UROLOGICAL ONCOLOGY

Cystectomy for Transitional Cell Carcinoma of the Bladder: Results of a Surgery Only Series in the Neobladder Era
Hautmann RE, Gschwend JE, de Petriconi RC, Kron M, Volkmer BG
Department of Urology, Faculty of Medicine, University of Ulm, Germany
J Urol. 2006; 176: 486-92; discussion 491-2

• Purpose: We studied the effect of radical cystectomy for transitional cell carcinoma of the bladder on survival and failure patterns when the 2 surgical standards cystectomy and neobladder were combined, when possible.
• Materials and methods: A consecutive series of patients undergoing radical cystectomy with pelvic lymph node dissection for transitional cell carcinoma of the bladder with curative intent was analyzed. Patients with neoadjuvant radiotherapy/chemotherapy were excluded. Pathological characteristics based on the 2002 TNM system, recurrence-free/overall survival and metastatic patterns were determined.
• Results: A total of 788 patients with a mean age +/- SD of 65 +/- 10 years and a mean followup of 53.5 months who underwent surgery between 1986 and 2003 were analyzed. A neobladder was constructed in 75.4% of patients. Ten-year recurrence-free and overall survival rates were 59.1% and 44.9%, respectively. Positive lymph nodes were present in 143 patients (18%). The rate of recurrence-free survival at 5 years was 82.5% for pT2a pN0, 61.9% for pT2b and pT3a pN0, and 53.1% for pT3b pN0 disease. Local and distant failure rates were 4% and 9.5% for organ confined tumors, 15.9% and 19.2% for nonorgan confined tumors, and 20.4% and 45.1% in patients with positive lymph nodes, respectively.
• Conclusions: In patients with organ confined, lymph node negative transitional cell carcinoma excellent survival data can be achieved as long as the tumor is limited to the inner half of the detrusor. These data on a large group of patients support early aggressive surgical management for invasive bladder cancer. The results of this surgery only series may serve as a reference for other treatment modalities for bladder cancer.
  
  
• Editorial Comment
  This impressive series of cystectomy only in all stages of transitional carcinoma is certainly a reference for other treatment modalities – as the authors themselves proudly state.
  Still some aspects may be worth considering. An overall tumor-specific survival rate of roughly 60% after 10 years means that 40% of patients have died of their tumor. These 40% certainly deserve more or other therapy than cystectomy only as their disease was not cured finally. Looking more closely into the N+ group with roughly 15% recurrence-free survival after already 5 years, or into the T3bN0 group with 42 % recurrence-free survival after 10 years may support this statement. Adjuvant systemic chemotherapy, still far from ideal, might be one of such therapies to consider in these high-risk patients, as recent metaanalyses suggest.

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