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Natural history of positive urinary cytology after radical cystectomy
H.B. Grossman / Urologic Oncology: Seminars and Original Investigations 25 (2007) 271–280
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0.68, P ⬍ .002), African American race (OR 0.43, P ⫽ .003), and higher comorbidity index (OR 0.71, P ⫽ .03), and directly associated with male sex (OR 1.45, P ⫽ .002), higher education level (OR 1.54, P ⫽ .03), and year of surgery (OR ⬎ or ⫽ 1.56, P ⬍ .001 for all year categories vs. 1992–1994). Treatment at academic (OR 1.43, P ⫽ .003) and NCI-designated cancer centers (OR 5.50, P ⬍ .001) and by high-volume providers (OR 1.49, P ⬍ .001) was independently associated with continent reconstruction. Conclusions: Disparities in the utilization of continent urinary diversion after radical cystectomy suggest that demographic, socioeconomic, provider-based, and clinical variables predict the likelihood that those undergoing radical cystectomy will receive continent reconstruction. Regionalization of bladder cancer care may ameliorate many of the disparities noted but must be balanced against the risk imposed by a delay in care.
Commentary Evaluation of the Surveillance, Epidemiology, and End Results national cancer registry and Medicare claims for 1992 through 2000 document significant variation in the methods of urinary diversion after radical cystectomy. Older individuals, African-Americans, women, and those with higher comorbidity were significantly less likely to receive a continent diversion. Patients treated at academic centers or by high-volume providers were more likely to have a continent diversion. The rates of continent diversion increased with more recent times. This snapshot shows that continent diversions are being used more frequently than in the past. Whether this trend will persist and decrease the unevenness in the application of continent urinary diversion remains to be seen. doi:10.1016/j.urolonc.2007.03.003 H. Barton Grossman, M.D. Natural history of positive urinary cytology after radical cystectomy. Raj GV, Bochner BH, Serio AM, Vickers A, Donat SM, Herr H, Lin O, Dalbagni G, Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY. J Urol 2006;176:2000 –5 Purpose: The natural history and risk of disease progression in patients with positive urine cytology after radical cystectomy for urothelial carcinoma has not been adequately elucidated. Materials and Methods: An institutional review board approved, retrospective review in patients undergoing radical cystectomy was performed to identify those with positive urinary cytology after radical cystectomy. Cox proportional hazards regression was used to determine factors associated with positive cytology after radical cystectomy and upper tract recurrence after positive cytology. Survival curves and probabilities were examined by Kaplan-Meier analysis. Results: A total of 101 patients with at least a single positive urinary cytology result after radical cystectomy were identified. Ureteral involvement in the radical cystectomy specimen was significantly associated with subsequent positive cytology. At the first positive urinary cytology only 9 of 101 patients (9%) had documented urothelial recurrence but eventually 57 of 101 had radiographic evidence of urothelial recurrence. Median freedom from radiological evidence of urothelial recurrence after positive cytology was 2.1 years and ureteral involvement was associated with a higher likelihood of urothelial recurrence. Despite surgical and chemotherapeutic interventions median survival after urothelial recurrence was 2.1 years. Conclusions: Urine cytology may have a valuable role for detecting upper tract recurrence after radical cystectomy. Most patients with positive cytology after radical cystectomy eventually have radiological evidence of urothelial recurrence. These data may help clarify natural history in patients with positive cytology after radical cystectomy. Additionally, these data indicate the need for diligent evaluation for recurrent disease and potentially the role of early adjuvant therapy in patients with positive cytology after radical cystectomy.
Commentary Patients with bladder cancer are at risk for recurrence in the upper tract. This retrospective review examined the ability of urine cytology to detect upper tract disease after radical cystectomy. Of 1,408 patients who had at least 1 urine cytology after radical cystectomy, 101 (7.2%) had at least 1 positive test. Of them, 40% had a positive cytology within 1 year of the cystectomy. The rates of continent and loop urinary diversions in these patients were almost equal. A history of ureteral involvement was strongly associated with a positive cytology, and positive cytology was predictive of upper tract recurrence. However, only 9% of the patients with a positive cytology were found to have a recurrence at the first positive cytology. The median time to recurrence after positive cytology was 2.1 years. Of the 101 patients with a positive cytology, 57 were found to have recurrent urothelial cancer. Urine cytology can be used to monitor patients after radical cystectomy. Patients with positive cytology after radical cystectomy need careful assessment of their upper tracts and close monitoring for recurrence. doi:10.1016/j.urolonc.2007.03.005 H. Barton Grossman, M.D.
