Muscle-invasive and Metastatic Bladder Cancer

Full Text Guidelines Summary of Changes Scientific Publications & Appendices Pocket Guidelines Archive Panel

2017

New relevant references have been identified through a structured assessment of the literature and incorporated in the various chapters of the 2017 EAU Muscle-invasive and Metastatic Bladder Cancer Guidelines.

Key changes in the 2017 print are:

  • Section 3.2.6 Gender – This section has been expanded with additional data.
  • Section 5.1.4 Urinary cytology and urinary markers – This section has been expanded with additional data.
  • Section 6.2.4 Prognostic markers – A new section has been included.
  • Section 7.4.4.1 Preparations for surgery – A new section on pain management has been included as well as additional data on estimated glomerular filtration rate.
  • Section 7.4.4.2.1 Ureterocutaneostomy – This section has been expanded with additional data.
  • Table 7.6 Management of neobladder morbidity – Additional information has been added.
  • Section 7.8.10 Role of immunotherapy – This is a new section.

 

1.4.2.1    Change in a summary of evidence

7.8.11     Summary of evidence and recommendations for metastatic   disease

Summary of evidence for metastatic disease LE
PD-L1 inhibitor atezolizumab has been FDA approved for patients that have progressed during or after previous platinum-based chemotherapy based on the results of a phase-II trial. 2a

 

2016

All chapters of the 2016 RCC Guidelines have been updated, based on the 2015 version of the guideline.

Conclusions and recommendations have been rephrased and added to, throughout the current document.

Key changes in the 2016 print:

Two new sections have been included based on systematic reviews performed using standard Cochrane SR methodology; http://www.cochranelibrary.com/about/about-cochrane-systematicreviews.html.

  1. What are the oncological and functional outcomes of sexual-function preserving cystectomy compared with standard radical cystectomy in men with bladder cancer? [5].
  2. What are the oncological and functional outcomes of pelvic organ-preserving cystectomy compared with standard radical cystectomy in women with bladder cancer? [6].

Section 7.4.3.3 – Laparoscopic/robotic-assisted laparoscopic cystectomy, has been completely revised.

Changes in Summary of evidence and recommendations:

 3.3.3 Recommendations for the assessment of tumour specimens 

Recommendation GR
Record the number of lymph nodes and number of positive lymph nodes. A*
Record lymphatic or blood vessel invasion.
Record presence of CIS.

*Upgraded following panel consensus.

CIS = carcinoma in situ.

7.4.3.1.1 Summary of evidence and recommendations for sexual sparing techniques in men

Summary of evidence
The majority of patients motivated to preserve their sexual function will benefit from sexual-preserving techniques.
None of the sexual-preserving techniques (prostate/capsule/seminal/nerve sparing) have shown to be superior and no particular technique can be recommended.

 

Recommendations LE GR
Offer sexual-preserving techniques to men motivated to preserve their sexual function since the majority will benefit. 2 B
Select patients based on:• Organ-confined disease;• Absence of any kind of tumour at the level of the prostate, prostatic urethra or bladder neck. 2 A
Do not offer sexual-preserving cystectomy as standard therapy for MIBC. C

MIBC = muscle-invasive bladder cancer.

 7.4.3.2.4 Summary of evidence and recommendations for sexual sparing techniques in women

Summary of evidence
Data regarding pelvic organ-preserving radical cystectomy for female patients remain immature.

 

Recommendations LE GR
Offer sexual-preserving techniques to female patients motivated to preserve their sexual function since the majority will benefit. 3 C
Select patients based on:• Organ-confined disease;• Absence of tumour in bladder neck or urethra. C
Do not offer pelvic organ-preserving radical cystectomy for female patients as standard therapy for MIBC. C

MIBC = muscle-invasive bladder cancer.

