Salvage cystectomy after irradiation failure

Recent clinical studies have revealed the superiority of planned preoperative irradiation therapy followed by cystectomy compared to either treatment modality alone. There remains a select group of patients who for personal or medical reasons are not candidates for planned preoperative irradiation and cystectomy, and these patients undergo radical irradiation therapy as the sole treatment modality. Nearly 80% of these patients with invasive bladder cancer treated by definitive irradiation therapy will fail within 5 years, and many of these might become candidates for salvage cystectomy. Our 37 consecutive patients who failed definitive irradiation therapy were treated by salvage cystectomy. The selection for the operative procedure, morbidity and mortality, and survival data are reviewed. The mortality rate for this group was 8.1% and the early complication rate was 24%. However, none of the patients who underwent a 2-stage procedure or who had an early perineal approach died. In addition, only 1 (7%) of the staged patients had an early complication. The over-all survival for the entire group of 37 patients was 38%. However, those patients with pathological stage O or A disease had a 63% survival compared to a dismal 19% for those with stage B or greater disease. Our experience leads us to recommend that salvage cystectomy be performed early after irradiation failure. Selective use of the initial perineal approach in male patients and the use of staged cystectomy after urinary diversion in some of these high risk patients have resulted in a marked decrease in the morbidity and mortality.