Partial cystectomy for muscle-invasive transitional and squamous carcinoma of the bladder-is it safe?

In 1994, we presented to the SIU our results with partial cystectomy as definitive therapy for primary bladder cancer. We concluded that it was effective therapy for highly selected patients (pts), and the advantages over radical cystectomy made it an attractive option if eligible (∼5%). However, with further experience and longer follow-up, it is obvious that some pts are at increased risk when the entire bladder is not removed. We herein present our current results and offer recommendations to decrease the potential risk for pts who do undergo partial cystectomy. From 1/82 to 7/96, we performed partial cystectomy with the intent to cure on 24 pts with primary bladder cancer (TCC-23, SCC-1). Pts were highly selected and eligible only if the tumor was their first, solitary, and located where it permitted a 2 cm margin without re-implantation. Tumors were clinical stage T2-13, T3a-4, and T3b-7. No serious surgical complications occurred. Median follow-up was 36 months (range 6-148). Because of the path findings, 10 pts got adjuvant therapy: XRT-1, systemic chemotherapy-8, and BCG-1. Four pts died of intercurrent disease without recurrence of bladder cancer (21, 36, 44, & 51 months). Three pts died of metastatic bladder cancer, 2 at 6 & 18 months (bladders normal); 1 pt, however, had a grade III T1 recurrence at 41 months and died of widespread metastatic disease. Six other pts had recurrent bladder cancers, all superficial, 7 to 100 months after partial cystectomy, 5 of whom required only TUR-BT ±BCG. However, 1 pt had a recurrence at 100 months and received BCG, but 43 months later he developed TCC of the prostatic ducts with stromal invasion and +LNs and is getting MVAC. Another pt got BCG for 2 superficial recurrences at 73 & 76 months, then a radical cystectomy for a T1 recurrence 23 months later. Thus, only 11/24 (46%) never recurred, but 3 of these 11 pts have less than 12 months follow-up and may yet manifest recurrence. Although partial cystectomy can control the primary tumor, especially in conjunction with adjuvant therapy, we conclude that pts with muscle-invasive tumors are at high risk for recurrent cancer despite very careful selection. Many recurrences will be superficial, but 2 of our pts had late recurrences that progressed to metastatic disease. If partial cystectomy is performed, we recommend close and indefinite follow-up with cystoscopy and urinary cytology. For patients who recur, early "salvage" cystectomy should be considered.