Prostate-specific Antigen–Based Prostate Cancer Screening: Reduction of Prostate Cancer Mortality After Correction for Nonattendance and Contamination in the Rotterdam Section of the European Randomized Study of Screening for Prostate Cancer

BackgroundLarge randomized screening trials provide an estimation of the effect of screening at a population-based level. The effect of screening for individuals, however, is diluted by nonattendance and contamination in the trial arms.ObjectiveTo determine the prostate cancer (PCa) mortality reduction from screening after adjustment for nonattendance and contamination.Design, setting, and participantsA total of 34 833 men in the core age group, 55–69 yr, were randomized to a screening or control arm in the Rotterdam section of the European Randomized Study of Screening for Prostate Cancer (ERSPC). Prostate-specific antigen (PSA) testing was offered to all men in the screening arm at 4-yr intervals. A prostate biopsy was offered to men with an elevated PSA. The primary end point was PCa-specific mortality.Outcome measurements and statistical analysisNonattendance was defined as nonparticipation in the screening arm. Contamination in the control arm was defined as receiving asymptomatic PSA testing or a prostate biopsy in the absence of symptoms. Relative risks (RRs) were calculated with an intention to screen (ITS) analysis and after correction for nonattendance and contamination using a method that preserves the benefits obtained by randomization.Results and limitationsThe ITS analysis resulted in an RR of 0.68 (95% confidence interval [CI], 0.53–0.89) in favor of screening at a median follow-up of 13 yr. Correction for both nonattendance and contamination resulted in an RR of 0.49 (95% CI, 0.27–0.87) in favor of screening.ConclusionsPCa screening as conducted in the Rotterdam section of the ERSPC can reduce the risk of dying from PCa up to 51% for an individual man choosing to be screened repeatedly compared with a man who was not screened. This benefit of screening should be balanced against the harms of overdiagnosis and subsequent overtreatment.Trial registrationISRCTN49127736.     

Adjuvant Radiotherapy for Patients with Locally Advanced Prostate Cancer-A New Standard?

CONTEXT: After radical prostatectomy (RPE) pathologically advanced disease is detected in 38% to 52% of patients. Retrospective data on the role of postoperative radiotherapy (RT) are controversial. OBJECTIVES: To clarify in how far an adjuvant radiation treatment (ART) in cases of locally advanced disease affects outcome, three randomised trials have been started. The available data are critically reviewed. EVIDENCE ACQUISITION: Relevant publications were detected by searching the Medical Literature Analysis and Retrieval System Online (MEDLINE) and the Public/Publisher MEDLINE (PUBMED; National Library of Medicine journal articles database) databases using the medical subject headings "prostatic neoplasms," "radiotherapy," and "adjuvant." A major emphasis was placed on the results of the randomised trials. EVIDENCE SYNTHESIS: The European Organization for Research and Treatment of Cancer (EORTC) trial number 22911, Southwest Oncology Group (SWOG) trial number 8794, and German Intergroup trial ARO 96-02/AUO AP 09/95 randomised patients to receive ART with 60 Gray (Gy) and 60-64 Gy (SWOG trial), respectively. The majority of patients had undetectable PSA levels postoperatively. The data concordantly show that ART improves biochemical progression-free survival rates (EORTC trial, progression-free survival rate after 5 yr: 74.0% with ART vs 52.6% without ART; SWOG trial, after 5 yr: approximately 73% vs approximately 44%, respectively; and ARO 96-02/AUO AP 09/95 trial, after 5 yr: 72% vs 54%, respectively). The EORTC trial shows improved local control of cancer progression (p<0.0001) for treated patients. The SWOG trial demonstrates an improved freedom from hormonal treatment (5-yr: 21% with ART vs 10% without ART). A statistically significant benefit with regard to metastasis-free survival and overall survival was not seen. Genitourinary and gastrointestinal toxicity was moderate, with late side-effects (> or = grade 3) between 3% (in the ARO 96-02 trial) and <5% (in the EORTC trial). CONCLUSION: Biochemical progression-free survival and local control are significantly improved by postoperative RT with 60 Gy. Patients should be offered adjuvant treatment when they are at high risk for local relapse (especially with positive surgical margins).     

