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Introduction: Despite its proven benefit, studies have reported poor use of perioperative chemotherapy (POC) in bladder cancer (BC) patients undergoing radical cystectomy (RC). We evaluated POC use in Quebec between January 2000 and September 2016. Methods: Using provincial health administrative databases, data were retrospectively collected from patients from two years before RC until December 2016 or death. Logistic regression was used to identify variables predicting POC use. Survival analyses were conducted using Cox regression. Analyzed covariates were age, sex, comorbidities, year of RC, residence and hospital region, distance to hospital, hospital type and size, and hospital’s and surgeon’s RC volume. Results: A total of 790/4656 patients (17.0%) received POC. Neoadjuvant chemotherapy (NAC) use increased in recent years: 3.5% (2009), 11.2% (2012), and 20.7% (2015). POC use was increased in patients with recent surgery, a younger age, less comorbidities, residing closer to the hospital of surgery, and a high surgeon’s RC volume (p

Background: Hematuria is one of the most common findings on urinalysis in patients encountered by primary care physicians. In many instances it can also be the first presentation of a serious urological problem. As such, we sought to evaluate current practices adopted by primary care physicians in the workup and screening of hematuria. Methods: Questionnaires were mailed to all registered primary care physicians across Quebec. Questions covered each physician’s personal approach to men and postmenopausal women with painless gross hematuria or with asymptomatic microscopic hematuria, as well as screening techniques, general knowledge with regards to urine collection and sampling, and referral patterns. Results: Of the surveys mailed, 599 were returned. Annual routine screening urinalysis on all adult male and female patients was performed by 47% of respondents, regardless of age or risk factors. Of all the respondents, 95% stated microscopic hematuria was associated with bladder cancer. However, in an older male with painless gross hematuria, only 64% of respondents recommended further evaluation by urology. On the other hand, in a postmenopausal woman with 2 consecutive events of significant microscopic hematuria, only 48.6% recommended referral to urology. Findings were not associated with the gender of the respondent, experience or geographic location of practice (urban vs. rural). Interpretation: There seems to be reluctance amongst primary care physicians to refer patients with gross or significant microscopic hematuria to urology for further investigation. A higher level of suspicion and further education should be implemented to detect serious conditions and to offer earlier intervention when possible.

Introduction: We sought to evaluate the contemporary role of a pathology review on management implications of patients with bladder cancer.Methods: A total of 98 consecutive specimens from transurethral resections in patients with suspected bladder tumours were reviewed at our institution by genitourinary pathologist. Patients were classified into risk groups according to pathology reports obtained before and after review. A management course was proposed according to local institutional practice patterns and main urological guidelines.Results: Overall, 34.7% of pathological reviews had significant changes associated with management implications, the majority of which were due to changes in risk category (and/or stage). On review pathology, 12 patients were recommended radical cystectomy instead of conservative management and two patients avoided radical cystectomy. Six patients initially staged as T1 and whose staging did not change after review had a proposed change in management in the form of early cystectomy as a treatment option, as they were deemed very high-risk secondary to high-risk features (such as carcinoma in situ or lymphovascular invasion found on review). Ten patients initially staged as T2 demonstrated high-risk features on review.Conclusions: Review by genitourinary pathologist remains important, as it defines more clearly the tumour risk category and influences the management of T1‒T2 bladder cancer patients. A complete initial pathological report has the potential to further decrease the discrepancy between initial and review reports.

