Soft Tissue Surgical Margin Status is a Powerful Predictor of Outcomes After Radical Cystectomy: A Multicenter Study of More Than 4,400 Patients

Novara, Giacomo; Svatek, Robert S.; Karakiewicz, Pierre I.; Skinner, Eila C.; Ficarra, Vincenzo; Fradet, Yves; Lotan, Yair; Isbarn, Hendrik; Capitanio, Umberto; Bastian, Patrick J.; Kassouf, Wassim; Fritsche, Hans‐Martin; Izawa, Jonathan I.; Tilki, Derya; Dinney, Colin P.; Lerner, Seth P.; Schoenberg, Mark; Volkmer, Bjoern G.; Sagalowsky, Arthur I.; Shariat, Shahrokh F.

doi:10.1016/j.juro.2010.02.021

Cited by 177 publications

(95 citation statements)

References 14 publications

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“…Using SM status as a surrogate marker for quality of surgery, the 12.1% positive SM rate here is lower than published literature that suggests 12.3% to 15% as a threshold. 15,16 The extent of PLND and its therapeutic role in bladder cancer is debatable. Suffice it to say that the presence of LN metastasis is one, if not the most, important prognostic indicator for RFS and OS in patients undergoing RC for clinically localized disease.…”

Section: Discussionmentioning

confidence: 99%

“…The high rate of positive SM is an issue as rates of soft tissue SM are reported from 2% to 6% in major published series. 15 This major limitation may be explained due to the data collection that did not differentiate between soft tissue, ureteral and urethral margins. The limited median follow-up time, explained by most patients being treated after 2005, is too short to capture all events.…”

Section: Discussionmentioning

confidence: 99%

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Natural history of pT3-4 or node positive bladder cancer treated with radical cystectomy and no neoadjuvant chemotherapy in a contemporary North-American multi-institutional cohort

Power

Kassouf

Bell

et al. 2012

CUAJ

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Background: The present study documents the natural history and outcomes of high-risk bladder cancer after radical cystectomy (RC) in patients who did not receive neoadjuvant chemotherapy during a contemporary time period. Methods: We analyzed 1180 patients from 1993 to 2008 with >pT3N0 or pT0-4N+ bladder cancer who underwent RC ± standard (sLND) or extended (eLND) lymph node dissection from 8 Canadian centres. Results: Of the 1180 patients, 55% (n = 643) underwent sLND, 34% (n = 402) underwent ePLND and 11% did not undergo a formal LND. Of the total number of patients, 321 (27%) received adjuvant chemotherapy. The median follow-up was 2.1 years (range: 0.6 to 12.9). Overall 30-day mortality was 3.2%. Clinical and pathological stages T3-4 were present in 6.1% and 86.7% of the patients, respectively; this demonstrates a dramatic understaging. Overall survival (OS) at 2 and 5 years was 60% and 43%, respectively. Patients who received adjuvant chemotherapy had a 2-and 5-year disease-specific survival (DSS) of 72% and 57% versus 64% and 51% for those who did not (log-rank p = 0.0039). The 2-and 5-year OS for high-risk node-negative disease was 67% and 52%, respectively, whereas for node-positive patients, the OS was 52% and 32%, respectively (p < 0.001). The OS, DSS and RFS for patients with pN0 were significantly improved compared to those who did not undergo a LND (log-rank p = 0.0035, 0.0241 and 0.0383, respectively). Interpretation: This series suggests that bladder cancer outcomes in advanced disease have improved in the modern era. The need for improved staging investigations, use of neoadjuvant chemotherapy and performance of complete LND is emphasized.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Natural history of pT3-4 or node positive bladder cancer treated with radical cystectomy and no neoadjuvant chemotherapy in a contemporary North-American multi-institutional cohort

Power

Kassouf

Bell

et al. 2012

CUAJ

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“…Patients with PSMs had a 5-yr CSS of only 32% [95]. In another large multi-institutional analysis of 4400 ORC patients, the incidence of PSMs was 6.3% [96]. A potential challenge of RARC and limitation of current robotic technology is in treating bulkier tumors because of the lack of tactile feedback.…”

