Bladder carcinoma

1. MIBC

2. • OVER ALL 20 to 30% of patients will present with muscle-invasive bladder cancer at
the time of initial presentation.(NMIBC is 70 to 80%)
• Majority of patients present with MIBC at the time of initial presentation ie if we
proceed to TUR and send the sample to pathology at initial presentation it is MIBC only
but a smaller subset (approximately 20%) will progress to muscle-invasive disease after
an initial diagnosis of non–muscle-invasive bladder cancer. May be coz of noncompliant
patient or attenders or any other delay.

3. PROMPT TREATMENT TO MIBC??
•Muscle-invasive bladder cancer is a highly
lethal entity and if left untreated will result
in mortality within 2 years of diagnosis in
85% of cases (Prout and Marshall, 1956).

4. CLINICAL STAGING
• Clinical staging for bladder cancer is the assessment of disease extent before radical
cystectomy, whereas pathologic stage is determined by microscopic analysis of radical
cystectomy and pelvic lymphadenectomy specimens
• CLINICAL STAGING BY FOLLOWING METHODS 
• 1) TUR Specimen
• 2)Bimanual examination under anaesthesia
• 3) liver function tests
• 4) chest radiography, and contrast-enhanced cross-sectional imaging of the abdomen
• 5) pelvis with upper tract imaging

5. TUR
• Gold standard method for establishing the diagnosis of muscle- invasive bladder cancer. In addition to
pathologic staging,TUR also can provide valuable information on histologic variants that may direct
therapeutic decision making.
• Complete resection of macroscopic tumor is advisable when it is safe and feasible.
• Complete resection decreases local tumor burden and may optimize the response to neoadjuvant
chemotherapy, or for patients undergoing chemoradiotherapy it may improve the likelihood of
successful bladder preservation.
• The status of the bladder neck in women and the prostatic urethra in men should also be carefully
evaluated at the time of initial resection, as it can affect clinical decision making with regard to
neoadjuvant chemotherapy (prostatic stromal invasion), surgical management of the urethra, choice of
urinary diversion at the time of radical cystectomy, and clinical target volumes in radiotherapy. (even to
avoid recurrences).

6. PROSTATIC URETHRAL BX
• Using a resectoscope, a full loop of tissue is taken from the midprostate (or bladder neck
in shorter prostates) to the mid- to distal verumontanum and 5 and 7 o'clock adjacent
to the verumontanum.This is the site of the highest concentration of prostatic ducts and
the area where carcinoma in situ (CIS) is most likely to be found.
• The full-thickness prostatic resection allows the pathologist to evaluate the interface
between the urethral mucosa, prostatic ducts, and stroma, which allows for accurate
staging of the prostatic urethra.
• Negative prostatic urethral biopsies are associated with negative apical urethral margins,
and it has been suggested that they can replace the need for intraoperative frozen
section at the time of radical cystectomy

7. SIGNIFICANCE OF PU BX
• The absolute risk for urethral recurrence following cystectomy ranges from 4% to 8% in
men
• The majority of urethral recurrences are symptomatic, but in patients who are deemed
at high risk for such events, periodic cytology can be useful for detection of recurrences
• Risk factors for urethral recurrence include non–muscle-invasive disease on final
pathology and prostatic urethral involvement
• The extent of prostatic involvement is also predictive of urethral recurrence. Prostatic
stromal invasion is associated with the highest risk (as high as 30%) compared with that
of prostatic urethral CIS and ductal or acinar involvement

8. THIS CHANGESTHE EXTENT OFTUMOUR REMOVAL
• Urethrectomy should be considered in men with diffuse CIS of the prostatic urethra or
ducts or if there is prostatic stromal invasion. Preoperative evaluation of the prostatic
urethra via biopsy can be performed to characterize further the risk for urethral
recurrence and help dictate intraoperative management of the distal urethra and choice
of urinary diversion.

