Umar Iqbal1, Ahmed S Elsayed2,3, Zhe Jing4, Michael Stoeckle5, Carl Wijburg6, Peter Wiklund7, Abolfazl Hosseini8, Prokar Dasgupta9,10, Muhammad Shamim Khan11, Ashok Hemal12,13, Eric H Kim14, Andrew A Wagner15, Franco Gaboardi16, Koon Ho Rha17, Thomas Maatman18, Derya Balbay19, Qiang Li20, Ahmed Hussein21, Khurshid A Guru22,23. 1. Roswell Park Cancer Insitute, Urologic Oncology, Buffalo, New York, United States; umar.iqbal@roswellpark.org. 2. Roswell Park Cancer Insitute, Urologic Oncology, Buffalo, New York, United States. 3. Cairo University Kasr Alainy Faculty of Medicine, 63527, Cairo, United States; Ahmed.Elsayed@roswellpark.org. 4. Roswell Park Cancer Insitute, Urologic Oncology, Buffalo, New York, United States; zhe.jing@roswellpark.org. 5. Universitat des Saarlandes, 9379, Urologie, Saarbrucken, Germany; michael.stoeckle@uks.eu. 6. Arnhem, Netherlands; cwijburg@rijnstate.nl. 7. Solna, Sweden; peter.wiklund@karolinska.se. 8. Karolinska Institutet, Urology, 171 76 Stockholm, Stockholm, Sweden, 171 76 Stockhol; abolfazl.hosseini-aliabad@karolinska.se. 9. King's College London, 4616, MRC Centre for Transplantation, Guy's Hospital, London, United Kingdom of Great Britain and Northern Ireland, SE19RT. 10. Guy's and St Thomas' NHS Trust, Department of Urology, Guy's Hospital, London, United Kingdom of Great Britain and Northern Ireland, SE19RT; prokarurol@gmail.com. 11. London, London, United Kingdom of Great Britain and Northern Ireland; shamimatguys@gmail.com. 12. Wake Foresty University Baptist Medical Center, Urology, Medical Center Blvd, Winston-Salem, North Carolina, United States, 27157. 13. United States; ahemal@wakehealth.edu. 14. Washington University School of Medicine, Urology, 4960 Children's Place, Box 8242, St. Louis, Missouri, United States, 63110; ehkim@wustl.edu. 15. Beth Israel Deaconess Medical Center and Harvard Medical School, Urology, 330 Brookline Ave., Boston, Massachusetts, United States, 02215; awagner@bidmc.harvard.edu. 16. Urology, Milan, Italy; gaboardi.franco@hsr.it. 17. Severance Hospital, Yonsei University, Urology, Yonseiro 50-1, Seodaemun-gu, Seoul, Korea, Seoul, Korea (the Republic of); khrha@yuhs.ac. 18. Metro Health: University of Michigan Health, Urological Surgery, Wyoming, Michigan, United States; maatmant@aol.com. 19. Istanbul, Turkey; mderyabalbay@yahoo.com. 20. Roswell Park Cancer Insitute, Urologic Oncology, Buffalo, New York, United States; qiang.li@roswellpark.org. 21. 11 Linwood aveBuffalo, United States, 14209; Ahmed.Aly@roswellpark.org. 22. Roswell Park Cancer Insitute, Urologic Oncology, Elm and Carlton Streets, Buffalo, New York, United States, 14263. 23. Roswell Park Cancer Institute, Urologic Oncology, Elm and Carlton Streets, Buffalo, United States, 14263; khurshid.guru@roswellpark.org.
