T1G3 bladder tumours: the case for radical cystectomy

Abstract

Introduction: Many factors degrade the initially favourable results of conservative treatment of T1G3 bladder tumours, leading to a permanent risk of progression and death. On the other hand, immediate radical cystectomy, while ensuring optimal local control of the disease, would be excessive in some patients in part because of its purported impact on quality of life.

Methods: To contribute to the ongoing debate on T1G3 optimal treatment the literature was reviewed to organize evidences in favour of radical cystectomy by focusing on two main issues: the impact of time on the initial results of conservative treatment and quality of life after cystectomy.

Results: A critical appraisal of conservative treatment efficacy was structured by comparing survival curves after either conservative treatment or radical cystectomy. It highlighted that after conservative treatment the patients remained under the burden of lifelong risk of progression and death. The positive impact of maintenance BCG and the frequent resort to cystectomy after conservative treatment further illustrated the limits of bladder conservative treatments. On the other hand, evidences were shown that quality of life was not critically affected by radical cystectomy and that surgical techniques could be further adapted to its preservation. The influence of age at cystectomy on functional results was highlighted. However, identifying a prognostic factor for the success of conservative treatment would put an end to the controversy by allowing a tailored attitude to every patient's unique situation. The importance of uropathologist's expert evaluation, including the depth of invasion, was emphasized.

Conclusion: While ensuring optimal control of the disease, the indiscriminate use of radical surgery would be excessive in a significant minority of patients who do well under conservative treatment. It is suggested to consider as typical cases for immediate surgery, young patients with "deep" T1 tumours (>T1a or >1.5mm in depth) with at least one additional factors of bad prognosis: multifocality, association of carcinoma-in-situ, prostatic involvement, site difficult to resect.