Management of high-grade papillary Ta or T1 bladder cancer after restaging transurethral resection: A retrospective study comparing Bacillus Calmette-Guerin therapy upfront versus a third resection

PURPOSE

Performing restaging transurethral bladder resection (reTURB) for high-risk non-muscle invasive bladder cancer (NMIBC) reduces the risk of recurrence and tumour understaging. Management of residual high-grade papillary Ta or T1 after reTURB has changed this last 10years in international recommendations. This study aimed to compare the recurrence free survival according to the different management procedures performed.

MATERIALS AND METHODS

Patients who underwent reTURB for initial high-risk NMIBC between 2011 and 2020 were included. Patients with residual high-grade papillary Ta or T1 tumour after reTURB were divided into two groups: BCG instillations upfront versus BCG following a third-look resection (3TURB). Patient and tumour characteristics, BCG instillations, recurrence-free survival were retrospectively analysed.

RESULTS

A total of 162 high-risk patients were included. Sixty-one (37.7%) had residual high-grade papillary Ta or T1 at reTURB: 35 (21.6%) had BCG instillations upfront, 18 (11.2%) had a 3TURB and 8 (5%) had other management. The mean follow-up was 34.2weeks±20.2. Recurrence-free survival was significantly better in patients who underwent BCG instillations upfront (P<0.0043). Recurrence after BCG therapy following reTURB was significantly lower in patients with no residual NMIBC at 6 (92.5% vs. 72.4%, P<0.004) and 12months (85% vs. 67.3%, P<0.03).

CONCLUSIONS

The efficacy of intravesical BCG is compromised in case of residual tumour following TURB. The role of a 3TURB following a positive reTURB is not yet determined. This study has confirmed that residual tumor following reTURB is a negative predictive factor but could not demonstrate the value of a 3TURB compared to upfront BCG.

LEVEL OF EVIDENCE: 3

The Immunoscore in Localized Urothelial Carcinoma Treated with Neoadjuvant Chemotherapy: Clinical Significance for Pathologic Responses and Overall Survival

Simple Summary

The prognosis of localized muscle-invasive bladder cancer is poor and the prognostic and predictive biomarkers of the response to treatment are lacking. We retrospectively investigated the role of the Immunoscore in the neoadjuvant setting, where the Immunoscore is a standardized quantitative assay of lymphocytes in the tumor microenvironment. We found it allowed for the stratification of patient prognoses and the prediction of response to neoadjuvant chemotherapy.

Abstract

(1) Background—The five-year overall survival (OS) of muscle-invasive bladder cancer (MIBC) with neoadjuvant chemotherapy and cystectomy is around 50%. There is no validated biomarker to guide the treatment decision. We investigated whether the Immunoscore (IS) could predict the pathologic response to neoadjuvant chemotherapy and survival outcomes. (2) Methods—This retrospective study evaluated the IS in 117 patients treated using neoadjuvant chemotherapy for localized MIBC from six centers (France and Greece). Pre-treatment tumor samples were immunostained for CD3+ and CD8+ T cells and quantified to determine the IS. The results were associated with the response to neoadjuvant chemotherapy, time to recurrence (TTR), and OS. (3) Results—Low (IS-0), intermediate (IS-1–2), and high (IS-3–4) ISs were observed in 36.5, 43.7, and 19.8% of the cohort, respectively. IS was positively associated with a pathologic complete response (pCR; p-value = 0.0096). A high IS was found in 35.7% of patients with a pCR, whereas it was found in 11.3% of patients without a pCR. A low IS was observed in 48.4% of patients with no pCR and in 21.4% of patients with a pCR. Low-, intermediate-, and high-IS patients had five-year recurrence-free rates of 37.2%, 36.5%, and 72.6%, respectively. In the multivariable analysis, a high IS was associated with a prolonged TTR (high vs. low: p = 0.0134) and OS (high vs. low: p = 0.011). (4) Conclusions—This study showed the significant prognostic and predictive roles of IS regarding localized MIBC.