Real-time Magnetic Resonance–guided High-intensity Focused Ultrasound Focal Therapy for Localised Prostate Cancer: Preliminary Experience

Five patients with unifocal, biopsy-proven prostate cancer (PCa) evident on multiparametric magnetic resonance imaging (MRI) were treated with magnetic resonance–guided focused ultrasound (MRgFUS) ablation before radical prostatectomy (RP). An endorectal probe featuring a phased-array focused ultrasound transducer was positioned for lesion ablation under MRI guidance. The tissue temperature and accumulation of thermal damage in the target zone was monitored during the procedure by MRI thermometry. Overlap between the ablation area and the devascularisation of the target lesion was evaluated by contrast-enhanced MRI performed immediately after treatment. The procedure was uneventful, and no adverse events were observed. RP was safely performed without significant surgical difficulties in relation to the previous MRgFUS treatment. The histopathology report showed extensive coagulative necrosis, with no residual tumour in the ablated area. Significant bilateral residual tumour, not evident on pretreatment MRI, was observed outside the treated area in two patients. MRgFUS ablation of focal localised PCa is feasible and, if confirmed in appropriate studies, could represent a valid option for the focal treatment of localised PCa.     

Prevalence of Hypospadias in Danish Boys: A Longitudinal Study, 1977–2005

Background

Hypospadias is a relatively common congenital malformation. Data on temporal trends in prevalence of hypospadias are conflicting. It is unclear whether changes of maternal age distribution over time are associated with changes in hypospadias prevalence.

Objective

To study changes in prevalence of hypospadias in Denmark during a 29-yr period and to investigate whether maternal age was associated with the prevalence of hypospadias.

Design, setting, and participants

Through Denmark's National Patient Registry, covering all Danish hospitals, we identified all boys diagnosed with hypospadias in Denmark. From the Danish Medical Birth Registry, we obtained information on maternal age and on the annual total number of live-born boys from 1977 to 2005.

Measurements

Prevalence of hypospadias at birth.

Results and limitations

Among 921 745 boys born alive from 1977 to 2005, we identified 3490 boys with hypospadias. The prevalence increased from 0.24% in 1977 to 0.52% in 2005, corresponding with an annual increase in prevalence of 2.40% (95% confidence interval: 1.94–2.86). The prevalence of hypospadias did not differ according to maternal age. The mean annual prevalence was 0.38% in sons of mothers aged ≤25 yr, 0.37% in sons of mothers aged 26–30 yr, 0.39% in sons of mothers aged 31–35 yr, and 0.39% in sons of mothers >35 yr.

Conclusions

The hypospadias prevalence was increasing in Denmark from 1977 to 2005. Increased maternal age did not explain this trend.     

Image-Guided Prostate Biopsy Using Magnetic Resonance Imaging–Derived Targets: A Systematic Review

Context

Technical improvements in prostate magnetic resonance imaging (MRI) have resulted in the use of MRI to target prostate biopsies.

Objective

To systematically review the literature to compare the accuracy of MRI-targeted biopsy with standard transrectal biopsy in the detection of clinically significant prostate cancer.

Evidence acquisition

The PubMed, Embase, and Cochrane databases were searched from inception until December 3, 2011, using the search criteria ‘prostate OR prostate cancer’ AND ‘magnetic resonance imaging OR MRI’ AND ‘biopsy OR target’. Four reviewers independently assessed 4222 records; 222 records required full review. Fifty unique records (corresponding to 16 discrete patient populations) directly compared an MRI-targeted with a standard transrectal approach.

Evidence synthesis

Evidence synthesis was used to address specific questions. Where MRI was applied to all biopsy-naive men, 62% (374 of 599) had MRI abnormalities. When subjected to a targeted biopsy, 66% (248 of 374) had prostate cancer detected. Both targeted and standard biopsy detected clinically significant cancer in 43% (236 or 237 of 555, respectively). Missed clinically significant cancers occurred in 13 men using targeted biopsy and 12 using a standard approach. Targeted biopsy was more efficient. A third fewer men were biopsied overall. Those who had biopsy required a mean of 3.8 targeted cores compared with 12 standard cores. A targeted approach avoided the diagnosis of clinically insignificant cancer in 53 of 555 (10%) of the presenting population.

Conclusions

MRI-guided biopsy detects clinically significant prostate cancer in an equivalent number of men versus standard biopsy. This is achieved using fewer biopsies in fewer men, with a reduction in the diagnosis of clinically insignificant cancer. Variability in study methodology limits the strength of recommendation that can be made. There is a need for a robust multicentre trial of targeted biopsies.     

