HYU Onc - Bladder and Upper Tract Flashcards

1
Q

Microhematuria definition

A

> or = 3 RBCs/hpf on microscopic evaluation of a single, properly collected urine specimen

Evaluation should not change based on presence or absence of AC/anti-plt meds

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2
Q

Microhematuria: Low-Risk

A

Must meet ALL of the following criteria:

Women < 50yo
Men < 40yo
<10 pack-years
3-10 RBCs/hpf
No prior episodes of MF
No other risk factors

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3
Q

Microhematuria: Intermediate Risk

A

If you meet ANY of the following criteria:

Women 50-59 yo
Men 40-59 yo
11-30 pack years
11-25 RBCs/ hpf
Presence of additional risk factors
Previously low-risk without prior evaluation and 3-25 RBCs/hpf

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3
Q

Microhematuria: Intermediate Risk

A

If you meet ANY of the following criteria:

Women 50-59 yo
Men 40-59 yo
11-30 pack years
11-25 RBCs/ hpf
Presence of additional risk factors

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4
Q

Microhematuria: High Risk

A

If you meet ANY of the following criteria:

Man or woman >60yo
>30 pack years
>25 RBCs/hpf
History of gross hematuria
Previously low-risk without prior evaluation and >25 RBCs/hpf

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5
Q

Management of low-risk microhematuria

A

Shared decision making

Can repeat UA within 6 months or
Cysto + US

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6
Q

Management of intermediate-risk microhematuria

A

Cysto + RUS

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7
Q

Management of high-risk microhematuria/gross hematuria

A

Cysto (for all)
CTU > MRU > retrograde pyelograms and noncon axial imaging or RUS

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8
Q

Additional risk factors for urothelial carcinoma

A

Irritative LUT voiding symptoms
History of cyclophosphamide of ifosfamide chemotherapy
Family history of US or lynch syndrome
Occupational exposure to benzene chemicals or aromatic amines
History of chronic indwelling foreign body in the urinary tract

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9
Q

Imaging when microhematuria in a patient with family history of RCC or known genetic renal tumor syndrome

A

Perform upper tract imaging regardless of risk stratification

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10
Q

When use urine cytology and markers in MH patients?

A

Do not use in initial MH evaluation
Can use cytology for patients with persistent MH + irritative LUTS or RFs for CIS after a negative initial MH workup

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11
Q

MH follow-up after negative evaluation

A

Repeat UA in 12 months

If UA negative, discontinue further evaluation
If UA persistent MH, shared decision making regarding need for initial evaluation

After negative evaluation, initiate further evaluation if new gross hematuria, increasing degree of MH, or new urologic symptoms

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12
Q

Bladder Cancer Staging

A

Tis = mucosa
T1 = lamina propria
T2 = Muscularis propria
- a = inner
- b = outer
T3 = Perivesical tissue/fat
- a = microscopic
- b = macroscopic
T4 = Extravesical
- a = adjacent organs
- b = body wall

Ta: This refers to noninvasive papillary carcinoma. This type of growth often is found on a small section of tissue that easily can be removed with TURBT.

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13
Q

Low risk bladder cancer

A

LG solitary Ta less than or = to 3 cm
PUMLUMP

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14
Q

Intermediate Risk Bladder Cancer

A

Recurrence of LG Ta within 1 year
Solitary LG Ta >3cm
Multifocal LG Ta
HG Ta < or = to 3 cm
Any LG T1

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15
Q

High Risk Bladder Cancer

A

HG T1
Any Recurrent HG Ta
HG Ta > 3 cm or multifocal
Any CIS
Any BCG failure in HG patient
Any variant histology (micropapillary, sarcomatoid, plasmacytoid)
Any LVI
Any HG prostatic urethral involvement

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16
Q

Positive cytology with normal cysto in a patient with a history of NMIBC

A

Consider upper tract imaging, prostatic urethral biopsies, blue light cysto, ureteroscopy, random bladder biopsies

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17
Q

Variant histology, extensive squamous or glandular differentiation, + LVI

A

Obtain GU pathologist review
Offer restaging TURBT 4-6 weeks after diagnostic TURBT (if attempting to spare bladder)
Or, offer up front radical cystectomy

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18
Q

When is the use of urine markers appropriate?

