BJUI. Cystectomy in the elderly: does the survival benefit in younger patients translate to the octogenarians?

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1 Urologil Onology CYSTECTOMY IN THE ELDERLY CHAMIE et l. BJUI BJU INTERNATIONAL Cystetomy in the elerly: oes the survivl enefit in younger ptients trnslte to the otogenrins? Krim Chmie, Brin Hu, Rlph W. evere White n Lrs M. Ellison Deprtment of Urology, University of Cliforni, Dvis, Srmento, CA, USA Aepte for pulition 23 Jnury 2008 Stuy Type Prognosis (ineption ohort) Level of Eviene 1 OBJECTIVE To etermine whether the survivl enefit hieve with ril ystetomy (RC, the referene stnr for treting musleinvsive ler ner) in younger ptients justifies its use in otogenrins. PATIENTS AND METHODS We use the Surveillne Epiemiology n En Results t of the Ntionl Cner Institute n ientifie ptients from who were ignose with musle-invsive ler ner, n were trete with either RC or riotherpy. The t were nlyse for ge, gener, re, extent of lymphenetomy n use of eth. We strtifie the ptients y ge groups (<60, 60 69, n >79 yers), n use Kpln-Meier survivl nlysis to ompre tretment strtegies y ge group. RESULTS In ll, 8034 ptients h RC n 2773 riotherpy; RC ws the primry metho of tretment in ll ge groups exept for otogenrins. Those who h RC h sizele overll survivl vntge in ll ge groups, exept for the otogenrins (18 vs 15 months). This smll survivl vntge improve only slightly (23 vs 15 months) when exluing ptients hving nol or istnt metstsis. The otogenrins who hve RC with limite pelvi lymph noe issetion or RC lone reeive little (16 vs 15 months) or no survivl enefit. However, ner-speifi survivl ws signifintly higher in those who h RC, inluing otogenrins. CONCLUSIONS Otogenrins hve some enefit to nerspeifi survivl from RC if it inlues stnr lymphenetomy. The issue is how to etter selet the ptients, s the overll survivl vntge in these ptients over riotherpy is negligile. KEYWORDS neoplsms, ler, ystetomy, riotherpy, ge, otogenrin INTRODUCTION Bler ner is ommon mlignny tht isproportiontely ffets the elerly. Nerly three-qurters of inient ses re ignose in ptients ge 65 yers [1]. Ril ystetomy (RC) is the most ommon tretment for musle-invsive ler ner, ut not ll ptients re pproprite nites for RC. Age, rightly or wrongly, is often mjor onsiertion when weighing tretment options [2]. Comine pltinumse hemotherpy n rition hs een n remins n lterntive minsty for efinitive lol tretment. It is well unerstoo tht elerly ptients generlly hve higher opertive risks n more omoriities thn younger groups. These risks might e ompoune fter surgery y the metoli isturnes tht n rise s result of urinry iversion. For this group, lning the reltive vlue of survivl enefit ginst qulity of life is more iffiult n vrie thn for younger popultions. With vile non-rc protools, mny ptients n gin some survivl enefit, while t the sme time voiing the potentil risks of mjor surgery. Nevertheless, while elerly ptients hve higher opertive risks, the risks of ler-spring protools (hemotherpy n or rition) re lso higher in this group. As is the se for mny proviers, urologists re seeing more elerly ptients presenting with or progressing to musle-invsive isese. It ws not ler from the reporte stuies on ystetomy if otogenrins gin survivl enefit of equl proportion to tht hieve y younger ptients. Mny of the reports relte to RC in the elerly hve fouse on short-term sfety n tolerne of surgery [3,4]. Thus we evlute the survivl enefit, if ny, tht otogenrins n expet from RC. We use the Ntionl Cner Institute (NCI) Surveillne Epiemiology n En Results (SEER) progrmme t n onute n ge-group survivl nlysis of ptients ignose n trete for musle-invsive ler ner etween 1992 n PATIENTS AND METHODS We use the SEER progrm, ntionl prospetive ner registry mintine y the NCI tht inlues informtion from 17 popultion-se ner registries from vrious res of the USA, inluing the sttes of Connetiut, Iow, New Mexio, Uth, Hwii, Kentuky, Louisin, New Jersey, Greter Cliforni, n the metropolitn res of Detroit, Sn Frniso, Settle-Puget Soun, Atlnt, Los Angeles, Sn Jose- 284 JOURNAL COMPILATION 2008 BJU INTERNATIONAL 102, oi: /j x x

