A Systematic Review and Meta-analysis of Delay in Radical Cystectomy and the Effect on Survival in Bladder Cancer Patients

Context: The complexity of bladder cancer diagnosis and staging results in delays in definitive treatment of muscle-invasive bladder cancer by radical cystectomy. Objective: This systematic review and meta-analyses aim to assess the impact of delays in radical cystectomy. Evidence acquisition: A systematic review was conducted by searching Medline and Ovid Gateway using protocol-driven search terms in August 2019, with no time limit on the studies included. The identified studies were assessed according to strict criteria and using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist and Risk of Bias in Non-randomised Studies-of Interventions (ROBINS-I) tool. Meta-analyses were conducted based on the type of delay. Random-effect models were used whereby the presence of a delay was the exposure variable and overall survival was the outcome of interest, for which pooled hazard ratios were calculated. Evidence synthesis: Nineteen studies were eligible for inclusion (17 532 patients), of which 10 were included in the meta-analyses. A longer delay between bladder cancer diagnosis and radical cystectomy resulted in a pooled hazard ratio of 1.34 (95% confidence interval [CI]: 1.18-1.53) for overall death. For a delay between transurethral resection and cystectomy, we found a pooled hazard ratio of 1.18 (95% CI: 0.99-1.41) for overall death. A pooled hazard ratio of 1.04 (95% CI: 0.93-1.16) was calculated for a longer delay between neoadjuvant chemotherapy and radical cystectomy. Conclusions: A delay in radical cystectomy after diagnosis was found to have a significantly detrimental effect on overall survival for bladder cancer patients. However, there was huge heterogeneity in how a delay was defined. Patient summary: In this review, we investigated the effect of a delay in radical treatment on survival. This review highlights the importance of scheduling radical cystectomies in a timely manner whilst monitoring factors such as comorbidities and scheduling, in order to treat patients requiring radical cystectomy without delay. (C) 2019 European Association of Urology. Published by Elsevier B.V. All rights reserved.