Atlas of Ex Vivo Prostate Tissue and Cancer Images Using Confocal Laser Endomicroscopy: A Project for Intraoperative Positive Surgical Margin Detection During Radical Prostatectomy

BACKGROUND

Confocal laser endomicroscopy (CLE) is an optical device that aims to image histological architecture and may be used to reduce positive surgical margins. The ability of CLE to describe prostatic and periprostatic tissues, and prostate cancer (PCa) is still an object of investigation.

OBJECTIVE

To create an atlas of ex vivo CLE images of prostatic and periprostatic tissues, and PCa in order to recognise different prostatic structures.

DESIGN, SETTING, AND PARTICIPANTS

From November 2017 to February 2018, 15 patients underwent radical prostatectomy for biopsy-proven PCa.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Based on preoperative data and macroscopic examination, tumour location was assessed and confirmed on frozen sections. Prior to ex vivo CLE analysis, prostates were stained with fluorescein 10%. We used a GastroFlex probe to collect images of periprostatic tissue (adipose tissue, fibrous and connective tissues, vessels, nerve sheets, seminal vesicles, and urethra). Normal prostatic glands and tumour tissue according to the Gleason grade were analysed. Each PCa Gleason score was represented.

RESULTS AND LIMITATIONS

A total of 139 video clips and 237 pictures of prostatic and periprostatic tissues were collected. Among them, we selected 16 highly representative images. Adipose tissue, fibrous tissue, and connective tissue were supposable in all 15 specimens. PCa glands captured fluorescein in their cytoplasm, normal prostatic glands did not capture fluorescein, and glandular structures were easily recognisable. The principal limitation of this study is its ex vivo nature of the study.

CONCLUSIONS

Each CLE image was correlated with the corresponding haematoxylin/eosin/saffron definitive pathology image, allowing building of an atlas as a necessary tool to assess the diagnostic performance of CLE during radical prostatectomy in achieving negative surgical margins.

PATIENT SUMMARY

In this study, we aim to provide an atlas of images illustrating prostatic, periprostatic, and PCa tissues obtained using Cellvizio confocal laser endomicroscopy as a tool for further interpretation of intraoperative surgical margins during radical prostatectomy.

[Prostate laser photovaporisation in patients at high risk of bleeding]

Introduction

Les patients sous traitement anticoagulant sont à risque élevé de saignement lors de la résection transurétrale de la prostate ou de l'adénomectomie par taille vésicale et ils se voient souvent récuser pour la chirurgie de l'hyperplasie bénigne de la prostate symptomatique. En Utilisant la photovaporisation de la prostate, les patients à haut risque peuvent subir en toute sécurité la chirurgie. Nous avons évalué l'innocuité et l'efficacité de la photovaporisation de la prostate (PVP) chez les patients sous anticoagulants en cours avec les dérivés de la coumarine, l'aspirine ou le clopidogrel, se plaignant de symptômes d'hypertrophie bénigne de la prostate.

Méthodes

Entre janvier 2009 et mai 2010, 47 hommes sous anticoagulation systémique ont subi une photovaporisation de la prostate. Les données ont été recueillies sur les caractéristiques démographiques, les comorbidités, les complications, la natrémie, l'hémoglobine, le débit urinaire maximal, le résidu post-mictionnel, l'IPSS et les complications.

Résultats

L'âge moyen était de 78 ans, le volume prostatique moyen était de 44g et le PSA était de 3.4ng/ml. Parmi les 10 patients (21.2%) étaient sous AVK, 27 (57.4%) étaient sous aspirine, 2 (4.2%) étaient sous clopidogrel, un sous fondaparinux et 6 (12.7%) étaient sous 2 anticoagulants ou plus. Le score ASA moyen était de 3. La durée moyenne de fonctionnement de l'appareil était de 38 minutes, l'énergie moyenne utilisée était de 200kJ. La durée moyenne d'hospitalisation était de 2 jours. Les complications survenant dans les 30 jours comprenaient une infection urinaire chez 5 patients (10.6%), une dysurie chez 4 patients et une hémorragie retardée chez 4 autres (8.5%). Un seul de ces patients a nécessité une transfusion sanguine et aucun patient n'a nécessité une réintervention. En 3 mois de suivi un seul patient a nécessité une incision du col vésical pour sclérose du col. Aucune incontinence ou sténose urétrale n'a été rapportée. Des améliorations significatives ont été notées dans l'IPSS, le débit urinaire maximal et le résidu post-mictionnel.

