UROLOGICAL ONCOLOGY

doi: 10.1590/S1677-55382010000600026

Clinical outcome in a contemporary series of restaged patients with clinical T1 bladder cancer
Dalbagni G, Vora K, Kaag M, Cronin A, Bochner B, Donat SM, Herr HW
Division of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
Eur. Urol. 2009; 56: 903-910

• Objectives: To evaluate the indications for early and deferred cystectomy and to report the impact of this tailored approach on survival.
  Design, Setting, and Participants: We retrospectively studied 523 patients seen at our institution who were initially diagnosed with T1 disease between 1990 and 2007.
  Measurements: Variables analyzed included age, gender, multifocality, multifocal T1 disease, carcinoma in situ, grade, recurrence rate, and restaging status. End points were overall and disease-specific survival.
  Results and Limitations: A restaging transurethral resection (TUR) was performed in 523 patients. Of the patients who underwent restaging, 106 (20%) were upstaged to muscle-invasive disease and 417 patients were considered true clinical T1 (cT1); 84 of the latter group underwent immediate cystectomy. The median follow-up for survivors was 4.3 yr. The cumulative incidence of disease-specific death at 5 yr was 8% (95% confidence interval [CI], 5-13%), 10% (95% CI, 5-17%), and 44% (95% CI, 35-56%) for those restaged with lower than T1, T1, and T2 disease, respectively. Immediate cystectomy was more likely in patients with cT1 disease at restaging than in those with disease lower than cT1, but there were no other obvious differences in clinical characteristics between those with and without immediate cystectomy. Survival was not statistically different for patients who underwent an immediate cystectomy versus those who were maintained on surveillance with deferred cystectomy if deemed appropriate. Of 333 patients who did not undergo immediate cystectomy, 59 had a deferred cystectomy, and the likelihood of deferred cystectomy was greater in those with T1 disease on restaging TUR (hazard ratio: 2.40; 95% CI, 1.43-4.01; p=0.001).
  Conclusions: Restaging TUR should be performed in patients diagnosed with cT1 bladder cancer to improve staging accuracy. Patients with T1 disease on restaging are at higher risk of progression and should be considered for early cystectomy.

• Editorial Comment
  The timing of cystectomy in T1 bladder cancer is a matter of debate since years. Here, the authors from a tertiary referral center present their series of 523 patients and analyze variables which may help with the decision to remain conservatively, or proceed with radical surgical therapy. Interestingly, re-TUR was performed in all patients and yielded a high rate of 20% upstaging to muscle-invasive disease. If true T1 was considered, the disease-specific mortality at 5 years was 10%, with no survival differences between those patients undergoing early cystectomy versus those with no or deferred cystectomy. Clearly, these data support an initial conservative approach in select patient with true pT1. In any case, a re-TUR is mandatory.

Dr. Andreas Bohle
Professor of Urology
HELIOS Agnes Karll Hospital
Bad Schwartau, Germany
E-mail: boehle@urologie-bad-schwartau.de