Survival Benefit of Radical Prostatectomy in Lymph Node–Positive Patients with Prostate Cancer

Background

Positive lymph node (LN) status is considered a systemic disease state. In prostate cancer, LN-positive diagnosis during pelvic LN dissection (PLND) potentially leads to the abandonment of radical prostatectomy (RP).

Objective

To compare the overall survival (OS) and relative survival (RS; as an estimate for cancer-specific survival) in LN-positive patients with or without RP.

Design, setting, and participants

Between 1988 and 2007, a total of 35 629 men with prostate cancer were identified at the Munich Cancer Registry; of those, 1413 patients had positive LNs.

Intervention

Of these 1413 LN-positive patients, prostatectomy was abandoned in 456 LN-positive patients, whereas 957 underwent RP despite the LN-positive finding.

Measurements

Crucial analyses are based on 938 LN-positive patients (688 with RP and 250 without RP) with complete data regarding age, grade, and prostate-specific antigen (PSA). OS (Kaplan-Meier estimates) and RS are presented, and Cox regression analysis was used to show the influence of predictors such as clinical stage, age at surgery, number of positive LNs, PSA level, grade, and extent of surgery.

Results

Median follow-up was 5.6 yr. OS of patients at 5 yr and 10 yr was 84% and 64%, respectively, with RP and was 60% and 28%, respectively, with aborted RP. The RS of patients at 5 yr and 10 yr was 95% and 86%, respectively, with RP and was 70% and 40%, respectively, with abandoned surgery. There was an imbalance, however, in the number of positive LNs: 17.2% with RP had four or more positive nodes versus 28% in the patient group without RP. In the multivariate model, RP was a strong independent predictor of survival (hazard ratio: 2.04 [95% confidence interval, 1.59–2.63; p < 0.0001]).

Conclusion

LN-positive patients with complete RP had improved survival compared to patients with abandoned RP. These results suggest that RP may have a survival benefit and the abandonment of RP in node-positive cases may not be justified.     

Real-Time Magnetic Resonance Imaging–Guided Focal Laser Therapy in Patients with Low-Risk Prostate Cancer

Two patients with low-risk prostate cancer (PCa) were treated with outpatient in-bore magnetic resonance imaging (MRI)–guided focal laser ablation.     

Could Differences in Treatment Between Trial Arms Explain the Reduction in Prostate Cancer Mortality in the European Randomized Study of Screening for Prostate Cancer?

BackgroundDifferential treatment between trial arms has been suggested to bias prostate cancer (PC) mortality in the European Randomized Study of Screening for Prostate Cancer (ERSPC).ObjectiveTo quantify the contribution of treatment differences to the observed PC mortality reduction between the screening arm (SA) and the control arm (CA).Design, setting, and participantsA total of 14 136 men with PC (SA: 7310; CA: 6826) in the core age group (55–69 yr) at 16 yr of follow-up.Outcome measurements and statistical analysisThe outcomes measurements were observed and estimated numbers of PC deaths by treatment allocation in the SA and CA, respectively. Primary treatment allocation was modeled using multinomial logistic regression adjusting for center, age, year, prostate-specific antigen, grade group, and tumor-node-metastasis stage. For each treatment, logistic regression models were fitted for risk of PC death, separately for the SA and CA, and using the same covariates as for the treatment allocation model. Treatment probabilities were multiplied by estimated PC death risks for each treatment based on one arm, and then summed and compared with the observed number of deaths.Results and limitationsThe difference between the observed and estimated treatment distributions (hormonal therapy, radical prostatectomy, radiotherapy, and active surveillance/watchful waiting) in the two arms ranged from −3.3% to 3.3%. These figures, which represent the part of the treatment differences between arms that cannot be explained by clinicopathological differences, are small compared with the observed differences between arms that ranged between 7.2% and 10.1%. The difference between the observed and estimated numbers of PC deaths among men with PC was 0.05% (95% confidence interval [CI] −0.1%, 0.2%) when applying the CA model to the SA, had the two groups received identical primary treatment, given their clinical characteristics. When instead applying the SA model to the CA, the difference was, as expected, very similar—0.01% (95% CI −0.3%, 0.2%). Consistency of the results of the models demonstrates the robustness of the modeling approach. As the observed difference between trial arms was 4.2%, our findings suggest that differential treatment explains only a trivial proportion of the main findings of ERSPC. A limitation of the study is that only data on primary treatment were available.ConclusionsUse of prostate-specific antigen remains the predominant explanation for the reduction in PC mortality seen in the ERSPC trial and is not attributable to differential treatment between trial arms.Patient summaryThis study shows that prostate cancer deaths in the European screening trial (European Randomized Study of Screening for Prostate Cancer) were prevented because men were diagnosed and treated earlier through prostate-specific antigen screening, and not because of different, or better, treatment in the screening arm compared with the control arm.     