A

For NMIBC, can use biomarkers to assess response to BCG and to adjudicate equivocal cytology
- Should NOT use in lieu of cytology
- Should NOT use for surveillance of low risk patients with with normal cytology
- SHOULD use cytology with surveillance cystoscopy for IR and HR disease

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19
Q

When do you perform a restaging TURBT?

A

Within 6 weeks of initial TURBT

If incomplete resection

If pathology is high-risk HG Ta OR HG T1
Must get muscle in specimen

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20
Q

Single dose intravesical MMC or gemcitabine use?

A

Postop

Consider in suspected/known LG disease within 24 hours of TURBT, except in cases of suspected perforation or extensive resection

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21
Q

When do you use BCG?

A

Don’t use in LR
Consider in IR
Use in HR

If it works, maintenance BCG (3 weekly doses starting 3 months after induction) for 1 year in IR and 3 years in HR

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22
Q

What is maintenance BCG dosing/timing?

A

If it works, maintenance BCG (3 weekly doses starting 3 months after induction) for 1 year in IR and 3 years in HR

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23
Q

What do you do for persistent/recurrent NMIBC s/p 1 induction course of BCG?
- Ta?
- CIS?
- HG T1?

A

Ta - Second induction course of BCG
CIS - Second induction course of BCG
RC w/o NAC also an option for both of these

