Optimizing treatment selection: outcomes of radical cystectomy in patients eligible for trimodal therapy.

Abstract

Purpose: This study examines oncological and functional outcomes in a subset of patients eligible for trimodal therapy (TMT) within a large radical cystectomy (RC) cohort. It aims to determine whether TMT should be offered to all eligible patients, rather than exclusively to patients with significant comorbidities who are at high perioperative risk.

Methods: We conducted a retrospective analysis of 509 patients with urothelial carcinoma (pT1-pT4) who underwent RC between 2014 and 2020. Patients were divided into TMT eligible (n = 74), and TMT ineligible (n = 431) cohorts based on preoperative criteria. Key endpoints included blood loss, operative duration, urinary diversion type, adjuvant chemotherapy, and overall and progression-free survival (OS, PFS). Functional outcomes were assessed using validated quality of life (QoL) questionnaires.

Results: RC patients who were eligible for TMT demonstrated significantly better oncological outcomes, with higher overall survival (OS) (HR: 2.774, p < 0.001) and progression-free survival (PFS) (HR: 3.689, p < 0.001). They also experienced lower intraoperative blood loss (544.59 ml vs. 740.50 ml, p = 0.002) and were more likely to receive continent urinary diversion (55.1% vs. 38.8%, p = 0.01), with nearly 50% undergoing ileal neobladder reconstruction. Adjuvant chemotherapy was administered more frequently in the TMT-ineligible group (20.8% vs. 6.4%, p = 0.003). Apart from a significant difference in the positive support domain of the ISSS (p = 0.01), no significant differences in functional outcomes were observed.

Conclusion: TMT eligible patients undergoing RC have better oncological outcomes and more favourable perioperative parameters compared to TMT ineligible patients. These findings highlight the need for careful patient counselling when considering TMT as an alternative to RC. Future prospective studies are warranted to optimise treatment selection and functional outcome assessment in bladder cancer.