Determining the optimal time for Radical Cystectomy following Neoadjuvant chemotherapy

To determine whether the recovery window (RW) between neoadjuvant chemotherapy (NAC) and radical cystectomy (RC) affects 90-day post-operative morbidity and incidence of lymph node metastasis.

We reviewed patients treated with NAC and RC from 1995-2013 for ≤ cT4N0M0bladder cancer. The association of the RW with 90-day perioperative morbidity and lymph node metastasis was determined. Generalized linear models were used to determine predictors of each endpoint. Patients were stratified into 4 RWs by 21-day intervals (18-42; 43-63; 64-84; and ≥85 days) from last day of NAC to RC.

We evaluated 306 patients with RW information during the study period. The median RW was 46 days (18-199 days). There was no difference in overall morbidity, readmission, or major complication rates among the 4 RWs. In the multivariable analysis extravesical disease was an independent predictor of overall morbidity (OR=1.95; 95% CI:1.16-3.26;p=0.011). Age (OR=1.05;95% CI:1.02-1.09;p=0.004), and surgical time ≥7 hours (OR=2.87;95% CI:1.52-5.42;p=0.001) were independent predictors of major complications. Only surgical time ≥7 hours was a predictor of readmission (OR=2.24;95% CI:1.26-3.98;p=0.006). A RW ≥85 days had the highest incidence of pN+ (40%). In a separate multivariable model that included clinical predictors for pN+, a RW ≥85 days was an independent predictor of nodal metastasis (OR=2.92;95% CI:1.20-7.09;p=0.018).

Patients treated with NAC for bladder cancer can undergo RC between 2.5-12 weeks (18-84 days) after NAC with no difference in risk of perioperative morbidity. Delaying surgery beyond 12-weeks was associated with a significant risk of lymph node metastasis. This article is protected by copyright. All rights reserved.

BJU international. 2018 Mar 23 [Epub ahead of print]

Chinedu O Mmeje, Cooper R Benson, Graciela M Nogueras-González, Isuru S Jayaratna, Jianjun Gao, Arlene O Siefker-Radtke, Ashish M Kamat, Colin P Dinney, Neema Navai, Jay B Shah

Department of Urology, The University of Texas, M.D. Anderson Cancer Center, Houston, TX., Department of Genitourinary Medical Oncology, The University of Texas, M.D. Anderson Cancer Center, Houston, TX., Department of Biostatistics, The University of Texas, M.D. Anderson Cancer Center, Houston, TX., Department of Urology, Stanford University, Palo Alto, CA.