Urethral Surveillance after Radical Cystectomy

T. Burnhope, M. Kitchen, A. Chakravarti, D. Mak, I. Wharton, West Midlands Urology Research Collaborative
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Abstract

Radical cystectomy (RC) is commonly performed with curative intent for primary or recurrent high-risk non-muscle-invasive and muscle-invasive bladder cancers. Urethral recurrence (UR) within the residual urethra, often proximally where the epithelial lining comprises urothelial cells, is a rare but well-described occurrence associated with adverse clinical outcomes. Current national guidelines therefore suggest that male patients with a defunctioned urethra should undergo annual endoscopic or urethral washing surveillance for 5 years following RC, to identify UR early, where local disease management (e.g., urethrectomy) may still be possible. Anecdotally, however, urethroscopy and urethral washing cytology appear to be infrequently performed. Our regional trainee-led research collaborative evaluated the frequency and tim-ing of urethral surveillance in the West Midlands in comparison to National Institute for Health and Care Excellence (NICE) guidelines. Patients and methodsOur 10-year cross-sectional retrospective regional analysis included 495 patients from 2008–2018. Clinical and demographic data were collected alongside cross-sectional staging and imaging, and timings and frequency of urethral endoscopic surveillance or urethral washing cytology. ResultsOverall, 159 (35.2%) patients received one (or more) surveillance urethroscopy. A minority of surveillance urethroscopies were annual, with hugely variable frequency or intervals ranging from every 4–50 months. Only 81 (19.6%) patients had urethral surveillance in keeping with the frequency suggested by NICE guidelines. At 10 years, disease-specific mortality was 42.0%, and overall or all-cause mortality was 44.7%. The overall UR rate (as detected by staging CT and/or urethroscopy) was 1.0% (n = 4); all four cases of UR were found in patients with positive urethral margins after RC who did not undergo immediate urethrectomy. ConclusionsOur regional urethral surveillance practice following RC is heterogeneous and suboptimal in comparison to NICE guidelines. Our UR rate was so low that we are unable to assert whether early detection has any clinical benefit, and therefore we cannot advocate routine urethral surveillance, but suggest that patients with positive urethral margins should be offered immediate urethrectomy post RC. In addition, we encourage collaborative urological research and data collection to generate higher volume series, more representative and generalisable data, and more meaningful conclusions.
根治性膀胱切除术后尿道监测
根治性膀胱切除术(RC)通常用于原发性或复发的高风险非肌浸润性和肌浸润性膀胱癌。残留尿道内的尿道复发(UR),通常发生在上皮上皮细胞组成的近端,是一种罕见但描述良好的与不良临床结果相关的发生。因此,目前的国家指南建议,尿道功能障碍的男性患者应在尿道切除术后5年内每年接受内镜或尿道冲洗监测,以早期发现尿路,在局部疾病治疗(如尿道切除术)仍有可能的情况下。然而,有趣的是,尿道镜检查和尿道冲洗细胞学检查似乎很少进行。我们的区域培训生领导的研究合作评估了尿道口监测的频率和时间在西米德兰兹郡与国家健康和护理卓越研究所(NICE)的指导方针进行比较。患者和方法我们对2008-2018年的495例患者进行了10年的横断面回顾性区域分析。临床和人口统计数据与横断面分期和成像、尿道内窥镜检查或尿道冲洗细胞学检查的时间和频率一起收集。结果159例(35.2%)患者接受了一次(或多次)尿道镜检查。少数尿道镜检查每年进行一次,频率或间隔变化很大,从每4-50个月不等。只有81例(19.6%)患者进行了符合NICE指南建议频率的尿道监测。10年时,疾病特异性死亡率为42.0%,总体或全因死亡率为44.7%。总UR率(通过分期CT和/或尿道镜检查)为1.0% (n = 4);所有4例尿路均发生在尿道边缘呈阳性且未立即行尿道切除术的患者中。结论与NICE指南相比,RC术后区域尿道监测实践存在异质性和次优性。我们的尿路发生率很低,因此我们不能断言早期发现是否有任何临床益处,因此我们不能提倡常规尿道监测,但建议尿道边缘呈阳性的患者在RC后应立即行尿道切除术。此外,我们鼓励合作泌尿学研究和数据收集,以产生更大的体积系列,更具代表性和普遍性的数据,和更有意义的结论。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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