www.auajournals.

org/journal/juro

Complications and Outcomes of Salvage Cystectomy

after Trimodality Therapy
Alberto Pieretti, Ross Krasnow, Michael Drumm, Andrew Gusev, Douglas M. Dahl,
Francis McGovern, Michael L. Blute, William U. Shipley, Jason A. Efstathiou,* Adam S. Feldman†
and Matthew F. Wszolek‡
From the Department of Urology (AP), The University of Texas MD Anderson Cancer Center, Houston, Texas, Department of Urology (RK), MedStar Washington
Hospital Center, Washington, D.C., Department of Radiation Oncology (MD, WUS, JAE), Massachusetts General Hospital, Harvard Medical School, Boston,
Massachusetts, Department of Urology (AG, DMD, FM, MLB, ASF, MFW), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

Purpose: Salvage cystectomy is required for some patients with intravesical

Abbreviations
recurrence after trimodality therapy. We compared postoperative outcomes be-
and Acronyms
tween salvage cystectomy post-trimodality therapy, primary cystectomy and
primary cystectomy with prior history of nontrimodality therapy abdominal or DSS [ disease-specific survival
pelvic radiotherapy. MIBC [ muscle-invasive bladder
cancer
Materials and Methods: We included 265 patients who underwent radical cys-
tectomy at Massachusetts General Hospital for cT1-T4 bladder cancer between PC [ primary cystectomy
2003 and 2013. Patients were grouped as salvage cystectomy post-trimodality PC with Hx XRT [ primary cys-
therapy, primary cystectomy or primary cystectomy with prior history of non- tectomy with prior history of
trimodality therapy abdominal or pelvic radiotherapy. Early (
90 days) and late nonTMT abdominal or pelvic
(>90 days) complications were compared. Disease-specific survival and overall radiotherapy
survival were calculated using a Cox regression model, and adjusted survival RC [ radical cystectomy
curves were generated. SC [ salvage cystectomy post-
Results: The median followup from the time of cystectomy was 65.5 months. TMT
There was no difference in intraoperative and early complications between the TMT [ trimodality therapy
groups. The detection of late complications was higher in salvage cystectomy TURBT [ transurethral
post-trimodality therapy compared to primary cystectomy and primary cys- resection of bladder tumor
tectomy with prior history of nontrimodality therapy abdominal or pelvic
radiotherapy (p[0.03). In multivariable Cox regression analysis, salvage cys- Accepted for publication January 26, 2021.
* Financial and/or other relationship with
tectomy post-trimodality therapy was associated with a higher incidence of any Boston Scientific, Blue Earth Diagnostics, Taris
late (HR 2.3, p[0.02) and major late complications (HR 2.1, p <0.05). There was Biomedical.
no difference in disease-specific survival (p[0.8) or overall survival (p[0.9) † Financial and/or other relationship with
Olympus America, Inc., Roche Pharmaceuticals,
between the groups. Janssen Pharmaceuticals.
Conclusions: Salvage cystectomy post-trimodality therapy for intravesical ‡ Correspondence: Department of Urology,
Massachusetts General Hospital, Harvard Medi-
recurrence post-trimodality therapy has an intraoperative and early complica-
cal School, 55 Fruit St., GRB 1102, Boston,
tion rate comparable to primary cystectomy and primary cystectomy with prior Massachusetts 02114 (telephone: 857-238-3838;
history of nontrimodality therapy abdominal or pelvic radiotherapy. Salvage FAX: 617-726-6131; email: mwszolek@mgh.har-
vard.edu).
cystectomy post-trimodality therapy is associated with a higher risk of overall
and major late complications than primary cystectomy. The disease-specific
survival and overall survival of patients who require salvage cystectomy post-
trimodality therapy are comparable to both groups.