2 CYSTECTOMY IN THE ELDERLY TABLE 1 Ptient emogrphis n isese vriles strtifie y ge n tretment Age group, yers < >79 Vrile BP/RT RC P BP/RT RC P BP/RT RC P BP/RT RC P No. of ptients Gener (% women) Re, % Cusin Afrin-Amerin Other Cuse of eth, % Bler ner < < Other mlignnies Criovsulr <1 Pulmonry < Dietes Stge, % T T T < < <1 Nol metstsis, % < < < <1 Distnt metstsis, % < < Gre, % Low High Monterey, Rurl Georgi, n the Alsk Ntive Tumor Registry. In ll, 26% of the USA popultion ws use for the nlysis. Dt re ollete on ll inient ses of ner, initil tretment n survivl. Susequent interventions n reurrene t re not ollete. Trine strtors ollet the informtion from hospitl reors, outptient linis, rition entres, privte lortories n physiins offies. FIG. 1. Kpln-Meier urves for mein overll survivl of ptients with musle-invsive ler ner strtifie y ge n tretment. Overll Survivl for <60 Cohort Mein Survivl 74 vs. 28 months Cox HR 1.64 ( ) Overll Survivl for Cohort Mein Survivl 49 vs. 24 months Cox HR 1.54 ( ) A t itionry supplie y SEER ws use to eoe 115 linil vriles. All inient ler ner ses (Interntionl Center for Disese, oe 188) etween the yers 1992 n 2004 were ientifie. The finl group of ptients inlue those with musle-invsive TCC of the ler who t the time of ignosis were trete with either RC or y ler-spring proeure with riotherpy (RT). Ptients were exlue if their T stge, histology, gre, or primry tretment were unknown, or if ler-spring protool ws not omine with RT. For eh ientifie se, t on ge, gener, re, histology, tumour stge n gre, tretment, ministrtion of RT, whether pelvi lymphenetomy (PLND) ws Overll Survivl for Cohort Mein Survivl 33 vs. 19 months Cox HR 1.52 ( ) Overll Survivl for >79 Cohort Mein Survivl 18 vs. 15 months Cox HR 1.32 ( ) JOURNAL COMPILATION 2008 BJU INTERNATIONAL 285

3 CHAMIE ET AL. performe, numer of lymph noes exmine, numer of lymph noes positive, use of eth, n time to eth from te of ignosis were strte. All nlyses use the TNM stging system t ignosis. Ptients with rinom in situ, T1 n Tx ler ner were exlue from the nlysis. Tumour gre ws lssifie s either high (gre 2 n 3) or low (gre 1). We efine tretment s either RC or ler preservtion with RT (BP/RT). Within the SEER t there is informtion on RT, ut no oe t for hemotherpy. Bler preservtion refers to those ptients who h trnsurethrl resetion of ler tumour (TURBT) or prtil ystetomy n RT. RC refers to ptients who h RC with or without RT. We efine stnr PLND s 10 lymph noes; nything less ws esignte limite PLND n ses with n unknown numer of lymph noes were exlue in the nlysis of PLND on survivl. Ptients were strtifie into ge groups of <60, 60 69, n >79 yers, n Kpln-Meier survivl nlysis n the logrnk test use to ompre tretment strtegies y ge group. Cox proportionl hzrs moels were onstrute using the key linil vriles tht iffere ross tretment strtegies. In stepwise fshion, we seletively eliminte ptients with istnt metstsis (M1), then nol isese (N+, N1, N2 n N3). Nol isese ws pthologil ignosis in the RC rm n linil ignosis in the BP/RT rm. Age group, yers Vrile < >79 No. of ptients Lymph noes issete > Unknown No. of ptients Lymph noes positive > Unknown FIG. 2. Kpln-Meier urves for mein CSS in ptients strtifie y ge n tretment. Cner Speifi Survivl for <60 Cohort Mein Survivl NR vs. 43 months Cox HR 1.69 ( ) Cner Speifi Survivl for Cohort Mein Survivl 132 vs. 40 months Cox HR 1.31 ( ) TABLE 2 The extent of PLND n nol isese strtifie