Abstract
The main topics of this thesis are: 1) the feasibility of laparoscopic radical cystectomy (LRC), 2) the application and value of the pelvic lymph node dissection (PLND) at radical cystectomy (RC) in the Netherlands and 3) the application and value of neoadjuvant (chemo) therapy and RC in the Netherlands. In
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part I, based on the results of three case series (N=74) we concluded that the LRC can be considered a cost-neutral and oncological safe procedure with complication rates comparable to open RC series in younger and elderly patients. Data linkage with the Netherlands Cancer Registry (NCR) showed that RC seems to be feasible in a larger percentage of elderly patients than it is currently applied in the Netherlands. In part II we studied the effect of lymph node count (LNC) at RC in a high volume referral centre in 274 patients. We concluded that if surgeons adhere to a standardized standard pelvic lymph node dissection (PLND) template, LNC at RC does not affect long-term survival. Still this does not preclude an association with survival on a population-based level. In a NCR study in 7313 patients with cT2-4aN0/xM0 urothelial bladder cancer (BC) we estimated that PLND versus no PLND at RC was associated with an absolute survival benefit of 8% and that LNC ≥10 was associated with a 22% decrease in death-risk. These findings confirm that PLND should be an integral part of RC. In another NCR study (N=3.524) we assessed if PLND became an integral part of RC after the introduction of centralization of care for BC in 2010. PLND rate increased from 84% in 2006 to 96% in 2012. Median LNC increased from 7 to 13 and node positive disease from 18 to 24%. After centralization of care, PLND at RC has become standard of care. Furthermore, results suggest more adequate template extension and adherence to contemporary guidelines in recent years. In part III we assessed multiple aspects on perioperative treatment and RC in the Netherlands. A temporal trend analysis in 10.338 cTa/ is, cT1-4, cN0-3, cM0-1 BC patients who underwent RC with curative between 1995 and 2013 showed that the usage of neoadjuvant chemotherapy (NAC) increased from 0.6% in 1995 to 21% in 2013. Currently, neoadjuvant or adjuvant radiotherapy and adjuvant chemotherapy are hardly administered anymore. Though 21% might suggest underutilization, literature review estimated that upfront RC (without NAC), can be curative in over 80% of patients with clinically localised disease (cT2). To further explore these findings we conducted a NCR study and included a cohort of 5.570 patients who underwent RC for cT2-4aN0M0 urothelial BC. In patients with cT2 BC, transurethral resection only resulted in a complete pathological downstaging in 25%. After NAC this was 43%. In contrast in patients with locally advanced disease (cT3-4a), this was 8% versus 37%. NAC was associated with improved survival in patients with cT3-4a disease only (5-yr OS: 36 vs. 55%). Our results contribute to the debate to consider a more tailored use of perioperative chemotherapy.
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