Introduction: According to TNM staging, pathological T4ab are comprehensive of the invasion of prostate, seminal vesicles, uterus or vagina and pelvic or abdominal wall. However, few data are available on the perioperative and oncological outcomes of specific organ invasion. Materials and Methods: A total of 917 consecutive bladder cancer (BCa) patients treated with radical cystectomy (RC) at a single institution between 1990 and 2015 were studies. Cox regression analyses were used to stratify pT4ab according to the site of invasion and survival. Results: Overall, 176 (19.2%) and 40 (4.4%) patients harbored pT4a or pT4b disease. Specifically, 84 (9.2%) patients reported prostate and/or SVI invasion, 62 (6.8%) prostate only, 16 (1.7%) uterus, 14 (1.5%) vaginal, 24 (2.6%) pelvic wall, and 16 (1.7%) abdominal wall invasion. The median follow-up in pT4 patients was 48 months. The 1-year cancer-specific mortality (CSM) rates were 71, 65, 24, 50, 50, and 72%, for vaginal, uterus, prostate only, prostate and/or seminal vesicles, pelvic wall, and abdominal wall invasions, respectively. At multivariable Cox regression, the invasion of prostate only (hazard ratio [HR] 3.53), prostate and/or SVI (HR 4.98), uterus (HR 7.16), vagina (HR 6.12), pelvic (HR 11.81), abdominal (8.36) were associated with adverse CSM. Conclusions: Our study described the differences in survival related to invasion site in pT4 patients, confirming poor survival expectancies in this subgroup. Patients with prostate invasion only seem to be associated with better survival than those affected by concomitant invasion of seminal vesicles. Uterus and vaginal invasions were associated with poor survival outcomes. Patients Summary: In this study, we looked at the outcome of locally advanced invasive BCa (stage pT4) in patients treated with RC at a tertiary referral hospital. We analyzed the differences in survival related to the specific organ invasion. We confirmed poor survival in this subgroup of patients. Only patients who had prostate invasion only seem to have a better survival.

Keywords:
Bladder cancer, Radical cystectomy, pT4, Locally advanced, Survival
1.
Siegel RL, Miller KD, Jemal A. Cancer statistics, 2018. CA Cancer J Clin. 2018 Jan; 68(1): 7–30.
2.
Alfred Witjes J, Lebret T, Compérat EM, Cowan NC, De Santis M, Bruins HM, et al. Updated 2016 EAU Guidelines on Muscle-invasive and Metastatic Bladder Cancer. Eur Urol. 2017 Mar; 71(3): 462–475.
3.
Stein JP, Lieskovsky G, Cote R, Groshen S, Feng AC, Boyd S, et al. Radical cystectomy in the treatment of invasive bladder cancer: long-term results in 1,054 patients. J Clin Oncol. 2001 Feb; 19(3): 666–75.
4.
Greene FL, Page DL, Fleming ID. Urinary bladder. AJCC Cancer Staging Manual. 6th ed. New York: Springer; 2002.
5.
Messer JC, Shariat SF, Dinney CP, Novara G, Fradet Y, Kassouf W, et al. Female gender is associated with a worse survival after radical cystectomy for urothelial carcinoma of the bladder: a competing risk analysis. Urology. 2014 Apr; 83(4): 863–7.
6.
Moschini M, Soria F, Klatte T, Wirth GJ, Özsoy M, Gust K, et al. Validation of Preoperative Risk Grouping of the Selection of Patients Most Likely to Benefit From Neoadjuvant Chemotherapy Before Radical Cystectomy. Clin Genitourin Cancer. 2017 Apr; 15(2): e267–e273.
7.
Shariat SF, Svatek RS, Tilki D, Skinner E, Karakiewicz PI, Capitanio U, et al. International validation of the prognostic value of lymphovascular invasion in patients treated with radical cystectomy. BJU Int. 2010 May; 105(10): 1402–12.
8.
Novara G, Svatek RS, Karakiewicz PI, Skinner E, Ficarra V, Fradet Y, et al. Soft tissue surgical margin status is a powerful predictor of outcomes after radical cystectomy: a multicenter study of more than 4,400 patients. J Urol. 2010 Jun; 183(6): 2165–70.
9.
Liberman D, Alasker A, Sun M, Ismail S, Lughezzani G, Jeldres C, et al. Radical cystectomy for patients with pT4 urothelial carcinoma in a large population-based study. BJU Int. 2011 Mar; 107(6): 905–11.
10.
