BACKGROUND AND OBJECTIVE: Identifying evidence-based and measurable quality-of-care indicators is crucial for optimal management of patients requiring radical cystectomy (RC) for muscle-invasive bladder cancer (MIBC). RC with urinary diversion and lymphadenectomy is the standard treatment for patients with MIBC. Preoperatively, neoadjuvant chemotherapy (NAC) with cisplatin-based combinations improves survival outcomes and is the recommended standard of care for eligible patients. Intraoperatively, lymph node dissection (LND) by, at least, following a standard pelvic lymph node template improves overall- and recurrence-free survival and allows for accurate tumour staging. Avoiding positive soft tissue surgical margins (STSM) should be a main target intraoperatively since they are almost universally associated with mortality. Implementing enhanced recovery after surgery (ERAS) programs can reduce lengths of hospital stay (LOS) and postoperative complication rates without increasing readmission rates after RC. Moreover, several studies have shown that smoking negatively affects local and systemic treatment outcomes in bladder cancer (BC) patients. Therefore, smoking cessation counselling for smokers should be an essential part of bladder cancer management regardless of the disease state. METHODS: We performed a comprehensive, non-systematic review of the latest literature to define indicators representing the best evidence available for optimal care of MIBC patients treated with RC. KEY CONTENT AND FINDINGS: In this review, we propose five major quality indicators that are easily implementable for optimized management of MIBC patients treated with RC, including: usage of cisplatin-based NAC in eligible patients, ensurance of negative STSM, performance of (at least) a standard pelvic template LND, implementation of ERAS strategies, and professional smoking cessation counselling. CONCLUSIONS: Optimal management of MIBC needs to be framed by evidence-based, reproducible, and measurable quality indicators that will allow for guidance and comparative effectiveness assessment of clinical practices; adherence to them is likely to improve patients' prognoses by a tensible margin. For the treatment of MIBC patients with RC, we identified five essential quality indicators. KEYWORDS: Assessment; bladder cancer (BC); muscle-invasive bladder cancer (MIBC); cystectomy; radical cystectomy (RC); quality.

Department of Urology 2nd Faculty of Medicine Charles University Prague Czech Republic

Department of Urology Comprehensive Cancer Center Medical University of Vienna Vienna Austria

Department of Urology King Fahad Specialist Hospital Dammam Saudi Arabia

Department of Urology King Faisal Medical City Abha Saudi Arabia

Department of Urology Luzerner Kantonsspital Lucerne Switzerland

Department of Urology Medical University of Silesia Zabrze Poland

Department of Urology Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences Okayama Japan

Department of Urology The Jikei University School of Medicine Tokyo Japan

Department of Urology University Hospital Zurich Zurich Switzerland

Department of Urology University Medical Center Hamburg Eppendorf Hamburg Germany

Department of Urology University of Texas Southwestern Dallas Texas USA

Department of Urology Weill Cornell Medical College New York New York USA

Division of Urology Department of Special Surgery Jordan University Hospital The University of Jordan Amman Jordan

Institute for Urology and Reproductive Health Sechenov University Moscow Russia

Men's Health and Reproductive Health Research Center Shahid Beheshti University of Medical Sciences Tehran Iran

Research Center for Evidence Based Medicine Tabriz University of Medical Sciences Tabriz Iran

Zobrazit více v PubMed

Siegel RL, Miller KD, Jemal A. Cancer statistics, 2020. CA Cancer J Clin 2020;70:7-30. 10.3322/caac.21590 PubMed DOI

Teoh JY, Huang J, Ko WY, et al. Global Trends of Bladder Cancer Incidence and Mortality, and Their Associations with Tobacco Use and Gross Domestic Product Per Capita. Eur Urol 2020;78:893-906. 10.1016/j.eururo.2020.09.006 PubMed DOI

Putluri N, Shojaie A, Vasu VT, et al. Metabolomic profiling reveals potential markers and bioprocesses altered in bladder cancer progression. Cancer Res 2011;71:7376-86. 10.1158/0008-5472.CAN-11-1154 PubMed DOI PMC