HG T1 - RC

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24
Persistent/recurrent HG or CIS within 6 months of 2 induction courses BCG or induction + maintenance BCG?
No more BCG Unwilling or unfit for RC after 2 courses of BCG with recurrence within 12 months --> clinical trial vs other intravesical therapy (valrubicin, gemcitabine, docetaxel), vs. systemic pembro for CIS
25
Cystoscopy follow-up for bladder cancer patients
After initial evaluation/treatment, first surveillance cysto should be within 3-4 months If this is negative, the frequency of subsequent surveillance cysto (w/ cytology if IR/HR) varies based on risk stratification
26
Low-risk NMIBC surveillance cysto schedule
After initial evaluation/treatment, first surveillance cysto should be within 3-4 months Next cysto 6-9 months later Then yearly Shared decision making after 5 years *In-office fulguration is an option for LG Ta disease with <1cm papillary recurrence
27
Intermediate-risk NMIBC surveillance cysto schedule
After initial evaluation/treatment, first surveillance cysto should be within 3-4 months Cysto/cytology q3-6 months x2 years q6-12 months x2 years Then yearly Consider surveillance upper tract imaging every 1-2 years
28
High-risk NMIBC surveillance cysto schedule
After initial evaluation/treatment, first surveillance cysto should be within 3-4 months Cysto/cytology q3-4 months x2 years q6 months x2 years Then yearly Consider surveillance upper tract imaging every 1-2 years
29
Treatment for BCG sepsis - MOA for the drugs?
Corticosteroids + NSAIDs + Isoniazid 300mg + Rifampin 600mg + Ethambutol 1200mg daily Isoniazid inhibits mycobacterial cell wall formation Rifampin inhibits RNA polymerase Ethambutol inhibits mycobacterial cell wall formation Pyridoxine (B6) is administered with Isoniazid to prevent peripheral neuropathy
30
Persistent fever without sepsis or UTI following BCG
Isoniazid x 3 months
31
Timing of BCG and TURBT
Don't give BCG until >1 week after TURBT due to risk of BCG sepsis
32
Can you give BCG in immunocompromised patients?
BCG is safe in immunocompromised patients - Including patients with autoimmune disease, transplant patients, and patients undergoing systemic chemotherapy BCG is dependent on an intact immune system, so use MMC (DNA x-linker) for intravesical therapy in patients on immunosuppression (chronic steroids for RA or anti-TNFa for Crohn's)
33
Urothelial CIS of the prostatic urethra during TURP?
Repeat BCG Tx to reduce recurrence of CIS
34
Positive cytology and negative cysto?
Prostatic urethral biopsies should include at 5 and 7 o'clock positions, where the ejaculatory ducts insert These are most common sites of occult disease
35
Granulomatous prostatitis
Common following iBCG No intervention needed mBCG can continue
36
Valrubicin uses
Valrubicin is FDA approved for BCG-refractory CIS and HR disease in a non-cystectomy candidate
37
Recurrent tiny (<1cm) low grade Ta after BCG
fulgurate and observe
38
Persistent CIS after induction in a high risk patient
Repeat induction BCG
39
Best method for detecting recurrent CIS after induction BCG
blue-light cysto Hexaminolevulinate
40
BCG-unresponsive
Persistent/recurrent NMIBC must undergo iBCG + at least one mBCG to be 'BCG-unresponsive'
41
Anktiva
IL-15 superantagonist - used with BCG in BCG- unresponsive CIS +/- Ta/T1
42
Side effects of MMC
9% rash (contact dermatitis) 6-41% chemical cystitis
43
How to optimize MMC effectiveness
Void/CIC prior Dehydration to prevent dilution Alkalinization with Na-bicarb Increase drug concentration (want 40mg/20mL) Not helpful: abx, NSAIDs, antimuscarinics
44
T1 tumors with aggressive features (>3 cm, micropapillary/variant histology, concomitant CIS, LVI)
Up front cystectomy without NAC
45
When do you treat asymptomatic ileal conduit urine cultures?
Asymptomatic IC cultures are >75% positive Only need to be treated if culture grows proteus or pseudomonas due to risk of stone formation
46
Risk of LN metastasis at time of RC performed for recurrent T1 or CIS
10-15%
47
Nephroureterectomy in a patient with one kidney and prior RC/IC
Leave IC in place for use with future renal transplant
48
Persistent disease (any) on mid-cycle TURBT during chemoradiation
Proceed to RC
49
Urine Assay: UroVysion FISH
Detects aneuploidy from chromosome 3, 7 and 17 and homozygous loss of chromosome 9p21 Can adjudicate equivocal urine cytology
50
Urine Assay: ImmunoCyt
Immunohistochemistry for urothelial antigens Can adjudicate equivocal cytology
51
Urine Assay: BladderCheck
Enzyme innunoassay for NMP22 Used with cytology for Dx and surveillance
52
