Surgical approach in patients with T4 bladder cancer as primary treatment: Disaster or option with improved quality of life

Objectives: Whereas local control is often insufficient in conservative management of T4 bladder cancer, neoadjuvant chemotherapy delays definite treatment, which could result in increased therapy-associated morbidity and mortality during the course of the disease. Primary cystectomy has been reported to be associated with a high complication rate and unsatisfactory clinical efficacy. Herein, we report postoperative outcome in 21 T4 bladder cancer patients subjected to primary cystectomy. Materials and Methods: Twenty-one patients underwent radical cystectomy for T4 (T4a/b: 14 and seven cases, respectively) bladder cancer. At the time of surgery, eight patients had regional lymph node metastases (N2: 6; N3: 2). The average age was 64 (52-77) years (≥70 years: n = 7). The postoperative follow-up was 13 (1-36) months for the whole group. Results: Mean duration of postoperative hospitalization was 19 (11-50) days. Whereas 10 patients received no intra - or postoperative blood transfusions, an average number of 3 (1-7) blood units were administered in the remaining cases. The mean postoperative hemoglobin value of patients not receiving any blood transfusions was 10 (8.5 - 11.4) g/dl. Major therapy-associated complications were paresthesia affecting the lower extremities (n = 3) as well as insignificant pulmonary embolism, enterocutaneous fistulation and acute renal failure in one patient, respectively. At the time of data evaluation, 11 patients were still alive after a follow-up of 20 (6-36) months. Four patients ≥70 years at the time of cystectomy were still alive 11, 11, 22 and 31 months following surgery, respectively. Conclusion: Primary cystectomy for T4 bladder cancer is a technically feasible approach that is associated with a tolerable therapy-related morbidity/mortality. Additionally, a satisfactory clinical outcome is observed even in a substantial number of elderly patients.