Shariat SF, Kim J, Raptidis G, et al. Association of p53 and p21 expression with clinical outcome in patients with carcinoma in situ of the urinary bladder. Urology 2003;61:1140-5. 10.1016/S0090-4295(03)00236-X PubMed DOI

Svatek RS, Shariat SF, Novara G, et al. Discrepancy between clinical and pathological stage: external validation of the impact on prognosis in an international radical cystectomy cohort. BJU Int 2011;107:898-904. 10.1111/j.1464-410X.2010.09628.x PubMed DOI

Sylvester RJ, Rodríguez O, Hernández V, et al. European Association of Urology (EAU) Prognostic Factor Risk Groups for Non-muscle-invasive Bladder Cancer (NMIBC) Incorporating the WHO 2004/2016 and WHO 1973 Classification Systems for Grade: An Update from the EAU NMIBC Guidelines Panel. Eur Urol 2021;79:480-8. 10.1016/j.eururo.2020.12.033 PubMed DOI

Witjes JA, Bruins HM, Cathomas R, et al. EAU Guidelines on Muscle-invasive and Metastatic Bladder Cancer. Milan: EAU Annual Congress, 2021.

Chang SS, Bochner BH, Chou R, et al. Treatment of Non-Metastatic Muscle-Invasive Bladder Cancer: AUA/ASCO/ASTRO/SUO Guideline. J Urol 2017;198:552-9. 10.1016/j.juro.2017.04.086 PubMed DOI PMC

Babjuk M, Burger M, Compérat E, et al. EAU Guidelines on Non-muscle-invasive Bladder Cancer (TaT1 and CIS). Milan: EAU Annual Congress, 2021.

Chang SS, Boorjian SA, Chou R, et al. Diagnosis and Treatment of Non-Muscle Invasive Bladder Cancer: AUA/SUO Guideline. J Urol 2016;196:1021-9. 10.1016/j.juro.2016.06.049 PubMed DOI

Flaig TW, Spiess PE, Agarwal N, et al. NCCN Guidelines Insights: Bladder Cancer, Version 5.2018. J Natl Compr Canc Netw 2018;16:1041-53. 10.6004/jnccn.2018.0072 PubMed DOI

Leow JJ, Bedke J, Chamie K, et al. SIU-ICUD consultation on bladder cancer: treatment of muscle-invasive bladder cancer. World J Urol 2019;37:61-83. 10.1007/s00345-018-2606-y PubMed DOI

Monteiro LL, Witjes JA, Agarwal PK, et al. ICUD-SIU International Consultation on Bladder Cancer 2017: management of non-muscle invasive bladder cancer. World J Urol 2019;37:51-60. 10.1007/s00345-018-2438-9 PubMed DOI

Groeben C, Koch R, Baunacke M, et al. In-Hospital Outcomes after Radical Cystectomy for Bladder Cancer: Comparing National Trends in the United States and Germany from 2006 to 2014. Urol Int 2019;102:284-92. 10.1159/000496347 PubMed DOI

Hedgepeth RC, Zhang Y, Skolarus TA, et al. Variation in use of lymph node dissection during radical cystectomy for bladder cancer. Urology 2011;77:385-90. 10.1016/j.urology.2010.08.050 PubMed DOI

Novara G, Catto JW, Wilson T, et al. Systematic review and cumulative analysis of perioperative outcomes and complications after robot-assisted radical cystectomy. Eur Urol 2015;67:376-401. 10.1016/j.eururo.2014.12.007 PubMed DOI

Khanna A, Saarela O, Lawson K, et al. Hospital Quality Metrics for Radical Cystectomy: Disease Specific and Correlated to Mortality Outcomes. J Urol 2019;202:490-7. 10.1097/JU.0000000000000282 PubMed DOI

Ehdaie B, Atoria CL, Lowrance WT, et al. Adherence to surveillance guidelines after radical cystectomy: a population-based analysis. Urol Oncol 2014;32:779-84. 10.1016/j.urolonc.2014.01.024 PubMed DOI

Zaffuto E, Bandini M, Gazdovich S, et al. Contemporary rates of adherence to international guidelines for pelvic lymph node dissection in radical cystectomy: a population-based study. World J Urol 2018;36:1417-22. 10.1007/s00345-018-2306-7 PubMed DOI