Shariat SF, Karakiewicz PI, Palapattu GS, Lotan Y, Rogers CG, Amiel GE, et al. Outcomes of radical cystectomy for transitional cell carcinoma of the bladder: a contemporary series from the Bladder Cancer Research Consortium. J Urol. 2006 Dec; 176(6 Pt 1): 2414–22; discussion 2422.
11.
Isbarn H, Jeldres C, Zini L, Perrotte P, Baillargeon-Gagne S, Capitanio U, et al. A population based assessment of perioperative mortality after cystectomy for bladder cancer. J Urol. 2009 Jul; 182(1): 70–7.
12.
Nagele U, Anastasiadis AG, Merseburger AS, Corvin S, Hennenlotter J, Adam M, et al. The rationale for radical cystectomy as primary therapy for T4 bladder cancer. World J Urol. 2007 Aug; 25(4): 401–5.
13.
May M, Brookman-May S, Burger M, Gilfrich C, Fritsche HM, Rink M, et al. Concomitant seminal vesicle invasion in pT4a urothelial carcinoma of the bladder with contiguous prostatic infiltration is an adverse prognosticator for cancer-specific survival after radical cystectomy. Ann Surg Oncol. 2014 Nov; 21(12): 4034–40.
14.
Ploussard G, Rotondo S, Salomon L. The prognostic significance of bladder neck invasion in prostate cancer: is microscopic involvement truly a T4 disease? BJU Int. 2010 Mar; 105(6): 776–81.
15.
Furukawa J, Miyake H, Hara I, Takenaka A, Fujisawa M. Upper urinary tract recurrence following radical cystectomy for bladder cancer. Int J Urol. 2007 Jun; 14(6): 496–9.
16.
Tilki D, Svatek RS, Karakiewicz PI, Isbarn H, Reich O, Kassouf W, et al. Characteristics and outcomes of patients with pT4 urothelial carcinoma at radical cystectomy: a retrospective international study of 583 patients. J Urol. 2010 Jan; 183(1): 87–93.
17.
Kaushik D, Frank I, Eisenberg MS, Cheville JC, Tarrell R, Thapa P, et al. Gender-specific survival following radical cystectomy for pT4 bladder cancer. World J Urol. 2014 Dec; 32(6): 1433–9.
18.
Haque W, Verma V, Butler EB, Teh BS. National Practice Patterns and Outcomes for T4b Urothelial Cancer of the Bladder. Clin Genitourin Cancer. 2017 Sep; 16(1): 42–49.e1.
19.
Vallo S, Gilfrich C, Burger M, Volkmer B, Boehm K, Rink M, et al. Comparative analysis of the effect of prostatic invasion patterns on cancer-specific mortality after radical cystectomy in pT4a urothelial carcinoma of the bladder. Urol Oncol. 2016 Oct; 34(10): 432.e1–8.
20.
Aziz A, Shariat SF, Roghmann F, Brookman-May S, Stief CG, Rink M, et al. Prediction of cancer-specific survival after radical cystectomy in pT4a urothelial carcinoma of the bladder: development of a tool for clinical decision-making. BJU Int. 2016 Feb; 117(2): 272–9.
21.
May M, Aziz A, Brookman-May S, Roghmann F, Noldus J, Rink M, et al. Prognostic impact of infiltration of the vagina and/or uterus in women undergoing anterior pelvic exenteration for urothelial carcinoma of the bladder: results of a contemporary multicentre series. World J Urol. 2015 Mar; 33(3): 343–50.
22.
Moschini M, Soria F, Susani M, Korn S, Briganti A, Roupret M, et al. Impact of the Level of Urothelial Carcinoma Involvement of the Prostate on Survival after Radical Cystectomy. Bladder Cancer. 2017 Jul; 3(3): 161–9.
23.
Patel AR, Cohn JA, Abd El Latif A, Miocinovic R, Steinberg GD, Paner GP, et al. Validation of new AJCC exclusion criteria for subepithelial prostatic stromal invasion from pT4a bladder urothelial carcinoma. J Urol. 2013 Jan; 189(1): 53–8.
24.
Moschini M, Luzzago S, Zaffuto E, Dell’Oglio P, Gandaglia G, Mattei A, et al. The surgical management of patients with clinical stage T4 bladder cancer: A single institution experience. Eur J Surg Oncol. 2017 Apr; 43(4): 808–814.
25.
Moschini M, D’Andrea D, Korn S, Irmak Y, Soria F, Compérat E, et al. Characteristics and clinical significance of histological variants of bladder cancer. Nat Rev Urol. 2017 Nov; 14(11): 651–68.
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2019
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