Abstract
INTRODUCTION: We sought to describe the incidence, risk factors, and survival outcomes associated with pathological upstaging from non-muscle invasive bladder cancer (NMIBC) to muscle invasive bladder cancer (MIBC) after robot-assisted radical cystectomy (RARC). METHODS: We reviewed the International Robotic Cystectomy Consortium database between 2004 and 2020. Upstaging was defined as ≥pT2 or pN+ at final pathology from clinical <T2N0M0. Descriptive statistics were used to summarize data. Cochran-Armitage test was used to depict upstaging trend over time. Multivariate regression models were used to depict variables associated with upstaging. Kaplan Meier curves were used to describe disease-specific (DSS), recurrence-free (RFS), and overall survival (OS). RESULTS: 463 patients underwent RARC for NMIBC. Upstaging occurred in 145 (31%) patients. Upstaged patients were older (70 vs 67 years, p <0.01), more likely to have American Society of Anesthesiologists score (≥3) (55% vs 44%, p=0.04) and had higher rate of preoperative hydronephrosis (26% vs 10%, p <0.01). They were more likely to have positive surgical margins (10% vs 3%, p= 0.01), recurrences (28% vs 9%, p<0.01), and to receive adjuvant/salvage treatment (26% vs none, p <0.01). On multivariate analysis, upstaging was associated with older age (OR 1.04; CI 1.01-1.07, p<0.01), cT1 vs cTis (OR 4.25; CI 1.57-11.48, p <0.01), cT1 vs cTa (OR 2.92; CI 1.40-6.06, p<0.01), and preoperative hydronephrosis (OR 3.18; CI 1.60-6.32, p<0.01). Upstaged patients had worse 5-year RFS (53 % vs 85%, log rank p<0.01), DSS (66% vs 93%, log rank p<0.01), and OS (49% vs 74%, log rank p<0.01). The rate of upstaging did not significantly change over time (38% in 2004 to 27% in 2019, p=0.17). CONCLUSION: Upstaging to MIBC occurred in a significant proportion of patients after RARC for NMIBC and was associated with worse survival outcomes. Older patients, those with cT1 disease and hydronephrosis were more likely to upstage.
INTRODUCTION: We sought to describe the incidence, risk factors, and survival outcomes associated with pathological upstaging from non-muscle invasive bladder cancer (NMIBC) to muscle invasive bladder cancer (MIBC) after robot-assisted radical cystectomy (RARC). METHODS: We reviewed the International Robotic Cystectomy Consortium database between 2004 and 2020. Upstaging was defined as ≥pT2 or pN+ at final pathology from clinical <T2N0M0. Descriptive statistics were used to summarize data. Cochran-Armitage test was used to depict upstaging trend over time. Multivariate regression models were used to depict variables associated with upstaging. Kaplan Meier curves were used to describe disease-specific (DSS), recurrence-free (RFS), and overall survival (OS). RESULTS: 463 patients underwent RARC for NMIBC. Upstaging occurred in 145 (31%) patients. Upstaged patients were older (70 vs 67 years, p <0.01), more likely to have American Society of Anesthesiologists score (≥3) (55% vs 44%, p=0.04) and had higher rate of preoperative hydronephrosis (26% vs 10%, p <0.01). They were more likely to have positive surgical margins (10% vs 3%, p= 0.01), recurrences (28% vs 9%, p<0.01), and to receive adjuvant/salvage treatment (26% vs none, p <0.01). On multivariate analysis, upstaging was associated with older age (OR 1.04; CI 1.01-1.07, p<0.01), cT1 vs cTis (OR 4.25; CI 1.57-11.48, p <0.01), cT1 vs cTa (OR 2.92; CI 1.40-6.06, p<0.01), and preoperative hydronephrosis (OR 3.18; CI 1.60-6.32, p<0.01). Upstaged patients had worse 5-year RFS (53 % vs 85%, log rank p<0.01), DSS (66% vs 93%, log rank p<0.01), and OS (49% vs 74%, log rank p<0.01). The rate of upstaging did not significantly change over time (38% in 2004 to 27% in 2019, p=0.17). CONCLUSION: Upstaging to MIBC occurred in a significant proportion of patients after RARC for NMIBC and was associated with worse survival outcomes. Older patients, those with cT1 disease and hydronephrosis were more likely to upstage.