Schroeck FR, Smith N, Shelton JB. Implementing risk-aligned bladder cancer surveillance care. Urol Oncol 2018;36:257-64. 10.1016/j.urolonc.2017.12.016 PubMed DOI PMC

Ghoneim MA, el-Mekresh MM, el-Baz MA, et al. Radical cystectomy for carcinoma of the bladder: critical evaluation of the results in 1,026 cases. J Urol 1997;158:393-9. 10.1016/S0022-5347(01)64487-2 PubMed DOI

Bassi P, Ferrante GD, Piazza N, et al. Prognostic factors of outcome after radical cystectomy for bladder cancer: a retrospective study of a homogeneous patient cohort. J Urol 1999;161:1494-7. 10.1016/S0022-5347(05)68936-7 PubMed DOI

Dalbagni G, Genega E, Hashibe M, et al. Cystectomy for bladder cancer: a contemporary series. J Urol 2001;165:1111-6. 10.1016/S0022-5347(05)66440-3 PubMed DOI

Stein JP, Skinner DG. Radical cystectomy for invasive bladder cancer: long-term results of a standard procedure. World J Urol 2006;24:296-304. 10.1007/s00345-006-0061-7 PubMed DOI

Mari A, Campi R, Tellini R, et al. Patterns and predictors of recurrence after open radical cystectomy for bladder cancer: a comprehensive review of the literature. World J Urol 2018;36:157-70. 10.1007/s00345-017-2115-4 PubMed DOI PMC

Isbarn H, Jeldres C, Zini L, et al. A population based assessment of perioperative mortality after cystectomy for bladder cancer. J Urol 2009;182:70-7. 10.1016/j.juro.2009.02.120 PubMed DOI

Hanna N, Trinh QD, Seisen T, et al. Effectiveness of Neoadjuvant Chemotherapy for Muscle-invasive Bladder Cancer in the Current Real World Setting in the USA. Eur Urol Oncol 2018;1:83-90. 10.1016/j.euo.2018.03.001 PubMed DOI

Grossman HB, Natale RB, Tangen CM, et al. Neoadjuvant chemotherapy plus cystectomy compared with cystectomy alone for locally advanced bladder cancer. N Engl J Med 2003;349:859-66. 10.1056/NEJMoa022148 PubMed DOI

Yin M, Joshi M, Meijer RP, et al. Neoadjuvant Chemotherapy for Muscle-Invasive Bladder Cancer: A Systematic Review and Two-Step Meta-Analysis. Oncologist 2016;21:708-15. 10.1634/theoncologist.2015-0440 PubMed DOI PMC

Pfister C, Gravis G, Fléchon A, et al. Randomized Phase III Trial of Dose-dense Methotrexate, Vinblastine, Doxorubicin, and Cisplatin, or Gemcitabine and Cisplatin as Perioperative Chemotherapy for Patients with Muscle-invasive Bladder Cancer. Analysis of the GETUG/AFU V05 VESPER Trial Secondary Endpoints: Chemotherapy Toxicity and Pathological Responses. Eur Urol 2021;79:214-21. 10.1016/j.eururo.2020.08.024 PubMed DOI

Necchi A, Anichini A, Raggi D, et al. Pembrolizumab as Neoadjuvant Therapy Before Radical Cystectomy in Patients With Muscle-Invasive Urothelial Bladder Carcinoma (PURE-01): An Open-Label, Single-Arm, Phase II Study. J Clin Oncol 2018;36:3353-60. 10.1200/JCO.18.01148 PubMed DOI

Svatek RS, Shariat SF, Lasky RE, et al. The effectiveness of off-protocol adjuvant chemotherapy for patients with urothelial carcinoma of the urinary bladder. Clin Cancer Res 2010;16:4461-7. 10.1158/1078-0432.CCR-10-0457 PubMed DOI

Bajorin DF, Witjes JA, Gschwend JE, et al. Adjuvant Nivolumab versus Placebo in Muscle-Invasive Urothelial Carcinoma. N Engl J Med 2021;384:2102-14. 10.1056/NEJMoa2034442 PubMed DOI PMC

Lucca I, Rouprêt M, Kluth L, et al. Adjuvant cisplatin-based combined chemotherapy for lymph node (LN)-positive urothelial carcinoma of the bladder (UCB) after radical cystectomy (RC): a retrospective international study of >1500 patients. BJU Int 2015;115:722-7. 10.1111/bju.12829 PubMed DOI

Hong X, Li T, Ling F, et al. Impact of surgical margin status on the outcome of bladder cancer treated by radical cystectomy: a meta-analysis. Oncotarget 2017;8:17258-69. 10.18632/oncotarget.12907 PubMed DOI PMC

Xylinas E, Rink M, Novara G, et al. Predictors of survival in patients with soft tissue surgical margin involvement at radical cystectomy. Ann Surg Oncol 2013;20:1027-34. 10.1245/s10434-012-2708-5 PubMed DOI

Novara G, Svatek RS, Karakiewicz PI, et al. Soft tissue surgical margin status is a powerful predictor of outcomes after radical cystectomy: a multicenter study of more than 4,400 patients. J Urol 2010;183:2165-70. 10.1016/j.juro.2010.02.021 PubMed DOI

Moschini M, Soria F, Mathieu R, et al. Propensity-score-matched comparison of soft tissue surgical margins status between open and robotic-assisted radical cystectomy. Urol Oncol 2019;37:179.e1-7. 10.1016/j.urolonc.2018.10.012 PubMed DOI

Dotan ZA, Kavanagh K, Yossepowitch O, et al. Positive surgical margins in soft tissue following radical cystectomy for bladder cancer and cancer specific survival. J Urol 2007;178:2308-12; discussion 2313. 10.1016/j.juro.2007.08.023 PubMed DOI

Canter D, Guzzo TJ, Resnick MJ, et al. A thorough pelvic lymph node dissection in presence of positive margins associated with better clinical outcomes in radical cystectomy patients. Urology 2009;74:161-5. 10.1016/j.urology.2009.01.024 PubMed DOI

Raj GV, Tal R, Vickers A, et al. Significance of intraoperative ureteral evaluation at radical cystectomy for urothelial cancer. Cancer 2006;107:2167-72. 10.1002/cncr.22238 PubMed DOI

Sari Motlagh R, Mori K, Aydh A, et al. Impact of hospital and surgeon volumes on short-term and long-term outcomes of radical cystectomy. Curr Opin Urol 2020;30:701-10. 10.1097/MOU.0000000000000805 PubMed DOI

Laukhtina E, Rajwa P, Mori K, et al. Accuracy of Frozen Section Analysis of Urethral and Ureteral Margins During Radical Cystectomy for Bladder Cancer: A Systematic Review and Diagnostic Meta-Analysis. Eur Urol Focus 2021. [Epub ahead of print]. doi: .10.1016/j.euf.2021.05.010 PubMed DOI

Stein JP, Lieskovsky G, Cote R, et al. Radical cystectomy in the treatment of invasive bladder cancer: long-term results in 1,054 patients. J Clin Oncol 2001;19:666-75. 10.1200/JCO.2001.19.3.666 PubMed DOI

Horn T, Zahel T, Adt N, et al. Evaluation of Computed Tomography for Lymph Node Staging in Bladder Cancer Prior to Radical Cystectomy. Urol Int 2016;96:51-6. 10.1159/000440889 PubMed DOI

Koppie TM, Vickers AJ, Vora K, et al. Standardization of pelvic lymphadenectomy performed at radical cystectomy: can we establish a minimum number of lymph nodes that should be removed? Cancer 2006;107:2368-74. 10.1002/cncr.22250 PubMed DOI

D'Andrea D, Abufaraj M, Soria F, et al. Association of super-extended lymphadenectomy at radical cystectomy with perioperative complications and re-hospitalization. World J Urol 2020;38:121-8. 10.1007/s00345-019-02769-9 PubMed DOI PMC

Gschwend JE, Heck MM, Lehmann J, et al. Extended Versus Limited Lymph Node Dissection in Bladder Cancer Patients Undergoing Radical Cystectomy: Survival Results from a Prospective, Randomized Trial. Eur Urol 2019;75:604-11. 10.1016/j.eururo.2018.09.047 PubMed DOI

