Staged treatment of invasive carcinoma of bladder

Role of planned preoperative irradiation in the management of clinical stage B2-C (T3) bladder carcinoma in the 1980s

In recent years the role of planned preoperative irradiation in the management of clinical stage B2-C (T3) bladder cancer has been questioned by a number of investigators. Much of the confusion regarding the efficacy of combined therapy results from studies that compare the results of treatment of pathological stage B2-C patients treated by cystectomy alone versus clinical stage B2-C patients treated by preoperative irradiation plus cystectomy. Such comparisons are biased because of 1) the exclusion of a large number of pathological stage D patients from cystectomy-alone series and their inclusion in preoperative irradiation plus cystectomy series and 2) the inclusion in the cystectomy-alone series of patients whose clinical stages were less than or equal to T2. The purpose of this paper is to compare the results of treatment in patients with clinical stage B2-C bladder carcinoma following radical cystectomy alone versus preoperative irradiation plus cystectomy. This article reviews the rationale for administering preoperative irradiation, the effect of preoperative irradiation on the pathological specimen (including down-staging, the effect on regional lymph nodes, and radioresponsiveness according to tumor configuration, i.e., papillary vs. solid), the impact of preoperative irradiation on pelvic recurrence and 5-year survival, and the effect of preoperative irradiation on operative and postoperative complications. This paper cites all known literature on the subject in the English language. Data comparing 5-year survival results of radical cystectomy alone versus preoperative irradiation plus cystectomy are analyzed in three different ways: a) retrospective comparisons of historical results, b) comparison of contemporaneous "modern-day" (1960-1980) series comprising 1185 patients who received either radical cystectomy alone or preoperative irradiation plus cystectomy, and c) review of the results of six randomized trials. Preoperative results are also analyzed according to dose level (2,000 cGy versus 4,000 cGy vs. 4,500-5,000 cGy). The data presented indicate that the addition of preoperative irradiation to cystectomy for clinical stage B2-C (T3) bladder cancer adds approximately 15-20 percentage points to the 5-year survival, leading to a survival figure that is approximately half again that achieved by cystectomy alone.

Planned preoperative irradiation in the management of clinical stage B2-C (T3) bladder carcinoma

In recent years the role of planned preoperative irradiation in the management of clinical Stage B2-C (T3) bladder cancer has been questioned by a number of investigators. Much of the confusion regarding the efficacy of combined therapy results from studies that compare the results of treatment of pathological Stage B2-C patients treated by cystectomy alone versus clinical Stage B2-C patients treated by preoperative irradiation plus cystectomy. Such comparisons are biased because of (1) the exclusion of a large number of Stage D patients from cystectomy-alone series and their inclusion in preoperative irradiation plus cystectomy series and (2) the inclusion in the cystectomy-alone series of patients whose clinical stages were less than or equal to T2. The purpose of this paper is to compare the results of treatment in patients with clinical Stage B2-C bladder carcinoma following radical cystectomy alone versus preoperative irradiation plus cystectomy. This article reviews the rationale for administering preoperative irradiation, the effect of preoperative irradiation on the pathological specimen (including down-staging, the effect on regional lymph nodes, and radioresponsiveness according to tumor configuration, i.e., papillary vs. solid), the impact of preoperative irradiation on pelvic recurrence and 5-year survival, and the effect of preoperative irradiation on operative and postoperative complications. This paper cites all known literature on the subject in the English language. Data comparing 5-year survival results between radical cystectomy alone versus preoperative irradiation plus cystectomy are analyzed in three different ways: (a) retrospective comparisons of historical results, (b) review of the results of 6 randomized trials, and (c) comparison of concomitantly treated "modern-day" (1960-1980) series treated by either radical cystectomy alone versus preoperative irradiation plus cystectomy in 1185 patients. Preoperative results are also analyzed according to dose level (2000 rad versus 4000 rad versus 4500-5000 rad). The data presented indicate that the addition of preoperative irradiation to cystectomy for clinical Stage B2-C (T3) bladder cancer adds approximately 15 to 20 percentage points to the 5-year survival, leading to a survival figure that is approximately half-again that achieved by cystectomy alone.

Complications of radical cystectomy and correlation with nutritional assessment

Single stage radical cystectomy and ileal conduit remains the procedure of choice for invasive bladder cancer and is a formidable operation performed on an elderly population. A retrospective review of 69 radical cystectomies was done to evaluate not only operative mortality and complication rate, but also the nutritional status of the patients and its relationship to the frequency of complications. Preoperative nutritional status was assessed by total lymphocyte count and serum albumin. There was an operative mortality rate of 2.9 per cent and early complication rate of 41 per cent. The findings suggest that patients with severe nutritional depletion should receive hyperalimentation prior to cystectomy to reduce serious postoperative complications.

Supracystic urine diversion in patients with bladder carcinoma treated by cystectomy preceded by "short radiotherapy" (2000 R)

The authors assessed the results of supracystic urine diversion in 50 patients treated by cystectomy for bladder carcinoma who had "short radiotherapy" (2000 R) before the operation. It was found that preoperative radiotherapy caused no difficulties during subsequent cystectomy and the observed postoperative complications should be related rather to the surgical technique. It seems that indications to urine diversion by the method of Goodwin or Coffey should be considered with greater caution. In patients past the age of 65 years and those with more advanced neoplasms (T-3, T-4) bilateral ureterocutaneostomy should be performed more frequently for suprapubic urine diversion.

Postdiversion precystectomy irradiation for cancer of the bladder

This is the first report of a 4-year prospective trial of integrated irradiation and cystectomy in the management of advanced bladder carcinoma. Patients are treated sequentially with staging laparotomy and urinary diversion, highdose preoperative irradiation (5,000 rad/30 treatments/42 days), and total cystectomy. Twenty-eight consecutive patients have been entered into the study; all had Grade III or IV tumor or clinical evidence of invasion (Jewett Stage B1-D1). Local control has been achieved in 21 of 22 patients, and the 4-year actuarial survival is 54%. The initial staging procedure not only defines inoperable patients, but also allows completion of urinary diversion prior to small bowel irradiation with fewer anastomotic problems. Acute and chronic complications have been minimal, and there have been no treatment-related deaths.

One-stage radical cystectomy for bladder carcinoma: operative mortality, cost/benefit analysis

An analysis of cystectomies performed between September 1, 1969 and December 31, 1974 was conducted to determine the rates of morbidity (59 per cent) and operative mortality (4.1 per cent). Comparison of these figures for single operations with data published form other sources concerning staging of the therapeutic procedures suggests that there is no benefit for the patient relative to surgical morbidity or mortality if the latter course is followed. Conversely, prolongation of hospital experience, multiple operations, absence from productive activity and increased health care cost are associated with the staged procedures. Application of cost-benefit analysis suggests that this experience may act as a model to evaluate competing forms of therapy involving other disorders. When costs are not equivalent and benefits are the same the more expensive form of therapy should not be offered except for unusual circumstances.