This initiative was undertaken in response to concerns regarding the variation in management and in outcomes of patients with bladder cancer throughout centres and geographical areas in Canada. Population-based data have also revealed that real-life survival is lower than expected based on data from clinical trials and/or academic centres. To address these perceived shortcomings and attempt to streamline and unify treatment approaches to bladder cancer in Canada, a multidisciplinary panel of expert clinicians was convened last fall for a two-day working group consensus meeting. The panelists included urologic oncologists, medical oncologists, radiation oncologists, patient representatives, a genitourinary pathologist, and an enterostomal therapy nurse. The following recommendations and summaries of supporting evidence represent the results of the presentations, debates, and discussions. Methodology

Introduction: The aim of this case series is to present two cases of renal granulomas discovered incidentally post-intravesical Bacillus Calmette-Guerin (BCG) installations and were managed conservatively. Case reports: The first case is a 68-year-old man with bladder and right ureteral orifice carcinoma in situ. After transurethral resection of the right ureteral orifice and bladder tumours, he received 6 + 3 weekly intravesical installations of BCG and then 6 + 3 weekly intravesical installations of BCG with interferon alpha (IFN) in the presence of an indwelling ureteral stent since he had refused cystoprostatectomy. At the 18-month follow-up, his computed tomography scan showed two right renal masses. Biopsy demonstrated non-necrotizing granulomatosis. Serial follow-up with imaging studies showed complete resolution of these masses without antituberculous medications. The second case is a 74-year old man with left renal high-grade papillary urothelial carcinoma. After ureteral meatotomy and insertion of indwelling ureteral stents, he received 6 weekly intravesical installations of BCG followed by 3 weekly installations of BCG and IFN prior to the definitive management with laparoscopic left nephroureterectomy. Final pathology showed pT1 urothelial carcinoma and an incidental finding of BCG-related renal granulamotosis. The patient has been asymptomatic and did not require anti-tuberculous medications. Conclusions: While these two cases demonstrate the ability of intravesical BCG to reach the renal pelvis, patients with a history of intravesical BCG with incidental renal masses may benefit from renal biopsy. These renal granulomas may resolve without antituberculous medications.

Introduction: Enhanced recovery pathways are standardized, multidisciplinary, consensus-based tools that provide guidelines for evidence-based decision-making. This study evaluates the impact of the implementation of a clinical care pathway on patient outcomes following radical prostatectomy in a universal healthcare system.Methods: Medical charts of 200 patients with prostate cancer who underwent open and minimally invasive radical prostatectomy at a single academic hospital from 2009 to 2012 were reviewed. A group of 100 consecutive patients’ pre-pathway implementation was compared with 99 consecutive patients’ post-pathway implementation. Duration of hospital stay, complications, post-discharge emergency department visits and readmissions were compared between the 2 groups.Results: Length of hospital stay decreased from a median of 3 (interquartile range [IQR] 4 to 3 days) days in the pre-pathway group to a median of 2 (IQR 3 to 2 days) days in the post-pathway group regardless of surgical approach (p < 0.0001). Complication rates, emergency department visits and hospital readmissions were not significantly different in the pre- and post-pathway groups (17% vs. 21%, p = 0.80; 12% vs. 12%, p = 0.95; and 3% vs. 7%, p = 0.18, respectively). These findings were consistent after stratification by surgical approach. Limitations of our study include lack of assessment of patient satisfaction, and the retrospective study design.Conclusions: The implementation of a standardized, multidisciplinary clinical care pathway for patients undergoing radical prostatectomy improved efficiency without increasing complication rates or hospital readmissions.

