PURPOSE: There is lack of evidence regarding the indication for re-transurethral resection of bladder tumor (reTURBT) for Ta high grade (HG) non-muscle invasive bladder cancer (NMIBC). This study aims to evaluate the oncological outcomes of patients with TaHG NMIBC to determine the benefit from performing reTURBT. METHODS: We relied on a multicenter cohort of 317 TaHG NMIBC from 12 centers who underwent TURBT and a subsequent complete Bacillus Calmette-Guérin induction from 2009 to 2021. Kaplan Meier analyses estimated recurrence free survival (RFS) and progression free survival (PFS) according to reTURBT. Sub-analyses evaluated PFS in patients with multiple risk factors indicating necessity for reTURBT according to international guidelines (multifocality, size > 3 cm, recurrent cancer, carcinoma in situ, lymph vascular invasion, histological variant, incomplete and absence of muscle layer at index TURBT). Multivariable cox-regression analysis predicted recurrence and progression. RESULTS: Of the 317 patients, 123 (39%) underwent reTURBT, while 194 (61%) did not. Residual disease was detected in 46% of cases, with a 3.2% upstaging rate. Median follow-up was 30 months. The 3-year RFS was higher in patients who underwent reTURBT (79% vs. 58%, p < 0.001), but no significant difference was observed in PFS. ReTURBT reduced the risk of recurrence [multivariable hazard ratio: 0.45, 95% Confidence interval (CI) 0.29-0.71]. Among patients who did not undergo reTURBT, those with ≥ 2 risk factors had lower 3-year PFS (73% vs. 92%, p < 0.001) than those with 0-1 risk factor, whereas no difference in 3-year PFS was observed in patients who underwent reTURBT regardless of the number of risk factors (85% vs. 87%, p = 0.8). CONCLUSION: ReTURBT demonstrated efficacy in reducing recurrence among patients with TaHG NMIBC, yet its impact on progression remained uncertain. Our study underscores the importance of adhering to current international guidelines, particularly for patients with multiple risk factors indicating necessity for reTURBT.
- Klíčová slova
- Non muscle invasive bladder cancer, Progression, Re-transurethral resection of bladder tumor, Recurrence, Ta high grade,
- MeSH
- cystektomie * metody MeSH
- invazivní růst nádoru * MeSH
- lidé středního věku MeSH
- lidé MeSH
- lokální recidiva nádoru epidemiologie MeSH
- nádory močového měchýře * chirurgie patologie MeSH
- reoperace MeSH
- retrospektivní studie MeSH
- senioři MeSH
- stupeň nádoru MeSH
- transuretrální resekce močového měchýře MeSH
- uretra MeSH
- výsledek terapie MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- multicentrická studie MeSH
PURPOSE: There is a paucity of long-term objective and patient-reported outcomes after definitive perineal urethrostomy for complex urethral strictures. Our objective is to determine comprehensive long-term success of perineal urethrostomy with our 15-year experience at a reconstructive referral center. MATERIALS AND METHODS: Patients who underwent perineal urethrostomy between 2009 and 2023 were identified. A comprehensive long-term follow-up was conducted, evaluating both objective outcomes (retreatment-free survival) and subjective outcomes through the use of validated questionnaires. Additionally, to provide further context for our findings, we conducted a scoping review of all studies reporting outcomes following perineal urethrostomy. RESULTS: Among 76 patients, 55% had iatrogenic strictures, with 82% previously undergoing urethral interventions. At a median follow-up of 55 months, retreatment-free survival was 84%, with 16% of patients experiencing perineal urethrostomy recurrent stenosis. Patient-reported outcomes revealed a generally satisfactory voiding function (Urethral Stricture Surgery Patient-Reported Outcome Measure Lower Urinary Tract Symptoms score) and continence (International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form), with median scores of 4 (range 0-24) and 0 (range 0-21), but with bimodal distributions of sexual function scores (median International Index of Erectile Function-Erectile Function domain: 3.5; median Male Sexual Health Questionnaire-Ejaculation Scale: 21). Treatment satisfaction was very high with a median International Consultation on Incontinence Questionnaire-Satisfaction outcome score of 21 (range 0-24). The scoping review revealed varying success rates ranging from 51% to 95%, highlighting difficulties in comparison due to variable success definitions and patient case mix. CONCLUSIONS: Perineal urethrostomy provides effective treatment for complex anterior urethral strictures, with high patient satisfaction, preserved continence function, and favorable voiding outcomes. It presents a viable option for older and comorbid patients, especially after thorough counseling on expected outcomes and potential risks.
