EAU 2019: Who Lives Better? Quality of Life after Bladder Preserving Trimodal Therapy Versus Radical Cystectomy

Barcelona, Spain (UroToday.com) In the Common Problems in Muscle Invasive and Advanced Bladder Cancer: Evidence-Based Debates session at the 2019 European Association of Urology meeting EAU 2019, Dr. Arnulf Stenzl presented the following case to facilitate the debate between Drs. Jim Catto and Alison Birtle titled: "Who lives better - quality of life after bladder-preserving therapy (Trimodal Therapy) versus radical cystectomy"  Dr. Catto and Dr. Birtle debated the quality of life outcomes following radical cystectomy compared to bladder preservation therapy. The index patient was as follows: a 58-year-old former smoker with urothelial carcinoma of the bladder with progression from HG T1 despite induction BCG, to HG T2 with hydronephrosis.

Prospective studies have shown that at 6-12 months following radical cystectomy, the mean functional score has typically recovered. Furthermore, at 3 months of recovery, patients have returned to their baseline number of steps per day. These trends are also seen in chair-to-stand ability and disability questionnaire results, among others. Additionally, in a 2007 study, no significant differences were seen in cancer specific quality of life or functional domains via questionnaires in patients undergoing ileal conduit compared to cutaneous ureterostomy or orthotopic urinary diversion.

In the second half of the debate, Dr. Birtle, first discussed the 2003 Zeitman data, showing that quality of life and urodynamic findings of patients undergoing bladder preservation have good long term urinary function with an average bladder capacity of 400cc and only 20% having bladder or bowel incontinence. A 2002 paper demonstrated superior potency with 38% of trimodal patients compared to 13% of cystectomy patients having intercourse in the previous month. Dr. Birtle discussed three studies demonstrating long term toxicity and quality of life after bladder preservation to be equal or superior to radical cystectomy (quality of life, fewer concerns regarding appearance, less life interference from cancer treatment). A recent 2018 Markov model analysis demonstrated improvement in the quality-adjusted life years for patients treated with trimodal bladder preservation compared to cystectomy. Lastly, in BC 2001 (James et al), the quality of life deterioration that patients experience during treatment recovers to baseline by 6-12 months post-treatment.

The risks and benefits and maintaining one’s native bladder compared to surgical extirpation with reconstruction must constantly be evaluated. Closely balancing quality of life outcomes with oncologic control is paramount.

Presented by: Jim Catto, MB, ChB, PhD, FRCS (Urol)1 and Alison Birtle, MD, MB, BS, MRCP, FRCR2
1. Department of Oncology, University of Sheffield, Sheffield, United Kingdom
2. Department of Oncology, Lancashire Teaching Hospital, Preston, United Kingdom

Written by: David B. Cahn, DO, MBS, Fox Chase Cancer Center, Philadelphia, Pennsylvania, Twitter:@dbcahn at the 34th European Association of Urology (EAU 2019) #EAU19 conference in Barcelona, Spain, March 15-19, 2019.