Urine Assay: BTA
Enzyme immunoassay for bladder tumor antigen
53
Nephrogenic Adenoma - What is it? - Sxs? - Tx?
Rare benign metaplastic response to urothelium injury Hematuria and irritative voiding sxs Cystoscopy looks like low-grade papillary tumor TUR + > or = 1 years of antibiotic suppression
54
Inverted papilloma of the ureter
Can behave malignantly, so survey bladder and upper tracts Conservative management with surveillance for at least two years is recommended
55
Instillation of periop chemo after complete TURBT only works if given within how long?
24 hours after surgery
56
5mm filling defect in distal ureter + biopsy shows LG UC
Ureteroscopic tumor ablation
57
Risk of upper tract UC in patient with bladder Ca diagnosis?
10%
58
Risk of bladder cancer in patients with UTUC diagnosis?
~40%
59
How to follow cystitis glandularis?
Could have risk of transformation to adenocarcinoma Survey with cysto or UA
60
Lit: SWOG 8216 1991
Intravesical BCG > Doxorubicin for preventing NMIBC recurrence RCT BCG = immune system activator Doxorubicin = DNA intercalator
61
Lit: BCG Complications 1992
Intravesical BCG is generally well tolerated but can lead to serious adverse effects 2.9% fever 0.9% granulomatous prostatitis 0.7% PNA/hepatitis 0.5% arthralgias 1% hematuria 0.3% rash 0.3% ureteral obstruction 0.4% epididymitis 0.2% contracted bladder 0.1% renal abscess 0.4% sepsis 0.1% cytopenia
62
Management of BCG-related complications? - Fever >38.5C - Allergic reaction - Acute severe illness - Sepsis
Fever >38.5C: Isoniazid 300mg daily for 3 months - Can resume BCG when asymptomatic Allergic reaction: Isoniazid 300mg daily for 3 months - Further BCG if benefits outweigh risks Acute severe illness: Isoniazid 300mg, rifampin 600mg, ethambutol 1200mg daily for 6 months - No further BCG Sepsis: Isoniazid 300mg, rifampin 600mg, ethambutol 1200mg daily for 6 months - Also consider prednisone 40mg
63
Lit: Post-TURBT MMC 1996
Post-TURBT MMC decreases risk of recurrence RCT 5-year follow-data favored MMC over nothing
64
Lit: SWOG 8507 2000
Maintenance BCG doubles RFS compared to induction BCG alone in HR NMIBC RCT Similar 5-yr OS
65
Lit: Valrubicin for BCG-refractory CIS 2000
FDA-approved for treatment of BCG-refractory CIS in non-cystectomy candidates Phase III trial Valrubicin = anthracycline chemo - DNA intercalation
66
Lit: EORTC 30692 2013
3 years (vs. 1 year) of mBCG is helpful in HR (but not IR) NMIBC RCT
67
Lit: SWOG S0337 2018
Immediate post-TURBT Gemcitabine reduces recurrence of low-risk NMIBC RCT Gemcitabine = DNA synthesis inhibitor
68
Lit: KEYNOTE 057 2021
Pembrolizumab is approved for use in BCG-unresponsive NMIBC Single arm
69
Lit: Nadofaragene Firadenovec for BCG-unresponsive NMIBC 2021
CIS unresponsive to BCG may have durable response to nadofaragene Phase III trial Nadofaragene = delivers IFN-alpha/2beta cDNA to bladder epithelium and activates immune system FDA approved in 2022
70
BCG: MOA
Immune system activator
71
MMC: MOA
Alkylating chemotherapy - DNA cross-linker
72
Valrubicin: MOA
Anthracycline chemotherapy - DNA intercalation
73
Gemcitabine: MOA
DNA synthesis inhibitor
74
Pembrolizumab: MOA
IgG4-mAb to PD-1 Decreases T-cell suppression Increases T-cells killing cancer cells This is IV/systemic
75
Nadofaragene: MOA
Delivers IFN alpha/2beta to bladder epithelium Activates immune system
76
BCG Shortage recommendations: 2020
Don't use BCG in LR disease For IR disease, use intravesical chemo (MMC, gemcitabine, epirubicin, docetaxel) Use the available BCG for HR NMIBC induction - If needed, BCG dose can be reduced to 1/2 or 1/3rd strength If enough BCG is available to offer mBCG - reduce to 1/3rd strength and limit to one year of maintenance If BCG shortage --> prioritize iBCG for HR over mBCG If BCG is unavailable --> MMC is the preferred alternative
77
Newly diagnosed CIS and BCG is unavailable
MMC
78
HR bladder cancer patients with HR features (HGT1 + CIS, LVI, PUI, variant histology) who are surgical candidates and who are unwilling to take any oncologic risk by using a non-BCG regimen
Offer radical cystectomy
79
Workup for patients with suspected UTUC
Cystoscopy Cross-sectional imaging of upper tracts with contrast and with delays Also, diagnostic URS with washings and biopsy of any concerning lesions identified
80
If bladder and upper tract tumors discovered during evaluation of upper tracts?
Deal with bladder lesions in same sitting as upper tract eval
81
If upper tract is difficult to access due to stricture?
Minimize risk of ureteral injury by using gentle dilation techniques such as ureteral stenting Don't use a sheath or try to dilate
