eMedicine Specialties > Urology > Cancer, Bladder, Penis, and Urethra
Cystectomy, Partial: Follow-up
Updated: Jan 14, 2008
Outcome and Prognosis
RecurrenceThe major disadvantage of partial cystectomy compared with radical cystectomy is the issue of recurrence in the bladder. This implies a risk of disease progression, metastasis, and death from cancer. Recurrence rates associated with partial cystectomy have been reported as 19-78%. Relapses seem to be influenced by tumor stage T3b, poorly differentiated (grade III) tumors, and tumor size (>4 cm) rather than by the histologic subtype of the bladder cancer.
- Various studies and their corresponding recurrence rates are as follows:
- Resnick and O'Connor (1973)25 - 76%
- Evans and Texter (1975)26 - 40%
- Novick and Stewart (1976)27 - 50%
- Peress et al (1977)28 - 54%
- Cummings et al (1978)29 - 49%
- Schoborg et al (1979)30 - 70%
- Faysal and Freiha (1979)3 - 78%
- Jardin and Vallencien (1984)6 - 78%
- Lindahl et al (1984)31 - 58%
- Kaneti (1986)32 - 38%
- Dandekar et al (1995)33 - 43%
- Holzbeierlein et al (2004)8 - 19%
- Kassouf et al (2006)34 - 49%
Peress et al noted that preoperative grade is an important prognostic factor in determining the risk of recurrence after partial cystectomy.28 They studied 61 patients with stage A transitional cell carcinoma and found that 54% of patients with high-grade lesions experienced recurrence after partial cystectomy and eventually died of their disease. Recent work by Kassouf et al has shown that a higher pathological stage at time of partial cystectomy was associated with shorter recurrence-free survival. Older studies by Resnick and O'Connor and by Faysal and Freiha have also confirmed these findings.25,3
These high local recurrence rates reflect the natural history of bladder cancer. Transitional cell carcinoma of the bladder is thought to be a global disease of the urothelium. Recurrences and survival outcomes depend on tumor stage and grade. Conservative management of Ta-T2 disease with transurethral resection alone results in a 60% recurrence rate. Those with tumors prior to that have an 84% recurrence rate, with nearly half of all tumor recurrences being multifocal. Of all patients who initially present, two thirds have superficial (Ta, T1) disease, and two thirds of these patients experience recurrence (with 20% of the recurrences being of a higher grade). Death from transitional cell carcinoma occurs in 5% of patients with grade 1 disease, 16% of patients with grade II disease, 28-35% of patients with grade III/stage Ta disease, and 83% of patients with grade III/stage T2 disease.
Recurrences are treated in various ways. Transurethral resection and/or fulguration, intravesical chemotherapy, radiotherapy, repeat partial cystectomy, and radical cystectomy are all forms of treatment. Of all patients who undergo partial cystectomy as original therapy, 4-15% eventually undergo radical cystectomy with urinary diversion.
SurvivalMany studies have examined the survival of patients with bladder cancer after partial cystectomy. Many have noted the relationship between tumor stage and grade and survival. Five-year survival rates varied from 35-80%; this compares with the 50-60% survival rate of a contemporary radical cystectomy series. Kassouf et al showed that patients undergoing partial cystectomy who had a prior history of superficial tumors had a decreased overall and advanced recurrence-free survival.34 This finding is not surprising given that these patients have already demonstrated evidence of a global field effect within the urothelium. When rigid patient selection criteria are followed, partial cystectomy becomes a viable alternative to radical cystectomy.
Recent data from MD Anderson also suggests that adjuvant chemotherapy is associated with prolonged advanced recurrence-free survival.34 However, no study has demonstrated that adjuvant chemotherapy offers any survival benefit over chemotherapy at the time of recurrence. Adjuvant chemotherapy should be considered in patients with extravesical extension or pelvic lymph node metastases who undergo partial cystectomy.
