Surgical approach in patients with T4 bladder cancer as primary treatment: Disaster or option with improved quality of life

Abstract

Objectives:Whereas local control is often insufficient in conservative management of T4 bladder cancer, neoadjuvant chemotherapy delays definite treatment, which could result in increased therapy-associated morbidity and mortality during the course of the disease. Primary cystectomy has been reported to be associated with a high complication rate and unsatisfactory clinical efficacy. Herein, we report postoperative outcome in 21 T4 bladder cancer patients subjected to primary cystectomy.Materials and Methods:Twenty-one patients underwent radical cystectomy for T4 (T4a/b: 14 and seven cases, respectively) bladder cancer. At the time of surgery, eight patients had regional lymph node metastases (N2: 6; N3: 2). The average age was 64 (52-77) years (≥70 years: n = 7). The postoperative follow-up was 13 (1-36) months for the whole group.Results:Mean duration of postoperative hospitalization was 19 (11-50) days. Whereas 10 patients received no intra - or postoperative blood transfusions, an average number of 3 (1-7) blood units were administered in the remaining cases. The mean postoperative hemoglobin value of patients not receiving any blood transfusions was 10 (8.5 - 11.4) g/dl. Major therapy-associated complications were paresthesia affecting the lower extremities (n = 3) as well as insignificant pulmonary embolism, enterocutaneous fistulation and acute renal failure in one patient, respectively. At the time of data evaluation, 11 patients were still alive after a follow-up of 20 (6-36) months. Four patients ≥70 years at the time of cystectomy were still alive 11, 11, 22 and 31 months following surgery, respectively.Conclusion:Primary cystectomy for T4 bladder cancer is a technically feasible approach that is associated with a tolerable therapy-related morbidity/mortality. Additionally, a satisfactory clinical outcome is observed even in a substantial number of elderly patients.

Radical cystectomy for clinical T4b urothelial carcinoma: An Ontario, single-center experience

“…Despite some guidelines suggesting RC should be reserved for patients who respond to NAC, Kuczyk et al postulate that if patients do not respond to NAC, their benefit from RC is reduced due to the risk of disease progression from treatment delay. 8 A retrospective analysis of 896 patients with T4b N0-3 M0 from the National Cancer Database suggests that the receipt of RC was associated with overall survival of 14.2 months, regardless of other treatments patients received. 11 This is higher than overall survival associated with treatment using chemotherapy or chemoradiation.…”

“…Kuczyk et al reported on a German cohort of seven patients with T4b bladder cancer, who did not receive NAC, and concluded primary RC without NAC was technically feasible, with acceptable overall survival. 8 The literature supporting RC for T4b MIBC is sparse and guidelines are both unclear and inconsistent with their recommendations. Further evidence supporting the role of RC in the treatment of T4b MIBC is required.…”