Innovations in Non-Muscle Invasive Bladder Cancer

Full steam ahead on the fourth day of EAU16. Following the morning’s Plenary Session on ageing and the lower urinary tract, Thematic Session 13 addressed non-muscle invasive bladder cancer (NIMBC) through several hot-topic and state-of-the-art lectures.

Dr. Gianluca Giannarini (IT) spoke on evidence-based upper urinary tract (UUT) surveillance in patients with bladder cancer, or rather, the lack thereof.

“In terms of the evidence base, we only have retrospective, non-comparative, non-controlled cohort studies at our disposal,” he said. “There have been a few surveillance protocols for UUT, but these are diverse, non-validated and mainly stage-adapted.”

“We therefore have no high-grade recommendations on whom to monitor, how to monitor, how often of for how long patients should be monitored for upper tract urothelial carcinoma (UTUC).”

Giannarini concluded his Hot Topic Lecture with some directions for next steps: “The risk of upper tract urothelial carcinoma in bladder cancer patients is a lifelong constant, and high-grade recommendations as to schedule, intensity and duration of UUT surveillance cannot be made at present.”

“Risk-adapted UUT surveillance, that is to say intensive CT-urography for high-risk NMIBC, is not sufficient to prevent the chance of nephroureterectomy or disease progression. The use of genomics will help identify optimal candidates for UUT surveillance.”

Kidney-sparing treatment of UTUC

Dr. Sharokh Shariat (AT) followed with his state-of-the-art lecture on the merits of kidney-sparing surgery (KSS) over radical nephroureterectomy.

Showing some examples of removed kidneys with in some cases only small tumours, Shariat pointed out that “at the moment, one size fits all and there is a serious risk of over-treatment.” His lecture was based on three questions: Why should urologists consider KSS, if it is safe and equally as effective as radical surgery, and finally which patients should be considered for kidney-sparing surgery.

“The rationale for kidney-sparing surgery is clear, but I must disclose that data is currently weak. Ureteroscopy is useful for diagnosis, but there is a risk of delaying the definitive treatment.” Shariat emphasized that diagnostic URS increased the risk of intravesical recurrence, as published by Sung et al, Plos One 2015.

Shariat also recommended the use of a digital ureteroscope for the best results, and demonstrated a “push” technique with the Piranha. He impressed on urologists that it was also their responsibility to inform their patients on the dangers of smoking, seeing as it was associated with recurrence and mortality. The cessation of smoking for >10 years reduces the risk significantly.