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Background: Grade of non–muscle-invasive bladder cancer (NMIBC) is an important prognostic factor for progression. Currently, two World Health Organization (WHO) classification systems (WHO1973, categories: grade 1–3, and WHO2004 categories: papillary urothelial neoplasm of low malignant potential [PUNLMP], low-grade [LG], high-grade [HG] carcinoma) are used. Objective: To ask the European Association of Urology (EAU) and International Society of Urological Pathology (ISUP) members regarding their current practice and preferences of grading systems. Design, setting, and participants: A web-based, anonymous questionnaire with ten questions on grading of NMIBC was created. The members of EAU and ISUP were invited to complete an online survey by the end of 2021. Thirteen experts had previously answered the same questions. Outcome measurements and statistical analysis: The submitted answers from 214 ISUP members, 191 EAU members, and 13 experts were analyzed. Results and limitations: Currently, 53% use only the WHO2004 system and 40% use both systems. According to most respondents, PUNLMP is a rare diagnosis with management similar to Ta-LG carcinoma. The majority (72%) would consider reverting back to WHO1973 if grading criteria were more detailed. Separate reporting of WHO1973-G3 within WHO2004-HG would influence clinical decisions for Ta and/or T1 tumors according the majority (55%). Most respondents preferred a two-tier (41%) or a three-tier (41%) grading system. The current WHO2004 grading system is supported by a minority (20%), whereas nearly half (48%) supported a hybrid three- or four-tier grading system composed of both WHO1973 and WHO2004. The survey results of the experts were comparable with ISUP and EAU respondents. Conclusions: Both the WHO1973 and the WHO2004 grading system are still widely used. Even though opinions on the future of bladder cancer grading were strongly divided, there was limited support for WHO1973 and WHO2004 in their current formats, while the hybrid (three-tier) grading system with LG, HG-G2, and HG-G3 as categories could be considered the most promising alternative. Patient summary: Grading of non–muscle-invasive bladder cancer (NMIBC) is a matter of ongoing debate and lacks international consensus. We surveyed urologists and pathologists of European Association of Urology and International Society of Urological Pathology on their preferences regarding NMIBC grading to generate a multidisciplinary dialogue. Both the “old” World Health Organization (WHO) 1973 and the “new” WHO2004 grading schemes are still used widely. However, continuation of both the WHO1973 and the WHO2004 system showed limited support, while a hybrid grading system composed of both the WHO1973 and the WHO2004 classification system may be considered a promising alternative.

Context: Bladder recurrences have been reported in 22–47% of patients after surgery for upper urinary tract urothelial carcinoma (UTUC). This collaborative review focuses on risk factors for and treatment strategies to reduce bladder recurrences after upper tract surgery for UTUC. Objective: To review the current evidence on risk factors and treatment strategies for intravesical recurrence (IVR) after upper tract surgery for UTUC. Evidence acquisition: This collaborative review is based on a literature search of PubMed/Medline, Embase, Cochrane Library, and currently available guidelines on UTUC. Relevant papers on bladder recurrence (etiology, risk factors, and management) after upper tract surgery were selected. Special attention has been paid to (1) the genetic background of bladder recurrences, (2) bladder recurrences after ureterorenoscopy (URS) with or without a biopsy, and (3) postoperative or adjuvant intravesical instillations. The literature search was performed in September 2022. Evidence synthesis: Recent evidence supports the hypothesis that bladder recurrences after upper tract surgery for UTUC are often clonally related. Clinicopathologic risk factors (patient, tumor, and treatment related) have been identified for bladder recurrences after UTUC diagnosis. Specifically, the use of diagnostic ureteroscopy before radical nephroureterectomy (RNU) is associated with an increased risk of bladder recurrences. Further, a recent retrospective study suggests that performing a biopsy during ureteroscopy may further worsen IVR (no URS: 15.0%; URS without biopsy: 18.4%; URS with biopsy: 21.9%). Meanwhile, a single postoperative instillation of intravesical chemotherapy has been shown to be associated with a reduced bladder recurrence risk after RNU compared with no instillation (hazard ratio 0.51, 95% confidence interval 0.32–0.82). Currently, there are no data on the value of a single postoperative intravesical instillation after ureteroscopy. Conclusions: Although based on limited retrospective data, performing URS seems to be associated with a higher risk of bladder recurrences. Future studies are warranted to assess the influence of other surgical factors as well as the role of URS biopsy or immediate postoperative intravesical chemotherapy after URS for UTUC. Patient summary: In this paper, we review recent findings on bladder recurrences after upper tract surgery for upper urinary tract urothelial carcinoma.

