For decades, RC has been the gold standard for treatment of muscle-invasive bladder cancer and refractory non-muscle-invasive disease. However, even with the advents in surgical techniques and perioperative care, it remains with considerable morbidity and mortality, especially for LAD (pT3–T4 and/or lymph node-positive) [14]. We aimed to explore the outcomes of RARC in the setting of locally advanced bladder cancer and whether the quality of surgical care affected survival in this setting or not (Additional file 2: Table S1).
Although RC in LAD (alone or as part of multimodality approach) may be of considerable risks, other alternatives, as bladder preservation modalities, which usually entail radiation and chemotherapy combined with transurethral resection (TUR) of the primary tumor, do not provide adequate primary tumor control. Additionally, they may be associated with worse voiding symptoms, uncontrollable bleeding, repeated hospital readmissions and poor quality of life [15]. Inadequate local tumor control may also cause fistulation, ureteral obstruction and symptomatic distant metastasis [6]. Consequently, approximately one-quarter of the patients will undergo salvage cystectomy for symptom relief [16]. RC following extensive chemo-irradiation and multiple TURs has very limited clinical efficacy and usually associated with even higher morbidity and mortality [17]. Therefore, resection of the bladder with an adequate safety margin and extended lymph node dissection may offer symptomatic relief and offer some oncological benefits especially when combined with chemotherapy for control of micrometastatic disease [6].
The present outcomes showed similar perioperative outcomes between LAD and OCD, with only modest difference in the estimated blood loss (444 vs. 376). More patients in the LAD showed PSM (14% vs. 2%, p < 0.001) and experienced recurrence more often (39% vs. 10%, p < 0.001). This can be explained by disease aggressiveness. Even with adequate surgical techniques, LAD cohort may still experience more positive soft tissue surgical margins, which is associated with disease relapse [18, 19].
Survival following RARC depends on several key factors: stage of disease at presentation, patient age and comorbidities, and the quality of operative management [5, 20, 21]. Deal management should include multidisciplinary consultation regarding NAC, a procedure that respects oncological principles, optimized perioperative care and the availability of adequate institutional resources [22]. Disease factors mainly drive survival outcomes for bladder cancer. The adverse impact of advanced pT stage and nodal status has been shown, and long-term survival is dismal when bladder cancer invades the pelvic sidewall or adjacent structures [3, 4, 12, 23, 24]. Nodal involvement had a clear negative prognostic impact independent of pT stage [24].
While disease and patient characteristics are less controllable, disease management and perioperative care are “modifiable” and should be optimized. It has been previously shown that independent of patient and disease characteristics, high-quality surgical care is associated with RFS, DSS and OS [22]. In the current study, more patients in the OCD received higher quality of care when compared to LAD (90% vs. 83%), which is attributed primarily to the pathologic criteria that include positive soft tissue surgical margins (Table 1). The improvement in surgical care provided for patients with time corresponds to increased trends of utilization of NAC and is in agreement with data from National Medicare, which shows a 37% decline in mortality [22, 25]. Our findings confirm that quality of surgical care is mandatory to optimize OS for all patients, irrespective of their disease status. Among patients with OCD, those who received a higher quality of surgical care demonstrated better OS at 5 years (70% vs. 55%, p = 0.03). Among patients with LAD, disease control benefit (in terms of RFS and DSS) has been additionally demonstrated. This reflects that a quality surgery that involves thorough lymphadenectomy is worthwhile and can provide recurrence-free and disease-free survival benefit even in patients with the locally advanced and micrometastatic disease. However, controversies do exist with respect to the required extent of lymphadenectomy and the number of nodes that should be retrieved. It has been concluded that bilateral and meticulous lymphadenectomy up to the common iliac artery is adequate and that such a dissection would provide a yield of approximately 20 lymph nodes [22]. The introduction of NAC has been associated with improved survival in these patients, especially in patients with complete pathological response [8]. Meticulous surgical clearance and extended lymph node dissection are crucial for achievement of optimal survival following RARC.
Other factors that have been shown in this study to affect survival included female gender, ASA score, intracorporeal diversion and continent diversion. Females in general have worse outcomes of bladder cancer. The effects of the diversion technique and type may be related to patient selection bias, where sicker patients usually receive conduits that are mostly performed intracorporeally, or may be related to longer operative times associated with intracorporeal diversion.
The present study has its limitations. First, the limitations inherent to retrospective analysis are well recognized. Second, the study includes 24 different institutions which may vary in their management protocols. Still, our study reflects real practice patterns and may be used for better patient counseling. Regarding QCS score, an equal weight was assigned for each of the parameters used, which may not reflect their actual importance. Also, the pathologic criteria of QCS may still be affected by disease stage, which can affect the assessment of the quality of surgical care.
