Tarrell, Robert

ObjectivesTo evaluate the differences in estimated glomerular filtration rate decline by urinary diversion type (incontinent diversion vs continent diversion) and preoperative estimated glomerular filtration rate among patients undergoing radical cystectomy and urinary diversion.MethodsWe evaluated 1383 patients treated with radical cystectomy between 1980–2006 who had a preoperative estimated glomerular filtration rate of 45‐89 mL/min/1.73 m2. Estimated glomerular filtration rate was estimated using Chronic Kidney Disease Epidemiology Collaboration equations, and patients were stratified by preoperative estimated glomerular filtration rate into chronic kidney disease 2 (estimated glomerular filtration rate 60–89 mL/min/1.73 m2) and chronic kidney disease 3a (estimated glomerular filtration rate 45–59 mL/min/1.73 m2). Multiple definitions of estimated glomerular filtration rate decline were evaluated: (i) 10‐point decline in estimated glomerular filtration rate; (ii) 20% decline in estimated glomerular filtration rate; and (iii) 10% decline in estimated glomerular filtration rate. Time to estimated glomerular filtration rate decline was compared using the Kaplan–Meier method stratified by diversion type. Cox regression models were used to evaluate the association of diversion type with estimated glomerular filtration rate decline risk.ResultsIn total, 74% (1021/1383) of patients underwent incontinent diversion and 26% (362/1383) underwent continent diversion. Preoperative chronic kidney disease 2 and chronic kidney disease 3a were noted among 59% and 41% of patients who underwent incontinent diversion, versus 74% and 26% with continent diversion. Median follow up after RC was 11.2 years. The rate of estimated glomerular filtration rate decline in patients with incontinent diversion versus continent diversion was similar when stratified by preoperative chronic kidney disease 2 and preoperative chronic kidney disease 3a, regardless of estimated glomerular filtration rate decline definition. On multivariable analysis, continent diversion was not associated with estimated glomerular filtration rate decline for patients with preoperative chronic kidney disease 3a.ConclusionsThe risk of estimated glomerular filtration rate decline over 10 years was not significantly different after incontinent diversion versus continent diversion among patients with preoperative chronic kidney disease 2 or chronic kidney disease 3a. Continent diversion does not appear to confer an independently increased risk of estimated glomerular filtration rate decline in patients with preoperative chronic kidney disease 3a.

Objectives To evaluate oncological outcomes after combination intravesical therapy with gemcitabine ( GC ) and mitomycin C ( MMC ) in the setting of recurrent non‐muscle‐invasive bladder cancer ( NMIBC ) after failure of previous intravesical therapy. Patients and Methods We retrospectively identified patients with recurrent NMIBC after previous intravesical therapy, who refused or were not candidates for cystectomy, between 2005 and 2011. GC and MMC were sequentially instilled weekly for 6–8 weeks. Data were collected regarding patient demographics, bladder cancer history, and number and type of intravesical therapies before GC / MMC . Outcomes evaluated included time to recurrence and/or progression after GC / MMC . Recurrence‐free outcomes were estimated using the Kaplan–Meier method, and Cox proportional hazards regression models were used to test the association of clinicopathological features with outcomes. Results In all, 27 patients were identified, 23 with high‐risk disease (high‐grade or carcinoma in situ ) and four with intermediate‐risk disease (multifocal or recurrent low‐grade). All patients received prior intravesical therapy, and 17 patients (63%) received multiple courses. Twenty‐four patients were treated with BCG . The median (range) disease‐free survival of all patients was 15.2 (1.7–39.3) months. Seventeen patients (63%) developed recurrent bladder cancer, a median of 15.2 months after therapy. One patient progressed to muscle‐invasive disease 5 months after treatment, and one developed metastatic disease 22 months after treatment. Three patients went on to cystectomy. Ten patients (37%) had no evidence of disease at last follow‐up, with a median follow‐up of 22.1 months. Conclusion The combination of intravesical GC and MMC could offer durable recurrence‐free survival to some patients with recurrent NMIBC who are not candidates for, or refuse, cystectomy.