Introduction: Radical cystectomy (RC) is a very complex urologic procedure. Despite improvements in practice, technique and process of care, it is still associated with significant complications, including death, with reported postoperative mortality rates ranging from 0.8% to 8%. We examine the quality of surgical care indicators and document the mortality rates at 30, 60 and 90 days after RC across Quebec.Methods: Within the Régie de l’assurance maladie du Québec (RAMQ) administrative database (this database provides prospectively collected universal data on all medical services) and the Institut de la statistique du Québec (ISQ) database (this provides vital status data), we used procedure codes to identify patients who underwent RC for bladder cancer in Quebec over 10 years (between 2000 and 2009), as well as RC outcomes and dates of death. Data obtained were retrospectively analyzed in relation to multiple parameters, including patient characteristics and healthcare providers’ volumes. The outcomes analyzed included postoperative complications and mortality rates at 30, 60 and 90 days.Results: A total of 2778 RC were performed in 48 hospitals by 122 urologists across Quebec. Among them, 851 (30.6%) patients had at least one postoperative complication and 350 (12.6%) patients had more than one complication. The overall mortality rates at 30, 60 and 90 days were 2.8%, 5.3% and 7.5%, respectively, with significantly elevated 90-day mortality rates in some centres. In the multivariate analysis, increased age was associated with increased risk of post-RC complications and mortality. For example, patients over 75 had more chance of having at least one postoperative complication (odds ratio [OR] 1.66, 95% confidence interval [CI]:1.31-2.11) and mortality at 90 days (OR 3.28, 95% CI: 2.05-5.26). Provider volume effect on outcomes was statistically significant, with large hospitals having decreased risk of 30-day mortality (OR 0.29, 95% CI: 0.12-0.70), 60-day mortality (OR 0.41, 95% CI:0.26-0.82) and 90-day mortality (OR 0.52, 95% CI: 0.29-0.93) when compared to smaller hospitals. Surgeon volume showed weak, but not statistically significant, evidence of reduced odds of mortality for the high-volume surgeon. Limitations of our study include reliance on administrative data, which lack some relevant clinical information (such as patient functional status and tumour pathological characteristics) to perform risk adjustment analysis.Conclusion: Our study demonstrates that postoperative outcomes after RC in Quebec varies based on several parameters. In addition, 30-day postoperative mortality after RC in Quebec appears acceptable. However, 90-day postoperative mortality rates remain significantly elevated in some centres, particularly in the elderly. This requires further research.

Introduction: According to the Royal College objectives of training in urology, urologic surgical procedures are divided as category A, B and C. We wanted to determine the level of proficiency required and achieved by urology training faculty for Royal College accreditation.Methods: We conducted a survey that was sent electronically to all Canadian urology training faculty. Questions focused on demographics (i.e., years of practice, geographic location, subspecialty, access to robotic surgery), operating room contact with residents, opinion on the level of proficiency required from a list of 54 surgical procedures, and whether their most recent graduates attained category A proficiency in these procedures.Results: The response rate was 43.7% (95/217). Among respondents, 92.6% were full timers, 21.1% practiced urology for less than 5 years and 3.2% for more than 30 years. Responses from Quebec and Ontario formed 69.4% (34.7% each). Of the respondents, 37.9% were uro-oncologists and 75.7% reported having access to robotic surgery. Sixty percent of faculty members operate with R5 residents between 2 to 5 days per month. When respondents were asked which categories should be listed as category A, only 8 procedures received 100% agreement. Also, results varied significantly when analyzed by sub-specialty. For example, almost 50% or more of uro-oncologists believed that radical cystectomy, anterior pelvic exenteration and extended pelvic lymphadenectomy should not be category A. The following procedures had significant disagreement suggesting the need for re-classification: glanular hypospadias repair, boari flap, entero-vesical and vesico-vaginal fistulae repair. Overall, more than 80% of faculty reported that their recent graduating residents had achieved category A proficiency, in a subset of procedures. However, more than 50% of all faculty either disagreed or were ambivalent that all of their graduating residents were Category A proficient in several procedures.Conclusions: There is sufficient disagreement among Canadian urology faculty to suggest another revision of the current Royal College list of category A procedures.

