Sarcomatoid urothelial carcinoma accompanied by elevated serum beta-HCG: Two case reports

Sarcomatoid urothelial carcinoma is a rare and aggressive variant. Serum beta-hCG levels are used as a tumor marker in gestational trophoblastic diseases and germ cell tumors, but may also be elevated in high-grade bladder cancers. Here, we report two urothelial carcinoma cases with sarcomatoid differentiation that relapsed early after surgery with elevated serum beta-hCG levels. The first case was a 65-year-old female and the second case was a 67-year-old man with sarcomatoid urothelial carcinoma located in the ureter and renal pelvicalyceal system, both of them relapsed with elevated beta-hCG serum level to 146.8 mIU/ mL and 242 mIU/mL, respectively. They died a few months after initial diagnosis;4.9 and 2.5 months respectively. Both sarcomatoid variant and beta-hCG expression were associated with poor prognosis and advanced stage. However, beta-hCG is not used as a tumor marker in urinary tract cancers yet, and its relationship with variant pathologies has not been clarified. We need multi-centered studies to reveal this relationship.Copyright © 2023, Derman Medical Publishing. All rights reserved.

Impact of the time of surgical delay on survival in patients with muscle-invasive bladder cancer.

Background and objectives: Patients with muscle-invasive bladder cancer (MIBC) often experience a waiting period before radical surgery for numerous reasons; however, the COVID-19 outbreak has exacerbated this problem. Therefore, it is necessary to discuss the impact of the unavoidable time of surgical delay on the outcome of patients with MIBC. Methods: In all, 165 patients from high-volume centers with pT2-pT3 MIBC, who underwent radical surgery between January 2008 and November 2020, were retrospectively evaluated. Patients' demographic and pathological information was recorded. Based on the time of surgical delay endured, patients were divided into three groups: long waiting time (> 90 days), intermediate waiting time (30-90 days), and short waiting time (≤ 30 days). Finally, each group's pathological characteristics and survival rates were compared. Results: The median time of surgical delay for all patients was 33 days (interquartile range, IQR: 16-67 days). Among the 165 patients, 32 (19.4%) were classified into the long waiting time group, 55 (33.3%) into the intermediate waiting time group, and 78 (47.3%) into the short waiting time group. The median follow-up period for all patients was 48 months (IQR: 23-84 months). The median times of surgical delay in the long, intermediate, and short waiting time groups were 188 days (IQR: 98-367 days), 39 days (IQR: 35-65 days), and 16 days (IQR: 12-22 days), respectively. The 5-year overall survival (OS) rate for all patients was 58.4%, and that in the long, intermediate, and short waiting time groups were 35.7%, 61.3%, and 64.1%, respectively (P = 0.035). The 5-year cancer-specific survival (CSS) rates in the long, intermediate, and short waiting time groups were 38.9%, 61.5%, and 65.0%, respectively (P = 0.042). The multivariate Cox regression analysis identified age, time of surgical delay, pT stage, and lymph node involvement as independent determinants of OS and CSS. Conclusion: In patients with pT2-pT3 MIBC, the time of surgical delay > 90 days can have a negative impact on survival.

Efficacy and safety of atezolizumab concurrent with radiotherapy in patients with muscle-invasive bladder cancer: An interim analysis of the ATEZOBLADDERPRESERVE phase II trial (SOGUG-2017-A-IEC(VEJ)-4)

