What is included in the long-term surveillance following radical cystectomy?

Updated: Nov 27, 2016
  • Author: Michael Christopher Large, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Answer

Because recurrence is a significant risk following radical cystectomy, frequent and appropriate surveillance is essential.

A group from the University of Texas MD Anderson Cancer Center retrospectively reviewed their post–radical cystectomy surveillance protocol for 382 patients and concluded that a stage-specific approach was most appropriate. [23] With a median follow-up of 38 months, 97 of 382 (25%) patients experienced recurrences, with a median time to recurrence of 12 months. The 4 most common sites of recurrence (in decreasing order of incidence) included the lung, pelvis, bone, and liver. Seventy-four percent of recurrences were asymptomatic, and 43 of the 72 asymptomatic recurrences were detected with chest radiography or liver function serum tests.

Only 5% of patients with pT1 disease had subsequent metastases, and all were identified with chest radiography or liver function tests. Among 10 patients who were found to have asymptomatic intra-abdominal recurrences based on CT scan findings, 9 had pT3 disease. Patients with pT2 and pT3 disease had recurrence rates of 20% and 40%, respectively. All recurrences in patients with pT2 or pT3 disease occurred within 24 months.

Based on these findings, the group recommends that patients with pT1 disease should undergo an annual history, physical examination, chest radiography, liver function tests, and alkaline phosphatase assessment. Patients with pT2 disease should undergo the same studies, but they should be performed every 6 months for 3 years, then annually. Patients with pT3 disease should be observed similarly to those with pT2 disease, except surveillance should start at 3 months, with CT scanning performed at 6, 12, and 24 months. All patients with TCC, particularly those at higher risk of recurrence (distal ureteral involvement at cystectomy, multiple recurrent bladder tumors, CIS), should undergo upper tract radiographic studies every 1-2 years.

There is conflicting data regarding whether routine post-cystectomy surveillance improves survival. A retrospective study from the Mayo clinic of 1600 patients with median follow-up of 9.8 years suggested that five and 10-year overall survival is improved in patients with asymptomatic versus symptomatic recurrence; 46% and 26% versus 22% and 10%, respectively (p < 0.0001). Patients with symptomatic recurrence had a 60% increased risk for death versus those with asymptomatic recurrence (p = 0.0001). [24]

A large study in Germany, however, casts doubt on this purported value of imaging after cystectomy. [25] Of 1270 patients who underwent radical cystectomy, tumors recurred in 154 asymptomatic patients and 290 symptomatic patients. The overall survival rates at 1, 2, and 5 years in the two groups were 22.5%, 10.1% and 5.5% versus 18.9%, 8.2% and 2.9%, respectively. Based on this experience, symptom-guided follow-up may provide survival outcomes that are similar to those associated with imaging-based examinations. Additional studies are needed to validate these findings.

For excellent patient education resources, visit eMedicineHealth's patient education articles Bladder Cancer and Blood in the Urine.


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