y ge for those trete with RC Cner Speifi Survivl for Cohort Mein Survivl 141 vs. 42 months Cox HR 1.55 ( ) Cner Speifi Survivl for >79 Cohort Mein Time 37 vs. 22 months Cox HR 1.21 ( ) RESULTS The totl numer of ptients ignose with ler ner etween 1992 n 2004 in the SEER tse ws We exlue se on our pre-set riteri n thus the finl group omprise ptients, 8034 who h RC n 2773 who h BP/RT; Tle 1 summrizes the ptient emogrphis strtifie y ge n tretment. RC ws more ommon thn BP/RT for ll ge groups exept for the otogenrins. Among otogenrins, 1227 ptients h BP/RT wheres 904 h RC. The proportion of women inrese with ge, rehing pek ( %) in the otogenrins. Younger women ( 69 yers ol) were more likely to hve RC thn BP/RT, ut in the elerly ptients ( 70 yers ol) there ws no sttistilly signifint ifferene. While there ws no ifferene in re etween the tretment options, there ws grul inrese in the numer of Cusins in the elerly popultion. Bler ner ws the most ommon use of eth in ll ge groups n for oth tretments. However, the gretest ifferene in ler ner-ssoite mortlity etween the tretment rms ws in the younger popultion. Also, the ptients who h BP/RT were more likely to ie from other non-mlignnt uses (riopulmonry isese) thn those who h RC. Vrition in isese ftors re lso liste in Tle 1; those who h RC were more likely to hve extrvesil isese thn those who h BP/RT. Ptients who h RC h grul inrese in T3 isese with inresing ge 286 JOURNAL COMPILATION 2008 BJU INTERNATIONAL

4 CYSTECTOMY IN THE ELDERLY FIG. 3. Kpln-Meier urves for the mein non-css in ptients strtifie y ge n tretment. Cox HR 1.62 ( ) Cox HR 1.30 ( ) Non-Cner Relte Survivl for <60 Cohort Non-Cner Relte Survivl for Cohort Mein Survivl 146 vs. 89 months Cox HR 1.92 ( ) Non-Cner Relte Survivl for Cohort Non-Cner Relte Survivl for >79 Cohort Mein Survivl 89 vs. 62 months Cox HR 1.58 ( ) FIG. 4. Kpln-Meier urves for mein overll survivl in ptients strtifie y ge, tretment n whether they h PLND. Overll Survivl for <60 Cohort Mein Survivl 98 vs. 49 vs. 28 Overll Survivl for Cohort Mein Survivl 35 vs. 28 vs. 19 months Overll Survivl for Cohort Mein Survivl 54 vs. 37 vs. 24 months Overll Survivl for >79 Cohort Mein Survivl 21 vs. 15 vs. 15 months (<60, 53.1%; 60 69, 54.9%; 70 79, 58%; n >79, 60.7%). This grul inrese ws not pprent mongst those trete with BP/RT. For tumour gre, >90% of ptients in oth tretment rms h high-gre isese. Tle 2 summrizes the PLND t; mongst those who h RC PLND ws more ommon in the younger ptients. There ws grul eline in PLND with inresing ge (<60, 86.2%; 60 69, 84.1%; 70 79, 80.6%; n >79, 75.8%). Figure 1 shows the overll survivl mong the four ge groups; the enefit of RC over BP/RT ws most rmti mong younger ptients. The mein overll survivl for those ge <60 yers ws 74 months fter RC vs 28 months fter BP/RT (Cox proportionl hzrs 1.64; 95% CI ; Fig. 1). In those ge yers the survivl enefit from RC ws 49 months, vs 24 months for BP/RT (1.54, ; Fig. 1). In those ge yers the survivl enefit ws still signifintly higher in the RC rm, t 33 vs 19 months (1.52, ; Fig. 1). However, mong the otogenrins the survivl enefit, while still present, ws signifintly smller, t 18 vs 15 months (1.32, ; Fig. 1). In Fig. 2, ner-speifi survivl (CSS) is shown for the four ge groups. The ptients who h RC h etter CSS regrless of ge. The CSS for the youngest group (<60 yers) ws not rehe, while it ws 43 months for those trete with BP/RT (1.69, ; Fig. 2). Those ge yers who h RC reeive similr CSS vntge, t 141 vs 42 months (1.55, ; Fig. 2). This enefit ws lso note in those ge yers, t 132 vs 40 months (1.31, ; Fig. 2). While this survivl enefit remine, it ws lso iminishe for those otogenrins who h RC, t 37 vs 22 months (1.21, ; Fig. 2). While omoriity t re not ville on SEER, the use of eth is oumente. To etermine whether ptients trete with BP/RT were eqully likely to ie from nonner-relte uses s their RC ounterprts, we ompre the tretment strtegies in eh ge group, s shown in Fig. 3. There ws little ifferene in the younger groups, ut s expete, mong the elerly (70 79 yers) n the otogenrins, those who h BP/RT h shorter mein survivl s result of omori isese. JOURNAL COMPILATION 2008 BJU INTERNATIONAL 287

