Vaginal cuff recurrence after radical cystectomy: an under – studied site of bladder cancer relapse

Vol. 44 (3): 491-499, May – June, 2018

doi: 10.1590/S1677-5538.IBJU.2017.0376


ORIGINAL ARTICLE

Fabio Zattoni 1, 2, Alessandro Morlacco 1, 2, Avinash Nehra 1, Igor Frank 1, Stephen A. Boorjian 1, Prabin Thapa 3, R. Jeffrey Karnes 1
1 Department of Urology, Mayo Clinic, Rochester, Minnesota, USA; 2 Clinica Urologica, Dipartimento di scienze Chirurgiche, Oncologiche e Gastroenterologiche, Azienda Ospedaliero – Universitaria di Padova, Padova, Italy; 3 Health Sciences Research, Mayo Clinic, Rochester, MN, USA

ABSTRACT

Introduction: Vaginal cuff recurrence of tumor following radical cystectomy is a rare site of disease recurrence, however it has never been specifically studied. The aim of the study is to evaluate incidence, risk factors, and long-term oncologic outcomes of vaginal cuff recurrence in a cohort of female patients treated with radical cystectomy for invasive urothelial carcinoma of the bladder.

Materials and Methods: From 1985 to 2012, a prospectively maintained institutional bladder cancer registry was queried for vaginal cuff recurrence post radical cystectomy. Overall mortality and cancer-specific mortality were reported using the Kaplan-Meier method for patients with vaginal cuff recurrence, recurrence at another local or distant site, and those without evidence of recurrence. Comparisons were performed using the log-rank test. Cox proportional hazards regression model was performed to assess predictors of vaginal cuff recurrence.

Results: From 469 women treated with radical cystectomy for bladder cancer, 34 patients (7.3%) developed vaginal cuff recurrence, 130 patients (27.7%) had recurrence involving either a local or distant site, and 305 patients (65%) had no evidence of recurrence. The 5-year overall mortality-free survival rate was 32.4% for vaginal cuff recurrence, but 25.0% for other sites of recurrence. Cancer-specific mortality-free survival rate was 32.4% for vaginal cuff recurrence, and 30.3% for the other sites of recurrence. Multivariate Cox proportional hazards regression analysis demonstrated that the presence of tumor in posterior location at radical cystectomy (Hazard Ratio [HR], 0.353 [95% CI, 0.159-0.783]) and anterior vaginectomy, compared to no vaginectomy (HR, 2.595 [95% CI, 1.077-6.249]) were independently associated with vaginal cuff recurrence.

Conclusion: Anterior vaginectomy, despite our best attempts, is perhaps not sufficient to prevent vaginal cuff recurrence. Therefore, follow-up evaluation is essential, and further studies are necessary to address the optimal approach for initial management.

Patient Summary: Although vaginal cuff recurrence is an unusual site of recurrence, careful evaluation is needed before cystectomy and during follow-up to identify patients at risk.

Keywords: Urinary Bladder Neoplasms; Female; Neoplasm Metastasis; Recurrence

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