Primary T1G3 bladder cancer: organ preserving approach or immediate cystectomy?

In this retrospective nonrandomized study we compared the long-term outcome in patients with newly diagnosed stage T1G3 bladder cancer treated with transurethral resection and bacillus Calmette-Guerin or immediate cystectomy.

Of 121 patients with a median age of 67 years (range 36 to 88) diagnosed with primary T1G3 bladder cancer between 1976 and 1999, 92 were treated by transureteral resection with additional intravesical bacillus Calmette-Guerin and 29 were treated with immediate cystectomy.

Of the 92 patients treated with an organ preserving approach 29 remained disease-free, local recurrence developed in 33 (36%) and progression developed in 30 (33%) at a median followup of 6.9 years (range 0.6 to 16.5). Of these 92 patients 27 (29%) underwent deferred cystectomy at a median of 12.9 months (range 4.8 to 136), of whom 10 (37%) with a median postoperative followup of 19 months (range 2 to 173) died of progressive disease with a median survival of 13 months (range 3 to 34) after cystectomy. The majority of patients who died of progressive disease refused cystectomy, were referred too late for cystectomy, were inoperable or had upper urinary tract disease. Six of the 29 patients (21%) undergoing immediate cystectomy had progression at a median of 13.2 months (range 5.5 to 37). Overall and tumor specific survival at 5 years in patients treated with an organ preserving approach was 69% and 80%, and in those treated with immediate cystectomy it was 54% and 69%, respectively.

The results of this analysis demonstrate that the concept of an organ preserving approach is acceptable and spares the bladder in approximately half of the patients with primary T1G3 bladder cancer. Of the patients 30% require deferred cystectomy, making meticulous, close followup mandatory.