Key Words: cystectomy, urinary bladder neoplasms, salvage therapy,

postoperative complications

0022-5347/21/2061-0029/0 https://doi.org/10.1097/JU.0000000000001696
THE JOURNAL OF UROLOGY® Vol. 206, 29-36, July 2021
Ó 2021 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC. Printed in U.S.A.

www.auajournals.org/jurology j 29
Copyright © 2021 American Urological Association Education and Research, Inc. Unauthorized reproduction of this article is prohibited.
30 OUTCOMES OF SALVAGE CYSTECTOMY AFTER TRIMODALITY THERAPY
RADICAL cystectomy has traditionally been the
standard treatment of muscle-invasive bladder
cancer with 5-year and 10-year survival rates of
74% to 92% for pathological organ-confined lymph
node-negative disease.1e3 Nonetheless, periopera-
tive complications, patient desire to avoid urinary
tract reconstruction and long-term morbidity still
plague the procedure. Bladder-sparing trimodality
therapy has become an accepted alternative in
appropriately selected MIBC patients with onco-
logic outcomes comparable to RC series.4e6 The
multidisciplinary approach combines maximally
safe transurethral resection followed by concurrent
radiation and radiosensitizing chemotherapy. TMT
protocols and patient selection over the past 2 de-
cades have evolved. The contemporary complete
response rate is 88%, and 5-year disease-specific
survival has increased to 84%.4 Due to the risk of
incomplete response to TMT or subsequent intra-
vesical recurrence, close surveillance is required,
and salvage cystectomy is ultimately necessary for
approximately 11% to 16% of patients in contem-
porary cohorts.4,5
Concern about the safety and oncologic efficacy of
post-TMT SC has been, in part, an explanation for
the lack of widespread utilization of TMT in
appropriate patients. Our previous retrospective
analysis on SC after TMT identified a 69% 90-day
complication rate with major complications
comprising 16%. This risk of acute complications
was higher than other primary radical cystectomy
series; however, this report lacked a control group
for comparative analysis.7 Likewise, the survival
outcomes of post-TMT SC are incompletely
described. To our knowledge, we present the only
series comparing SC after TMT to groups who un-
derwent either PC or PC with prior history of
nonTMT abdominal/pelvic radiotherapy. We aim to
analyze the comparative risk of acute and long-term
complications of SC post-TMT and describe the
comparative survival outcomes.
MATERIALS AND METHODS
We retrospectively identified 294 patients as undergoing a
radical cystectomy at Massachusetts General Hospital
between 2003 and 2013. RC for benign causes (10), or
clinical stage cTa or cTis disease (19) were excluded.
Thus, only patients who underwent RC for clinical stage
cT1-T4N0M0 disease were considered for analysis (265).
All TMT patients initially had MIBC, and the reported
clinical stage in this manuscript reflects the status of the
intravesical recurrence after TMT that prompted salvage
cystectomy. TMT patients initially underwent maximal
transurethral resection of bladder tumor followed by in-
duction chemoradiation and were often treated per
various Radiation Therapy Oncology Group protocols.8e16
TMT patients with complete response to chemoradiation
after cystoscopy, cytology and cross-sectional imaging
Copyright © 2021 American Urological Association Education and Research, Inc. Unauthorized reproduction of this article is prohibited.
went on to receive consolidative chemoradiation.12,16
Tumor staging was standardized per the American Joint
Committee on Cancer TNM standard.17 Data were
abstracted from direct chart review by the authors (A.P.,
R.K., M.F.W.). Study approval was obtained from the
institutional review board (IRB No. 2015P001721).
Patients were divided into 3 groups: primary cys-
tectomy (216), primary cystectomy with history of
nonTMT (eg prostate cancer or rectal cancer) abdominal/
pelvic radiation (28), and salvage cystectomy for intra-
vesical recurrence after TMT (21). The primary outcome
was complication rates. Complications were stratified by
early (
90 days) and late (>90 days). Grade of complica-
tion was categorized using the Clavien-Dindo score as
minor (grades 1e2) or major (grades 3e5).18 Secondary
outcomes were overall survival and disease-specific sur-
vival. The date of death was confirmed using publicly
available death records and medical records. The cause of
death was investigator defined.
Categorical data were described using Fisher’s exact
test, and continuous variables were described using the
Wilcoxon rank-sum test. Early complications were eval-
uated using multivariable binary logistic regression, with
the outcome being an early complication (yes or no) from
the day of surgery until postoperative day 89. The pre-
dicted probability of an early complication was calculated
using predictive margins. A landmark analysis of late
complications starting on postoperative day 90 was esti-
mated using a multivariable Cox regression analysis to
obtain hazard ratios. The model was built using the clin-
ically significant covariates of age, clinical stage, Charlson
score, history of tobacco use, and type of urinary diversion,
selected a priori based on known association with compli-
cations following cystectomy. OS and DSS were also calcu-
lated using a Cox regression model, and adjusted survival
curves were generated. All calculations were 2-sided, and a
p value <0.05 was considered to be statistically significant.
The analysis was performed using Stata v.14.2 (StataCorp,
College Station, Texas).
RESULTS
Patients
We found 265 patients who underwent radical cys-
tectomy for clinical stage cT1eT4 disease and ful-
filled inclusion criteria. Of the 265 patients, 20 had
laparoscopic radical cystectomy, 16 robotic and 229
open; all the urinary diversions were open in the
minimally invasive cases. The distribution was
nonsignificant among the 3 groups. The event-free
median followup among the living patients from
the time of cystectomy was 65.5 months. Preopera-
tive and operative characteristics are listed in table
1 by group. Significant differences were present in
age, type of urinary diversion, neoadjuvant chemo-
therapy immediately prior to RC, and lymphovas-
cular invasion in the TURBT specimen. There was
no significant difference in the clinical stage prior to
cystectomy. For the SC patients, the reported clin-
ical stage was at the time of cystectomy, not at the
 OUTCOMES OF SALVAGE CYSTECTOMY AFTER TRIMODALITY THERAPY 31

Table 1. Characteristics of 265 patients

Salvage Cystectomy Primary Cystectomy
Primary Cystectomy after TMT with prior nonTMT XRT p Value
No. pts 216 23 28
Mean yrs age 66.3 69.1 69.1 <0.001
Mean body mass index (kg/m2) 28.8 27.8 27.8 0.9
Mean Charlson Score 9.3 9.0 9.0 0.09
No. gender (%): 0.2
Male 166 (76.9) 18 (85.7) 25 (89.2)
Female 50 (23.1) 3 (14.3) 3 (10.7)
No. tobacco use (%): 0.06
No 59 (27.3) 1 (4.8) 7 (25)
Yes 157 (72.7) 20 (95.2) 21 (75)
No. alcohol consumption (%): 0.4
No 86 (39.8) 6 (28.6) 9 (32.1)
Yes 130 (60.2) 15 (71.4) 19 (67.8)
No. clinical T stage (%): 0.7
T1N0M0 42 (19.4) 3 (14.3) 8 (28.5)
T2 N0M0 128 (59.3) 13 (61.9) 15 (53.5)
T3/T4 N0M0 46 (21.3) 5 (23.8) 5 (17.8)
Mean cm tumor size 4.7 4.0 4.0 0.9
No. hydronephrosis (%): 0.3
No 134 (62.0) 16 (76.2) 20 (71.4)
Yes 82 (38.0) 5 (23.8) 8 (28.5)
No. lymphovascular invasion at TURBT (%): 0.02
No 189 (87.5) 21 (100) 28 (100)
Yes 27 (12.5) 0 (0) 0 (0)
No. pathological T stage (%): 0.9
pT0 41 (19.0) 4 (19.0) 4 (14.2)
pTa/is 1 (0.5) 0 (0) 0 (0)
pT1 17 (7.9) 2 (9.5) 2 (7.1)
pT2 40 (18.5) 2 (9.5) 6 (21.4)
pT3/4 117 (54.2) 13 (61.9) 16 (57.1)
No. neoadjuvant chemotherapy (%): 0.001
No 175 (81.0) 21 (100) 28 (100)
Yes 41 (19.0) 0 (0) 0 (0)
Mean ml estimated blood loss 1,200 900 900 0.6
No. type of urinary diversion (%): 0.007
Ileal conduit 196 (90.7) 18 (85.7) 28 (100)
Neobladder 20 (9.3) 1 (4.7)
Indiana pouch 2 (9.5)

time of TMT. All SC patients initially had MIBC at complications were present in 5.1% of PC, 19.0% of
time of TMT. The median time to cystectomy after SC and 14.3% of PC with Hx XRT groups (p[0.01,
radiation therapy was 106 months for the nonTMT table 2). Infectious complications were present in
group (PC with Hx XRT) and 18 months for the 17.1% of PC, 38.1% of SC and 7.1% of PC with Hx
prior TMT group (SC). XRT groups (table 2, p[0.02). Neurological com-
plications were present in 5.6% of PC, 23.8% of SC
Early Complications (£90 days)
There was no difference in length of stay, estimated
blood loss or intraoperative complications, including
Table 2. Incidence of any early complications by organ system
vascular or bowel/rectal injury among the 3 groups
(table 1 and data not shown, respectively). The % Salvage % Primary
% Primary Cystectomy Cystectomy with
positive margin rate was not significantly different Early Complications Cystectomy after TMT prior nonTMT p
between the 3 groups (6.5% for PC, 4.7% for SC and (
90 Days) (216 pts) (21 pts) XRT (28 pts) Value
7.1% for PC with Hx XRT, p >0.05). The incidence of Any early complication 60.1 76.2 60.7 0.3
any early complication for PC, SC and PC with Hx (
90 Days)
XRT was 60.1%, 76.1% and 61.0%, respectively Metabolic 11.6 19 7.1 0.4
Hematologic 17.6 28.6 17.9 0.4
(p[0.36; table 2). There was also no difference in Cardiac 9.7 19. 17.9 0.1
the predicted probability of an early complication Respiratory 5.1 19. 14.3 0.01
among the 3 groups (fig. 1). In terms of any early Infectious 17.1 38.1 7.1 0.02
Gastrointestinal 21.3 23.8 14.3 0.6
complications by organ system, the incidence of Neurological 5.6 23.8 0 0.01
metabolic, hematologic, cardiac, vascular, gastroin- Vascular 8.3 9.5 7.1 0.9
testinal and genitourinary complications were Genitourinary 4.6 9.5 0 0.2
Other 5.6 9.5 7.1 0.5
similar among the 3 groups (table 2). Respiratory

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32 OUTCOMES OF SALVAGE CYSTECTOMY AFTER TRIMODALITY THERAPY

Table 3. Incidence of any late complications by organ system

% Primary
% Primary % Salvage Cystectomy with
Late Complications Cystectomy Cystectomy after prior nonTMT
(>90 Days) (206 pts) TMT (19 pts) XRT (27 pts) p Value
Metabolic 4.4 10.5 3.7 0.3
Hematologic 0.5 0 0 0.9
Cardiac 0.5 0 0 0.9
Respiratory 0.5 0 3.7 0.3
Infectious 7.8 26.3 11.1 0.03
Gastrointestinal 4.4 26.3 14.8 <0.01
Neurological 0.5 0 0 0.9
Vascular 3.9 10.5 0 0.19
Genitourinary 8.3 26.3 14.8 0.03
Other 0.5 0 0 0.9

