Background Preoperative lymph node staging in upper tract urothelial carcinoma (UTUC) using 18F-Fluorodeoxyglucose (FDG) positron emission tomography combined with computed tomography (PET-CT) is sparsely reported. Objective This study investigates the diagnostic accuracy of PET-CT and conventional computed tomography (CT) for detecting regional lymph node metastases in patients with UTUC, using histopathology as the reference standard. Design setting and participants A total of 75 consecutive patients with UTUC, who underwent radical nephroureterectomy (RNU) with regional lymphadenectomy (rLAE) between 2014 and 2024, were retrospectively analyzed. All patients underwent preoperative PET-CT. Outcome measurements and statistical analysis Accuracy for PET-CT and CT was compared with histopathology in fractionated lymphadenectomy specimens in the total cohort and in the subgroup that did not receive preoperative chemotherapy (PC). Results and limitations Of the 75 patients, 48 were male (64%), 23 (31%) received PC, and 18 (24%) had histologically confirmed lymph node metastases. For all patients, results for PET-CT and their 95% confidence intervals were as follows: sensitivity 83% (59–96), specificity 70% (57–82), and positive likelihood ratio (LR+) 2.8 (1.8–4.4), compared with 39% (17–64), 83% (70–91), and 2.2 (1.0–5.0) for CT, respectively. In the subgroup of 52 patients who did not receive PC, PET-CT showed a sensitivity of 75% (43–95), specificity of 90% (76–97), and LR+ of 7.5 (2.8–20.1), while CT yielded 25% (6–57), 93% (80–98), and 3.3 (0.8–14.4), respectively. The primary limitation of the study is the limited sample size, particularly the small number of patients with confirmed nodal metastases. Conclusions Preoperative PET-CT demonstrates promising diagnostic accuracy for regional lymph node staging in patients with UTUC.

The International Bladder Cancer Group (IBCG) has proposed a prognostic model for intermediate risk (IR) non-muscle invasive bladder cancer (NMIBC) for clinical decision-making. We applied the IBCG IR model in a population-based Swedish setting in patients with primary IR NMIBC diagnosed 2013–2014 in BladderBaSe 2.0. Patients were stratified into low-risk (unifocal and tumour size < 3 cm) and intermediate-risk (multiple and/or tumour size ≥ 3 cm) for estimation of 1- and 3-year recurrence-free survival (RFS). Among 710 patients with IR NMIBC, 329 (46%) and 381 (54%) were categorized as low- and intermediate-risk, respectively. Probabilities of disease recurrence or death at 1 and 3 years in low-risk patients were 19% (95% confidence interval [CI]: 15–23) and 41% (95% CI: 35–46), versus 27% (95% CI: 22–31) and 45% (95% CI: 40–50) in the intermediate-risk group. In a sensitivity analysis including only patients receiving serial adjuvant instillations (n = 152) the corresponding probabilities at 1 and 3 years were 19% (95% CI: 10–28) and 33% (95% CI: 22–43) versus 15% (95% CI: 7–23) and 31% (95% CI: 20–41), respectively. Thus, no clinically meaningful difference in recurrence-free survival was observed between International Bladder Cancer Group low- and intermediate-risk groups in this population-based primary non-muscle invasive bladder cancer setting.

Background: Upper tract urothelial carcinoma (UTUC) is rare, and contemporary data on real-world healthcare resource utilisation and costs are limited. The objective of this study is to describe long-term healthcare resource utilisation among patients with upper tract urothelial carcinoma (UTUC) and to identify clinical and treatment-related drivers of costs. Methods: We conducted a retrospective, population-based cohort study including all patients diagnosed with UTUC between 2019 and 2023 in Region Skåne, Sweden. Patients were identified through the Swedish National Register for Urinary Bladder Cancer (SNRUBC) and linked to regional healthcare databases covering primary, secondary, and tertiary care. The primary outcome was annual direct healthcare cost per patient, derived from Diagnosis-Related Group (DRG) cost data and expressed in 2023 international dollars (Int$). Secondary outcomes were cost patterns and predictors stratified by treatment modality: robot-assisted nephroureterectomy (RANU), open nephroureterectomy (ONU), segmental ureterectomy (SU), and endourological treatment (ET). Results: Among 278 included patients, most were older adults and/or with substantial comorbidity, and over half underwent radical nephroureterectomy. The adjusted mean annual cost was Int$36,870 in 2019, decreasing to Int$30,004 in 2023. In the subgroup treated with ONU, systemic treatment was associated with a higher adjusted cost ratio and in the subgroup operated with SU, female sex was associated with a higher adjusted cost ratio. Comorbidity was a cost driver in the ET subgroup. Conclusions: UTUC care in this Swedish region has become less resource-intensive over a short period. These results can provide a basis for planning UTUC services and highlight targets for cost-conscious, patient-centred optimisation of care.

