Radical transurethral resection and chemotherapy in the treatment of muscle-invasive bladder cancer: a long-term follow-up

OBJECTIVE: To evaluate the treatment of patients with muscle-invasive bladder cancer (T2-T4a) by radical transurethral resection (TUR) and cisplatin-methotrexate systemic chemotherapy. PATIENTS AND METHODS: Fifty patients with transitional cell carcinoma (TCC) of the bladder (nine T2, 36 T3 and five T4a) were treated by 'complete' TUR of the bladder tumour followed by 2-6 cycles of cisplatin (70 mg/m2) and methotrexate (40 mg/m2) chemotherapy. The median (range) tumour size was 3 (1-7 cm). In six patients, attempted TUR at the dome of the bladder led to intraperitoneal perforation; the tumour was excised by partial cystectomy in these patients. The latest follow-up results from 57 patients treated by radical TUR and methotrexate alone, reported previously, are included. RESULTS: At the first evaluation cystoscopy immediately after completing chemotherapy, 38 patients were tumour-free, eight had persistent muscle-invasive TCC and four had Ta, T1+CIS disease. With an overall median follow-up of 47 months, 10 additional patients relapsed with muscle-invasive carcinoma in the bladder after a median interval of 15.6 months; three patients developed Ta, T1 tumours, three Ta, T1 + CIS, and six CIS only. Six of the 10 recurrent invasive tumours were at the same site, but four were at a different site in the bladder. Although during follow-up 12 patients developed superficial recurrence that required endoscopic treatment, the bladder was preserved (free of muscle-invasive cancer) in 37 of 50 patients. In 30 of these 37, this was achieved with no need for salvage radiotherapy or cystectomy. Six patients died from metastatic TCC with no tumour in the bladder. CONCLUSION: In this selected group of patients, muscle-invasive bladder cancer was controlled by TUR and systemic chemotherapy, preserving normal bladder function in 60% of patients without apparently comprising overall survival.     

Intravenous urography in patients with transitional cell carcinoma of the bladder. The incidence and implications of ureteral obstruction.

In order to study the value of excretory urography in the diagnosis of transitional cell carcinoma of the bladder, and also the incidence and implications of ureteral obstruction, 100 consecutive patients were studied. Of 73 patients with superficial tumours (stages Tis, Ta, T1) only 1 (1,4%) had hydronephrosis as a result of the bladder tumour. However, 2 further patients had hydronephrosis secondary to synchronous ureteral tumours. Of the 27 patients with muscle-invasive tumours, 10 (37%) had hydronephrosis at the time of diagnosis. Four patients who had normal upper tracts initially, developed hydronephrosis during follow-up: 1 due to progression of a superficial tumour to stage T3, 1 due to the development of an ureteral tumour, and 2 due to fibrosis of the intramural ureter after transurethral resection of superficial tumours. The presence of ureteral obstruction at the time of diagnosis most often implies a muscle-invasive tumour, but the possibility of a synchronous ureteral tumour must also be considered. Fibrous strictures of the distal ureter can occur after transurethral resection of superficial bladder tumours.     

Clinical significance of the "palpable mass" in patients with muscle-infiltrating bladder cancer undergoing cystectomy after pre-operative radiotherapy

Between 1976 and 1985, 132 patients with T2/T3/T4a bladder cancer underwent cystectomy after pre-operative radiotherapy (46 Gy: 67 patients; 20 Gy: 65 patients). After a median time of 41 months, 62 patients were alive; 51 had died from recurrent bladder cancer and 19 from intercurrent disease without recurrence of their malignancy. Distant metastases developed in 40 patients, accompanied in 5 cases by local recurrence. Local recurrence was the first sign of relapse in 11 patients. In 3 patients the localisation of the relapse remained unknown. The corrected 5-year survival rate was 60%. T category and a palpable bladder tumour were independent pre-treatment prognostic factors in a Cox regression analysis, together with the interval between initial diagnosis and cystectomy. The presence of a palpable tumour before the start of treatment was associated with a particularly poor prognosis in T3/T4a tumours, whereas the survival of patients with non-palpable T3/T4a tumours was similar to that of patients with T2 bladder cancer. Another important prognostic factor was post-irradiation stage reduction (no residual muscle infiltration in the cystectomy specimen). Significantly more patients with non-palpable bladder tumours experienced post-radiation stage reduction than did those with a palpable tumour. However, the prognostic value of stage reduction was statistically significant only in patients with palpable bladder tumours.     