Hollenbeck BK, Ye Z, Wong SL, et al. Hospital lymph node counts and survival after radical cystectomy. Cancer 2008;112:806-12. 10.1002/cncr.23234 PubMed DOI

Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg 2002;183:630-41. 10.1016/S0002-9610(02)00866-8 PubMed DOI

Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997;78:606-17. 10.1093/bja/78.5.606 PubMed DOI

Lemanu DP, Singh PP, Stowers MD, et al. A systematic review to assess cost effectiveness of enhanced recovery after surgery programmes in colorectal surgery. Colorectal Dis 2014;16:338-46. 10.1111/codi.12505 PubMed DOI

Kehlet H, Dahl JB. Anaesthesia, surgery, and challenges in postoperative recovery. Lancet 2003;362:1921-8. 10.1016/S0140-6736(03)14966-5 PubMed DOI

Kehlet H. Fast-track colorectal surgery. Lancet 2008;371:791-3. 10.1016/S0140-6736(08)60357-8 PubMed DOI

Patel HR, Cerantola Y, Valerio M, et al. Enhanced recovery after surgery: are we ready, and can we afford not to implement these pathways for patients undergoing radical cystectomy? Eur Urol 2014;65:263-6. 10.1016/j.eururo.2013.10.011 PubMed DOI

Shabsigh A, Korets R, Vora KC, et al. Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology. Eur Urol 2009;55:164-74. 10.1016/j.eururo.2008.07.031 PubMed DOI

Cerantola Y, Valerio M, Persson B, et al. Guidelines for perioperative care after radical cystectomy for bladder cancer: Enhanced Recovery After Surgery (ERAS(®)) society recommendations. Clin Nutr 2013;32:879-87. 10.1016/j.clnu.2013.09.014 PubMed DOI

Pozo C, Shariat SF, D'Andrea D, et al. Enhanced Recovery after Radical Cystectomy. Curr Opin Urol 2019;29:227-38. 10.1097/MOU.0000000000000594 PubMed DOI

Pang KH, Groves R, Venugopal S, et al. Prospective Implementation of Enhanced Recovery After Surgery Protocols to Radical Cystectomy. Eur Urol 2018;73:363-71. 10.1016/j.eururo.2017.07.031 PubMed DOI

Tyson MD, Chang SS. Enhanced Recovery Pathways Versus Standard Care After Cystectomy: A Meta-analysis of the Effect on Perioperative Outcomes. Eur Urol 2016;70:995-1003. 10.1016/j.eururo.2016.05.031 PubMed DOI PMC

Williams SB, Cumberbatch MGK, Kamat AM, et al. Reporting Radical Cystectomy Outcomes Following Implementation of Enhanced Recovery After Surgery Protocols: A Systematic Review and Individual Patient Data Meta-analysis. Eur Urol 2020;78:719-30. 10.1016/j.eururo.2020.06.039 PubMed DOI

Freedman ND, Silverman DT, Hollenbeck AR, et al. Association between smoking and risk of bladder cancer among men and women. JAMA 2011;306:737-45. 10.1001/jama.2011.1142 PubMed DOI PMC

Kuper H, Boffetta P, Adami HO. Tobacco use and cancer causation: association by tumour type. J Intern Med 2002;252:206-24. 10.1046/j.1365-2796.2002.01022.x PubMed DOI

Gallaway MS, Henley SJ, Steele CB, et al. Surveillance for Cancers Associated with Tobacco Use - United States, 2010-2014. MMWR Surveill Summ 2018;67:1-42. 10.15585/mmwr.ss6712a1 PubMed DOI PMC

Islami F, Goding Sauer A, Miller KD, et al. Proportion and number of cancer cases and deaths attributable to potentially modifiable risk factors in the United States. CA Cancer J Clin 2018;68:31-54. 10.3322/caac.21440 PubMed DOI

Lenis AT, Lec PM, Chamie K, et al. Bladder Cancer: A Review. JAMA 2020;324:1980-91. 10.1001/jama.2020.17598 PubMed DOI