Background: Combined-modality treatments are bladder-preserving alternatives for patients (pts) who are not candidates for radical cystectomy by medical reasons, refusal, or patientś choice. Immune therapies seem to potentiate tumor-specific immune response induced by radiotherapy (RT). Combination of RT with anti-PD-1/PD-L1 therapy appears safe and there are signs of promising activity. The aim of this study is to assess the efficacy and safety of atezolizumab (ATZ) concurrent with external beam radiotherapy (EBRT) for the treatment of muscle-invasive bladder cancer (MIBC) with bladder preservation intent. Here we present an interim analysis. Methods: This is an open, multicenter, and phase II trial, sponsored by SOGUG, in pts with confirmed diagnosis of MIBC in clinical stages cT2-T4a N0 M0 who are not candidates for radical cystectomy. Treatment consists of 6 doses of ATZ 1200 mg IV every 3 weeks, starting on day 1 of EBRT, and 60 Gy of RT in 30 fractions over 6 weeks at 2 Gy/day. The primary endpoint of the study is pathological complete response (pCR) defined as a response of grade 5 according to Miller and Payne criteria, 1 to 2 months after the last dose of ATZ. A planned interim analysis has been performed (data cut-off date: November 2021) on the primary endpoint to avoid exposure to ineffective treatment according to the minimax two-stages Simon's design (stopping rule: 9 out of the first 13 evaluable pts should achieve pCR). Incidence of adverse events (AE) and serious AE (SAE) has been also secondarily assessed. Results: From September 2019 to November 2021, 39 pts were screened, of whom 13 were excluded due to non-compliance with eligibility criteria. Thus, the evaluable population consisted of 26 pts. The safety analysis was performed in 22 pts who had received at least one dose of ATZ. 14 pts were assessed pathologically and, thus, included in interim efficacy analysis (median age: 78.6 years;clinical stage: 71.4% T2a, 14.3% T2b, 7.1% T3a, 7.1% T3b). All 14 pts had achieved pCR at the cut-off date. 20/22 (91%) pts experienced at least one AE, with asthenia (11 pts), diarrhea (9 pts), and urinary tract infection (4 pts) being the most common. 9 SAEs were reported in 7 (32%) pts (bacteriemia, COVID-19 infection, depressed LVEF, unknown origin fever, hepatic toxicity, kidney failure, rectorrhagia, respiratory infection, and urinary sepsis). 6 (27%) pts suffered AEs leading to treatment discontinuation. No AEs leading to death occurred. 17 pts with available data on survival were alive at the cut-off date. Conclusions: Interim results suggest that ATZ combined with EBRT is a feasible and effective treatment in terms of pCR, with a manageable safety profile. The final results from this trial will provide information about its effects on clinical outcome, including survival and updated safety findings.

Outcomes and Prognostic Factors of Patients with Urothelial Carcinoma Undergoing Radical Cystectomy and pT0 in the Final Histology Without Neoadjuvant Chemotherapy.

Purpose: Absence of tumor in the final histopathology after radical cystectomy (RC) is a rare but potentially favorable outcome. Therefore, we aimed to analyze outcomes and prognostic factors of patients with urothelial carcinoma (UC) undergoing RC and T0 in the final histology without neoadjuvant chemotherapy at a high-volume academic center. Patients and Methods: We retrospectively analyzed patients undergoing RC for pure UC between 2004 and 2020. Cancer-specific survival (CSS) and overall survival (OS) were calculated using Kaplan-Meier analysis and group comparison by Log rank test. Potential prognostic factors were analyzed using univariate Cox regression models. Results: A total of 1051 patients with UC underwent RC. 72 patients (6.7%) showed pT0 in the final histology. Across all T-stages, 5-year CSS was significantly different with 88% for pT0, 80% for pTa/pTis, 78% for pT1, 76% for pT2, 51% for pT3 and 27% for pT4 in our cohort (p=0.001). Neither instillation therapy (HR 0.31, 95% CI 0.07-1.43), number of TURB prior RC (HR 1.47, 95% CI 0.25-6.18), use of photodynamic diagnostics (PDD) (HR 0.64, 95% CI 0.14-3.02), performing a second resection (HR 0.87, 95% CI 0.27-2.86), muscle-invasive disease prior RC at any TURB (HR 0.7, 95% CI 0.2-2.39) or muscle-invasive disease in the TURB prior RC (HR 1.0, 0.31-3.29) were associated with CSS in univariate analysis. Conclusion: pT0 reveals a survival benefit in patients undergoing RC for UC and therefore presents a distinctive tumor entity. As clinical and cystoscopic characteristics do not improve patient stratification, further research is warranted to define risk groups in this specific tumor entity.

ICONIC: Impact of Covid-19 on Outcomes iN muscle Invasive bladder Cancer - preliminary Results from a prospective IBUS (International British Urological Society) led multicentre collaborative study

Introduction: The Covid-19 pandemic in the UK led to much un-certainty about the delivery of cancer services. A shift from established therapy (and its timing) in patients with Muscle invasive Bladder Cancer (MIBC) has potential deleterious consequences. To understand outcomes, we formed a collaborative to measure overall and diseasefree survival at 3-years in patients with non-metastatic MIBC (Figure 1) treated during the UK's first wave of Covid-19. Secondary aims included comparison between treatment modalities and pre-Covid controls. Patients and Methods: The collaborative included clinicians from 13 major centres, representing 3 UK nations. A prospective clinical audit, endorsed by the National Cancer Research Institute, was started to collect comprehensive data. MIBC patients discussed at the multidisciplinary meeting (MDM) between 1/3/2020-30/06/2020 were included. Results: At submission, data were available from 12 centres for 299 patients. The mean age was 69.3 years (27- 90), and there were 72 female and 227 male patients. Mean Charlson Co-morbidity Index was 5 (1-12). Preliminary analysis of available data indicate the following: MDM recommendations for (at least) 1 in 4 patients were deemed as being modified from standard practice. Twenty six patients received neoadjuvant chemotherapy. In total (from available data), 99 received radical radiotherapy and 146 underwent radical cystectomy (65 and 74 specified as open and robotic assisted, respectively). Preliminary analysis suggests that 1 in 3 patients had died within 1 year. Conclusions: Preliminary Results indicate that recommendations for MIBC patients were significantly altered consequent to the pandemic and mortality was high. Analyses towards endpoints are awaited.

The Impact of the COVID-19 Pandemic on Bladder Cancer Care in the Netherlands

BACKGROUND: The COVID-19 pandemic has disrupted regular health care with potential consequences for non-COVID diseases like cancer. To ensure continuity of oncological care, guidelines were temporarily adapted. OBJECTIVE: To evaluate the impact of the COVID-19 outbreak on bladder cancer care in the Netherlands. METHODS: The number of bladder cancer (BC) diagnoses per month during 2020-2021 was compared to 2018-2019 based on preliminary data from the Netherlands Cancer Registry (NCR). Additionally, detailed data were retrieved from the NCR for the cohort diagnosed between March 1st-May 31st 2020 (first COVID wave) and 2018-2019 (reference cohort). BC diagnoses, changes in age and stage at diagnosis, and time to first-line treatment were compared between both periods. Changes in treatment were evaluated using logistic regression. RESULTS: During the first COVID wave (week 9-22), the number of BC diagnoses decreased by 14%, corresponding with approximately 300 diagnoses, but increased again in the second half of 2020. The decline was most pronounced from week 13 onwards in patients≥70 years and patients with non-muscle invasive BC. Patients with muscle-invasive disease were less likely to undergo a radical cystectomy (RC) in week 17-22 (OR=0.62, 95% CI=0.40-0.97). Shortly after the start of the outbreak, use of neoadjuvant chemotherapy decreased from 34% to 25% but this (non-significant) effect disappeared at the end of April. During the first wave, 5% more RCs were performed compared to previous years. Time from diagnosis to RC became 6 days shorter. Overall, a 7% reduction in RCs was observed in 2020. CONCLUSIONS: The number of BC diagnoses decreased steeply by 14% during the first COVID wave but increased again to pre-COVID levels by the end of 2020 (i.e. 600 diagnoses/month). Treatment-related changes remained limited and followed the adapted guidelines. Surgical volume was not compromised during the first wave. Altogether, the impact of the first COVID-19 outbreak on bladder cancer care in the Netherlands appears to be less pronounced than was reported for other solid tumors, both in the Netherlands and abroad. However, its impact on bladder cancer stage shift and long-term outcomes, as well as later pandemic waves remain so far unexamined.

IMPACT OF SARS-COV-2 PANDEMIC ON THE DIAGNOSIS AND SURGICAL INTERVENTION OF COMMON UROLOGICAL CONDITIONS: RESULTS FROM A MULTI-INSTITUTIONAL DATABASE FROM THE UNITED STATES

INTRODUCTION AND OBJECTIVE: The SARS-CoV-2 (COVID) pandemic threatened access to healthcare, raising concerns that patients were going underdiagnosed and undertreated. The aim of our study was to understand the impact of the COVID pandemic on diagnosis and surgical management of common urological conditions. METHODS: Using a large multi-center electronic health record network (TRINETx) consisting of 46 healthcare organizations, we conducted an epidemiological study investigating the number of patients newly diagnosed with common urological conditions and those undergoing urologic surgeries at yearly intervals from March 1st, 2016 to March 1st, 2021. Relevant international classification of diseases (ICD) codes used to identify urologic conditions are elaborated on in Table 1. Current procedural terminology (CPT) codes used to identify surgeries are detailed in Figure 1. We then determined the percentage of newly diagnosed patients who underwent surgery for each specific year. RESULTS: We saw a decrease in number of all urologic surgeries being performed during the initial year of the pandemic (Figure 1). From March 2020-2021, there was a >20% decrease in surgical case load for benign prostatic hyperplasia procedures (-29.5%), prostate biopsies (-30.1%), incontinence procedures (-33.6%), and vasectomies (-22.8%), compared to the preceding year. Radical cystectomies and orchiectomies saw the lowest decrease, -5.9% and -8.6%, respectively. A similar trend was seen in the number of individuals newly diagnosed with urologic conditions and percentage of patients undergoing surgical intervention. The lowest drops were seen with ureteral stent placements (-5.0%) and prostate biopsies (-3.1%). CONCLUSIONS: The number of people receiving urologic diagnoses and surgical case load for urologic procedures significantly reduced during the first year of the COVID pandemic. Providers should be aware of this healthcare disparity, and greater efforts made to identify these missed patients moving forward.