Renal Tumor Biopsies for Evaluation of Small Renal Tumors: Why,in Whom,and How?

Context

Renal tumor biopsies (RTBs) gained popularity in the evaluation of small renal tumors (SRTs) because imaging alone is insufficient to show the underlying aggressiveness of SRTs and more ablative therapies without definitive histology are available.

Objective

To describe why, in whom, and how RTB should be performed for the evaluation of SRTs.

Evidence acquisition

Data were obtained from English-language studies on the use of RTB for the evaluation of solid SRTs in vivo listed in PubMed.

Evidence synthesis

The reasons for RTBs are (1) the increasing incidence of SRTs; (2) the finding that a significant number of SRTs (20%) are benign; (3) the availability of new management options, such as ablative therapy and surveillance strategies; and (4) the fact that imaging alone is unable to predict biologic behavior. In addition, advances in pathologic evaluation have improved the ability of RTB to differentiate the underlying tumor.Three studies of RTB for SRTs in vivo performed under computed tomography (CT) guidance together with a complete histopathologic evaluation gave accuracies for predicting malignancy, grading, and renal cell cancer subtype of 92–96%, 70–76%, and 78–92%, respectively. RTB was insufficient or inconclusive in 3–21% of cases. RTB was underutilized in ablative therapies of SRT (20–45% had no or inconclusive histology). The use of RTB was limited in multiple renal tumors and hybrid tumors. The complication rate was low (<5%), major complications were very rare (<1%), and tumor spreading has been reported only anecdotally. RTB are recommended to help in differentiating benign from malignant SRTs prior or during ablative therapies and in follow-up, especially after radiofrequency (RF) ablation.

Conclusions

RTB is a safe and accurate procedure by which to evaluate SRTs. RTB can help in defining patient management—especially the use of ablative surgery—and to find benign renal tumors.     

Neoadjuvant Temsirolimus Effectiveness in Downstaging Advanced Non–Clear Cell Renal Cell Carcinoma

A 35-year-old woman presented with a 12-cm right renal mass with retroperitoneal lymph node involvement and pulmonary and bone metastases. Renal mass biopsy revealed an unclassified high-grade non–clear cell renal cell carcinoma (RCC) with eosinophilic cells. Due to the extent of the disease, neoadjuvant temsirolimus was initiated. After 6 wk of treatment, a significant downstaging of the disease and complete disappearance of the metastases were noticed on computed tomography scan. Three months later, a laparoscopic radical nephrectomy and lymphadenectomy was performed. Final pathology confirmed a high-grade non–clear cell RCC, with necrotic changes on lymph node specimens, pT1bN0Mx.     

The Role of Radical Prostatectomy and Lymph Node Dissection in Lymph Node–Positive Prostate Cancer: A Systematic Review of the Literature

Context

Because pelvic lymph node (LN)-positive prostate cancer (PCa) is generally considered a regionally metastatic disease, surgery needs to be better defined.

Objective

To review the impact of radical prostatectomy (RP) and pelvic lymph node dissection (PLND), possibly in conjunction with a multimodal approach using local radiotherapy and/or androgen-deprivation therapy (ADT), in LN-positive PCa.

Evidence acquisition

A systematic Medline search for studies reporting on treatment regimens and outcomes in patients with LN-positive PCa undergoing RP between 1993 and 2012 was performed.

Evidence synthesis

RP can improve progression-free and overall survival in LN-positive PCa, although there is a lack of high-level evidence. Therefore, the former practice of aborting surgery in the presence of positive nodes might no longer be supported by current evidence, especially in those patients with a limited LN tumor burden. Current data demonstrate that the lymphatic spread takes an ascending pathway from the pelvis to the retroperitoneum, in which the internal and the common iliac nodes represent critical landmarks in the metastatic distribution. Sophisticated imaging technologies are still under investigation to improve the prediction of LN-positive PCa. Nonetheless, extended PLND including the common iliac arteries should be offered to intermediate- and high-risk patients to improve nodal staging with a possible benefit in prostate-specific antigen progression-free survival by removing significant metastatic load. Adjuvant ADT has the potential to improve overall survival after RP; the therapeutic role of a trimodal approach with adjuvant local radiotherapy awaits further elucidation. Age is a critical parameter for survival because cancer-specific mortality exceeds overall mortality in younger patients (<60 yr) with high-risk PCa and should be an impetus to treat as thoroughly as possible.