Aveyard P, Adab P, Cheng KK, et al. Does smoking status influence the prognosis of bladder cancer? A systematic review. BJU Int 2002;90:228-39. 10.1046/j.1464-410X.2002.02880.x PubMed DOI

Fleshner N, Garland J, Moadel A, et al. Influence of smoking status on the disease-related outcomes of patients with tobacco-associated superficial transitional cell carcinoma of the bladder. Cancer 1999;86:2337-45. 10.1002/(SICI)1097-0142(19991201)86:11<2337::AID-CNCR23>3.0.CO;2-6 PubMed DOI

Lammers RJ, Witjes WP, Hendricksen K, et al. Smoking status is a risk factor for recurrence after transurethral resection of non-muscle-invasive bladder cancer. Eur Urol 2011;60:713-20. 10.1016/j.eururo.2011.07.010 PubMed DOI

Rink M, Furberg H, Zabor EC, et al. Impact of smoking and smoking cessation on oncologic outcomes in primary non-muscle-invasive bladder cancer. Eur Urol 2013;63:724-32. 10.1016/j.eururo.2012.08.025 PubMed DOI PMC

Crivelli JJ, Xylinas E, Kluth LA, et al. Effect of smoking on outcomes of urothelial carcinoma: a systematic review of the literature. Eur Urol 2014;65:742-54. 10.1016/j.eururo.2013.06.010 PubMed DOI

Cacciamani GE, Ghodoussipour S, Mari A, et al. Association between Smoking Exposure, Neoadjuvant Chemotherapy Response and Survival Outcomes following Radical Cystectomy: Systematic Review and Meta-Analysis. J Urol 2020;204:649-60. 10.1097/JU.0000000000000813 PubMed DOI

Gild P, Vetterlein MW, Seiler R, et al. The association of cigarette smoking and pathological response to neoadjuvant platinum-based chemotherapy in patients undergoing treatment for urinary bladder cancer - A prospective European multicenter observational study of the EAU Young Academic Urologists (YAU) urothelial carcinoma working group. Surg Oncol 2020;34:312-7. 10.1016/j.suronc.2020.06.006 PubMed DOI

Mori K, Mostafaei H, Abufaraj M, et al. Smoking and bladder cancer: review of the recent literature. Curr Opin Urol 2020;30:720-5. 10.1097/MOU.0000000000000697 PubMed DOI

Janisch F, Shariat SF, Schernhammer E, et al. The interaction of gender and smoking on bladder cancer risks. Curr Opin Urol 2019;29:249-55. 10.1097/MOU.0000000000000602 PubMed DOI

Demark-Wahnefried W, Aziz NM, Rowland JH, et al. Riding the crest of the teachable moment: promoting long-term health after the diagnosis of cancer. J Clin Oncol 2005;23:5814-30. 10.1200/JCO.2005.01.230 PubMed DOI PMC

Gritz ER, Fingeret MC, Vidrine DJ, et al. Successes and failures of the teachable moment: smoking cessation in cancer patients. Cancer 2006;106:17-27. 10.1002/cncr.21598 PubMed DOI

Bassett JC, Gore JL, Chi AC, et al. Impact of a bladder cancer diagnosis on smoking behavior. J Clin Oncol 2012;30:1871-8. 10.1200/JCO.2011.36.6518 PubMed DOI

Rink M, Zabor EC, Furberg H, et al. Impact of smoking and smoking cessation on outcomes in bladder cancer patients treated with radical cystectomy. Eur Urol 2013;64:456-64. 10.1016/j.eururo.2012.11.039 PubMed DOI

Rasmussen M, Fernández E, Tønnesen H. Effectiveness of the Gold Standard Programme compared with other smoking cessation interventions in Denmark: a cohort study. BMJ Open 2017;7:e013553. 10.1136/bmjopen-2016-013553 PubMed DOI PMC

Dimick JB, Birkmeyer NJ, Finks JF, et al. Composite measures for profiling hospitals on bariatric surgery performance. JAMA Surg 2014;149:10-6. 10.1001/jamasurg.2013.4109 PubMed DOI PMC