Bladder preservation—learning what we don't know

Outcomes of radical cystectomy in potential candidates for bladder preservation therapy

OBJECTIVE

To analyze the outcomes of patients with urothelial-type bladder cancer (UBC) who optimally met selection criteria for bladder preservation therapy (BPT) but were treated with radical cystectomy (RC) instead.

METHODS

We identified consecutive patients with clinical stage cT2N0M0 UBC who underwent RC with curative intent at our center. Patients without carcinoma in situ, hydronephrosis, multifocality, or mixed histology were classified as BPT eligible. Patients with ≥1 contraindications were considered BPT ineligible. Clinicopathologic characteristics and survival outcomes for BPT-eligible patients were compared with those of the ineligible patients.

RESULTS

Of the 275 patients who had cT2N0M0 UBC, 157 (57.1%) were BPT ineligible (carcinoma in situ = 54; hydronephrosis = 77; multifocality = 29; mixed histology = 55; ≥2 contraindications = 51). BPT-eligible and -ineligible patients did not statistically differ with regard to age, sex, race, or neoadjuvant chemotherapy. Of the BPT-eligible patients, 24.1% had occult positive lymph nodes and 36.4% had pT3 or pT4 tumors at RC. On multivariate analysis, mixed histology (odds ratio = 3.18; 95% confidence interval [CI], 1.18-8.56) and progression from noninvasive disease to cT2 (odds ratio = 4.81 [95% CI, 1.67-13.85]) were independently associated with upstaging. Two-year overall survival was higher in BPT-eligible patients (76.7% vs 57.1%; P = .003; hazard ratio = 0.48 [95% CI, 0.3-0.78]). BPT-eligible patients also had better cancer-specific mortality on competing risk analysis (sub-hazard ratio = 0.46 [95% CI = 0.29-0.72]; P = .001).

CONCLUSION

Substantial clinicopathologic stage discrepancies occurred even in patients seemingly ideal for BPT, which may provide insight into BPT failures. Furthermore, substantial survival discrepancies existed for BPT-eligible and BPT-ineligible patients, underscoring the heterogeneity of cT2 disease. In the absence of randomized trials, comparisons between RC and BPT must factor in selection bias.

Effect of internal iliac artery chemotherapy after transurethral resection of bladder tumor for muscle invasive bladder cancer

OBJECTIVE

To evaluate the clinical effect of transurethral resection of bladder tumor (TUR-BT) combined with internal iliac artery chemotherapy and intravesical instillation therapy for muscle invasive bladder cancer (MIBC).

METHODS

From February 2007 to April 2014, 62 patients with MIBC were treated with TUR-BT combined with intravesical instillation therapy, with or without internal iliac artery chemotherapy, and the chemotherapy regimen is gemcitabine and cisplatin (GC). The bladder preservation and survival rate as well as cancer-specific survival (CSS) rate and overall survival (OS) rate of the two groups were compared.

RESULTS

Sixty-two patients were followed-up for 26-102 months with an average of 58.4±3.1 months. Recurrence-free survival (RFS) at 2-year for TUR + GC group and TUR group were 77.8% and 53.8%, respectively. Bladder preserved rate (BPR) at 3-year for TUR + GC group and TUR group were 94.4% and 80.8%. CSS rate at 2-year for TUR + GC group and TUR group were 94.4% and 84.6%. The disease-free survival (DFS) at 1-year for TUR + GC group and TUR group were 83.3% and 61.5%, and 77.8% and 53.8% for the 2(nd) year. OS at 2-year for TUR + GC group and TUR group were 88.9% and 92.3%.

CONCLUSIONS

TUR-BT and intravesical instillation therapy combined with internal iliac artery chemotherapy for MIBC had a better outcome at RFS, BPR and DFS than the treatment without internal iliac artery chemotherapy, and no difference in OS and CSS.