Radical cystectomy for invasive tumors of the bladder in patients over 70 years of age

The authors present a series of forty patients operated for invasive bladder tumors by radical cystectomy. All patients were older than 70 and had a complicated medical history. Mortality was 1 in 40 and the morbidity was low. The conclusion is that radical cystectomy is a safe procedure in elderly patients.     

Tumor recurrence in the remnant urothelium of females undergoing radical cystectomy for transitional cell carcinoma of the bladder: long-term results from a single center

PURPOSE: We analyzed the risk factors and incidence of secondary TCC of the remnant urothelium in women following radical cystectomy for TCC of the bladder. MATERIALS AND METHODS: A total of 85 women with a mean age of 64.5 years with clinically localized TCC of the bladder underwent radical cystectomy between 1992 and 2004. Orthotopic bladder substitution was performed in 46 females, while 39 underwent nonorthotopic urinary diversion. Of the entire cohort 22 (26%) patients underwent cystectomy for multifocal or recurrent TCC. Followup examinations were performed at 6-month intervals. RESULTS: Mean followup in the entire cohort was 49.8 months (median 42). Intraoperative frozen sections obtained from the urethra and distal ureters were negative for TCC and CIS in all patients. Four women (4.7%) had TCC in the remnant urothelium at a mean of 56 months postoperatively. These patients had undergone cystectomy for multifocal or recurrent TCC (4 of 22 or 18%). No secondary TCC was seen in the 63 patients with solitary invasive or nonrecurrent bladder cancer (p <0.05). Urethral recurrence was found in 2 patients (4.3%) 65 and 36 months after orthotopic neobladder surgery, respectively. In the orthotopic group 1 patient (2.1%) had an upper urinary tract tumor 76 months after surgery, while in the nonorthotopic group 1 (2.5%) was found to have an upper urinary tract tumor 48 months postoperatively. CONCLUSIONS: Recurrent or multifocal TCC may represent a risk factor for secondary TCC of the remnant urothelium after cystectomy. In our series all recurrent tumors were late recurrences (more than 36 months postoperatively). Because the rate of urethral recurrence in the current series corresponds to that reported in men (2% to 6%), urethra sparing cystectomy with orthotopic bladder replacement does not appear to compromise the oncological outcome in women.     

A predictive model of survival after radical cystectomy for carcinoma of the bladder

OBJECTIVE: To evaluate the effect of patient and tumour characteristics on the disease-free survival after radical cystectomy for infiltrating bladder cancer, and to use these to help in constructing a meaningful prognostic index. METHODS: The disease-free survival was initially evaluated in 1026 patients (the reference series, 1969-1990). A multivariate analysis showed that the tumour P stage, grade and nodal involvement were the only factors which had an independent and significant association with survival. The computed regression coefficients were then used to classify patients into one of four risk categories and the results then validated by applying the model to a prospective test series (1991-1995). RESULTS: The 5-year disease-free survival of both groups was similar. When the results for the risk categories of the reference series were compared with those of the test series, there was no significant difference. CONCLUSION: This comprehensive prognostic model for the results of radical cystectomy was validated and verified in a prospective group of patients. Adjuvant therapies are indicated for patients with a high risk score.     

Analysis of early complications after radical cystectomy: results of a collaborative care pathway

PURPOSE: We examined our recent series of patients who underwent radical cystectomy to determine and analyze the early perioperative morbidity of the procedure in a contemporary series treated with the guidance of a clinical pathway. MATERIALS AND METHODS: We reviewed the records of 304 consecutive patients who underwent radical cystectomy from December 1995 to July 2000. We specifically evaluated complications that developed within 30 days of the procedure. Potential variables predictive of early morbidity were analyzed, including patient age, gender, race, American Society of Anesthesiologists score, type of urinary diversion, smoking history, estimated blood loss, transfusion requirement, pathological stage and operative time. RESULTS: The overall minor complication rate was 30.9% (94 of 304 patients). Postoperative ileus was the most common minor complication, affecting 54 patients (18%). Increased blood loss and major complications predicted a significantly higher likelihood of ileus on multivariate analysis (p = 0.02 and 0.001, respectively). Major complications in 15 patients (4.9%) correlated with higher American Society of Anesthesiologists score, surgical intensive care unit admission and transfusion requirement (p = 0.01, <0.001 and 0.001, respectively). The early mortality rate was 0.3% (1 patient). CONCLUSIONS: Within the framework of a clinical pathway, radical cystectomy can be performed safely with an acceptable rate of early minor and major complications. Delay in the return of bowel function is the most common minor complication. Increased estimated blood loss, transfusion requirement and a major complication predicted a higher likelihood of postoperative ileus. The acceptable rate of early morbidity in this series in a 5-year period validates its use in patients undergoing radical cystectomy.     

