RECONSTRUCTIVE UROLOGY

Is there a role for bladder preserving strategies in the treatment of muscle-invasive bladder cancer?
Kuczyk M, Turkeri L, Hammerer P, Ravery V, and European Society for Oncological Urology
Department of Urology, Hannover University Medical School, D-30625 Hannover, Germany
Eur Urol. 2003; 44: 57-64

• Single modality bladder sparing therapy for muscle-invasive bladder cancer, including transurethral resection, systemic chemotherapy or radiotherapy have been demonstrated to result in insufficient local control of the primary tumor as well as decreased long-term survival of the patients when compared to radical cystectomy. Therefore, multimodality treatment protocols that aim at bladder preservation and involve all of the aforementioned approaches have been established. Arguments for combining systemic chemotherapy with radiation are to sensitize tumor tissue to radiotherapy and to eradicate occult metastases that have already developed in as many as 50% of patients at the time of first diagnosis. It has been shown that the clinical outcome observed with this approach approximates that after radical cystectomy. Additionally, a substantial number of patients survive with an intact bladder. However, bladder preserving approaches are costly, and require close co-operation between different clinical specialists as well as very close follow-up. The good long-term results obtained after cystectomy and creation of an orthotopic neobladder make the possible advantage of a bladder preservation strategy questionable in consideration of quality of life issues. Additionally, side effects related to bladder sparing therapy may result in an increased morbidity and mortality in those patients who in fact need to undergo surgery due to recurrent or progressive disease. Multimodality bladder sparing treatment is a therapeutic option that can be offered to the patient at centers that have a dedicated multidisciplinary team at their disposal. However, radical cystectomy remains the standard of care for muscle-invasive bladder tumors.
  
• Editorial Comment
  In the majority of cases bladder reconstruction is necessary after radical cystectomy due to bladder neoplasms. Despite the fact that the majority of both male and female patients with bladder cancer are nowadays eligible for an orthotopic bladder substitution the search for bladder preserving strategies thus avoiding any bladder reconstruction continues.
  The review by Kuczyk et al. outlines the results of the more recent protocols of multimodality bladder preservation in locally advanced transitional cell cancer of the bladder. All studies lack a control group – cystectomy monotherapy – to which patients were randomly assigned. But in selected patients, 5-year survival rates with an intact bladder between 36 and 41 % was obtained. However, the multimodality strategies to achieve a complete long term response were complex, costly, cumbersome for patients and treating physicians, and required a certain infrastructure available usually only in large centers. Despite all the efforts some patients still required a salvage cystectomy, which tends to be technically more difficult and often does not allow features which might be important for the patients’ future quality of life such as nerve preservation for potency, or an orthotopic neobladder with good results regarding continence. Another aspect are recurrent superficial tumors in the initially successfully treated preserved bladders which may be seen even beyond 5 years.
  Surprisingly mortality in the multimodality therapy group was higher in some series than in contemporary radical cystectomy studies (up to 4 % due to chemotherapy vs. 1-2% due to perioperative mortality). A quality of life advantage in the bladder preserved patients has not been substantiated to date. In fact it may be difficult to prove in some series were patients suffer from reduced bladder capacity, severe urgency, and repeat surgery due to superficial tumor recurrences in the long term. Therefore one may conclude that cystectomy in combination with a refined technique of bladder reconstruction to date remains the best option to treat locally advanced bladder cancer. We should continue to search for ways to treat these with bladder preserving strategies, however, only under strict protocols and only in large centers with good interdisciplinary cooperation.

Dr. Arnulf Stenzl
Professor and Chairman of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany