The View Outside of the Box: Reporting Outcomes Following Radical Cystectomy Using Pentafecta From a Multicenter Retrospective Analysis

Abstract

We aimed at characterization of the patients undergoing radical cystectomy (RC) using the prognostic model (a modified pentafecta). In the multicenter retrospective study, we enrolled 304 patients with bladder cancer (pTis-4N0-2M0) who underwent RC between 2015 and 2020 in experienced centers. The definition of the pentafecta was as follows: no Clavien–Dindo grade III–V complications at 90 days and no long-term complications related to urinary diversion <12 months, negative surgical margins, ≥10 lymph nodes (LNs) resected, and no recurrence ≤12 months. RC-pentafecta achievement rate was 22% (n = 67), varying from 47% to 88% attainment rate for different pentafecta components, and was the lowest for sufficient LN yield. Both 12-month recurrence-free survival (RFS) and cancer-specific mortality were compromised in pentafecta failers compared with achievers (57.8% vs. 100% and 33.8% vs. 1.5%, respectively). The following were identified as crucial predictors of RC pentafecta achievement: modality of the surgery, type of urinary diversion, histological type of bladder cancer, advanced staging, and elevated preoperative serum creatinine. In conclusion, we found that the pentafecta achievement rate was low even in high-volume centers in patients undergoing cystectomy. The complexity of the procedure directly influenced the attainment rate, which in turn led to an increase in cancer-specific mortality rate among the pentafecta failers.

Oncological validation and discriminative ability of pentafecta criteria after open radical cystectomy

“…Fourth, it is arguable that PC for RC should be assessable peri-operatively. Diversion-related complications have been extensively discussed as a pentafecta metric to reflect long-term functional outcomes [12][13][14][15][16][17][18]. Similarly to recurrence at 12 months, such metrics are unfortunately not suitable for perioperative patient stratification and counselling.…”

“…The first endpoint of our study was PC attainment, which was defined as fulfilment of all five PC [8,[12][13][14][15][16][17][18]. The second endpoint was OM, which was defined as time from RC to death from any cause.…”

“…A few studies have validated PC in patients undergoing robot-assisted, conventional laparoscopic and open RC (ORC) [12][13][14][15][16][17][18]. These studies have in common that oncological follow-up did not exceed 3 years and PC attainment was merely dichotomized into all PC (5/5) attained vs all PC not attained (≤4/5) [12][13][14][15][16][17][18].…”

“…A few studies have validated PC in patients undergoing robot-assisted, conventional laparoscopic and open RC (ORC) [12][13][14][15][16][17][18]. These studies have in common that oncological follow-up did not exceed 3 years and PC attainment was merely dichotomized into all PC (5/5) attained vs all PC not attained (≤4/5) [12][13][14][15][16][17][18]. Thus, it is still not known whether the number of attained PC has an impact on oncological endpoints, given that previous studies did not investigate the discriminative ability of PC attainment [12][13][14][15][16][17][18].…”

Are We Ready to Implement Molecular Subtyping of Bladder Cancer in Clinical Practice? Part 1: General Issues and Marker Expression

“…Nevertheless, differences resulting from biological features and molecular subtyping, which are the main causes of such clinical variability, cannot be assessed by available risk-stratification systems. Attempts have been made to assess the prognostic role of single to combined markers, both in MIBCs and in NMIBCs, with controversial results [ 17 , 18 , 19 ], including a recent multicenter retrospective analysis on the impact of pentafecta on oncological outcomes of patients undergoing RC [ 20 ]. Since all available treatment options carry side effects and/or risk of failure, the need for reliable biomarkers for patients’ risk stratification and therapeutic management to be applied in clinical practice is still unfulfilled.…”