SUO - AUA 2020 Summer Webcast: Three Papers in the Past Year That Have Changed My Practice: Bladder Cancer

(UroToday.com) To conclude the 2020 Society of Urologic Oncology Summer Virtual Webcast bladder cancer session, Janet Kukreja, MD, from the University of Colorado discussed three papers published this year that have changed her practice.

The first paper was by Steinberg et al. entitled “Multi-Institution Evaluation of Sequential Gemcitabine and Docetaxel as Rescue Therapy for Nonmuscle Invasive Bladder Cancer” published in the Journal of Urology.1 Indeed, intravesical therapies for patients with BCG failure nonmuscle invasive bladder cancer remain a critical focus of ongoing research. This was a retrospective study of 276 patients from 8 institutions from 2009-2018 that were Bacillus Calmette–Guérin (BCG) unresponsive and were not surgical candidates. All patients underwent a six-week induction period and six of the institutions offered 24-month maintenance schedules. There were 26 patients that had urinary symptoms impacting their treatment, however, only nine patients (3%) were unable to tolerate a full induction course of therapy. One and two-year recurrence-free survival rates were 60% and 46%, and high-grade recurrence-free survival rates were 65% and 52%, respectively. Among patients with carcinoma in situ (CIS) alone, the one-year recurrence-free survival rate was 61%, whereas the 2-year rate was 38%. 

Ten patients (3.6%) had disease progression on transurethral resection. Forty-three patients (15.6%) went on to cystectomy (median 11.3 months from induction), of whom 11 (4.0%) had progression to muscle invasion. Dr. Kukreja notes that dwell time and protocols were not the same at all institutions and this was a highly selected population. Currently, the National Comprehensive Cancer Network (NCCN) guidelines now include gemcitabine/docetaxel as an option, which is particularly of interest for patients of low-risk in the BCG shortage era.

The second paper discussed by Dr. Kukreja was by Carvalho et al. titled “Considerations about Non-Metastatic Bladder Cancer Management During the COVID-19 Pandemic” published as a Commentary in Bladder Cancer.2 This paper was influential to Dr. Kukreja for creating institutional guidelines and advocating for patients to utilize OR resources in the setting of elective cases being postponed and shortages of personal protective equipment and hospital beds. A flow diagram summarizing the stratification of non-muscle-invasive and muscle-invasive disease is as follows:

StratificationNon-MuscleInvasive_SUO2020.png

The third paper highlighted by Dr. Kukreja was by Ahmadi et al. entitled “Use of indocyanine green to minimize uretero-enteric strictures after robotic radical cystectomy” published in the British Journal of Urology International.3 This was a retrospective analysis from 2014-2016 of all surgeons performing robotic-assisted radical cystectomy (132 and 47 patients were in the non-indocyanine green (ICG) group and the ICG group, respectively); post-op follow-up with CTs and magnetic resonance imaging scans (MRIs) were performed and further workup entailed a loopogram or cystogram, as well as nuclear imaging as needed. Strictures were confirmed when nephrostomy tubes were placed. During the pre-ICG era, these surgeons had a 10.6% stricture rate (6% left vs 2% bilateral), however with use of ICG 0/47 patients had strictures with more than 1 year of follow-up. Dr. Kukreja uses ICG after the anastomosis is performed to confirm vascularization prior to ureteral implantation into the ileum. In her opinion, there are no real side effects or contraindications to using ICG for these patients.

Presented by: Janet Kukreja, MD, University of Colorado, Aurora, CO, USA 

Written by: Zachary Klaassen, MD, MSc – Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, Augusta, GA, USA, Twitter: @zklaassen_md, at the Society of Urologic Oncology (SUO) - American Urologic Association (AUA) 2020 Summer Webcast Program, July 18, 2020.

References:

  1. Steinberg RL, Thomas LJ, Brooks N, et al. Multi-Institution Evaluation of Sequential Gemcitabine and Docetaxel as Rescue Therapy for Nonmuscle Invasive Bladder Cancer. J Urol 2020 May;203(5):902-909.
  2. Carvalho FLF, Galloway LAS, Saoud R, et al. Considerations about Non-Metastatic Bladder Cancer Management During the COVID-19 Pandemic. Bladder Cancer 2020;6:99-106.
  3. Ahmadi N, Ashrafi AN, Hartman N, et al. Use of indocyanine green to minimize uretero-enteric strictures after robotic radical cystectomy. BJU Int 2019 Aug;124(2):302-307.
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