POD-7.03: Micropapillary Bladder Cancer: Comparison of Outcomes with Up-front Cystectomy and Neoadjuvant Chemotherapy

PODIUM SESSIONS

crease of SAA followed by a decrease on the 7th till 10th post-operative day. Conclusions: These results demonstrated that SAA-1 is a valuable biomarker for prognostic evaluation and monitoring of patients with RCC. There is a correlation with therapy response. Further studies have to show the individual course of SAA-1 after surgery in order to define the value of SAA-1 as a sensitive and specific follow-up marker.

Podium Session POD-7: Bladder Cancer Saturday, November 22 1015-1230 POD-7.01 Laparoscopic Radical Cystectomy: Our Results After 85 Consecutive Patients Castillo O1,2, Vidal I1, Foneron A1, Campos R1, Feria M1 1 Department of Urology, Clinica Indisa, Santiago, Chile; 2Facultad De Medicina, Universidad De Chile, Santiago, Chile Introduction and Objectives: Laparoscopic radical cystectomy (LRC) is considered a controversial surgical technique due the lack of extensive oncology follow-up studies. We present our mid-term results of a series of consecutive patients. Materials and Methods: Eighty-five patients received LRC with intra or extracorporeal urinary diversion between August 2000 and August 2007 using a transperitoneal technique of 5 ports. The laparoscopic surgical technique was assisted in 80 cases and performed completely intracorporeal in 5 cases (Mainz II type derivation). An extensive lymphatic dissection was performed in each case. The surgical technique included radical cistoprostatectomy, cystectomy with preservation of the prostate, anterior exenteration and radical cystectomy with preserving of the uterus depending on the specific indication and surgical approach. Ileal conduit (23), heterotopic reservoir (20) and ortotopic neobladder (42) were used as a urinary diversion. The overall survival and disease associated with were revised in patient records. Results: The average operative time was 283 minutes (180-420). Bleeding average was 460 cc. (150-1500). The average time of follow-up was 23 months (5-38). Seventy-five patients (93%) did not have local recurrence and 46 (57%) survived free of disease. The overall survival rate was 63%. The histopathological study reported tran-

sitional cell carcinoma pT1-4N1-2M0, adenocarcinoma, squamous cell carcinoma, and non-Hodgkin’s lymphoma at 74, 3, 2 and 1 patients, respectively. The average number of nodes in the surgical specimen was 16.8 (8-26). The positive surgical margins were 11% throughout the series. Thirteen patients had positive lymph node disease. Fifteen patients were included in combined treatment protocols. Sixteen patients died of bladder cancer. Intraoperative, perioperative and late complications occurred in 7, 4 and 9 patients, respectively. Conclusions: In our experience, LRC shows acceptable oncological results. Increased number of patients and monitoring are needed to define objectively the current role of this procedure in the treatment of invasive bladder cancer. POD-7.02 Neobladder Reconstruction After Extraperitoneal Ultrasound Assisted Radical Cystectomy: A Report on an Easy Procedure Austoni E1, Colombo F2, Guarneri A2, Cazzaniga A2 1 Department of Urology, Milan University, Milan, Italy; 2Milano Cuore S.Giuseppe Hospital, Milan, Italy Introduction and Objectives: We illustrate our procedure for ileal bladder reconstruction after simplified ultrasound assisted extraperitoneal cystectomy. The technique is easy, with a short surgical time, low complication rates, and entails the construction of a particular singlefolding ileal pouch, combining modified features of Studer’s and Wallace technique (single folding, antiperistaltic ureteral anastomosis). We called it Milano Neobladder. Material and Methods: Between 20042006, 38 patients with bladder cancer underwent extraperitoneal ultrasound-assisted cystectomy, using Ultrcision and “digitoclasic” dissection with a significant decrease of blood loss and surgical time. A 40 cm terminal ileal segment was used to construct the neobladder and the two proximal segments were detubularized for pouch fashioning by a single vertical folding, so as to facilitate descent of the loop into the pelvis. The ureteral anastomosis to the non-detubularized distal ileum segment was performed, as per Studer and Wallace techniques, but our procedure favours the antiperistaltic ureteral anastomosis with the distal ileum segment over Studer’s isoperistaltic anastomosis with the proximal ileum segment, thus avoiding risks of mesenteric torsion while low

