Characteristics and Outcomes of Patients With pT4 Urothelial Carcinoma at Radical Cystectomy: A Retrospective International Study of 583 Patients

Purpose: We describe cancer specific outcomes in patients with pT4 bladder urothelial carcinoma at radical cystectomy in a large international Cohort. Materials and Methods: We reviewed the records of 4,257 patients treated with radical cystectomy for bladder urothelial carcinoma at 12 centers. No patient received any preoperative systemic chemotherapy or radiotherapy. Results: Of the 4,257 patients 583 (14%) had pT4 bladder urothelial carcinoma, of whom 83.7% were male, 85.2% had substage pT4a disease, 24.9% had positive soft tissue surgical margins, 57.8% had lymphovascular invasion and 53.5% had lymph node metastasis. Median followup was 55.0 months. Overall estimated 5-year recurrence-free and cancer specific survival was 29% (95% Cl 22-32) and 31% (95% Cl 25-36), respectively. On multivariate analysis female gender (p = 0.005 and p = 0.001), positive soft tissue surgical margins (p = 0.014 and p < 0.001), lymphovascular invasion (p = 0.016 and p = 0.005), pT4b substage (p = 0.041 and p = 0.002, respectively) and lymph node involvement (each p < 0.001) were independently associated with disease recurrence and cancer specific mortality. Conclusions: Patients with pT4 bladder urothelial carcinoma have highly variable outcomes. Features associated with metastatic tumor dissemination (ie lymph node invasion and lymphovascular invasion) and local disease burden (ie soft tissue surgical margins and pT4 substage) are associated with poor outcomes in patients with pT4 bladder urothelial carcinoma. Further research is needed to understand why female patients with pT4 bladder urothelial carcinoma have a worse outcome than their male counterparts.