Purpose Although associated with an overall favorable survival rate, the heterogeneity of non-muscle invasive bladder cancer (NMIBC) affects patients’ rates of recurrence and progression. Risk ...stratification should influence evaluation, treatment and surveillance. This guideline attempts to provide a clinical framework for the management of NMIBC. Materials and Methods A systematic review utilized research from the Agency for Healthcare Research and Quality (AHRQ) and additional supplementation by the authors and consultant methodologists. Evidence-based statements were based on body of evidence strength Grade A, B, or C and were designated as Strong, Moderate, and Conditional Recommendations with additional statements presented in the form of Clinical Principles or Expert Opinions. Results A risk-stratified approach categorizes patients into broad groups of low-, intermediate-, and high-risk. Importantly, the evaluation and treatment algorithm takes into account tumor characteristics and uniquely considers a patient’s response to therapy. The 38 statements vary in level of evidence, but none include Grade A evidence, and many were Grade C. Conclusion The intensity and scope of care for NMIBC should focus on patient, disease, and treatment response characteristics. This guideline attempts to improve a clinician’s ability to evaluate and treat each patient, but higher quality evidence in future trials will be essential to improve level of care for these patients.
MicroRNAs have been identified as potential cancer biomarkers due to their presence and stability in many body fluids including urine and plasma, but the relationship of the pattern of expression of ...these messengers across various biological media has not been addressed and could provide important information in order to translate these biomarkers for epidemiologic or clinical use.
We analyzed microRNA of matched FFPE-tumor tissue, plasma, urine exosomes (n = 16) and WBCs (n = 11) from patients with bladder cancer, using Nanostring miRNA assays and droplet digital PCR for validation. Pearson correlations were used to compare expression between media.
Numerous microRNAs were detected and overlapping from specific bio-specimen sources. MiR-4454 and miR-21 overexpression was found in three sources: tumor, WBCs and urine. Additionally, miR-15b-5p, miR-126-3p, miR-93-5p, and miR-150-5p were common to tumor/WBCs, while miR-720/3007a, miR-205, miR-200c-3p and miR-29b-3p common to tumor/urine. Significant associations were noted between the log-adjusted average miRNA counts in tumor vs. WBCs (r = 0.418 p < 0.001), and tumor vs. urine (r = 0.38 p < 0.001). No association was seen tumor vs. plasma exosome miRs (r = 0.07 p = 0.06).
MicroRNA profiling from matched samples in patients shows a significant number of microRNAs up regulated in bladder tumors are identifiable in urine exosomes and WBCs of the same patient, but not in blood plasma. This study demonstrated varying relationships between miRNA detected in biological media from the same patient, and serves to inform the potential of urine-based microRNAs as biomarkers for bladder cancer and potentially other malignancies.
To assess the association of low- vs. guideline-recommended high-intensity cystoscopic surveillance with outcomes among patients with high-risk non-muscle invasive bladder cancer (NMIBC).
A ...retrospective cohort study of Veterans Affairs patients diagnosed with high-risk NMIBC between 2005 and 2011 with follow-up through 2014. Patients were categorized by number of surveillance cystoscopies over two years following diagnosis: low- (1-5) vs. high-intensity (6 or more) surveillance. Propensity score adjusted regression models were used to assess the association of low-intensity cystoscopic surveillance with frequency of transurethral resections, and risk of progression to invasive disease and bladder cancer death.
Among 1,542 patients, 520 (33.7%) underwent low-intensity cystoscopic surveillance. Patients undergoing low-intensity surveillance had fewer transurethral resections (37 vs. 99 per 100 person-years; p<0.001). Risk of death from bladder cancer did not differ significantly by low (cumulative incidence CIn 8.4% 95% CI 6.5-10.9) at 5 years) vs. high-intensity surveillance (CIn 9.1% 95% CI 7.4-11.2) at 5 years, p = 0.61). Low vs. high-intensity surveillance was not associated with increased risk of bladder cancer death among patients with Ta (CIn 5.7% vs. 8.2% at 5 years p = 0.24) or T1 disease at diagnosis (CIn 10.2% vs. 9.1% at 5 years, p = 0.58). Among patients with Ta disease, low-intensity surveillance was associated with decreased risk of progression to invasive disease (T1 or T2) or bladder cancer death (CIn 19.3% vs. 31.3% at 5 years, p = 0.002).
Patients with high-risk NMIBC undergoing low- vs. high-intensity cystoscopic surveillance underwent fewer transurethral resections, but did not experience an increased risk of progression or bladder cancer death. These findings provide a strong rationale for a clinical trial to determine whether low-intensity surveillance is comparable to high-intensity surveillance for cancer control in high-risk NMIBC.
