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What's known on the subject? and What does the study add?• Urothelial carcinoma of the bladder (UCB) is more prevalent in men than women; however, in women the tumour stage is generally more advanced at the time of the diagnosis and the prognosis is worse. Possible explanations include anatomical, genetic and socio-economic factors.• The study shows that clinical symptoms before the first-time diagnosis of UCB did not differ between the sexes, while primary care and referral patterns did. Women were more likely to receive symptomatic treatment or therapies for alleged UTIs without further investigation or referral to urological evaluation. The study highlights the fact that there may be a diagnostic delay in women which could contribute to the gender-dependent disparities in stage distribution and prognosis of UCB. Objective• To evaluate gender-dependent disparities regarding clinical symptoms, referral patterns or treatments before diagnosis of urothelial carcinoma of the bladder (UCB). Patients and Methods• A consecutive series of patients with newly diagnosed UCB completed a questionnaire at the time of admission for elective transurethral resection of a bladder tumour (TURBT).• The questionnaire surveyed the presence of haematuria, dysuria, urgency and bladder pain as well as the number of consultations and treatments before urological evaluation.• Tumour characteristics, clinical symptoms, treatments and referrals were compared between men and women in the patient series. Results• In men (n = 130) the distribution of tumour stages was pTa 62.3%, pT1 23.1% and pT Ն 2 12.3%. The respective percentages in women (n = 38) were pTa 57.9%, pT1 23.7% and pT Ն 2 18.4% (P > 0.05).• The prevalence of clinical symptoms in men vs women was as follows: gross haematuria 65 vs 68%, dysuria 32 vs 44%, urgency 61 vs 47%, and nocturia 57 vs 66%, respectively (P > 0.05).• A total of 78% of men vs 55% of women directly consulted a urologist (P < 0.05).• Symptomatic treatment for voiding disorders/pain was given without further evaluation to 19% of men vs 47% of women 1 year before the diagnosis of UCB (P < 0.05).• A total of 3.8% of men vs 15.8% of women received three or more treatments for urinary tract infections (UTIs) within the same time period (P < 0.05). Conclusions• In the present study there were no gender-related differences in clinical symptoms of UCB, but women were more likely to be treated for voiding complaints or alleged UTIs without further evaluation or referral to urology than men.• Gender-dependent disparities in referral patterns exist and might delay definitive diagnosis of UCB in women.

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BackgroundA multicentre study was conducted to investigate the impact of sarcopenia as an independent predictor of oncological outcome after radical cystectomy for bladder cancer.MethodsIn total, 500 patients with available digital computed tomography scans of the abdomen obtained within 90 days before surgery were identified. The lumbar skeletal muscle index was measured using pre‐operative computed tomography. Cancer‐specific survival (CSS) and overall survival (OS) were estimated using Kaplan–Meier curves. Predictors of CSS and OS were analysed by univariable and multivariable Cox regression models.ResultsBased on skeletal muscle index, 189 patients (37.8%) were classified as sarcopenic. Patients with sarcopenia were older compared with their counterparts (P = 0.002), but both groups were comparable regarding to gender, comorbidity, tumor, node, metastasis (TNM) stage, and type of urinary diversion (all P > 0.05). In total, 234 (46.8%) patients died, and of these, 145 (29.0%) died because of urothelial carcinoma of the bladder. Sarcopenic patients had significantly worse 5 year OS (38.3% vs. 50.5%; P = 0.002) and 5 year CSS (49.5% vs. 62.3%; P = 0.016) rates compared with patients without sarcopenia. Moreover, sarcopenia was associated independently with both increased all‐cause mortality (hazard ratio, 1.43; 95% confidence interval 1.09–1.87; P = 0.01) and increased cancer‐specific mortality (hazard ratio, 1.42; 95% confidence interval, 1.00–2.02; P = 0.048). Our results are limited by the lack of prospective frailty assessment.ConclusionsSarcopenia has been shown to be an independent predictor for OS and CSS in a large multicentre study with patients undergoing radical cystectomy for bladder cancer.