Introduction: Our objective is to assess differences in practice patterns and outcomes across 3 regions in bladder cancer patients treated with radical cystectomy under a universal healthcare system.Methods: In total, we included 2287 patients treated with radical cystectomy at 8 Canadian centres from 1998 to 2008. Variables included various clinico-pathologic parameters, recurrence, and death stratified into different regions.Results: In total, 1105 patients were from the east region (group1), 601 from the centre region (group 2), and 581 from the west region of Canada (group 3). The median follow-up of groups 1, 2, and 3 was 22.1, 17.1, and 28.6 months, respectively. Although the overall rate of neoadjuvant chemotherapy was low (3.1%), rates were higher in group 2 compared with groups 1 and 3 (p = 0.07). Continent diversions and extended lymphadenectomy were performed in 23.5%, 8.5%, 23.9% and 39.7%, 27.7%, 12.6% across groups 1, 2, and 3, respectively. There were statistically significant differences in gender distribution, performance of lymphadenectomy, presence of concomitant carcinoma in situ and lymphovascular invasion across the 3 groups. There were no differences among the 3 geographical locations in terms of stage, surgical margin status, and use of adjuvant chemotherapy. The mean number of days from the transurethral resection of the bladder tumour to cystectomy was 50, 79, 69 days for groups 1, 2, 3, respectively (p = 0.0006). The 5-year overall survival was 53.6%, 66.8%, and 52.4% for groups 1, 2 and 3, respectively (p < 0.0001).Conclusions: Significant variations in practice patterns were noted across different geographic regions in a universal healthcare system. Use of continent diversions, extended lymphadenectomy, and neoadjuvant chemotherapy remains low across all 3 regions. Treatment delays are significant.

Introduction: Our objective was to determine the proportion of publications arising from abstracts presented at the Quebec Urological Association (QUA). We wanted to analyze differences in publication rates according to certain parameters, and to examine the quality of publications using journal impact factors.Methods: All abstracts presented at the annual meetings of the QUA between 2000 and 2010 were obtained from the QUA archives and searched using the PubMed database. Variables included: institute, number of abstracts presented, year of presentation and publication, impact factor of publishing journal (according to 2010 Thomson Reuters report), time to publication (months), research type, presenter and location of research. Kaplan Meier methods were used for analysis.Results: By May 2012, 248 out of 439 abstracts (QUA 2000 to 2010) were published in peer-reviewed journals, resulting in a publication rate of 56%. There were significant differences in publication rates according to institution, research type and location of research. Researchers from non-Quebec institutions were twice as likely to publish compared to those from Quebec institutions (Cox HR 2.13, CI 1.20-3.76, p < 0.01).Discussion: The QUA publication rate was considerably higher than previously studied by the American Urological Association (37.8%) and British Association of Urological Surgeons (≈42%); however length of follow-up and presentation types differed. Research conducted outside Quebec was more likely to be published, reflecting the multi-institution robust study designs and higher level of evidence. Factors influencing publication deserve further attention, and clinicians are encouraged to conduct research with intent to publish.

Dans ce numero du JAUC, le docteur Mayson et ses confreres1 du Comite socio-economique de l’AUC font etat des resultats d’un sondage effectue aupres des urologues au Canada, au sujet de la privatisation des soins de sante. Bien que l’on ne puisse pas etablir de conclusions generales sur l’opinion collective des urologues canadiens, en s’appuyant sur un taux de reponse de 20 % d’un sondage de 9 questions, certains resultats devraient retenir notre attention. En particulier, plus de la moitie des repondants recoivent deja un paiement direct de la part de patients pour services rendus; cela indique que beaucoup d’urologues avaient deja une composante privee, si petite fut-elle, a leur exercice. D’ailleurs, il serait interessant de regarder la proportion de soins prives d’ici quelques annees, puisque dans plusieurs coins du pays, la porte a deja ete ouverte a certaines activites privees. D’autre part, 65 % des repondants croient que les Canadiens devraient avoir le choix d’opter pour des soins de sante prives, ce qui contraste avec les quelques 20 % qui trouvent qu’au contraire, ces soins ne devraient pas etre permis du tout. Encore plus important a noter, la plupart des repondants (74 %) croient que la presence d’un systeme prive parallele n’affecterait pas de facon negative la sante des patients traites dans le systeme public; en meme temps, 58 % estiment que la sante des patients dans le systeme prive s’ameliorerait. En conclusion, beaucoup de repondants trouvent que de permettre la privatisation ameliorerait la sante de ceux qui peuvent se le permettre, mais pas celle des patients du systeme de sante public. Cette opinion s’avere quelque peu contraire a celle des promoteurs des soins prives, et qui font valoir de surcroit que le systeme public serait soulage de certaines depenses, et ameliorerait du meme coup l’acces et les soins dans le systeme public. Tel que mentionne dans le document, l’objectif final du Comite socio-economique de l’AUC est de mettre au point une politique, au sujet de la privatisation, similaire a d’autres associations medicales canadiennes et provinciales. Il est regrettable de constater que ce premier essai de collecte d’opinions s’est revele inadequat, puisque seulement une infime partie des adherents a repondu au sondage. Cependant, nous deploierons plus d’efforts pour obtenir l’opinion des urologues dans le but de mieux cerner notre position collective. Mais avant cela, il serait utile de tenir un debat constructif. De plus, plusieurs promoteurs de la privatisation ont propose que certaines procedures ne soient pas toutes couvertes universellement afin de soulager le systeme public. Il serait interessant de sonder les urologues du Canada pour voir les procedures qu’ils seraient prets a faire retirer du systeme public. Pour terminer, il est curieux de constater que les Etats-Unis discutent actuellement de la transition vers un modele de type canadien, alors que nous abordons au meme moment la question de se diriger vers la direction opposee. Comme la plupart des choses dans la vie, une position centrale et moderee est souvent la position juste.