The optimum timing of radical cystectomy for patients with recurrent high-risk superficial bladder tumour

OBJECTIVE: To establish the optimum time of radical cystectomy (RC) for patients with recurrent high-risk superficial bladder tumours after the failure of intravesical therapy. PATIENTS AND METHODS: Among 318 patients with transitional cell carcinoma treated with RC and with no neoadjuvant therapy, there were 46 with clinical stage Ta, T1 or Tis refractory to transurethral resection associated with intravesical therapy. These patients had at least one of: (i) high-risk superficial bladder tumours after failure of two consecutive induction courses of intravesical therapy; (ii) superficial bladder tumours with prostatic stromal invasion; (iii) superficial bladder tumours with mucosa/ducts involvement after failure of one course of intravesical therapy; (iv) uncontrolled superficial tumours with transurethral resection associated or not with intravesical therapy. Progression and cause-specific survival of these patients were compared to those with muscle-invasive tumours. Univariate and multivariate analyses of predictive factors for cause-specific survival were also used in patients with superficial tumours. The incidence of significant prognostic factors was compared in both superficial and muscle-invasive tumours, as were the progression pattern and survival. RESULTS: The progression-free and cause-specific survival of patients with superficial tumours was 54% and 67%, respectively, with no significant difference from those with muscle-invasive tumours. In multivariate analysis, positive lymph-nodes and prostatic stromal invasion were significant and independent variables for survival. The incidence of positive lymph nodes was 15% vs 30% (P < 0.05) and of stromal invasion was 32% vs 1.5% (P < 0.001) in patients with superficial and muscle-invasive tumours, respectively. Accounting for the progression pattern in patients with superficial tumours, extravesical urothelial recurrence prevailed over local or distant recurrences (30% vs 15%), whereas in patients with muscle-invasive tumours the opposite occurred (5% vs 33%, respectively). The cause-specific survival of patients with superficial tumour and prostatic stromal invasion was one of three, and in those who developed extravesical urothelial recurrence was 28.5%. CONCLUSION: In patients with recurrent high-risk superficial bladder cancer after intravesical therapy, our criteria for RC were inappropriate, and patients had a survival rate similar to those with muscle-invasive tumours. RC might have been used too late, as there was a high incidence of prostatic stromal invasion and extravesical urothelial recurrence after RC. Both events seem to be responsible of the low cause-specific survival. Predictive factors for progression are needed to indicate early RC in patients with recurrent high-risk superficial tumours. From a previous analysis the pathological pattern of the clinical lack of response (T1, G3, bladder carcinoma in situ and prostate involvement) to intravesical therapy evaluated at 3 months might be important for predicting progression, and an early RC at that time might be useful.     

Recurrence and progression in stage T1G3 bladder tumour with intravesical bacille Calmette-Guérin (Danish 1331 strain)

OBJECTIVE: To report recurrence and progression rates in patients with T1G3 superficial bladder carcinoma treated with intravesical bacille Calmette-Guérin (BCG, Danish 1331 strain) after complete transurethral resection. PATIENTS AND METHODS: Data from the records of 111 patients with T1G3 bladder carcinoma treated between January 1991 and December 1999 were analysed for recurrence, progression, salvage therapy and survival. RESULTS: Of the 111 patients with T1G3 bladder tumours, 69 had intravesical BCG therapy, 20 radical cystectomy and 22 only transurethral resection (TUR). Of the 69 patients receiving BCG therapy 37 (54%) had no recurrence, and 24 (35%) had a recurrence that was not muscle-invasive (Ta/T1) and were treated with TUR only. The remaining eight (12%) progressed to muscle invasion and had salvage cystectomy. During the follow-up six patients died, four from disease and three from other causes, while the remaining 63 are alive and well. Of the other 42 patients, 15 are alive after radical cystectomy and 18 after TUR. CONCLUSION: This series further confirms the benefits of intravesical BCG (Danish 1331) in an adjuvant setting; furthermore, this treatment facilitates bladder preservation by reducing recurrences and delaying the progression in many patients.     