Objectives Ipsilateral recurrence is a relevant outcome measure after kidney-sparing surgery (KSS) for urothelial upper tract carcinoma (UTUC). However, studies comparing ipsilateral recurrence after segmental ureterectomy (SU) and endourological treatment (ET) are lacking. This study aimed to quantitatively assess ipsilateral recurrence in ET and SU for UTUC to inform patient counselling and future study design.Design Systematic review and meta-analysis.Setting A systematic literature search, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), identified relevant studies from inception to September 2024. Random-effects meta-analysis was conducted to estimate the year-wise and pooled ipsilateral recurrence separately for ET and SU. Heterogeneity was explored by subgroup and meta-regression analyses and risk of bias was assessed using Joanna Briggs Institute Critical Appraisal Checklist as well as funnel plots and Egger’s regression test.Participants Patients undergoing ET or SU included in eligible studies reporting ipsilateral recurrence outcomes.Main outcome measures Time-to-event-derived ipsilateral recurrence probabilities and crude pooled ipsilateral recurrence proportions.Results Seventy-four studies were included, of which 40 reported ipsilateral recurrence after ET and 34 after SU (n=3044). In 11 of these, time-to-event data were available. Time-to-event-derived ipsilateral recurrence probabilities after 4 years were 0.53 (95% CI 0.25 to 0.80) after ET and the corresponding crude ipsilateral recurrence proportion was 0.48 (95% CI 0.39 to 0.57) with considerable heterogeneity (p<0.001 Cochran’s Q test). Time-to-event-derived ipsilateral recurrence probabilities after 4 years were 0.20 (95% CI 0.11 to 0.30) after SU with a crude ipsilateral recurrence proportion of 0.11 (95% CI 0.08 to 0.13) with moderate heterogeneity (p=0.20 Cochran’s Q test). The estimates are derived from separate single-arm studies with differing tumour characteristics, treatment indications, surveillance protocols and other selection mechanisms that cannot be adjusted for. Results are limited by sparse reporting of numbers at risk and censoring, and lack of uniform reporting of outcome-related variables.Conclusions Ipsilateral recurrence outcomes following SU were homogenous across studies. Direct comparative evidence evaluating ET versus SU remains lacking. Future studies should emphasise standardised reporting on outcomes and associated variables in KSS, as ipsilateral recurrence is a clinically important endpoint for patient counselling in UTUC.PROSPERO registration number CRD42025640780.

BACKGROUND:Muscle invasive bladder cancer (MIBC) is an aggressive disease with a high mortality rate. Radical cystectomy (RC) is the standard treatment for MIBC and selected non-muscle invasive bladder -cancer (NMIBC) cases. The NorCys-study (NCT04523038, NCT04537221 and NCT04523025) aims to validate biomarkers predicting RC outcomes. This report describes RC practice patterns across the Nordic countries. MATERIALS AND METHODS:This prospective, multi-institutional study included bladder cancer patients undergoing RC with or without preoperative chemotherapy in all five Nordic countries from 5/2020 to 1/2025. Clinical and pathological data were collected prospectively into REDCap database and analysed using descriptive statistics, Wilcoxon rank sum and Pearson's Chi-squared tests. RESULTS:A total of 1,642 patients from 15 centres were enrolled. Of these, 35% (531) had clinical NMIBC (T1-Tis-Ta), and 65% (999) had cT2-4 disease. Preoperative chemotherapy was administered to 398/929 (43%) cT2-4 or node-positive patients. The most common neoadjuvant chemotherapy (NAC) regimens were gemcitabine - cisplatin (GC) (275/475 [58%]) and dose-dense methotrexate, vinblastine, doxorubicin and cisplatin (dd-MVAC) (144/475 [30%]). Robot-assisted RC was the most common surgical approach administered in 886 of 1,472 (60%) cases, with variation between centres. Ileal conduit was the predominant diversion method in 1,375 out of 1,465 cases (94%). Median surgical time was 322 min, blood loss was 300 mL and hospital stay was 9 days. Final pathology demonstrated pT0 in 29%, ≥pT2 in 43% and lymph node metastases 203 (17%). CONCLUSION:This study reports current RC practices amongst Nordic countries. Patient cohorts did not differ between countries, and although the practices were generally similar, some differences were noted in chemotherapy regimens, the use of robotic-assisted surgery and rates of early RC.

