. We aimed to validate the diagnostic performance of VI-RADS in differentiating muscle-invasive (MIBC) from non-muscle-invasive bladder cancer (NMIBC) in a real-world setting.

METHODS

Between December 2019 and February 2022 suspected primary bladder cancer patients were reviewed. Those with proper multiparametric MRI (mpMRI) protocol for VI-RADS before any invasive treatment were included. Patients were locally staged according to transurethral resection, second resection, or radical cystectomy as the reference standard. Two experienced genitourinary radiologists who were blinded to clinical and histopathological data evaluated the mpMRI images independently and retrospectively. The diagnostic performance of both radiologists and the interreader agreement were analyzed.

RESULTS

Among 96 patients, 20 (20.8%) had MIBC, and 76 (79.2%) had NMIBC. Both radiologists had great diagnostic performance in diagnosing MIBC. The first radiologist had an area under curve (AUC) of 0.83 and 0.84, the sensitivity of 85% and 80%, and the specificity of 80.3% and 88.2% for VI-RADS ≥3 and ≥4, respectively. The second radiologist had an area under curve (AUC) of 0.79 and 0.77, the sensitivity of 85% and 65%, and the specificity of 73.7% and 89.5% for VI-RADS ≥3 and ≥4, respectively. The overall VI-RADS score agreement between the two radiologists was moderate (κ = 0.45).

CONCLUSION

VI-RADS is diagnostically powerful in differentiating MIBC from NMBIC prior to transurethral resection. The agreement between radiologists is moderate.

What's new in WHO fifth edition - urinary tract

The fifth edition of the WHO Blue Book on urological tumours, specifically in the bladder chapter, represents a refinement and update in the classification of bladder tumours building on the aggregate major changes made in previous editions. Progress in the molecular underpinnings of urothelial tumours, particularly with promising stratifiers for more precision-based treatment approaches, have been made. Special attention has been paid to burning questions in bladder pathology, such as grading, heterogeneous lesions, inverted tumours and substaging. The concept of neuroendocrine tumours will be explained precisely.