Quality of life after radical treatment for muscle invasive bladder cancer: A systematic review and meta-analysis.
Authors: Francolini Giulio , Ghoshal Arun , Caini Saverio , Piazzini Tessa , Becherini Carlotta , Detti Beatrice , Di Cataldo Vanessa , Valzano Marianna , Ganovelli Michele , Allegra Andrea Gaetano , Frosini Giulio , Burchini Luca , Visani Luca , Salvestrini Viola , Olmetto Emanuela , Loi Mauro , Simontacchi Gabriele , Desideri Isacco , Meattini Icro , Livi Lorenzo 
Published: March 2023

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Background: Radical cystectomy (RC) with or without perioperative chemotherapy is considered the standard treatment option for Muscle invasive bladder cancer (MIBC), despite poor oncological outcomes. However, RC is often burdened by significant impact on quality of life (QoL); Continence preserving methods (e.g continent cutaneous urinary diversion and orthotopic neobladder-ONB), have been proposed as alternatives to improve the postoperative QoL, but real benefit of these approaches is questioned. Bladder sparing approach, such as trimodal therapy (TMT) emerged as an alternative to surgery. Aiming to assess the impact of these treatment options from the patients’ perspective, we undertook a systematic review and meta-analysis of literature, focusing on studies specifically reporting QoL data about each of the above mentioned approaches. Main purpose of this review is to compare available treatment options from the QoL point of view and highlight the potential advantage of a bladder sparing approach if compared to different postoperative urinary diversion methods. Methods: A systematic review was carried out including all prospective and retrospective studies enrolling patients treated with radical intent for non-metastatic MIBC from 1999 to 2021 (either RC or TMT). All studies included specifically reported QoL for one of the main treatment approaches explored (RC followed by ileal conduit urinary diversion-ICUD, ONB or TMT). Review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement Results: Fifty studies were included in the final analysis, assessing QoL after RC followed by ICUD or ONB in 6 and 15 cases, respectively. Six studies addressed QoL after TMT. ICUD vs ONB and TMT vs ICUD/ONB comparisons were carried out in 21 and 1 studies, respectively. Pooled analysis for EORTC QLQ- C30 and BLM-30 questionnaires showed that ONB yielded a significant advantage if compared to ICUD only for Physical Functioning (pooled mean standardized difference -0.73 SD, p-value 0.019, I 2 =93%) and for Emotional Functioning (pooled mean standardized difference -0.16 SD, p-value 0.029, I 2 =0%). A trend in favour of higher mean reported values after TMT for Global Health Score, Physical Functioning and Role Functioning was found, if compared to both RC approaches. Conclusions: Significant benefit for ONB if compared to ICUD was detected only for specific subdomains of QoL questionnaires. No direct comparison with TMT is available, but data suggest advantage of this approach if compared to both reconstructive scenarios. These data should be used in clinical practice to help well informed patients decision about local treatment choice.