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High-grade T1 (formerly T1G3) bladder cancer (BCa) has a high propensity to recur and progress. To review the current literature on the management of T1G3 BCa and to provide recommendations for its treatment. The diagnosis of T1G3 disease is difficult because pathologic staging is often unreliable and because of the risk of significant understaging at initial transurethral resection (TUR) of bladder tumour. The incidence of transitional cell carcinoma (TCC) of the bladder worldwide is in excess of 336000 [1]. T1G3 tumours have a high propensity to recur and progress to muscle invasion and are associated with a significant risk of metastasis and death. The mainstay of diagnosis and initial treatment of T1G3 BCa is transurethral resection (TUR). Interobserver variability in pathology interpretation is another source of error in properly assigning a T1G3 diagnosis. The ability to correctly assign stage and grade to T1G3 tumours depends on adequate TUR technique. For all cases of newly diagnosed T1G3 TCC, a secondary TUR 4–6 wk after the primary TUR is strongly recommended.
In addition to the diagnostic benefit, repeat TUR has the ability to detect and potentially clear residual TCC.
Adjuvant intravesical bacillus Calmette-Guérin (BCG) immunotherapy is the treatment of choice for bladder preservation with T1G3 TCC. Five-year survival; all other survival rates are those reported at last follow-up for the respective study. Recurrence rates have ranged from 23% to 74%, and progression rates have ranged from 5% to 49%. Based on these data and consensus within the urologic community, BCG is the preferred intravesical treatment for high-risk bladder TCC.
Patients experiencing severe side-effects from full-dose BCG can be considered for dose reduction, which may, however, compromise efficacy. Herr recently reviewed the data supporting maintenance BCG for high-risk non–muscle-invasive TCC and questioned, based upon methodologic limitations in the cited trials and a paucity of positive studies, the routine use of maintenance BCG for the prevention of tumour progression [37].
Compliance with therapy is also an issue, as only 16% of the SWOG trial participants completed all seven planned cycles. Late BCG failures are defined as patients with an initial complete response (CR) to BCG treatment (no tumour 6 mo after TUR) but with a subsequent recurrence [39]. BCG for late BCG failure patients as a salvage treatment for T1 cancers has been studied only to a limited extent. A third cycle of BCG is definitely not indicated because of success rates as low as 6% [44].
Thus, for patients with an initial T1G3 diagnosis and recurrence after BCG therapy, salvage treatment with a second course of BCG should be reserved for patients with pTa or CIS recurrences. Device-assisted therapy has also been investigated as a means of increasing the efficacy of intravesical chemotherapy.
The relatively high recurrence and progression rates associated with conservatively treated T1G3 TCC (Table 1) make cystectomy an option for these patients. Rates reported are those reported at study completion and not necessarily 5-yr actuarial values.
Risk stratification involves assessing the probability of progression and local failure with conservative treatment.
Noncompliance or intolerance to adjuvant intravesical therapy or tumours in a location difficult to access transurethrally are indications for immediate or early cystectomy. A limited number of reports assessing the role of radiation therapy (RT) with or without chemotherapy for the treatment of T1G3 TCC are available.
The excellent CSS and OS rates achieved with cystectomy for stage T1 TCC (Table 2) must be weighed against the understandable wish of the patient to preserve his or her own bladder along with the risks and morbidity of cystectomy. Kulkarni et al performed decision analysis that enabled comparisons of cystectomy and BCG while accounting for detriments in QoL related to either treatment (level 2b) [54]. Analysis and interpretation of data: Kulkarni, Hakenberg, Gschwend, Thalmann, Kamat, Kassouf, Zlotta. Drafting of the manuscript: Kulkarni, Hakenberg, Gschwend, Thalmann, Kamat, Kassouf, Zlotta. Critical revision of the manuscript for important intellectual content: Kulkarni, Hakenberg, Gschwend, Thalmann, Kamat, Kassouf, Zlotta. Biosolids are derived from wastewater sludge, mainly a mix of water and organic materials that are a by-product of the sewage treatment processes.
