[Results of radical cystectomy for management of invasive bladder cancer with special reference to prognostic factors and quality of life depending on the type of urinary diversion].
Bladder cancer is one of the main problems in urology in terms of diagnosis and treatment, due to its high incidence, high recurrence rate, and difficulties in prognosis of its natural history. According to Polish epidemiological reports, bladder cancer was the fifth cause of death due to malignant diseases in 1993 (1.2% in females and 4.0% in males). Radical cystectomy remained for over forty years the main method of treatment in cases of invasive bladder cancer. Improvements in postoperative care, surgical techniques and methods of urine diversion made cystectomy a widely performed, low mortality procedure. The analysis of prognostic factors with their influence on survival is helpful in patient qualification and prognosis of long-term outcome. The objective was to study retrospectively the results of radical cystectomy in cases of invasive bladder cancer with an emphasis on negative prognostic factors affecting survival. An evaluation of the quality of life (QL) depending on urine diversion method was performed. The material consisted of 95 patients (77 males and 8 females, mean age 59.6) who underwent cystectomy at the Department of Urology, Pomeranian Academy of Medicine, between 1989 and 1998. In 46 cases (48.4%) the Bricker's ileal conduit was performed. Ileal neobladders were created in 24 cases (25.2%) and in 25 patients (26.3%) other types of urine diversion were used. Among 37 survivals (38.6%) 20 patients were evaluated by means of physical examination, abdominal ultrasonography, laboratory parameters, blood gas analysis, urine culture, and QL questionnaires. Median follow-up time was 17.4 months. Survival curves were calculated according to the Kaplan-Meier's method. Statistical significance was established using Cox and Cox-Mantel tests. Histopathologic examination revealed transitional cell carcinoma in 97.8% of the bladders. Basing on the pathologic stage, patients were assigned to 2 groups: organ confined disease (pT2-3a, 41.3%) and perivesical or adjacent organ involvement (pT3b-4, 58.7%). The tumor was graded G1, G2 and G3 in 3.4%, 22.5%, and 74.1%, respectively. Pelvic lymph node involvement was histologically confirmed in 31 patients (35.2%). Different forms of adjuvant or neoadjuvant therapy, e.g. radiotherapy, systemic chemotherapy, intra-arterial chemotherapy, electrochemotherapy were used in 28 patients. In the postoperative period 7.3% of patients died. The negative factors with significant prognostic value were identified as non organ-confined tumors pT3b-T4 (p = 0.00002), lymph node involvement pN+ (p = 0.0001), and high grade tumors G3 (p = 0.01). All these parameters were responsible for the high death rate during 500 days postoperatively. The patient's age or preoperative hydronephrosis did not influence the overall survival. The 5-year survival for organ confined and remaining tumors was 44.1% and 11.6%, respectively (Tab. 1). Overall 5-year survival rate was 22%. The highest mortality and the highest risk of cancer-related death occurred during the first year from operation (Fig. 1 and 2). QL was evaluated basing on a specific questionnaire completed by 20 patients. The quality of life was similar in all groups of urine diversion (ileal conduit, neobladder, simple diversion), but some differences concerning general health status were revealed. Patients with Bricker's ileal conduit rated their present health status worse than the other groups. Patients with continent urinary diversion presented the best emotional status and lowest rate of disturbances in self care, professional, social and leisure activities. Surprisingly, high QL in patients with simple urine diversion (ureterocutaneostomy or nephrostomy) suggests a good adaptation to the so created difficult situation. Radical cystectomy is the best method of treatment in invasive bladder cancer, although it offers a poor chance of curing the patient. Eventually, only one-fifth of the patients survive 5 years. Half of the deaths occur during the first year from surgery. The best candidates for radical cystectomy are patients with low or medium grade organ confined tumors. In other cases this is just a palliative procedure, thereby justifying the selection of simple methods of urine diversion.
Słojewski
M
M
Kliniki Urologii Instytutu Chirurgii Pomorskiej Akademii Medycznej w Szczecinie.
D002295:Carcinoma, Transitional Cell / Q000401:mortality / Q000473:pathology / Q000556:secondary / Q000601:surgery*; D017024:Chemotherapy, Adjuvant; D015653:Cystectomy / Q000379:methods* / Q000401:mortality; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D011379:Prognosis; D011788:Quality of Life; D018714:Radiotherapy, Adjuvant; D012189:Retrospective Studies; D015996:Survival Rate; D001749:Urinary Bladder Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D014547:Urinary Diversion / Q000379:methods*