Trimodal therapy versus radical cystectomy for cT2N0M0 urothelial muscle-invasive bladder cancer: Single-center experience

The Role of Salvage Cystectomy After Prior Trimodality Therapy: A Multinational Match-paired Analysis

BACKGROUND AND OBJECTIVE

Trimodality therapy (TMT) with transurethral resection followed by radiation of the urinary bladder and chemotherapy is associated with similar long-term survival rates to radical cystectomy (RC) for well-selected patients. Nevertheless, salvage RC may become necessary in 10% of patients receiving TMT. We aimed to assess the perioperative and long-term outcomes of salvage RC after prior TMT through a large multinational cohort study.

METHODS

We included patients with pure urothelial cancer of the urinary bladder. Patients undergoing salvage RC after prior TMT due to recurrence in the urinary bladder from 13 high-volume centers were matched with a propensity score analysis in a 1:1 ratio with patients without prior TMT undergoing primary RC. The two groups were adjusted for institution, age, histological status, American Society of Anesthesiologists score, and surgical technique (open or minimally invasive RC).

KEY FINDINGS AND LIMITATIONS

We included 118 patients (59 per group) with a median age of 73 yr (interquartile range [IQR]: 66-79). Seven patients (11%) developed severe, grade 4 or 5 perioperative complications during RC after prior TMT. The 30- and 90-d survival rates of salvage RC after prior TMT were 93% and 91%, respectively. RC in patients with prior TMT was associated with higher blood loss by 297 ml (95% confidence interval [CI]: 73-520, p = 0.010) and higher odds of admission to the intensive care unit (odds ratio: 2.8, 95% CI: 1.2-6.7, p = 0.017) than primary RC in matched patients. At a median follow-up of 10 mo (IQR: 5-34), 29 deaths occurred in patients requiring RC after prior TMT. Prior TMT was associated with worse overall survival than primary RC (hazard ratio: 1.9, 95% CI: 1.2-4.1, p = 0.032).

CONCLUSIONS AND CLINICAL IMPLICATIONS

Salvage RC after TMT and primary RC have comparable perioperative outcomes. Patients undergoing salvage RC after TMT may have worse overall survival in the long term, likely reflecting tumor biology.

Bladder Cancer and the Urinary Microbiome-New Insights and Future Directions: A Review

The presence of a microbiome in the urinary system has been established through recent advancements in technology and investigation of microbial communities in the human body. The study of the taxonomic and genomic ecology of microbial communities has been greatly improved by the use of metagenomics. The research in this area has expanded our understanding of microbial ecosystems and shows that the urinary tract contains over 100 species from over 50 genera, with Lactobacillus, Gardnerella, and Streptococcus being the most common. Previous studies have suggested that the microbiota in the urinary tract may play a role in carcinogenesis by causing chronic inflammation and genotoxicity, but more research is needed to reach a definite conclusion. This is a narrative review. We conducted a search for relevant publications by using the databases Medline/PubMed and Google Scholar. The search was based on keywords such as "urinary microbiome," "bladder cancer," "carcinogenesis," "urothelial carcinoma," and "next-generation sequencing." The retrieved publications were then reviewed to study the contribution of the urinary microbiome in the development of bladder cancer. The results have been categorized into four sections to enhance understanding of the urinary microbiome and to highlight its role in the emergence of bladder cancer through alterations in the immune response that involve T-cells and antibodies. The immune system and microbiome play crucial roles in maintaining health and preventing disease. Manipulating the immune system is a key aspect of various cancer treatments, and certain gut bacteria have been linked to positive responses to immunotherapies. However, the impact of these treatments on the urinary microbiome, and how diet and lifestyle affect it, are not well understood. Research in this area could have significant implications for improving bladder cancer treatment and patient outcomes.