Immediate radical cystectomy vs conservative management for high grade cT1 bladder cancer: is there a survival difference?

Study Type – Aetiology (individual cohort) Level of Evidence 2b What's known on the subject? and What does the study add? For patients with high grade (HG) non-muscle invasive urothelial cell cancer (UCC) of the bladder, transurethral resection of bladder tumor (TURBT) in conjunction with induction and maintenance intravesical therapy is a commonly used treatment modality. Early cystectomy, although offering the best opportunity for cure, would in turn constitute overtreatment in some cases. Conservative management strategies, as opposed to radical surgery, are a viable treatment option within a well selected subset of patients with HG T1 UCC. OBJECTIVE •  To determine whether a survival difference exists between patients with high grade (HG) cT1 urothelial cell carcinoma (UCC) receiving immediate radical cystectomy (IRC) as opposed to those choosing bladder-sparing therapy. PATIENTS AND METHODS •  Between January 1990 and August 2010, 349 patients were retrospectively identified with a diagnosis of HG cT1 UCC of the bladder. Patients were divided into two groups: those who underwent IRC and those treated with conservative management (CM), consisting of transurethral resection of the bladder tumour (TURBT) and intravesical therapy. IRC was defined as surgery within 90 days of HG cT1 diagnosis with no intervening transurethral resection (TUR) or intravesical therapy (IVT). Trends in patient selection and cancer-specific survival (CSS) were analyzed over consecutive decades. •  The primary outcome was to compare CSS among patients during consecutive decades whereby management paradigms shifted from IRC to CM. The secondary outcome was to examine whether patient selection changed over time for each respective intervention. RESULTS •  One hundred and thirteen patients underwent IRC and 236 had CM. From 1990 to 1999, only 90 patients were diagnosed with HG cT1 disease, and a majority of patients (n= 54) underwent IRC. From 2000 to 2010, only 23% (59/259) of the patients with HG cT1 underwent IRC. Despite 42.3% more patients successfully maintaining their bladder in the long-term, no difference in 5 year bladder CSS was noted between decades (77% vs 80% consecutively, P= 0.566). A subset analysis of risk factors for bladder cancer progression/recurrence demonstrated more patients with lymphovascular invasion (LVI) on TUR underwent IRC in the current era (13/59 (22.0%) vs 13/200 (6.5%), P < 0.001). These findings remain to be validated in prospective work at other institutions. CONCLUSION •  Conservative management strategies are a viable treatment option within a well selected subset of patients with HG cT1 UCC.