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Radical Radiotherapy And Cystectomy For Bladder Cancer Have Similar Morbidity, Mortality

Radical radiotherapy and cystectomy for treatment of invasive bladder cancer appear to yield similar morbidity and mortality rates, according to a retrospective study.

R. Chahal and colleagues from the department of urology, Orchard House, Pinderfields and Pontefract NHS Trust, Wakefield, England, investigated the morbidity and mortality associated with radical cystectomy and radical radiotherapy for the treatment of invasive carcinoma of the bladder.

They identified 398 patients with invasive carcinoma of the bladder who underwent treatment in the Yorkshire region of England between 1993 and 1996. Among these patients, 302 received radical radiotherapy and 96 received radical cystectomy.

A retrospective review of patient medical data revealed that the patients who underwent radiotherapy were significantly older than those who underwent cystectomy (71 versus 66 years of age). However, there was no difference between the two groups with respect to the distribution of American Society of Anaesthesiologists (ASA) tumour grades. Both groups of patients experienced significant delays between the time of diagnosis and treatment: 4.3 weeks in the cystectomy group and 9 weeks in the radiotherapy group.

The 30-day treatment-associated mortality rate was 3.1% for cystectomy and 8.3% for radiotherapy. The three-month treatment-associated mortality rate was 0.3% for cystectomy and 1.65% for radiotherapy. Among the 302 patients who received radiotherapy, 57 or 18.8% subsequently underwent salvage cystectomy. Among these patients, 30-day mortality after salvage cystectomy was 8.8% and three-month mortality after salvage cystectomy was 15.7%.

Most cases of early morbidity following primary and salvage cystectomy were due to gastrointestinal complications. Bowel complications, both leakage and obstruction were the major cause of death following salvage cystectomy. Urinary leakage occurred in 4% of cystectomy cases, both primary and salvage. During the follow-up period after cystectomy, most complications were due to recurrent pyelonephritis and intestinal obstruction.

Following radical radiotherapy, most complications were due to bladder and gastrointestinal complications, primarily irritative bladder and rectum. Severe bladder problems resulting in a non-functional bladder occurred in 6.3% of patients, and 2.3% of patients required surgery to relieve bowel obstruction.

Overall, 43.6% of patients who underwent radiotherapy experienced recurrences in the bladder. Of these, 40% had stage T2 disease or greater.

Five-year survival was 37.4% among patients who underwent radiotherapy and 36.5% among patients who underwent cystectomy. The difference in these rates was not statistically significant. Multivariate analysis revealed that the only independent predictors of five-year survival were tumour stage, ASA grade and sex.

Based on these findings, the investigators concluded that radical radiotherapy and radical cystectomy for the treatment of invasive bladder cancer yield similar five-year survival rates. Both treatments are associated with significant mortality and morbidity rates, and gastrointestinal complications accounted for most complications. Treatment-associated mortality was two- to threefold higher at three months than it was at 30 days, which emphasises the importance of the later period as a true indicator of the risk of cystectomy. Only clinical T stage, sex and ASA grade were independent predictors of five-year survival.
Eur Urol 2003 Mar;43:3:246-57. "A study of the morbidity, mortality and long-term survival following radical cystectomy and radical radiotherapy in the treatment of invasive bladder cancer in Yorkshire."

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