Biosolids may also contain traces of synthetic organic compounds and metals, including arsenic, cadmium, chromium, lead, mercury, nickel and selenium.
Biosolids can be applied as a fertiliser to improve and maintain productive soils and stimulate plant growth.
Biosolids are graded according to chemical composition and the level of pathogens remaining after production.
What you flush down the toilet and plug-holes in your house eventually requires treatment at a sewage treatment plant.
This video produced by the Centre for Integrated Biowaste Research in New Zealand descibes the wastewater treatment process in simple terms. During sewage treatment, microorganisms digest (eat) the sewage, completely breaking down the original organic solids that have been discharged into the sewerage system. Biosolids comprise dead micro-organisms, a small portion of active microorganisms, and any inert solids such as sand which have come down the sewer. The final quality of the biosolids produced depends on the quality of the sewage entering the treatment plant and the treatment process.
Strict state and national guidelines in Australia and New Zealand specify the way in which specific biosolids can be used. Sprained Ankle - IntroductionMost sport players have twisted their ankle at least once considering that rolled ankle is one of top sport injuries so I decided to cover everything about ankle sprain in this article. ACL Injuries ACL or Anterior Cruciate Ligament is one of four knee ligaments holding the knee joint together.
ACL Injury Rehab ACL Injury Rehab will be needed after every ACL ligament tear or mild sprain. Common Soccer Injuries I wanted to create one web page with information on common soccer injuries and what these injuries feel like so that you can sometime recognize what is going on when it does happen to you or your players. Hamstring Exercises Many athletes and regular people have hurt their hamstring at one point in their life and know how discomforting a hurt hamstring can feel. Treatment for Injured Hamstring Hamstring injury treatment will vary depending on the severity of the injury. Hamstring Injury Hamstring muscle injuries occur very frequently in athletes participating in various physically demanding sports that require sprinting and sudden change of movement and speed. Hamstring Stretches Stretching the hamstring muscles is very important for our overall health as it reduces lower back pain and gives us strong and lean hamstrings that will help with our lower body range of motion.
High Ankle Sprain Ankle Syndesmosis injuries are often referred to what people call high ankle injury due to ankle swelling and ankle joint pain in the ligaments above the ankle. How To Tape Your Ankle Ankle taping is a big part of preventing ankle injury for players participating in any type of sport where running and change of direction is required, such as soccer, football, basketball etc. Knee Injuries Knee injuries are very common in sports that require running and soccer is one of many sports where ligament injuries are bound to happen to every player sooner or later. LCL Injuries LCL (lateral collateral ligament) is one of the four knee ligaments holding the knee in place. LCL Rehab When it comes to LCL ligament injury, time is the best healing process and surgery is rarely required for treatment of common lateral collateral ligament injuries.
MCL Injury MCL or Medial Collateral Ligament is one of the FOUR major ligaments that hold the knee together preventing it from sliding left and right or back and forth. MCL Rehab MCL rehab is needed after an MCL ligament injury and time is the best friend in getting over the MCL knee injury. PCL Injury PCL ligament crosses with the ACL ligament preventing our knee from moving back and forth. PCL Rehab PCL injury rehab will be different depending on the level or degree of knee injury suffered.
Sprained Ankle Most sport players have twisted their ankle at least once considering that rolled ankle is one of the top sport injuries so I decided to cover everything about ankle sprain in this article. Concussion Treatment Following a concussion, rest is the best answer for concussion treatment.
AbstractThe 2007 National Pressure Ulcer Advisory Panel pressure ulcer update and the October 2008 facility reimbursement changes by the Centers for Medicare & Medicaid Services for Stage III or IV pressure ulcers add resource burdens to healthcare facilities. Risk stratification of patients based on pathologic features at initial TUR or at recurrence can select those most appropriate for bladder preservation compared to those for whom cystectomy should be strongly considered. Risk stratification based on pathologic features at initial transurethral resection or at recurrence can select those most appropriate for bladder preservation compared to those for whom cystectomy should be strongly considered.