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0.68, P ⬍ .002), African American race (OR 0.43, P ⫽ .003), and higher comorbidity index (OR 0.71, P ⫽ .03), and directly associated with male sex (OR 1.45, P ⫽ .002), higher education level (OR 1.54, P ⫽ .03), and year of surgery (OR ⬎ or ⫽ 1.56, P ⬍ .001 for all year categories vs. 1992–1994). Treatment at academic (OR 1.43, P ⫽ .003) and NCI-designated cancer centers (OR 5.50, P ⬍ .001) and by high-volume providers (OR 1.49, P ⬍ .001) was independently associated with continent reconstruction. Conclusions: Disparities in the utilization of continent urinary diversion after radical cystectomy suggest that demographic, socioeconomic, provider-based, and clinical variables predict the likelihood that those undergoing radical cystectomy will receive continent reconstruction. Regionalization of bladder cancer care may ameliorate many of the disparities noted but must be balanced against the risk imposed by a delay in care.
Commentary Evaluation of the Surveillance, Epidemiology, and End Results national cancer registry and Medicare claims for 1992 through 2000 document significant variation in the methods of urinary diversion after radical cystectomy. Older individuals, African-Americans, women, and those with higher comorbidity were significantly less likely to receive a continent diversion. Patients treated at academic centers or by high-volume providers were more likely to have a continent diversion. The rates of continent diversion increased with more recent times. This snapshot shows that continent diversions are being used more frequently than in the past. Whether this trend will persist and decrease the unevenness in the application of continent urinary diversion remains to be seen. doi:10.1016/j.urolonc.2007.03.003 H. Barton Grossman, M.D. Natural history of positive urinary cytology after radical cystectomy. Raj GV, Bochner BH, Serio AM, Vickers A, Donat SM, Herr H, Lin O, Dalbagni G, Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY. J Urol 2006;176:2000 –5 Purpose: The natural history and risk of disease progression in patients with positive urine cytology after radical cystectomy for urothelial carcinoma has not been adequately elucidated. Materials and Methods: An institutional review board approved, retrospective review in patients undergoing radical cystectomy was performed to identify those with positive urinary cytology after radical cystectomy. Cox proportional hazards regression was used to determine factors associated with positive cytology after radical cystectomy and upper tract recurrence after positive cytology. Survival curves and probabilities were examined by Kaplan-Meier analysis. Results: A total of 101 patients with at least a single positive urinary cytology result after radical cystectomy were identified. Ureteral involvement in the radical cystectomy specimen was significantly associated with subsequent positive cytology. At the first positive urinary cytology only 9 of 101 patients (9%) had documented urothelial recurrence but eventually 57 of 101 had radiographic evidence of urothelial recurrence. Median freedom from radiological evidence of urothelial recurrence after positive cytology was 2.1 years and ureteral involvement was associated with a higher likelihood of urothelial recurrence. Despite surgical and chemotherapeutic interventions median survival after urothelial recurrence was 2.1 years. Conclusions: Urine cytology may have a valuable role for detecting upper tract recurrence after radical cystectomy. Most patients with positive cytology after radical cystectomy eventually have radiological evidence of urothelial recurrence. These data may help clarify natural history in patients with positive cytology after radical cystectomy. Additionally, these data indicate the need for diligent evaluation for recurrent disease and potentially the role of early adjuvant therapy in patients with positive cytology after radical cystectomy.
Commentary Patients with bladder cancer are at risk for recurrence in the upper tract. This retrospective review examined the ability of urine cytology to detect upper tract disease after radical cystectomy. Of 1,408 patients who had at least 1 urine cytology after radical cystectomy, 101 (7.2%) had at least 1 positive test. Of them, 40% had a positive cytology within 1 year of the cystectomy. The rates of continent and loop urinary diversions in these patients were almost equal. A history of ureteral involvement was strongly associated with a positive cytology, and positive cytology was predictive of upper tract recurrence. However, only 9% of the patients with a positive cytology were found to have a recurrence at the first positive cytology. The median time to recurrence after positive cytology was 2.1 years. Of the 101 patients with a positive cytology, 57 were found to have recurrent urothelial cancer. Urine cytology can be used to monitor patients after radical cystectomy. Patients with positive cytology after radical cystectomy need careful assessment of their upper tracts and close monitoring for recurrence. doi:10.1016/j.urolonc.2007.03.005 H. Barton Grossman, M.D.