Safety of Neoadjuvant Chemotherapy in Patients with Muscle-Invasive Bladder Cancer and Malignant Ureteral Obstruction

Objectives To determine whether patients with muscle-invasive bladder cancer (MIBC) and ureteral obstruction can safely receive neoadjuvant cisplatin-based chemotherapy (NAC). Also, to determine whether such patients require relief of obstruction with a ureteral stent or percutaneous nephrostomy (PCN) prior to beginning NAC. Patients and methods We performed a single-institution retrospective analysis of MIBC patients receiving NAC and falling into three groups: NO=no ureteral obstruction; RO=relieved ureteral obstruction; URO=unrelieved ureteral obstruction. To address whether patients with obstruction can safely receive NAC, we compared patients with NO to those with RO with primary outcome of premature chemotherapy discontinuation. To investigate whether patients with obstruction should have obstruction relieved prior to NAC, we compared RO to URO patients using a primary composite outcome of grade ≥ 3 adverse events, premature chemotherapy discontinuation, dose reduction, or dose interruption. Primary outcomes were compared using multivariable logistic regression. Sensitivity analyses were performed for the RO vs URO comparison in which patients with only mild degrees of obstruction were excluded from the URO group. Results 193 patients with NO, 49 with RO, and 35 with URO were analyzed. There were no statistically significant differences between those with NO and those with RO in chemotherapy discontinuation (15% vs 22%, p=0.3) or any secondary outcome. There was no statistically significant difference between those with RO and URO in the primary composite outcome (51% vs 53%, p=1) or any secondary outcome. Conclusion Patients with ureteral obstruction can safely receive NAC. Relief of obstruction was not associated with increased safety of NAC delivery.