9. BIMANUAL EXAMINATION UNDER ANESTHESIA
• HOW??  The examination is performed typically by placing the dominant hand on the suprapubic
region and one or two fingers from the nondominant hand in the rectum (males) or vagina.This
should be performed with the bladder drained and without a Foley catheter in place to maximize
palpation of the bladder.
• WHEN?? Bimanual examination can be performed at the time of initial tumor resection and should
be done before and after resection.
• INTERPRETATION?? Findings described originally by Marshall are T2a: nonpalpable;T2b: induration
but no three-dimensional mass;T3a: three-dimensional mass that is mobile;T4a: invading adjacent
structures such as the prostate, vagina, or rectum;T4b: fixed to pelvic sidewall and not mobile.
• LIMITATIONS?? Bimanual examination is not 100% accurate in predicting final tumor pathology,
with an 11% clinical overstaging and a 31% clinical understaging rate reported

10. CROSS-SECTIONAL IMAGING
• Abdominal and pelvic cross-sectional imaging are recommended by the National Comprehensive
Cancer Network (NCCN) when muscle-invasive disease is suspected beforeTUR
• The timing of imaging relative toTUR is also important to note  Although it is optimal to
obtain cross-sectional imaging before TUR, if imaging is obtained subsequently, it should be
delayed approximately 7 days postprocedure to minimize inflammatory artifact, which can be
mistaken for T3 disease
• A high suspicion for extravesical disease is warranted when hydronephrosis is noted on cross-
sectional imaging.The presence of hydronephrosis on staging CT is associated with an increased
risk for extravesical disease (27.8% vs. 17.3%) at the time of cystectomy

11. z

12. RADICAL CYSTECTOMY
• For patients with clinical T2–T4a, N0, M0 disease, radical cystectomy and bilateral pelvic lymph
node dissection remains the gold standard therapy by which all other treatment modalities should
be compared.
• Although utilization varies with age and comorbidities, approximately 80% of muscle-invasive
patients who undergo definitive management have a radical cystectomy
• Radical cystectomy provides excellent local control, with pelvic recurrence rates as low as 4% in
patients with node-negative disease
• Randomized trial data have demonstrated superior outcomes with neoadjuvant systemic
chemotherapyBut in NMIBC delay in treatment for > 12 weeks survival is poor which is proved
in many studies and trials and clinically some patients may not show favourable outcomes with this
delaying local treatment is the only disadvantage of neoadj CT to be noted.

13. WHAT TO REMOVE ANDWHAT TO PRESERVE??
• In men, radical cystectomy includes excision of the surrounding perivesical soft tissue,
prostate, and seminal vesicles, and, in women, it includes the ovaries, uterus with cervix,
and anterior vagina.
• Since the mid-2000s, greater emphasis has been placed on urinary and sexual quality of
life following cystectomy.This has led to a greater interest in organ preservation in both
men and women.
• In men, preservation of the neurovascular bundles, some or all of the prostate, and the
seminal vesicles have been reported in an attempt to improve postoperative quality of
life  but not at the cost of oncological outcome hence weigh the risk of organ
preservation.

14. • If prostatic preservation is considered, transurethral sampling of the prostatic urethra
and bladder neck is advisable to maximize appropriate patient selection and consider
preserving either Apical or total or posterior sparing of prostate.
• Functional outcomes after prostate preservation tend to be directly associated with the
amount of tissue spared at the time of surgery.
• Though althese are options still on oncologic prospective cystoprostatectomy remains
the gold standard.

15. INWOMEN
• Preservation of the uterus, ovaries, and vagina has also been explored in women at the time
of radical cystectomy.
• Although an anterior exenteration has classically been advocated in women at the time of
radical cystectomy, urothelial carcinoma rarely involves the gynecologic organs, with an
overall incidence of approximately 5% of cases (Chang et al., 2002).
• Unless there is tumor involvement of the bladder neck, a complete urethrectomy can be
omitted at the time of cystectomy, allowing for orthotopic bladder substitution in women.
• carefully selected patients can also forgo removal of the uterus and anterior vagina, which
potentially allows for better anatomic support for a neobladder and preserves the
autonomous nerves.