Objective: Treatment delays have been associated with adverse outcomes in patients with bladder cancer treated with radical cystectomy (RC). We sought to evaluate the impact of treatment delay on disease recurrence and survival in patients with bladder cancer treated with partial cystectomy (PC) in Quebec. Methods: We reviewed and obtained billing records for all patients who underwent PC and/or RC for bladder cancer in Quebec between 1983 and 2005. Analysis included age, sex, year of surgery, surgeon’s age, hospital type, preoperative and postoperative visits with accompanying diagnoses and dates of death. Results: A total of 714 patients underwent PC. The median patient age was 70 years. Two-hundred nineteen (30.7%) patients experienced recurrence; of these, 52 (23.7%) required salvage RC. Five-year overall and recurrence-free survival for patients who underwent PC were 49.8% and 40.3%, respectively. Patients delayed more than 12 weeks from transurethral resection of bladder tumours (TURBT) to PC were at significantly increased risk of requiring salvage RC compared with those delayed 12 weeks or less (hazard ratio [HR] 3.0, p < 0.001). Patients who underwent salvage RC had worse survival than patients who had upfront RC (HR 1.5, p = 0.006). Variables including age, sex, presence of hematuria, intravesical therapy, surgeon age, hospital PC volume, surgeon PC volume, type of hospital (academic v. nonacademic) or year of surgery were not significantly associated with PC treatment delay. Conclusion: Treatment delay in patients with bladder cancer managed with PC was associated with increased risk of salvage RC. Patients with bladder cancer who underwent salvage RC had worse outcomes than those who had upfront cystectomy. Objectif : Chez les patients atteints de cancer de la vessie traites par cystectomie radicale (CR), un delai avant l’instauration du traitement est associe a des resultats defavorables. Nous avons tente d’evaluer l’impact d’un tel delai sur la recidive de la maladie et le taux de survie des patients atteints de cancer de la vessie traites par cystectomie partielle (CP) au Quebec. Methodologie : Les dossiers de facturation ont ete obtenus pour les patients ayant subi une CP et/ou une CR pour le traitement d’un cancer de la vessie au Quebec de 1983 a 2005. L’analyse tenait compte de l’âge, du sexe, de l’annee de l’intervention chirurgicale, de l’âge du chirurgien, du type d’hopital, des visites preoperatoires et postoperatoires, des comorbidites et des dates de deces. Resultats : En tout, 714 patients dont l’âge moyen etait de 70 ans ont subi une CP. De ce nombre, 219 patients (30,7 %) ont presente une recidive, dont 52 (23,7 %) necessitant une CR de sauvetage. La survie globale apres 5 ans et la survie sans recidive chez les patients ayant subi une CP etaient respectivement de 49,8 % et de 40,3 %. Un intervalle superieur a 12 semaines entre la resection transuretrale de la tumeur et la CP a ete associe a un taux accru de CR de sauvetage en comparaison avec un intervalle de 12 semaines ou moins (risque relatif [RR] 3,0, p < 0,001]. La CR de sauvetage etait associee a un taux inferieur de survie en comparaison avec les patients traites par CR des le depart (RR 1,5, p = 0,006). Les autres variables, soit l’âge, le sexe, la presence d’une hematurie, le recours a une therapie intravesicale, l’âge du chirurgien, le nombre de CP effectuees a l’hopital, le nombre de CP effectuees par le chirurgien, le type d’hopital (universitaire ou non universitaire), et l’annee de l’intervention chirurgicale n’ont pas ete associees de facon significative au delai avant la CP. Conclusion : Le delai avant l’instauration du traitement chez les patients atteints de cancer de la vessie traites par CP a ete associe a un taux accru de CR de sauvetage. Les patients atteints de cancer de la vessie qui ont subi une CR de sauvetage presentaient une issue de la maladie moins favorable que les patients traites par cystectomie des le depart.

