The Role of Salvage Cystectomy After Prior Trimodality Therapy: A Multinational Match-paired Analysis.

Background and objective: Trimodality therapy (TMT) with transurethral resection followed by radiation of the urinary bladder and chemotherapy is associated with similar long-term survival rates to radical cystectomy (RC) for well-selected patients. Nevertheless, salvage RC may become necessary in 10% of patients receiving TMT. We aimed to assess the perioperative and long-term outcomes of salvage RC after prior TMT through a large multinational cohort study.

Methods: We included patients with pure urothelial cancer of the urinary bladder. Patients undergoing salvage RC after prior TMT due to recurrence in the urinary bladder from 13 high-volume centers were matched with a propensity score analysis in a 1:1 ratio with patients without prior TMT undergoing primary RC. The two groups were adjusted for institution, age, histological status, American Society of Anesthesiologists score, and surgical technique (open or minimally invasive RC).

Key findings and limitations: We included 118 patients (59 per group) with a median age of 73 yr (interquartile range [IQR]: 66-79). Seven patients (11%) developed severe, grade 4 or 5 perioperative complications during RC after prior TMT. The 30- and 90-d survival rates of salvage RC after prior TMT were 93% and 91%, respectively. RC in patients with prior TMT was associated with higher blood loss by 297 ml (95% confidence interval [CI]: 73-520, p = 0.010) and higher odds of admission to the intensive care unit (odds ratio: 2.8, 95% CI: 1.2-6.7, p = 0.017) than primary RC in matched patients. At a median follow-up of 10 mo (IQR: 5-34), 29 deaths occurred in patients requiring RC after prior TMT. Prior TMT was associated with worse overall survival than primary RC (hazard ratio: 1.9, 95% CI: 1.2-4.1, p = 0.032).

Conclusions and clinical implications: Salvage RC after TMT and primary RC have comparable perioperative outcomes. Patients undergoing salvage RC after TMT may have worse overall survival in the long term, likely reflecting tumor biology.