To demonstrate the surgical technique for prophylactic mesh placement in the sublay position during ileal conduit creation because literature suggests that prophylactic mesh placement at the time of ...cystectomy may reduce the risk of parastomal hernias with low risk of mesh-related complications. Parastomal hernias are one of the most common complications following ileal conduit construction and occur in 17-65% of patients undergoing cystectomy with urinary diversion. Review of our institutions data demonstrated a high incidence of hernias associated with ileal conduits, which have substantial burden to patients, surgeons, and the healthcare system.
This is a retrospective chart review of data from a single surgeon who performed cystectomy with ileal conduit for 12 patients with bladder cancer between January, 2021-March, 2022 at our institution. These dates were chosen based on the timing of availability of literature suggesting a benefit from prophylactic mesh placement. Preliminary data was analyzed determine the incidence of parastomal hernia and mesh-related complications.
A total of 12 patients underwent cystectomy with ileal conduit between January, 2021-March, 2022 at our institution. Eleven patients (92%) had prophylactic mesh placed during their procedure. Median follow up was 5.4 months (0.8-8 months). Two patients (17%) developed a parastomal hernia which was detected clinically and/or radiographically. The hernias occurred in patients with mesh and within 6 months of cystectomy. One patient had stomal stenosis eventually requiring surgical revision. There were no mesh infections or mesh removals.
Parastomal hernias are a common and morbid complication of ileal conduit urinary diversion. Our early experience demonstrates that the procedure is straightforward, adds little time to the surgical procedure, and is associated with a low complication rate. Our experience is too small and follow up too short to confirm that the results of the randomized trial can be matched at our center.
To quantify the short-term burden associated with continent diversion relative to ileal conduit creation.
Bladder cancer patients who underwent radical cystectomy in 2019 and 2020 were identified in ...the American College of Surgeons National Surgical Improvement Program database using current procedural terminology codes and pathology reports. Patients were grouped by urinary diversion performed: ileal conduit versus continent diversion (neobladder or cutaneous reservoir). Multiple logistic regression was used to examine the association between type of urinary diversion and 30-day outcomes, including postoperative complications, all-cause readmissions, and mortality, adjusting for baseline differences.
Of 4,755 patients who underwent radical cystectomy, 677 underwent continent diversion (14.2%). These patients were significantly younger (median 62 vs 71 years, P <.01) and less likely to have diabetes (13.6% vs 20.1%, P <.01), COPD (3.7% vs 7.1%, P<0.01), and prior pelvic radiation (5.5% vs 13.1%, P <.01). A greater proportion of continent diversion patients experienced a postoperative complication (56.0% vs 48.9%, P <.01) and all-cause readmission (30.3% vs 20.4%, P <.0). After adjustment, continent diversion patients had 1.4 (95% CI: 1.1-1.7) and 1.7 (95% CI: 1.4-2.1) times the odds of experiencing a postoperative complication or all-cause readmission, respectively. There was no statistically significant difference in mortality (OR 1.2, 95% CI: 0.5-2.9).
Compared to ileal conduit creation, continent urinary diversion is associated with increased odds of postoperative complications and readmission to the hospital within 30 days of surgery. Bladder cancer patients undergoing cystectomy and seeking continent diversion should be counseled on the increased short-term morbidity associated with this specific type of diversion.
Background: In Japan, the tail and body of the pancreas are generally removed for dissection of lymph nodes along the splenic artery. A new pancreas-preserving method was developed to decrease the ...postoperative complications due to pancreatic resection. Patients and Methods: Between 1981 and 1989, 110 patients were registered in a randomized controlled trial, which included total gastrectomy plus dissection of lymph node along the splenic artery, either with (55 patients: Group A) or without (55: Group B) pancreas tail resection. In Group B, the splenic artery and spleen were removed and the pancreas was preserved. There were no significant differences between the two groups in terms of sex, age, location, microscopic classification, or disease stage. The postoperative complications and survival rates were compared between the two groups. Results: The average number of dissected nodes along the splenic artery was 4.6 and 4.1 for Groups A and B, respectively. The amounts of blood loss during the operation were 994 ml and 904 ml for groups A and B, respectively. Anastomosis failure and/or pancreatic fistula occurred in nine patients in Group A (16%) and seven in Group B (13%). One year after the operation, a glucose tolerance test showed diabetes in 6% and impaired glucose tolerance in 33% of patients in group A, while these findings were normal in group B. The 5-year survival rates were 80% and 76.7% for groups A and B, respectively. Conclusions: The pancreas-preserving method described here was superior to the more common pancreas resecting method with regard to surgical risk and postoperative glucose tolerance.
Objectives
To examine trends in online search behaviours related to prostate cancer on a national and regional scale using a dominant major search engine.