Section: Potency Recovery After Robot-assisted Radical Cystectomymentioning

confidence: 99%

“…From the systematic review, the weighted average of positive margins in RARC series was 5.6%, which is comparable to the large open series cited earlier. In the aforementioned analysis of 4400 ORC patients, margin-positive rates by stage were 2.3% for pT2, 7.6% for pT3, and 24% for pT4 disease [96]. The effects of the learning curve as institutions adopted this new technology and patient selection toward earlier stage disease likely affected reported margin rates and should be considered when interpreting outcomes.…”

Section: Potency Recovery After Robot-assisted Radical Cystectomymentioning

confidence: 99%

Systematic Review and Cumulative Analysis of Oncologic and Functional Outcomes After Robot-assisted Radical Cystectomy

et al. 2015

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Context: Although open radical cystectomy (ORC) is still the standard approach, laparoscopic radical cystectomy (LRC) and robot-assisted radical cystectomy (RARC) are increasingly performed.Objective: To report on a systematic literature review and cumulative analysis of pathologic, oncologic, and functional outcomes of RARC in comparison with ORC and LRC.Evidence acquisition: Medline, Scopus, and Web of Science databases were searched using a free-text protocol including the terms robot-assisted radical cystectomy or da Vinci radical cystectomy or robot* radical cystectomy. RARC case series and studies comparing RARC with either ORC or LRC were collected. A cumulative analysis was conducted.Evidence synthesis: The searches retrieved 105 papers, 87 of which reported on pathologic, oncologic, or functional outcomes. Most series were retrospective and had small case numbers, short follow-up, and potential patient selection bias. The lymph node yield during lymph node dissection was 19 (range: 3-55), with half of the series following an extended template (yield range: 11-55). The lymph node-positive rate was 22%. The performance of lymphadenectomy was correlated with surgeon and institutional volume. Cumulative analyses showed no significant difference in lymph node yield between RARC and ORC. Positive surgical margin (PSM) rates were 5.6% (1-1.5% in pT2 disease and 0-31% in pT3 and higher disease). PSM rates did not appear to decrease with sequential case numbers. Cumulative analyses showed no significant difference in rates of surgical margins between RARC and ORC or RARC and LRC.Neoadjuvant chemotherapy use ranged from 0% to 31%, with adjuvant chemotherapy used in 4-22% of patients. Only six series reported a mean follow-up of >36 mo. Three-year disease-free survival (DFS), cancer-specific survival (CSS), and overall survival (OS) rates were 53-74%, 68-83%, and 72-80%, respectively. The 5-yr DFS, CSS, and OS rates were 53-74%, 66-80%, and 39-66%, respectively. Similar to ORC, disease of higher pathologic stage or evidence of lymph node involvement was associated with worse survival. Very limited data were available with respect to functional outcomes. The 12-mo continence rates with continent diversion were 83-100% in men for daytime continence and 66-76% for nighttime continence. In one series, potency was recovered in 63% of patients who were evaluable at 12 mo. Conclusions

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“…Complication rates vary around 20%. Nevertheless, the pelvic control of the disease is in general satisfactory with surgery only (13), Positive margins or lymph node involvement are adverse risk factors for recurrence and patient survival (23,24).…”

Section: Postoperative Radiotherapymentioning

confidence: 99%

The role of radiotherapy in urinary bladder cancer: current status

et al. 2012

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Soft Tissue Surgical Margin Status is a Powerful Predictor of Outcomes After Radical Cystectomy: A Multicenter Study of More Than 4,400 Patients

Cited by 177 publications

References 14 publications

Natural history of pT3-4 or node positive bladder cancer treated with radical cystectomy and no neoadjuvant chemotherapy in a contemporary North-American multi-institutional cohort

Natural history of pT3-4 or node positive bladder cancer treated with radical cystectomy and no neoadjuvant chemotherapy in a contemporary North-American multi-institutional cohort

Systematic Review and Cumulative Analysis of Oncologic and Functional Outcomes After Robot-assisted Radical Cystectomy

The role of radiotherapy in urinary bladder cancer: current status

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