VIENNA—Radical cystectomy should be considered in all cases of muscle-invasive, non-metastatic bladder cancer, according to Marek Babjuk, MD, PhD, who presented an evidence-based argument for this approach at the 7th Meeting of the European Association of Urology Section of Oncological Urology.

Neoadjuvant chemotherapy prior to radical cystectomy should be reserved for selected patients, Dr. Babjuk said.

“My opinion, based on the evidence, is that the most important treatment is surgery,” said Dr. Babjuk, Professor and Chairman of the Department of Urology, 2nd Faculty of Medicine, Charles University in Prague. Meta-analyses of trials showing that neoadjuvant chemotherapy is beneficial compared with cystectomy alone did not take into account the variations in the quality of surgery in the trials.

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“Furthermore, we must understand that the routine practice outside the trials can be different in specific points,” Dr. Babjuk said. “It must reflect additional criteria as are patients’ age and performance status, which are frequently worse than in trial patients as well as specific clinical situation like unmanageable bleeding from locally extended tumor.”

He told Renal & Urology News that his center’s current practice is to use chemotherapy before cystectomy in most patients at highest risk of progression—that is, those with gross extravesical extension (stage T3 and T4) and enlarged nodes. The exceptions are individuals with bleeding where early surgery is necessary or older patients with serious comorbidities whose health may be unduly compromised by toxicity from the chemotherapy.

“But in the latter cases it must always be an individual decision,” Dr. Babjuk added. “And this practice also reflects the practices in many centers in Europe.”

He presented an overview of the literature on cystectomy accompanied by lymph node dissection. Data indicate that this approach is associated with a low risk of late recurrence and only a 10%-12% rate of local recurrence. The largest series published in the past century show five-year recurrence-free survivals of 72%-74% for pT2, 40%-52% for pT3, and 28%-44% for pT4 tumors respectively.