Bladder Tumors 135-142 12th ed

Question 1

Is healthy diet and risk of urothelial cancer related?

Answer 1

There is a clear association between a healthy diet and a decreased
risk of urothelial cancer.

Question 2

What are associated with development of bladder cancer?

Answer 2

There is no convincing evidence that alteration in fluid intake,
alcohol consumption, ingestion of artificial sweeteners, or analgesic
abuse increase the risk of bladder cancer; however, chronic
irritation, bacterial infection, and radiation have all been associated
with the development of bladder cancer.

Question 3

What is the prognosis of prostatic urethral involvement based on layers involved?

Answer 3

Prostatic urethral involvement by transitional cell carcinoma without
invasion carries a relatively good prognosis; when it invades the
prostatic stroma, the prognosis is less good, and when it directly
invades the substance of the prostate from the bladder, the prognosis
is poor.

Question 4

What genetic factors are associated with poor prognosis? Which one has a better prognosis?

Answer 4

In muscularis propria invasive urothelial cancer, alterations in TP53,
RB, and PTEN are poor prognostic indicators.

Genetic alterations in low-grade non-muscularis propria invasive
disease include alterations in FGFR-3 and deletions in chromosome
9.

Question 5

Most important risk factor for progression of NMIBC

Answer 5

Grade

Question 6

In low-risk disease are you required to do random biopsies?

Answer 6

All suspicious lesions should be sampled, but random biopsies are
not required in low-risk patients.

Question 7

Is immediate intravesical therapy beneficial for high grade disease?

Answer 7

No

Question 8

Contraindications to BCG intravesical therapy

Answer 8

BCG is contraindicated in the setting of a disrupted urothelium
because of the risk of intravasation and BCG sepsis.

Question 9

If patient fails 2 courses of intravesical BCG, what are his options?

Answer 9

Following failure of a second course of intravesical therapy, patients
can be enrolled in clinical trials of new agents, consider combination
intravesical therapy, or proceed to cystectomy.

Question 10

Hallmark of surveillance

Answer 10

Cystoscopy is the hallmark of surveillance. The surveillance
schedule should be individualized on the basis of risk stratification of
the most recently resected tumor.

Question 11

What are the risk factors for metastases?

Answer 11

Lymphatic and vascular invasion are risk factors for metastases. The incidence of pelvic node metastases is directly related to the
depth of invasion and the presence of lymphovascular invasion.

Question 12

What is the prognosis of muscularis propria invasive bladder cancer?

Answer 12

As many as 50% of patients with muscularis propria–invasive

bladder cancer succumb to their disease.

Question 13

Who are the appropriate candidates for bladder preservation?

Answer 13

Appropriate candidates for bladder preservation (transurethral tumor
resection, chemotherapy, and radiation therapy thereby preserving
the bladder) are those who have
1. a solitary T2 lesion of small
diameter
2. no associated hydronephrosis
3. a visibly complete
resection
4. Such patients should have normal renal function.

Question 14

How are neuroendocrine bladder tumors treated?

Answer 14

Treatment of neuroendocrine bladder tumors includes neoadjuvant
chemotherapy and surgical resection; neuroendocrine tumors may be
associated with a paraneoplastic syndrome (hypercortisolism and
hypercalcemia).

Question 15

Where should biopsy of the prostatic urethra be done?

Answer 15

The highest concentration of prostatic ducts are located from the
mid-prostate to the veru at the 5 and 7 o’clock positions and are the
locations where CIS of the prostatic urethra is most likely to be
found (biopsy should be performed in this location).

Question 16

Who are not good candidates for cisplatin chemotherapy?

Answer 16

Patients who are not good candidates for cisplatin chemotherapy are
those with
1. a poor performance status, 2. creatinine clearance less than
60 mL/min
3. hearing loss, peripheral neuropathy
4. heart failure.

Question 17

What is the best practice regarding TURBT resection of bladder tumor and inclusion of muscle.

Answer 17

Initial transurethral resection of a bladder tumor should routinely be
performed to include muscle. There should be a 2-cm visibly
negative margin on the surface.

Question 18

Which patients are amenable to partial cystectomy?

Answer 18

Patients amenable to partial cystectomy should have a solitary lesion
without associated CIS in which a 2-cm margin may be obtained,
which is far enough away from the ureteral orifices and bladder
neck that closure can be accomplished without compromising these
structures.

Question 19

What are the boundaries of standard lymph node dissection in radical cystectomy?

Answer 19

The boundaries of a standard lymph node dissection are the
genitofemoral nerve laterally, internal iliac artery medially, Cooper
ligament caudally, and crossing of the ureter at the common iliac
artery cranially.

Question 20

Is mechanical and antibiotic prep necessary in cystectomywith urinary diversion?

Answer 20

In preparation for a cystectomy and urinary diversion, mechanical
and antibiotic bowel prep is controversial. The data to justify
omitting this preparation come, for the most part, from the general
surgical literature in which the bowel is not opened in the peritoneal
cavity as it is in urology, particularly in continent diversions.
Administration of intravenous antibiotic prophylaxis 30–60 minutes
before the incision is recommended.

Question 21

What type of ureteral intestinal anastomosis has the lowest stricture rate?

Answer 21

Antirefluxing anastomoses
have a 10%–20% stricture rate; refluxing anastomoses have a 3%–
10% stricture rate. The Wallace ureteral intestinal anastomosis has
the lowest stricture rate.

Question 22

What conduit can lead hematuria-dysuria syndrome?

Answer 22

Complications specific to the use of stomach include the hematuriadysuria
syndrome and uncontrollable metabolic alkalosis in some
patients

Question 23

What factors need to be met for a patient to be considered for retentive diversion?

Answer 23

If the patient is able to achieve a urine pH of 5.8 or less, can establish
a urine osmolality of 600 mOsm/kg or greater in response to water
deprivation, has a GFR that exceeds 60 mL/min, and has minimal
protein in the urine, he or she may be considered for a retentive
diversion.