Materials and Methods
Google Trends was ...queried using the terms ‘prostate cancer’, ‘prostate‐specific antigen’ (PSA), and ‘prostate biopsy’ between January 2004 and January 2019. Search volume index (SVI), a measure of relative search volume on Google, was obtained for all terms and examined by region and time period: pre‐US Preventive Services Task Force (USPSTF) Grade D draft recommendation on PSA screening; during the active Grade D recommendation; and after publication of the recent Grade C draft recommendation.
Results
Online interest in PSA screening differed by time period (P < 0.01). The SVI for PSA screening was greater pre‐Grade D draft recommendation (82.7) compared to during the recommendation (74.5), while the SVI for PSA screening was higher post‐Grade C draft recommendation (90.4) compared to both prior time periods. Similar results were observed for prostate biopsy and prostate cancer searches. At the US state level, online interest in prostate cancer was highest in South Carolina (SVI 100) and lowest in Hawaii (SVI 64). For prostate cancer treatment options, online interest in cryotherapy, prostatectomy and prostate cancer surgery overall increased, while searches for active surveillance, external beam radiation, brachytherapy and high‐intensity focused ultrasonography remained stable.
Conclusion
Online interest in prostate cancer has changed over time, particularly in accordance with USPSTF screening guidelines. Google Trends may be a useful tool in tracking public interest in prostate cancer screening, diagnosis, and treatment, especially as it relates to major shifts in practice guidelines.
Immune profiles have been associated with bladder cancer outcomes and may have clinical applications for prognosis. However, associations of detailed immune cell subtypes with patient outcomes remain ...underexplored and may contribute crucial prognostic information for better managing bladder cancer recurrence and survival.
Bladder cancer case peripheral blood DNA methylation was measured using the Illumina HumanMethylationEPIC array. Extended cell-type deconvolution quantified 12 immune cell-type proportions, including memory, naïve T and B cells, and granulocyte subtypes. DNA methylation clocks determined biological age. Cox proportional hazards models tested associations of immune cell profiles and age acceleration with bladder cancer outcomes. The partDSA algorithm discriminated 10-year overall survival groups from clinical variables and immune cell profiles, and a semi-supervised recursively partitioned mixture model (SS-RPMM) with DNA methylation data was applied to identify a classifier for 10-year overall survival.
Higher CD8T memory cell proportions were associated with better overall survival HR = 0.95, 95% confidence interval (CI) = 0.93-0.98, while higher neutrophil-to-lymphocyte ratio (HR = 1.36, 95% CI = 1.23-1.50), CD8T naïve (HR = 1.21, 95% CI = 1.04-1.41), neutrophil (HR = 1.04, 95% CI = 1.03-1.06) proportions, and age acceleration (HR = 1.06, 95% CI = 1.03-1.08) were associated with worse overall survival in patient with bladder cancer. partDSA and SS-RPMM classified five groups of subjects with significant differences in overall survival.
We identified associations between immune cell subtypes and age acceleration with bladder cancer outcomes.
The findings of this study suggest that bladder cancer outcomes are associated with specific methylation-derived immune cell-type proportions and age acceleration, and these factors could be potential prognostic biomarkers.
To examine discomfort, anxiety, and preferences for decision making in patients undergoing surveillance cystoscopy for non–muscle-invasive bladder cancer (NMIBC).
Veterans with a prior diagnosis of ...NMIBC completed validated survey instruments assessing procedural discomfort, worry, and satisfaction, and were invited to participate in semistructured focus groups about their experience and desire to be involved in surveillance decision making. Focus group transcripts were analyzed qualitatively, using (1) systematic iterative coding, (2) triangulation involving multiple perspectives from urologists and an implementation scientist, and (3) searching and accounting for disconfirming evidence.
Twelve patients participated in 3 focus groups. Median number of lifetime cystoscopy procedures was 6.5 (interquartile range 4-10). Based on survey responses, two-thirds of participants (64%) experienced some degree of procedural discomfort or worry, and all participants reported improvement in at least 2 dimensions of overall well-being following cystoscopy. Qualitative analysis of the focus groups indicated that participants experience preprocedural anxiety and worry about their disease. Although many participants did not perceive themselves as having a defined role in decision making surrounding their surveillance care, their preferences to be involved in decision making varied widely, ranging from acceptance of the physician's recommendation, to uncertainty, to dissatisfaction with not being involved more in determining the intensity of surveillance care.
Many patients with NMIBC experience discomfort, anxiety, and worry related to disease progression and not only cystoscopy. Although some patients are content to defer surveillance decisions to their physicians, others prefer to be more involved. Future work should focus on defining patient-centered approaches to surveillance decision making.
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