Recurrence-Free Survival After Radical Cystectomy of Patients Downstaged by Transurethral Resection

Objectives: The finding of bladder cancer invading the detrusor muscle on transurethral resection (TUR) is one of the clearest indications for radical cystectomy. To the extent that detrusor invasion is, in practical effect, a binary variable, the variety of outcomes after radical cystectomy in these patients belies the simplicity of this approach. In this context, we assessed bladder cancer recurrence-free survival among patients noted to have muscle-invasive urothelial carcinoma (transitional cell cancer [TCC]) on staging TUR subsequently found to have non-muscle-invasive TCC at radical cystectomy (downstaged). Methods: The records of 248 consecutive patients who underwent radical cystectomy for TCC at a single academic institution from 1994 to 2002 were retrospectively reviewed. Of these patients, 112 (45%) had documented muscle-invasive disease by TUR and were clear of gross residual tumor on cystoscopy before radical cystectomy. Results: Of the 112 patients, 25 (22.3%) were downstaged to non-muscle-invasive disease (Stage pT1 or less) at cystectomy and 87 (77.7%) had persistent muscle-invasive disease (Stage pT2 or greater) at cystectomy. Recurrence occurred in 4 downstaged patients (16.0%) compared with 29 patients (33.3%) who were not downstaged (P = 0.094). Kaplan-Meier analysis demonstrated a statistically significant improvement in recurrence-free survival with downstaging (log-rank P = 0.008). Multivariate analysis demonstrated a threefold reduction in recurrence risk with tumor downstaging (hazard ratio 0.33, 95% confidence interval 0.10 to 1.12) that approached statistical significance (P = 0.075). Nodal status was the strongest predictor of RFS. Conclusions: Downstaging from muscle-invasive TCC on TUR to non-muscle-invasive TCC at radical cystectomy can be associated with a reduced risk of recurrence even after adjusting for lymph node status and adjuvant chemotherapy.