16. BILATERAL PELVIC LYMPH NODE DISSECTION
SIGNIFICANCE
• Approximately 25% of patients will have pathologic lymph node metastases at the time of
cystectomy (Lerner et al., 1993).
• Lymph node status is the most powerful surrogate for long-term recurrence-free and OS following
radical cystectomy (Poulsen et al., 1998; Stein et al., 2001).
• Skinner (1982) was first to report the value of a meticulous pelvic lymph node dissection,
demonstrating better local control rates, potential for cure, and acceptable morbidity in patients
undergoing radical cystectomy.
• multiple surgical series have demonstrated the profound impact of nodal involvement at the time
of radical cystectomy, with approximately 70% to 80% of patients with lymph node metastasis
ultimately experiencing disease recurrence in contrast with approximately 30% of patients with a
negative pelvic lymph node dissection (Shariat et al., 2006b; Stamatakis et al., 2012).

17. • The extent of lymph node dissection at the time of cystectomy has been shown as an
independent predictor of survival and local recurrence, even when chemotherapy status
and other pathologic factors are controlled

18. ANATOMIC EXTENT OF PELVIC LYMPH NODE
DISSECTION AND LANDING ZONES
• Whereas the importance of a lymph node dissection seems undebatable, what actually
constitutes an adequate lymph node dissection and its exact therapeutic benefit remains
less clear.
• Secondary drainage sites include higher echelon nodes, including the common iliac, para-
aortic, interaortocaval, and paracaval lymph nodes (Abol-Enein et al., 2004; Leissner et al.,
2004;Vazina et al., 2004).

19. MANSOURA, EGYPT, ABOL-ENEIN ET AL. (2004)
• evaluated the extent and distribution of positive lymph nodes in 200 consecutive patients with rad
cystectomy and PLND superiorly till IMA branch of aorta FOR 4yrs.
• Of which 24% were having positive LN with a mean of 8 positive LN
• In 22 patients only a single LN was positive of which 21 located in endopelvis.
• METASTASIS OUT SIDETHETRUE PELVIS WAS SEEN ONLY IN MULTINODAL DISEASE
PATIENTS AND WAS ASSOCIATED WITH INVOLVEMENT OF ILIAC AND OR OBTURATOR
NODES IN ALL PATIENTS.
• TO CONCLUDE  The authors found no evidence of “skip” metastasis in patients with
positive nodes.The authors suggested that the obturator and internal iliac nodes represent
the sentinel lymphatic drainage areas and that if lymphadenectomy proved to be negative on
frozen-section analysis at the time of surgery, a more superior dissection was not warranted.

20. STANDARD AND EXTENDED PLND
• A standard pelvic lymph node dissection was defined superiorly by the iliac bifurcation
and included the external iliac, hypogastric, and obturator lymph node packets.
• An extended dissection also included the nodal packets to the level of the aortic
bifurcation to no more than 2 cm proximal to the bifurcation.The common iliac and
presacral nodes were also included in the extended dissection template.

21. MSKCC GROUP
• Reported in 144 patients undergoing either standard or extended LN dissection obviously the
no. of positive LN were higher in extended LN dissection but still no staging advantage is found
though with both groups having same number of patients with positive LN.
• Four percent of patients presented with positive lymph nodes identified within the para-aortic
packets, all of whom also showed positive lymph nodes in lower dissection packets.
• The authors did note four patients with micrometastatic disease to the common iliac vessels
only, concluding that this area should be considered part of the standard lymph node dissection.

22. THOUGH ANATOMIC EXTENT OF LN DISSECTION REMAINS DEBATABLE
• Standard ln dissection  Based on anatomic mapping studies, it is recommended that a
standard pelvic lymph node dissection at the time of radical cystectomy include the
lymph node packets from the external iliac lymph vessels up to the level of the common
iliac bifurcation cephalad and the genitofemoral nerve laterally to the ureter medially.
• An extended template dissection should include the tissue extending above the common
iliac bifurcation to the aortic bifurcation and presacral region.
• Finally, with a superextended lymph node dissection, the tissue up to the level of the
inferior mesenteric artery should be included.