Table 3. Survival Rates by Tumor Grade
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Table
| Source | Five-year Survival (%) | Ten-year Survival (%) | ||||
|---|---|---|---|---|---|---|
| Grade I | Grade II | Grade III/IV | Grade I | Grade II | Grade III/IV | |
| Magri (1962) 35 | 88 | 33 | 34 | - | - | - |
| Utz et al (1973) 1 | 100 | 48 | 39 | - | - | - |
| Novick and Stewart (1976) 27 | 100 | 75 | 40 | 0 | 67 | 8 |
| Brannan et al (1978) 2 | 50 | 62 | 55 | 50 | 33 | 30 |
| Cummings et al (1978) 29 | 100 | 96 | 32 | - | - | - |
| Schoborg et al (1979) 30 | 75 | 62 | 26 | 50 | 28 | 4 |
| Faysal and Freiha (1979) 3 | 100 | 53 | 30 | 25 | 20 | 8 |
| Merrell et al (1979) 4 | 78 | 56 | 22 | 83 | 32 | 0 |
| Kaneti (1986) 32 | 75 | 46 | 46 | - | - | - |
| Dandekar et al (1995) 33 | 100 | 94.4 | 53.5 | - | - | - |
| Source | Five-year Survival (%) | Ten-year Survival (%) | ||||
|---|---|---|---|---|---|---|
| Grade I | Grade II | Grade III/IV | Grade I | Grade II | Grade III/IV | |
| Magri (1962) 35 | 88 | 33 | 34 | - | - | - |
| Utz et al (1973) 1 | 100 | 48 | 39 | - | - | - |
| Novick and Stewart (1976) 27 | 100 | 75 | 40 | 0 | 67 | 8 |
| Brannan et al (1978) 2 | 50 | 62 | 55 | 50 | 33 | 30 |
| Cummings et al (1978) 29 | 100 | 96 | 32 | - | - | - |
| Schoborg et al (1979) 30 | 75 | 62 | 26 | 50 | 28 | 4 |
| Faysal and Freiha (1979) 3 | 100 | 53 | 30 | 25 | 20 | 8 |
| Merrell et al (1979) 4 | 78 | 56 | 22 | 83 | 32 | 0 |
| Kaneti (1986) 32 | 75 | 46 | 46 | - | - | - |
| Dandekar et al (1995) 33 | 100 | 94.4 | 53.5 | - | - | - |
Table 4. Survival Rates by Tumor Stage
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Table
| Source | Five-year Survival (%) | Ten-year Survival (%) | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| T0 | T1 | T2 | T3 | T4 | Overall | T0 | T1 | T2 | T3 | T4 | Overall | |
| Magri (1962) 35 | - | 80 | 38 | 26 | 0 | 42 | - | - | - | - | - | - |
| Long et al (1962) 36 | 80 | 67 | 43 | 9 | 0 | - | - | - | - | - | - | - |
| Cox et al (1969) 37 | - | - | 20 | 16 | - | - | - | - | - | - | - | - |
| Resnick and O'Connor (1978) 25 | 75 | 71 | 77 | 12.5 | 20 | 35 | - | - | - | - | - | - |
| Utz et al (1973) 1 | - | 68 | 47 | 29 | 0 | 39 | - | - | - | - | - | - |
| Evans and Texter (1975) 26 | - | 69 | 43 | 14 | 0 | 0 | - | - | - | - | - | 21 |
| Novick and Stewart (1976) 27 | - | 67 | 53 | 20 | - | 46 | - | 67 | 44 | - | - | 36 |
| Brannan et al (1978) 2 | 100 | 69 | 54 | 33 | 0 | 57 | - | 31 | 36 | 11 | - | 32 |
| Cummings et al (1978) 29 | - | 79 | 80 | 6 | - | 60 | - | - | - | - | - | - |
| Schoborg et al (1979) 30 | 69 | 69 | 29 | 12 | 100 | 43 | - | 37 | 0 | 0 | 0 | 12 |
| Faysal and Freiha (1979) 3 | 75 | 58 | 29 | 7 | 0 | 40 | 21 | 15 | 13 | 7 | 0 | 9 |
| Merrell et al (1979) 4 | 100 | 100 | 67 | 25 | - | 48 | - | 100 | 33 | 0 | 0 | 32 |
| Lindahl et al (1984) 31 | - | 59 | 38 | - | - | 42 | - | 48 | 25 | - | 0 | 38 |
| Kaneti (1986) 32 | - | 68 | 40 | 33 | 0 | 48 | - | - | - | - | - | - |
| Dandekar et al (1995) 33 | - | - | 100 | 88.5/45.7a | - | 80.1 | - | - | - | - | - | - |
| Source | Five-year Survival (%) | Ten-year Survival (%) | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| T0 | T1 | T2 | T3 | T4 | Overall | T0 | T1 | T2 | T3 | T4 | Overall | |
| Magri (1962) 35 | - | 80 | 38 | 26 | 0 | 42 | - | - | - | - | - | - |
