Clinical under staging of high risk nonmuscle invasive urothelial carcinoma treated with radical cystectomy

Purpose: The role of radical cystectomy in patients with nonmuscle invasive urothelial carcinoma of the bladder remains controversial. The risk of ove rtreatment must be balanced against the potential benefit of aggressive the rapy. We reviewed our results in these patients with a particular emphasis on clinical under staging. Materials and Methods: We reviewed the records of 214 consecutive patients who underwent radical cystectomy for urothelial carcinoma between April 199 5 and August 1999, focusing on those with nonmuscle invasive, stages TI or less disease. We assessed clinical and pathological data as well as outcome s based on pathological disease extent. Results: A total of 78 patients (36%) underwent radical cystectomy for clin ical stages TI or less disease. Indications included disease refractory to intravesical therapy in 29 cases (37%), pathological findings reflective of high grade stage T1 or multifocal disease in 26 (33%), radiographic suspic ion of invasive disease in 15 (20%) and severe symptoms in 8 (10%). Cancer was clinically under staged with stages pT2 or greater disease in 31 patien ts (40%) according to final pathology results. Under staging was most prono unced in the 10 patients (67%) with suspicious radiography and in the 18 (6 4%) with absent muscle in the biopsy specimen. Of the 78 patients with path ological stages pT1 disease or less 98% had no evidence of disease compared to 65% with stages pT2 or greater disease (p <0.01). Conclusions: Despite the intent to perform early cystectomy a significant p ercent of patients harbored occult muscle invasive and/or metastatic diseas e. In clinical and pathological, superficial stages T1 or less cases diseas e-free survival was excellent. Due to these results, the selection of high risk superficial transitional cell carcinoma cases for continued bladder sp aring treatment should include uninvolved muscle on biopsy and absent radio graphic suspicion of invasion.