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EAU 2018

EAU 2018: Challenges in Prevention of Bladder Recurrence

Copenhagen, Denmark (UroToday.com) Dr. Baard presented a talk on bladder recurrence and how to prevent it in patients with upper tract urothelial cancer (UTUC). UTUC and bladder involvement:

  • 2-6% bilateral disease
  • 17% have concurrent bladder cancer
  • 22-47% develop intravesical recurrence (IVR) following radical nephroureterectomy (RNU)

Patient’s with low-risk disease are usually not undergoing RNU based on risk stratification, so their risk of IVR is lower. However, there is concern with potential recurrence due to tumor seeding from endoscopic management – Marchioni BJUI 2017 found that patients treated with RNU without prior diagnostic ureteroscopy (dURS) had a 16.7-46% risk of IVR, while those that had prior dURS had a 39.2-60.7% risk of IVR. However, multiple other studies have demonstrated that this does not translate to differences in terms of RFS (non-bladder recurrence), MFS or OS, the more important oncologic outcomes

  • IVR is thought to occur due to two possible mechanisms:
  • Intraluminal seeding – free-floating UTUC seed in the bladder
  • Panurothelial disease – entire urinary tract is at genetic risk of developing disease
Seisen EU 2015 completed a systematic review of factors associated with IVR. They found that beyond patient-specific factors (male gender, prior bladder cancer, CKD), certain tumor specific (positive pre-op cytology, ureteral tumor location, invasive pT stage, necrosis) and treatment specific factors (Laparoscopic RNU, extravesical RNU and positive surgical margins) are associated with IVR. 

In terms of prevention of IVR following dURS, she briefly discussed the theories behind high intrapelvic pressures (due to pressure bags for visualization) leading to IVR. This can be alleviated due by use of access sheaths, which reduce pressure and maybe bypass the bladder – though this is not proven. She also discussed the possibility of using intravesical chemotherapy after dURS, knowing its utility following RNU (O’Brien ODMIT-C trial). 

Her take-home points:

1) Consider dURS on selective basis, only if needed – only if it will change management
2) Kidney sparing surgery when applicable
3) Assess predictors of IVR
4) Respect general endoscopic safety rules
5) Consider single-dose intravesical chemotherapy – though further data is needed


Presented by: J. Baard, Amsterdam, The Netherlands

Written by: Thenappan Chandrasekar, MD Clinical Fellow, University of Toronto, twitter: @tchandra_uromd at the 2018 European Association of Urology Meeting EAU18, 16-20 March, 2018 Copenhagen, Denmark