| Long et al (1962) 36 | 80 | 67 | 43 | 9 | 0 | - | - | - | - | - | - | - |
| Cox et al (1969) 37 | - | - | 20 | 16 | - | - | - | - | - | - | - | - |
| Resnick and O'Connor (1978) 25 | 75 | 71 | 77 | 12.5 | 20 | 35 | - | - | - | - | - | - |
| Utz et al (1973) 1 | - | 68 | 47 | 29 | 0 | 39 | - | - | - | - | - | - |
| Evans and Texter (1975) 26 | - | 69 | 43 | 14 | 0 | 0 | - | - | - | - | - | 21 |
| Novick and Stewart (1976) 27 | - | 67 | 53 | 20 | - | 46 | - | 67 | 44 | - | - | 36 |
| Brannan et al (1978) 2 | 100 | 69 | 54 | 33 | 0 | 57 | - | 31 | 36 | 11 | - | 32 |
| Cummings et al (1978) 29 | - | 79 | 80 | 6 | - | 60 | - | - | - | - | - | - |
| Schoborg et al (1979) 30 | 69 | 69 | 29 | 12 | 100 | 43 | - | 37 | 0 | 0 | 0 | 12 |
| Faysal and Freiha (1979) 3 | 75 | 58 | 29 | 7 | 0 | 40 | 21 | 15 | 13 | 7 | 0 | 9 |
| Merrell et al (1979) 4 | 100 | 100 | 67 | 25 | - | 48 | - | 100 | 33 | 0 | 0 | 32 |
| Lindahl et al (1984) 31 | - | 59 | 38 | - | - | 42 | - | 48 | 25 | - | 0 | 38 |
| Kaneti (1986) 32 | - | 68 | 40 | 33 | 0 | 48 | - | - | - | - | - | - |
| Dandekar et al (1995) 33 | - | - | 100 | 88.5/45.7a | - | 80.1 | - | - | - | - | - | - |
a Stage T3a/T3b
Future and Controversies
Controversy still exists regarding combinations of chemotherapy or radiotherapy with or without bladder-sparing surgical techniques of partial cystectomy or transurethral resection versus traditional radical cystectomy. Newly evolving bladder-sparing protocols are currently being investigated as alternatives to radical surgery.
Studies on chemoradiative therapy involving agents such as methotrexate, vinblastine, doxorubicin (Adriamycin), and cisplatin (MVAC protocol) and bladder-sparing transurethral resection of tumor have shown that functional bladders can be preserved in 36-44% of patients at 5 years. The disease-specific 5-year survival rates range from 48-63%.
Newer agents currently being investigated include ifosfamide, gemcitabine, paclitaxel, and cisplatin combinations. These chemoradiative protocols will provide alternatives to radical cystectomy with urinary diversion.
When partial cystectomy is compared with radical cystectomy and the newer bladder-sparing protocols, partial cystectomy has advantages over radical cystectomy because it retains a functional native bladder. It also has the advantage over chemoradiative bladder-sparing techniques because it avoids the morbidity, mortality, toxicity, complexity, and expense of chemotherapy and radiation. In carefully selected patients, partial cystectomy seems to be the procedure of choice for muscle-invasive bladder cancer because its success rivals that of radical cystectomy. It also remains highly useful in various benign conditions. Future investigations are needed to define its evolving role.
The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Martin I Resnick, MD, to the development and writing of this article.
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Keywords
bladder cancer, partial cystectomy, cystectomy, transitional cell carcinoma, bladder sparing, urachal carcinoma, bladder diverticula, cystic hydatid disease, cavernous hemangioma, interstitial cystitis, colovesical fistula, vesicovaginal fistula, bladder endometriosis, urothelial cancer, urothelial malignancy, bladder carcinoma, segmental resection of the bladder