Upper tract tumours following cystectomy for bladder cancer. Is routine intravenous urography worthwhile?

The incidence and presentation of upper tract tumours were studied in 180 patients who had previously undergone cystectomy for transitional cell carcinoma of the bladder. Intravenous urography was performed routinely 3 months after cystectomy, 1 year later and at 3-yearly intervals thereafter. Ten patients developed upper tract tumours; 1 presented with loin pain and the remainder with haematuria. Six patients underwent nephroureterectomy and 5 of them lived for at least 4 years; 4 were inoperable and only 1 survived longer than 6 months. In this series, all patients with upper tract tumours presented with symptoms and routine intravenous urography failed to detect any asymptomatic lesions. Routine radiological assessment of the upper tracts to detect tumours is not justified following cystectomy.     

Robot‐assisted radical cystectomy: intermediate survival results at a mean follow‐up of 25 months

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To assess the overall and disease‐specific survival rates of patients undergoing robot‐assisted radical cystectomy (RARC) compared with historical open cystectomy.

PATIENTS AND METHODS

Survival, pathological and demographic data were collected on all patients undergoing RARC for bladder cancer from both Tulane University Medical Center and Mayo Clinic Arizona. Of a total of 80 RARCs we only included those with a follow‐up of ≥6 months from surgery. Survival curves were compared with those from historical series of open cystectomy.

RESULTS

Of the 80 patients 59 were identified as having a follow‐up of ≥6 months from the date of surgery. The mean (range) follow‐up was 25 (6–49) months. Overall survival rates at 12 and 36 months were 82% and 69%, respectively, and disease‐specific survival rates were 82% and 72% at 12 and 36 months, respectively. These results are comparable to survival rates from open cystectomy. As expected, patients with lymph node‐positive disease fared worse than those with lymph node‐negative disease. Patients with extravesical lymph node‐negative disease (pT3, pT4) fared worse than patients with organ‐confined lymph node‐negative disease. Also, patients with lymph node‐positive disease fared worse than those with extravesical lymph node‐negative disease, which is consistent with historical results of open cystectomy.

CONCLUSIONS

RARC has a comparable survival rate to open cystectomy in the intermediate follow‐up. Further study with a longer follow‐up and more patients is necessary to determine any long‐term survival benefits.     

Transitional cell carcinoma of the urethra in men after radical cystectomy for bladder cancer. Is prophylactic urethrectomy indicated?

A retrospective study of the incidence and clinical course of transitional cell carcinoma of the urethra is reported. Of 110 consecutive male patients who underwent cystectomy during a 9-year period, 9 had or developed a urethral tumour. Five patients undergoing radical cystectomy had known or suspected urethral involvement which was confirmed at urethrectomy. All 5 had deeply invasive (T3 or T4) transitional cell carcinomas of the bladder and subsequently died of metastatic disease. Four patients underwent urethrectomy because of signs or symptoms of urethral recurrence at an average interval of 2.5 years after cystectomy. There were two deaths in this group, neither of which appeared to be due to urethral recurrence. Six additional patients had undergone prophylactic urethrectomy because of prostatic urethral involvement or diffuse carcinoma in situ in the cystectomy specimen, and none had identifiable tumour in the anterior urethra. The residual urethra is a potential focus for recurrent tumour and this necessitates careful follow-up with serial cytology, but the low incidence of urethral recurrence (3.5% in this series) does not appear to warrant routine urethrectomy at the time of cystectomy.     

浸润性膀胱癌腹腔镜下根治性膀胱切除术43例

目的 探讨腹腔镜下根治性膀胱切除的手术方法和临床体会.方法 自2003年12月至2006年10月我们对43例浸润性膀胱癌患者实施了腹腔镜根治性膀胱切除术.手术采用经腹腔入路5部位穿刺法.结果 43例手术中,18例行输尿管皮肤造口术,25例行回肠膀胱术.2例因术中损伤直肠中转开腹行直肠修补术,1例术后放置肛管引流1周,另1例则行乙状结肠造瘘术.41例手术获得成功,腹腔镜下切除全膀胱连同淋巴结清扫的手术时间为140～270 min,平均195.4 min;术中出血150～700 ml,平均273.7 ml,术中术后输血3例;术后2～3 d下床活动;术后病理示3例盆腔淋巴结阳性.结论 腹腔镜根治性膀胱切除术治疗浸润性膀胱癌安全可行,能明显减小手术创伤、减少手术并发症、缩短患者恢复时间.     

