The role of salvage cystectomy after prior trimodality therapy.

781 Background: Trimodality therapy (TMT) with transurethral resection followed by radiation of the urinary bladder and chemotherapy is associated with similar long-term survival rates compared to radical cystectomy (RC) for well-selected patients. Nevertheless, salvage RC may become necessary in 10% of patients receiving TMT. We aimed to assess the perioperative and long-term outcomes of salvage RC after prior TMT through a large multinational cohort study. Methods: We included patients with pure urothelial cancer of the urinary bladder. Patients undergoing salvage RC after prior TMT due to recurrence in the urinary bladder from 11 high-volume centers were matched with a propensity score matching on a 1:1 ratio with patients without prior TMT undergoing primary RC. The two groups were adjusted for institution, age, histological status, ASA score, and surgical technique. Results: We included 108 patients (54 per group) with a median age of 74 years (IQR: 66-78). The two groups did not differ in terms of operative time (TMT: 250 versus non-TMT: 251 minutes, p = 0.9), intraoperative blood loss (TMT: 550ml versus non-TMT: 600ml, p = 0.2), and perioperative Clavien-Dindo complications (p = 0.9). At a follow-up of 16 months (IQR: 6-38), 45 (42%) deaths occurred. Prior TMT was associated with higher mortality rates in the survival analysis (log-rank test: p = 0.037). Accordingly, the progression rates were higher in patients with prior TMT (log-rank test: p = 0.047). Conclusions: Salvage RC after TMT is associated with similar perioperative outcomes compared to primary RC. Nevertheless, patients undergoing salvage RC after TMT may present worse progression rates and overall survival in the long term. Therefore, systemic therapies should be considered in patients with recurrence after TMT.