The role of radical cystectomy in patients with clinical T4b bladder cancer.

Objectives: Patients with clinical T4b bladder cancer (extension to pelvic wall and/or adjacent organs other than prostate, vagina, or uterus) are commonly considered unresectable. We hypothesized that select patients might achieve durable benefit from multiagent chemotherapy and extirpative surgery.

Methods: We identified patients with clinical T4bN0 bladder cancer from our IRB-approved database of patients undergoing radical cystectomy (n = 1,194). Relevant demographic, clinical, and pathologic data were compiled. Overall (OS), disease-specific (DSS), and recurrence-free survival (RFS) were analyzed by Kaplan-Meier estimation. Cox proportional hazards regression modeling was used to evaluate the influence of several potential prognostic factors.

Results: Twenty-three patients (16 male) with a median age of 65 years met study criteria. Chemotherapy was administered preoperatively to 19 (83%) and postoperatively to 8 (35%) patients. Eight patients died of disease and 1 of other causes. The 1-, 2-, and 5-year DSS was 91% (95% C.I. 70%-98%), 66% (95% C.I. 42%-83%), and 60% (95% C.I. 34%-78%), respectively. Eight of 17 patients with pT2-4 tumors succumbed to disease compared with none of 6 who were ≤ pT1 (P = 0.04). Other predictors of decreased DSS included positive surgical margins (HR = 5.34, 95% C.I. 1.25-22.83) and presence of pathologic nodal metastasis (HR = 29.33, 95% C.I. 3.13-275.19). Variant histology was more common in this cohort than in the overall cystectomy database (43% vs. 11%).

Conclusions: Long-term survival can be achieved in a proportion of patients with cT4b bladder cancer undergoing chemotherapy and extirpative surgery. Careful selection of patients and meticulous surgical technique to avoid positive margins are critical.