Innovations in Urologic Practice Archives

When is Radical Cystectomy Indicated for NMIBC?

Guilherme Godoy, MD, MS | Mar 2022

Guilherme Godoy, MD, MPH, Assistant Professor of Urology at Baylor College of Medicine, in Houston, Texas, discusses the role of cystectomy in non-muscle invasive bladder cancer (NMIBC). He begins by describing the management options for NMIBC, including transurethral resection of the bladder tumor (TURBT), intravesical treatment, systemic therapy, and radical cystectomy. Dr. Godoy then explains the importance of re-TURBT, stating that it is one of the most critical steps in management for reducing understaging and improving intravesical therapy response in patients. He summarizes the indicators for cystectomy, including failure to resect, adverse pathology, and treatment failures. Dr. Godoy reviews data from a large single-institution retrospective study showing a significant difference in recurrence-free survival, cancer-specific survival, and overall survival in favor of the primary muscle invasion at presentation group vs. the progressive MIBC group. He then discusses data from a systematic review and meta-analysis of 14 studies on oncological outcomes of primary and secondary MIBC, finding worse outcomes overall for secondary muscle invasive cystectomy. Dr. Godoy looks at the European and AUA risk stratification tables, focusing on how both support aggressive management of high risk disease. He shows data from a study of the impact of variant histology on outcomes with intravesical immunotherapy, finding 40% progression-free survival compared to 17.5% in conventional bladder cancer. He states that all of this data supports cystectomy as an important and integral tool in the management of NMIBC due to its excellent oncological outcomes and potential benefit of abbreviated management and follow-up for aggressive NMIBC despite its morbidity, though the treatment may not be appropriate for everyone.

Innovations in Urologic Residency Education

Wesley A. Mayer, MD | Mar 2022

Wesley A. Mayer, MD, Associate Professor of Medicine, Assistant Dean of Graduate Education, and Vice Chair of Education in the Scott Department of Urology at Baylor College of Medicine in Houston, Texas, discusses innovations in urologic residency education in the face of changing technology and COVID-19. He begins with a brief history of medical training, explaining that the apprenticeship model was standard until around the start of the 20th century, when William Halstead began to develop the traditional surgical education experience featuring intense and repetitive experiences with surgical patients. Dr. Mayer then lists new challenges in modern surgical training, including work-hour restrictions, influence from other high-stakes fields, an increasingly litigious environment, rising expectations from the public, a progressive physician shortfall, and generational changes in learning style and needs. He argues that to meet these challenges, modern surgical training should: leverage simulators as well as inanimate and animate models; deconstruct complex surgeries into component skills; incorporate structured objective assessment tools; utilize concise, constructive, real-time feedback; address broader stressors impacting trainees, such as wellness and burnout; develop non-surgical skills; and innovate through servant leadership. Dr. Mayer then discusses recent innovations in open surgical training, highlighting the benefits of using cost-effective models based on cheaper materials and 3D printing rather than expensive traditional benchtop models and cadaveric simulations. He moves on to look at innovations in endoscopic surgical training and innovations in laparoscopic/robotic surgical training, emphasizing the benefits of virtual reality training models and video-based coaching. Dr. Mayer summarizes the recent experience of resident education in the Scott Department, particularly focusing on the department’s participation in a trial of SIMPL, a smartphone-based surgical skills assessment tool. He then briefly expands upon innovative feedback models and ways to manage trainee wellness and burnout. Dr. Mayer also considers the effect of COVID-19 on surgical training, observing that while the pandemic led to reduced resident work hours and increased concern that residents would not be able to meet minimum case requirements, the rise of videoconferencing allowed for the positive development of nationwide urology didactics. He closes the presentation by discussing innovative educational uses of social media and the importance of non-technical skills training.

