Predictors of Benign Ureteroenteric Anastomotic Strictures After Radical Cystectomy and Urinary Diversion.

OBJECTIVE: To determine predictors of symptomatic ureteroenteric anastomotic strictures (UAS) formation following radical cystectomy (RC) and urinary diversion (UD). MATERIALS AND METHODS: A total of 2,888 consecutive patients who underwent open RC at our institution from 1995 to 2014 were included for analysis. Data were collected from institutional databases and individual medical records. Symptomatic benign UAS was defined as percutaneous nephrostomy tube insertion for rising creatinine or unilateral hydronephrosis by comparing preoperative and postoperative imaging. Univariate and multivariable Cox proportional hazards models were utilized to identify features associated with UAS formation. RESULTS: UAS developed in 123 of 2888 patients following RC. There were 94 symptomatic and 29 asymptomatic strictures. Median follow-up was 32 months (IQR 12, 72) for patients without stricture. Higher BMI (P = 0.002), ASA score >2 (P < 0.0001), lymph node positive disease (P = 0.027), and 30-day postoperative grade 3I+ complications (P = 0.017) on univariate analysis and male gender on multivariable analysis were significantly associated with time to stricture development. However, history of prior abdominal surgery (PAS) had the strongest association with time to stricture formation (HR 3.25, 95% CI 1.78, 5.94, P = 0.0001). Risk of developing a stricture within 10 years was 1.9% for patients without PAS vs 9.3% with PAS. CONCLUSION: Associated factors with an increased risk of benign UAS include higher BMI, ASA score >2, lymph node involvement, grade 3/4 complications within 30 days, male sex, and a history of PAS. We conclude that while surveillance is important for patients who undergo cystectomy for malignancy, it may be beneficial for patients with history of PAS to undergo more intensive follow-up compared to those patients without history of PAS.

Sequential adjuvant chemotherapy after surgical resection of high-risk urothelial carcinoma.

BACKGROUND: Despite definitive surgery, the survival of patients with high-risk urothelial carcinoma (UC) is poor. Adjuvant cisplatin-based chemotherapy may be beneficial, but it is restricted by the need for normal renal function (RF). Sequential administration of adjuvant chemotherapy facilitates drug delivery and improves survival in patients with breast cancer. The objective of this study was to evaluate the feasibility and survival impact of adjuvant, sequential chemotherapy in patients with high-risk UC. METHODS: Fifty patients were treated on 2 simultaneous protocols between 1997 and 2004. The patients on Protocol A (normal RF) received doxorubicin and gemcitabine (AG) followed by paclitaxel and cisplatin. The patients on Protocol B (impaired RF) received AG followed by paclitaxel plus carboplatin. Overall survival (OS) and disease-specific survival (DSS) were compared with a group of 203 contemporary control patients who had similar pathology and RF and who underwent surgery alone. RESULTS: The median follow-up of protocol patients was 6.5 years (range, 0.9-8.6 years), and 25 patients remained alive. The median follow-up of the control group was 4.7 years (0.0-9.2), and 68 patients remained alive. The median OS for patients on Protocol A was greater than that for controls who had good RF (4.6 years vs 2.5 years; P = .03). The median OS for patients on Protocol B was greater than that for controls who had impaired RF (3.4 years vs 2 years; P = .04). DSS for the protocol and matched control groups was similar (good RF: 4.6 years vs 3 years; P = .24; impaired RF: 3.4 years vs 3.3 years; P = .40). CONCLUSIONS: In this nonrandomized study, adjuvant, sequential chemotherapy for patients with high-risk UC did not improve DSS over that observed with surgery alone.