- Klíčová slova
- anterior urethral stricture, patient-reported outcome measures, perineal urethrostomy, sexual function, treatment satisfaction,
- MeSH
- časové faktory MeSH
- dospělí MeSH
- hodnocení výsledků péče pacientem * MeSH
- lidé středního věku MeSH
- lidé MeSH
- následné studie MeSH
- perineum * chirurgie MeSH
- retrospektivní studie MeSH
- senioři MeSH
- striktura uretry * chirurgie MeSH
- uretra chirurgie MeSH
- urologické chirurgické výkony u mužů metody MeSH
- výsledek terapie MeSH
- zákroky plastické chirurgie metody MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- Publikační typ
- časopisecké články MeSH
- scoping review MeSH
- MeSH
- anastomóza chirurgická škodlivé účinky metody MeSH
- lidé MeSH
- močový měchýř chirurgie MeSH
- striktura uretry * chirurgie MeSH
- uretra * chirurgie MeSH
- urologické chirurgické výkony u mužů metody MeSH
- ústní sliznice * transplantace MeSH
- zákroky plastické chirurgie metody MeSH
- Check Tag
- lidé MeSH
- mužské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- komentáře MeSH
OBJECTIVE: To present long-term experience with buccal mucosa posterior urethroplasty (BMPU) for refractory posterior urethral stenosis (PUS) or vesicourethral anastomosis stenosis (VUAS) either by perineal approach (PA) or by endourethroplasty (EUP). MATERIALS AND METHODS: A single-center retrospective study of 38 consecutive patients operated on between 1999 and 2022. BMPU consisted of the transfer of onlay or tubular buccal mucosa grafts into dilated and/or incised strictures through an open or endourological approach. If VUAS or PUS recurred with short stenosis within the first 12 months after surgery, it was transected by a cold-knife direct vision internal urethrotomy (DVIU), referred to as an "auxiliary" DVIU. The primary outcome was 3-year stricture recurrence-free survival (SRFS). RESULTS: BMPU by perineal approach and EUP were performed in 27 (71%) and 11 (29%) patients, respectively. The 3-year SRFS was 65% for the whole cohort, with rates of 63% for the perineal approach and 73% for endourological approach. With permitted auxiliary DVIU, 3-year SRFS for the whole cohort was 81%. De novo incontinence occurred in 2 out of 18 preoperatively continent patients. Limitations include the retrospective nature of the single-center study and a small, heterogenous cohort of patients. CONCLUSION: We present 2 techniques of substitution urethroplasty with BMG in the management of PUS and VUAS with a low rate of recurrence or de novo incontinence. A novel endourological approach (EUP) is a promising minimally invasive alternative to the perineal approach.