This issue of CUAJ presents 3 very interesting articles with very different technological approaches for treatment of prostate and kidney cancer. Each approach has very similar objectives: organ preservation, minimally invasive ablative therapy and less morbidity compared to standard therapies. The progress in percutaneous ablative measures for urological cancer treatment is excitingly rapid. It is clear that the future holds promise for such modalities and, in a relatively short period, many new modalities are now available for testing. The 2 major impediments to most of these new approaches remain suboptimal real-time imaging and localization of cancers, and the lack of molecular imaging tools to visualize prognostic features. It would be unfortunate if ablative therapies, originally designed for entire organ ablation in situ (as for prostate cancer), were too quickly applied to focal therapy or “male lumpectomy” without proper assessment. Nevertheless, advances in imaging are progressing just as fast with the development of microscopic probes or tagged biomarkers to illuminate targets. A whole new field of molecular imaging is evolving and we need to be riding this wave. I am confident that the future is bright, with better and more precise imaging and prognostication leading the way for molecular surgery. We look forward to follow-up reports from these authors on their experience in this exciting field. It is important that urologists maintain their leadership role in the growth of these image-guided therapies. Urologists should be involved in the development of imaging tools for cancer localization and treatment delivery, similar to our advocacy for the use of new systemic targeted therapies for urological cancers. It is clear that the urological surgeon of the not-too-distant future will be using a combination of targeted drugs, functional imaging and energy delivery systems much more than the DeBakey and Metz. In my office, there is an oil painting hanging on the wall depicting surgeons performing open surgery. After admiring its artistic beauty, a patient wondered whether surgery was still being done this way. I haven’t yet taken down the painting!

Background: Many studies have suggested that nutritional factors may affect prostate cancer development. The aim of our study was to evaluate the relationship between dietary habits and prostate cancer detection.Methods: We studied 917 patients who planned to have transrectal ultrasonography–guided prostatic biopsy based on an elevated serum prostate specific antigen (PSA) level, a rising serum PSA level or an abnormal digital rectal examination. Before receiving the results of their biopsy, all patients answered a self-administered food frequency questionnaire. In combination with pathology data we performed univariable and multivariable logistic regression analyses for the predictors of cancer and its aggressiveness.Results: Prostate cancer was found in 42% (386/917) of patients. The mean patient age was 64.5 (standard deviation [SD] 8.3) years and the mean serum PSA level for prostate cancer and benign cases, respectively, was 13.4 (SD 28.2) μg/L and 7.3 (SD 4.9) μg/L. Multivariable analysis revealed that a meat diet (e.g., red meat, ham, sausages) was associated with an increased risk of prostate cancer (odds ratio [OR] 2.91, 95% confidence interval [CI] 1.55–4.87, p = 0.027) and a fish diet was associated with less prostate cancer (OR 0.54, 95% CI 0.32–0.89, p = 0.017). Aggressive tumours were defined by Gleason score (≥ 7), serum PSA level (≥ 10 μg/L) and the number of positive cancer cores (≥ 3). None of the tested dietary components were found to be associated with prostate cancer aggressivity.Conclusion: Fish diets appear to be associated with less risk of prostate cancer detection, and meat diets appear to be associated with a 3-fold increased risk of prostate cancer. These observations add to the growing body of evidence suggesting a relationship between diet and prostate cancer risk.

