Upstaging and Survival Outcomes for Non-Muscle Invasive Bladder Cancer After Radical Cystectomy : Results from the International Robotic Cystectomy Consortium

Abstract

Introduction: We sought to describe the incidence, risk factors, and survival outcomes associated with pathologic upstaging from non-muscle invasive bladder cancer (NMIBC) to muscle invasive bladder cancer (MIBC) after robot-assisted radical cystectomy (RARC).

Methods: We reviewed the International Robotic Cystectomy Consortium database between 2004 and 2020. Upstaging was defined as ≥pT2 or pathologic node positive (pN+) at final pathology analysis from clinical <T2N0M0. Descriptive statistics were used to summarize data. Cochran–Armitage test was used to depict upstaging trend over time. Multivariate regression models were used to depict variables associated with upstaging. Kaplan–Meier curves were used to describe disease-specific survival (DSS), recurrence-free survival (RFS), and overall survival (OS).

Results: A total of 463 patients underwent RARC for NMIBC. Upstaging occurred in 145 (31%) patients. Upstaged patients were older (70 vs 67 years, p < 0.01), more likely to have American Society of Anesthesiologists (ASA) score (≥3; 55% vs 44%, p = 0.04), and had higher rate of preoperative hydronephrosis (26% vs 10%, p < 0.01). They were more likely to have positive surgical margins (10% vs 3%, p = 0.01), recurrences (28% vs 9%, p < 0.01), and to receive adjuvant/salvage treatment (26% vs 3%, p < 0.01). On multivariate analysis, upstaging was associated with older age (odds ratio [OR] 1.04; confidence interval [CI] 1.01–1.07, p < 0.01), cT1vs cTis (OR 4.25; CI 1.57–11.48, p < 0.01), cT1vs cTa (OR 2.92; CI 1.40–6.06, p < 0.01), and preoperative hydronephrosis (OR 3.18; CI 1.60–6.32, p < 0.01). Upstaged patients had worse 5-year RFS (53% vs 85%, log rank p < 0.01), DSS (66% vs 93%, log rank p < 0.01), and OS (49% vs 74%, log rank p < 0.01). The rate of upstaging did not significantly change over time (38% in 2004 to 27% in 2019, p = 0.17).

Conclusion: Upstaging to MIBC occurred in a significant proportion of patients after RARC for NMIBC and was associated with worse survival outcomes. Older patients, those with cT1 disease and hydronephrosis were more likely to upstage.