23. • however, clinical recent and ongoing clinical trials will ultimately answer this question.
• The German Urologic Oncology Group (GUO) prospective, randomized trial comparing
limited dissection (obturator, internal and external iliac nodes) with extended dissection
(limited plus deep obturator, presacral, paracaval, interaortocaval, and paraaortal nodes)
did not demonstrate a 5-year difference in recurrence-free or cancer-specific survival
between these two groups  however the extended arm showed improvement which is
nonsignificant though.

24. AWAITED
• We also await the results of the Southwest Oncology Group (SWOG) S1011
prospective, randomized trial comparing survival in cystectomy patients undergoing
extended or standard pelvic lymph node dissection (NCT01224665).

25. NUMBER OF LYMPH NODES IDENTIFIED AT THE TIME
OF CYSTECTOMY
• Leissner et al. (2000) retrospective study in 447 patients of mainz,Germany used
16 node threshold coz for the survival analysis correlation between the total number of
lymph nodes removed and the percentage of positive nodes was strongest at this count.
• Capitanio et al. (2009) studied 731 patients and concluded a 25-node minimum as a
reasonable cutoff to adequately stage and detect lymph node metastasis.
• There is no general consensus in the literature regarding the exact threshold of nodes at
which a survival benefit can be predicted, with most studies reporting numbers in the 9
to 16 range (Herr, 2003; Herr et al., 2002; Hollenbeck et al., 2008; Konety et al.,
2003; Leissner et al., 2000; May et al., 2011; Stein et al., 2003). Koppie et al.
(2006)

26. MORE STUDIES ARE NEEDEDTO CONFIRMTHE NUMBER.
• BUT many clinicians consider a minimum threshold of 10 LN’s to avoid locoregional /
pelvic failure.
• Lymph Node Density  LND is %age of +ve LN to total LN’s if < 20% then there is a
favourable 5yrs disease specific survival following radical cystectomy.
• Extracapsular Nodal extension  extranodal extension was significantly associated with
both disease recurrence and cancer- specific mortality.
• Similarly, Seiler et al. (2011) reported an extranodal extension to be an independent
predictor of OS and DSS in a smaller cohort (N = 162) of node-positive patients.

27. INTRAOPERATIVE DECISION MAKING
• Grossly Positive Nodes and T4b Disease  abort radical cystectomy and go for cisplatin
based chemotherapy  then Patients who have a radiographic complete or partial
response to systemic therapy are candidates for and should be evaluated for cystectomy.
• Patients who do achieve a complete response appear to have a significant survival advantage
with 5-year cancer-specific survival rates of 63% (Meiger et al., 2014).
• Herr also reported tha the overwhelming majority of patients who initially respond to
chemotherapy but do not have surgery are destined to recur , and therefore consolidative
cystectomy should be strongly considered in appropriate surgical candidates who respond
to systemic therapy.
•

28. • If adenopathy is encountered at the time of cystectomy, a frozen section should be taken
to confirm metastasis, and an extended lymph node dissection and radical cystectomy
should be completed when feasible.
• Consider aborting cystectomy when 1)unresectable disease
2)evidence of extensive periureteral disease
3)bladder fixed to pelvic side wall or
4)rectosigmoid invasion.

29. INTRAOPERATIVE FROZEN SECTIONS OF THE URETER
• The incidence of involvement of the distal ureter with tumor on final pathology at the
time of radical cystectomy was 6% to 8%
• There is no definitive recommendation for the precise length of the distal ureter that
should be removed at the time of surgery. Final ureteral margin status has proven to be
an independent predictor of upper tract recurrence following cystectomy
• overall incidence of upper tract recurrence following cystectomy is a relatively rare event
ranging from 2% to 8%

30. • risk factors for upper tract recurrence following cystectomy includes 
1) bladder CIS,
2)distal ureteral involvement with tumor,
3)high-grade pTa-T1 disease
Upper tract recurrences are mcly between 2 – 4yrs post cystectomy and unfortunately
carry a poorer prognosis and often locally advanced when compared to denovo upper
tract malignancies.