5 CHAMIE ET AL. After exluing nol n metstti isese, there ws signifint improvement in CSS for those who h RC. Interestingly, the otogenrins mein CSS oule with the exlusion of nol metstsis (from 37 to 74 months). To ssess whether the elerly enefit from PLND to the sme extent s their younger ounterprts, we su-strtifie se on RC with or without PLND (Fig. 4). All ge groups, exept for the very elerly (>79 yers) h n overll survivl enefit from RC regrless of PLND (Fig. 4 ). The very elerly who h RC with no PLND h no overll survivl enefit over those who h BP/RT (15 vs 15 months). The very elerly who h RC with PLND h enefit of 6 months (21 vs 15 months; Fig. 4). There ws similr pttern for CSS (Fig. 5); those who h RC with no PLND still h CSS enefit when ompre with those who h BP/RT, ut this ws smllest mongst the very elerly (27 vs 22 months; Fig. 5). We lso ompre those who h stnr PLND ( 10 lymph noes) with those who h limite PLND (<10) n to BP/RT (Fig. 6). All ge groups h signifint enefit from stnr PLND n while limite PLND provie some survivl enefit, it ws negligile in the very elerly (16 vs 15 months). From Fig. 7 there ws CSS enefit in ll ge groups with RC, lthough the enefit ws signifintly lrger in those tht who stnr PLND. DISCUSSION RC provie longer overll n CSS thn BP/ RT in ll ge groups; there is mrke overll survivl enefit from RC in those ge <80 yers. For ptients ge 80 yers the overll survivl enefit ws mesurle ut smller. When exmining CSS there ws 15- month vntge of RC for otogenrins; this eme 52 months when ptients with nol or metstti isese were exlue. It ppers tht ompeting uses of mortlity hve isproportiontely negtive effet in otogenrins reltive to younger ptients. Others hve stuie the effet of ge on survivl fter RC, n the results were mixe. For exmple, Clrk et l. [5] stuie 1054 ptients with lolly invsive ler ner strtifie y ge, n foun oth worse FIG. 5. Kpln-Meier urves for mein CSS in ptients strtifie y ge, tretment n whether they h PLND. Cner-Speifi Survivl for <60 Cohort Mein Survivl NR vs. NR vs. 43 months without PLND with PLND Cner-Speifi Survivl for Cohort Mein Survivl NR vs. 144 vs. 40 months without PLND with PLND overll survivl n isese-free reurrene in those of vne ge. Others hve lso foun worse overll n CSS with inresing ge [6,7]. However, Chhl et l. [8] exmine the overll 5-yer survivl for 398 ptients with invsive ler ner trete with ril RT n RC, n foun tht ge ws not n inepenent preitor of survivl for either tretment. This ws lso reporte y others inepenently [9 11]. Konety n Joslyn [11], fter similr review of SEER, foun tht overll survivl ppers to e ssoite with ftors unrelte to isese, e.g. ge, sex n site, wheres CSS ws iretly influene y isese-relte ftors, e.g. stge n extent of PLND. However, in their nlysis ptients with superfiil isese were not exlue. Also, the efinition of filure ws eth from ny ner, rther thn ler nerspeifi mortlity. We not only foun tht the elerly were less likely to hve RC, ut lso PLND. The effet of PLND, espeilly stnr PLND, hs een shown to iretly influene survivl [12 14]. In the present nlysis, it ws ler tht without PLND with PLND Cner-Speifi Survivl for Cohort Mein Survivl NR vs. 65 vs. 42 months Cner-Speifi Survivl for >79 Cohort Mein Survivl 42 vs. 27 vs. 22 months without PLND with PLND ompromising stnr opertion y omitting PLND virtully nelle ny survivl enefit from RC for the very elerly. In