A population-based study of 538 patients with newly detected urinary bladder neoplasms followed during 5 years

OBJECTIVE: To describe in detail the diagnosis and clinical course of an unselected population-based cohort of patients with newly diagnosed bladder neoplasms. MATERIAL AND METHODS: A total of 538 patients registered in the Stockholm region with newly diagnosed primary bladder neoplasms (transitional cell carcinomas) in 1995 and 1996 were followed for at least 5 years. All hospitals and urology units in the region participated in the study. Treatment and follow-up were performed according to a standard-of-care programme. Routine pathological reports were used. Original case records were scrutinized on location in 2001. In addition, a tumour bank of freshly frozen tumour tissue was established. RESULTS: The calculated 5-year cancer-specific survival rate for the 538 patients in the cohort was 78%. No patient (0/29) with TaG1 tumours showed progression or died of bladder cancer. Only 2/187 patients (1%) with stage Ta and grade 2A or 2B tumours died of bladder cancer. In contrast, after 5 years of follow-up, patients with TaG3 and T1G2B tumours had disease-specific death rates of 20% and 27%, respectively. The result of the first cystoscopy examination after the initial resection of non-invasive tumours was of prognostic value. Recurrent disease was present in 62% (248/402) of all patients with Ta and T1 tumours at diagnosis and patients with T1 tumours had recurrences earlier than those with Ta tumours. Moreover, 32% (35/110) of the patients who presented with T1 tumours at diagnosis progressed to muscle-invasive disease during the follow-up period. The overall prognosis for patients presenting with muscle-invasive tumours (T2+) was dismal, with 69% (80/116) of the patients dying of the disease. CONCLUSIONS: We analysed a population-based cohort of patients with urinary bladder neoplasms in order to establish a clearly defined and unselected clinical series, with the main aims of comparing and evaluating the clinical utility of new molecular biology techniques. In the present series, TaG1 tumours behaved benignly. The disease-specific mortality rate was low for initial TaG2 tumours, intermediate for initial TaG3 and T1 tumours and high for initial T2+ tumours.     

Total cystectomy after intravesical bacillus Calmette-Guérin (Tokyo strain) therapy for superficial bladder cancer: Experience in Japan

To clarify which patients might most require total cystectomy after intravesical bacillus Calmette-Guérin (BCG) therapy, we reviewed data for 111 individuals with superficial bladder cancer. Of the 111 patients, 73 received the BCG treatment for prophylaxis of intravesical recurrence after transurethral resection (group 1), 24 therapeutically for Ta or T1 tumours (group 2), and 14 for eradicating carcinomas in situ (CIS, group 3). Although the BCG therapy significantly reduced frequencies of recurrence in group 1, 27 patients (37%) did develop tumours again. Tumours disappeared in 18 of 24 patients (75%) in group 2, and in 11 of 14 (79%) in group 3. The rate of disease progression was 6% for all 111 patients: 3% (2/73) for group 1, 17% (4/24) for group 2, and 7% (1/14) for group 3. A total of 16 of the 111 patients (14%) underwent total cystectomy, the respective figures being 7% in group 1, 29% in group 2, and 29% in group 3. Indications for total cystectomy were progression in 7, recurrent multiple tumours in 5, persistent CIS in 2, a contracted bladder in 1, and occurrence of bilateral renal pelvic cancer in 1. Thus, 4 of 6 patients (67%) who had tumours unresponsive to BCG therapy in group 2 demonstrated progression and necessitated total cystectomy. Because tumours persisting after BCG therapy are frequently of the muscle-invasive type, such cases should be regarded as candidates for immediate total cystectomy.     

