UROLOGICAL ONCOLOGY

Primary T1G3 bladder cancer: organ preserving approach or immediate cystectomy?
Thalmann GN, Markwalder R, Shahin O, Burkhard FC, Hochreiter WW, Studer UE
Department of Urology and Institute of Pathology, University of Bern, Inselspital, Bern, Switzerland
J.Urol. 2004; 172: 70-75.

• Purpose: In this retrospective nonrandomized study we compared the long-term outcome in patients with newly diagnosed stage T1G3 bladder cancer treated with transurethral resection and bacillus Calmette-Guerin or immediate cystectomy.
• Materials and Methods: Of 121 patients with a median age of 67 years (range 36 to 88) diagnosed with primary T1G3 bladder cancer between 1976 and 1999, 92 were treated by transureteral resection with additional intravesical bacillus Calmette-Guerin and 29 were treated with immediate cystectomy.
• Results: Of the 92 patients treated with an organ preserving approach 29 remained disease-free, local recurrence developed in 33 (36%) and progression developed in 30 (33%) at a median followup of 6.9 years (range 0.6 to 16.5). Of these 92 patients 27 (29%) underwent deferred cystectomy at a median of 12.9 months (range 4.8 to 136), of whom 10 (37%) with a median postoperative followup of 19 months (range 2 to 173) died of progressive disease with a median survival of 13 months (range 3 to 34) after cystectomy. The majority of patients who died of progressive disease refused cystectomy, were referred too late for cystectomy, were inoperable or had upper urinary tract disease. Six of the 29 patients (21%) undergoing immediate cystectomy had progression at a median of 13.2 months (range 5.5 to 37). Overall and tumor specific survival at 5 years in patients treated with an organ preserving approach was 69% and 80%, and in those treated with immediate cystectomy it was 54% and 69%, respectively.
• Conclusions: The results of this analysis demonstrate that the concept of an organ preserving approach is acceptable and spares the bladder in approximately half of the patients with primary T1G3 bladder cancer. Of the patients 30% require deferred cystectomy, making meticulous, close followup mandatory.
  
  
• Editorial Comment
  This paper is an non-randomized observation of patients with high risk bladder cancer treated either with TUR-B and BCG or with immediate cystectomy.
  The data suggest alltogether that T1G3 bladder carcinoma is a dangerous disease but can be treated effectively by TUR-B and BCG. Cystectomy may be prevented by this treatment, according to this conservative estimate, in approximately 50%.
  Interestingly, if patients were looked upon closely, median time to progression, overall mortality, and all other outcome data were similar between two groups. In both groups around 15% showed positive lymph nodes at lymphadenectomy.
  Tumor specific survival at 5 years was 80% and 69%, respectively (not significant). In the group of patients treated with immediate cystectomy 48% died. Even more interestingly, for tumor specific survival the difference was significant in favor of deferred cystectomy ( p = 0.02 ).

Dr. Andreas Bohle
Professor of Urology
HELIOS Agnes Karll Hospital
Bad Schwartau, Germany