COMPARISON OF INTRAVESICAL THERAPY AND SURGERY AS TREATMENT OPTIONS FOR RECURRENT BLADDER CANCER (CISTO): UPDATE ON AN ONGOING MULTICENTER PRAGMATIC STUDY

INTRODUCTION AND OBJECTIVE: Patients with non-muscleinvasive bladder cancer (NMIBC) that recurs after treatment with intravesical Bacillus Calmette-Guerin (BCG) must weigh the risk of progression of bladder cancer and loss of a window of potential cure with medical therapy against the risk of morbidity and loss of quality of life (QOL) with radical cystectomy. The CISTO Study (NCT03933826) is a pragmatic, prospective observational cohort study comparing medical therapy (i.e., intravesical therapy or systemic immunotherapy) with radical cystectomy for recurrent highrisk NMIBC. Here we report on the design and progress of the CISTO Study. METHODS: 900 patients with recurrent high-risk NMIBC that has failed first-line BCG and who have chosen to undergo standard of care treatment will be enrolled. Patient stakeholders helped determine the primary outcome: 12-month patient-reported QOL using the EORTC QLQ-C30. Secondary outcomes include urinary and sexual function, decisional regret, financial distress, healthcare utilization, return to work/normal activities, progression, and recurrence-free, metastasis-free, and overall survival. Participants will be followed for up to 3 years. RESULTS: Enrollment is active at 32 sites across the US, including 23 university-based centers and 9 community sites. As of November 1, 2021, 173 participants have been enrolled, 104 of whom chose medical therapy and 69 of whom chose radical cystectomy. The completion rate for the primary outcome of QOL at 12 months is 94% (15 out of 16 participants to date). The inclusion of electronic consent and collection of PROs allowed recruitment and follow-up to continue remotely during the COVID-19 pandemic. Significant pandemic-related challenges have included slow study start-up at sites, staffing, periods of suspension, and delays in patients obtaining care. Strategies to address these challenges include improved methods for onboarding and training sites, all-site communication, confirming study eligibility, ing EHR data, and remote monitoring while adhering to the highest study standards. CONCLUSIONS: The CISTO Study will compare patient reported outcomes for those undergoing medical therapy with radical cystectomy for recurrent high-risk NMIBC. The CISTO Study has the potential to fill critical evidence gaps and provide for personalized, patient-centered care.

EFFECT OF NEOADJUVANT CHEMOTHERAPY IN IMPROVING OVERALL SURVIVAL OF T2-4AN0M0 BLADDER CANCER PATIENTS: A SYSTEMIC REVIEW AND META-ANALYSIS ACCORDING TO EAU COVID-19 RECOMMENDATION