Long-term progression and death rates as high as 53% and 34%, respectively, have been reported [3]. Each article's title and abstract were reviewed for their appropriateness regarding clinical management of T1G3 TCC of the bladder.
The resection must include the muscular layer and should be as complete as possible without bladder perforation. In a study of 1400 patients pooled from five European Organisation for Research and Treatment of Cancer (EORTC) randomised, controlled studies of adjuvant intravesical therapy for Ta and T1 BCa, agreement on lamina propria invasion was only 42.9% (level 2b) [10].
Excessive cautery artefacts can make pathologic interpretation difficult and should be avoided.
A meta-analysis performed by Sylvester et al analysed 1476 patients from seven randomised, controlled trials of prophylactic chemotherapy versus no prophylaxis after TUR (level 1a) [17].
Contraindications to its use include very deep resections, bladder perforation, and prior documented allergic reaction.
Because at least 27% of patients harbour residual tumour (with the highest reported rates of 62%) [9], repeat resections may have a therapeutic benefit. Although upstaging of T1G3 lesions to pT2 disease or higher automatically selects patients for radical therapy, Herr and colleagues demonstrated that evidence of T1 disease on repeat TUR portends future muscle invasion (level 2b) [24]. Standard induction therapy comprises six weekly instillations after diagnosis of T1G3 disease after complete resection, although this regimen is largely non–evidence based.
For studies in which data for T1G3 tumours are not reported separately, combined data with the proportion of cases made up of T1G3 lesions are provided.
Where available, the reported disease-specific survival (DSS) and overall survival (OS) estimates also ranged widely. Shelley and colleagues published a Cochrane Review, updated in 2008, assessing the impact of BCG therapy on medium- and high-risk TCC compared to TUR alone (level 1a) [25].


MMC is a reasonable alternative only in situations where adjuvant BCG is contraindicated (allergy, intolerance to BCG, or immunosuppressed states) and immediate cystectomy is refused [30].
Although these provocative arguments should be considered prior to prescribing maintenance BCG, until strong evidence suggests otherwise, the data nevertheless support maintenance BCG for all cases of T1G3 TCC treated with a bladder-sparing approach. In fact, less than half of the patients completed more than three cycles, suggesting that the noted significant impact of maintenance therapy was achieved up front during therapy. Of 126 patients with an initial pT1 lesion, Brake et al reported that 89 (71%) had a lasting response to a single course of BCG [40].
To avoid cystectomy, other intravesical salvage options for BCG failures have been studied. Patients with a pT1 recurrence are at high risk of progression and should definitely be offered cystectomy. Intravesical gemcitabine has been used for the treatment of high-risk BCa after BCG failure. Local hyperthermia coupled with MMC has been shown to have improved efficacy over MMC alone in the treatment of high-risk superficial TCC.
Although restaging TUR refines local cancer staging, thereby decreasing the risk of understaging T1 lesions, approximately 13% of patients will still be understaged even after re-TUR (level 3b) [51]. First, the perioperative mortality and morbidity rate following cystectomy is not trivial at 1–6% (level 2c) [52] and 30% (level 2b) [53], respectively.
This is particularly important because a number of series have demonstrated that delays in cystectomy can lead to worse outcomes. Identifying candidates at high risk for progression would help to identify clearly patients who should undergo early cystectomy. 1 illustrates a possible treatment algorithm for newly diagnosed T1G3 tumours based on the information we have presented in this review.
Weiss and colleagues retrospectively evaluated the impact of radiochemotherapy for high-risk T1 BCa in 141 patients followed for a median of 62 mo (level 3b) [62]. Intravesical treatment may result in bladder preservation but not without risk and morbidity. Not surprisingly, they found that the treatment associated with the highest gain in quality-adjusted life expectancy (QALE) was dependent on patient age and comorbidity.