UROLOGY 72 (Supplement 5A), November 2008

pressure of the ileal neobladder may prevents reflux. Results: There were two deaths due to metastatic disease. Thirty-six patients were living free from recurrence. Surgery lasted an average of 3 hours and 18 minutes and only 2 patients required blood transfusions. Histology reports the presence of transitional cell carcinoma in all patients. Four patients experienced complications resolved conservatively. Ultrasound and Voiding Cystogram confirmed no refluxes. Continence rate was 92%. Conclusions: Our vertical single-folded ileal neobladder after extraperitoneal ultrasound assisted radical cystectomy seems to be an easy procedure yielding satisfactory outcomes. Longer-term follow-up is required. POD-7.03 Micropapillary Bladder Cancer: Comparison of Outcomes with Upfront Cystectomy and Neoadjuvant Chemotherapy Kamat A, Chiong E, Taylor J, Siefker-Radtke A, Grossman H, Dinney C MD Anderson Cancer Center, Houston, USA Introduction and Objectives: Micropapillary bladder carcinoma (MPBC) is a rare but aggressive variant of urothelial carcinoma. Here, we aim to compare the outcomes of patients with MPBC, who underwent radical cystectomy (RC), with or without neoadjuvant chemotherapy (NC). Materials and Methods: We performed a review of the clinical presentation and outcomes of 75 consecutive patients who underwent RC for surgically resectable (⬍⫽ cT4a) MPBC. Data was analyzed using Fisher exact test or t-test analysis, proportional hazards models and Kaplan– Meier survival analyses. Results: The mean patient age was 65.5 years and mean follow-up was 44.1 months. Stages at initial presentation were Ta: 1, Tis: 1, T1: 21, T2: 45, T3: 5, and T4a: 2 patients. Neoadjuvant chemotherapy (comprising various platinum-based regimens, many on clinical trials), was administered to 32% patients including 75% patients with clinical stage ⬍/⫽T2, and 25% patients with clinical stage ⬎/⫽T3. Overall, there was no difference in survival outcomes. When NC⫹RC group was compared to the RC alone group: median recurrence-free survival was 81.2 vs. 78.7 months (p⫽0.96), median cancer-specific survival was 89.5 vs. 185.5 months (p⫽0.71), and median overall survival was 61.9 vs. 102.5 months (p⫽0.85). Even when patients were strati-

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PODIUM SESSIONS

fied into risk groups based on factors such as clinical stage, lymphovascular invasion and hydronephrosis, survival with RC alone was equal to NC⫹RC. The finding of “pT0” in cystectomy specimens did not confer survival advantage. Conclusions: Radical cystectomy remains the treatment of choice for patients presenting with surgically-resectable MPBC. Existing regimes of neoadjuvant chemotherapy do not seem to provide demonstrable benefit for these patients. POD-7.04 The Role for Radical Cystoprostatectomy in Patients with Clinical T4b Bladder Cancer Kamat A, Black P, Dinney C, Grossman H, Siefker-Radtke A MD Anderson Cancer Center, Houston, USA Introduction and Objectives: Patients with clinical T4b bladder cancer (extension to pelvic wall and/or adjacent organs other than prostate, vagina or uterus) are commonly considered unresectable. We hypothesized that select patients might achieve durable benefit from multiagent chemotherapy and extirpative surgery. Materials and Methods: We identified patients with clinical T4bN0 bladder cancer from our IRB- approved database of patients undergoing radical cystectomy (n ⫽1194). Relevant demographic, clinical and pathologic data were compiled. Overall (OS) disease-specific (DSS) and recurrence-free survival (RFS) were analyzed by Kaplan-Meier estimation. Cox proportional hazards regression modeling was used to evaluate the influence of several potential prognostic factors. Results: Twenty-three patients (17 male) with a median age of 65 years met study criteria. Chemotherapy was administered pre-operatively to 19 (83%) and post-operatively to 8 (35%) patients. Nine patients died of disease and one of other causes. The 1-, 2- and 5-year DSS was 91% (95% C.I. 70-98%), 66% (95% C.I. 42-83%) and 60% (95% C.I. 34-78%), respectively. Nine of 17 patients with pT2-4 tumors succumbed to disease compared to none of 6 who were ⱕ pT1 (p⫽0.04). Other predictors of decreased OS included positive surgical margins (HR⫽5.34, 95% C.I. 1.2522.83) and presence of pathologic nodal metastases (HR⫽29.33, 95% C.I. 3.13275.19). Variant histology was more common in this cohort than in the overall cystectomy database (43% vs. 11%). Conclusions: Long-term survival can be achieved in a proportion of patients with cT4b bladder cancer undergoing chemo-

