The EAU’s annual conference is the largest urological event with thousands of healthcare professionals. In a four-day program, lectures, case discussions and debates were presented as well as live surgeries. In addition, speakers from the fields of nursing and patient care also had their say to emphasize the multidisciplinary nature of the field.
The diagnosis and risk stratification of patients with upper tract urothelial carcinoma (UTUC) remains a clinical challenge. A non-invasive urine test capable of detecting UTUC and providing prognostic information has the potential to transform clinical practice. One study investigated the performance of urine comprehensive genomic profiling (uCGP) in a cohort of patients treated for UTUC [1]. For this purpose, 67 urine samples were taken from 54 patients prior to surgical extirpation of UTUC. uCGP was performed using the UroAmp assay (Convergent Genomics), which quantifies somatic tumor mutations from DNA contained in urine. The UroAmp algorithms for disease classification and grade prediction were previously validated for bladder urothelial carcinoma (BLCA) and tested together with an exploratory threshold adapted for UTUC with Lynch syndrome detection. The primary analysis was disease classification versus pathology. Secondary analyses included grade prediction and cytologic classification versus pathology, variant comparison by stage, and variant comparison with de novo pathologically confirmed high-grade (HG) BLCA.
The grade distribution was 95% HG and 5% low grade (LG). The stage distribution was 24% pTa, 18% pT1, 12% pT2, 27% pT3, 4% pT4, 10% pTis, 3% unknown and 2% pT0. uCGP provided unambiguous results for all 67 samples and correctly classified 88% of UTUC patients using the validated BLCA algorithm and 91% using the UTUC-adapted algorithm. The only pT0 sample was correctly classified as cancer-negative. Cytology was performed on 39 samples, yielded clear results in 26 (67%) and correctly classified 62% of the UTUC samples. uCGP correctly classified 100% of atypical cytology results using the UTUC-adapted algorithm. The HG prediction algorithm achieved a prevalence-adjusted PPV of 100%. Invasive tumors (T1-T4) were enriched with TERT, TP53, PIK3CA and CREBBP mutations, while superficial tumors (Ta, Tis) were enriched with KMT2D and STAG2 mutations. The strongest predictors for HG BLCA over HG UTUC were mutations in ERBB2, TERT, ERBB3, ARID1A, PLEKHS1 and copy number gain in SOX4, which was only observed in HG BLCA. These results demonstrate that uCGP can identify genomic features associated with UTUC and provide definitive results in cases of atypical cytology. Unique genomic patterns provide information about the grade and origin of the tumor. Although further studies are needed, these results suggest that uCGP may provide diagnostic and prognostic information for the evaluation of UTUC.
Risk stratification of UTUC after bladder cancer
UTUC recurring after non-muscle invasive bladder cancer (NMIBC) is rare and only known to a limited extent. They usually come from population-based cancer registries or from cohorts with a relatively small number of patients to determine the frequency of upper tract imaging. The aim of one study was to determine the risk factors for UTUC after NMIBC in a large, multi-institutional cohort of patients [2]. Clinicopathologic data were collected from NMIBC patients treated between 2005 and 2022. Patients were excluded if they had a previous or synchronous UTUC at the time of initial diagnosis of NMIBC. Patients received intravesical Bacillus Calmette-Guérin or chemotherapy when indicated. The presence of UTUC was determined by pathologic confirmation or clear upper tract imaging. A multivariable Cox regression was performed to identify unfavorable prognostic factors for UTUC.
A total of 3036 patients were analyzed, including 1281 (42%) at low risk, 556 (18%) at intermediate risk, 1027 (34%) at high risk and 172 (6%) at very high risk, according to the European Association of Urology (EAU) risk groups. The average age was 71 years and 705 (23%) of the patients were female. 1943 (64%) patients had Ta disease, 928 (31%) had T1 disease and 165 (5%) had primary CIS. During a median follow-up of 4.3 years, 62 (2%) patients developed UTUC after NMIBC. The median time to UTUC diagnosis was 2.0 years. In multivariable analyses, only high-grade disease and multiple tumors were associated with an increased risk of UTUC.