 7.4.3.3.1 Summary of evidence and recommendations for laparoscopic/robotic-assisted laparoscopic cystectomy

Summary of evidence LE
RARC has a longer operative time (1-1.5 hours), major costs; but shorter LOS (1-1.5 days) and less blood loss compared to ORC. 1
RARC series suffer from a significant stage selection bias when compared to ORC. 1
Grade 3, 90-day complication rate is lower with RARC. 2
Most endpoints, if reported, including intermediate term oncological endpoint and QoL are not different between RARC and ORC. 2
Surgeons experience and institutional volume are considered the key factors for outcome of both RARC and ORC, not the technique. 2
Recommendations on how to define challenging patients and an experienced RARC surgeon are still under discussion. 3
The use of neobladder after RARC still seems under-utilised, and functional results of intracorporeally constructed neobladders should be studied. 4

 

Recommendations GR
Inform the patient of the advantages and disadvantages of ORC and RARC to select the proper procedure. C
Select experienced centres, not specific techniques, both for RARC and ORC. B
Beware of neobladder under-utilisation and outcome after RARC. C

LOS = length of hospital stay; ORC = open radical cystectomy; QoL = quality of life; RARC = robot-assisted radical cystectomy.

2015

The literature in the complete document has been assessed and updated, whenever relevant.

Key changes for the 2015 publication:

  • Section 7.4.2 on timing and delay of cystectomy was revised.
  • Section 7.4.4.2.5 on orthotopic neobladder; additional information on female patients has been included.
  • A table on the management of neobladder morbidity (Table 7.1) has been included.
  • Section 7.6.4 on multimodality bladder-preserving treatment was completely revised.

Conclusions and recommendations have been rephrased and added to throughout the current document. The sections where changes were made (additional information or a change in the grade of recommendation occurred) can be found below:

 

3.3.3        Recommendations for the assessment of tumour specimens

Mandatory evaluations
Depth of invasion (categories pT2 vs pT3a, pT3b or pT4);
Margins with special attention paid to the radial margin, prostate, ureter, urethra and peritoneal fat and uterus and vaginal top.
Histological subtype, if it has clinical implications;
Extensive lymph node representation (more than nine).
Optional evaluations
Bladder wall blood vessel invasion;
Pattern of muscle invasion.

 

7.2.4        Conclusions and recommendations for neoadjuvant chemotherapy

Conclusions LE
Neoadjuvant chemotherapy has its limitations regarding patient selection, current development of surgical techniques, and current chemotherapy combinations.

 

 7.4.6        Conclusions and recommendations for radical cystectomy and urinary diversion

Conclusions LE
No conclusive evidence exists as to the optimal extent of LND.

LND = lymph node dissection.

 

7.6.2.1     Conclusions and recommendation for external beam radiotherapy

Conclusions LE
External beam radiotherapy alone should only be considered as a therapeutic option when the patient is unfit for cystectomy or a multimodality bladder-preserving approach. 3
Radiotherapy can also be used to stop bleeding from the tumour when local control cannot be achieved by transurethral manipulation due to extensive local tumour growth.

 

Recommendation GR
Radiotherapy alone is not recommended as primary therapy for localised bladder cancer. B

 

 

2014

For this 2014 update, the following changes should be noted:

Chapter 2
Epidemiology and risk factors: The literature has been updated. Section 2.3, Genetic factors, is a new section. The conclusions and recommendations have stayed the same for Chapter 2.

Chapter 3
Classification: The literature has been updated, particularly Section 3.3, with the inclusion of additional morphological subtypes and new information on substaging in node-negative disease after cystectomy.

Chapter 4
Diagnosis and staging: Section 4.1.8, Second resection, was revised. No other changes have been made.

Chapter 6
Neoadjuvant chemotherapy: The literature for this chapter has been updated and the text was reformatted.

Chapter 7
Radical surgery and urinary diversion: All the literature has been updated for this entire chapter. Section 7.1.6, Radical cystectomy, includes the key findings of a finalized systematic review on the extent of lymph node dissection. The literature for Section 7.1.7, Laparoscopic/robotic-assisted laparoscopic cystectomy, has been updated and a new recommendation has been included in favour of open radical cystectomy.

