Surgical Management of Bladder Cancer Flashcards
The administration of neoadjuvant chemotherapy has improved survival in muscle-invasive bladder cancer from:
a. 16 to 42 months.
b. 23 to 54 months.
c. 37 to 51 months.
d. 46 to 77 months.
e. 75 to 85 months.
d. 46 to 77 months. In a seminal randomized trial, Grossman and colleagues compared the treatment of muscle-invasive bladder cancer with radical cystectomy alone or surgery followed by three cycles of MVAC chemotherapy (methotrexate, vinblastine, doxorubicin, and cisplatin). They demonstrated a significant improvement in survival (46 vs. 77 months) in the neoadjuvant chemotherapy arm. This study serves as the basis for current treatment paradigms in muscle-invasive bladder cancer (Grossman etal., 2003).
Upper-tract imaging for urothelial carcinoma may include all of the following EXCEPT:
a. renal ultrasound.
b. computed tomography (CT) abdomen and pelvis. c. whole-body positron emission tomography (PET)/CT.
d. magnetic resonance imaging (MRI) abdomen and pelvis.
e. retrograde pyelogram.
c. Whole-body positron emission tomography (PET)/CT. Conventional staging evaluation for upper-tract urothelial carcinoma should include evaluation of both the kidney parenchyma and the urothelial lumen. Although PET/CT can be useful for a staging evaluation, the resolution of imaging within the urinary tract is limited by the excretion of contrast material and lack of granular resolution.
MRI-based contrast agents are absolutely contraindicated at which glomerular filtration rate (GFR) level?
a. <15 mL/min
b. <20 mL/min
c. <30 mL/min
d. <35 mL/min
e. <60 mL/min
c. <30 mL/min. Although gadolinium contrast should be administered with caution in patients whose GFR is between 30 and 60 mL/min, it is absolutely contraindicated in those with GFR <30 mL/min. This is due to the risk of nephrogenic systemic sclerosis.
The improvement in 5-year survival and median survival when more than 10 lymph nodes are removed is approximately:
a. 15%, 24 months.
b. 10%, 36 months.
c. 20%, 24 months.
d. 5%, 15 months.
e. 15%, 15 months.
e. 15%, 15 months. In a study of surgical factors that influence outcomes in bladder cancer treatment, Herr and colleagues found that a lymph node dissection inclusive of more than 10 nodes was associated with improvement in survival of 15 months (Herr etal., 2004).
Which of the following statements is TRUE?
a. Urethral recurrence following radical cystectomy is approximately 8% at 5 years.
b. Even patients with a negative intraoperative urethral frozen section are at high risk for recurrence.
c. The negative predictive value of urethral frozen section is poor.
d. Orthotopic neobladder is protective against urethral recurrence and therefore a positive urethral margin is not a contraindication.
e. Orthotopic neobladder can only be performed after nerve-sparing radical cystectomy.
a. Urethral recurrence following radical cystectomy is approximately 8% at 5 years. Factors that influence the risk of recurrence after radical cystectomy include orthotopic substitution with a positive urethral margin on frozen section analysis. This should be considered a contraindication for such a diversion. In addition, the negative predictive value is useful in the evaluation of urethral margins, and the risk of recurrence is only 8% at 5 years (Freeman etal., 1996).
Which of the following statements is FALSE regarding nerve-sparing radical cystectomy?
a. A technique analogous to radical prostatectomy is used.
b. Sexual function is similar for capsular-sparing and conventional nerve-sparing techniques.
c. Age is a strong predictor of the return of erectile function.
d. Nerve sparing does not increase local recurrence rates.
e. Ejaculatory function can be maintained with subtotal prostate resection.
b. Sexual function is similar for capsular-sparing and conventional nerve-sparing techniques. The rate of natural potency after radical cystectomy with conventional nerve sparing is lower than that of analogous prostatectomy series. Studies examining sexual function after subtotal resection (e.g., prostate sparing) have demonstrated improved results (Spitz etal., 1999); however, caution is advised because of the high risk of concurrent occult prostate cancer and potential for increased local recurrence.