Figure 1. Predicted probability of any early complication (
90 type of diversion were not associated with an
days). increased risk of any late complication.
The number of late major complications (Clavien-
Dindo Grade 3e5) was 48 for PC, 11 for SC and 10
and 0% of PC with Hx XRT groups (table 2,
for PC with Hx XRT. The adjusted freedom from
p[0.007).
late major complications analysis did not demon-
In terms of severity of complications, there was
strate a difference among the 3 groups (p[0.1; fig. 3).
no difference between the 3 groups in risk of major
On secondary analysis, SC was associated with a
complications defined as Clavien-Dindo grade 3-5
higher complication rate compared to PC (p[0.049;
(27.7% for PC, 33.3% for SC, and 21.4% for PC with
fig. 3) and there was no difference between the 2 prior
Hx XRT groups, p[0.65). The difference in major
radiation groups (SC vs PC with XRT, p[0.6; fig. 3).
complications remained insignificant in the
On multivariable Cox regression analysis, SC was
adjusted analysis (data not shown).
associated with an increased risk of major late com-
plications compared to PC (HR[2.1, 95% CI 1.0e4.2,
Late Complications (>90 days) p <0.05; table 6).
Late complications were detected after PC, SC, and
PC with Hx XRT in 49, 12, and 10 patients, Survival
respectively. The incidence of metabolic, hemato- The 5-year DSS from the time of RC was similar
logic, cardiac, respiratory, neurological and vascular among the 3 groups (63.0% for PC, 63.8% for SC,
complications was similar between groups (table 3). and 61.1% for PC with Hx XRT). The 5-year OS was
Infectious complications were present in 7.8% of PC, also similar between the 3 groups (47.8% for PC,
26.3% of SC and 11.1% of PC with Hx XRT groups 29.0% for SC, and 45.5% for PC with Hx XRT). On
(table 3, p[0.03). Gastrointestinal complications adjusted analysis there was no significant difference
were present in 4.4% of PC, 26.3% of SC, and 14.8% in disease specific or overall survival (p[0.8 and
of PC with Hx XRT groups (table 3, p <0.01). Geni- p[0.9 respectively, fig. 4, A and B).
tourinary complications were present in 8.3% of
PC, 26.3% of SC and 14.8% of PC with Hx XRT
Table 4. Types of late genitourinary and gastrointestinal
groups (table 4, p[0.03).
complications
The adjusted freedom from any late complica-
tions analysis demonstrated a difference between PC with
PC SC Hx XRT p Value
the groups (overall p[0.03, fig. 2). On a secondary
analysis, the rate of any late complication between Genitourinary
No. pts 17 4 5
SC and PC with XRT (2 groups that received prior % Genitourinary complications:
radiation therapy) was not statistically significant Stoma stenosis 23.5 25 0 0.6
(p[0.5), and there was an increased risk of com- Ureteral stricture 47.1 75 60 0.7
Urolithiasis 17.6 0 20 0.9
plications after SC compared to PC (p[0.02). On Other category 11.8 0 20 0.9
multivariable Cox regression analysis, previous Gastrointestinal
TMT (SC group) was associated with a higher inci- No. pts 9 4 5
% Gastrointestinal complications:
dence of complications compared to PC (HR[2.3, Parastomal or ventral hernia 22.2 25 20 0.9
95% CI 1.2e4.4, p[0.02; table 5). Other covariates Small bowel obstruction 55.6 75 40 0.8
including age, prior nonTMT radiation therapy, Fistulas 11.1 0 20 0.9
Large bowel obstruction 11.1 0 20 0.9
clinical stage, Charlson score, smoking status and

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 OUTCOMES OF SALVAGE CYSTECTOMY AFTER TRIMODALITY THERAPY 33

Table 5. Multivariable Cox regression analysis of any late

complication
HR (95% CI) p Value
Prior TMT vs primary cystectomy 2.3 (1.2e4.4) 0.02
Prior pelvic radiation (nonTMT) vs 1.6 (0.80e3.37) 0.1
primary cystectomy
Age 1 (0.97e1.02) 0.8
Clinical stage 0.9 (0.75e1.20) 0.6
Charlson score 1 (0.89e1.22) 0.5
Tobacco 1.8 (0.93e3.51) 0.08
Continent urinary diversion 0.8 (0.32e2.24) 0.7

compared to primary cystectomy in our analysis.

