Radical cystectomy for bladder cancer: The case for early intervention

Approximately 20% of patients with bladder cancer are found to harbor invasive disease at presentation. Radical cystectomy remains the gold standard for patients with muscle invasive urothelial carcinoma of the bladder and is an important option for patients with high-grade non-muscle invasive disease, including those who have recurrent disease after intravesical therapy or disease refractory to attempted conservative therapy [1]. In fact, as many as one third of contemporary cystectomies are performed among patients with clinical stage Ta/T1 or carcinoma in situ (CIS). Most of these patients have tumor characteristics that would be considered high risk for disease progression, and many have previously undergone multiple failed attempts at bladder preservation, providing ample justification for exenterative surgery. In the decision process, most of these patients are offered what some would consider an "early cystectomy," because they are believed to have non-muscle invasive tumors. Unfortunately, pathologic staging at the time of cystectomy indicates that 35% to 50% of these patients, in fact, harbor muscle invasive disease, including micrometastases in 10% to 15%. In addition, patient outcomes seem to be directly related to the pathologic stage, implying an adverse effect owing to a delay in treatment [2]. Despite the intent to perform early cystectomy, the reality remains that for an unacceptably high percentage of these patients, this notion is, in fact, a misreckoning. The concept of early or perhaps better-described "timely" cystectomy can be extended further to patients with muscle invasive disease. Improvements in surgical technique and perioperative care have led to decreased mortality and morbidity rates [3]. Despite these improvements and the use of orthotopic urinary diversion, many patients do not proceed quickly to radical cystectomy for different reasons. These reasons include the time needed for the completion of a metastatic evaluation and preoperative medical preparation, physician scheduling delays, patient comorbidities, the time taken by patients seeking multiple opinions, the initiation of neoadjuvant therapies such as radiation or chemotherapy, and socioeconomic issues, among others. Although it is prudent to evaluate patients thoroughly and to assess perioperative risk in preparation for radical cystectomy, unnecessary delays can have adverse consequences. Increasingly, reports of the negative impact of a delay in cystectomy on pathologic staging are emerging [4,5]. Furthermore, delaying cystectomy in patients with invasive disease has been associated with a decrease in disease-specific survival [6,7]. Herein, the authors review the status of early cystectomy in different settings with an emphasis on strategies design to align this concept with its intention to reduce deaths among patients with this potentially lethal disease.