Urinary diversion: options, patient selection, and outcomes

Improved survival following radical cystectomy for bladder cancer as a result of advancements in combination chemotherapy and surgical technique has resulted in a philosophical change in the surgeon's approach to urinary diversion selection. Aims have evolved from the mere diversion of urine to a functional bowel conduit such as an ileal conduit or ureterosigmoidostomy, to providing the optimal diversion for the patient's quality of life. While quality of life is important, one must also consider the stage of cancer and individual patient comorbidities. Which diversion provides the best local cancer control, the lowest potential for complications (short and long term), and the easiest emotional adjustment in lifestyle while still allowing the timely completion of chemotherapy and therapeutic goals? A multidisciplinary approach to diversion selection that includes the patient, the medical oncologist, radiation oncologist, internist, and surgeon is ideal. We describe the three most commonly used types of diversions today, including conduits, continent cutaneous reservoirs, and orthotopic urethral diversions, as well as issues relative to patient selection and functional outcomes in patients undergoing radical cystectomy for the treatment of bladder cancer

12th Annual Meeting of the Society of Urologic Oncology (SUO) Bladder Cancer Sessions I and II summary report

Health care reform with the Affordable Care Act aims to control health care costs, in part, through the use of comparative effectiveness research and quality of care measures. Bladder cancer is one of the most expensive malignancies to manage as related to the need for continuous monitoring and the treatment of recurrence. The use of clinical practice guidelines relying on evidence based medicine in the management of patients with bladder cancer will help to ensure quality of care and cost containment. The goal of session I was to provide a thorough discussion of the quality of care and cost issues related to bladder cancer including an examination of levels of evidence, implementation and compliance with clinical practice guidelines, the use of standardized reporting methodologies, and comparative effectiveness research. Bladder cancer is a common malignancy with a variable biology and natural history. Although the majority of patients are diagnosed with non-invasive disease, approximately 20–40% of patients either present with or develop more advanced disease. The 5-year survival for patients with lymph node involvement at the time of surgery is 20–30% and patients with metastatic disease treated with chemotherapy have a median survival of only 15 months. Novel approaches for the management of patients with bladder cancer are desperately needed. The goal of session II was to review the current state of translational research in bladder cancer as related to both early and late stage disease including a discussion of novel molecular targets and targeted therapeutics, pharmacogenomics to predict response to therapy, and exploring the role for agents targeting angiogenesis

PD11-10 A 10-ITEM CHECKLIST CHECKLIST IMPROVES REPORTING OF CRITICAL PROCEDURAL ELEMENTS DURING TRANSURETHRAL RESECTION OF BLADDER TUMOR

Previous studies have demonstrated significant variation in recurrence rates after transurethral resection of bladder tumor, likely due to differences in surgical quality. We sought to create a framework to define, measure and improve the quality of transurethral resection of bladder tumor using a surgical checklist. We formed a multi-institutional group of urologists with expertise with bladder cancer and identified 10 critical items that should be performed during every high quality transurethral bladder tumor resection. We prospectively implemented a 10-item checklist into practice and reviewed the operative reports of such resections performed before and after implementation. Results at all institutions were combined in a meta-analysis to estimate the overall change in the mean number of items documented. The operative notes for 325 transurethral bladder tumor resections during checklist use were compared to those for 428 performed before checklist implementation. Checklist use increased the mean number of items reported from 4.8 to 8.0 per resection, resulting in a mean increase of 3.3 items (95% CI 1.9–4.7) on meta-analysis. With the checklist the percentage of reports that included all 10 items increased from 0.5% to 27% (p <0.0001). Surgeons who reported more checklist items tended to have a slightly higher proportion of biopsies containing muscle, although not at conventional significance (p = 0.062). The use of a 10-item checklist during transurethral resection of bladder tumor improved the reporting of critical procedural elements. Although there was no clear impact on the inclusion of muscle in the specimen, checklist use may enhance surgeon attention to important aspects of the procedure and be a lever for quality improvement

Final Results of a Phase I Trial of WST-11 (TOOKAD Soluble) Vascular-Targeted Photodynamic Therapy for Upper Tract Urothelial Carcinoma.

PURPOSE: Vascular-targeted photodynamic therapy (VTP) with the intravascular photosensitizing agent padeliporfin (WST-11/TOOKAD-Soluble) has demonstrated therapeutic efficacy as an ablative treatment for localized cancer with potential adaptation for endoscopic management of upper tract urothelial carcinoma (UTUC). This phase I trial (NCT03617003) evaluated the safety of VTP with WST-11 in UTUC. MATERIALS AND METHODS: Nineteen patients underwent up to 2 endoscopic VTP treatments, with follow-up for up to 6 months. Patients who had residual or recurrent UTUC (any grade/size) failing prior endoscopic treatment or were unable or unwilling to undergo surgical resection were eligible for inclusion. The primary endpoint was to identify the maximally tolerated dose (MTD) of laser light fluence. A dose escalation model was employed, with increasing light fluence (100-200mW/cm) using a modified continual reassessment method. The secondary endpoint was treatment efficacy, defined by absence of visible tumor and negative urine cytology 30 days post-treatment. RESULTS: Fourteen (74%) patients received the MTD of 200mW/cm, 2 (11%) of whom experienced a dose-limiting toxicity. The initial 30-day treatment response rate was 94% (50% complete, 44% partial). Eight patients underwent a second treatment, with a final observed 68% complete response rate. Leading toxicities were flank pain (79%) and hematuria (84%), which were transient. No ureteral strictures associated with treatment were identified during follow-up. CONCLUSIONS: VTP with WST-11 has an acceptable safety profile with strong potential as an effective, kidney-sparing endoscopic management option for UTUC. The recently initiated multi-center phase 3 ENLIGHTED trial (NCT04620239) is expected to provide further evidence on this therapy