The value of a second transurethral resection in evaluating patients with bladder tumours

OBJECTIVES: To evaluate the usefulness of a second transurethral resection for superficial and muscle-invasive bladder tumours. METHODS: A review of the literature relevant to repeat resection for bladder tumours was conducted using Medline Services. RESULTS: Transurethral resection of the bladder has two shortcomings: underestimating clinical stage, and overlooking other lesions. A second transurethral resection, when performed 2-6 weeks after the initial resection, corrects clinical staging errors in 9-49% of cases and detects residual tumour in 26-83% of cases. A second resection is particularly warranted for T1 tumours since 2-28% of them prove to be muscle-invasive, thus requiring a change in management. For muscle-invasive tumours, a second resection may be performed only if bladder sparing is being considered, as it helps to exclude the presence of tumour sites contra-indicating conservative treatment. CONCLUSIONS: A second transurethral bladder resection may be warranted for T1 tumours, and for invasive tumours when a bladder preservation is planned.     

Long-term results of intravesical bacillus Calmette-Guérin therapy for stage T1 superficial bladder cancer

OBJECTIVES: To examine in a prospective study the incidence of recurrence and progression in patients with Stage T1 bladder carcinoma after complete transurethral resection of the bladder tumor and adjuvant immunotherapy with bacillus Calmette-Guérin (BCG). METHODS: Between July 1987 and April 1999, 126 patients presenting to our clinic with a superficial urothelial carcinoma of the bladder (Stage pT1, grade 1-3) received adjuvant intravesical immunotherapy with BCG after complete transurethral resection of the bladder tumor. In the case of recurrence of superficial tumor (pTa, pT1, or carcinoma in situ), patients received a second cycle of BCG. For muscle-invasive tumor progression (pT2, pT3, or pT4), radical cystectomy was recommended. Six of the patients (5%) presented with Stage pT1,G1 tumor, 74 (59%) with Stage pT1,G2 tumor, and 46 patients (36%) with Stage pT1,G3 tumor. Median follow-up was 53 months (range 3 to 144). RESULTS: One hundred eight patients (86%) remained tumor-free with a retained bladder during the follow-up after one or two 6-week cycles of BCG. Twenty-four patients (19%) had a recurrence of superficial tumor, 13 (10%) had muscle-invasive progression after the first BCG cycle, and an additional 4 (3%) had progression after the second BCG cycle. Six patients (5%) underwent radical cystectomy, and 9 patients (7%) died as a result of tumor progression. The tumor-free survival rate of all patients was 89% (112 of 126). CONCLUSIONS: Adjuvant immunotherapy with BCG after complete transurethral resection of the bladder tumor represents a highly effective primary treatment for Stage T1 carcinoma of the bladder. Even in Stage pT1,G3 tumor, immediate radical cystectomy does not appear necessary.     

The value of a second transurethral resection for T1 bladder cancer

OBJECTIVE: To evaluate a series of repeat transurethral resections (TURs) of tumour in patients with T1 bladder cancer, usually used to ensure a complete resection and to exclude the possibility muscle-invasive disease. PATIENTS AND METHODS: In all, 136 consecutive patients had a second TUR because of a histopathological diagnosis of T1 transitional cell carcinoma (TCC) after their initial TUR. Of the 136 patients, 101 were first presentations and 35 had recurrent tumours. The second TUR was done 4-6 weeks later. The evaluation included the presence of previously undetected residual tumour, changes to histopathological staging/grading, and tumour location. RESULTS: In all, 71 patients (52%) had residual disease according to findings from specimens obtained during the second TUR. The staging was: no tumour, 65 (48%); Ta, 11 (8%); T1, 32 (24%); Tis, 15 (11%); and > or = T2, 13 (10%). Histopathological changes that worsened the prognosis (>T1 and or concomitant Tis) were found in 21% of patients. Residual malignant tissue was found in the same location as the first TUR in 86% of the patients, and at different locations in 14%. Overall, 28 patients (21% of the original 136) had a radical cystectomy as a consequence of the second TUR findings. CONCLUSIONS: A routine second TUR should be advised in patients with T1 TCC of the bladder, to achieve a more complete tumour resection and to identify patients who should have a prompt cystectomy.     