Improved functional rehabilitation
The benefits of prehabilitation as a strategy to improve functional recovery and reduce complications have been demonstrated in certain surgical patient groups. The aim of the present study was to evaluate the impact of a multimodal prehabilitation program in patients undergoing robotic-assisted radical prostatectomy (RARP) and to determine whether it is associated with faster recovery of quality of life, better functional outcomes, and less perioperative anxiety and complications [3]. So far, a total of 83 patients have been included in the study – 42 of them with a follow-up period of at least three months. The patients in the pre-HAB group had better scores in almost all components of the HRQoL questionnaires and lower scores on the anxiety and depression scales one month after the operation. Regarding the PC-specific QoL questionnaires, the pre-HAB group had less impact of urinary symptoms and better continence outcomes one month after RARP. In addition, fewer complications occurred in the pre-HAB group in the first 30 days. There were no differences between the groups at other follow-up times (baseline, before surgery or three months after surgery). No differences in physical or erectile function were observed at any time during the follow-up.
Female sexuality after radical cystectomy
Radical cystectomy (RC) is the gold standard in the treatment of muscle-invasive bladder cancer (MIBC). Approximately 25% of all MIBC patients are women. In women, RC also includes the removal of the ovaries, the uterus and the anterior vaginal wall. Extensive pelvic surgery can lead to devascularization of the clitoris and damage to the autonomic and sensory nerves, which may have a significant impact on sexual function. However, sexual function in women after RC has only been studied to a limited extent. A national cross-sectional study and a questionnaire survey were conducted for this purpose [4]. The Danish Cancer Registry (CAR) was used to determine the study population. All living patients diagnosed with bladder cancer between January 2015 and December 2020 were included. Data on gender, age, somatic and psychiatric comorbidities, perioperative and postoperative complications were taken from the Central Person Register (CPR) and the Danish National Patient Register (LPR). Exclusion criteria: Alzheimer’s disease or dementia registered in the LPR. The survey consisted of the following questionnaires: EORTC-QLQ-C30, EORTC-QLQ-NMIBC24 or EORTC-QLQ-BLM30, and EORTC-SHQ22. In addition, eight questions were added specifically on women’s sexual health.
A total of 8289 BC patients were identified, of whom 3933 (47%) responded. Of the 840 women who responded, 151 women who were treated with RC completed the questionnaire. All of them had an ileal conduit ad modum Bricker. The average age was 71. Thirty (21%) women said they were very worried about resuming sexual activity after RC, and 51 (34%) said they were very worried about resuming vaginal intercourse. A change in the perception of vaginal size after RC was reported by 25 (17%) as slight, by 27 (18%) as moderate and by 33 (22%) as very strong. The ability to have an orgasm before RC was reported by 137 (90%). 43 (28%) reported that it took longer for them to orgasm after RC and 62 (41%) had given up trying altogether. Anorgasmia after RC was reported by 23 (26%) of sexually active women. Vaginal intercourse after RC was attempted by 54 (35%) of the women. Pain during and after penetration was reported by 29 (54%) and 23 (43%) in ≥50% of the trials.
Lymph of the prostate at a glance
Extended pelvic lymph node dissection (ePLND) during radical prostatectomy (RP) is the gold standard for lymph node staging in patients with high-risk prostate cancer. Lymphatic drainage of the prostate is complex and poorly understood. The aim of one study was to map lymphatic spread in high-risk prostate cancer by correlating the location of the index tumor (IT) in the prostate with the location of positive lymph nodes after super-extensive PLND (sePLND) [5]. Fifty-six patients with pN1 disease were included, selected from several prospective studies of patients undergoing RP. All patients underwent RP with sePLND at the University Hospitals of Leuven between May 2008 and July 2016. All eligible patients had at least one tumor-involved lymph node on postoperative pathology, but all were cN0M0 on preoperative MRI/CT and bone scan. All IT were assigned to specific areas within the prostate by a specialized pathologist using the PI-RADSv2 scheme. All positive lymph nodes (LN+) were mapped in different anatomical regions of the sePLND template, which consisted of a standard ePLND template and additional presacral and common iliac regions. The position of the IT in the prostate was correlated with the position of the LN+ in the sePLND template.
