Long-term Safety Profile of Salvage Cystectomy After Trimodality Therapy Seems Acceptable

Radical cystectomy and trimodality therapy (TMT)—maximally safe transurethral resection followed by concurrent radiation and radiosensitizing chemotherapy—are the two accepted curative options for treating localized muscle-invasive bladder cancer. TMT has not been widely implemented, however, partly because salvage cystectomy (SC) is required in about 11%–29% of patients due to recurrent invasive bladder cancer and/or chemoradioresistant disease.

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In The Journal of Urology, Matthew F. Wszolek, MD, urologist and chair of Quality and Safety in the Department of Urology at Massachusetts General Hospital, and urologic oncologist at Mass General Cancer Center, and colleagues report that most patients who undergo SC are cured and have a tolerable immediate, early and long-term safety profile.

Study Methods

The subjects in this retrospective study were 265 patients who underwent radical cystectomy for clinical stage cT1 to T4N0M0 disease at Massachusetts General Hospital between 2003 and 2013. The researchers divided them into three groups:

1. PC (n=216)—primary cystectomy
2. PC/XRT (n=28)—primary cystectomy in patients who had a history of non-TMT abdominal/pelvic radiation therapy, such as for prostate or rectal cancer
3. SC (n=21)—salvage cystectomy for intravesical recurrence after TMT

Median follow-up from the time of cystectomy was 65.5 months.

Early Complications (≤90 Days)

In the PC, PC/XRT and SC groups, respectively:

• Respiratory complications were present in 5%, 14% and 19% of patients (P=0.01)
• Infectious complications—17%, 7% and 38% (P=0.02)
• Neurological complications—6%, 0% and 24% (P=0.007)

There was no difference between groups in intraoperative complications, estimated blood loss, length of stay, overall rates of any complication or overall rates of major complications (Clavien–Dindo grade 3–5).

Late Complications

In the PC, PC/XRT and SC groups, respectively:

• Infectious complications—8%, 11% and 26% (P=0.03)
• Gastrointestinal complications—4%, 15% and 26% (P<0.01)
• Genitourinary complications—8%, 15% and 26% (P=0.03)

The overall rate of late complications was higher with SC than PC or PC/XRT (P=0.03). In multivariable analysis, SC was associated with a higher incidence of any late complications (HR, 2.3; P=0.02) and major late complications (HR, 2.1; P<0.05) compared with PC, but differences between SC and PC/XRT were not statistically significant.

Survival

In adjusted analyses, there were no significant differences between groups in five-year disease-free survival or five-year overall survival from the time of cystectomy. The five-year disease-free survival rate in the SC group was 64%.

Caveats

The higher rates of late complications with SC in this study, compared with PC, seem acceptable since survival was similar between the groups. However, the small number of patients in the SC group should be noted. At Mass General, only 16% of patients who undergo TMT require SC, according to a previous retrospective study published in The Journal of Urology.

The results of this study may not apply to centers with less experience in performing TMT or to every patient who has a recurrence after TMT.

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