However, the SC after TMT group did not have a
significantly different rate of any late complication
Figure 2. Adjusted freedom from any late complications for primary or major late complications when compared directly
cystectomy, salvage cystectomy and primary cystectomy with prior
medical history of nonTMT abdominal/pelvic XRT.
to the PC after nonTMT radiation.
Post TMT SC patients had relatively more in-
fectious, gastrointestinal, and genitourinary com-
plications, which is at least anecdotally consistent
DISCUSSION
with our experience. The most frequent gastroin-
Radical cystectomy and TMT remain the 2 accepted
testinal complications were small bowel obstruction
curative options for localized MIBC. However, TMT
and parastomal or ventral hernia. The most
has not been widely implemented for various rea-
frequent genitourinary complications were stoma
sons. One of the concerns surrounding TMT is the
stenosis and ureteral stricture (table 4). This
management of localized intravesical recurrences
observation is hypothesis-generating and may be
that may require salvage cystectomy, which is
due to the TMT radiation field, including the geni-
required in approximately 11% to 29% of TMT pa-
tourinary organs (including distal ureters) as well
tients.4,5,7 There is a paucity of literature describing
as relatively more small intestine when compared to
safety and survival outcomes for post-TMT SC. This
most nonTMT radiation fields. It is possible that
manuscript compares the incidence of complications
technical modifications such a constructing a colon
as well as survival outcomes between SC, PC and
instead of ileal conduit and using as proximal ureter
PC in patients with history of nonTMT pelvic radi-
as possible for the ureteral-to-conduit anastomosis
ation in a single institution, multiple surgeons with
may mitigate the higher rate of late gastrointestinal
extensive experience with TMT and radical
and genitourinary complications such as ureteral
cystectomy.
stricture, stoma stenosis and small bowel obstruc-
Our manuscript illustrates that the immediate
tion in the SC group. In addition, all TMT patients
morbidity of post-TMT SC in terms of intraoperative
received radiosensitizing chemotherapy as well as
complications, including bowel/rectal injury and
adjuvant systemic chemotherapy after completing
vascular injury, estimated blood loss, and early
complications (
90 days) is comparable to both
primary RC and RC in patients who had nonTMT
abdominal or pelvic radiation. However, SC after
TMT is associated with a higher overall rate of late
complications (>90 days), including major compli-
cations (Clavien-Dindo 3e5) compared to PC. In our
series, the overall late complication rate is compa-
rable to other reported late complication rates in RC
patients who had prior chemotherapy or radiation
therapy. The rates in these series vary widely,
ranging from 33% to 77%.7,19e23 Our reported late
complications rate includes a >2-year median fol-
lowup, which may in part explain why our results
are toward the higher end of this spectrum. When
correcting for other factors potentially associated
with the risk and severity of late complications,
Figure 3. Adjusted freedom from late major (Clavien-Dindo
TMT remained a significant independent predictor
Grade 3e5) complications for PC, SC and PC with Hx XRT.
of both overall and major late complications when

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34 OUTCOMES OF SALVAGE CYSTECTOMY AFTER TRIMODALITY THERAPY

Table 6. Multivariable Cox regression analysis of late major
(Clavien-Dindo grade 3e5) complications
HR (95% CI)
Prior TMT vs primary cystectomy 2.1
Prior pelvic radiation (nonTMT) vs 1.6
primary cystectomy
Age 1.0 (0.98e1.02)
Clinical stage 0.9
Charlson score 1.1
Tobacco 1.7
Continent urinary diversion 0.9
concurrent chemoradiation. The increased use of
chemotherapy in the post-TMT group compared to
the PC and PC with Hx of XRT group may poten-
tially explain these observations, including the
higher overall rate of late complications.
Perhaps most importantly, DSS and OS from
the time of cystectomy were similar between the
groups. The 63.8% 5-year DSS in the post TMT SC
group is encouraging. Although SC patients have
recurrent invasive bladder cancer and/or persis-
tent chemoradioresistant disease, the majority of
them are salvaged by radical cystectomy. Although
post-TMT SC has a higher rate of late complica-
tions, this increased delayed morbidity may be
acceptable as the majority of patients are sal-
vaged, and the increased risk of late complications
does not impact their overall survival. The in-
creased late complication rate in the SC group is
likely multifactorial from the radiation fields,
including bowel and distal ureters, as well as the
delayed effects of systemic chemotherapy, as dis-
cussed above.
Our study has several limitations. This is a
retrospective analysis of a single institution with
p Value extensive experience with TMT so these results may
(1.0e4.2) 0.049
not be widely applicable. Further, the number of
(0.8e3.3) 0.2 patients in the SC and PC with Hx of XRT group
limits analysis. Only about 16% of TMT patients
0.9
require SC in our contemporary experience, so the
(0.7e1.1) 0.3
(0.90e1.3) 0.3 overall number of patients included is small.4 Pa-
(0.84e3.4) 0.1 tients who had SC were well-selected patients by
(0.32e2.3) 0.8
the surgical team. These results may not apply to
every patient with recurrence after TMT. The
groups presented in this series represent a 10-year
period, during which chemoradiation protocols and
perioperative care, such as Enhanced Recovery
after Surgery (ERASÒ) protocols, have evolved and
were not captured. New studies taking into consid-
eration the different protocols of postoperative care
and chemoradiation must be done to determine
their role in complications and survival.
CONCLUSIONS
SC for intravesical recurrence post-TMT has an
intraoperative, immediate safety, and early
complication rate that is comparable to PC and PC
with Hx XRT. However, SC is associated with a
higher risk of any and major late complications,
including infectious, gastrointestinal, and genito-
urinary complications. When compared directly to
PC with Hx XRT, though, SC does not have a
significantly higher risk of any or major late com-
plications. This potential increase in late morbidity
is acceptable, however, as SC has comparable DSS
and OS to PC and PC with Hx XRT. Although a

