EURURO Vol. 71 No. 4

Platinum Priority – Editorial

Referring to the article published on pp. 545–557 of this issue

Facing the Fate of the Remnant Urothelium After Radical

Cystectomy: There Is Room for Improvement

Malte W. Vetterlein, Felix K.-H. Chun, Luis A. Kluth

Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

Despite the curative intent of radical cystectomy (RC) for

patients with muscle-invasive and high-risk non–muscle-

invasive bladder cancer, approximately 32% will suffer from

disease recurrence within 5 yr

[1] ,

which significantly

worsens cancer-specific survival. Secondary urothelial

tumors (SUTs) are relatively rare; hence, for this subgroup

of patients, there is a lack of valid evidence to aid in

implementing adequate risk prediction tools, defining

standardized follow-up protocols, and determining optimal

treatment strategies. The principal problem is not the

number of patients presenting with SUTs, but the severity

and progression of this particular subentity, which eventu-

ally leads to fatal outcomes.

When presenting with recurrent cancer, patients can be

stratified into those for whom there are still potentially

curative treatment strategies available (ie, noninvasive or

early invasive SUT of the upper urinary tract or the urethra)

and those with distant metastases for whom palliative

protocols might be more suitable. From a clinical perspec-

tive, several landmarks after RC are of great importance and

may influence the patient’s ultimate fate. First, patient

counseling after RC has to incorporate recommendations

for regular follow-up. Therefore, we need evidence-based

risk assessment relying on easily accessible clinicopatho-

logic characteristics after surgery, which may predict the

probability of developing potentially treatable SUT. Sec-

ond, after identifying patients at the highest risk, stan-

dardized follow-up protocols are mandatory to diagnose

recurrences at the earliest possible (asymptomatic) stage.

Third, when SUT is diagnosed, substantiated treatment

strategies aimed at the best oncologic outcome are

necessary in each case.

In this issue of

European Urology

, Gakis et a.

[2]

present a

meticulous systematic review on the risk factors, incidence,

outcomes, and different treatment strategies for SUT after

RC with the aim of finally facing the fate of the remnant

urothelium, providing comprehensive evidence on how to

deal with this open question. As ‘‘fate’’ implies a certain

helplessness and surrender, this work may provide a basis

for overcoming some arbitrariness and surging ahead with

profound evidence-based concepts. The authors should be

applauded for putting a great deal of effort into summariz-

ing the literature and shedding some light on a clinically

relevant scenario. What can we deduce from the current

findings and how do we translate these into clinical

practice?

It is noteworthy that risk factors are quite similar for

both upper urinary tract and urethral SUT. The authors

conclude that the risk factors identified may be a

reflection of two theoretical concepts: (1) a lower risk of

cancer-specific mortality for certain tumor stages (non–

muscle-invasive disease, pN0 status, low-grade tumors)

and thus a potential for development of subsequent SUT

during intermediate- to long-term follow-up; and (2) the

tumor-specific nature of panurothelial spread (carcinoma in

situ, tumor multifocality, prior upper urinary tract tumors,

and positive ureteral/urethral margins at permanent

section). Intriguingly, there is evidence that the number

of risk factors directly correlates with SUT of the upper tract

(8.4% for patients with 1–2 risk factors; and 13.5% for

patients with 3–4 risk factors

[3]

). In this context, the next

step to take is quite obvious; future research should focus

on the development of accurate prediction tools to estimate

the individual risk of SUT in the individual patient. Along

E U R O P E A N U R O L O G Y 7 1 ( 2 0 1 7 ) 5 5 8 – 5 5 9

available at

www.scienced irect.com

journal homepage:

www.europeanurology.com

DOI of original article:

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

* Corresponding author. Department of Urology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany.

Tel. +49 160 97734488; Fax: +49 40 741042444.

E-mail address:

L.Kluth@uke.de

(L.A. Kluth).

http://dx.doi.org/10.1016/j.eururo.2016.11.016

0302-2838/