Prognosis of bladder carcinoma in patients treated with cystectomy

Prognostic criteria for bladder tumors are the stage and grade of the tumor in the present series of 82 patients, in which all patients received the same treatment. These criteria are related and the combined evaluation increases the prognostic accuracy for the disease. In addition, the diameter and not the number of bladder tumors on primary diagnosis is an important prognostic sign. A significant number of tumors at the first clinical evaluation were apparently understaged and undergraded and to a lesser degree overstaged and overgraded as compared with cystectomy specimen evaluations. Despite the total cystectomy, even the patients with superficial bladder lesions, a significant number died from the bladder tumor and 1/4 of the patients had metastases at post mortem examination. The 5 year overall survival with total cystectomy was 40% and for 10 years 15%. Other adjuvant forms of therapy pre- and post-operatively must be assessed.     

Prognostic significance of vascular invasion in patients with bladder cancer who underwent radical cystectomy

BACKGROUND: The objective of this study was to determine whether vascular invasion (i.e. lymphatic and blood vessel invasion) could be a useful prognostic predictor in patients with locally invasive transitional cell carcinoma (TCC) of the bladder who underwent radical cystectomy. METHODS: This series included 114 consecutive patients undergoing radical cystectomy for primary TCC of the bladder between November 1989 and July 2003. Several clinicopathological characteristics of these patients were analyzed, focusing on the association between vascular invasion and disease recurrence after radical cystectomy. RESULTS: Lymphatic and blood vessel invasions were detected in 55 (48.2%) and 33 (29.8%) specimens, respectively. Lymphatic invasion was significantly associated with pathological stage, tumor grade, lymph node metastasis, blood vessel invasion and disease recurrence, whereas blood vessel invasion was significantly related to pathological stage, lymph node metastasis, lymphatic invasion and disease recurrence. Recurrence-free survival in patients with lymphatic invasion was significantly lower than that in those without lymphatic invasion, and a similar significant difference in recurrence-free survival was observed between patients with and without blood vessel invasion. However, multivariate analysis using the Cox proportional hazards model showed that only pathological stage and lymph node metastasis could be used as independent predictors for disease recurrence after radical cystectomy. CONCLUSIONS: Despite a significant association between several prognostic parameters, vascular invasion was not an independent predictor of disease recurrence; therefore, if there are other conventional parameters available, there might not be any additional advantage to considering the presence of vascular invasion when predicting the prognosis of patients undergoing radical cystectomy for TCC of the bladder.     

Our experience in the surgical treatment of peritoneal hydatid disease

The Authors report on a series of 9 patients with peritoneal hydatidosis submitted to surgery during the period between 1974 and 2003. In 5 cases the cyst was solitary, while in 3 patients the cysts were multiple, in 1 spread and in 2 there was a concomitant liver hydatidosis. In 2 patients the disease was asymptomatic, while 4 cases were revealed by pain and 3 by an abdominal mass. The diagnosis was made at the operation in 3 patients, while it was performed by ultrasonography in 1 case, by CT scan in 4 and by both methods in 1. All patients were operated on: 7 underwent total cystectomy and partial cystectomy with external drainage of residual cavity was performed in one; the spread disease was managed by omentectomy, ovariectomy and appendectomy. Postoperative course was regular without mortality and major morbidity in all patients. Two recurrences occurred 71 and 20 months after removal of the primary cysts and they were managed by total cystectomy. The Authors believe that the diagnosis of peritoneal hydatid disease is today more accurate because of the new image techniques and the surgical procedure should be tailored to each patient depending on size, location and complications of the cyst, although the results of radical treatment are better.     

