Radical cystectomy versus bladder-preserving therapy in muscle-invasive bladder cancer patients after nephroureterectomy for upper tract urothelial carcinoma: a multicenter retrospective analysis

Abstract

Purpose: Although radical cystectomy (RC) and concurrent chemoradiotherapy (CCRT) are curative options for muscle-invasive bladder cancer (MIBC), the optimal treatment strategy for MIBC patients with a history of nephroureterectomy for upper tract urothelial carcinoma (UTUC) remains unclear. This retrospective analysis was conducted to compare survival rates and evaluate prognostic factors related to treatment outcomes. Material and Methods: We conducted a multi-institutional retrospective study of patients with MIBC after nephroureterectomy for UTUC between 2005 to 2023. Out of 75 patients, 30 underwent bladder-preserving therapy (BPT), including 22 patients who underwent radiation therapy (RT) and 8 patients who underwent CCRT, while 45 patients underwent RC. The overall survival (OS), cancer-specific survival (CSS), and progression-free survival (PFS) after BPT and RC were evaluated using Kaplan-Meier curves. Cox regression analysis was used to identify variables associated with OS, CSS, and PFS. Posttreatment changes in renal function were compared. Results: At 3 years, the OS, CSS, and PFS rates in the BPT group were 52.4%, 71.7%, and 31.3%, respectively, with no significant difference compared to RC. In multivariate analysis, bladder cancer T stage was the only predictive factor for OS, CSS, and PFS. Similar results were also observed in the RT group compared to RC. A significant decrease in renal function was detected among patients in the RC group, while patients in the BPT group maintained preserved renal function. Patients in the BPT group experienced a lower grade of toxicity after treatment compared to those in the RC group, and the rates of survival with functional bladder at 1 year, 3 years, and 5 years were 87.0%, 69.9%, and 69.9%, respectively. Conclusions: Bladder-preserving therapy, including RT alone, may be a viable treatment option for patients with MIBC who have undergone nephroureterectomy, as it can achieve comparable oncologic outcomes to RC, while potentially preserving bladder and renal function. 목적: 근침윤성 방광암의 치료로 근치적 방광절제술과 동시항암방사선요법이 치료 방법으로 제시되고 있으나, 상부 요로상피암에 대해 신우요관절제술을 받은 환자들을 대상으로 한 치료 방법에 대한 연구는 부족한 상황이다. 본 후향적 연구는 두 치료 방법에 따른 생존율을 분석하고자 하였다. 방법: 2005년부터 2023년까지 상부 요로상피암에 대해 신우요관절제술을 받은 이후 근침윤성 방광암이 발생한 환자들을 대상으로 다기관 후향적 분석을 시행하였다. 75명 중 30명은 방광보존술, 그 중 22명은 방사선치료, 8명은 동시항암방사선요법을 시행받았고, 45명은 근치적 방광절제술을 받았다. 전체생존기간(OS), 암특이생존기간(CSS), 무진행생존기간(PFS)을 카플란-마이어 곡선을 이용해 구하였다. 콕스 회귀분석을 통해 각 생존기간에 영향을 미치는 변수들을 확인하였으며, 치료 전후 신장기능의 변화를 구하였다. 결과: 방광보존술을 받은 환자들의 3년째 OS, CSS, PFS은 각각 52.4%, 71.7%, 31.3%였으며, 두 치료법 사이 유의미한 차이는 없었다. 다변량 회귀분석에서 방광암의 T stage만이 생존기간에 영향을 주는 유일한 변수였다. 근치적 방광절제술을 받은 환자군에서 치료 후 신장기능이 유의미하게 감소하였으나, 방광보존술에서는 유지되었으며 치료 후 부작용 등급도 낮았다. 결론: 방광보존술은 신우요관절제술을 받은 과거력이 있는 근침윤성 방광암 환자에게 근치적 방광절제술과 비슷한 치료효과를 볼 수 있으며, 신장기능과 방광기능의 보존에도 우월하다.