INTRODUCTION AND OBJECTIVE: In situation with the COVID-19 outbreak, the EAU guidelines Rapid Reaction Group provided recommendations to guide muscle invasive bladder cancer (MIBC) priorities, and they recommended that neoadjuvant chemotherapy should be considered omitted in T2/3 focal N0M0 MIBC patients. This meta-analysis aims to evaluate the efficacy of neoadjuvant chemotherapy compared to radical cystectomy alone in improving overall survival of T2-4aN0M0 MIBC patients. METHODS: Following the PRISMA guideline, PubMed, EMBASE, and Cochrane Library were searched up to September 2021. The articles were searched with keywords muscle-invasive bladder cancer, neoadjuvant chemotherapy, cystectomy, and overall survival. Participants, patients with T2-4aN0M0 MIBC;Interventions, T2- 4aN0M0 MIBC patients who underwent neoadjuvant chemotherapy;Outcomes, comparison of overall survival included for analysis. The overall survival was analyzed as hazard ratio (HR) and 95% confidence interval (CI) and presented in a forest plot. We also conducted a sub-analysis of only T2N0M0 MIBC patients. Quality assessments were performed independently by two reviewers using the Scottish Intercollegiate Guidelines Network. RESULTS: A total of 8 studies were included in the metaanalysis. 8 studies were intermediate risk for detection bias and there were no major problems. In T2-4aN0M0 MIBC patients, the overall survival was significantly better in the neoadjuvant chemotherapy + radical cystectomy group than in the radical cystectomy alone group (HR, 0.79;95% CI, 0.69-0.92;p=0.002) (Fig. 1A). A subgroup analysis was performed on only T2N0M0 MIBC patients and 5 studies were included. There was no difference in overall survival between the neoadjuvant chemotherapy + radical cystectomy group and the radical cystectomy alone group (HR, 0.83;95% CI, 0.69-1.02;p=0.06) (Fig. 1B). CONCLUSIONS: As recommended by the EAU guidelines Rapid Reaction Group, it is thought that patients with T2N0M0 MIBC should strongly consider omitting neoadjuvant chemotherapy until the end of the COVID-19 pandemic. Whether to omit neoadjuvant in T2- 4aN0M0 MIBC should be discussed further, and studies targeting only T2-3N0M0 MIBC are expected to proceed further.

EXAMINING THE 1-YEAR IMPACT OF COVID-19 ON UROLOGY RESIDENT SURGICAL EXPERIENCE: AN ANALYSIS OF NATIONAL SURGICAL CASE LOGS

INTRODUCTION AND OBJECTIVE: The emergence of the COVID-19 pandemic resulted in elective surgical closures beginning in March 2020. In the immediate 6-months after COVID-19 began, there was a significant reduction in national resident operative experience. Our objective is to evaluate the impact of COVID-19 on urology resident surgical experience the year before and after COVID-19 using a national surgical case log registry. METHODS: Canadian national urology resident case log data (T-Res) was analyzed for the 2-year time period from March 15, 2019 - March 14, 2021 with respect to the 14 most commonly performed urological procedures. The 12-month time period prior to COVID-19 was compared to the 12-month time period after COVID-19. Data was analyzed from 11 residency programs with regular active users generating case logs over this time period. Total and specific case volumes per program and per resident user of the time period were analyzed. A paired Wilcoxon signed-rank test was used for comparison of mean cases pre- and post-COVID-19 with an alpha of 0.05 defined as significant. RESULTS: A total of 26,715 procedures were recorded over the 24-month period among 150 unique resident users in 11 training programs. In the 12-months prior to COVID-19, 11,906 procedures were logged while 14,809 procedures were logged in the 12-months after. Nationally, mean total case numbers per program (1082.4 vs. 1346.3;p=0.27) and per resident were not significantly reduced in the 12-months after COVID-19 when compared to 12-months prior (144.5 vs. 135.9;p=0.53). For specific surgeries by program, mean volumes per resident before and after COVID-19 were not significantly different including TURBT (18.5 vs. 19.4;p=0.66), TURP (11.3 vs. 11.7;p=0.72), PCNL (4.1 vs. 3.3;p=0.80), circumcision (6.9 vs. 5.9;p=0.25), hypospadias repair (0.9 vs. 0.6;p=0.39), hydrocelectomy (3.9 vs. 2.6;p=0.37), orchidopexy (4.2 vs. 4.1;p=0.99), ureteroscopy (18.6 vs. 21.3;p=0.53), stent insertion (17.7 vs. 16.7;p=0.77), radical prostatectomy (4.9 vs. 4.8;p=0.89), radical nephrectomy (3.6 vs. 4.0;p=0.75), partial nephrectomy (2.4 vs. 3.0;p=0.29), radical cystectomy (2.8 vs. 3.2;p=0.51), and cystolitholapaxy (3.1 vs. 2.5;p=0.48). While nationally overall case volumes were stable, 3/11 (27.3%) of programs continue to report a significant reduction in surgical volumes 1 year after COVID-19 even when adjusted for number of resident users. CONCLUSIONS: Based on this national case log sample resident operative experience has rebounded one year after COVID-19. However, 27.3% of programs still report significantly reduced case volumes per resident after COVID-19 and this may warrant further examination to ensure focal deficiencies in training don't arise.

