What is the role of cystectomy in the treatment of non-muscle-invasive bladder cancer?

Updated: Feb 23, 2021
  • Author: Kara N Babaian, MD, FACS; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Answer

Eliminating visible lesions with resection is preferable prior to intravesical BCG, but some CIS lesions may not be readily visible. Blue-light cystoscopy may improve the detection of CIS. [110] Patients who do not respond to BCG instillations often find cystectomy difficult to accept and, instead, want to continue trying various intravesical instillations.

The difficulty of accurately staging CIS preoperatively was demonstrated by Tilki and a group of international investigators. [112] These researchers reported that of 243 patients who were considered to have only CIS before cystectomy, only 117 (48.1%) were found to actually have CIS; 20 patients (8.2%) had no cancer (pT0), and 19 patients (7.8%) had urothelial cancer only. The disease was up-staged in 36% of the patients. The overall 5-year recurrence-free and cancer-specific survival was 74% and 85%, respectively.

From 35-50% of patients who undergo cystectomy for Ta, T1, or CIS are discovered to have muscle-invasive disease, with 10-15% demonstrating microscopic lymph node metastasis. According to the NCCN guidelines, cystectomy should involve at least bilateral node dissection, including iliac and obturator nodes. [1]

Patients with T1 high-grade cancer in association with diffuse CIS are at especially high risk of progression, and they may be treated with early cystectomy based on a decision made by the physician and patient. The EAU guidelines recommend that immediate cystectomy be considered for such patients. [69]

CIS progresses to muscle-invasive disease in upwards of 80% of affected patients, with 20% of patients found to have muscle-invasive disease at the time of cystectomy. High-grade T1 tumors that recur despite BCG have a 50% likelihood of progressing to muscle-invasive disease. Cystectomy performed prior to progression yields a 90% 5-year survival rate. The 5-year survival rate drops to 30-50% in muscle-invasive disease. The EAU guidelines strongly advocate cystectomy in patients with early BCG failure. [69]


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