21 April 2012

The second plenary session in the 9th Meeting of the EAU Section of Oncological Urology (ESOU) which opened in Hamburg, Germany, yesterday tackled issues in bladder cancer, particularly in non-muscle invasive disease, in three debate sessions that covered cystoscopy techniques, medical therapy and cystectomy.

Professors P. Malmstrom (SE) and ESOU Chairman Maurizio Brausi (IT) debated on the EAU Guidelines on bladder cancer with focus on maintenance Bacillus Calmette-Guerin (BCG), with Malstrom defending the guidelines and Brausi arguing against maintenance BCG. The second debate tackled white or blue light cystoscopy, with Theo De Reijke (NL) and Tim O’Brien (UK) taking opposing views. In the last debate Markus Kuczyk argued against R, Sanchez-Salas (FR) with Salas fielding pro arguments in favor of prostate-sparing cystectomy and Kuczyk defending his views on radical cystectomy in high grade tumors.

In the first debate, Malmstrom argued  that BCG remains the most effective intravesical treatment in NMIBC although controversies remain such as the issue of maintenance BCG. He cited two meta-analyses which showed that BCG was superior to mitomycin-C in preventing recurrences only in the trials with maintenance BCG.

“It is now evident that immunotherapy in the form of BCG has to be given longer than just an induction course to have maximal benefit,“ said Malmstrom and added that as for instillation therapy the role of progression/survival is difficult if not impossible to analyse properly, He also noted that toxicity has become less of a problem today, and underscored that the optimal duration o f maintenance is not known  and deserves further study,

For his part, Brausi made the following points:

  • BCG with maintenance is the best treatment for preventing recurrence in intermediate and high-risk NMIBC;
  • There is no difference in progression between maintenance and no-maintenance BCG therapy;
  • Patients who recur after B CG induction course can be re-treated by a second-cycle rather than exposing all patients to toxicity associated with maintenance;
  • Prospective, randomized study is needed to solve this dilemma (maintenance vs. no maintenance BCG), and, finally;
  • The quality of first TUR plays again a major role on the results.

In the second debate De Rijke argued that photodynamic diagnosis (PDD) added to the TURB resulted in decreased recurrence rate in those centres were standard re-section was performed. “What is important of course is if better resection results in reduction in recurrence rates and eventually in reduced progression rates,” said De Rijke, as he added that the data on this point is scarce. However, he noted that recent studies have shown that fewer recurrences are seen when TURB is combined with PDD.

De Rijke also said that although PDD has higher costs, the technique in the long-term reduces recurrence rates which eventually leads to a cost reduction.

“For the time being, the indications for applying PDD are patients with positive cytology and negative cystoscopy, the follow-up of high-risk patients  and in performing TURB in order to perform a more complete TURB,” added De Rijke.

In his rebuttal, O’Brien said three issues have to be answered regarding the use of blue light cystoscopy, namely: How good is the evidence? Is blue cystoscopy simply a training tool? Does it costs too much?

“The reported studies mix new and recurrent tumours; histological endpoints are used in recurrence; studies with very positive end results are re-reported,” said O’Brien as he stressed that all these issues have led to confusion about the true effect of blue light. He added that in his own hospital experience his department spent the most money in 2010 on blue light at the cost of around 50,000 euros.

“The technique should not be used for every bladder tumor cystoscopy,” he said. “There should be a selective use in those with multimodal tumors; large non-muscle invasive tumors and in situations where urine cytology is positive but white light cystoscopy is negative.”

In the last debate on NMIBC, Sanchez-Salas said that prostate-sparing cystectomy is very critical and is indicated for pT1 high-grade tumors and solotary pT2 urothelial cancer (with no multimodal CIS and bladder neck involvement). He also said that prostate TCC and prostate cancer must be ruled out. “Moreover, oncological and functional outcomes must be accurately balanced,” he said, reiterating that the approach is “not for all but an option for some (highly selected) patients.”

On the other hand, Kucyk voiced his opposition to prostate-sparing cystectomy saying that radical cystoprostatectomy is oncologically safe. “This approach reveals good functional results and has acceptable morbidity and mortality,” he said.

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