Figure 4. Adjusted disease-specific survival (A) and overall survival (B) for PC, SC and PC with Hx XRT

Copyright © 2021 American Urological Association Education and Research, Inc. Unauthorized reproduction of this article is prohibited.
 OUTCOMES OF SALVAGE CYSTECTOMY AFTER TRIMODALITY THERAPY 35

minority of patients have recurrent and/or persis- prior radiation and chemotherapy, the majority of
tent invasive bladder that requires salvage cys- SC patients are cured with tolerable immediate and
tectomy and despite the potential side effects of delayed safety profile.

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EDITORIAL COMMENT
In this single institutional series, the authors report
their experience with salvage cystectomy following
trimodal therapy. In this retrospective review, the
early and late complications of cystectomy as well as
disease-specific survival and overall survival were
described and compared to patients treated with
primary cystectomy as well as with cystectomy
following abdominopelvic radiotherapy for non-
urothelial malignancies. Salvage cystectomy had a
reported early and late complication rate of 76% and
63%, respectively. The reported early complication
rates are in line with other contemporary series and
showed no differences when compared to primary
cystectomy or cystectomy after radiation for a non-
urothelial malignancy. Only the comparison of late
complications in the salvage cystectomy group
versus the primary cystectomy group reached sta-
tistical significance in this analysis with cystectomy

Copyright © 2021 American Urological Association Education and Research, Inc. Unauthorized reproduction of this article is prohibited.
36 OUTCOMES OF SALVAGE CYSTECTOMY AFTER TRIMODALITY THERAPY

after TMT having more late complications versus
primary cystectomy. The DSS and OS survival were
similar between the 3 groups and did not reach
significance (p[0.8 and p[0.9, respectively).
This series highlights the feasibility of surgical
salvage therapy in patients initially treated with
TMT. Reported invasive cancer recurrence rates
vary depending on the series reported, with some
series approaching 30% recurrence rates following
trimodal therapy.1 Therefore, it is critical that
salvage cystectomy be a viable option for selected
patients who recur after TMT. The authors do
demonstrate that salvage cystectomy can be per-
formed with acceptable complication rates. Howev-
er, the technical difficulty of this surgery and the
associated early and late complications should not
be underestimated, and patients should be exten-
sively evaluated and risk-stratified prior to pro-
ceeding with salvage cystectomy. Furthermore, this
is a nonrandomized trial at an institution with a
large experience in TMT as well as salvage cys-
tectomy, and as the authors caution, these cases and
results may not be extrapolated to less experienced
centers.
The authors describe their surgical outcomes
with this patient population, and the inclusion of a
comparison group with prior irradiation in their
analysis is unique. Salvage cystectomy following
trimodal therapy is feasible with acceptable
complication rates and good survival, emphasizing
that patients with a history of TMT may be offered
salvage cystectomy at an experienced center if TMT
fails.
Matthew M. Banti and Jeffrey M. Holzbeierlein
Department of Urology
University of Kansas Health System
Kansas City, Kansas

REFERENCE
1. Coppin C, Gospodarowicz M, James K et al: Improved local control of invasive bladder cancer by concurrent cisplatin and preoperative or definitive radiation. The National
Cancer Institute of Canada Clinical Trials Group. J Clin Oncol 1996; 14: 2901.

Copyright © 2021 American Urological Association Education and Research, Inc. Unauthorized reproduction of this article is prohibited.