31. INTRESTING!!!
• In a study those with initial positive margins, 83% were subsequently converted to a negative margin with
further resection. Interestingly, those with an initial positive margin but negative final margin still were at
higher risk for upper tract recurrence (hazard ratio [HR] = 4.88, 95% confidence interval [CI] 3.02 to
7.90, P < .001) compared with those with initial negative margins.
• These findings suggest that patients with ureteral disease at the time of cystectomy experience an
increased risk for upper tract recurrence regardless of margin status, but this risk can be at least partially
mitigated by achieving a negative margin.
• In other study ureteral margins that were not converted to negative intraoperatively were associated
with poorer cancer-specific mortality, but only in patients with negative soft tissue margins and without
nodal metastasis.

32. SKIP LEISONS IN URETER
• i.e negative distal frozen, positive proximal permanent margin (mcly)  identified in of
patients with CIS.
• Hence given the findings outlined earlier, it appears logical to attempt to clear the distal
ureter when feasible at the time of radical cystectomy.
• When frank tumor is encountered, it should be resected to a negative margin.When CIS
only is encountered, maximal resection without compromising ureteral length for urinary
diversion is advocated, as it is debatable whether a negative CIS margin reduces upper
tract recurrence or is definitively associated with poorer outcome.

33. PROSTATIC UROTHELIAL CARCINOMA AND MANAGEMENT OF
THE DISTAL URETHRA
• The absolute risk for urethral recurrence following cystectomy ranges from 4% to 8% in men
• Most of urethral recurrences are symptomatic though if we suspect the patient as high risk then periodic
cytology may help us.
• High risk or recurrences in patients with 
• non–muscle-invasive disease on final pathology and prostatic urethral involvement.
• The extent of prostatic involvement is also predictive of urethral recurrence highest is prostatic stromal
involvement though prostatic CIS or ductal or acinar involvement also carries some risk.
• Urethrectomy should be considered in men with diffuse CIS of the prostatic urethra or ducts or if there is
prostatic stromal invasion  for this Preoperative evaluation of the prostatic urethra via biopsy can be
performed
• Some experts advocate urethrectomy only if positive apical urethral margin is observed.

34. MANAGINGTHE FEMALE URETHRA
CONCOMITANT INVOLVEMENT OFTHE URETHRA IN WOMENWITH BLADDER CANCER RANGES FROM 2%TO 12%
• Before female orthotopic bladder substitution became more commonplace, complete
removal of the female urethra at the time of radical cystectomy was routine.
• Clinical features associated with an increased risk for distal urethral tumor involvement
include primary tumor location at the bladder neck, vaginal involvement, or inguinal
lymphadenopathy
• Frozen- section analysis of the distal urethra has demonstrated high correlation with final
urethral margin and should be performed in all women in which orthotopic bladder
substitution is being considered

35. ONCOLOGIC OUTCOMES FOLLOWING RADICAL CYSTECTOMY
• Pathologic tumour stage and LN mets are strongest predictors of recurrence and
survival.
• Strongest predictor of outcome is  non organ confined disease i.e > T2
• Single greatest predictor of survival is LN status.
• Other variables affecting the prognosis are  margin status , LVI, molecular markers, age,
BMI, surgical expertise.
• Imp to remember that recurrences are mcly seen in first 2yrs in MIBC.

36. FOR PELVIC FAILURE
• Three risk groups were defined for pelvic failure:
• Low risk  less than pT3 disease;
• Intermediate risk pT3–4, negative margins, and greater than 10 lymph nodes identified
• High riskpT3–4 with positive margins or less than 10 lymph nodes identified.
• This model consistently stratifies pelvic failure risk in geographically and temporally
diverse radical cystectomy cohorts, with 5-year pelvic failure rates of approximately 8%
for low-risk groups, 19% to 21% for intermediate-risk groups, and 41% to 46% for high-
risk groups (Christodouleas et al., 2014; Ku et al., 2014; Novotny et al., 2015).

