Early versus deferred cystectomy for initial high-risk pT1G3 urothelial carcinoma of the bladder: do risk factors define feasibility of bladder-sparing approach?

OBJECTIVES: We compared long-term outcome in patients with initial pT1G3 bladder cancer (BC) treated with early versus deferred cystectomy (CX) for recurrent pT1G3 or muscle-invasive BC after an initial bladder-sparing approach. The aim of this study was to compare survival rates and to analyse the influence of the recognised risk factors multifocality, tumour size, and carcinoma in situ (CIS) in initial transurethral resection of the bladder.
METHODS: Between 1995 and 2005, a total of 105 patients were diagnosed with initial pT1G3 BC featuring>or=2 risk factors. Forty-five percent had multiple tumours, 73% tumours>3 cm in size, and 46% CIS. All patients were offered early CX. Fifty-one percent of patients opted for early and 49% underwent deferred CX for recurring BC. Risk factors were distributed evenly between the groups.
RESULTS: Upstaging in the CX specimen was found in 30% of cases. No risk factor was related to upstaging. The 10-yr cancer-specific survival rate was 78% in early CX and 51% in deferred CX (p<0.01). No risk factor predicted cancer-related death in early CX. In survival analysis, CIS was related to a lower cancer-specific survival rate in deferred CX (p<0.001).
CONCLUSIONS: Early as opposed to deferred CX seems to prolong the cancer-specific survival rate in high-risk pT1G3 BC. Patients with CIS should be considered for early CX owing to reduced cancer-specific survival in case of deferred CX.