Bladder preservation with BCG and RC are the current standard treatment modalities of choice for these tumours. Kulkarni had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. When treated and managed appropriately, they can be beneficially used for a number of purposes. Biosolids can only be considered as such once they fulfil the requirements of a set of approved biosolids management guidelines.
These contaminants limit the extent to which biosolids can be used, with all applications regulated by appropriate government authorities in each State and federally.
Approximately 55% is applied to agricultural land and around 30% is disposed of in landfill or stockpiled. A typical sewage treatment plant uses a range of treatment processes to produce recycled water and biosolids.
Sewage consists of used water from household activities such as washing dishes and clothes, taking a shower, flushing the toilet and even cleaning your teeth.
This discharge is usually regulated and limits are set so that any potentially dangerous compounds are not allowed in the sewer at levels that might cause harm to the environment or people. The Australian and New Zealand water industries use some of the most advanced wastewater treatment and biosolids production technology and quality assurance programs in the world. Ankle joint pain should go away later.Extensive bruising around the injured ligament is to be expected. The ultimate goal of these updates and changes is to decrease the overall rate of hospital-acquired pressure ulcers. Treatment with bacillus Calmette-Guérin (BCG) risks progression and metastases but may preserve the bladder. Nevertheless, many of these tumours can be treated successfully with bladder-preservation approaches.
Although a wide variety of chemotherapeutic agents were used in the pooled trials (mitomycin C [MMC], doxorubicin, epirubicin, and thiotepa), the majority of centres use MMC (40mg in 40cm3 of saline) as the prophylactic chemotherapeutic agent of choice.
First, a repeat resection of the previously resected site 2–6 wk after the initial resection (along with any other cystoscopically suspicious areas) will provide more accurate staging information. Divrik and colleagues provided randomised, controlled evidence supporting this notion (level 1b) [23]. Of 92 T1 patients with residual T1 disease at second resection, 82% progressed to muscle invasion by 5 yr. The heterogeneity in outcomes is likely related to a combination of factors, including differences in patient selection (eg, differing rates of concomitant CIS), in the quality of TUR (eg, differing rates of muscularis propria sampling), in the use of secondary TUR, in the use of maintenance instillation regimens and agents, as well as variable times of follow-up. Six randomised trials involving 585 patients, of which more than half were pT1, were included.
Undoubtedly, patients experience significantly fewer local and systemic side-effects with adjuvant MMC compared to BCG [27], but the potentially aggressive nature of T1G3 TCC necessitates the use of the most effective treatment. The maintenance protocol consisted of three weekly BCG instillations at 3 and 6 mo post-TUR and semiannually thereafter for 3 yr. This notion is supported by a report from Decobert and colleagues [38] in which 111 patients at high risk for recurrence (32% pT1) received BCG as per the SWOG maintenance protocol (level 2b).
Many urologists also consider cystectomy as the appropriate treatment for late BCG failures. Of the 37 recurrences, 13 were muscle invasive, and the remaining 24 were treated with repeat resection and a second course of BCG.
In a phase 2 trial involving 467 unselected superficial BCa patients with at least one BCG failure, the combination of BCG plus interferon-α resulted in a disease-free rate of 45% at 24-mo median follow-up [45]. In a phase 2 trial of intravesical gemcitabine for BCG-refractory BCa where cystectomy was recommended but refused, Dalbagni and colleagues noted a CR, defined as negative cystoscopy, cytology, and biopsy at first surveillance of 50% (15 of 30; level 3b) [46]. Second, cystectomy may have a detrimental impact on quality of life (QoL) secondary to long-term changes in sexual, gastrointestinal, and genitourinary function (although it should be remembered that BCG therapy can also impair QoL because of frequent follow-up, surveillance cystoscopy, lower urinary tract symptoms, and the risk of disseminated BCG infection [54]).