- MeSH
- anastomóza chirurgická * metody škodlivé účinky MeSH
- časové faktory MeSH
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladiství MeSH
- mladý dospělý MeSH
- močový měchýř chirurgie MeSH
- perineum chirurgie MeSH
- retrospektivní studie MeSH
- senioři MeSH
- striktura uretry * chirurgie MeSH
- uretra * chirurgie MeSH
- urologické chirurgické výkony u mužů * metody škodlivé účinky MeSH
- ústní sliznice * transplantace MeSH
- výsledek terapie MeSH
- zákroky plastické chirurgie metody škodlivé účinky MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladiství MeSH
- mladý dospělý MeSH
- mužské pohlaví MeSH
- senioři MeSH
- Publikační typ
- časopisecké články MeSH
BACKGROUND: En bloc resection of bladder tumor (ERBT) is an established surgical treatment method for patients with non-muscle invasive bladder cancer (NMIBC) in tumors less than 3 cm. Data regarding the efficacy and safety of ERBT on larger than 3 cm tumors are sparse and its efficacy compared to conventional transurethral resection (TURBT) remains unclear. The aim of this study was to prospectively compare the feasibility, safety and oncological outcomes of laser (Tm-fiber) ERBT and TURBT in patients with primary bladder lesions ≥3 cm. METHODS: A cohort of 45 patients who underwent surgery for primary NMIBC between February 2018 and March 2022 was collected prospectively. There was no randomization. All procedures were performed by two experienced surgeons. Inclusion criteria were as follows: age >18 years, primary Ta or T1 bladder tumor with a diameter of ≥3 cm, no more than 3 tumors and no history of upper tract urothelial carcinoma. Exclusion criteria were carcinoma in situ or invasion into muscle layer (≥T2). ERBT was performed with thulium fiber laser (IPG, Russia). Primary endpoints included efficacy with recurrence-free survival (RFS) at 3, 6 and 12 months. Secondary endpoints were safety parameters, perioperative data and specimen quality (the presence of muscle layer in specimens). RESULTS: Twenty-eight patients underwent laser ERBT and 17 conventional TURBT. The location and size of the tumors were comparable in both groups. The success rate was 93.3% in the ERBT group with two cases of conversion from ERBT to TURBT. Detrusor muscle was present in 92.8% patients in the ERBT group versus 70.5% in the TURBT group (P=0.04). Obturator nerve reflex was observed only in the TURBT group: 17.6% vs. 0.0% (P=0.02). The frequency of other complications was comparable between the two groups. RFS was not statistically different between the two methods at 3 (93.9% vs. 94.1%, P=0.87), 6 (89.3% vs. 82.3%, P=0.5) and 12 months (89.3% vs. 70.6%, P=0.11). CONCLUSIONS: Laser ERBT is a feasible and safe procedure to manage bladder tumors larger than 3 cm. While it seems safer than TURBT, its effect on efficacy remains to be assessed in larger trials.
- MeSH
- cystektomie * metody MeSH
- laserová terapie * metody škodlivé účinky přístrojové vybavení MeSH
- lidé středního věku MeSH
- lidé MeSH
- nádory močového měchýře * chirurgie patologie radioterapie MeSH
- prospektivní studie MeSH
- senioři MeSH
- studie proveditelnosti MeSH
- tumor burden MeSH
- uretra chirurgie MeSH
- výsledek terapie MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- srovnávací studie MeSH
BACKGROUND: High-level evidence supporting the role of repeat transurethral resection (reTUR) in non-muscle-invasive bladder cancer (NMIBC) is lacking. A randomized controlled trial (RCT) assessing whether immediate reTUR has an impact on patient prognosis is essential. However, since such a RCT will require enrollment of a high number of patients, a preliminary feasibility study is appropriate. OBJECTIVE: To assess the feasibility of an RCT investigating the impact of immediate reTUR + adjuvant bacillus Calmette-Guérin (BCG) versus upfront induction BCG after initial TUR in NMIBC. DESIGN, SETTING, AND PARTICIPANTS: Eligible patients were randomly assigned to receive either reTUR + adjuvant BCG or upfront induction BCG after TUR. Patients with macroscopically completely resected high-grade T1 NMIBC, with or without concomitant carcinoma in situ, and with detrusor muscle (DM) present in the initial TUR specimen were considered eligible for inclusion. Exclusion criteria included lymphovascular invasion (LVI), histological subtypes, hydronephrosis, concomitant upper tract urothelial carcinoma (UTUC), or urothelial carcinoma within the prostatic urethra. The aim was to enroll 30 patients in this feasibility study. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The patient recruitment rate was the primary outcome. Oncological outcomes (recurrence-free and progression-free survival) were secondary endpoints. RESULTS AND LIMITATIONS: Overall, 30 patients (15 per arm) were randomized over a period of 14 mo (August 2020-October 2021). Two eligible patients refused the randomization, resulting in a patient compliance rate of 93.3% for the study protocol. We excluded 49 ineligible patients before randomization because of histological subtypes (n = 16, 33%), LVI (n = 9, 18%), DM absence in the TUR specimen (n = 12, 24%), metastatic disease (n = 5, 10%), concomitant UTUC (n = 3, 6%), or hydronephrosis (n = 4, 8%). At reTUR, persistent disease was found in four patients (29%) and upstaging to muscle-invasive disease in one (7%). Over median follow-up of 17 mo, disease recurrence was detected in three patients (23%) in the reTUR arm and six patients (40%) in the upfront BCG arm. Progression to muscle-invasive disease was observed in one patient treated with upfront BCG. CONCLUSIONS: The feasibility of conducting an RCT comparing upfront BCG versus reTUR + BCG in high-grade T1 NMIBC has been demonstrated. Our results underline the need to screen a large number of patients owing to characteristics meeting the exclusion criteria in a high percentage of cases. PATIENT SUMMARY: We found that a clinical trial of the role of a repeat surgical procedure to remove bladder tumors through the urethra would be feasible among patients with high-grade non-muscle-invasive bladder cancer. These preliminary results may help in refining the role of this repeat procedure for patients in this category.
- Klíčová slova
- Bacillus Calmette-Guérin, High-grade T1 non–muscle-invasive bladder cancer, Randomized controlled trial, Repeat transurethral resection,
- MeSH
- adjuvancia imunologická * terapeutické užití MeSH
- BCG vakcína * terapeutické užití aplikace a dávkování MeSH
- cystektomie metody MeSH
- invazivní růst nádoru * MeSH
- kombinovaná terapie MeSH
- lidé středního věku MeSH
- lidé MeSH
- nádory močového měchýře neinvadující svalovinu MeSH
- nádory močového měchýře * chirurgie patologie farmakoterapie MeSH
- reoperace MeSH
- senioři MeSH
- studie proveditelnosti * MeSH
- uretra MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- randomizované kontrolované studie MeSH
- srovnávací studie MeSH
- Názvy látek
- adjuvancia imunologická * MeSH
- BCG vakcína * MeSH
In recent years, several international urological societies have published guidelines on the diagnosis, treatment, and follow-up of urethral strictures, but a guideline for the German-speaking region has not been available to date. This summary provides a detailed comparison of the guidelines of the European Association of Urology (EAU), American Urological Association (AUA) and the Société Internationale d'Urologie (SIU) with regard to the treatment of anterior urethral strictures, i.e. from the bulbar urethra to the meatus. In the following work, differences and specific recommendations in the guidelines are highlighted. In particular, the three guidelines largely agree with regard to diagnostic workup and follow-up. However, divergences exist in the management of anterior urethral strictures, particularly with regard to the use of endoscopic therapeutic approaches and the use of urethral stents. In addition, the EAU provides more comprehensive and detailed recommendations on urethroplasty techniques and specific patient follow-up. The EAU guidelines are the most current and were the first to include instructions for urethral strictures in women and individuals with gender incongruence after genital approximation surgery. Reconstructive urology is a rapidly evolving specialty and, thus, the clinical approach has been changing accordingly. Although guideline recommendations have become more inclusive and comprehensive, more high-quality data are needed to further improve the level of evidence.