82
In cases where ureteroscopy cannot be safely performed or is not possible, but UTUC is suspected?
An attempt at selective upper tract washing or barbotage for cytology may be made and pyeloureterography performed in cases where good quality imaging such as CT or MR urography cannot be obtained
83
Should you inspect both sides when one UT is concerning for cancer? Or only one?
At the time of ureteroscopy for suspected UTUC, clinicians should not perform ureteroscopic inspection of a radiographically and clinically normal contralateral upper tract.
84
For patients with suspected/diagnosed UTUC, when do you send them to genetic counseling?
If they have a personal or family history of Lynch Syndrome (colorectal, ovarian, endometrial, gastric, biliary, small bowel, pancreatic, prostate, skin and brain cancer)
85
Favorable low-risk UTUC features
Biopsy Low-grade Negative cytology No invasion No obstruction Normal nodes Unifocial, papillary in appearance No lower tract involvement Treatment: Ablation preferred, no systemic therapy
86
Unfavorable Low-Risk UTUC features
Biopsy Low-grade No HGUC on cytology No invasion Can have obstruction Normal Nodes Multifocal Papillary appearance Can have bladder involvement Ablative therapy can be offered, No systemic therapy
87
Favorable High-Risk UTUC features
Biopsy high-grade Any cytology No invasion No obstruction Normal nodes Unifocal Papillary appearance No lower tract involvement Ablative therapy in rare, selected cases Recommend neoadjuvant or adjuvant systemic therapy
88
Unfavorable High-Risk UTUC features
Biopsy high-grade HGUC on cytology Invasion Obstruction Suspicious nodes Multifocal Sessile or Flat lesions Lower tract involvement Ablation for palliation Recommend neoadjuvant or adjuvant systemic therapy
89
Initial management option for patients with LR favorable UTUC
Tumor ablation
90
Initial management option offered to patients with LR unfavorable UTUC and select patients with HR favorable disease who have low-volume tumors or who cannot undergo Radical Nephroureterectomy
Tumor ablation
91
Tumor ablation - retrograde or antegrade? Next endo eval?
Tumor ablation may be accomplished via a retrograde or antegrade percutaneous approach and repeat endoscopic evaluation should be performed within three months
92
Role of intravesical or pelvicalycel chemo in UTUC ablation?
Following ablation of UTUC tumors and after confirming there is no perforation of the bladder or upper tract, clinicians may instill adjuvant pelvicalyceal chemotherapy (Conditional Recommendation; Evidence Level: Grade C) or intravesical chemotherapy (Expert Opinion) to decrease the risk of urothelial cancer recurrence.
93
Pelvicalyceal therapy with BCG may be offered to patients with HR favorable UTUC after complete tumor ablation or patients with upper tract carcinoma in situ (CIS)
Pelvicalyceal therapy with BCG may be offered to patients with HR favorable UTUC after complete tumor ablation or patients with upper tract carcinoma in situ (CIS)
94
When do you perform NephU in LR UTUC?
When tumor ablation is not feasible or evidence of risk group progression is identified in patients with LR UTUC, surgical resection of all involved sites either by RNU or segmental resection of the ureter should be offered
95
Choice therapy for patients with HR UTUC?
Clinicians should recommend RNU or segmental ureterectomy for surgically eligible patients with HR UTUC. Make sure to also give a single dose of chemo intravesically
96
Best treatment option for surgically eligible patients with HR and unfavorable LR UTUC cancers endoscopically confirmed as confined to the lower ureter in a functional renal unit
Distal ureterectomy and ureteral reimplantation is the preferred treatment Make sure to also give a single dose of chemo intravesically When performing NU or distal ureterectomy, the entire distal ureter including the intramural ureteral tunnel and ureteral orifice should be excised, and the urinary tract should be closed in a watertight fashion
97
LND in UTUC surgery?
For patients with LOW RISK UTUC, clinicians MAY perform LND at time of NU or ureterectomy For patients with HIGH RISK UTUC, clinicians SHOULD perform LND at time of NU or ureterectomy
98
When to consider neoadjuvant chemo in UTUC management?
Clinicians should offer cisplatin-based NAC to patients undergoing RNU or ureterectomy with HR UTUC, particularly in those patients whose post-operative eGFR is expected to be less than 60 or those with other medical comorbidities that would preclude platinum-based chemotherapy in the post-operative setting
