Clinical application and efficacy analysis of partial cystectomy combined with intravesical chemotherapy in muscle-invasive bladder cancer

Bladder cancer is prone to multiple occurrences, recurrence and metastases, and different patients have different risks of progression, so bladder preservation therapy cannot be applied to all MIBC patients and strict patient selection is required before surgery. Moreover, Some patients with uroepithelial carcinoma of the bladder can be treated with PC to achieve the same local treatment effect as RC with complete tumour removal and lymph node dissection [13,14,15]. In clinical practice, patients with MIBC are often divided into medium-risk and high-risk groups based on certain risk factors (MIBC is a malignant tumour of the urinary tract and has a greater risk, so some experts believe that there is no low-risk group) [16, 17]. The risk of tumour progression and metastasis after surgery is much greater in the high-risk group than in the medium-risk group. In order to demonstrate the effectiveness of PC + bladder instillations treatment, the patients enrolled in the PC group were strictly selected in this study. The main criteria were primary tumour, single tumour, tumour TNM stage within T2-3N0M0 and pathological type of uroepithelial carcinoma. A total of 102 patients, 32 in the PC group and 70 in the RC group, were enrolled in the study according to strict enrolment criteria. In the PC group, bladder instillations was routinely performed 2–4 weeks after surgery. There were no statistically significant differences between the two groups in terms of age, gender, tumour stage, presence of vascular and nerve invasion, presence of carcinoma in situ and presence of tissue variation. Both groups had PC group superior to RC group in postoperative complications, but there was no significant difference in infection of surgical incision within 30 days after surgery. Some studies have shown that the infection of the surgical site is closely related with age, BMI, ASA score, having diabetes and other underlying diseases [18]. The occurrence of postoperative complications is also closely related to the surgical method. For patients undergoing laparoscopic surgery, the incidence of postoperative complications is lower and the postoperative recovery is faster [19].

The follow-up results showed that the 5-year OS, PFS and DSS in the PC group were 44.6%, 54.8% and 62.4%, respectively, while the 5-year OS, PFS and DSS in the RC group were 52.6%, 62.1% and 68.0%, respectively, there is no statistically significant difference between the two groups. The combined treatment regimen can achieve the same tumour control effect as RC treatment. Fujii et al. [20] performed PC-based BPT on 84 MIBC patients in 2015, and the long-term postoperative follow-up showed a high 5-year DSS and OS of 96% and 94%, which was significantly different from the results of our study ( PC group DSS and OS of 62.4% and 44.6%, respectively). Fujii et al. initially enrolled a total of 292 patients with MIBC, first undergoing tumour reduction surgery by TURBT, followed by low-dose concurrent radiotherapy for the patients, finally, partial bladder resection was performed in 84 patients with non-muscle invasive bladder cancer residuals that were isolated and small in size, did not invade the bladder neck, did not have multiple carcinomas in situ, and did not have residual cancer tissue at the surgical site after radiotherapy the regimen involved radiotherapy and theoretically had a therapeutic effect on the possible presence of micrometastases, and the regimen was preceded by TURBT and the results of the procedure were assessed prior to PC, theoretically excluding patients with MIBC who were at greater risk of progression already. This shows that radiotherapy can control tumors to some extent and can greatly improve DSS and OS in patients. In recent years, radiotherapy has become a more attractive alternative to metastatic lesion clearance in oligometastatic patients because it is less invasive and can significantly improve patient outcomes [21]. Furthermore, Chalasani V [22] has stated that the presence of tissue variants in pathological specimens should be taken seriously as they may indicate the risk of disease progression, and in this study there were 2(6.1%) and 7 (10%) cases in each of the PC and RC groups (p = 0.716) with no statistically significant difference between the two groups, but the presence of tissue variants may have reduced both groups due to respective OS and DSS, and these may have caused these differences. The incidence of surgical complications in the PC and RC groups was 28.1% (9/32)) and 50.0% (35/70) respectively (p = 0.033), a statistically significant difference (p < 0.05), with the RC group having a higher rate of postoperative complications, a result that is in line with the findings of several other studies [23, 24].

Both groups had a higher risk of tumour recurrence and metastasis after surgery. A total of 40% (12/30) of the PC group had recurrence or metastasis. There were 6 patients with distant metastases, including 1 small bowel metastasis who died more than 2 months after reduction surgery, 1 lung metastasis, 1 pharyngeal metastasis and 3 lymph node metastases, for which no special treatment was given. Six patients had local recurrences, two of which had muscular infiltration and were treated with salvage RC, one of whom died of multiple metastases more than 6 months after surgery, and one of whom was treated with postoperative gemcitabine plus cisplatin (GC) chemotherapy and survived despite urethral metastases, as the tumour was controlled by timely detection and complete excision. Two patients were treated with TURBT after postoperative detection of recurrence in the bladder, one died shortly after recurrence, one eventually developed pancreaticobiliary cancer and died, and the other two patients died after recurrence without special management. As the study was retrospective, there was not complete uniformity in terms of treatment strategy, while some patients and families refused radical bladder cancer surgery and failed to achieve timely salvage RC treatment for patients with recurrence in the bladder detected early as recommended by the guidelines [25], which may have reduced the OS to some extent for the PC group. A total of 25.4% (16/63) of the patients in the RC group had metastases after surgery, including 3 urethral metastases, 4 colon metastases, 3 liver metastases, 1 lung metastasis, 2 bone metastases, 4 single site lymph node metastases and 6 multiple metastases (lung, colorectal, lymph node and bone). 3 patients with urethral metastases underwent urethrectomy and 1 is currently alive; 2 patients with lymphatic metastases were treated with local radiotherapy and 1 is still alive. The remaining patients with metastases were not given any special treatment and all had died by the end of the follow-up period. Therefore, it is extremely important for patients with MIBC to have regular post-operative reviews to detect metastases or recurrence early and to intervene in appropriate ways (e.g. salvage RC, radiotherapy, chemotherapy, local tumour reduction) to prolong their survival if the tumour can be controlled. In this study BPT achieved similar tumour control to RC, with a bladder preservation survival rate of 45.5% and an even higher bladder preservation rate of 93.8% in surviving patients, we believe that the BPT option is worth exploring.

In this study, we found that patients with partial bladder resection were not statistically significant in tumor recurrence or distant metastasis and bladder cancer-specific death, which may not have a longer follow-up time, with some limitations, and a longer follow-up time is needed to clarify the clinical efficacy of partial bladder resection. In addition, considering that this study is a retrospective single-centre study, the small sample size affects the reliability of the evidence and a multi-centre, large sample size, randomised controlled study could be conducted subsequently to verify the feasibility of this treatment option.

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