Introduction:

Although radical cystectomy (RC) is the gold standard treatment for patients with muscle-invasive urothelial carcinoma of the bladder (UCB), it remains a morbid procedure.  Partial cystectomy (PC) is not recommended by AUA guidelines as previous studies have been limited by small cohorts, short-term follow-up, and lack of direct comparison to RC. Herein, we compare peri-operative complications and long-term oncologic outcomes between patients undergoing PC and RC for UCB.  

Methods:

We queried a prospectively maintained database to identify patients undergoing PC and RC for UCB between 1980-2020.  Multivariable logistic regression analysis was performed to compare 90-day major complications between PC and RC. Multivariable Cox regression analyses were used to examine the association of PC vs RC with oncologic outcomes as well as variables associated with intravesical recurrence after PC.

Results:

In total, 277 patients underwent PC and 3474 patients underwent RC. PC was associated with fewer 90-day major complications (16.2 % vs 33 %, p<0.01) and 90-day readmission (5.8% vs 16.1%, p<0.01) relative to RC. On multivariable analysis adjusting for patient factors, PC was associated with fewer 90-day major complications relative to RC (OR 0.41, P<0.01). After PC, the 5-year intravesical recurrence risk was 40% (Figure 1) and 5-year salvage cystectomy risk was 21%. Factors associated with intravesical recurrence after PC on multivariable regression were: older age (HR 1.03, p=0.03), higher Charlson comorbidity index (HR 1.12, p=0.02), and pT3/pT4 vs p<2 disease (HR 1.87, p=0.03). Notably, a history of carcinoma in situ either prior to PC or incidentally found in the PC pathologic specimen was not associated with increased intravesical recurrence (HR 0.837, p=0.46). PC did not compromise systemic cancer control relative to RC with similar metastasis-free survival (HR 1.06, P=0.59) and cancer-specific survival (HR 1.13, P=0.21) on multivariable analysis (Figure 2).

Conclusion:

In this large, single institution cohort, we found that PC provides similar oncologic outcomes to RC with less peri-operative morbidity. Half of patients undergoing PC experienced intravesical recurrence, the majority of which were treated with intravesical therapy alone. Rates of salvage cystectomy following PC were 21% at five years. Older patients with comorbidities and pT3/4 disease were most at risk for intravesical recurrence after PC and should be counseled accordingly.

Funding: N/A