Shariat - Figure 52
High-risk NMI Bladder Cancer: Radical Cystectomy – When?
FIG. 52: For T1 high-grade bladder cancer, I regard radical cystectomy as a treatment option, because this often determines survival in these patients. The likelihood of benefit with radical cystectomy decreases with advancing disease stage and with delay between diagnosis and treatment. At diagnosis, I always consider immediate cystectomy as one of the options, while taking into consideration all of the difficulties of that surgery, its morbidities, and its poor quality of life compared to conservative management.
When considering BCG, I also always discuss the option of early radical cystectomy with the patient. This is not immediate radical cystectomy, but after some time has passed. Should the patient’s disease remain NMI, then one can continue with intravesical salvage therapy. Often in these cases, if radical cystectomy is triggered, it will then be too late to be of benefit in some of these patients. Nevertheless, some patients will benefit from salvage intravesical therapies. Should the tumor progress to muscle-invasive disease from T1, then cystectomy will be too late in many of these patients, and mortality risk is significantly higher compared with those who received an immediate or early radical cystectomy. Keeping these progression stages in mind helps us to discuss the data with the patients and reach assured decision-making together.
