Prospective analysis of a radical cystectomy series at a tertiary care center in Sri Lanka –is there room to improve the outcome?

Abstract

IntroductionBladder cancer (BC) is a common malignancy and ranks tenth globally. Radical cystectomy remains the gold standard for organ confined muscle invasive bladder cancer (MIBC). It has proven efficacy on local disease control and tumour free survival (TFS). Notwithstanding the improvement of techniques and peri-operative care, this procedure is associated with high peri-operative morbidity. Despite the abundance of descriptive studies on demography there are only a few local studies published on the long-term outcome of surgical treatment. Present analysis of radical cystectomy series with minimum 3-year follow up will fill the gap in literature as first reported long-term study in the local setting Methodology Twenty-six consecutive cystectomies performed over two years from April 2016 at a single tertiary center were prospectively analysed for demography peri-operative and long-term outcome. Median follow-up was 43.5 months. ResultsMedian age was 60 (range 35-74) years. Ninety-two percent were males. Twenty-two out of 26 (85%) were presented with haematuria. Eighty-one percent (21/26) had urothelial bladder cancer (UBC) out of which, 77% (20/26) were males with a mean age of 59.6years. Four out of five who had nonurothelial bladder cancer (NUBC) were males. Fourty-two percent (11/26) were smokers and death percentage was markedly high among smokers than nonsmokers. No other known risk factors were identified among the rest. Thirty-eight-point five percent (10/26) were pT3b and pT4a, while 53.8% (14/26) were pT3 or above tumours.Majority (62%) of complications fell into minor category (Clavien-I/II) with an average blood loss of 850 ml and a transfusion rate of 15% (4/26).Thirty day and 90day mortality rates were 3.8% and 7.7% respectively rising to one-year mortality of 23%. Four out of twenty-six cystectomy operations were done for palliation. Three-year overall survival (OS) was 61% [CI 41.5% -79.7%]. Out of the 12 deaths, 8 (67%) were due to cancer progression while 4 had local recurrences. Among the patients who were cancer free, three-year survival was at 84% [CI 68.1% -93.7%], while cancer-specific three-year survival rate was at 72%[CI 54.3% -87.2%]. With majority of survivors, 57% (8/14) were maintained normal renal functions. SummaryDespite the fact that radical cystectomy which undoubtedly provide significant improvement in cancer free survival in high-risk MIBC, the present study emphasized relatively inferior outcomes in the developing world due to the delayed presentation.Fifty-three point eight percent (14/26), pT3 or pT4a tumours which is associated with poor cancer specific survival and partly due to the nativity of the caregivers in offering early radical surgery with acceptable complication rates. It was also evident from this study that not only tobacco smocking seems to be the most prevalent risk factor but also associated with significantly poor long term survival