The need for such a strategy has been recognised by a recent international consensus panel on T1 BCa that subclassified T1 tumours into high-risk and low-risk variants based on multifocality, associated CIS, tumour location (dome or anterior bladder wall), or residual T1 disease on restaging TUR [44]. It supports a bladder-preservation regimen in patients without identifiable risk factors while helping to identify those individuals at risk for progression in whom immediate or early cystectomy should be performed. Of the 84 patients with T1G3 disease, 89% achieved a CR (no tumour on restaging TUR 6 wk after completion of radiochemotherapy). As a result of cost, inconvenience, potential for toxicity, and a lack of benefit over conventional intravesical therapies, the authors concluded that RT cannot be recommended for routine use as a bladder-preservation strategy.
Although CSS remains of paramount importance, QoL considerations, which are difficult to assess, cannot be ignored. Younger, healthier patients had higher QALE when treated with cystectomy, but after age 65, a higher QALE was noted with BCG treatment. The decision to pursue bladder preservation versus cystectomy depends on a number of tumour factors, which can indicate the risk of progression. Australia has one of the strictest regulatory regimes for biosolids production and application in the world. The water content of the solids is then reduced, usually by passing through mechanical processes. In 2007, nearly 13% of all pressure ulcers reported through PA-PSRS were categorized as Stage III or IV; more than 26% of the total reports did not include any pressure ulcer staging information.
Cystectomy may offer the best opportunity for cure but is associated with morbidity and a risk of mortality, and it may constitute potential overtreatment for many cases of T1G3 tumours.
For a bladder-sparing approach, intravesical BCG should be given as induction with maintenance dosing. The dilemma facing the urologist is how best to treat these tumours in a timely manner so that the chances of bladder preservation and cancer control are maximised while the risks of overtreatment with radical therapy are minimised. Tumour visibility and completeness of resection can be aided by fluorescence cystoscopy (or photodynamic diagnosis), although this diagnostic modality is not available in all jurisdictions [6]. Discrepancies in grade were also noted in this study, with grade 3 agreement only observed in 61.3% of cases.
The importance of the quality of TUR was shown by Brausi et al in their assessment of 2410 EORTC patients from seven phase 3 adjuvant intravesical therapy trials (level 2b) [16]. This is particularly important because the probability of understaging a T1G3 tumour ranges from 20–70%, depending on the presence of muscularis propria in the sample.
In their study, T1 patients (11% T1G3) were randomised to TUR plus adjuvant intravesical MMC versus TUR plus MMC followed by re-TUR 2–6 wk later. In contrast, of 260 T1 patients without lamina propria invasion on re-TUR (stage distribution on re-TUR: 149 T0, 87 carcinoma in situ [CIS], 24 Ta), only 19% progressed at 5 yr. Despite these discrepancies, these studies point to the need for long-term surveillance of patients with T1G3 BCa. At 12 mo, the recurrence rate was 26% for patients treated with adjuvant BCG compared to 51% in patients treated by TUR alone.
In a subgroup analysis of high-risk patients receiving maintenance BCG, the risk reduction compared to MMC was 49%. In a number of cases, efficacy and safety did not appear to be compromised for T1G3 tumours [32] and [33], but recent reports by Martinez-Pineiro et al [34] and Yoneyama et al [35] have suggested worse outcomes with low-dose regimens in T1G3 patients, with trends towards reduced DSS and RFS (level 2b).
The durable response rate, however, was much lower, with a 1-yr RFS in responders of only 21%. Table 2 lists the contemporary series in which T1 tumours were treated immediately or early with radical cystectomy (RC; level 2b).
Because up to 18% (Table 2) of T1 patients have positive lymph nodes, cystectomy can be both diagnostic and therapeutic with regard to nodal metastases.
Finally, RC may be considered overtreatment for many patients because a conservative bladder-sparing approach with BCG is effective in approximately 50% of cases. They hypothesised that the delay to definitive, radical surgery with increasing endoscopic interventions may have contributed to the increase in progression. All pathology identified after the first cystoscopic assessment assumes adequate transurethral resection (ie, re-resection of T1 lesions). Long-term results, however, showed that the 10-yr risk of progression for T1G3 patients was 29%, with a 10-yr DSS of 71%.
