AUA 2017: Panel Discussion - Clinical Bladder Cancer Quandaries: What to Do Today and in the Future?

Boston, MA (UroToday.com) This was a case based discussion led by Dr. Chang. He presented a case of a 48y male smoker with gross hematuria. Cystoscopy in office shows 2cm papillary tumor x 2. TURBT is complete and without perforation. There are a few erythematous lesions. Dr. Chang asks the panel if they would give Mitomycin C adjuvant in this setting? Dr. Sexton and Steinberg would not, citing a few severe cystitis cases. Dr. Palou would act based on cytology from office cystoscopy (would not give if high grade cytology). Dr. Chang asked if erythema should be biopsied? Dr. Palou would, in addition to prostatic urethra biopsies. Dr. Steinberg would not biopsy prostatic urethra up front, due to unclear benefit and side effects. Continuing with the case, the pathology showed HGT1 with muscle present. +LVI and +CIS. Next steps? Repeat TURBT, induction bcg, or early cystectomy? Dr. Sexton provided thoughtful feedback. If he had ++LUTS, he would personally want cystectomy. The patient decided to Re-TUR, which showed HGT1, and patient elected for induction BCG. At 3 months, how do you evaluate the patient? Office cysto? General anesthesia/TURBT?

Dr. Lee recommends re-staging with TUR. So does Dr. Chang. Dr. Palou and Dr. Steinberg would recommend office cysto/cytology. He undergoes TURBT with bluelight and there are erythematous lesions only visible under bluelight. Cytology is atypical. Path: CIS but no residual T1. Continues bcg. The case was cut short here.

How do you use cytology post-cystectomy? Dr. Sexton uses for UTUC surveillance, and finds it to be anticipatory.
How do you monitor urethral remnant after cystectomy? Dr. Steinberg has found during his career that the prostatic urethra pathology has not been terribly predictive of urethral recurrence, and so will not routinely perform a prophylactic urethrectomy. Postoperatively, he acts only on blood per meatus, and does not survey with urethral washes. Dr. Palou has seen that multifocal NMIBC who underwent cystectomy have higher rates of UT recurrence (13% v 1%), but urethral recurrence is not related. He does perform urethral washes.

Dr. Chang next asked the panel of their practice regarding ureteral margins at cystectomy? Dr. Sexton does but acknowledges the controversy, especially the data that suggest that there is no effect of CIS at margin on DSS or OS. But sequential dissection to achieve negative margin, does prevent UT recurrence, which can be difficult to manage.

Dr. Lee does take margins, but noted the USC experience published in 2016 with very low UT recurrence rates.

Presented by: Sam Chang, MD, MBA Vanderbilt University Medical Center, Juan Palou, MD, PhD, FEBU Fundacio Puigvert. Universitat Autònoma de Barcelona. Barcelona, Gary Steinberg, MD University of Chicago, Cheryl Lee, MD The Ohio State University, Wade Sexton, MD Moffitt Cancer Center

Contributed by: Jed Ferguson, MD/PhD and Ashish Kamat, MD. MD Anderson Cancer Center, Department of Urology.

at the 2017 AUA Annual Meeting - May 12 - 16, 2017 – Boston, Massachusetts, USA

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