Background Although the performance of immunocytology has been established in the surveillance of patients with urothelial carcinoma of the bladder (UCB), its value in the initial detection of UCB in patients with painless hematuria remains unclear. Objective To determine whether immunocytology improves our ability to predict the likelihood of UCB in patients with painless hematuria. Further, to test the clinical benefit of immunocytology in this setting using decision curve analysis. Design, setting, and participants The subjects were 1182 consecutive patients without a history of UCB presenting with painless hematuria and were enrolled at three centres. Intervention All patients underwent upper-tract imaging, cystourethroscopy, voided urine cytology, and immunocytology analysis. Bladder tumors were biopsied and histologically confirmed as UCB. Measurements Multivariable regression models were developed. Area under the curve was measured and compared using the DeLong test. A nomogram was constructed from the full multivariable model. Decision curve analysis was performed to evaluate the clinical benefit associated with use of the multivariable models including immunocytology. Results and limitations Immunocytology had the largest contribution to a multivariable model for the prediction of UCB (odds ratio: 18.3; p < 0.0001), which achieved a 90.8% predictive accuracy. Decision curve analysis revealed that models incorporating immunocytology achieved the highest net benefit at all threshold probabilities. Conclusions Immunocytology is a strong predictor of the presence of UCB in patients who present with painless hematuria. Incorporation of immunocytology into predictive models improves diagnostic accuracy by a statistically and clinically significant margin. The use of immunocytology in the diagnostic workup of patients with hematuria appears promising and should be further evaluated.

Study Type – Prognosis (case series) Level of Evidence 4 What's known on the subject? and What does the study add? The degree of comorbidity significantly affects the course of patients with bladder cancer undergoing radical cystectomy (RC). To our knowledge this is the first study comparing four different comorbidity indices in patients undergoing RC for urothelial carcinoma to assess the best clinical predictors for 90‐day perioperative mortality. We concluded that the ASA score should be the method of choice, as it showed a predictive ability superior to that of ECOG and CCI, and is much easier to generate than the ACE‐27. OBJECTIVE To evaluate which of the following among the Adult Comorbidity Evaluation‐27 (ACE‐27), the Charlson Comorbidity Index (CCI), the Eastern Cooperative Oncology Group performance status (ECOG) and the American Society of Anesthesiologists (ASA) comorbidity scores correlate best with perioperative mortality after radical cystectomy (RC) for urothelial carcinoma (UC) of the bladder. PATIENTS AND METHODS A study was carried out on 555 unselected consecutive patients without neoadjuvant chemotherapy who underwent RC for UC of the bladder from 2000 to 2010 at one of two institutions. Patients' medical records were reviewed retrospectively. We established a defined binary linear progression model based on clinical variables to predict perioperative mortality <90 days after RC (90PM). To this model we added, individually, the comorbidity indices ACE‐27, CCI, ECOG, and ASA to assess their predictive capacity regarding 90PM. RESULTS The overall 90PM was 7.9%. Age (P= 0.01) and clinical distant metastatic tumour stage (P= 0.002) were independent predictors for 90PM in the multivariate analysis. Each of the four investigated comorbidity indices was able to significantly increase the predictive capacity of the basic model: ECOG +13.5%, (odds ratio [OR]: 1.61, P= 0.036; area under the curve [AUC] 74.7), ASA Score +28.3% (OR: 2.19, P= 0.004; AUC 76.1), Charlson Index +12.3% (OR: 1.31, P= 0.047; AUC 73.8) and ACE‐27 + 29.8% (OR: 1.72, P= 0.004; AUC 76.1). CONCLUSIONS ASA and ACE‐27 show a nearly identical clinical predictive value for perioperative mortality. Both scores could be considered for clinical practice. With regard to ease of generation and availability, the ASA score can be regarded as the best instrument.

Trifecta and pentafecta incorporate essential criteria in terms of outcome reporting and might be considered for the improvement of standardized quality assessment after RC for UCB.

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