INTERRUPTIONS IN BLADDER CANCER CARE DURING THE COVID-19 PUBLIC HEALTH EMERGENCY

INTRODUCTION AND OBJECTIVE: The COVID-19 pandemic has impacted various clinical and research processes in urologic care. As part of a pragmatic clinical trial in bladder cancer, we collected information regarding the impact of COVID-19 at participating sites, which provides insight into how the pandemic has imposed constraints on clinical bladder cancer care and research. METHODS: Starting in May 2020, we distributed a monthly survey to sites participating in CISTO (Comparison of Intravesical Therapy and Surgery as Treatment Options for Bladder Cancer, NCT0393382). The survey included questions about interruptions in routine clinical bladder cancer care, specifically assessing elective surgery restrictions, impact on radical cystectomy, TURBT, office cystoscopies, intravesical therapy, and intravesical bacillus Calmette- Guerin (BCG) supply. We report survey responses for sites that responded to > 50% of the monthly surveys from May 2020 to October 2021. RESULTS: From May 2020 through October 2021, 21 sites (66%) had > 50% monthly response rate. The time periods of greatest limitations on bladder cancer procedures (Figure 1) were May-July 2020, Dec-Jan 2020/2021, and Sept-Oct 2021, corresponding to the peak waves of COVID-19 infections. Elective surgery was most affected, with limitations or holds in those time periods at up to 76%, 38%, and 28% of CISTO sites, respectively. Most of the restrictions involved surgeries that required inpatient stays, potential intensive care unit admission, and staffing shortages. 9 sites (28%) experienced transient BCG shortages during the survey period. CONCLUSIONS: Clinical activity was most limited during the initial COVID-19 surge in Spring/Summer 2020. Despite higher COVID- 19 infection rates in subsequent waves, bladder cancer clinical activity has been maintained at CISTO sites throughout the COVID pandemic. Periodic BCG shortages continue to affect bladder cancer care across the US. (Figure Presented).

Efficacy of pre and rehabilitation in radical cystectomy on health related quality of life and physical function: A systematic review.

Objective: The efficacy of prehabilitation or rehabilitation interventions on radical cystectomy (RC) patient reported outcomes (PROs), and patient centered outcome has not yet been thoroughly explored in prior reviews, therefore the aim of this review is to evaluate the efficacy of a single or multi-modal prehabilitation or/and postoperative rehabilitation interventions compared to standard treatment on postoperative complications after RC. Methods: We performed a three-step search strategy in PubMed, Cinahl, Embase, Cochrane Library, and Web of Science. We used Covidence for the screening of articles, risk of bias assessment, and data-extraction. GRADE was used to assess the risk of bias in outcomes across studies. Where meta-analysis was possible, we used the random effect method due to substantial heterogeneity. The remaining outcomes were summarized narratively. Results: We identified fourteen studies addressing one of the outcomes. None of the studies provided evidence to support that prehabilitation and/or rehabilitation interventions can improve global health related quality of life (HRQoL) in RC surgery or can reduce postoperative complications significantly. However, preoperative and postoperative education in stoma care can significantly improve self-efficacy and we found significant added benefits of sexual counseling to intracavernous injections compared to injection therapy alone. Likewise, an intensive smoking and alcohol cessation intervention demonstrated a significant effect on quit rates. Physical exercise is feasible and improves physical functioning although it does not reduce the postoperative complications. Conclusions: Currently, no evidence of efficacy of prehabilitation and/or rehabilitation interventions to improve the overall HRQoL or postoperative complications after RC exists. We found evidence that education in stoma care improved self-efficacy significantly. Adequately powered randomized controlled trials (RCTs) are needed to generate high-quality evidence in this field.

Feasibility of a geriatric comanagement (GERICO) pilot program for patients 75 and older undergoing radical cystectomy.