In 2008, bladder cancer was estimated to be the fourthmost common male cancer accounting for 6% of all can -cers and the eighth highest cancer-related mortality rate inCanadian men. The most common type is urothelial carci-noma (greater than 90%), followed by adenocarcinoma,squamous cell and small cell carcinoma. Risk factors thathave been associated with bladder cancer include smok -ing, chronic inflammatory changes in the bladder (due topersistent bladder stones, recurrent urinary tract infections,indwelling catheters or schistosomiasis) and chemothera -peutic exposure, such as cyclophosphamide.

Background: Radical cystectomy may provide optimal survival outcomes in the management of clinical T1 bladder cancer. We present our data from a large, multi-institutional, contemporary Canadian series of patients who underwent radical cystectomy for clinical T1 bladder cancer in a single-payer health care system. Methods: We collected a pooled database of 2287 patients who underwent radical cystectomy between 1993 and 2008 in 8 different centres across Canada; 306 of these patients had clinical T1 bladder cancer. Survival data were analyzed using Kaplan-Meier method and Cox regression analysis. Results: The median age of patients was 67 years with a mean follow- up time of 35 months. The 5-year overall, disease-specific and disease-free survival was 71%, 77% and 59%, respectively. The 10-year overall and disease-specific survival were 60% and 67%, respectively. Pathologic stage distribution was p0: 32 (11%), pT1: 78 (26%), pT2: 55 (19%), pT3: 60 (20%), pT4: 27 (9%), pTa: 16 (5%), pTis: 28 (10%), pN0: 215 (74%) and pN1-3: 78 (26%). Only 12% of patients were given adjuvant chemotherapy. On multivariate analysis, only margin status and pN stage were independently associated with overall, disease-specific and disease-free survival. Interpretation: These results indicate that clinical T1 bladder cancer may be significantly understaged. Identifying factors associated with understaged and/or disease destined to progress (despite any prior intravesical or repeat transurethral therapies prior to radical cystectomy) will be critical to improve survival outcomes without over-treating clinical T1 disease that can be successfully managed with bladder preservation strategies. Contexte : La cystectomie radicale peut donner des resultats optimaux en lien avec la survie dans la prise en charge d’un cancer de la vessie de stade clinique T1. Nous presentons ici les donnees provenant d’une recente etude multicentrique de grande envergure portant sur des patients canadiens ayant subi une cystectomie radicale pour le traitement d’un cancer de la vessie de stade clinique T1 dans un systeme de sante a payeur unique. Methodologie : Nous avons cumule les donnees provenant de 2 287 patients ayant subi une cystectomie radicale entre 1993 et 2008 dans 8 centres differents au Canada; 306 de ces patients presentaient un cancer de la vessie de stade clinique T1. Les donnees liees a la survie ont ete analysees a l’aide de la methode de Kaplan-Meier et du modele de regression de Cox. Resultats : L’âge median des patients etait de 67 ans, et la duree moyenne du suivi, de 35 mois. La survie globale, la survie specifique a la maladie et la survie sans maladie apres 5 ans etaient de 71 %, 77 % et 59%, respectivement. La survie globale et la survie specifique a la maladie apres 10 ans etaient de 60 % et 67 %, respectivement. Les stades pathologiques se repartissaient ainsi : p0 : 32 (11 %), pT1 : 78 (26 %), pT2 : 55 (19 %), pT3 : 60 (20 %), pT4 : 27 (9 %), pTa : 16 (5 %), pTis : 28 (10 %), pN0 : 215 (74 %) et pN1-3 : 78 (26 %). Seulement 12 % des patients ont recu une chimiotherapie adjuvante. A l’analyse multivariee, seuls le statut des marges chirurgicales et le stade pN etaient independants de la survie globale, la survie specifique a la maladie et la survie sans maladie. Interpretation : Ces resultats indiquent que le stade d’un cancer de la vessie d’abord classe comme T1 peut avoir ete grandement sous-evalue. L’identification des facteurs associes a un cancer dont le stade a ete sous-evalue et/ou a une maladie destinee a evoluer (malgre un traitement intravesical anterieur ou des traitements transuretraux repetes avant la cystectomie radicale) jouera un role crucial dans la hausse des taux de survie sans surtraiter la maladie clinique de stade T1 pouvant etre prise en charge de facon efficace par des strategies de conservation de la vessie.