In den letzten Jahren haben verschiedene internationale urologische Fachgesellschaften Leitlinien zur Diagnostik, Behandlung und Nachsorge von Harnröhrenstrikturen veröffentlicht, eine Leitlinie für den deutschsprachigen Raum ist jedoch bis dato nicht verfügbar. Diese Zusammenfassung bietet einen detaillierten Vergleich der Leitlinien der European Association of Urology (EAU), American Urological Association (AUA) und der Société Internationale d’Urologie (SIU) im Hinblick auf die Behandlung anteriorer Harnröhrenstrikturen, also von der bulbären Harnröhre bis zum Meatus urethrae. In der folgenden Arbeit werden Unterschiede und exklusive Empfehlungen in den Leitlinien besonders herausgestellt. Insbesondere in Bezug auf die diagnostische Abklärung und Nachsorge stimmen die drei Leitlinien größtenteils überein. Divergenzen bestehen jedoch beim eigentlichen Management der anterioren Harnröhrenstrikturen, insbesondere in Bezug auf den Einsatz endoskopischer Therapieansätze und die Verwendung von Harnröhren-Stents. Darüber hinaus bietet die EAU umfassendere und detailliertere Empfehlungen zu Urethroplastiktechniken und der spezifischen Nachsorge der Patienten. Die EAU-Leitlinien sind die aktuellsten und die ersten, die Anweisungen für Harnröhrenstrikturen bei Frauen und Personen mit Geschlechtsinkongruenz nach genitalangleichender Operation beinhalten. Die rekonstruktive Urologie ist ein sich rasch weiterentwickelndes Fachgebiet und die klinische Vorgehensweise verändert sich dementsprechend dynamisch. Obwohl die Leitlinienempfehlungen inklusiver und umfassender geworden sind, sind weitere qualitativ hochwertige Daten erforderlich, um das Evidenzniveau weiter zu verbessern.
- Klíčová slova
- Endoscopy, Evidence-based medicine, Hypospadias, Patient-reported outcome measures, Urethroplasty,
- MeSH
- lidé MeSH
- správnost dat MeSH
- striktura uretry * diagnóza MeSH
- uretra chirurgie MeSH
- urologie * MeSH
- zákroky plastické chirurgie * MeSH
- Check Tag
- lidé MeSH
- ženské pohlaví MeSH
- Publikační typ
- anglický abstrakt MeSH
- časopisecké články MeSH
- přehledy MeSH
- Geografické názvy
- Spojené státy americké MeSH
In light of recently published international guidelines concerning the diagnosis, treatment, and aftercare of urethral strictures and stenoses, the objective of this study was to synthesize an overview of guideline recommendations provided by the American Urological Association (AUA, 2023), the Société Internationale d'Urologie (SIU, 2010), and the European Association of Urology (EAU, 2023). The recommendations offered by these three associations, as well as the guidelines addressing urethral trauma from the EAU, AUA, and the Urological Society of India (USI), were assessed in terms of their guidance on posterior urethral stenosis. On the whole, the recommendations from the various guidelines exhibit considerable alignment. However, SIU and EAU place a stronger emphasis on the role of repeated endoscopic treatment compared to AUA. The preferred approach for managing radiation-induced bulbomembranous stenosis remains a subject of debate. Furthermore, endoscopic treatments enhanced with intralesional therapies may potentially serve as a significant treatment modality for addressing even fully obliterated stenoses.
Die vorliegende Arbeit verfolgte das Ziel, angesichts der kürzlich veröffentlichten internationalen Leitlinien zur Diagnose, Therapie und Nachsorge von Harnröhrenstrikturen und -stenosen eine Zusammenfassung der Empfehlungen der American Urological Association (AUA, 2023), der Société Internationale d’Urologie (SIU, 2010) und der European Association of Urology (EAU, 2023) zu erstellen. Die Empfehlungen dieser drei urologischen Gesellschaften sowie die Leitlinien zu Harnröhrentraumata der EAU, AUA und der Urological Society of India (USI) wurden hinsichtlich ihrer Therapiestrategien für posteriore Harnröhrenstenosen ausgewertet. Insgesamt zeigen sich weitgehende Übereinstimmungen in den Empfehlungen der verschiedenen Leitlinien. Im Vergleich zur AUA betonen SIU und EAU jedoch die Bedeutung wiederholter endoskopischer Behandlungen stärker. Die optimale Therapie für strahleninduzierte bulbomembranöse Stenosen bleibt ein kontrovers diskutiertes Thema. Zusätzlich könnten erweiterte endoskopische Behandlungen mit intraläsionalen Therapien eine wichtige Rolle bei der Behandlung von vollständig obliterierten Strikturen spielen.