Reappraisal of the role of radical radiotherapy and salvage cystectomy in the treatment of invasive (T2/T3) bladder cancer

One hundred and eighty-two patients with invasive (T2/T3) bladder cancer were treated by radical radiotherapy at the London Hospital between 1974 and December 1985. Cystectomy was reserved for patients whose tumours either did not respond completely to radiation or recurred later, provided they were fit for surgery and had not developed distant metastases. The overall corrected 5-year survival rate was 40%; 75 patients responded to radiation and did not relapse during the period of follow-up; 20 patients had an initial response to radiation but subsequently relapsed, with a 5-year survival rate following relapse of 20%. Of these, 11 patients had a cystectomy with a 5-year survival following relapse of 36%, whereas all 9 patients who did not have a cystectomy died within 3 years; 87 patients who did not respond to radiation had a 5-year survival rate of 18%. Of these, 22 patients underwent salvage cystectomy with a 5-year survival of 47%, whereas the 65 patients who did not have a cystectomy had a 5-year survival of 3%. These results justify a policy of radical radiotherapy and salvage cystectomy rather than elective cystectomy in the treatment of invasive bladder cancer.     

The fate of G3pT1 bladder cancer

Poorly differentiated (G3) cancers are known to have a worse prognosis than other superficial bladder tumours. In the period 1976 to 1987, 53 patients with G3pT1 disease were treated by radical radiotherapy with a 5-year survival rate of 64%. Thirteen patients (25%) developed an invasive tumour during the follow-up period. The presence of secondary carcinoma in situ was associated with a poor prognosis. These results are better than those reported for transurethral resection alone and suggest that radiotherapy is the treatment of choice in G3 superficial tumours.     

Management of T1G3 tumours of the bladder

T1G3 tumours are the most aggressive superficial tumours of the bladder, with a high risk of recurrence and progression. Complete endoscopic resection of the tumour is the first diagnostic and therapeutic step in T1G3 management. A second resection should be done at 1 month to avoid residual tumour and misdiagnosis of a muscle infiltrative cancer. As a result of treatment by instillations of Calmette and Guérin bacillus following endoscopic resection, a 5-year survival rate of 80% has been reported, with 50 to 60% of bladder preservation. BCG is the only conservative treatment that has proven effectiveness on both tumour recurrence and progression. Long term protocols seem to give the best results. Endovesical chemotherapy is not commonly used as its impact on progression has not been demonstrated. Radical cystectomy can be chosen as first line treatment in patients with particularly aggressive tumours. Long term and close surveillance should be achieved in every patient.     

Transurethral resection of 1250 bladder tumours

A total of 1250 bladder tumours were subjected to transurethral resection (891 curative, 107 palliative operations, 252 TUR biopsies). Complication rate was 9.9%, mortality rate 0.8%. In patients with primary tumours the 1-year recurrence rate after TUR was 23.8%, the 3-year rate was 36.6%, with an increase in proportion to stage. The 5-year survival rate was 66.5%. Within five years 9% of the patients died from tumour generalization, also with a rising tendency in proportion to stage. TUR as a curative method is suitable mainly for the removal of Ta and T1, under circumstances also of T2 G1-G2 tumours.     