A study of the morbidity,mortality and long-term survival following radical cystectomy and radical radiotherapy in the treatment of invasive bladder cancer in Yorkshire

OBJECTIVES: To study the morbidity of radical cystectomy and radical radiotherapy in the treatment of patients with invasive carcinoma of the bladder and to report the long-term survival following these treatments. PATIENT AND METHODS: 398 patients with invasive carcinoma of the bladder treated between 1993 and 1996 in the Yorkshire region were studied. Of 398 patients studied, 302 patients received radical radiotherapy and 96 underwent radical cystectomy. A retrospective review of patients' case notes was performed to construct a highly detailed database. Crude estimates of survival differences were derived using Kaplan-Meier methods. Log-rank tests (or, where appropriate, Wilcoxon tests) were used to test for the equality of these survivor functions. These functions were produced as all-cause survival. The proportional hazards regression modelling was used to assess the impact of definitive treatment on survival. A backwards-stepwise approach was used to derive a final predictive model of survival, with likelihood ratio tests to assess the statistical significance of variables to be included in the model. RESULTS: The patients undergoing radiotherapy were significantly older (mean age: 71 years versus 66 years), but no difference was identified in the distribution of American Society of Anaesthesiologists (ASA) grades in the two treatment groups. The stage distribution of cases in the treatment groups was not significantly different. Significant treatment delays were observed in both treatment groups. The median time from being seen in the clinic to transurethral resection of bladder tumour (TURBT) and subsequent radical treatment (cystectomy or radiotherapy) was 4.3 and 9 weeks, respectively. Age was the most significant independent factor accounting for treatment delays (p < 0.001). The 30-day and 3-month treatment-associated mortality for radical cystectomy and radiotherapy was 3.1% and 8.3% and 0.3% and 1.65%. Of the patients who received radiotherapy, 57 (18.8%) were subsequently subjected to a salvage cystectomy. For these 57 patients, 30-day and 3-month mortality after the salvage cystectomy were 8.8% and 15.7%. Gastrointestinal complications were the major source of early morbidity after primary and salvage cystectomy. Bowel leakage occurred in 3% following radical and 8.7% after salvage cystectomy. Bowel complications (leakage and obstruction) were the major cause of death following salvage cystectomy. No specific cause was predominant in those undergoing radical cystectomy with intestinal anastomotic leakage and urinary leakage accounting for one death each. Exacerbation of co-morbid conditions accounted for the remaining causes of mortality. Urinary leakage occurred in 4% following both forms of cystectomy. Recurrent pyelonephritis and intestinal obstruction were responsible for the majority of complications in the follow-up period. Bladder and gastrointestinal complications accounted for the majority of complications following radical radiotherapy. Some degree of irritative bladder and rectal were noted commonly. Severe bladder problems, which rendered the bladder non-functional or required surgical correction, occurred in 6.3% of patients. 2.3% of patients underwent surgery for bowel obstruction related to radiotherapy induced bowel strictures. Following radiotherapy, 43.6% of patients had a recurrence in the bladder at varying intervals post-treatment. Of these, 40% had > or =T2 disease. The 5-year survival following radiotherapy (with or without salvage cystectomy) was 37.4% while 36.5% of patients were alive 5 years after radical cystectomy. There was no statistically significant difference in the overall 5-year survival figures between the two primary treatments. Tumour stage, ASA grade and sex were the only independent predictors of 5-year survival on multivariate analysis. CONCLUSIONS: This retrospective regional study shows that there is no significant difference in the 5-year survival of patients with invasive bladder cancer treated with either radical radiotherapy or radical cystectomy. All forms of radical treatment for bladder cancer are associated with a significant treatment-associated morbidity and mortality. Gastrointestinal complications were responsible for the majority of complications. The treatment-associated mortality at 3 months was two- or three-fold higher than the 30-day mortality; emphasising its importance as an indicator of the true risks of cystectomy. The clinical T stage, the sex and the ASA grade of the patient were the only independent predictors of survival. The data in this series suggests that radical radiotherapy and radical cystectomy should be both considered as valid primary treatment options for the management of invasive bladder cancer.     

Problems in the surgical treatment of interstitial cystitis.

