Practice Changing Papers

Bhoj Raj LuitelNepal Speaker Practice Changing PapersPractice Changing Papers in the Management of Urothelial Carcinoma Dr Bhojraj Luitel, Asst Professor Department of Urology and Kidney Transplant Surgery, Tribhuvan University Teaching Hospital, Kathmandu, Nepal Email: drbhojraj@gmail.com Introduction and Objectives: Muscle invasive Urothelial carcinoma (MIUC) has a higher tendency of recurrence and progression despite aggressive surgery and chemotherapy. There exists a gray area in the extent of lymph node dissection as well. Recent trials with immunotherapy have opened the door to optimal management of MIUC. This Scoping review aims to review the current role of perioperative immunotherapy and the role of extended lymph node dissection to improve disease-free survival and overall survival in patients undergoing radical cystectomy for MIUC. Materials and Methods: A scoping review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping review (PRISMA-ScR) guidelines. Electronic database searches and manual searches of literature, including websites of key publishers, were conducted. Using the Population, Intervention, Comparison, and Outcome (PICO) framework. This review included: patients with MIUC, radical cystectomy, trials with perioperative chemotherapy and immunotherapy, Standard vs extended pelvic lymphadenectomy. Results: Out of the literature searched, only four articles met the inclusion criteria. Those four seminal articles were selected based on the publication within the last year, novelty, impact on practice, and foundation for future research. The landmark NIAGARA Trial evaluates the efficacy and safety of perioperative durvalumab combined with neoadjuvant chemotherapy in patients with muscle-invasive bladder cancer. The study reveals that the addition of durvalumab significantly improved event-free and overall survival compared to chemotherapy alone. The 2025 update of the CheckMate274 trial was also published, which reaffirms nivolumab’s efficacy and safety in the adjuvant setting for MIUC, supporting its continued use to delay recurrence and potentially improve survival. Further follow-up is needed to assess long-term OS benefits and refine patient selection fully. Similarly, the results of the AMBASSADOR Trial evaluate the efficacy of adjuvant pembrolizumab compared to observation in patients with high-risk muscle-invasive urothelial carcinoma after radical surgery. It demonstrated significant benefits of adjuvant pembrolizumab therapy compared to observation in high-risk MIUC. The SWOG S1011 Clinical Trial investigated the effectiveness of extended lymphadenectomy compared to standard lymphadenectomy in improving survival rates for patients with muscle-invasive bladder cancer undergoing radical cystectomy. It was a negative study and provided level I evidence that extended lymphadenectomy does not provide significant survival benefits over standard lymphadenectomy and may increase surgical risks. Conclusion: Adjuvant checkpoint inhibitor therapy shows promise in improving disease-free survival for certain patients with high-risk muscle-invasive urothelial carcinoma. There is a knockout of extended lymphadenectomy during radical cystectomy. Key Words: MIUC, Immunotherapy, Chemotherapy, Radical cystectomy, practice-change