37. NEOADJUVANTTHERAPY FOR MUSCLE- INVASIVE BLADDER CANCER
• Significance?? Approximately 50% patients who are treated with cystectomy alone will
progress to metastatic disease.
• Logic behind its use??  Its better tolerated before surgery.
 Micro metastatic disease is dealt well.
 Downstage bulky and LA tumours for higher chance of negative
margins.
 Only disadvantage of neoadjuvant chemotherapy is a delay in definitive local therapy for
patients who do not respond to chemotherapy and thus experience disease progression.

38. • Based on the randomized trial results and subsequent meta-analyses, cisplatin- based
neoadjuvant chemotherapy is associated with an OS advantage of 5% to 6% and a
pathologic complete response rate of 30% to 40%.
• Currently the NCCN guidelines recommend that clinicians strongly consider
neoadjuvant cisplatin-based chemotherapy for cT2N0M0 patients and recommend
neoadjuvant cisplatin-based chemotherapy for cT3–T4aN0M0 patients.
• Regimens  MVAC , CA or MVEC.

39. ADJUVANTTHERAPY FOR MIBC
• Rationale  unlike neoadjuvant CT this doest waste anytime i.e allows immediate local
treatment with cystectomy and avoids any delay in patients with chemo resistant
tumours.
• This can also treat micromets post surgery.
• Regimens are same as that of NA CT.
• Given in pT3 – T4 or node positive disease.
• NCCN currently favours Neoadjuvant instead of adjuvant CT.
• However for pT3 – T4 or Node +ve disease  prefer NA + SX + Adjuvant CT.

40. ADJUVANT RT
• The strongest indication is for those with positive soft tissue surgical margins.
• This is being studied also in patients who has high risk of pelvic failure i.e (pT3-T4 or
node positive disease with less than 10 LN identified).
• The main disadvantage of ADJ RT is SBO in post operative period hence use with
caution.

41. BLADDER PRESERVATION
• Bladder preservation is a curative intent paradigm that should be considered in two
distinct populations:
• (1) patients who have high operative risks as a result of comorbidities and frailty.
• (2) patients who are fit for radical cystectomy but have limited burden of disease, adequate
normal bladder urothelial and function, and are motivated to retain their bladder.
• Can be done via two approaches  1)Trimodality therapy.  (rigorously studies recently)
2)Single modality therapy.(For completely unfit and frail patients)

42. TRIMODALITYTHERAPY
AGGRESSIVE VISIBLY COMPLETETUR + CT +RT
• When carefully selected have similar long term cancer control outcomes to that of radical
cystectomy.
• Can go for this bladder preservation method in patients who have limited burden of the disease.
(About 6 to 19% of the MIBC patients)
• i.e Who has unifocal and small (<4cm) tuomour without frank extravesicular extension on imaging
i.e not T3b or no HUN and should be grossly and totally resected by TUR.
• AVOIDTHIS IN patients with poor baseline bladder function and if in c/o diffuse CIS and
importantly in patients with LONG LIFE EXPECTANCY  as we give RT as a part of regimen
chance of secondary malignancies are more in patients with long life expectancy.

43. STRATEGIES FORTRIMODAL BLADDER PRESERVATION.
• split-course and continuous-course therapy.
• Split-course therapy is based on the premise of mid- treatment restaging and is only
appropriate for patients who are surgically fit and thus eligible for an immediate salvage
cystectomy.
• Here patients are administered induction chemoradiation therapy to approximately 40 Gy, which
is followed by restaging with cross-sectional imaging and endoscopic evaluation. If persistent
invasive disease is noted, radical cystectomy is recommended.Those without persistent invasive
disease undergo consolidative chemoradiotherapy to approximately 60 to 64 Gy.

44. • Continuous-course treatment involves a full course of chemoradiation therapy
followed by an endoscopic restaging examination 3 to 4 months after therapy to allow
time for an adequate response to therapy.
• Continuous-course treatment is an appropriate option for both surgically fit and unfit
patients. Given the same total dose, continuous-course treatment is more intensive than
split-course treatment because continuous-course therapy is completed over a shorter
period, which limits the opportunity for both tumor and normal tissue cell repopulation.

