Abstract
BackgroundAlthough pathological factors remain the main determinate of survival for patients with bladder cancer, quality of surgical care is crucial for satisfactory outcomes. Using a validated quality score, we investigated the impact of surgical factors on the overall survival (OS), recurrence-free survival (RFS) and disease-specific survival (DSS) in patients with locally advanced and organ-confined disease (OCD). Retrospective review of IRCC database includes 2460 patients from 29 institutions across 11 countries. The final cohort included 1343 patients who underwent RARCs between 2005 and 2016. Patients with locally advanced disease (LAD) (> pT2 and/or N +) were compared with OCD (≤ pT2/N0). Validated Quality Cystectomy Score (QCS) based on four sets of quality metrics was used to compare surgical performance. Kaplan–Meier method was used to compute RFS, CSS and OS rates. Multivariable stepwise logistic regression was used to evaluate variables associated with RFS, DSS and OS.Results48% had LAD. When compared to patients with OCD, they received neobladders less frequently (17% vs. 28%, p < 0.001) and experienced higher estimated blood loss (513 vs. 376 ml, p = 0.05). Postoperatively, more patients in the LAD group received adjuvant chemotherapy (24% vs. 4%, p < 0.001) and positive surgical margins (14% vs. 2%, p < 0.001) and had higher 90-day mortality (6% vs. 2%, p < 0.001). On multivariable analysis, female gender, higher QCS score, intracorporeal diversion, pT stage, positive lymph node status and recurrence are considered as predictors of survival. Patients with OCD exhibited better RFS, DSS and OS than patients with LAD. For patients with OCD, higher QCS was associated with improved OS but not RFS or DSS. On the other hand, patients with LAD and higher QCS exhibited higher RFS, DSS and OS when compared to those with lower QCS.ConclusionQuality of surgical care can affect disease control and OS in patients with bladder cancer treated with robot-assisted radical cystectomy.
Highlights
Pathological factors remain the main determinate of survival for patients with bladder cancer, quality of surgical care is crucial for satisfactory outcomes
Quality of surgical care can affect disease control and overall survival (OS) in patients with bladder cancer treated with robot-assisted radical cystectomy
The score comprises four domains that measure surgical quality of Robot-assisted radical cystectomy (RARC) independent of patient and disease characteristics and assigned a star score depending on the number of quality metrics fulfilled (Additional file 1: Fig. S1)
Summary
Pathological factors remain the main determinate of survival for patients with bladder cancer, quality of surgical care is crucial for satisfactory outcomes. Using a validated quality score, we investigated the impact of surgical factors on the overall survival (OS), recurrence-free survival (RFS) and disease-specific survival (DSS) in patients with locally advanced and organ-confined disease (OCD). Robot-assisted radical cystectomy (RARC) has been increasingly utilized for muscle-invasive bladder cancer, as it provides similar oncological efficacy to open radical cystectomy (RC) and is superior in terms of perioperative outcomes and recovery [1]. 37% of patients have locally advanced disease (LAD) (extravesical disease (> pT2) and/or positive lymph nodes) at surgery [2]. Similar to ovarian cancer and renal cell carcinoma, surgery offers good local control, decreases tumor burden and may be associated with survival benefit [7]. Advents in neoadjuvant chemotherapy (NAC) have been associated with significant pathologic downstaging and improved survival, and surgery may be done even with curative intent in this setting [8]
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