Outcomes of radical cystectomy in potential candidates for bladder-preservation therapy.

Abstract

357 Background: Outcomes for Bladder Preservation Therapy (BPT) in urothelial-type bladder cancer (UBC) are often compared to those achieved by Radical Cystectomy (RC). However, BPT patients are usually “carefully selected” which may limit comparisons. Our objective was to analyze the outcomes of RC within a “carefully selected” patient cohort. Methods: We identified 471 consecutive patients with UBC who underwent RC with curative intent from 1987 to 2008 at a single academic center. Patients were considered eligible for BPT if tumors were clinical T2 without carcinoma in-situ (CIS), hydronephrosis, multiple invasive tumors, or mixed histology. Patients with ≥1 contraindications were considered ineligible. Renal function was not factored into eligibility. Clinicopathologic characteristics and survival outcomes for BPT eligible patients were compared to ineligible patients. Results: 275 patients had cT2 tumors, of which 157 (57.1%) were ineligible for BPT (CIS=54; hydro=77; multiple tumors=29; mixed histology=55; ≥2 contraindications=51). BPT eligible and ineligible patients did not statistically differ with regards to age, gender, race, BMI, smoking, ASA score, or neoadjuvant chemotherapy. At time of RC, BPT eligible patients were less likely to have positive lymph nodes (p=0.01), pathologic LVI (p=0.02), & upstaging to pT3/pT4 (p=0.002). 2 and 5 year overall survival (OS) for all cT2 patients was 65.2% and 40.3%. 2 and 5 year OS was 76.7% and 44.2% for BPT eligible patients, but only 57.1% and 37.4% for ineligible (p=0.07). No statistical difference was seen in distant Recurrence Free Survival (RFS) (p=0.9), but BPT eligible patients had better local-RFS (p=0.05). 2-year Cancer Specific Survival (CSS) for all cT2, BPT eligible, and BPT ineligible patients was 71.8, 85.4%, and 62.3% respectively. Fine-Gray competing risk analysis revealed significantly better CSS for BPT eligible patients compared to those ineligible (Sub-HR=0.46 [CI=0.29-0.72] p=0.001). Conclusions: RC provides excellent CSS for patients potentially eligible for BPT. This should be included in an informed discussion of treatment options. In the absence of randomized trials, comparisons between RC and BPT must factor in selection bias.