ertin irumstnes, RC might e use for pllitive rther thn urtive resons. Unfortuntely, the urrent proeure-oing struture oes not pture therpeuti intent. However, it might e expete tht ptients for whom PLND ws omitte woul hve linil eviene of more extensive isese. We i not fin this to e evient in our ptient popultion. The time of tretment n reovery from RC is importnt mong ptients ge >80 yers. Stuies of ptients ge >70 yers foun the men hospitl sty fter RC to e ys [3,15]. In ition, ptients ge >79 yers were foun to e re-mitte to the hospitl 66% of the time within 6 months of RC, for either meil or surgil omplitions [16]. A long hospitl sty omine with reovery of funtion fter the hospitliztion n e signifint proportion of n elerly ptient s remining life, n shoul e ftore into the eision to proee with RC. 288 JOURNAL COMPILATION 2008 BJU INTERNATIONAL

6 CYSTECTOMY IN THE ELDERLY FIG. 6. Kpln-Meier urves for mein overll survivl in ptients strtifie y ge, tretment n the extent of PLND (stnr, 10 lymph noes; vs limite <10) vs BP/RT. Overll Survivl for Cohort <60 Mein Survivl NR vs. 74 vs. 28 months Overll Survivl for Cohort Mein Survivl 49 vs. 30 vs. 19 months Overll Survivl for Cohort Mein Survivl 65 vs. 47 vs. 24 months Overll Survivl for >79 Cohort Mein Survivl 25 vs. 16 vs. 15 months FIG. 7. Kpln-Meier urves for mein CSS in ptients strtifie y ge, tretment n the extent of PLND (stnr 10 lymph noes; vs limite, <10) vs BP/RT. Cner-Speifi Survivl for <60 Cohort Mein Survivl NR vs. NR vs. 43 months Cner-Speifi Survivl for Cohort Mein Survivl NR vs. 81 vs. 40 months Cner-Speifi Survivl for Cohort Mein Survivl NR vs. NR vs. 42 months Cner-Speifi Survivl for >79 Cohort Mein Survivl 57 vs. 30 vs. 22 months Although we feel tht the present stuy provies goo omprison etween longterm survivl in ptients with musleinvsive ler ner, there re some limittions. First, SEER ouments the inient ner ses n the primry tretment; ptient level t relte to omoriity re missing. Ajustment of risk se on Chrlson-type inex woul provie mrginlly etter preision in the nlysis. The likely senrio is tht omori risk justment is likely to use is towrs the null hypothesis (i.e. there is no ifferene in survivl etween RC n BP/ RT). Seon, re-hospitliztion rtes nnot e lulte using SEER lone. It is possile tht ptients whose lers re preserve hve repete mission for hemturi n ler pin. Hene, while the survivl enefit from RC over BP/RT might e smll in the very elerly, we might e unerestimting the qulity-of-life enefit from surgery. Thir, there might e unerstging in the BP/RT group. The T stge for the BP/RT ws se primrily on TURBT n linil mesures (CT). Previous reports oument tht up to hlf of ler ners thought to e linilly orgn-onfine re foun to hve extrvesil extension, n 25% to hve nol metstsis, respetively [17 19]. We expet tht uner-stging woul lso is towrs the null hypothesis of no ifferene etween the tretment groups. Fourth, SEER oes not report hemotherpeuti tretment. Two lrge stuies hve shown improve survivl with periopertive hemotherpy in ptients trete with RC [20,21]. We were unle to exmine the effet of juvnt or neojuvnt hemotherpy. Despite these limittions, we think tht our results will provie urologists n their ptients with vlule informtion when onsiering RC. In onlusion, in ntion with fstgrowing elerly popultion in whom ler ner is prevlent, iffiult eisions on tretments must involve n ssessment of opertive risks, qulity of life, n the survivl enefit. RC is well tolerte y the elerly n this hs een the min impetus for treting these ptients ggressively with urtive intent. We foun tht RC with stnr PLND provies the est long-term mortlity enefit for ll ptients, even when strtifie y ge. For those otogenrins with no serious ompeting risk ftors, ggressive surgery might provie 52 months of CSS enefit over BP/RT. However, suh JOURNAL COMPILATION 2008 BJU INTERNATIONAL 289

