Beyond the Abstract - Complications and long-term results of salvage cystectomy after failed bladder sparing therapy for muscle invasive bladder cancer, by Jairam R. Eswara, MD

BERKELEY, CA (UroToday.com) - While it is generally accepted that radical cystectomy after radiation and chemotherapy is technically challenging, our study sought to quantify and categorize the complications associated with this procedure. We examined salvage cystectomies after failure of combined modality bladder-preservation therapy for T2-4N0M0 transitional cell carcinoma of the bladder. Patients were stratified by the timing of cystectomy: an immediate cystectomy was performed if tumor was found upon the initial cystosocpy after induction chemoradiation, while a delayed cystectomy was performed for disease recurrence after consolidation chemoradiation. This series spanned three decades with 91% (83/91) of patients being treated on research protocols, and consequently there was some variability in treatment. The common approach among these protocols was maximal TURBT with no disease evident at the initiation of treatment, a cisplatin-based chemotherapy regimen, and 64Gy EBRT.

Complications of any grade occurred in 69% (63/91) of patients while major complications occurred in 16%. These rates are comparable to those of other series. Of the 128 total complications within 90 days, the most common major complications (Clavien 3-5) were gastrointestinal (5%) and genitourinary (5%). Of the 56 total complications after 90 days, the most common major complications were genitourinary (32%), specifically involving the urinary diversion such as stomal stenosis, stomal ischemia, and ureteroileal stricture. When cystectomies were stratified by timing, significant cardiovascular/hematologic complications (PE, MI, DVT, transfusion) within 90 days were more common in the immediate cystectomy group (37% vs. 15%, p=0.02). Tissue-healing complications (fascial dehiscence, wound infection, ureteral stricture, anastamotic stricture, stoma/loop revisions) were more common in the delayed cystectomy group (35% vs. 12%, p=0.05).

Several series have looked specifically at the rates of cystectomy complications after pelvic radiation (Table 1). Bochner reported 30-day complication rates of 33% while Nieuwenhuijizen reported 30-day complication rates of 0.33 complications/patient after bladder-sparing brachytherapy and EBRT.1,2 In the series by Wammack, 1.14 complications/patient at a median follow-up of 57 months were reported.3

Most recently, Eisenberg updated the USC series of 148 patients over 25 years who had undergone cystectomy after pelvic radiation4. Complication data were gathered using the Clavien system, but no data were provided regarding the rationale for radiation, timing of radiation, dose, and information on prior surgeries. They reported a 90-day complication rate of 77%, with 32% experiencing major complications (Clavien 3-5).

The overall 90-day complication rate in our series of 69% is slightly higher than the previously published rates of 44-66% for cystectomy after radiation, while the 90-day perioperative mortality rate of 2.2% is similar (0-4.7%).5 Our 90-day major complication rate of 16% is comparable, but slightly higher than that of similar series of non-radiated patients6, but less than that of other series involving pelvic radiation prior to cystectomy.4 There was a significantly higher 10-year disease-free survival rate among those who underwent a delayed cystectomy, likely reflecting the fact that those who underwent an immediate cystectomy had an incomplete response and potentially more aggressive disease. The overall 10-year disease-free survival of 48% is comparable to other contemporary cystectomy series.2,7 Salvage cystectomies following bladder-sparing chemoradiation have a slightly higher, although similar and acceptable, major complication rate compared to that seen in other contemporary primary cystectomy series. Immediate cystectomies are associated with higher cardiovascular/hematologic complications compared to delayed cystectomies which have more tissue-healing complications.

 

Table 1: A comparison of complications among cystectomy series.

References

No. Pts.

Prior Chemotherapy or Radiation

Overall Complication Rate

Major Complication Rate

Mortality

Postsurgical period (days)

Stein, et al.

1054

11%

28%

N/R

3%

120

Hautmann, et al. 

788

0%

28%

N/R

5%

120

Novarra, et al.

358

0%

49%

14%

3%

90

Donat, et al.

1142

Chemo 12%/ EBRT 4%

64%

13%

2.7%

90

Bochner, et al.


18

100%

33%

N/R

0%

30

Wammack, et al.


36

100%

1.14 comp/pt

N/R

0%

Median 57 mos.

Nieuwenhuijizen, et al.


27

100%

0.33 comp/pt

N/R

N/R

30

Eisenberg, et al.


148

100%

77%

32%

6.1%

90

Eswara, et al.

91

100%

69%

16%

2.2%

90

*N/R: not reported 


 

References:

  1. Bochner BH, Figueroa AJ, Skinner EC, Lieskovsky G, Petrovich Z, Boyd SD and Skinner DG: Salvage radical cystoprostatectomy and orthotopic urinary diversion following radiation failure. J Urol. 160: 29-33, 1998.
  2. Nieuwenhuijzen JA, Horenblas S, Meinhardt W, van Tinteren H and Moonen LM: Salvage cystectomy after failure of interstitial radiotherapy and external beam radiotherapy for bladder cancer. BJU Int. 94: 793-7, 2004.
  3. Wammack R, Wricke C and Hohenfellner R: Long-term results of ileocecal continent urinary diversion in patients treated with and without previous pelvic irradiation. J Urol. 167: 2058-62, 2002.
  4. Eisenberg MS, Dorin RP, Bartsch G, Cai J, Miranda G and Skinner EC: Early complications of cystectomy after high dose pelvic radiation. J Urol. 184: 2264-9, 2010.
  5. Ramani VA, Maddineni SB, Grey BR and Clarke NW: Differential complication rates following radical cystectomy in the irradiated and nonirradiated pelvis. Eur Urol. 57: 1058-63, 2010.
  6. Donat SM, Shabsigh A, Savage C, Cronin AM, Bochner BH, Dalbagni G, Herr HW and Milowsky MI: Potential impact of postoperative early complications on the timing of adjuvant chemotherapy in patients undergoing radical cystectomy: a high-volume tertiary cancer center experience. Eur Urol. 55: 177-85, 2009.
  7. Hautmann RE, Gschwend JE, de Petriconi RC, Kron M and Volkmer BG: Cystectomy for transitional cell carcinoma of the bladder: results of a surgery only series in the neobladder era. J Urol. 176: 486-92; discussion 491-2, 2006.


Written by:
Jairam R. Eswara, MD as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.

Complications and long-term results of salvage cystectomy after failed bladder sparing therapy for muscle invasive bladder cancer - Abstract

More Information about Beyond the Abstract