We present a risk-stratified approach for these lesions that should maximise the chances of safely identifying those patients in whom a bladder-preservation strategy can be pursued while also identifying those at high risk of progression for whom immediate or early cystectomy must be offered. The admission diagnosis and documentation of Stage III or IV pressure ulcers are essential to overall pressure ulcer identification, care, and ultimately, reduction. Immediate or early radical cystectomy (RC) should be offered to all patients with recurrent or multifocal T1G3 disease, those who are at high risk of progression, and those failing BCG treatment.


In this review, we focus on contemporary treatment strategies for T1G3 TCC of the bladder, highlighting the initial workup and diagnosis of these lesions, and then concentrating on treatment and outcomes of conventional and alternative treatments. Adequate sampling of muscularis propria is essential, as numerous studies have documented the risk of understaging T1 lesions at 50–70% in the absence of muscularis propria (level 2b) [7] and [8]. The impact of this change in grading on outcomes is not yet fully understood [12] and [13], although both grading systems contribute independent information regarding disease progression [14].
Nevertheless, a decrease in the odds of recurrence rate by 39% was found with immediate prophylactic chemotherapy.
If muscle is absent from the initial TUR, repeat resection is mandatory because of the high rate of understaging [8]. Patients in the repeat TUR group experienced a significantly improved 3-yr recurrence-free survival (RFS) of 69% compared to 37% in the group without secondary TUR. Based on these data, residual T1 TCC on repeat TUR was deemed a negative prognostic indicator and a potential indication for immediate cystectomy in T1G3 patients. Cookson and investigators reported on 86 high-risk patients (44% pT1, 81% diffuse CIS) with median follow-up of 184 mo, half of which received induction (but not maintenance) BCG. A meta-analysis by Sylvester et al demonstrated the benefit of adjuvant BCG on progression [26]. These results were corroborated in a meta-analysis conducted by Shelley involving 1527 patients from six randomised, controlled trials of BCG versus MMC treatment. Thus, in T1G3 TCC, dose-reduced BCG regimens must be used with caution, with additional investigation of the role of reduced dose BCG warranted. Although the impact of additional maintenance (three cycles vs four or more cycles) was not statistically significant, none of the 12 patients who received five or more cycles of maintenance BCG experienced a recurrence. A low short-term disease free rate of 13% in high-risk patients (including T1G3 patients) was also noted by Bartoletti et al (level 3b) [47]. DSS for these patients ranges between approximately 80% and 90%, which is probably an underestimate of the true survival conferred to T1 patients treated with cystectomy, because the patients in these retrospective series were likely selected to undergo cystectomy because of adverse pathology (eg, multifocality, associated CIS).
Fourth, cystectomy obviates the need for repeated intravesical therapies and simplifies follow-up. Thus, an approach using reliable risk stratification in order to decide which patients to offer early cystectomy versus conservative treatment is required. Herr and Sogani studied 307 high-risk BCa patients, 90 of whom underwent cystectomy on relapse (level 2b) [56]. The presence of two or more of these risk factors at T1G3 diagnosis identifies candidates who must be advised to undergo immediate cystectomy [57] and [59].
Of note, the vast majority of patients were satisfied with their urinary function, suggesting that combined TUR with radiochemotherapy maintained QoL while achieving respectable disease outcomes.
Rather, the type of tumour and its associated risk factors for progression along with patient factors such as age, comorbidity, and preferences must all be considered when making a final treatment recommendation. Regulators, such as State departments of Health and Environment strictly control the production, quality and application of biosolids. Risk reduction strategies include pressure ulcer protocol development, implementation, consistent documentation, and communication systems that extend along the entire continuum of care. Where possible, we have provided levels of evidence as per the modified Oxford Centre for Evidence Based Medicine scheme [4]. Even with muscularis in the specimen, understaging rates based on cystectomy pathology are reported between approximately 20% and 30% after single TUR [7] and [9]. Even after accounting for the number of tumours, the year of resection, and the institution at which the resection occurred, recurrence rates displayed significant variability.
