[Radical cystectomy in patients with non-muscle invasive bladder cancer who fail BCG therapy]

To assess the characteristics and outcomes of patients with non-muscle invasive bladder cancer (NMIBC) undergoing radical cystectomy (RC) due to BCG failure.

Ninety-five (11%) of the 864 patients undergoing radical cystectomy (RC) at our center from 1989 to 2002 had received prior treatment with BCG. Of these, 62 (65.2%) underwent RC due to relapsing, high-risk NMIBC or CIS despite BCG therapy. A stage >or= pT2 tumor was reported in the cystectomy specimen in 17 (27%) of these patients, who were considered to have been understaged. RC was performed for clinical progression in 33 patients (34.7%). Their last transurethral resection before RC showed invasive disease. A retrospective analysis was made of the outcomes of patients who underwent RC for BCG failure and the clinical and pathological differences between understaged patients and those with clinical progression.

Five-year CSS was 90% in 45 patients with clinical and pathological NMIBC and 50.6% in 50 patients with progression to muscle-infiltrating disease (clinical progression and understaged) (p < 0,05). There were no differences in survival in patients with clinical progression as compared to understaged patients. Median time from tumor diagnosis to tumor progression was 24 months (10th-90th percentile, 6-98 months). Patients with clinical progression had significantly more T1 tumors (p = 0.015) in TUR before progression and more pT3 tumors (p < 0.01) in the RC specimen. Understaged patients more often had pathological pT4 stages (p < 0.02).

In patients with high-risk NMIBCs who fail BCG therapy, RC should be performed before progression because survival is decreased when the RC specimen shows muscle-invasive disease. High-grade T1 tumors are responsible for most early clinical progressions. Patients with NMIBC may have subclinical progression, mainly within the prostate.