99
When to us adjuvant chemo in UTUC management?
Clinicians should offer platinum-based adjuvant chemotherapy to patients with advanced pathological stage (pT2–T4 pN0–N3 M0 or pTany N1–3 M0) UTUC after RNU or ureterectomy who have not received neoadjuvant platinum based therapy Adjuvant nivolumab therapy may be offered to patients who received neoadjuvant platinum-based chemotherapy (ypT2–T4 or ypN+) or who are ineligible for or refuse perioperative cisplatin (pT3, pT4a, or pN+).
100
Metastatic UTUC patients treatment?
In patients with metastatic (M+) UTUC, RNU or ureterectomy should not be offered as initial therapy Patients with clinical, regional node-positive (cN1-3, M0) UTUC should initially be treated with systemic therapy. Consolidative RNU or ureterectomy with lymph-node dissection may be performed in those with a partial or complete response
101
Upper tract CIS with low tolerance for nephrol loss (eg CKD, history of stones)
PCN with antegrade BCG instillation is more effective than ureteral stent placement and bladder instillation
102
Upper tract UC before age 55
Genetic counseling if positive for lynch syndrome (HNPCC)
103
Balkan Nephropathy
Long-term consumption of aristolochic acid increases the risk of UTUC and ESRD
104
Lit: (don't) POUT (it worked) Peri-operative chemotherapy vs. surveillance in Upper Tract UC 2020
Adjuvant systemic gem/cis improves DFS over placebo after NUx for advanced, non-metastatic UTUC This was surveillance vs. adjuvant gem/cis RCT
105
Lit: OLYMPUS 2022
MMC gel injected into upper tract weekly works to destroy low-grade UTUC but is associated with ureteral stenosis in almost 50% of patients Phase III 6 weekly instillations of Jelmyto - retrograde Complete responders eligible for monthly maintenance instillation
106
Need to stage non-metastatic muscle invasive bladder cancer prior to recommending treatment. How?
CT Urogram CBC CMP Chest imaging Bone imaging if clinical suspicion (increased ALP) or symptoms of bone mets
107
Role of NAC and AC in MIBC (non-metastatic)
Generally, patients should get cisplatin-based NAC followed by RC within 12 weeks of NAC Neoadjuvant carboplatin-based chemo should NOT be used (if cisplatin ineligible --> up front RC vs. clinical trial) Cisplatin-based adjuvant chemo if non-organ confined disease at cystectomy (T3, T4 or N+)
108
Cystectomy for M0 disease
Do bilateral pelvic lymph node dissection (BPLND) (at least external/internal iliac and obturator nodes) Remove bladder, prostate, SVs in med Remove bladder +/- adjacent organs in women Consider sexual function preserving procedures depending on extent of disease When creating a neobladder, verify a negative urethral margin first
109
Medications to use in cystectomy periop period
mu-opioid antagonists (alvimopan) unless contraindicated Pharmacologic VTE prophylaxis should be used
110
Bladder preservation in non-metastatic MIBC
Maximal TURBT Radiosensitization (cisplatin of 5-FU/MMC) EBRT Surveillance cysto RC for MIBC recurrence TURBT or RC for NMIBC recurrence Radiation monotherapy should not be offered
111
Follow-up for non-metastatic muscle invasive bladder cancer
Chest imaging Cross-sectional AP imaging q6-12 months x 3 years and then annually Labe q3-6 months for 3 years and then annually Monitor urethral remnant if present
112
MIBC, chemo type, and timing
Most patients with MIBC should get cisplatin-based NAC prior to RC
113
Contraindications to cisplatin-based chemotherapy
Poor performance status CrCl <60 Significant hearing loss Significant peripheral neuropathy NYHA Class 3+ HF
114
Muscle invasive small cell carcinoma treatment
Muscle invasive small cell carcinoma responds well to cisplatin based neoadjuvant chemo followed by surgery OR radiation (Cure rate 40-60% vs. 5-20% without NAC) Cisplatin + ETOPOSIDE (not gemcitabine) is the standard regimen
115
Treatment for pure variant histology (micropapillary, squamous, adenocarcinoma (colonoscopy required in workup), plasmacytoid, and sarcomatoid) tumors
Pure variant histology tumors should generally be treated with upfront cystectomy (no NAC)
116
MIBC in conjunction with variant histology should (generally) be managed how?
NAC prior to local treatment
117
Neoadjuvant chemo and NON-MIBC?
NAC has NOT been found to be of benefit in patient undergoing RC for non-muscle invasive disease
118
Major metabolic anomaly with ileum or colon diversion
HYPERchloremic metabolic acidosis - Due to absorption of ammonium ions (absorbed with Cl-) in exchange for carbonic acid and water (secreted)
119
Major metabolic anomaly with ileum or colon diversion - treatment?