Conclusions

Increasing evidence suggests that RP and extended PLND improve survival in LN-positive PCa. Our understanding of surgery of the primary tumor in LN-positive PCa needs a conceptual change from a palliative option to the first step in a multimodal approach with a significant improvement of long-term survival and cure in selected patients.     

Should All Patients with Non–Muscle-Invasive Bladder Cancer Receive Early Intravesical Chemotherapy after Transurethral Resection? The Results of a Prospective Randomised Multicentre Study

Background

To decrease recurrences in non–muscle-invasive bladder cancer (NMIBC), the European Association of Urology (EAU) guidelines recommend immediate, intravesical chemotherapy after transurethral resection (TUR) for all patients with Ta/T1 tumours.

Objective

To study the benefits of a single, early, intravesical instillation of epirubicin after TUR in patients with low- to intermediate-risk NMIBC.

Design, setting, and participants

In this prospective randomised multicentre trial, 305 patients with primary as well as recurrent low- to intermediate-risk (Ta/T1, G1/G2) tumours were enrolled between 1997 and 2004. Patients were randomly allocated to receive 80 mg of epirubicin in 50 ml of saline intravesically within 24 h of TUR or no further treatment after TUR.

Measurements

The primary end point was time to first recurrence.

Results and limitations

A total of 219 patients remained for analysis after exclusions. The median follow-up time was 3.9 yr. During the study period, 62% (63 of 102) of the patients in the epirubicin group and 77% (90 of 117) in the control group experienced recurrence (p = 0.016). In a multivariate model, the hazard ratio (HR) for recurrence was 0.56 (p = 0.002) for early instillation of epirubicin versus no treatment. In a subgroup analysis, the treatment had a profound recurrence-reducing effect on patients with primary, solitary tumours, whereas it provided no benefits in patients with recurrent or multiple tumours. Furthermore, patients with a modified European Organisation for Research and Treatment of Cancer (EORTC) risk score of 0–2 with and without single instillation had recurrence rates of 41% and 69%, respectively (p = 0.003), whereas the corresponding rates for those with a risk score of ≥3 were 81% and 85%, respectively (p = 0.35).

Conclusions

A single, early instillation of epirubicin after TUR for NMIBC reduces the likelihood of tumour recurrence; however, the benefit seems to be minimal in patients at intermediate or high risk of recurrence. Future trials will determine the value of early instillation in addition to serial instillations in NMIBC.     

Mini–Retroperitoneoscopic Clampless Partial Nephrectomy for “Low-complexity” Renal Tumours (PADUA Score ≤8)

An alternative to conventional laparoscopy when looking for virtually scarless surgery is mini-laparoscopy, a reproducible technique that preserves the triangulation concept. A drawback of this approach is the poor image quality provided by mini-scopes. The introduction of the SPIEs technology, a novel endoscopic camera allowing for better visualisation of anatomic details even with 3-mm optics, has boosted the use of a mini-laparoscopic approach in our centre for laparoscopic partial nephrectomy (LPN) to treat low-complexity renal masses. Allowing for inclusion criteria, 10 consecutive patients who satisfied inclusion criteria were enrolled in our prospective study undergoing clampless mini-retroperitoneoscopic LPN performed by a single surgeon with laparoscopic expertise. Preliminary data show that the approach seems to be safe and effective, with comparable outcomes to conventional LPN. Larger sample size and comparative studies are needed to confirm these findings. The evaluation of cosmetic results will be the focus of further studies.     

Durable Complete Response to Frontline Docetaxel in an Advanced Prostate Cancer Patient with Favourable CYP1B1 Isoforms: Suggestion for Changing Paradigms?

Docetaxel is currently indicated for androgen-independent, metastatic prostate cancer; there is also evidence demonstrating the role of CYP1B1 in modulating the activity of the drug. We present the case of a man with residual disease after radical prostatectomy treated successfully with docetaxel chemotherapy. After only two cycles of therapy, a complete remission was obtained and then consolidated with additional cycles of docetaxel and radiotherapy. Prospective genetic analysis had shown that the patient had a favourable CYP1B1 genotype. He has been disease free since August 2006. Prospective trials investigating this strategy are warranted.     