BACKGROUND: Retrospective studies have shown the beneficial impact of geriatric comanagement (GERICO) on perioperative outcomes of older adults with cancer. We prospectively assessed the feasibility of perioperative GERICO for older adults with bladder cancer undergoing radical cystectomy. METHODS: We conducted a pilot study wherein all patients 75 years and older undergoing radical cystectomy between October 2019 and November 2020 were referred to the Geriatric Service preoperatively. Feasibility was defined according to the percentage of patients who received preoperative evaluation by the Geriatrics Service, who were followed for more than 80% of their inpatient days and who had their surgery rescheduled for logistical reasons. Urology advanced practice provider (APP) satisfaction with the program was measured via an 11-item survey. RESULTS: Sixty-six eligible patients underwent radical cystectomy in the stated time frame; 59 (89%; 95% confidence interval [CI], 79-97%) were referred to the Geriatric Service for evaluation. The median age of patients who had geriatric comanagement was 79 years; 40 (68%) were male. Forty-one patients (69%) were visited on at least 80% of the days in which they were not in the intensive care unit. No surgeries were rescheduled for logistical reasons. Nine of the 12 urology APPs (75%) responded to the survey; all nine "somewhat" or "strongly" agreed with statements indicating satisfaction with the program. CONCLUSION: Despite the challenges of the COVID-19 pandemic, we showed that perioperative GERICO is feasible. Fully powered prospective randomized controlled trials should be conducted to assess GERICO's impact on perioperative outcomes of older adults with cancer.

Bladder cancer: what's new in 2020-2021

This article aims to give an up-to-date review of studies on the diagnosis and treatment of patients with bladder cancer (BCa). We emphasize that the assessment of treatment and prognosis using specific markers is a promising method. However, clinical data currently outpace the results of molecular testing. Patients with luminal BCa demonstrate worse response to pharmacotherapy than those with other BCa types. The implementation of new drugs such as avelumab, enfortumab, and new drug combinations into clinical practice raised hopes to improve treatment outcomes of patients with locally advanced and metastatic bladder cancer. The development of new pharmacotherapy and immunotherapy regimens will improve treatment outcomes. We describe the experience of some foreign countries with the treatment and outpatient follow-up of patients after radical cystectomy. The article also contains the guidelines by the European Association of Urology on the treatment of patients with urinary tract cancers during the COVID-19 pandemic.

Urothelial carcinoma in COVID-19: lessons from a pandemic and their impact on clinical practice.

The COVID-19 pandemic has modified the management of urothelial carcinoma (UC). Eighteen months after the onset of the pandemic, a scoping narrative review was able to state that radical cystectomy for UC should not be delayed beyond 10 weeks when neoadjuvant chemotherapy (NAC) was administered and 12 weeks when it was not. NAC should be considered when imminent chemotherapy cannot be performed. Early cystectomy should not be delayed when indicated for patients with high-risk non-MIBC. Patients with non-MIBC should still receive their induction doses of intravesical instillations. Diagnostic cystoscopy should not be deferred in symptomatic patients. Surgical management of upper tract urothelial carcinoma (UTUC) allows for a wider deferral interval.

Optimal Delivery of Follow-Up Care After Radical Cystectomy for Bladder Cancer.

PURPOSE OF REVIEW: To identify components representing optimal delivery of follow-up care after radical cystectomy because of bladder cancer and report the current level of evidence. METHODS: We conducted a systematic literature search of the following databases: Cochrane, MEDLINE, Embase, CINAHL, Web of Science, Physiotherapy Evidence Database and ClinicalTrials.gov. The search results were managed in Covidence Reference Manager and abstracts were screened by title. Articles relevant to the subject of interest were included and the results are reported narratively. RESULTS: Several studies have evaluated the positive impact of enhanced recovery after surgery (ERAS) on length of stay, albeit not on the further impact on 90-day postoperative complication rate, functional recovery, or mortality. Minimally invasive surgery may result in a slighter shorter length of stay compared to open surgery. Physical training combined with nutritional intervention can improve functional recovery up to one year after surgery. Nutritional supplements can preserve muscle and bone mass, and potentially improve recovery. Patient education in stoma care and prevention of infection can significantly improve self-efficacy and avoid symptoms of infection postoperatively. Moreover, specific devices like applications (apps) can support these efforts. Continued smoking increases the risk of developing postoperative complications while no evidence was found on the impact of continued alcohol drinking. Currently, there is no evidence on psychological well-being, sexual health, or shared decision making interventions with an impact on rehabilitation after radical cystectomy. CONCLUSION: Data are scarce but indicate that peri- and postoperative multi-professional interventions can reduce prevalence of sarcopenia, and improve functional recovery, physical capacity, nutritional status, and self-efficacy in stoma care (level 1 evidence). Continued smoking increases the risk of complications, but the effects of a smoking and alcohol intervention remain unclear (level 3 evidence). The results of this review provide guidance for future directions in research and further attempts to develop and test an evidence-based program for follow-up care after radical cystectomy.