A median of 27 LNs were removed per patient, with a median of 2 LN+ and 2 regions affected. Apical tumors spread preferentially in the inner, outer, and common iliac regions, with 32%, 27%, and 11% of all LN+ found in these three regions, respectively. In contrast, basal tumors spread preferentially in the obturator fossa and in the presacral region; 36% and 18% of all LN+ were found in these regions, respectively. Tumors in the peripheral zone were most likely to spread to the inner iliac region, accounting for 42% of all LN+. Forty-two (75%) ITs were strictly one-sided. Exclusively ipsilateral spread occurred in 43% and exclusively contralateral LN+ in 19% of patients. Prostate tumors of the apical, basal and peripheral zone have different lymph distribution patterns. Presacral LN dissection is not usually part of an ePLND, but is codominant in basal tumors. Depending on the location of the index tumor, we may consider using a modified PLND template.
Quality of life after penile cancer surgery
There are no large studies on health-related quality of life (HRQOL) and/or studies evaluating the predictors of reduced HRQOL after penile cancer surgery (PeCa). The aim of one study was therefore to compare the HRQOL results of patients who had undergone amputative surgery compared to penis-sparing procedures for the treatment of penile cancer, and at the same time to identify predictors of reduced HRQOL in this patient group [6]. Since 2016, every new PeCa patient has received questionnaires before surgery (baseline) and 3, 6, 12 and 24 months postoperatively. All included patients completed at least the baseline questionnaire and one of the follow-up questionnaires. The patients were divided into two surgical groups: Penis-sparing (local excision, glansectomy) and amputative surgery (partial and total penisectomy). A linear mixed effects model was used to evaluate the predictors for HRQOL.
According to the exclusion criteria, 242 patients were eligible for the analysis. The amputative group (n=137) was older and had more positive sentinel node procedures than the penis-sparing group (n=105). Both groups showed an improvement in HRQOL compared to the baseline value. Both groups were not satisfied with their sex life, although the IIEF-15 is not a specific questionnaire for patients with penile tumors. The mixed model analysis showed that HRQOL values were time-dependent, confirming the postoperative improvement. Predictors of HRQOL scores were general sexual satisfaction, satisfaction with urination, concerns about cancer, masculinity and pain.
Congress: European Association of Urology (EAU)
Literature:
- Pallauf M, et al: Performance of urinary comprehensive genomic profiling in patients with upper tract urothelial carcinoma. A0022. EAU24 – 39th Annual EAU Congress. 05.04.2024.
- Kwong J, et al: Risk of upper tract urothelial carcinoma recurrence following non-muscle invasive bladder cancer: A retrospective, multi-institutional analysis of 3,036 patients. A0100. EAU24 – 39th Annual EAU Congress. 05.04.2024.
- Carbonell E, et al: Multimodal prehabilitation before robotic-assisted radical prostatectomy. A randomized controlled trial. Preliminary results. A0009. EAU24 – 39th Annual EAU Congress. 05.04.2024.
- Milling RV, et al: Female sexual function after radical cystectomy. A0489. EAU24 – 39th Annual EAU Congress. 06.04.2024.
- Decloedt H, et al: Correlation between the location of the index tumor and the location of positive lymph nodes in high-risk prostate cancer – a monocentric positive lymph node mapping study. A0426. EAU24 – 39th Annual EAU Congress. 06.04.2024.
- Vreeburg MTA, et al: Quality of life after penile cancer surgery: Comparison between amputative and penile-sparing surgery. A0338. EAU24 – 39th Annual EAU Congress. 06.04.2024.
InFo ONKOLOGIE & HÄMATOLOGIE 2024; 12(2): 24-25 (published on 15.5.24, ahead of print)