Cystectomy is NOT the Desired Treatment for Bladder Cancer with Peritoneal, Liver, and Lung Metastases
Patients with disseminated metastatic bladder cancer involving multiple visceral organs (peritoneum, liver, lungs) should receive systemic chemotherapy as primary treatment, not cystectomy. 1 Surgery has no survival benefit in this setting and may worsen quality of life without improving outcomes.
Why Cystectomy is Contraindicated in Multi-Organ Metastatic Disease
Patients with visceral metastases to multiple organs have extremely poor prognosis with median survival of only 9-15 months even with optimal chemotherapy, and the presence of ≥2 metastatic organ sites is an independent predictor of significantly worse outcomes (HR: 2.1). 1, 2
Cystectomy provides no survival advantage when metastatic disease is present in multiple visceral organs (liver, lungs, peritoneum), as demonstrated in systematic reviews showing that patients with visceral metastases have only 6.8% five-year survival compared to 20.9% for lymph node-only disease. 1
The European Association of Urology and NCCN guidelines explicitly state that patients with disseminated metastatic disease should be treated with systemic therapy, not surgery. 1, 3
The Correct Treatment Approach
First-Line Systemic Therapy
Cisplatin-based combination chemotherapy (gemcitabine plus cisplatin or MVAC) is the standard first-line treatment for patients fit enough to tolerate cisplatin. 1, 3
For cisplatin-ineligible patients, immunotherapy with pembrolizumab (in PD-L1-positive patients) or carboplatin-based chemotherapy (in PD-L1-negative patients) should be considered. 3
When Surgery Might Be Considered (But Not in Your Case)
Metastasectomy may only be considered in highly select patients with oligometastatic disease (single or limited metastatic sites), excellent response to chemotherapy, and disease limited to lungs or lymph nodes—NOT liver, peritoneum, and lungs simultaneously. 1
The best candidates for metastasectomy are those with solitary lung or lymph node metastases, complete or near-complete response to chemotherapy, and no evidence of rapid progression. 1 Five-year survival after metastasectomy ranges from 28-72% in these highly selected cases. 1
Patients with liver metastases, peritoneal involvement, or multiple organ sites are explicitly poor candidates for surgical intervention, as these factors independently predict poor survival. 1
Critical Prognostic Factors
Visceral metastases (lung, liver, peritoneum) are independent predictors of worse outcomes compared to lymph node-only disease. 1
The number of metastatic sites is crucial: patients with ≥2 organ sites have substantially reduced survival compared to single-site disease. 1, 2
Response to initial chemotherapy serves as the most important prognostic indicator for subsequent outcomes and determines whether any consolidative approach might be considered. 1
Common Pitfalls to Avoid
Do not perform cystectomy in patients with widespread metastatic disease, as historical series show that surgery aborted due to extensive disease results in poor outcomes with no survival benefit. 1
Do not confuse locally advanced disease (T4b or M1a lymph node-only disease) with disseminated visceral metastases—the former may occasionally benefit from aggressive multimodal therapy including surgery, while the latter should receive systemic therapy only. 1
Recognize that peritoneal involvement represents advanced, disseminated disease with particularly poor prognosis and is a contraindication to surgical intervention. 2
Quality of Life Considerations
One study showed that metastasectomy in patients with symptomatic widespread disease actually reduced quality of life and sense of well-being in asymptomatic patients, while providing only palliative benefit in symptomatic cases. 1
Quality of life should be monitored in all phases of treatment, and palliative approaches should be prioritized when cure is not achievable. 3