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therapy and extirpative surgery. Careful selection of patients and meticulous surgical technique to avoid positive margins are critical. POD-7.05 The Role of Prostatic Urethral Biopsy in Counseling Patients Regarding Orthotopic Neobladder Reconstruction Kamat A, Kassouf W, Dinney C, Grossman H, Spiess P MD Anderson Cancer Center, Houston, USA Introduction and Objectives: Preoperative transurethral (TUR) prostatic urethral biopsy has been suggested to be of value in counseling patients on their suitability for orthotopic neobladder reconstruction. We sought to identify if it had value in predicting final distal urethral margin status at radical cystectomy. Materials and Methods: We studied 52 male patients, who underwent ileal neobladder reconstruction, out of 1006 patients undergoing radical cystectomy at our institution between 1990 and 2004. Variable collected include pathology of prostatic urethral biopsies, final pathology of the specimen, frozen section of the distal urethra, final urethral margins, and recurrence and survival data. Results: Of 252 patients, 245 had data regarding preoperative TUR prostatic urethral biopsy and/or frozen section of urethra at time of surgery: 127 patients had TUR of the prostatic urethra alone, 68 had urethral frozen section alone, and 50 had both. The incidence of positive urethral margin on final pathology was 1.1% (3/ 252) and urethral recurrence was 0.7% (2/252). The correlation between TUR findings and frozen section margins was only 68%; 16 patients with positive TUR had negative frozen section margins. The negative predictive value with respect to final margins was 99.4%, using TUR biopsy and 100% using frozen section. Conclusions: Patients with no tumor on TUR biopsy of the prostatic urethra have a high likelihood of negative urethral margins on final pathologic evaluation. However, a positive TUR prostatic urethral biopsy does not correlate with final margin and should not exclude patients from consideration for an orthotopic diversion. Optimal predictive power is obtain by intraoperative frozen section of urethral margin. POD-7.07 Can We Determine the Result of Repeat Transurethral Resection in

Patients with Newly Diagnosed Nonmuscle Invasive Bladder Cancer? Tomaskin R1, Elias B1, Machalekova K2, Slavik P2, Sopilko I1, Kliment J1 1 Department of Urology, Jessenius School of Medicine, Martin, Slovakia; 2Department of Pathology, Jessenius School of Medicine, Martin, Slovakia Introduction and Objectives: To avoid unnecessary repeat transurethral resection (reTUR) we calculated prognostic score to predict positive finding in reTUR specimen with regard to clinical and histopathological features. Materials and Methods: Between 1991 and 2007, a total of 260 consecutive patients (pts) with primary bladder cancer that fitted inclusion criteria designating for reTUR were included in our analysis. ReTUR was performed in 122 pts. The risk score was calculated according to significance of clinical and pathological tumor characteristics. Results: The mean age at operation was 64 years; median follow-up was 48 months. Characteristics of primary tumors were as follows: pTa 15.6%, pT1 70.5% and pTx 17 13.9%, G1 32.8%, G2 32.0%, G3 35.2%, multifocality 1-3 tumors/⬎ 3 tumors 68%/32%, diameter under/over 3 cm 68%/32%. The muscle was found in 65% of specimen, pathologist interpreted 26 of 43 specimens with no unambiguous muscle as pTa-1 (results of reTUR revealed 1 muscle invasive bladder cancer in this subgroup) and 17 tumors remained pTx with 2 cases of pT2 in reTUR. The positive reTUR histology was found in 40.2%. There was non-significant difference in pathological stage, muscle status in primary specimen and use of immediate epirubicin instillation between groups with positive and negative reTUR. The significant difference for grading and unfavourable cystoscopic findings was found in Chi-square test and confirmed in regresion analysis (p ⫽ 0.002 for both parameters). We weighted following parameters (pTa, G1, no unfavourable cystoscopic finding ⫽ 0, pTx, G2 and 1 unfavourable cystoscopic finding ⫽1, pT1 ⫽ 2, G3 ⫽ 3, two unfavourable cystoscopic findings ⫽ 3) and calculated risk score for positive reTUR histology. The incidence of positive histology was 20.6%, 30.2% and 64.4% for risk score 1-2, 3-4 and 5-8 (p ⬍ 0.001) or 26.0% and 64.4% for alternative risk score 1-4, 5-8 (p ⬍ 0.001, OR 5.2). Conclusions: In our cohort, the absence of muscle in TUR specimen was not associated with higher incidence of muscle invasive tumors. Immediate epirubicin instillation did not influence the incidence

UROLOGY 72 (Supplement 5A), November 2008