Even with muscularis propria sampling at first resection, several reports have documented occult T2 disease in up to 10% of second resections (level 2b) [9], [19], and [20]. Of these patients, 31% had progression after 5 yr, four of which cases occurred after 10 yr and one beyond 15 yr (level 1b) [3].
The meta-analysis of Böhle and Bock [29] corroborated Sylvester et al's data, as discussed above. Although these data support the idea of early efficacy of maintenance therapy, patients nevertheless should be encouraged to continue maintenance beyond three cycles.
Nevertheless, because the actuarial risk of progression with each additional 6-wk course of BCG is 7% [41], many urologists hesitate to provide a second course BCG except in select cases. In a recent report of 40 patients (90% pT1) followed for a median of 28 mo, 14 (35%) patients recurred, but no patients progressed [48]. Finally, we provide a recommended treatment algorithm for patients with T1G3 bladder cancer (BCa) that incorporates bladder preservation and radical therapeutic techniques based on defined risk groups.
The authors concluded that surgeon skill and resection technique were the major determinants of TUR outcome.
More recent reports have confirmed these findings but have suggested that the tumours prevented are primarily of the smaller variety (level 1a) [18].
These data suggest that the long-term risks associated with T1 bladder tumours are not trivial and mandate lifelong cystoscopic and cytologic follow-up. With respect to progression, Böhle and Bock in another meta-analysis analysed nine trials of BCG versus MMC adjuvant therapy comprising 2410 patients (level 1a) [29]. Soloway et al suggest a second course BCG if the recurrent lesion is Ta or CIS and cystectomy for recurrent T1G3 tumours [42]. On the basis of these preliminary data, intravesical gemcitabine cannot be recommended for pT1G3 TCC of the bladder. Likewise, Denzinger and colleagues examined 105 T1G3 patients with adverse pathologic features (at least two of multifocality, tumour size >3cm or CIS), all of whom underwent cystectomy (level 2b) [57]. Not listed are investigational molecular markers such as p53 or pRB, the prognostic ability of which in high-risk superficial BCa has not been established unequivocally (level 4) [60] and [61]. When a facility reports a pressure ulcer event through PA-PSRS, the two additional staging options appear in the event detail questions. Clearly, both the urologist and the pathologist play an important role in adequately defining T1G3 BCa.
This approach has been verified in a study of 214 patients with high-risk BCa who experienced T1 recurrence [43].
Further studies confirming these results are needed before this approach can be recommended. Fifty-four patients opted for immediate cystectomy, and 51 underwent deferred cystectomy at a median of 11.2 mo after initial TUR.
Clinical under staging of high risk nonmuscle invasive urothelial carcinoma treated with radical cystectomy. These stages include Suspected Deep Tissue Injury (SDTI) and Unstageable (see Table 1 for definitions of these and other stages). Unfortunately, a subset analysis with high-risk patients only was not possible in this study because of the small number of trials with high-risk patients.
A 71% cumulative incidence of progression to muscle invasion at 5 yr (48% death from disease) was noted for patients treated with second-course BCG compared to a 28% cumulative incidence of progression (31% death from disease) for patients treated with cystectomy (level 2b). These data clearly support the use of cystectomy in the treatment of patients with pT1G3 recurrence after BCG treatment. Lambert et al also noted poorer disease-free survival and DSS in a cohort of patients undergoing cystectomy for T1G3 TCC after 1998 versus those treated with cystectomy before 1998 (level 3b) [58]. PA-PSRS Definitions - Skin Integrity Stages   An SDTI indicates a localized discolored area of intact skin or a blood-filled blister. They postulated that the decrease in survival was the result of higher and perhaps inappropriately prolonged use of intravesical therapy in the modern era.