- Klíčová slova
- Endoscopy, Evidence-based medicine, Pelvic trauma, Stenosis, Urethroplasty,
- MeSH
- endoskopie MeSH
- lidé MeSH
- stenóza diagnóza MeSH
- striktura uretry * diagnóza MeSH
- uretra zranění MeSH
- urologie * MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- anglický abstrakt MeSH
- časopisecké články MeSH
- přehledy MeSH
- Geografické názvy
- Spojené státy americké MeSH
CONTEXT: Repeat transurethral resection (reTUR) is a guideline-recommended treatment strategy in high-risk non-muscle-invasive bladder cancer (NMIBC) patients treated with transurethral resection of bladder tumor (TURBT); however, the impact of recent procedural/technological developments on reTUR outcomes has not been assessed yet. OBJECTIVE: To assess the outcomes of reTUR for NMIBC in the contemporary era, focusing on whether temporal differences and technical advancement, specifically, photodynamic diagnosis and en bloc resection of bladder tumor (ERBT), affect the outcomes. EVIDENCE ACQUISITION: Multiple databases were queried in February 2023 for studies investigating reTUR outcomes, such as residual tumor and/or upstaging rates, its predictive factors, and oncologic outcomes, including recurrence-free (RFS), progression-free (PFS), cancer-specific (CSS), and overall (OS) survival. We synthesized comparative outcomes adjusting for the effect of possible confounders. EVIDENCE SYNTHESIS: Overall, 81 studies were eligible for the meta-analysis. In T1 patients initially treated with conventional TURBT (cTURBT) in the 2010s, the pooled rates of any residual tumors and upstaging on reTUR were 31.4% (95% confidence interval [CI]: 26.0-37.2%) and 2.8% (95% CI: 2.0-3.8%), respectively. Despite a potential publication bias, these rates were significantly lower than those in patients treated in the 1990-2000s (both p < 0.001). ERBT and visual enhancement-guided cTURBT significantly improved any residual tumor rates on reTUR compared with cTURBT based on both matched-cohort and multivariable analyses. Among studies adjusting for the effect of possible confounders, patients who underwent reTUR had better RFS (hazard ratio [HR]: 0.78, 95% CI: 0.62-0.97) and OS (HR: 0.86, 95% CI: 0.81-0.93) than those who did not, while it did not lead to superior PFS (HR: 0.74, 95% CI: 0.47-1.15) and CSS (HR: 0.94, 95% CI: 0.86-1.03). CONCLUSIONS: reTUR is currently recommended for high-risk NMIBC based on the persistent high rates of residual tumors after primary resection. Improvement of resection quality based on checklist applications and recent technical/procedural advancements hold the promise to omit reTUR. PATIENT SUMMARY: Recent endoscopic/procedural developments improve the outcomes of repeat resection for high-risk non-muscle-invasive bladder cancer. Further investigations are urgently needed to clarify the potential impact of the use of these techniques on the need for repeat transurethral resection in the contemporary era.
- Klíčová slova
- En bloc resection, Non–muscle-invasive bladder cancer, Photodynamic diagnosis, Repeat transurethral resection, Transurethral resection of bladder tumor,
- MeSH
- cystektomie * metody MeSH
- invazivní růst nádoru * MeSH
- lidé MeSH
- lokální recidiva nádoru MeSH
- nádory močového měchýře neinvadující svalovinu * patologie chirurgie MeSH
- reoperace * MeSH
- reziduální nádor MeSH
- uretra * chirurgie MeSH
- výsledek terapie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- metaanalýza MeSH
- systematický přehled MeSH
