title: Oncologic surveillance in bladder cancer following radical cystectomy: A systematic review and meta-analysis.
abstract: OBJECTIVE
  The existing guidance on bladder cancer surveillance following radical cystectomy is limited and variable. Additionally, the effect of surveillance on mortality is debatable. Herein, we perform a systematic review to evaluate the characteristics of alternative oncologic surveillance protocols and determine the association of detection of asymptomatic vs. symptomatic recurrences on mortality.
  
  
  METHODS
  An electronic search of PubMed, MEDLINE, EMBASE, and Cochrane Library databases was performed from 1970 to 2015. In all, 3 reviewers independently assessed the 1,729 candidate studies for eligibility and abstracted data based on an a priori established protocol. Outcomes were pooled using random effects meta-analysis.
  
  
  RESULTS
  We identified 7 studies for inclusion that were uncontrolled and thereby represented a body of evidence at high risk of bias; 5 studies developed surveillance protocols using a methodology similar to that of established guidelines. The majority proposed a pathologic stage-stratified approach, but ended surveillance for all patients at 5 years. Detection of asymptomatic recurrences was associated with a nonsignificant reduction in mortality (relative risk = 0.78; 95% CI: 0.58-1.04). This effect became statistically significant when upper and lower urinary tract recurrences were included in the analyses (relative risk = 0.69; 95% CI: 0.59-0.79).
  
  
  CONCLUSIONS
  Only sparse evidence supports alternative oncologic surveillance protocols for bladder cancer following radical cystectomy. The majority of existing protocols proposed similar strategies to those recommended by published guidelines. Detecting asymptomatic recurrences may lead to a reduction in overall mortality, which could provide a rationale for surveillance.
authors.affiliation: Department of Urology, Mayo Clinic, Rochester, MN. Electronic address: smerill1@hmc.psu.edu.
authors.forename: Suzanne B
authors.initials: SB
authors.lastname: Stewart-Merrill
authors.affiliation: Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
authors.forename: Fares
authors.initials: F
authors.lastname: Alahdab
authors.affiliation: Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
authors.forename: Khalid
authors.initials: K
authors.lastname: Benkhadra
authors.affiliation: Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
authors.forename: Zhen
authors.initials: Z
authors.lastname: Wang
authors.affiliation: Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
authors.forename: Atsushi
authors.initials: A
authors.lastname: Sorita
authors.affiliation: Department of Urology, Mayo Clinic, Rochester, MN.
authors.forename: Stephen A
authors.initials: SA
authors.lastname: Boorjian
authors.affiliation: Department of Urology, Mayo Clinic, Rochester, MN.
authors.forename: Igor
authors.initials: I
authors.lastname: Frank
authors.affiliation: Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
authors.forename: Mohammad Hassan
authors.initials: MH
authors.lastname: Murad
mesh_terms: D015653:Cystectomy / Q000379:methods*; D005500:Follow-Up Studies; D017408:Guidelines as Topic; D006801:Humans; D009364:Neoplasm Recurrence, Local; D017063:Outcome Assessment, Health Care / Q000379:methods*; D001749:Urinary Bladder Neoplasms / Q000601:surgery*
keywords: Bladder cancer; Cystectomy; Guidelines; Recurrence; Surveillance