Treat with: 1. Decreased transit time (CIC) 2. Alkalinizing agents (bicrab, citrate) 3. Inhibitors of Cl- transport (chlorpromazine, nicotinic acid)
120
Ureterosigmoid (colon) vs. ileal conduit - Metabolic derangements? - Risks?
Both create a hyperchloremic metabolic acidosis - Risk of colon cancer with colon conduit - Risk of worse (more frequent and more severe) metabolic derangements with colon Osteomalacia is most likely with colonic continent diversions - MAc gets buffered by bone with release of Ca++ - Mineralized bone is reduced and osteoid component becomes excessive - Lethargy, joint pain, proximal myopathy, elevated alk phos -- Treat by correcting acidosis with K-cit and Ca++ supplementation
121
Major metabolic abnormality seen after RC/IC
HYPER-Cl HYPO-K Metabolic acidosis
122
Jejunal conduit metabolic derangement
Also ACIDOSIS But with opposite electrolyte derangements So, HYPO-Cl and HYPER-K Treat by rehydrating and alkalinizing (PO hydration, NaCl and bicarb (NaHCO3))
123
Stomach conduit metabolic derangement and treatment
Stomach conduit abnormalities are like vomiting Metabolic alkalosis (lose your stomach acid) HYPO-Cl HYPO-K Tx: Rehydration with NS KCl replacement H2 blockers PPI
124
How does B12 deficiency present? When does it happenin Urology/bladder Ca?
B12 deficiency presents with anemia and neurologic abnormalities (numbness and postural hypotension) Nutritional problems (B12 deficiency and bile acid salt absorption) are less with colon when compared to ileum as long as ileocecal valve is left intact B12 is a coenzyme in the metabolism of homocysteine - Homocysteine will build up in serum in absence of adequate B12
125
Ileal conduit and 'water under the bridge'
IC should be formed "under" (inferior to) the bowel anastomosis
126
Most accurate way to assess renal function s/p ileal conduit
FeNa
127
Next step: decreased UOP and increased drain output 4 days after RC/IC
Place a catheter in stoma
128
Urinary ammonium excreted by the kidneys (collecting duct) is absorbed by intestinal conduit... What can happen next? Treatment? If symptoms are relatively mild?
The liver metabolizes the ammonia to urea (via ornithine cycle) If liver function is decreased, can lead to increased ammonia buildup and you can go into ammoniagenic coma Treat with oral neomycin or lactulose to reduce absorption in GI tract *If sxs are milder (lethargy with increased transaminases), start with continuous drainage of urinary diversion
129
Necrotic looking stoma. Next step?
Loop endoscopy with or without diagnostic lap to determine extent of ischemic segment prior to operative intervention If just very distal conduit is involved, can consider stoma revision alone without resection of the entire conduit
130
Next step?: Enteral-conduit fistula --> feculent urine
Start with catheter in conduit + low residue diet Surgical intervention PRN
131
Largest risk factor for parastomal hernia
Stoma placement lateral to the rectus abdominus
132
Next step?: Pyocystis s/p ileal conduit w/o cystectomy
First line treatment is bladder irrigations If persistent problems like sepsis, vesicovaginostomy formation improves symptoms without morbidity of cystectomy
133
Bowel prep needed for small bowel diversion?
No, mechanical bowel prep is NOT indicated for most patients having a diversion with small bowel
134
Next step: Calculus in ileal conduit?
Most will pass spontaneously - Initial observation is preferred in an asymptomatic patient in absence of hydronephrosis or other evidence of conduit obstruction
135
Next step?: Suspicious or positive urethral wash s/p RC/IC for BCG-refractory CIS
Staging imaging Urethrectomy if imaging negative
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Next step?: New hydronephrosis in patient with RC/IC
Loopogram to determine presence/absence of reflux If no reflux, get lasix renogram to determine level of obstruction - Consider CTU to evaluate for extrinsic vs. intrinsic mass at site of obstruction prior to nephrostomy tube placement +/- nephrostomy tube Endoscopic +/- laparoscopic management
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Ureteroenteric anastomotic strictures: Work-Up?
First rule out malignant cause of stricture (ureteroscopy +/- biopsy +/- cytology) The assess kidney function (renogram) Then consider length of strictures - If <2cm could try endoscopic procedure If > 2cm, open repair is best
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Causes of early vs. late ureteroenteric anastomotic strictures?
