The arguments for an early cystectomy in patients with urothelial carcinoma

At the initial diagnosis of bladder cancer, 70% of cases are diagnosed as non–muscle–invasive bladder cancer (NMIBC) and approximately 30% as muscle– invasive bladder cancer (MIBC). Among patients treated with radical cystectomy due to MIBC, 57% had muscle invasion at presentation, while 43% were initially diagnosed with NMIBC which had progressed, despite organ–preserving treatment. Approximately one–third of patients diagnosed with MIBC have undetected metastases at the time of treatment of the primary tumor, while 25% of patients who undergo radical cystectomy present with lymph node involvement at the time of surgery. In cases of MIBC, a cystectomy should not be delayed for >3 months because this delay can increase the risk of progression and cancer–specific mortality (Grade B, EAU Guidelines) [1, 2]. One of the most challenging clinical decisions concerning bladder cancer is the treatment of pT1 high grade tumors. This tumor category is very heterogeneous and requires a special approach. According to the EORTC data, intermediate and high– risk NMIBC should be treated with BCG (Bacillus Calmette Guerin) instillations for at least one year. An individual recurrence and progression risk profile can be assessed using the EORTC–trial, which is composed of over 2500 patients [3]. However, only 7% of the EORTC–collective has been treated with BCG, so the progression risk is overestimated here. The challenge is to find the balance between overtreatment and understaging [4]. The response to BCG–therapy depends on the residual tumor status in TUR and on the presence of CIS. BCG–failure occurs in about 50% of cases and is defined as a relapse or progression to MIBC, a higher tumor grade, or CIS during 3 month and 6 month follow up visits. Patients with BCG failure or recurrence after BCG are unlikely to respond to further BCG therapy; therefore, radical cystectomy is the preferred option. This underlines the need to recommend early radical cystectomy, especially The arguments for an early cystectomy in patients with urothelial carcinoma