Determining the optimal time for radical cystectomy after neoadjuvant chemotherapy

Objective To determine whether the recovery window (RW) between neoadjuvant chemotherapy (NAC) and radical cystectomy (RC) affects 90‐day postoperative morbidity and incidence of lymph node metastasis. Patients and methods We reviewed patients treated with NAC and RC from 1995 to 2013 for ≤cT4N0M0 bladder cancer. The association of the RW with 90‐day perioperative morbidity and lymph node metastasis was determined. Generalised linear models were used to determine predictors of each endpoint. Patients were stratified into four RWs by 21‐day intervals (18–42; 43–63; 64–84; and ≥85 days) from last day of NAC to RC. Results We evaluated 306 patients with RW information during the study period. The median (range) RW was 46 (18–199) days. There was no difference in overall morbidity, re‐admission, or major complication rates amongst the four RWs. In the multivariable analysis extravesical disease was an independent predictor of overall morbidity (odds ratio [OR] 1.95, 95% confidence interval [CI] 1.16–3.26; P = 0.011). Age (OR 1.05, 95% CI: 1.02–1.09; P = 0.004), and surgical duration ≥7 h (OR 2.87, 95% CI: 1.52–5.42; P = 0.001) were independent predictors of major complications. Only surgical duration ≥7 h was a predictor of re‐admission (OR 2.24; 95% CI: 1.26–3.98; P = 0.006). A RW of ≥85 days had the highest incidence of node‐positive disease (pN+; 40%). In a separate multivariable model that included clinical predictors for pN+, a RW of ≥85 days was an independent predictor of nodal metastasis (OR 2.92, 95% CI: 1.20–7.09; P = 0.018). Conclusion Patients treated with NAC for bladder cancer can undergo RC between 18 and 84 days (2.5–12 weeks) after NAC with no difference in the risk of perioperative morbidity. Delaying surgery beyond 12 weeks was associated with a significant risk of lymph node metastasis.