Chapter 8
Non-resectable tumours: This chapter has been condensed. No further changes were made.

Chapter 9
Pre-operative radiotherapy in muscle-invasive bladder cancer: This chapter has been condensed. No further changes were made.

Chapter 11
Adjuvant chemotherapy: The literature has been updated for the entire chapter. The text has been condensed.

Chapter 12
Metastatic disease: The literature for this chapter has been updated and the text has been condensed.

Chapter 14
Follow-up: Additional data has been included. In particular, Section 14.1.1, Local recurrence, and Section 14.1.2, Distant recurrences, have been revisited. A new section on post-cystectomy UTUC recurrences is included.

2013

For this 2013 update, for all updated sections, the literature has been assessed for currency. The following changes should be noted:

Chapter 2
Epidemiology and risk factors: Section 2.2.8 Carcinoma in situ) has been added.

Chapter 3

Classification: Sections 3.3, through 3.3.5 were revisited resulting in slightly adapted recommendations in section 3.3.4 (recommendations for the assessment of tumour specimens). Section 3.3.5 (pT2 substaging in node-negative disease after cystectomy) has been added.
Chapter 4
Diagnosis and staging: Sections 4.2.1.2 (CT imaging for local staging of MIBC), 4.2.2 (Imaging of lymph nodes in MIBC) and 4.2.3 Upper urinary tract urothelial carcinoma) have been added, as well as section 4.2.5 (Future developments).
Chapter 6
Neoadjuvant Chemotherapy: A new section 6.2 (The role of imaging to assess treatment response) has been included. The text has been updated with new literature resulting in amended conclusions and recommendations (section 6.4).
Chapter 7
Radical Surgery and Urinary Diversion: A new section 7.1.4 (MIBC and comorbidity) on co-morbidities and patient selection for orthotopic diversion has been added.
Chapter 12
Metastatic disease: New data has been added, in particular to section 12.3 (Standard first-line chemotherapy for “fit” patients).
Chapter 14
Follow-up: Additional data included on recurrences and secondary urethral tumours.

2012

For all Sections, the literature has been assessed and the guideline updated whenever relevant information was available. Of note are changes in sections:
Chapter 2
Epidemiology and risk factors: Sections 2.2.5 (Bladder Schistosomiasis) and 2.2.6 (Chronic urinary tract infection) have been updated.
Chapter 3
Classification: Section 3.3.2 (Pathologist’ handling of specimens); has been expanded.
Chapter 4
Diagnosis and staging: Section 4.2.1.1 (MR imaging for local staging of invasive bladder cancer); literature was revisited, resulting in amended recommendations.
Chapter 8
Non resectable tumours: A new section 8.3 on Supportive care has been included.Chapter 10
Bladder-sparing treatments for localised disease: Additional supportive evidence for TURB for selected patients has been added. Additional supportive evidence for EBRT monotherapy in highly selected patients. The multimodality bladder-preserving (10.4) treatment section has been expanded; potential benefit will depend on low stage and complete TUR as important prognostic factors.
Chapter 12
Metastatic disease: Section 12.9 (Treatment of bone metastases – bisphosphonates); new literature has been added, resulting in amended recommendations. The available new evidence on quality-of-life.
Chapter 13
has been added.
Chapter 14
Follow up: Additional data included on recurrences and secondary urethral tumours. Also a new follow-up table has been added.

2011

For this 2011 update, the following updates should be noted:
Chapter 1
Introduction
Chapter 2
Epidemiology and risk factors
Chapter 6
Neoadjuvant chemotherapy
Chapter 7
Radical surgery and urinary diversion
Chapter 12
Metastatic disease
Chapter 13
Quality of LifeFor this 2011 update, the following new additions should be noted:Chapter 10
(10.4 Multimodality bladder preserving strategies)Chapter 7 and 12
treatment algorithmsSmaller changes have been made throughout the document.