Two series of patients with histologically proven interstitial cystitis that was unresponsive to hydrostatic bladder distension and intravesical chemotherapy with dimethyl sulfoxide have been studied. In the first series 24 patients were treated by subtotal cystectomy and substitution cystoplasty without further consideration; 8 of these 24 patients had persistent frequency due to active disease in the remaining trigone and/or urethra and in 2 cases this was severe. Because of this experience the second group of patients had routine biopsy of the trigone and assessment of urethral sensation as part of the initial assessment. In those in whom the trigone was unaffected, treatment was unchanged. If the trigone was affected, total cystourethrectomy was performed with substitution cystourethroplasty unless the patient chose or was advised to avoid surgery altogether or to have a simpler option such as conduit or continent urinary diversion. Trigonal biopsies should be part of the routine assessment of all patients being considered for surgery, since residual active disease is a major cause of dissatisfaction after subtotal cystectomy and substitution cystoplasty.     

Robot-assisted laparoscopic radical cystectomy: initial experience on 27 consecutive patients

Recent reports have demonstrated that robot-assisted laparoscopic cystectomy is technically feasible. We report technical and functional results of a large series of patients undergoing laparoscopic cystectomy with the da Vinci surgical system (DVSS). A total of 27 patients (24 males) underwent laparoscopic radical cystectomy with the DVSS (intuitive surgical) between January 2004 and December 2005. Indications for cystectomy were muscle-invasive transitional cell carcinoma (TCC) or leiomyosarcoma of the urinary bladder (n = 24) and bladder shrinking following prior radiotherapy for TCC. A pelvic lymphadenectomy was a routine part of the procedure. Urinary diversions were ilieal conduits (n = 19) and ileal neobladders (n = 8). Mean operating time was 340 min (range 150–450) with a mean blood loss of 301 ml (range 50–550). The mean number of lymph nodes retrieved during lymphadenectomy was 23. Surgical margins were negative except in one case. After a mean follow-up of 10.2 months, two perioperative (anastomotic leakage, adhesions) and three postoperative complications (ileus, intestinal fistula, urinary tract obstruction) occurred. Six out of seven patients reported satisfying erectile function following nerve-sparing surgery. Day-time continence was completely restored after a mean 3.5 months in seven of eight patients. Robot-assisted laparoscopic cystectomy is a safe procedure. Satisfying functional and oncological short-term results can be achieved within acceptable operating time limits.     

Robot-assisted laparoscopic radical cystectomy

Recent reports have demonstrated that robot-assisted laparoscopic cystectomy is technically feasible. However, wide-spread acceptance of this promising technique is limited due to long operating times and lacking long-term data especially on oncological outcome. After establishing robot-assisted laparoscopic prostatectomy (n=250) we report technical and functional results of a large series of patients undergoing laparoscopic cystectomy with the da Vinci surgical system (DVSS).27 patients (24 males) underwent laparoscopic radical cystectomy with the DVSS (Intuitive Surgical) between Jan 2004 and Dec 2006. Indications for cystectomy were muscle-invasive transitional cell carcinoma (TCC) or leiomyosarcoma of the urinary bladder (n=24) and bladder shrinking following prior radiotherapy for TCC (n=3). A pelvic lymphadenectomy was routine part of the procedure. Urinary diversions were ilieal conduits (n=19) and ileal neobladders (n=8).Mean operating time was 340 minutes (range 150-450) with a mean blood loss of 301 mL (range 50-550). The mean number of lymph nodes retrieved during lymphadenectomy was 23. Surgical margins were negative except in one case. After a mean follow-up of 10.2 months, 2 perioperative (anastomotic leakage, adhesions) and 3 postoperative complications (ileus, intestinal fistula) occurred. 6/7 patients reported satisfying erectile function following nerve-sparing surgery. Day-time continence was completely restored after a mean 3.5 months in 7/8 patients.Robot-assisted laparoscopic cystectomy is a safe procedure. Satisfying functional and oncological short-term results can be achieved within acceptable operating time limits.     

Superficial bladder cancer treated by total cystectomy: Tumour characteristics and patient survival

Of 113 patients with bladder cancer who underwent total cystectomy from January 1980 to December 1990, 30 (27%) had superficial tumours (pTa, pTis, and pT1). Nineteen of these 30 patients (63%) were primarily treated by total cystectomy and the remaining 11 (37%) had a past history of treatment for bladder cancer. Major reasons for choice of total cystectomy were multifocal tumours, frequent recurrence, and diffuse carcinoma in situ. Histologically stage pT1, grade 3 tumours were frequently accompanied by carcinoma in situ and often by lymphatic invasion. None of the 24 patients undergoing pelvic lymphadenectomy had lymph node metastasis. Of 25 male patients 15 (60%) underwent simultaneous prophylactic urethrectomy. Two of the remaining 10 males (20%) not undergoing this additional operation died of subsequent urethral recurrence. The 5-year actuarial survival rate was 80% for the 30 patients when all causes of death were considered. It was concluded that patients with superficial bladder cancer who undergo total cystectomy without prophylactic urethrectomy require close follow-up with urethral washings for cytology to detect early urethral recurrence, an important determinant for survival.     