Conclusion

La PVP est caractérisé par d'excellentes propriétés hémostatiques et taux très faible de complications peropératoires même chez les patients sous 2 ou plusieurs agents anticoagulants. Sur la base de nos résultats péri-opératoires, nous recommandons la PVP comme traitement chirurgical de première intention chez les patients à haut risque de hémorragique souffrant de symptômes d'hypertrophie bénigne de la prostate.

[Vesicovaginal fistula]

Urinary fistula to the vagina has been described since the beginning of the written record. In developed nations, these fistulas are usually unfortunate complications of gynecologic or other pelvic surgery and radiotherapy. Historically, birth trauma accounted for most vesicovaginal fistulas, and it remains the major cause of urinary fistulas in many underdeveloped nations. Once a vesicovaginal fistula is suspected, a thorough vaginal examination should be performed to identify its size and location, especially in relation to the trigone and eliminate a ureterovaginal fistula which can be associated in up to 10% of cases. Numerous methods for the treatment of vesicovaginal fistulae have been described. Abdominal, and vaginal approaches are used for the repair of vesicovaginal fistulae. The approach selected is dependent on many factors, but is probably best determined by the experience and training of the surgeon. The techniques of the vaginal approach involve tension-free closure of the fistula with or without excision of the tract, creation of an anterior vaginal wall flap and appropriate use of vascularized interposition grafts. The abdominal approach may be used to treat all types of vesicovaginal fistulae and is the preferred approach when concomittant ureteral reimplantation is required. Postoperative care is similar for both vaginal and abdominal vesicovaginal fistula repair. Adequate uninterrupted bladder drainage is the most critical aspect of postoperative management. A voiding cystourethrogram is performed at 10 postoperative days to confirm closure of the fistula.

Renal autotransplantation for vascular disease: late outcome according to etiology

PURPOSE

The purpose of this study was to evaluate the early and late outcomes of renal autotransplantation (RAT) according to the etiology of the underlying renal artery disease.

MATERIAL AND METHODS

Between January 1985 and April 2001, we performed 68 RAT procedures in 57 patients. The surgical indications were fibromuscular dysplasia (FMD) for 34 RAT procedures in 30 patients (11 men, 19 women; mean age, 41.3 +/- 14.6 years), Takayasu's disease (TD) for 26 RAT procedures in 19 patients (five men, 14 women; mean age, 33.0 +/- 12.3 years), and atherosclerosis for eight RAT procedures in eight patients (seven men, one woman; mean age, 66.5 +/- 7.9 years). The incidence rate of hypertension was 87% in patients with FMD and 100% in patients with TD and atherosclerosis. The incidence rate of renal dysfunction was 75% in patients with atherosclerosis, 27% in patients with FMD, and 16% in patients with TD. Autotransplantation was isolated in 31 cases and was associated with another vascular procedure in 37 cases, including 22 thoracoabdominal aorta repairs and 11 abdominal aorta or iliac artery repairs. The technique used to achieve renal revascularization was direct reimplantation in 17 cases and indirect reimplantation in 51 cases. The conduit used for indirect reimplantation was an arterial autograft in 42 cases, a vein autograft in seven cases, and a prosthetic graft in two cases. Simultaneous revascularization of the contralateral kidney was performed in 21 patients and included nine RAT procedures. Contralateral nephrectomy was performed in five patients.

