High mortality rates after radical cystectomy: we must have acceptable protocols and consider the rationale of cutaneous ureterostomy for high-risk patients

Abstract

Bladder cancer is a common disease, and for T2-T4 stages, radical cystectomy is the first treatment option (1). An interesting Swedish study has evaluated the natural history of urothelial bladder cancer. After 6 months of diagnosis, 38% of patients develop metastasis if untreated (2). Five-year Cancer-specific survival is as low as 14% in such scenery, and overall survival is only 5% (2). On the other hand, if treated these patients have a 5-year CSS and OS of 60% and 48% respectively (2). Radical cystectomy is, therefore, the first option, as it is also stated by the EAU, NCCN, AUA / ASCO / ASTRO / SUO guidelines/consensus (3-5) is associated with a significant survival gain in comparison to observation (2), to multiple resections, chemotherapy or radiotherapy (6). In patients with stage II disease, cystectomy is associated with a three-fold increase in survival, increasing mean overall survival from 16 to 45 months (6). In a SEER study evaluating 328,560 patients, radical cystectomy and chemotherapy were the only factors associated with improvements in survival (7). Trimodal “bladder-sparing” approaches that combine maximal transurethral resection, chemotherapy, and radiotherapy or neoadjuvant chemotherapy with partial cystectomy are an option but only for a small percentage of patients (3). However, if we analyze data carefully, the guideline recommendations are rarely followed. In a SEER study that evaluated 6.737 patients in the USA with stage II disease (non-metastatic, muscle-invasive bladder cancer), only 8.3% underwent radical cystectomy (8). The odds of an octogenarian to undergo radical cystectomy in the USA is five-times lower than a young patient (8). Hispanic origin, Afro-American origin, and lower scholar level patients are also less treated properly when they have muscle-invasive bladder cancer (8). According to a very interesting study that evaluated 27,578 patients from the SEER, only 6% of patients with muscle-invasive bladder cancer (pT2-pT4) in the USA underwent radical cystectomy between 2007 and 2013 (8). Less than 19% of patients with pT2 disease in the USA undergo radical cystectomy (9). And why does this happen? The answer is because radical cystectomy is associated with high morbidity and mortality rates. When described in the late 1940s, radical cystectomy was associated with a perioperative mortality of 33% (10). In the 1970s perioperative mortality decreased to 11% (and remained around 2.1% to 4.7% after the 1980s) (11). Analyzing mortality after radical cystectomy is a slippery slope, as demonstrated in Table-1. Studies report distinctive data. In-hospital mortality is lower than 30-day mortality, which is two to three-fold lower than 90-day mortality. And these numbers vary widely (1, 12, 13). High mortality rates after radical cystectomy: we must have acceptable protocols and consider the rationale of cutaneous ureterostomy for high-risk patients _______________________________________________