What should be the patient's preference regarding the choice of hospital in the case of radical cystectomy? Evaluation of early complications after open radical cystectomy in a medium and high volume setting in one hospital.

PURPOSE: This study compares early complications after cystectomy and urinary diversion (UD) stratified by the surgical focus and case load of two different department chairpersons in a single institution in two time periods. Creating clear data about complications that can affect the quality of life is an important tool for patients to decide whether and where to perform this extensive surgery. HYPOTHESIS: A team of surgeons with a clear focus on pelvic surgery leads to lower complication rates in radical cystectomy. MATERIALS AND METHODS: Radical cystectomy was performed in two separate time periods under the patronage of two different chairmen in the same university hospital. The patient data were analyzed retrospectively and the complications 30 days after surgery were assessed using the Clavien-Dindo classification. RESULTS: Statistical analysis showed a significant difference in the severity of complications between the two time periods, A and B, in total (P<0.001). When placing patients into subgroups, significantly more complications in period A were also seen concerning sex (male, P<0.001; female, P=0.003), age (<70 years, P<0.001; >70 years, P≤50.001) tumor grade (low grade, P<0.001; high grade, P≤0.001), and UD (ileal conduit, P<0.001; neobladder, P<0.001). In a multivariable analysis, age (P=0.031) and type of UD (P=0.028) were determined as independent predictors for complications in period A. When joining the two periods together, the type of UD (P=0.0417), age (P=0.041), and the time periods (A/B) (P<0.001) show a significant association with the presence of complications. CONCLUSION: This study compares for the first time surgical complications in two time periods with different case load and surgical focus in one department. Categorization shows that patients should prefer radical cystectomy in centers of excellence or a high-volume hospital in order to keep complications at the lowest possible level and thus have the highest benefit for oncologic outcome and quality of life.

Does presence of squamous and glandular differentiation in urothelial carcinoma of the bladder at cystectomy portend poor prognosis? An intensive case-control analysis.

OBJECTIVE: The prognostic significance of squamous and glandular elements, the most common histologic variants of urothelial carcinoma of the bladder (UCB), is unclear. This study aimed to examine the sole influence of squamous or glandular or both differentiation on UCB outcome following cystectomy and to identify factors that explain the relatively poor prognosis observed in UCB patients with these differentiation elements. MATERIALS AND METHODS: A total of 2,444 patients who underwent radical cystectomy with extended lymph node dissection at a single referral center between 1976 and 2008 were considered. We identified 141, 97, and 21 patients with squamous, glandular, and squamous + glandular differentiation elements, respectively ("cases"). Pure UCB patients without differentiation were matched 1:1 to these cases for demographic, tumor, and treatment characteristics ("controls"). Cases were also compared with an independent cohort of 1,244 pure UCB controls. Recurrence-free and overall survivals were compared between cohorts using univariable and multivariable Cox proportional hazards analyses. RESULTS: Median follow-up for cases, controls, and independent control cohort was 15.2, 11.0, and 12.2 years, respectively. Cases were matched to controls for pathologic stage (chi-square P = 1.00) and administration of intravesical agents (P≥0.85), neoadjuvant (P≥0.31), and adjuvant (P≥0.96) chemotherapy. Cases were also balanced with controls for age, gender, and race (P≥0.30). Following this intensive matching, no differences in outcomes between cases and controls were observed (log-rank P≥0.12). Pathologic stage was predictive of outcome in cases with differentiation by multivariable analysis (P≤0.004). When compared to an independent control cohort, cases with differentiation were observed to present with higher pathologic stage at cystectomy (chi-square P≤0.005). CONCLUSIONS: Outcomes of UCB patients with squamous or glandular or both differentiation are similar to those of patients with pure UCB, given comparable demographic, clinicopathologic, and management characteristics. However, UCB with differentiation present with higher pathologic stage, thus explaining the aggressive clinical course in these patients.

Strategies for molecular expression profiling in bladder cancer.

Carcinoma of the urinary bladder involves alterations in multiple cellular pathways that dictate the pathology of the disease and clinical outcome of the patient. This includes alterations in regulation of the cell cycle, apoptotic mechanisms, signal transduction and tumor angiogenesis. Interrogation of alterations in multiple molecules associated with these pathways is leading to the development of biomarker panels that are capable of predicting an individual patient's outcome or response to specific treatments. With respect to gene expression profiling, two broad approaches may be identified: a global approach and a pathway-specific approach. The global approach involves a high-throughput effort to profile the entire genome, while the pathway-specific approach quantifies select genes across several pathways. While the former has a high potential for discovery of novel signatures, the latter is important in generating reproducible and concise panels that have the potential for rapid clinical implementation. A combination of both these approaches is needed for the identification and validation of robust marker panels of potential clinical importance in bladder cancer.