Staged based directed surveillance of invasive bladder cancer following radical cystectomy: valuable and effective?

Radical cystectomy with pelvic lymphadenectomy remains the optimal treatment for muscle invasive bladder cancer curing the majority of patients with organ conWned tumors (stage pT1-2), but only a minority of those with low-volume node positive (N1) disease or with locally advanced (stage pT3b-4), and rarely those with extensive node-positive (N2-3), or metastatic (M+) bladder cancer [1–7]. Approximately 50% of patients will suVer a distant recurrence following surgery, most (80–90%) within 24 months of surgery with the most common sites being lung, liver, and osseous [6–12]. Studies consistently show the risk of both local and distant recurrence increases with advancing pathologic stage and nodal burden of disease, whereas recurrences following chemotherapy for metastatic disease seem to have a predilection for prior sites of disease with the brain serving as a sanctuary site for delayed relapse [6–12]. The risk of urothelial recurrences in the upper tract or remnant urethra are also predictable and related to pretreatment clinical factors such as the presence of multifocal disease, diVuse carcinoma in situ, distal ureteral or intramural tunnel involvement, or prior disease involvement of the upper tracts or prostatic urethra [13–18]. The main goal of surveillance is to monitor for recurrence of the primary disease or secondary malignancies, with the assumption that close monitoring will result in earlier detection and treatment of a disease recurrence thereby improving outcome [19–21]. However, there is little data in muscle invasive bladder cancer that routine imaging/exams at predetermined intervals allows any earlier detection of a local or distant recurrence than performing those exams at the time of the Wrst symptom. Routine surveillance at predetermined intervals, however, may be eVective in detecting early urothelial recurrences in the remnant urethra and upper tract in which early intervention may impact survival. In addition, the documented risks and pattern for long-term surgical complications, metabolic abnormalities, and renal deterioration associated with urinary diversions relative to a patient’s baseline comorbidity’s, are being better characterized in series with ten or more years of follow-up [22, 23]. The high rate of long-term complications indicate a need to incorporate routine monitoring for these diversion related complications into current surveillance strategies. Nevertheless most surveillance protocols are staged based, and built on the recurrence patterns observed in retrospective reviews of radical cystectomy series [19– 21]. Prospective trials demonstrating the eVectiveness of this approach over symptom driven evaluation and intervention in bladder cancer are lacking; however, until prospective studies comparing varying frequencies of surveillance or symptom driven surveillance are performed it would seem prudent to utilize stage-based surveillance strategies employing the known risks and patterns of recurrence in bladder cancer. S. M. Donat (&) Department of Urology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10021, USA e-mail: donats@mskcc.org