Objective Long-Term Bladder Related Outcomes Affecting Quality Of Life Following Trimodality Therapy
Jillian Egan Kelly, MD1, Affan Zafar, MD1, Linda Nguyen, BS2, Matthew Wszolek, MD2, Niall Heney, MD, MBBCH2, Dimitar Zlatev, MD2, Richard Lee, MD, PhD2, David Miyamoto, MD, PhD2, Jason Efstathiou, MD2, Adam Feldman, MD, MPH2.
1Massachusetts General Hospital/Brigham and Women's Hospital, Boston, MA, USA, 2Massachusetts General Hospital, Boston, MA, USA.
Background: Trimodality therapy (TMT) for muscle invasive bladder cancer (MIBC) has been included in our national guidelines as an alternative to radical cystectomy.1,2 While limited bladder-related quality of life (QOL) outcomes exist, there remains a need to understand objective secondary long-term TMT outcomes affecting QOL.
Methods: A retrospective review of our IRB approved, institutional database was conducted. Occurrence of bladder stones, gross hematuria (GH), recurrent urinary tract infection (rUTI) and ureteral stricture was evaluated. Bladder stone was defined as any report of calcification in the bladder following completion of TMT. Patients who presented at least once to the emergency department (ED) were counted as having GH. rUTI was defined as 2 infections in 6 months or 3 in 1 year and was evaluated only in patients who retained their bladder over follow up. Ureteral strictures that occurred following salvage cystectomy were not included.
Results: 271 patients were included. 227 (83.8%) retained their bladder at a median follow up of 51.8 [interquartile range (IQR) 18.0-98.1] months (mo). 6 (2.2%) underwent cystectomy for benign causes including refractory lower urinary tract symptoms and poor bladder function (4, 1.5%), GH (1, 0.37%), and nonhealing fistula (1, 0.37%). Bladder stones occurred in 23 (8.5%) patients at a median time of 15.2 [IQR 8.3-23.6] mo. No treatment was needed in 10(43.5%). 1(4.4%) required cystolitholapaxy and 12 (53.2%) were removed endoscopically with forceps and/or irrigation. 49 (18.8%) patients had GH leading to an ED visit. Of these, 13 (26.5%) required no treatment, 12(24.5%) required catheter placement and hand irrigation, 14 (28.6%) needed continuous bladder irrigation, 5 (10.2%) required operative intervention and 5 (10.2%) required transfusion. 19 (8.4%) patients suffered from rUTI. 14 (5.3%) patients developed ureteral stricture at a median time of 27.8 [8.6-61.4] mo. 13 ( 92.9%) were managed with ureteral stents; 1 (7.1%) required percutaneous nephrostomy tube.
Conclusions: The rates of objective bladder related complications affecting QOL after TMT are relatively low. Similarly, the risk of developing an "end-stage bladder" requiring cystectomy and diversion is extremely low. These data support good QOL outcomes after TMT for MIBC. 
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