NARUS 2018: Indications for Early Cystectomy
Early RC should be considered in high grade T1 disease with deep lamina propria, concurrent CIS, presence of lymphovascular invasion, when the tumor is large, multiple or recurrent, and where there is associated prostatic urethral involvement. Additionally, when there is variant histology, CIS which is BCG unresponsive/refractory, and when there is high volume high grade Ta disease, early RC should also be considered.
It is noteworthy that bladder cancer is a field defect, and it does not progress in an orderly, step-wise manner. High grade urothelial carcinoma is a lethal and unpredictable disease. Under-staging and under-grading is rampant. T1 high grade (HG) disease is a most aggressive disease. If we were to treat it only with TURBT, the recurrence rate would be 69-80%, progression 33-48%, and the death rate would be 17-20% even with immediate cystectomy. It is crucial that re-resection is routinely performed in T1 HG disease due to the fact that residual disease at prior resection site is present in 40-75% of cases, and upstaging to T2 disease occurs in 25-50% of cases. The likelihood of T2 disease in T1 disease, when muscle is present is 14%, compared to 49% when muscle is not present. Node positive disease exists in up to 16% of T1 HG patients. Although BCG delays recurrence, it may not impact ultimate cancer specific survival (CSS). Despite treatment with BCG, some series have shown that progression occurs in approximately 15-53% of patients.
Early cystectomy confers a clear CSS when compared to delayed RC. Furthermore, it enables to obtain accurate pathologic staging, it is more appropriate for nerve sparing approach, it avoids multiple intravesical treatments, and offer a better cure rate. In summary, patient selection for early cystectomy is a key factor. Repeat thorough TURBT is required before consideration of conservative treatment. The longer we use ineffective intravesical therapies, the higher the risk of metastasis. Lastly, for healthy patients with high risk factors, initial RC should be strongly considered.
Presented by: Monish Aron, Keck School of Medicine of USC, Los Angeles, California, USA
Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at the 2018 North American Robotic Urology Symposium, February 16-17, 2018 - Las Vegas, NV