An SDTI may be difficult to detect in patients with dark skin tones, so accurate assessment skills are critical. If Stage III or IV pressure ulcers are not present upon admission but appear at the time of discharge, associated patient care will not be reimbursed.
Patients may be admitted from home or other facilities with existing pressure ulcers, and hospitals are faced with the challenge of identifying, staging, and carefully documenting such conditions upon admission.
Physicians or any qualified healthcare practitioners documenting the patient’s admitting diagnosis must indicate the presence and clinical data of pressure ulcer upon admission, so documented detailed and accurate admission skin assessments are essential to avoid any question as to when an ulcer occured.2,6   In 2007, nearly 13% of all pressure ulcers reported through PA-PSRS were categorized as Stage III or IV (see Table 2).
This percentage has remained unchanged from the June 2004 to December 2005 reports data discussed in the September 2006 issue of the Patient Safety Advisory.7  Clearly defined pressure ulcer reporting criteria includes pressure ulcer assessment, documentation, and precise ulcer staging. 2007 Pressure Ulcer Reports with  Stages Submitted through PA-PSRSThe number of PA-PSRS pressure ulcer reports that lack staging information, coupled with the new SDTI and Unstageable stages and the cost to treat these pressure ulcers add resource burdens to healthcare facilities. Facilities are obliged to provide education to all clinicians conducting skin assessments as to the pressure ulcer stages and documentation requirements. Physicians must be involved in the prevention of pressure ulcers and in the documentation of skin assessments upon patient admission so that pressure ulcers that are present on admission are not mistaken for hospital-acquired pressure ulcers.8Facilities may consider the development of a multi-disciplinary pressure ulcer prevention taskforce composed of wound ostomy and continence nurses, physicians, nurses, dietitians, physical therapists, and any departments involved with pressure ulcer prevention such as patient transport. High-risk patients may include those who are bedridden or those who have comorbid conditions such as poor circulation, poor nutrition, incontinence, obesity, and dry skin. Use a standard reassessment tool to reassess daily a patient’s pressure ulcer risk, as condition changes indicate, and with transfers to the next level of care.
Perform daily skin inspections, including skin temperature, turgor, color, moisture, and integrity status. Pay close attention to bony prominences, particularly the sacrum and heels, as these are the most common adult pressure ulcer locations. Use lift devices or heel-protector devices to assist in turning, repositioning, lifting, or transferring patients to prevent friction or shearing forces, which may contribute to skin integrity issues. Evaluate the facility’s support surfaces such as mattresses (including those in the operating room suites), pillows, and chair cushions to ensure that pressure-relieving surfaces are used. Establish and maintain par-levels for skin care devices and products in each patient care area to ensure that resources are available to healthcare providers to deliver consistent pressure ulcer prevention.3,6,11MonitorAssess and monitor patient’s calorie intake, and notify the prescriber or dietitian if the patient has an unintentional weight loss, as this and poor nutrition often contribute to pressure ulcer risk. A comprehensive nutritional assessment addressing risk factors, protein intake, hydration, caloric needs, vitamins, and minerals is essential to pressure ulcer prevention. Vitamin or dietary supplementation may be indicated for nutritionally compromised patients.6,10,11ProtectProtect patient’s skin from excessive moisture and dryness due to incontinence, perspiration, or wound drainage. Only use products that wick moisture away from the body.6,10 Educate Provide pressure ulcer prevention education about assessments, protocols, documentation, and communication systems to all levels of healthcare providers.
Provide prompt communication of modifications or additions to skin protocols or products to all healthcare providers.6,10NotesBlack J, Baharestani MM, Cuddigan J, et al. CMS improves patient safety for Medicare and Medicaid by addressing never events [fact sheet online]. Previous medical history includes a cerebrovascular accident and hypertension.Which factors may lead to hospital-acquired pressure ulcer formation for this patient?



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