Actualiser les recommandations du CCAFU pour la prise en charge des tumeurs de la vessie infiltrant le muscle vésical (TVIM). Une revue systématique (Medline) de la littérature de 2022 à 2024 a été effectuée en prenant en compte les éléments du diagnostic, les options de traitement et la surveillance des TVNIM et TVIM, en évaluant les références avec leur niveau de preuve. Le diagnostic de TVIM se fait après une résection tumorale la plus complète possible. Le bilan d'extension d'une TVIM repose sur l'uro-scanner couplé au scanner thoracique. L'IRM pelvienne multiparamétrique peut être une alternative. La cystectomie associée à un curage ganglionnaire standard est le traitement de référence des TVIM non métastatiques. Elle doit être précédée d'une chimiothérapie néoadjuvante à base de cispaltine chez les patients en bon état général avec une fonction rénale satisfaisante. Une entérocystoplastie est proposée chez l'homme et la femme en l'absence de contre-indications et lorsque la recoupe urétrale est négative à l'examen extemporané ; sinon l'urétérostomie cutanée transiléale est le mode de dérivation urinaire recommandé. L'inclusion de tous les patients dans un protocole de RAAC (récupération améliorée après chirurgie) est recommandée. Pour les TVIM métastatiques, une première ligne par enfortumab vedotin et pembrolizumab est recommandée. En deuxième ligne de traitement, une chimiothérapie à base de sels de platine est recommandée. L'actualisation des recommandations du CCAFU doit participer à améliorer la prise en charge des patients, mais aussi le diagnostic et la décision thérapeutique des TVIM. To update the CCAFU recommendations for the management of muscle invasive bladder cancer (MIBC). A systematic review (Medline) of the literature from 2022 to 2024 was carried out, taking into account the elements of the diagnosis, the treatment options and the monitoring of NMIBC and MIBC, evaluating the references with their level of evidence. The diagnosis of MIBC is made after the resection of as much of the tumour as possible. CT-urography coupled with chest CT scans are used to assess the extent of MIBC. Multiparametric pelvic MRI may be an alternative imaging approach. Cystectomy combined with standard lymph node dissection is the standard treatment for non-metastatic MIBC. Neoadjuvant cispaltine-based chemotherapy should be used in patients in good general condition with satisfactory renal function. Enterocystoplasty is proposed for men and women in the absence of contraindications and when urethral recutting is negative on extemporaneous examination; otherwise, transileal cutaneous ureterostomy is the recommended method of urinary diversion. All patients should be included in an improved recovery after surgery (ERAS) protocol. For metastatic MIBC, first-line treatment with enfortumab vedotin and pembrolizumab is recommended. Second-line treatment with platinum-based chemotherapy is recommended. Updating the CCAFU recommendations should improve patient management and enhance the diagnosis and treatment of MIBC. [ABSTRACT FROM AUTHOR]

Actualiser les recommandations du CCAFU pour la prise en charge des tumeurs de la vessie n'infiltrant pas le muscle vésical (TVNIM). Une revue systématique (Medline) de la littérature de 2022 à 2024 a été effectuée en prenant en compte les éléments du diagnostic, les options de traitement et la surveillance des TVNIM, en évaluant les références avec leur niveau de preuve. Le diagnostic de TVNIM (Ta, T1, CIS) se fait après une résection tumorale complète et profonde. L'utilisation de la fluorescence vésicale et l'indication d'un second look (4 à 6 semaines) contribuent à améliorer le diagnostic initial. Le risque de récidive et/ou progression tumorale est évalué en utilisant le score EORTC. La stratification des patients en faible, intermédiaire et haut risque permet de proposer le traitement adjuvant : instillations endovésicales de chimiothérapie (postopératoire immédiate, schéma d'attaque) ou de BCG (schéma d'attaque et d'entretien), voire l'indication d'une cystectomie pour les patients non répondeurs au BCG. L'actualisation des recommandations du CCAFU doit participer à améliorer la prise en charge des patients, mais aussi le diagnostic et la décision thérapeutique des TVNIM. To update the CCAFU recommendations for the management of non-muscle invasive bladder cancer (NMIBC). A systematic review (Medline) of the literature from 2022–2024 was performed, taking into account the elements of diagnosis, treatment options and monitoring of NMIBC and evaluating references with their level of evidence. The diagnosis of NMIBC (Ta, T1, or CIS) is made after complete and deep tumour resection. The use of bladder photodynamic diagnosis and the indication for a second TURBT (4 to 6 weeks later) help to improve the initial diagnosis. The risk of recurrence and/or tumour progression is assessed via the EORTC score. By stratifying patients into low-, intermediate- and high-risk groups, adjuvant treatment can be proposed, including endovesical instillations of chemotherapy (early postoperative intravesical chemotherapy), BCG (induction and maintenance regimen), or even the indication of cystectomy for BCG-unresponsive patients. Updating the CCAFU's recommendations should help improve patient management, as well as the diagnosis and treatment of NMIBC. [ABSTRACT FROM AUTHOR]