RESULTS

In the FMD group, early segmental infarction was observed in four cases. Secondary nephrectomy was necessary in one case (at 88 months). Actuarial survival rates were 96.2% +/- 0.03% at 5 years and 84.1% +/- 0.11% at 10 years. Secondary patency rates were 100% at 5 years and 92% +/- 0.07% at 10 years. Hypertension normalized or improved in 96% of patients. Renal function improved in 50% of patients. In the TD group, one patient died of multiple organ failure 4 days after the procedure. Nephrectomy was necessary in one case. The actuarial survival rate was 94.7% +/- 0.05% and the secondary patency rate was 91.3% +/- 0.05% at both 5 and 10 years. Hypertension normalized or improved in 89% of the cases, and kidney function improved in all cases. In the atherosclerosis group, nephrectomy was necessary during the early postoperative period in three cases and during late follow-up in two cases (at 9 months and at 68 months, respectively). Actuarial survival rates were 54.7% +/- 0.2% at 5 years and 18.2% +/- 0.16% at 10 years. The secondary patency rates were 50.0% +/- 0.17% at 5 years and 33.3% +/- 0.18% at 10 years. Hypertension normalized or improved in 50% of cases, and kidney function improved in 33% of cases.

CONCLUSION

RAT is highly effective for treatment of complex renovascular lesions related to FMD and TD. Although RAT is less effective for atherosclerosis, it may be the only alternative in cases involving extensive renovascular disease.

Computerised assessment of maximum urinary flow: an efficient, consistent and valid approach

OBJECTIVES

To evaluate the relative accuracy of a computerised method to quantitatively assess maximum urinary flow.

METHODS

A total of 1147 uroflows were evaluated by the computerised method and by three experts from different European countries. The sample consisted of uroflows from the respective visits by a 20% sample of randomly chosen patients (n = 223) with lower urinary tract symptoms with participation in two clinical trials in which the efficacy and safety of Permixon was evaluated. The proportions of automated maximum flow values included in the 10% extended range of experts (and their 95% confidence intervals) were assessed, as well as the concordance coefficients between experts and the computerised method and the paired Student's t-test for the average differences between experts and computer.

RESULTS

The rate of agreement between experts and computer varied between about 95 and 100% over factor levels for visit, type of machine and country. Concordance coefficients indicated good agreement between experts and the automated method. When looking at average differences between experts and the computer, the smallest differences were observed between experts 2, 3 and the computer (differences not statistically significant). Statistically significant average differences were observed between expert 1 and the other experts as well as between expert 1 and the computer.

CONCLUSIONS

The computerised assessment decreases the fraction of variability of maximum urinary flow caused by artifacts as well as intra- and inter-expert variation. The computerised assessment of maximum urinary flow is an efficient, consistent and valid approach to quantitatively assess maximum urinary flow in clinical trials.

Incidence and risk factors of bacteriuria after transurethral resection of the prostate

INTRODUCTION

Postoperative bacteriuria is a frequent event after transurethral resection of the prostate, despite the use of prophylactic antibiotics. Certain risk factors have been clearly established (preoperative urinary catheter or bacteriuria, operating time), while others remain uncertain.

MATERIALS AND METHODS

We conducted a prospective study in five urology centers, including non-catheterized patients with sterile preoperative urine undergoing transurethral resection of the prostate for benign prostatic hyperplasia. All received antibiotic prophylaxis with cefamandole. The incidence of bacteriuria and its risk factors were investigated.

RESULTS

The postoperative bacteriuria rate was 26% (26/101), with 8% on removal of the catheter, 14% between the 7th and 10th postoperative days and 5% 1 month postoperatively. Factors associated with bacteriuria on univariate analysis were: operating time, disconnection of the closed urine drainage system and postoperative catheterization > or =3 days. Two variables were associated on multivariate analysis (logistic regression): operating time >52 min (odds ratio 9.0, 95% confidence interval 2.1-39.0) and disconnection of the closed urine drainage system (odds ratio 26.3, 95% confidence interval 6.1; 6.1-113).