ABSTRACT Introduction We herein report two patients developing secondary adenocarcinomas arising in colonic segments used for urinary diversion a.m. Lundiana in a population‐based series 16 and 27 years after cystectomy, respectively. Case Presentation Following initial partial resection of the pouch, both patients experienced local recurrence; one subsequently developed distant metastases and died from secondary adenocarcinoma, whereas the other patient underwent extirpation of the pouch and re‐diversion with an ileal conduit. Conclusions Based on these patients, upfront radical surgery would have been a more effective treatment. In this patient population, clinical awareness but not screening for secondary adenocarcinomas seems to be the most appropriate strategy.

Compared with lung cancer (excluding lung adenocarcinoma), where a decreased incidence has been reported in Sweden following a decline in the prevalence of daily smokers, we observed an increased incidence of bladder cancer, especially in older men. Given that approximately half of the individuals diagnosed with either malignancy are current or former smokers, the reasons for this paradoxical shift in incidences between the diseases remain unclear. However, it is noteworthy that bladder cancer mortality did not rise in parallel with the increased incidence, and even decreased among men.

Upper tract urothelial carcinoma is a rare disease entity with complex diagnostic and treatment options. In the Swedish National Quality Register for Bladder and Urinary Tract Cancer (SNRUBC), prospective registration of tumour and treatment characteristics is performed with high coverage, where data including quality indicators are presented online (RODRET). Between 2023 and 2024 regional differences in the majority of quality indicators are observed in the SNRUBC, with target levels only met in a few regions. For some quality indicators, such as proportion of patients referred to multidisciplinary tumour board discussion or proportion receiving curative treatment and perioperative lymphadenectomy, an association with better performance and hospital volume above 10 patients per year was observed. A regional centralization of multidisciplinary tumour boards for these patients might decrease regional inequalities and improve quality metrics.

Objectives:To investigate the association between waiting time and outcomes in patients with upper tract urothelial carcinomas (UTUC). Patients and methods:We studied a population-based cohort of 858 patients in BladderBaSe 2.0 subjected to extirpative surgery for UTUC 2015-2019 in Sweden. Diagnostic waiting time (from referral to diagnosis, reference <1 week), treatment waiting time (from diagnosis to surgery, reference <5 weeks) and total waiting time (reference <10 weeks) were investigated in relation to disease-specific (DSS) and overall survival (OS) by multivariable Cox regression models. To further explore these associations, stage progression from preoperatively recorded clinical tumour stage to pathological tumour stage in the extirpated specimen was assessed by logistic regression. Results:Total waiting time was not associated with DSS, OS or stage progression. A diagnostic waiting time between 1 and 4 weeks was associated with better DSS (HR 0.57 [95% CI 0.35-0.94]) and OS (HR 0.60 [95% CI 0.41-0.87]). In the strata of patients with UTUC in the renal pelvis, a diagnostic waiting time > 4 weeks was associated with stage progression (OR 2.44 [95% CI 1.00-5.95]), and in patients with UTUC in the ureter, a treatment waiting time between 5 and 10 weeks was associated to worse DSS (HR 2.85 (95% CI 1.03-7.89). Conclusions:In general, shorter care pathways were linked to beneficial survival estimates, yet some estimates may be influenced by selection bias due to prioritizing short waiting times for patients with advanced and/or overt symptomatic tumours. Stage progression with increased waiting time may indicate an underlying causal mechanism.