Bladder-Sparing Trimodality Therapy

Daniel A. Hamstra, MD, PhD, FASTRO, FASCO | Mar 2022

Daniel A. Hamstra, MD, PhD, Chairman and Professor of Radiation Oncology at Baylor College of Medicine in Houston, Texas, discusses bladder-sparing trimodality therapy for patients with bladder cancer, explaining the role of each aspect of care, outcomes in terms of quality of life, and the potential future role of checkpoint inhibitors. He begins by noting that successful organ preservation approaches in oncology are common (e.g., in breast cancer, head and neck cancer, and extremity sarcoma) and can reasonably be applied to bladder cancer as well. Dr. Hamstra then introduces the standard care pathway for trimodality bladder preservation, from transurethral resection of bladder tumor (TURBT), to neoadjuvant chemotherapy, to radiotherapy with radiosensitizing agent, to follow-up with repeat cystoscopy. He goes into detail about the role of each portion of treatment, arguing that surgical management, concurrent chemotherapy, and radiation therapy are all critical to treatment success. Dr. Hamstra also discusses how radiation should be delivered in terms of effectiveness and toxicity and considers the question of whether to treat the bladder only or the pelvis and bladder with radiation. He then looks at patient-reported quality of life after bladder preservation, highlighting that while many patients report declines in bladder-related quality of life immediately following chemoradiotherapy, they generally improve to baseline after 6 months, and ⅔ of patients report stable or improved quality of life on long-term follow-up. Finally, Dr. Hamstra touches on future additions to bladder-sparing treatment such as checkpoint inhibitors, highlighting the ongoing INTACT trial of concurrent chemoradiation with or without atezolizumab for localized muscle invasive bladder cancer. He concludes that trimodality bladder preservation represents a viable but underutilized option for T2-T4 bladder cancer that requires coordinated care between urology, medical oncology, and radiation oncology. Dr. Hamstra reiterates that each component of treatment is critical, quality of life outcomes are excellent, and newer agents may also improve outcomes.

Managing NMIBC in the BCG Shortage Era

Seth P. Lerner, MD, FACS | Feb 2022

Seth P. Lerner, MD, Professor of Urology and holder of the Beth and Dave Swalm Chair in Urologic Oncology in the Scott Department of Urology at Baylor College of Medicine, explains the bacillus Calmette-Guérin (BCG) shortage and discusses how physicians should adjust treatment decisions for non-muscle invasive bladder cancer (NMIBC). He outlines a joint guideline statement made by the AUA, AACU, BCAN, SUO, LUGPA, and UCF on February 19, 2019, which stated that BCG should not be used for low-risk disease, that alternative intravesical chemotherapy should be used for second-line intermediate-risk disease, that patients with high-risk NMIBC should be prioritized for full-strength BCG, and that if full doses are unavailable then reduced doses should be used. Dr. Lerner then discusses the SWOG BCG maintenance protocol, which shows a clear benefit over other protocols. He reviews the BCG dose reduction process and describes how to bill for it. Dr. Lerner also gives an overview of a trial on optimizing mitomycin delivery that found that dehydrating the patient and ensuring the bladder is empty prior to instillation is key, and that optimized delivery can double recurrence-free survival at 5 years. Dr. Lerner outlines BCG-naive clinical trial agents and shows data indicating that gemcitabine with docetaxel can be used to supplement BCG treatment. He states that very high-risk patients should receive radical cystectomies early due to a dropoff in survival in patients who wait to receive cystectomies. Dr. Lerner concludes that optimized intravesical mitomycin and doublet chemotherapy regimens are active in both intermediate and high-risk disease, and that radical cystectomy’s complete and usually durable response for pathologic NMIBC should not be ignored.

Neoadjuvant vs. Adjuvant vs. None – “Perioperative Therapy”

A. Edward Yen, MD | Feb 2022

A. Edward Yen, MD, Assistant Professor of Medicine in the Hematology and Oncology Section at Baylor College of Medicine in Houston, Texas, summarizes research on perioperative therapies for bladder cancer and how they compare to each other. He begins with an overview of the current standard of care for muscle-invasive bladder cancer (MIBC), citing a Swiss study showing that after radical cystectomy there is still a problem of incurable disease relapse through overall survival rates below 63%, and another study showing that neoadjuvant cisplatin-based chemotherapy (NAC) combinations improve survival for MIBC by 5-8%. Dr. Yen then overviews NAC, highlighting the VESPER trial that compared cisplatin-gemcitabine (GC) and dose-dense MVAC (ddMVAC) in the perioperative MIBC setting and found that more patients were able to follow through with NAC than adjuvant chemotherapy (AC) by 21%. He discusses multiple immunotherapy trials that together show that patient responses seem better with chemo-immunotherapy than they do with immunotherapy alone. Dr. Yen then reviews the CheckMate-274 trial that found that adjuvant nivolumab treatment-related adverse effects were tolerable due to a 7% rate of being severe enough to end treatment vs. a 1.4% rate in the placebo arm. He also summarizes the IMvigor trial, which did not meet its primary endpoint of disease-free survival but found that positive ctDNA patients had an improvement from atezolizumab that was not seen in other patients. Dr. Yen concludes that GC and ddMVAC remain important perioperative chemotherapy regimens, that neoadjuvant and adjuvant therapies have situational uses, and more research will be key to refining these treatments further.