RADICAL CYSTECTOMY FOR HIGH-RISK PATIENTS WITH SUPERFICIAL BLADDER-CANCER IN THE ERA OF ORTHOTOPIC URINARY RECONSTRUCTION

Background. Many patients with aggressive clinically superficial bladder cancer ultimately die of their cancer, due in part to resistance to undergo radical cystectomy. Radical cystectomy is usually curative for patients with pathologic superficial tumors. Orthotopic urinary reconstruction has lessened the morbidity and lifestyle changes in patients after cystectomy, and may increase patient acceptance of cystectomy as therapy for high risk superficial tumors. Methods. A retrospective analysis was performed on 182 patients with clinically superficial bladder cancer (Ta, Tis, T1) who had radical cystectomy between 1971 and 1989, to determine the incidence of pathologic upstaging and to assess overall survival, cause-specific survival, and recurrence free survival, Indications for cystectomy included failure of intravesical chemo- or immunotherapy, high grade lamina propria invasive tumors, presence of bladder diverticulae, spread of superficial tumors into the prostatic urethra, and endoscopically uncontrollable tumors. Results. Pathologic upstaging to muscle-invasive or metastatic tumors occurred in 34% of patients, and of these, only half remained organ confined. Metastases were present in 8% of patients at the time of cystectomy. Mucosa-confined tumors were upstaged only 19% of the time, whereas tumors demonstrating lamina propria invasion (T1) were upstaged 40% of the time. Pathologic upstaging to muscle-invasive or metastatic disease was significantly associated with a decreased probability of survival (P = 0.042). With a median follow-up of 7.2 years, overall survival was estimated to be 86%, 72%, and 47%, and recurrence free survival 90%, 83%, and 77% at 2, 5, and 10 years, respectively. Conclusions. Pathologic upstaging to muscle-invasive or metastatic tumors occurs in one third of highly selected patients with clinically superficial bladder cancer who have had radical cystectomy, half of whom have extravesical disease. Survival is significantly decreased in this group of upstaged patients. With the alternative of orthotopic urinary diversion available to most men and women requiring cystectomy, radical cystectomy should be considered a viable alternative to continued conservative measures for selected patients with aggressive superficial bladder tumors.