Transurethral resection and intra-arterial chemotherapy for muscle-invasive bladder cancer

Thirty-three patients with muscle-infiltrating T2–T3a bladder carcinoma were treated by TUR through the full thickness of the bladder wall and extended into the perivesical fat. The solitary tumours were not more than 4 cm in diameter. Histology proved in every case tumour stages of pT2 (17 patients) or pT3a (16 patients), G2 or G3 transitional cell carcinoma and negative mucosal biopsies. After TUR the patients received 1 or 2 cycles of chemotherapy: 60 mg of doxorubicin, 50 mg of cisplatin, 1 g of 5-fluorouracil administered into the ipsilateral hypogastric artery. There was no perioperative mortality but one patient died of complications related to chemotherapy. During the first year of follow-up relapses of muscle-invasive cancer were observed in 3 patients (10%), two were subjected to cystectomy and one to repeated TUR. With a median follow-up of 34 months 27 patients are alive and have functional bladder. The actual 3-year and 5-year survival rates were 17/21 (81%) and 6/9 (67%), respectively. The results of this study suggest that in strictly selected patients extended TUR and intra-arterial chemotherapy may be a bladder-preserving treatment modality for muscle-invasive bladder cancer. Regular (three monthly cystoscopy, cytology, biopsy, CT) investigations and follow-up are necessary to detect recurrences.     

Chemotherapy for carcinoma in situ of the bladder

In an 8-year period, 71 patients were diagnosed as having carcinoma in situ of the bladder. Twenty patients with primary carcinoma in situ were treated with systemic cyclophosphamide or intravesical mitomycin C and 19 of them survived 3 years. Three patients required cystectomy: 1 for invasive cancer and 2 for intractable symptoms in the absence of tumour. Fifty-one patients had either secondary or concomitant carcinoma in situ. Systemic or intravesical chemotherapy was given to 28 patients in whom carcinoma in situ was associated with G1 or G2 exophytic superficial tumour: there was only one cancer death in 3 years. Fifteen patients with G3 carcinoma in situ associated with a G3 or invasive exophytic tumour were treated with radiotherapy: 9 responded but 4 of the 6 with radio-insensitive tumours died of cancer within 3 years. Eight patients with secondary carcinoma in situ were managed by transurethral resection alone: in 6 there was spontaneous regression and 2 developed muscle invasion within 1 year. These results compare well with those of immunotherapy or early radical surgery and suggest that chemotherapy should be given a trial in patients with carcinoma in situ.     

Repeated transurethral resection and intravesical BCG for extensive superficial bladder tumors.

PURPOSE: We report our experience with repeat transurethral resection (TUR) in a group of patients with superficial bladder tumors in whom complete resection in one session was impossible because of the extensive tumor burden. PATIENTS AND METHODS: Only the patients with such extensive (>10 g of resected tissue) tumors that we were unable to perform complete TUR initially were included in the present study. The patients underwent repeat TUR(s) 4 weeks after the previous one until complete resection of the tumor was achieved. After complete TUR, if the pathology examination confirmed superficial disease, the patients received intracavitery immunotherapy and were followed up thereafter. If pathology examination documented muscle-invasive disease, cystectomy was suggested. RESULTS: Of the 43 patients undergoing repeat TUR, 15 needed a second and 5 needed a third session to achieve complete resection. Of the patients, 28 (65%) had stage T1 and 15 (35%) has stage Ta tumor. Eight patients (19%) otherwise regarded as having superficial tumor were found to have muscle-invasive disease following repeat TURs. The mean follow-up of the remaining 35 patients with superficial disease was 34 months (range 1-126 months). Four of the patients with superficial disease progressed to T2 tumor. However, 16 patients achieved a state of complete response with no tumor recurrences during a mean of 38 months (range 4-126 month). The present protocol achieved bladder sparing in a total of 22 (63%) of the 35 patients with superficial disease. CONCLUSIONS: From the presented series, we suggest that one can use the combination of repeat TUR and intravesical immunotherapy in the management of bulky superficial bladder tumors in an effort to preserve the bladder.     

Preliminary results of concurrent cisplatin and radiation therapy in locally advanced bladder cancer.