7 CHAMIE ET AL. ptient is the exeption rther thn the rule, n most in this ge group either hve metstti isese, signifint omoriities or o not hve n iel opertion (RC n PLND) n therefore shoul expet enefit loser to 3 months. Our hllenge is to ientify these otogenrins who will enefit from surgery. CONFLICT OF INTEREST None elre. REFERENCES 1 Ries LAG, Kosry CL, Hnkey BF et l. Cner Sttistis Review, Bethes, MD: Ntionl Cner Institute, Aville t: sr/1975_2002/ se on Novemer 2004 SEER t sumission, poste to the SEER we site 2 Shrg D, Mitr N, Xu F et l. Cystetomy for musle-invsive ler ner: ptterns n outomes of re in the Meire popultion. Urology 2005; 65: Clrk PE, Stein JP, Groshen SG et l. Ril ystetomy in the elerly: omprison of linil outomes etween younger n oler ptients. Cner 2005; 104: Woo DP Jr, Montie JE, Mtmn TJ et l. Ril ystetomy for rinom of the ler in the elerly ptient. J Urol 1987; 138: Clrk PE, Stein JP, Groshen SG et l. Ril ystetomy in the elerly. Comprison of survivl etween younger n oler ptients. Cner 2005; 103: Tkshi M, Murse T, Mizuno S et l. Multivrite evlution of prognosti eterminnts in ler ner ptients. Urol Int 1987; 42: Thrsher JB, Frzier HA, Roertson JE et l. Clinil vriles whih serve s preitors of ner-speifi survivl mong ptients trete with ril ystetomy for trnsitionl ell rinom of the ler n prostte. Cner 1994; 73: Chhl R, Sunrm SK, Ienen R et l. A stuy of the moriity, mortlity n long-term survivl following ril ystetomy n ril riotherpy in the tretment of invsive ler ner in Yorkshire. Eur Urol 2003; 43: Dlgni G, Geneg E, Hshie M et l. Cystetomy for ler ner: ontemporry series. J Urol 2001; 165: Bssi P, Ferrnte GD, Pizz N et l. Prognosti ftors of outome fter ril ystetomy for ler ner: retrospetive stuy of homogeneous ptient ohort. J Urol 1999; 161: Konety BR, Joslyn SA. Ftors influening ggressive therpy for ler ner: n nlysis of t from the SEER progrm. J Urol 2003; 170: Konety BR, Joslyn SA, O Donnell MA. Extent of pelvi lymphenetomy n its impt on outome in ptients ignose with ler ner: nlysis of t from the Surveillne, Epiemiology n En Results Progrm t se. J Urol 2003; 169: Herr HW. The onept of lymph noe ensity is it rey for linil prtie? J Urol 2007; 177: Herr HW, Dotn Z, Dont SM et l. Defining optiml therpy for musle invsive ler ner. J Urol 2007; 177: Zei N, Weinkneht S, Kroepfl D. Ril ystetomy in ptients ge > or = 75 yers: n upte review of ptients trete with urtive n pllitive intent. BJU Int 2005; 95: Stroumkis N, Herr HW, Cookson MS et l. Ril ystetomy in the otogenrin. J Urol 1997; 158: Byrktr Z, Guruz G, Tsi AI et l. Stging error in the ler tumor: the orreltion etween stge of TUR n ystetomy. Int Urol Nephrol, 2001; 33: Firr V, Dlpiz O, Alri N et l. Correltion etween linil n pthologil stging in series of ril ystetomies for ler rinom. BJU Int 2005; 95: MLughlin S, Shephr J, Wllen E et l. Comprison of the linil n pthologi stging in ptients unergoing ril ystetomy for ler ner. Int Brz J Urol 2007; 33: Interntionl Collortion of Trilists. Neojuvnt ispltin methotrexte, vinlstine hemotherpy for musleinvsive ler ner: rnomise ontrolle tril. Lnet 1999; 354: Grossmn HB, Ntle RB, Tngen CM et l. Neojuvnt hemotherpy plus ystetomy ompre with ystetomy lone for lolly vne ler ner. N Engl J Me 2003; 349: 859 Corresponene: Krim Chmie, 4860 Y Street, Suite 3500, Srmento, CA 95817, USA. e-mil: krim.hmie@um.uvis.eu Arevitions: RC, ril ystetomy; BP/RT, ler preservtion n riotherpy; CSS, ner-speifi survivl; PLND, pelvi lymph noe issetion; NCI, Ntionl Cner Institute; SEER, Surveillne Epiemiology n En Results; TURBT, trnsurethrl resetion of ler tumour. 290 JOURNAL COMPILATION 2008 BJU INTERNATIONAL

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