Current Perspectives in the Management of High-Grade Invasive Bladder Cancer

Optimal management of high-grade invasive bladder cancer requires aggressive therapy, usually radical cystectomy with preoperative radiation therapy. Recent prospective studies have demonstrated that five-year survival rates for deeply invasive disease have improved to 45- 55% compared to a dismal less than 20% five-year survival for patients treated by definitive radiation therapy alone, or historical series in which cystectomy was used as single modality therapy. The incidence of pelvic lymph node involvement ranges from 10% in patients with P₁ and P_1S disease to 50% in patients with P₃ disease and implies the need to treat the pelvic nodes by lymphadenectomy or adequate preoperative radiation therapy whenever cystectomy is indicated. The improvements in surgical technique, pre-, and postoperative management have resulted in operative mortality as low as 1% and early complication rates as low as 24% for patients treated by single-stage radical cystectomy with pelvic node dissection and urinary diversion. Despite these advances, 50% or more of patients with high-grade invasive bladder cancer die of distant metastases, usually within two years, implying the need to scrutinize adjuvant chemotherapy in carefull controlled prospective studies.