Between March 1981 and March 1990, 15 patients with locally advanced transitional cell carcinoma of the bladder were treated concurrently with cisplatin and radiotherapy. Treatment comprised a radiation dose of 40-50 Gy in 20-25 fractions over 4-5 weeks and intravenous infusion of cisplatin with hydration during days 1-5 and 22-26. The total scheduled dose of cisplatin was 200 mg. A complete response (CR) was seen in 3 patients (2 T2 tumours and 1 T3) and the other 12 were regarded as partial responders. Two of the 12 partial responders (1 T2 tumour and 1 T4) underwent cystectomy after treatment, but 9 patients (2 T2, 6 T3 and 1 T4) underwent only transurethral resection. The remaining patient (with a T4 tumour) died from systemic disease, further treatment not being possible because of unrelated heart failure. In 3 CR patients and 9 with a partial response (PR), bladder function was preserved and they have survived for a mean of 18.3 months (range 5-47) after therapy. Although 4 patients in this group had recurrent bladder tumours and 1 died from cancer in another part of the body, 7 have survived with normal bladder function and no recurrence. It is concluded that concurrent cisplatin and radiation therapy is a safe and viable regimen and may be considered as a means of preserving the bladder in patients with locally advanced transitional cell carcinoma.     

Conservative management of advanced bladder cancer

Between January 1991 and October 1993, 32 consecutive patients with documented primary bladder tumours invading muscle received 3 cycles of methotrexate, vinblastin, doxorubicin and cisplatin (MVAC). The disease was re-staged by bimanual examination with the patient under anaesthesia, CT scanning and transurethral biopsy or resection. Of the 32 patients 2 underwent total or partial cystectomy and 30 did not, because re-staging showed no residual tumour in 8 (25%), stage T1–2 in 12 (37.5%) and far-advanced tumour in 10 (31.2%). The median follow-up was 2.8 years. Twelve patients with stage T1–2 tumour have required TUR, and cystectomy has not been necessary. Two patients who underwent total/partial cystectomy were all downstaged pathologically. Of the 10 failures 5 patients died of disease and 5 are alive with metastatic disease. The overall survival rate was 84.3% (27 of 32) and was 96.8% for patients with a functioning bladder. The data suggested that this active regimen can clinically induce down-staging in a significant number of patients with primary muscle-infiltrating bladder tumours. Transurethral resection plus MVAC chemotherapy is important for increased curability in patients with advanced bladder cancer.     

Treatment of 300 patients with bladder cancer]

From September 1973 to September 1989, 300 patients with bladder cancer were treated at the Department of Urology, Hyogo College of Medicine. They were 231 males and 69 females with an average age of 65.3 years old. The overall 5-year survival rate (Kaplan-Meier's method) was 64.7%. The 5-year survival rates were not different between male patients and female patients, or between patients with single tumor and patients with multiple tumors. Patients with vesical irritation symptoms had more unfavorable prognosis than patients with painless hematuria. Size and configuration of the tumors also affected the prognosis. Histological diagnosis was transitional cell carcinoma in 291 patients, squamous cell carcinoma in 7 patients, adenocarcinoma in one patient and undifferentiated carcinoma in one patient. In patients with transitional cell carcinoma, the 5-year survival rates according to histological grades were 93.5% for G1, 77.8% for G2 and 31.6% for G3. The 5-year survival rate according to clinical stage was 94.4% for Ta, 79.7% for T1, 66.7% for Tis, 46.1% for T2, 38.5% for T3 and 26.6% for T4. Transurethral resection of bladder tumor (TUR-b.t.) was performed in 208 patients as an initial operation and the 5-year survival rate in these patients was 78.6%. The 5-year survival rates for total cystectomy (52 patients), partial cystectomy (6 patients) and simple tumor resection (4 patients) were 51.9%, 25.0% and 37.5%, respectively. These findings suggest that superficial tumors (Ta, T1) can be controlled with TUR-b.t. but infiltrating tumors (T2, T3, T4) should be treated more vigorously with multidisciplinary approaches.(ABSTRACT TRUNCATED AT 250 WORDS)