L'objectif de ce travail était de proposer une mise à jour des recommandations du Comité de cancérologie de l'Association française d'urologie pour la prise en charge des tumeurs de la voie excrétrice supérieure (TVES). Une revue systématique de la littérature (Medline) sur l'épidémiologie, les facteurs de risque, le diagnostic, le pronostic, les options de traitement et la surveillance des TVES a été effectuée de 2022 à 2024 afin d'évaluer les références disponibles et leur niveau de preuve. Le diagnostic de cette pathologie rare, dont les principaux facteurs de risque spécifiques sont l'exposition à l'acide aristolochique et le syndrome de Lynch, repose sur l'uro-TDM et l'urétérorénoscopie souple avec prélèvements biopsiques. On distingue les lésions de bas et haut risque principalement sur la base du grade tumoral (bas/haut) et de l'aspect en imagerie (non infiltrant/infiltrant). La taille tumorale (< 2/≥ 2 cm), la focalité (uni/multifocale) et l'hydronéphrose (absent/présent) sont des critères plus relatifs. Le traitement chirurgical curatif de référence des TVES de bas risque est le traitement conservateur principalement par urétérorénoscopie/laser alors qu'il s'agit de la néphro-urétérectomie totale (NUT) pour les lésions de haut risque. Les traitements adjuvants après la NUT incluent une instillation intravésicale postopératoire de chimiothérapie afin de diminuer le risque de récidive vésicale, et une chimiothérapie à base de sels de platine pour les tumeurs pT2–T4 et/ou pN+. Le traitement de 1re ligne des TVES métastatiques comprend principalement la combinaison de l'enfortumab vedotin et du pembrolizumab. En cas de contre-indication, une chimiothérapie à base de sels de platine associée à une immunothérapie par nivolumab suivie d'une maintenance par nivolumab seul en cas de maladie contrôlée ou une chimiothérapie à base de sels de platine seule suivie d'une maintenance par avélumab en cas de maladie contrôlée peuvent être proposées. Le rythme et les modalités de la surveillance dépendent du stade de la maladie. Ces nouvelles recommandations doivent contribuer à améliorer la prise en charge des patients présentant une TVES. The purpose of this article was to propose an update of the French guidelines from the national committee ccAFU on upper tract urothelial carcinomas (UTUC). A systematic Medline search for epidemiology, risk factors, diagnosis, prognosis, treatment options and follow-up of UTUC was performed between 2022 and 2024 to evaluate available references and their levels of evidence. UTUC is a rare malignancy with specific risk factors including exposition to aristolochic acid and Lynch syndrome. Its diagnosis is based on the use of computed tomography urography and ureterorenoscopy with biopsies. A prognostic classification has been proposed to discriminate low- and high-risk lesions mainly based on tumor grade (low/high) and imaging aspect (non-infiltrative/infiltrative). Tumor size (< 2/≥ 2 cm), focality (uni/multifocal), and hydronephrosis (absent/present) are more relative risk factors. The standard of care for low-risk patients is currently conservative treatment using mainly ureterorenoscopy laser ablation, while radical nephroureterectomy (RNU) is advised for those with high-risk disease. Adjuvant treatments after RNU include the intravesical instillation of chemotherapy to decrease the risk of bladder recurrence, and the delivery of platinum-based chemotherapy in pT2–T4 and/or pN+ patients. First-line treatment for metastatic UTUC is based on the use of the combination of Enfortumab Vedotin plus Pembrolizumab. For unfit patients, a platinum-based chemotherapy plus Nivolumab followed by maintenance Nivolumab in those with at least stable disease or a platinum-based chemotherapy followed by maintenance Avelumab in those with at least stable disease can be proposed. The surveillance regimen and schedule depend on the disease stage. These updated guidelines will contribute to improve the management of patients diagnosed with UTUC. [ABSTRACT FROM AUTHOR]