Early = <1 year after surgery - Usually due to devascularization of the distal ureter or extreme angulation of the left ureter at the IMA (more common on left side) Late = usually a fibrotic response at the UE junction
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Open or endoscopic repair for: early UEA strictures? Late UEA strictures? Long? Short?
Short - can be managed endoscopically in first year or so after surgery Open surgical repair most effective Open repair typically needed for longer (>2 cm) or strictures that occur >1 yr after surgery
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What do you do for obstructed, nonfunctional kidney after RC/IC?
NephU should be considered because these units cannot be surveyed for upper tract recurrence using cytology
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Diarrhea after >40cm but <100cm of ileal resection and RC/IC?
Due to decreased ileal bile salt absorption, so there is increased bile salt delivery to the colon Colonic irritation and increased bicarb and water secretion (secretory diarrhea) Treat with cholestyramine (bile-acid sequestrant in the GI tract) and decreased fat intake
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Diarrhea after ileocecal valve or colon resection?
Decreased bowel transit time + osmotic diarrhea Treat with oral bulking agents and loperamide
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Contraindications for orthotopic ileal neobladder
Inability/unwillingness to catheterize Urethral stricture disease SUI GFR <50 Severe liver disease Positive urethral margin IBD (crohn's) Short bowel syndrome
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Maneuvers to do if there is difficulty reaching the urethral stump with neobladder
Reduce Trendelenburg Incise peritoneum over the neobladder mesentery Staple the medial/proximal mesentery while avoiding ischemia Release ileum around ileocecal junction Convert to ileal conduit or sigmoid neobladder
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Abdominal pain over continent diversion and explosive urinary leakage
Pouchitis Urine culture and empiric abx First line treatment is regular pouch irrigation Second line is prophylactic abx or urine acidification
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Why?: Isolated nocturnal incontinence s/p RC/NB
Associated with loss of afferent input from the detrusor to CNS, which normally causes a reflex rise in urethral pressure during reservoir filling
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What is bowel segment of choice in neobladder? Why?
Detubularized ileum Superior compliance Lowest likelihood of generating intermittent high-pressure contractions
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Next step?: Urethral recurrence in neobladder
If invasive disease --> urethrectomy + urinary diversion If superficial, can try to TUR or do intraurethral BCG
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Urethral recurrence after Studer (U-shaped) NB?
Urethrectomy + conversion of afferent limb into ileal conduit
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Omentum blood supply
Right gastroepiploic artery
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First branch off of the internal iliac
Umbilical artery - This gives off the superior vesical arteries before becoming the obliterated umbilical artery (medial umbilical ligament) Ureter passes medial to the medial umbilical ligament to reach the bladder Vas deferens enters the pelvis lateral to the epigastrics and then passes medially, anterior to the ureter, to reach the base of the prostate
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Branches of the External Iliac Artery
Inferior epigastric Deep circumflex iliac Femoral (gives rise to superficial and inferior external pudendal arteries, which supply blood to rhe penile and lateral scrotal skin, respectively)
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Posterior branches of the Internal Iliac Artery
Iliolumbar, lateral sacral, superior gluteal Ligation of the internal iliac should only be done distal to the posterior branch to avoid devascularization
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Anterior branches of the Internal Iliac Artery
Umbilical Obturator Inferior Gluteal Uterine (F) Vaginal (F) Inferior vesical (blood supply to prostate via prostatic and capsular branches) Middle Rectal Superior Vesical (blood supply to vas deferens via vesiculodeferential) Internal pudendal
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Celiac Artery Branches
Left Gastric artery Common Hepatic artery Splenic artery