# “Modernized” en Bloc Radical Cystectomy Versus Standard Radical Cystectomy: A Nationwide Multi-Institutional Propensity Score Matched Analysis

## TL;DR

A new surgical technique for bladder cancer, called modernized en bloc radical cystectomy, may improve survival rates compared to the standard method.

## Contribution

The study introduces and evaluates a modernized en bloc radical cystectomy technique for bladder cancer surgery.

## Key findings

- The en bloc technique showed significantly better 5-year recurrence-free survival compared to the standard method.
- Cancer-specific and overall survival rates were also higher with the en bloc approach.
- Female patients had notably better 5-year survival with the en bloc technique.

## Abstract

Despite the advances in medical technology over the last decades, there have only been minor improvements in survival after surgical removal of the bladder for advanced stages of bladder cancer. The investigators suggest that applying the principles of oncological surgery, i.e., extracting the embryonic area of the tumor–affected organ in one specimen and performing an en bloc approach, improves survival. This national Norwegian study included 935 patients treated with either the prior standard technique (n = 721) or this novel en bloc technique (n = 214). The outcome analyses included statistical models reducing possible biases influencing the differences in survival comparing the two groups. The findings indicate that the en bloc technique might yield significantly improved oncologcal outcomes.

Background: Pelvic lymph node dissection during standard radical cystectomy (stdRC) for muscle invasive bladder cancer is performed as separate templates. In the modernized en bloc radical cystectomy (mEbRC), the bladder is removed together with all its associated lymphatic tissue as one specimen. Our aim was to evaluate the oncological and surgical outcomes of mEbRC with a propensity-matched national cohort of stdRC cases. Methods: 935 patients (mEbRC: 214 and stdRC: 721) were eligible for analysis, and 1:2 propensity score matching was performed regressing mEbRC treatment on the variables age, gender, neoadjuvant chemotherapy, Charlson Comorbidity Index, lymph node metastases at final pathology, carcinoma in situ, and pT-stage. The primary outcome was recurrence-free survival (RFS). Secondary endpoints were overall survival (OS) and cancer-specific survival (CSS), survival for female patients. and perioperative measures. Results: There were no significant differences between the groups regarding complications, 30-day readmission rates, and 30- and 90-day mortality rates. In the propensity score matched groups, the 5-year RFS was 83% in the mEbRC group vs. 67% in the stdRC group (p < 0.001), the CSS was 89% and 78% (p ≤ 0.001), and OS 81% vs. 68% (p < 0.001) in the same groups, respectively. The results were confirmed by Cox regression analyses with hazard ratios ranging from 0.41 to 0.50 and p-values ≤ 0.001, favoring mEbRC. The 5-year OS for female patients was 86% for mEbRC and 60% for stdRC (p = 0.022). Conclusions: Performing mEbRC over stdRC might yield significantly better oncological outcomes, with equal survival rates for both genders.