Background: The province of Quebec has the highest incidence of urothelialtumours in Canada. Radical cystectomy remains the standard treatment for invasivebladder cancer. We have previously observed that prolonged delays betweentransurethral resection of bladder tumour (TURBT) and radical cystectomy leadto worse survival in Quebec.Objective: The aim of our study was to characterize the various periods of delaysustained by bladder cancer patients before radical cystectomy across Quebecand to determine their relation to survival.Methods: We obtained the billing records for all patients treated with radicalcystectomies for bladder cancer across Quebec from 1990 to 2002. Collectedinformation included patient age and sex; dates of family physician (FP) andspecialist visits with accompanying diagnoses; dates of cystoscopy, TURBT andCT scanning; surgeon age; surgical volume and dates of death.Results: We analyzed a total of 25 862 visits for 1633 patients. Median diagnosticdelays from FP to specialist, then to cystoscopy, then to TURBT and finallyfrom TURBT to CT were 20, 11, 4 and 14 days, respectively, over the entirestudy period. Median overall delay from FP visit to radical cystectomy was93 days. In addition, median FP to radical cystectomy delay progressivelyincreased from 1990 to 2000 from 58 to 120 days (p < 0.01). Multivariate analysesshowed that patients with an overall delay of either < 25 or > 84 dayshad a 2.1 and 1.4 times increased risk of dying, respectively (p ≤ 0.01).Conclusion: Preoperative delays have been progressively increasing over time.Overall, delays from FP to radical cystectomy of < 25 and > 84 days may translateinto worse outcomes. Poor survival in cases with < 25 days delay maybe attributed to case selection, with more advanced cases being managed muchquicker. Poor survival in cases with delays of > 84 days may be attributed todisease progression while awaiting completion of management.

Background: The present study documents the natural history and outcomes of high-risk bladder cancer after radical cystectomy (RC) in patients who did not receive neoadjuvant chemotherapy during a contemporary time period.Methods: We analyzed 1180 patients from 1993 to 2008 with >pT3N0 or pT0-4N+ bladder cancer who underwent RC ± standard (sLND) or extended (eLND) lymph node dissection from 8 Canadian centres.Results: Of the 1180 patients, 55% (n = 643) underwent sLND, 34% (n = 402) underwent ePLND and 11% did not undergo a formal LND. Of the total number of patients, 321 (27%) received adjuvant chemotherapy. The median follow-up was 2.1 years (range: 0.6 to 12.9). Overall 30-day mortality was 3.2%. Clinical and pathological stages T3-4 were present in 6.1% and 86.7% of the patients, respectively; this demonstrates a dramatic understaging. Overall survival (OS) at 2 and 5 years was 60% and 43%, respectively. Patients who received adjuvant chemotherapy hada 2- and 5-year disease-specific survival (DSS) of 72% and 57% versus 64% and 51% for those who did not (log-rank p = 0.0039). The 2- and 5-year OS for high-risk node-negative disease was 67%and 52%, respectively, whereas for node-positive patients, the OS was 52% and 32%, respectively (p < 0.001). The OS, DSS and RFS for patients with pN0 were significantly improved compared to those who did not undergo a LND (log-rank p = 0.0035, 0.0241 and 0.0383, respectively).Interpretation: This series suggests that bladder cancer outcomes inadvanced disease have improved in the modern era. The need for improved staging investigations, use of neoadjuvant chemotherapyand performance of complete LND is emphasized.