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Page 6 of 11 Cicione et al. Mini-invasive Surg 2021;5:47 https://dx.doi.org/10.20517/2574-1225.2021.52

5-year OS of 5% (95%CI: 1%-12%). Furthermore, the median time to death from any cause was 9 months.
As predictable, on multivariable analyses, after adjusting for age at diagnosis, sex, clinical stage, and tumor
stage, untreated patients had a higher risk of death from any cause [hazard ratio (HR) = 2.63; 95%CI: 1.65-
4.19; P < 0.001], progression to distant metastasis (HR = 2.40; 95%CI: 1.28-4.51; P = 0.006), and cancer
specific mortality (HR = 2.02; 95%CI: 1.24-3.30; P = 0.005).

Overall, between 10% and 15% of patients are already metastatic at diagnosis with a median survival rarely
exceeding 3-6 months before the development of effective chemotherapy . Mak et al. reported the rate of
[21]
[2]
metastatic disease among 468 patients treated with TMT, which ranged from 32% to 35%. However, no
studies on SRC with curative intent in this stage of disease were retrieved except for a palliative purpose.

Thus, we found that up to 30% of patients treated with primary TMT with a curative intent subsequently
required SRC after 1 year of TMT. Although no comparative studies with RC are still available, SRC with a
curative intent seems to be feasible with acceptable oncological outcomes. Moreover, the recent
introduction of immunotherapy in the chemotherapeutic armamentarium encourages further assessing
approaches that preserve the bladder.

Salvage radical cystectomy as palliative care: surgical outcomes
Bladder cancer is related to a significant morbidity for its debilitating symptoms. Among them, hematuria is
the most common presenting symptom occurring in approximately 85% of diagnosed cases. Beyond the
tumor mass, side effects of radiation or upper urinary tract neoplasms may be further reasons for bleeding.
Sometimes hematuria may be difficult to control, uncurable by irrigation or hemostatic trans-urethral
resection, and thus is potentially life threatening. Furthermore, the recurrence of gross intractable hematuria
is a significant concern, worsening the quality of residual life. Thus, SRC with a palliative intent may be an
effective treatment of choice.

Zebic et al. carried out seven SRCs with a palliative intent, namely the surgical indication was due to T4a
[25]
bladder cancer (3 patients) and pelvic malignancies leading to severe voiding symptoms, pain, and
hematuria with need for repeated blood transfusions. Among them, 3 patients were lost during follow-up, 2
patients died during recovery for complications, and 2 patients lived 366 days after surgery. The
preoperative risk was assessed by ASA score, resulting 4 patients ASA 4, two ASA 2, and one ASA 1.

[26]
Nagele et al. investigated clinical outcomes of 20 patients, with a mean age of 64 years, undergoing SRC
for T4-stage bladder cancer. After a mean follow-up of 13 months (range 1-36 months), 11 patients were
still alive. The authors reported only one lethal complication, namely an enterocutaneous fistula occurring
during recovery. No data on preoperative surgical risk were reported.

The study of Cochetti et al. included 12 patients who underwent RC for massive hematuria due to bladder
[27]
cancer and causing severe anemia (Hb level < 8 g/dL). The pathological exam showed pT4 stage in 6
patients, 2 patients with pT2, and 4 patients affected by pT3 stage disease. Major complications occurred in
18.5% of cases, while no deaths were recorded. Although all patients were defined as ASA 4, the mean
Charlson Index was 6 and median Karnofsky scale was 85. An ileal conduit was used as a urinary diversion
in all studies mentioned above, while ureterocutaneostomy was performed in the presence of severe
comorbidities and poor performance status.

Thus, the studies all showed that, if technically feasible, in patients with a decent frailty status and accepting
surgery, the future problems of bleeding may be completely obviated. Frailty is a new concept introduced to