Comparison of the clinical and pathologic staging in patients undergoing radical cystectomy for bladder cancer

Radical cystectomy (RCx) is perhaps the most effective therapeutic approach for patients with muscle-invasive bladder cancer. Unfortunately, clinical staging is imprecise and the degree of understaging remains high. This study retrospectively evaluated patients undergoing RCx with regard to pathologic outcomes and degree of upstaging to better identify features that may lessen clinical understaging.

141 consecutive patients with urothelial bladder carcinoma who were candidates for RCx with curative intent were retrospectively evaluated. Preoperative clinical and pathological (i.e. TURBT) features were compared to pathological outcomes in the cystectomy specimen. Patients were also evaluated as to whether cystectomy was performed as their primary (n = 91) versus secondary (n = 50) treatment for recurrent/progressive disease. Date of cystectomy ( 5 years prior to study) was also analyzed.

Of the 141 patients, 54% were upstaged on operative pathology. The greatest degree of upstaging occurred in those with invasive disease preoperatively (cT2-T3). Twenty-six percent of all patients had node-positive disease, and 75% of cT3 patients were node-positive. Seven of 101 (7%) patients with clinical T2 disease were unresectable at the time of surgery. In the primary (vs. secondary) RCx group, more patients were upstaged (63% vs. 40%), non-organ confined (62% vs. 38%), and LN positive (31% vs. 20%). In the more modern cohort, the degree of upstaging was not improved.

Pathologic findings after RCx often do not correlate with preoperative staging. Over half of patients undergoing cystectomy are upstaged on their operative pathology. An improved understanding of the relative frequency of upstaging in cystectomy patients may have important implications in the decision-making and selection for neoadjuvant and adjuvant therapies for these high-risk populations.