[Resumption of Enfortumab Vedotin Supported by Diagnosis of a Late- Onset Immune-Related Adverse Event in Metastatic Urothelial Carcinoma : A Case Report].

A 71-year-old man presented with exertional dyspnea. Chest radiography revealed multiple pulmonary nodules, and contrast-enhanced computed tomography showed findings suspicious of right renal pelvic cancer. Percutaneous lung tumor biopsy revealed a histological diagnosis of urothelial carcinoma, and right renal pelvic cancer cT3N2M1 was diagnosed. Favorable response was shown during primary chemotherapy with gemcitabine and cisplatin but resulted in tumor progression after four cycles. The patient was switched to a second-line treatment, pembrolizumab, which resulted in rapid tumor growth. Hyper-progression was suspected, and the patient was promptly switched to a third-line treatment, enfortumab vedotin. The tumor shrank significantly. After three treatment cycles, an adverse event of enteritis was observed. A biopsy of the intestinal mucosa led to a histopathologic diagnosis of late-onset immune-related adverse event; therefore, enfortumab vedotin could be continued.

Impact of the severity of urethrovesical anastomotic leakage on urinary continence following robot-assisted laparoscopic prostatectomy.

We assessed whether the severity of anastomotic urinary leakage detected during routine cystourethrography after robot-assisted laparoscopic prostatectomy (RALP) affects urinary continence recovery. Around 302 patients who underwent RALP between August 2013 and May 2019 were included retrospectively. According to routine cystourethrographic findings obtained on the sixth or eighth postoperative day, which indicated leakage severity, patients were divided into three groups: no-leakage, grade 1 (linear shaped leakage, but not spreading), and grade 2 (spreading strip-shaped leakage). The preoperative factors and intraoperative factors were compared between no-leakage and leakage group (grade 1 and grade 2). Continence recovery was compared between the three groups. Continence recovery was defined as no pad used or one security pad used in a day. Cystourethrography revealed anastomotic urinary leakage in 44 patients (14.5%), of which 20 patients (6.6%) had grade 1 leakage and 24 patients (7.9%) had grade 2 leakage. On multivariate logistic regression analysis, the only significant predictor for urethrovesical anastomotic urinary leakage on cystourethrography following RALP was intraoperative anastomotic leakage (OR 5.306; 95% CI 1.530-18.398, p = 0.009). Continence recovery rates for no-leakage, grade 1 leakage, and grade 2 leakage groups were 11%, 20%, and 25% after 1 month (P = 0.131); 25%, 25%, and 45.8% after 3 months (P = 0.474); 44.6%, 55%, and 60.8% after 6 months (P = 0.184); and 63.1%, 87.5%, and 78.2% after 12 months (P = 0.095), respectively. In conclusion, urinary leakage in urethrovesical anastomosis, even at its severity, had no negative effects on continence recovery after RALP.

Efficacy and toxicity of intravesical Bacillus Calmette-Guérin therapy in elderly patients with non-muscle-invasive bladder cancer.

OBJECTIVES: This study aimed to compare the efficacy and toxicity of intravesical Bacillus Calmette-Guérin (BCG) therapy between elderly and younger patients with non-muscle-invasive bladder cancer (NMIBC). MATERIAL AND METHODS: This retrospective study included 87 NMIBC patients who received intravesical BCG between January 2011 and December 2018. We compared the treatment outcomes of patients ≥75 and <75 years old. Our primary endpoint was intravesical recurrence-free survival after treatment. The secondary endpoint was the toxicity caused by intravesical BCG. RESULTS: The elderly and younger patients included 38 and 49 patients with mean ages of 80.6 and 66.3 years (p < 0.01), respectively. Their baseline parameters were similar, aside from age. The elderly and younger patients' 5-year recurrence-free survival rates were 59.4% and 51.6%, respectively, and were not significantly different (log-rank test, p = 0.72). Moderate to severe pain on micturition requiring prescription medications was observed more frequently in the elderly patients than in the younger patients (p < 0.01). No elderly patients required hospitalization for any adverse events. However, 3 (6.1%) younger patients were treated for urinary tract infection in the hospital. CONCLUSIONS: The efficacy and toxicity of intravesical BCG therapy for NMIBC patients are not associated with age. Therefore, elderly patients with high-risk NMIBC should be treated in the same manner as younger patients in clinical practice.