45. • Factor that likely affects the efficacy of trimodality therapy is the quality of theTUR.
• The rates of radical cystectomy for visibly complete resections are lower (11%)
compared with incomplete resections (42%) (Efstathiou et al., 2012).

46. SINGLE-MODALITYTREATMENT
THREE OPTIONS ARE 1) RT ALONE 2) RADICALTUR ONLY 3) CT ONLY
4)PARTIAL CYSTECTOMY
• RT alone in poor performance status or comorbidities patient.
• RadicalTUR only  Primary support for radical TUR as a single-modality therapy for
patients with T2 disease is largely based on the finding of p0 disease in approximately
10% of patients treated with radical cystectomy alone.
• Although specifically selected individuals can achieve a durable response with radical
TUR, most patients presenting with muscle-invasive bladder cancer are not appropriate
candidates and will not be cured with TUR monotherapy.

47. • If a patient is going to elect TUR monotherapy, that patient should be properly informed
regarding the risk for recurrent disease and should be appropriately selected based on clinical
criteria like
• negative restaging TUR
• no hydronephrosis
• no evidence of adenopathy
• tumor size less than 3 cm and
• lack of multifocal disease.

48. • Chemotherapy Monotherapy  patients with low-risk muscle-invasive tumors can be
cured with TUR and chemotherapy alone but recurrence chances are high.
• Partial Cystectomy  Compared with radical TUR, partial cystectomy offers two
distinct advantages. First, a full pelvic lymphadenectomy can be performed that allows for
complete staging. Second, the full thickness of bladder wall and associated perivesical fat
can be removed.
• This is feasible in small solitary tumours <25% of total bladder amenable to WLE with
2cm margin and should be away from ureteral orfice and No involvement of trigone and if
complete TUR is possible.
• Presence of CIS is a contraindication for this partial cystectomy.

49. PROGNOSTIC NOMOGRAMS FOR MUSCLE- INVASIVE BLADDER CANCER
• TNM staging system provides valuable prognostic information following radical
cystectomy. Despite its usefulness, there is often wide variation among patients with
regard to absolute risk for recurrence as a result of the heterogeneity of tumor biology
and patient characteristics.
• Nomograms have been developed in an effort to better predict the prognosis in patients
with muscle- invasive disease
• Two consortia have published easy-to-use nomograms for predicting recurrence
following radical cystectomy.

50. THE INTERNATIONAL BLADDER CANCER
CONSORTIUM (IBCC)
• The International Bladder Cancer Consortium (IBCC) collected data on 9064 patients
from 12 centers of excellence (Bochner et al., 2006).
• Significant variables in the nomogram included age, grade, pathologic stage, histologic
subtype, lymph node metastasis, and timing of surgery.
• The final nomogram was significantly superior to standard prediction models in
predicting disease-free survival following cystectomy (95% CI 0.75) compared with TNM
stage (95% CI 0.68) or standard pathologic grouping models (95% CI 0.62).

51. THE BLADDER CANCER RESEARCH CONSORTIUM (BCRC)
HAS ALSO PUBLISHED A POSTCYSTECTOMY NOMOGRAM
• BCRC published a postcystectomy nomogram based on 728 patients from three centers
• As opposed to the IBCC nomogram, all patients in the BCRC had urothelial histology.
Multivariate predictors of disease recurrence, cancer-specific mortality, and all-cause
mortality at 2, 5, and 8 years postcystectomy included pT stage, nodal status,
lymphovascular invasion, perioperative chemotherapy administration, and adjuvant
radiation therapy.
• Both nomograms have been validated in other patient cohorts (Zaak et al., 2010).

52. COBRA
• More recently, the Cancer of the Bladder Risk Assessment (COBRA) score has been
shown to be a relatively straightforward method of predicting mortality after radical
cystectomy
• Similar in concept to the CAPRA score for prostate cancer, this nomogram assigns
clinical variables including age, tumor stage, and lymph node density a risk score, and it is
relatively straightforward and easy to use compared with more complicated nomograms.

54. THANKYOU