Does the option of the ileal neobladder stimulate patient and physician decision toward earlier cystectomy?

PURPOSE: The primary goal of bladder replacement is to attempt to improve patient quality of life, not to increase survival, affect cancer prognosis or decrease renal metabolic complications. Nevertheless, we retrospectively determined whether orthotopic bladder replacement has an impact on the decision to perform cystectomy.
MATERIALS AND METHODS: From April 1986 to September 1994, 213 men a mean of 63 years old with stages pT2N0M0 to pT4N0M0 invasive bladder cancer were referred to our department for cystectomy. For 135 patients who underwent an ileal neobladder procedure and 78 who underwent conduit diversion median followup was 4.8 and 3.5 years, respectively. We evaluated the interval from the primary diagnosis of bladder cancer to cystectomy as well as the number of previous transurethral bladder resections. The 5-year cancer specific survival rates were calculated using the Kaplan-Meier method. The Wilcoxon and log rank tests, and the Cox proportional hazards model were used to determine statistical significance.
RESULTS: In the neobladder and conduit groups an average of 2.1 (range 1 to 18) and 4.1 (range 1 to 15) transurethral bladder resections was performed, respectively. Interval from the primary diagnosis to cystectomy was 11.8 months in the neobladder and 16.7 months in the conduit group. Cystectomy was performed 4.1 months after the diagnosis of invasive cancer in the neobladder group, whereas radical surgery was delayed for 15.4 months in the conduit group. Cancer specific 5-year survival rates were 76.6 and 28.35% in the neobladder and conduit groups, respectively. After stratifying according to tumor stage the 5-year survival rate was significantly higher for all disease stages in the neobladder than in the conduit group. The proportional hazards model revealed that this difference was not due to patient age at disease stages pT3bN0 and pT4N0 or by American Society of Anesthesiologists score. Independent prognostic factors for survival were diversion type and age. Delayed cystectomy was a risk factor only in advanced disease stages.
CONCLUSIONS: These data suggest that the ileal neobladder may decrease physician reluctance to perform cystectomy early in the disease process, increasing the survival rate. They also demonstrate that the ileal neobladder option significantly affects an earlier patient and physician decision in favor of cystectomy.