A Critical Analysis of Orthotopic Bladder Substitutes in Adult Patients with Bladder Cancer: Is There a Perfect Solution?

Context

Orthotopic bladder substitute (OBS) has been popularized over the past 2 decades as a diversion following radical cystectomy for invasive bladder cancer. Various reports, mostly single-center experiences, are published on patients with OBS.

Objective

This study reviews the literature regarding indications, postoperative care, complications, quality-of-life measures, as well as functional and oncologic outcomes that have been published on patients with OBS.

Evidence acquisition

An English-language literature review of the Medline database (1990 to January 2010) of published data on patients with OBS following radical cystectomy for bladder cancer was undertaken. Articles that included surgery for noncancer etiology were excluded.

Evidence synthesis

Indications and patient selection criteria have significantly widened over the past 2 decades. Comparable oncologic data have been reported between patients with OBS versus other diversions. Secondary urethral tumors seem less common in patients with OBS compared with those with conduits or continent cutaneous diversions. Durable daytime and nocturnal continence is achieved in 85–90% and 60–80%, respectively. Continence is inferior in elderly patients with OBS. Urinary retention remains significant in the female patients, ranging from 25% to 50%. Complications including electrolyte disturbances, altered sensorium and drug metabolism, mucus retention, rupture, urinary tract infections, and upper tract deterioration are reviewed.

Conclusions

Indications for OBS following radical cystectomy in patients with invasive bladder cancer have significantly widened over the past 2 decades. An OBS should be offered to both male and female patients in the absence of contraindications. Good long-term functional and oncologic outcomes can be achieved in patients with OBS treated in high-volume institutions by experienced surgeons with specific knowledge in the field. Preoperative patient information, patient selection, surgical techniques, and careful postoperative follow-up are the cornerstones to achieve good long-term results.     

Do Patients Benefit from Routine Follow-up to Detect Recurrences After Radical Cystectomy and Ileal Orthotopic Bladder Substitution?

Background

The need for and intensity of follow-up to detect disease recurrence after radical cystectomy (RC) for transitional cell carcinoma (TCC) remains a matter for debate.

Objective

To determine whether diagnosis of asymptomatic recurrence after RC by routine follow-up investigations confers a survival benefit versus symptomatic recurrence.

Design, setting, and participants

Retrospective analysis of 479 patients with nonmetastatic bladder TCC receiving no neoadjuvant chemotherapy/radiation therapy and prospectively followed with a standardised protocol for a median 4.3 yr (range: 0.3–20.9) after RC at an academic tertiary referral centre.

Intervention

RC and extended pelvic lymph node dissection with ileal orthotopic bladder substitution.

Measurements

Cancer-specific survival (CSS) and overall survival (OS) probability for asymptomatic and symptomatic recurrent patients were estimated using the Kaplan-Meier method. The effects of age, nerve-sparing surgery, pathologic tumour stage, lymph node status, adjuvant chemotherapy, mode of recurrence diagnosis, and recurrence site on survival were assessed with multivariable Cox regression models.

Results and limitations

Of the 174 of 479 patients (36.3%) with tumour recurrence, 87 were diagnosed by routine follow-up investigations and 87 by symptoms. Routine follow-up mostly detected lung metastases and urethral recurrences, while symptoms were predominantly the result of bone metastases and concomitant pelvic/distant recurrences. Of 24 patients with urethral recurrences, 13 had carcinoma in situ (CIS). Of these, 12 were successfully managed with urethra-sparing treatment, and 6 are still alive with no evidence of disease. Most other recurrent long-term survivors had lung and extrapelvic lymph node metastases. Cumulative 5-yr survival rates of the entire cohort were 69.8% (95% confidence interval [CI], 65.5–74.3%) for CSS and 61.9% (95% CI, 57.4–66.7%) for OS. In multivariable analysis, mode of recurrence diagnosis and site of initial recurrence were the only independent predictors of CSS and OS. Patients with recurrences detected by routine follow-up investigations and with secondary urothelial tumours as site of recurrence had a slightly but significantly higher survival probability.

Conclusions

Patients diagnosed with asymptomatic recurrences during our routine follow-up after RC had a slightly higher survival than patients with symptomatic recurrences. Routine follow-up appears particularly effective in early detection of urethral CIS, which can be treated conservatively. In addition, the predominance of lung and extrapelvic lymph node metastases in survivors may justify the use of routine cross-sectional imaging.