Anterior pelvic exenteration includes removal of the following EXCEPT:
a. uterus.
b. cervix.
c. ovaries.
d. urethra.
e. vaginal introitus.
e. Vaginal introitus. The vaginal introitus should be maintained for routine anterior exenteration. Satisfactory vaginal capacity can be maintained with both non–vaginal-sparing and vaginal-sparing approaches. In neither instance should a colpocleisis be performed as a matter of routine.
Partial cystectomy is appropriate in which of the following settings?
a. 4-cm T2 lesion in the trigone
b. 1-cm T2 lesion in the dome
c. 3-cm T2 lesion in the dome with carcinoma in situ (CIS) in one location
d. 1-cm T2 lesion with pelvic lymphadenopathy on imaging
e. CIS in two locations
b. 1-cm T2 lesion in the dome. In the setting of muscle-invasive bladder cancer, partial cystectomy can be considered in very select patients. In those with small lesions and a lack of concurrent CIS, the results of partial cystectomy approach those of radical cystectomy (Kassouf etal., 2006; Capitanio etal., 2009).
Enhanced recovery includes all of the following EXCEPT:
a. alvimopan.
b. neostigmine.
c. pharmacologic thromboembolism prophylaxis.
d. nasogastric suction.
e. early enteral feeding.
d. Nasogastric suction. Postoperative nasogastric suction should be considered in patients with compromised airway protection; however, this has not been demonstrated to enhance recovery and need not be incorporated to facilitate return of bowel function postoperatively. Early enteral feeding, neostigmine, and alvimopan have all demonstrated efficacy in improving return of bowel function following abdominal surgery.
Thromboembolism prophylaxis is needed:
a. immediately before incision.
b. postprocedure for 1 day.
c. postprocedure for 1 week.
d. postprocedure for 1 month.
e. both a and d.
e. Both a and d. In addition to the administration of prophylaxis prior to incision, a reduction in postoperative thromboembolic events from 4.6% to 0.8% was observed in patients treated for 4 weeks following abdominal or pelvic surgery (Kakkar etal., 2010).
The RAZOR trial demonstrated which of the following:
a. Inferior 2-year progression-free survival for open radical cystectomy
b. Inferior 2-year progression-free survival for robotic radical cystectomy
c. Superior oncologic outcomes for robotic radical cystectomy
d. Noninferior 5-year progression-free survival for robotic radical cystectomy
e. None of the above
e. None of the above. The RAZOR trial was designed as a prospective multiinstitutional noninferiority trial and demonstrated non-inferior progression-free survival at 2 years for robotic radical cystectomy when compared to open radical cystectomy (Parekh etal., 2018).
Which of the following statements is supported by level 1 evidence?
a. Robotic radical cystectomy with minimally invasive urinary diversion has a similar complication rate to an open approach.
b. Robotic radical cystectomy results in decreased blood loss when compared to open radical cystectomy.
c. Robotic radical cystectomy and open urinary diversion is oncologically inferior to an open approach.
d. Robotic radical cystectomy and minimally invasive urinary diversion is more costly than an open approach.
e. None of the above.
b. Robotic radical cystectomy results in decreased blood loss when compared to open radical cystectomy. The results of the RAZOR trial (Parekh etal., 2018) and the randomized study performed at Memorial Sloan Kettering Cancer Center (Bochner etal., 2014) demonstrated improvements in blood loss for robotic radical cystectomy. Notably both studies utilized an open technique for the urinary diversion.
Before endoscopic treatment of bladder cancer, the patient should have what?
Upper-tract imaging.
Initial transurethral resection of a bladder tumor should routinely be performed to include what? There should be a margin of how wide visible on the surface?
Muscle; 2cm
Immediately following transurethral resection of bladder tumors, intravesical instillation of what modestly reduces recurrences but has little effect on progression?
Epirubicin or mitomycin C