Invasive bladder cancer. Should patients who respond to radiotherapy be treated by cystectomy?

A retrospective study was carried out on the long-term survival (5-12 years) of 160 patients with invasive transitional cell cancer of the bladder treated with irradiation between 1972 and 1980. Following 40 Gy irradiation of the lower abdomen, treatment consisted of cystectomy or continued irradiation of the bladder region only. A full urological examination of the bladder established whether a patient was a responder or non-responder. The patients were divided into four groups: 27 responders treated with cystectomy and diversion; 48 responders treated with continued radiotherapy up to 65 Gy; 24 non-responders treated with cystectomy and diversion; 42 non-responders treated with continued radiotherapy up to 65 Gy. Survival and complications of treatment were compared with regard to category and grade of the tumours and sex and age of the patients. It was concluded that the responders who underwent cystectomy after 40 Gy irradiation survived longer than those who received a full course of radiotherapy. The responders had a better survival rate than non-responders, regardless of further treatment. Salvage cystectomy was rarely carried out and proved to be an unsatisfactory alternative, with a high operative risk and short survival.     

Roboterassistierte laparoskopische radikale Zystektomie

Recent reports have demonstrated that robot-assisted laparoscopic cystectomy is technically feasible. However, wide-spread acceptance of this promising technique is limited due to long operating times and lacking long-term data especially on oncological outcome. After establishing robot-assisted laparoscopic prostatectomy (n=250) we report technical and functional results of a large series of patients undergoing laparoscopic cystectomy with the da Vinci surgical system (DVSS). 27 patients (24 males) underwent laparoscopic radical cystectomy with the DVSS (Intuitive Surgical) between Jan 2004 and Dec 2006. Indications for cystectomy were muscle-invasive transitional cell carcinoma (TCC) or leiomyosarcoma of the urinary bladder (n=24) and bladder shrinking following prior radiotherapy for TCC (n=3). A pelvic lymphadenectomy was routine part of the procedure. Urinary diversions were ilieal conduits (n=19) and ileal neobladders (n=8). Mean operating time was 340 minutes (range 150–450) with a mean blood loss of 301 mL (range 50–550). The mean number of lymph nodes retrieved during lymphadenectomy was 23. Surgical margins were negative except in one case. After a mean follow-up of 10.2 months, 2 perioperative (anastomotic leakage, adhesions) and 3 postoperative complications (ileus, intestinal fistula) occurred. 6/7 patients reported satisfying erectile function following nerve-sparing surgery. Day-time continence was completely restored after a mean 3.5 months in 7/8 patients. Robot-assisted laparoscopic cystectomy is a safe procedure. Satisfying functional and oncological short-term results can be achieved within acceptable operating time limits.     

Treatment delay and prognosis in invasive bladder cancer

PURPOSE: We studied treatment delay, and the impact on disease specific survival and stage progression in a series of patients who had undergone cystectomy. MATERIALS AND METHODS: All 141 patients underwent radical cystectomy between 1990 and 1997 due to locally advanced bladder cancer. Treatment delay was defined as time from pathological confirmation of invasive disease to performance of cystectomy, and was registered retrospectively from the patient charts. Two patients received neoadjuvant chemotherapy and were excluded from further analyses. Followup continued until April 2003 with death due to bladder cancer as the end point. Causes of death were retrieved from the Swedish Cause of Death Registry. RESULTS: The median treatment delay was 49 days, but was significantly longer for the 71 cases who were referred from other hospitals (63 vs 41 days, p < 0.001). Treatment delay did not influence cumulative incidence of death from bladder cancer. Considering all cases, there was no significant correlation between treatment delay and stage progression. For clinical stage T2 tumors, median treatment delay was 76 days among patients with stage progression compared to 41 and 48 days for those with stage regression and stage equivalence, respectively (p = 0.20). CONCLUSIONS: Treatment delay was not found to influence disease specific survival in the present study. Furthermore, treatment delay was not significantly longer in cases that progressed compared to those with equal or lower pathological stage in the cystectomy specimen.