EURURO Vol. 71 No. 4

Platinum Priority – Collaborative Review – Urothelial Cancer

Editorial by Malte W. Vetterlein, Felix K.-H. Chun and Luis A. Kluth on pp. 558–559 of this issue

Systematic Review on the Fate of the Remnant Urothelium

after Radical Cystectomy

Georgios Gakis

a , * ,

Peter C. Black

b ,

Bernard H. Bochner

c ,

Stephen A. Boorjian

d ,

Arnulf Stenzl

a ,

George N. Thalmann

e ,

Wassim Kassouf

Department of Urology, Eberhard-Karls University of Tu¨bingen, Germany;

Department of Urologic Sciences, University of British Columbia, Vancouver, BC,

Canada;

Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA;

Department of Urology, Mayo Clinic,

Rochester, MN, USA;

Department of Urology, Inselspital Bern, University of Bern, Switzerland;

Division of Urology, McGill University, Montreal, QC, Canada

E U R O P E A N U R O L O G Y 7 1 ( 2 0 1 7 ) 5 4 5 – 5 5 7

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Article info

Article history:

Accepted September 22, 2016

Associate Editor:

Giacomo Novara

Keywords:

Bladder cancer

Radical cystectomy

Recurrence

Remnant

Upper urinary tract

Urethra

Urothelium

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Abstract

Context:

Urothelial carcinoma is considered a pan-urothelial disease. As such, the

remnant urothelium in the upper urinary tract and urethra following radical cystectomy

(RC) remains at risk for secondary urothelial tumors (SUTs).

Objective:

To describe the incidence, diagnosis, treatment, and outcomes of patients

with SUTs after RC.

Evidence acquisition:

A systematic search was conducted using PubMed database

according to Preferred Reporting Items for Systematic Reviews and Meta-analyses

guidelines to identify studies between 1970 and 2016 reporting on malignant diseases

of the urothelium after RC for bladder cancer. The search strategy separated between

upper and lower tract urothelial tumors.

Evidence synthesis:

Of a total of 1069 studies, 57 were considered for evidence synthesis.

SUTs occured in approximately 4–10% of patients after RC. Carcinoma in situ of the

bladder, a history of nonmuscle invasive bladder cancer, and tumor involvement of

[79_TD$DIFF]

the

distal ureter are the strongest risk factors for secondary upper tract tumors. Risk factors

for secondary urethral tumors represent urothelial malignancy in the prostatic urethra/

prostate and bladder neck (in women), nonorthotopic diversions, and positive findings on

permanent sections. The majority of patients (84%) with SUTs, presented with urothelial

recurrence without evidence of metastasis. Of those, 84.0% were treated with surgery,

10.5% with systemic chemotherapy and/or radiotherapy, and 5.6% with topical chemo-

therapy and/or immunotherapy. After a median follow-up of 91 mo (range: 26–155),

65.9% of patients died of disease and 21.5% died of other causes. Detection and treatment

of SUTs at an asymptomatic stage can reduce the risks of cancer-specfific and overall

mortality by 30%. A limitation of the study is that the available data were retrospective.

Conclusions:

SUTs are rare oncological events and most patients have an adverse

prognosis despite absence of distant disease at diagnosis. Therefore, surveillance of

the remnant urothelium should be implemented for patients with histological features

of panurothelial disease as it may improve timely detection and treatment.

Patient summary:

Secondary tumors of the renal pelvis, ureters, and urethra occur in

approximately 4–10% of patients after radical removal of the bladder for bladder cancer.

These patients’ prognoses are reduced, likely due to delayed diagnosis. Therefore,

routine surveillance might be important to detect tumors at an early stage.

* Corresponding author. Department of Urology, University Hospital Tu¨ bingen, Eberhard-Karls

University of Tu¨ bingen, Hoppe-Seyler Strasse 3, Tu¨ bingen D-72076, Germany.

Tel. +49-7071-2985092; Fax: +49-7071-295092.

E-mail address:

georgios.gakis@med.uni-tuebingen.de

(G. Gakis).

http://dx.doi.org/10.1016/j.eururo.2016.09.035

0302-2838/