CONCLUSIONS

The postoperative bacteriuria rate after transurethral resection of the prostate was high in this study, raising the question of the choice and/or duration of prophylactic antibiotics. Prevention of postoperative bacteriuria must be based on careful hemostasis, prevention of postoperative catheter disconnections, and limitation of the duration of postoperative catheterization.

[Study of the Ki-67 antibody immunolabeling of renal adenocarcinomas with or without renal vein thrombosis]

OBJECTIVES

The objective of this study was to compare the proliferation index (immunolabelling by monoclonal antibody Ki67 - MIB-1) of renal cell carcinomas as a function of the presence or absence of renal vein thrombus. Analysis of the numbers of Ki67-positive nuclei can be used to assess the degree of aggressiveness of the cell populations of these various carcinomas (tumour without thrombus, tumour with thrombus and neoplastic thrombus).

METHODS

Twenty three renal cell carcinomas with renal vein thrombus were matched for Furhman grade (1st degree), tumour volume (2nd degree) and the patient's age (3rd degree) with 23 renal cell carcinomas not presenting any vascular embolus on histology. Monoclonal antibody MIB-1 immunolabelling was performed on 69 paraffin-embedded specimens: 23 tumours with thrombosis, the 23 corresponding neoplastic thrombi and 23 tumours without vascular embolus.

RESULTS

A correlation between Furhman grade and the percentage of immunolabelled nuclei was observed (mean: 2.67% for low-grade tumours and 14.34% for high-grade tumours). No labelling difference was observed between the two populations of primary tumours (with thrombus/without embolus). Primary tumours presented significantly weaker Ki67 labelling than their corresponding neoplastic thrombus (mean of 2.47% versus 10.3%, p < 0.01).

CONCLUSION

This study shows that there is no difference of the proliferation index between tumours with neoplastic venous thrombus and those with no histological vascular embolus. However, a difference of proliferation index was observed between the primary tumour and its corresponding thrombus, which presented a statistically higher immunolabelling. This finding suggests that the thrombus possesses more dividing cells than the primary tumour, i.e. has a shorter doubling time.

[Erectile dysfunction after radical prostatectomy: value of preoperative programming of intracavernous injections]

OBJECTIVES

Vasoactive drugs used for self-administered intracavernous injections are currently the reference treatments for erectile dysfunction after radical prostatectomy. The acceptability of and compliance with this treatment often limit their use. This study analysed these two parameters as a function of the type of andrological management decided before radical prostatectomy.

MATERIAL AND METHOD

From January 1996 to January 1997, 45 sexually active patients, aged 52 to 69 years, requiring radical prostatectomy without preservation of the nervi erigentes, for localized prostate cancer, were included in this prospective study. Before the operation all 45 patients were informed about the high risk of erectile dysfunction following radical prostatectomy. Fifteen patients (group 1) did not receive any particular advice concerning the management of erectile dysfunction after radical prostatectomy, but were possibly referred for an andrology consultation depending on their complaints. Fifteen patients (group 2) were systematically referred for an andrology consultation three months after radical prostatectomy for information about the available treatment options. For 15 patients (group 3), the andrology consultation (3 months after the operation) had been planned before radical prostatectomy to perform a test injection of prostaglandin E1. The injections, started before the operation in this group 3, therefore constituted an integral part of the global management of prostate cancer. All these patients were followed for at least 1 year in the urology department.

RESULTS

Only 7 of the 15 patients of group 1 consulted an andrologist. Five of these patients received a test intracavernous injection versus 14 in group 2 and 15 in group 3. The 5 patients of group 1 who received an intracavernous injection accepted this modality as treatment versus 8 in group 2 and 12 in group 3. After one year, 4, 5 and 9 patients in groups 1, 2 and 3, respectively, continued intracavernous injections.

CONCLUSION

The management of erectile dysfunction after radical prostatectomy must start with the decision to operate. Systematic encouragement to use intracavernous injections after radical prostatectomy helps to improve access to this treatment for impotence. The acceptability, and especially the compliance, appear to be better in patients in whom intracavernous injections were integrated into the global management of their prostate cancer.