Background: The role of cystectomy in synchronous oligometastatic bladder cancer is unclear. Objective: To describe a population-based consecutive cohort with primary oligometastatic bladder cancer (M1a or M1b) treated with curative intent. Methods: Twenty consecutive patients with primary stage M1a or M1b bladder cancer subjected to induction chemotherapy and radical cystectomy 2013–2024 in the Southern healthcare region were identified in the Swedish National Register for Urinary Bladder Cancer. Primary staging and the evaluation of response to systemic induction chemotherapy were performed using [18F]fluorodeoxyglucose positron emission tomography with computed tomography (FDG PET-CT). After additional chemotherapy, consolidating radical cystectomy, lymphadenectomy and in selected patients, postoperative stereotactic radiotherapy or adjuvant nivolumab were applied. Disease-free survival (DFS) and overall survival (OS) from chemotherapy start were visualised by Kaplan-Meier curves. Results: Ten patients with retroperitoneal lymph node metastases, seven with single bone metastasis and three with inguinal metastases responding on three chemotherapy courses according to FDG PET-CT-evaluations were subjected to additional chemotherapy and subsequent radical cystectomy and lymphadenectomy with templates including lymph node metastases. Five patients with bone-oligometastatic disease received consolidating stereotactic radiotherapy, and three patients received adjuvant nivolumab. Postoperatively, one patient progressed in preoperatively known bone metastasis, and one patient displayed lack of chemotherapy response in the cystectomy specimen and was consequently subjected to second-line pembrolizumab treatment with palliative intent. At a median follow-up of 23 months, 10 patients (50%) were disease-free. Conclusions: Long-term survival was observed in some individuals after multimodal treatment for selected patients with synchronous oligometastatic bladder cancer. Patient summary: Amongst patients diagnosed with limited number of distant bladder cancer metastases, those responding on initial systemic chemotherapy can be selected for further treatment. After additional chemotherapy, radical cystectomy with lymphadenectomy and individually intensified treatment with consolidating radiation towards distant metastases and/or adjuvant systemic treatment with checkpoint inhibitors for 12 months, long-term survival was observed in some individuals despite a disease-entity with bad prognostic features.

Objective: To report national data on diagnostics and treatment of upper tract urothelial carcinoma (UTUC) from the Swedish National Registry of Urinary Bladder Cancer (SNRUBC). Patients and methods: Data from 2015 to 2021 were retrieved, and descriptive analyses were performed regarding incidence, diagnostic modalities, preoperative tumor staging, quality indicators for treatment including the use of standardized care pathways (SCP) and multidisciplinary tumor boards (MDTB). Time trends were explored for the study period. Results: Registrations included 1,213 patients with renal pelvic cancer and 911 patients with ureteric cancer with a median age of 74 (interquartile range [IQR] 70–77) and 75 (IQR 71–78) years, respectively. Incidence rates of UTUC were stable, as were proportions of curative treatment intent. Median number of days from referral to treatment was 76 (IQR 57–99) and 90 (IQR 72–118) days, respectively, for tumors of the renal pelvis and ureter, which remained unchanged after introduction of SCP in 2016. Noticeable trends included stable use of kidney-sparing surgery and increased use of MDTB. For radical nephroureterectomy (RNU), robot-assisted technique usage increased even for non-organ-confined tumors (cT3-4) and in one out of three patients undergoing RNU a bladder cuff excision was not registered. Conclusions: The population-based SNRUBC with high coverage contributes to the knowledge about UTUC with granular and generalizable data. The present study reveals a high proportion of patients not subjected to curatively intended treatment and suggests unmet needs to shorten lead times to treatment and use of bladder cuff excision when performing radical surgery for UTUC in Sweden.