Use of surgical checklist during transurethral resection increases detrusor muscle collection rate and improves recurrence-free survival in patients with non-muscle-invasive bladder cancer.

OBJECTIVE: To elucidate the therapeutic benefits of using a surgical checklist during transurethral resection for non-muscle-invasive bladder cancer. METHODS: A nine-item surgical checklist was established in January 2016 to assess disease risk and resection adequacy, and it was prospectively implemented into clinical practice. Patients diagnosed with non-muscle-invasive bladder cancer who underwent complete resection from January 2009 to August 2019 were included in this study. The presence of detrusor muscle in the transurethral resection specimen and the intravesical recurrence-free survival were compared between patients who underwent transurethral resection before and after surgical checklist implementation. RESULTS: A total of 125 patients who underwent transurethral resection after surgical checklist implementation were reviewed and compared with 125 patients who underwent transurethral resection before surgical checklist implementation. The use of the surgical checklist led to an increase in the proportion of transurethral resection specimens containing detrusor muscle (92% vs 69.6%, P < 0.01) and a decrease in the recurrence rate (19.2% vs 49.6%, P < 0.01). Multivariate analysis showed that transurethral resection without a surgical checklist was an independent predictive factor influencing the absence of detrusor muscle in the transurethral resection specimen (odds ratio 4.78, P < 0.01) and intravesical recurrence (hazard ratio 1.92, 95% confidence interval 1.14-3.23; P = 0.01). Kaplan-Meier plots showed that the recurrence-free survival rate was significantly lower when the surgical checklist was not used (log-rank test result P < 0.01). CONCLUSIONS: This study shows the therapeutic benefits of surgical checklist in improving the quality of resection during transurethral resection and reducing the recurrence rate in patients with non-muscle-invasive bladder cancer.

Impact of second transurethral resection on recurrence in patients with high-grade Ta bladder cancer.

OBJECTIVES: To clarify the potential therapeutic benefit of a second transurethral resection for high-grade Ta bladder cancer. METHODS: From January 2009 to August 2019, 521 patients with bladder tumors underwent initial transurethral resection procedures at Kagawa University Hospital. Patients diagnosed with high-grade Ta bladder cancer considered to have been resected completely were included in this study. Recurrence and progression rates were compared between patients who received a second transurethral resection and those who did not. RESULTS: We identified 97 eligible patients, including 22 patients who received a second transurethral resection. In terms of clinical characteristics, the proportion of patients with bladder cancer and upper urinary tract tumor history was lower in the second transurethral resection group than in the no second transurethral resection group (P < 0.01 and P = 0.03, respectively). The histopathological findings of 22 transurethral resection procedures were no cancer in 13 (59.2%), Ta in six (27.2%) and carcinoma in situ in three patients (13.6%). After the second transurethral resection, one patient (4.6%) had recurrent high-grade T1 bladder cancer. The no second transurethral resection group showed a 44% recurrence rate (33 patients), including five patients (6.7%) with progression, and consequently, had a higher rate of recurrence than in the second transurethral resection group (P < 0.01). Multivariate analysis showed that no second transurethral resection was the independent predictive factor influencing recurrence (hazard ratio 8.662, P = 0.04). The Kaplan-Meier curve showed that a second transurethral resection significantly decreased the recurrence rate than that of patients without a second transurethral resection (P < 0.01). CONCLUSIONS: A second transurethral resection can reduce the recurrence rate in high-grade Ta bladder cancer, showing a possible therapeutic benefit of this procedure.