Objective: Disease recurrence, particularly intravesical recurrence (IVR) after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC), is common. We investigated whether violations of onco-surgical principles before or during RNU, collectively referred to as surgical violation (SV), were associated with survival outcomes. Material and methods: Data from a consecutive series of patients who underwent RNU for UTUC 2001–2012 at Skåne University Hospital Lund/Malmö were collected. Preoperative insertion of a nephrostomy tube, opening the urinary tract during surgery or refraining from excising the distal ureter were considered as SVs. Survival outcomes in patients with and without SV (IVR-free [IVRFS], disease-specific [DSS] and overall survival [OS]) were assessed using multivariate Cox regression analyses (adjusted for tumour stage group, prior or concomitant bladder cancer, comorbidity and preoperative urinary cytology). Results: Of 150 patients, 47 (31%) were subjected to at least one SV. Overall, SV was not associated with IVRFS (HR 0.81, 95% CI 0.4–1.6) but with worse DSS (HR 1.9, 95% CI 1.03–3.7) and OS (HR 1.9, 95% CI 1.2–3) in multivariable analysis. Additional analyses with a broader definition of SV including also preoperative instrumentation of the upper urinary tract (ureteroscopy and/or double J stenting) showed similar outcomes for DSS (HR 2.1, 95% CI 1.1–4.3). Conclusion: Worse survival outcomes, despite no difference in IVR, for patients that were subjected to the violation of sound onco-surgical principles before or during RNU for UTUC strengthen the notion that adhering to such principles is a cornerstone in upper tract urothelial cancer surgery.

OBJECTIVE:To report population-based clinical presentation and outcomes in patients with urosymphyseal fistula (USF) after pelvic radiotherapy (RT).PATIENTS AND METHODS:A retrospective chart review was performed in 33 consecutive patients diagnosed with suspicion of USF in a tertial referral center from 2014-2022 to ascertain information about diagnostic delay, clinical presentation, precipitating causes, treatments received and outcomes during the median 22 months follow-up. Out of 33 consecutive patients with suspicion of USF, one female with vesicovaginal fistula, one patient developing RT-associated bladder angiosarcoma, four patients with short follow-up (<3 months), and three patients that during chart review not were considered to have a USF were excluded.RESULTS:In all, 24 males with a median age of 77 years were diagnosed with USF. Local pain was the predominating symptom in 17/24 (71%) patients. Endourologic manipulations preceded the diagnosis of USF in 16 patients. Five patients had a diagnostic delay of more than 3 months. At diagnosis, 20/24 patients had radiological signs of osteomyelitis, and five had a concomitant rectourethral fistula. Due to comorbidity, five patients were not amenable to any other interventions than urinary catheter or suprapubic tube in conjunction with long-term antibiotics, of which three died from infections related to the USF. Out of the remaining 19 patients receiving some form of urinary diversion, five had recurrent osteomyelitis, of which four did not undergo cystectomy in conjunction with surgery for the USF.CONCLUSIONS:Urethral endourologic interventions in patients previously subjected to pelvic RT should be performed cautiously.

Background Intravesical recurrence (IVR) after surgery for upper tract urothelial carcinoma (UTUC) is a clinical problem. We investigated if preoperative invasive diagnostic modalities (IDM) such as antegrade/retrograde uretero-pyelography and/or selective urine cytology/barbotage, and URS with or without concomitant biopsy are associated with IVR after radical surgery for UTUC. Risk of death from urothelial cancer and all causes was investigated as secondary outcomes. Methods We investigated a population-based cohort of 1038 consecutive patients subjected to radical surgery for UTUC 2015–2019 in Sweden, using the Bladder Cancer Data Base Sweden (BladderBaSe 2.0), comprising all patients in the Swedish National Registry of Urinary Bladder Cancer. Risk estimates of IVR, death from urothelial cancer, and all causes was assessed using multivariable Cox regression models. Results The study included 536 cases with and 502 without preoperative IDM. IDM was associated with increased risk of IVR (HR 1.24, 95% CI 1.03–1.52) and risk of urothelial cancer death (HR 1.56, CI 1.12–2.18), compared to no IDM after a median follow-up of 1.3 yrs. Stratified analysis for tumor location showed that IDM was associated with risk of IVR in ureteric cancer (HR 1.66, 95% CI 1.21–2.28) but not in renal pelvic cancer (HR 1.07, 95% CI 0.81–1.41). Limitations included the observational setting and the lack of variables such as tumour grade, multifocality and preoperative hydronephrosis. Conclusions Worse outcomes for patients subjected to preoperative IDM highlight the need for carefully considering diagnostic decisions for UTUC patients, specifically in tumours located in the ureter.