Radical cystectomy practice patterns in the Nordic countries: results from the prospective NorCys study
DOI:
https://doi.org/10.2340/sju.v61.45602Keywords:
Bladder cancer, radical cystectomy, neoadjuvant chemotherapyAbstract
Background: Muscle invasive bladder cancer (MIBC) is an aggressive disease with a high mortality rate. Radical cystectomy (RC) is the standard treatment for MIBC and selected non-muscle invasive bladder cancer (NMIBC) cases. The NorCys-study (NCT04523038, NCT04537221 and NCT04523025) aims to validate biomarkers predicting RC outcomes. This report describes RC practice patterns across the Nordic countries.
Materials and Methods: This prospective, multi-institutional study included bladder cancer patients undergoing RC with or without preoperative chemotherapy in all five Nordic countries from 5/2020 to 1/2025. Clinical and pathological data were collected prospectively into REDCap database and analysed using descriptive statistics, Wilcoxon rank sum and Pearson’s Chi-squared tests.
Results: A total of 1,642 patients from 15 centres were enrolled. Of these, 35% (531) had clinical NMIBC (T1-Tis-Ta), and 65% (999) had cT2-4 disease. Preoperative chemotherapy was administered to 398/929 (43%) cT2-4 or node-positive patients. The most common neoadjuvant chemotherapy (NAC) regimens were gemcitabine – cisplatin (GC) (275/475 [58%]) and dose-dense methotrexate, vinblastine, doxorubicin and cisplatin (dd-MVAC) (144/475 [30%]). Robot-assisted RC was the most common surgical approach administered in 886 of 1,472 (60%) cases, with variation between centres. Ileal conduit was the predominant diversion method in 1,375 out of 1,465 cases (94%). Median surgical time was 322 min, blood loss was 300 mL and hospital stay was 9 days. Final pathology demonstrated pT0 in 29%, ≥pT2 in 43% and lymph node metastases 203 (17%).
Conclusion: This study reports current RC practices amongst Nordic countries. Patient cohorts did not differ between countries, and although the practices were generally similar, some differences were noted in chemotherapy regimens, the use of robotic-assisted surgery and rates of early RC.
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References
Larønningen SAG, Bray F, Dahl-Olsen ED, et al. NORDCAN: cancer incidence, mortality, prevalence and survival in the Nordic countries, Version 9.4 (29.08.2024). Association of the Nordic Cancer Registries. Oslo: Cancer Registry of Norway; 2024.
Secher MS, Hyldgaard J, Jensen JB. The association between gender, stage and prognosis in bladder cancer patients undergoing radical cystectomy. Scand J Urol. 2023;57(1–6):10–14.
https://doi.org/10.1080/21681805.2023.2166103 DOI: https://doi.org/10.1080/21681805.2023.2166103
Witjes JA, Bruins M, Cathomas R, et al. EAU guidelines on muscle-invasive and metastatic bladder cancer 2022. European Association of Urology Guidelines 2022 Edition. presented at the EAU Annual Congress Amsterdam 2022. Arnhem, The Netherlands: European Association of Urology Guidelines Office; 2022.
Grobet-Jeandin E, Lenfant L, Pinar U, et al. Management of patients with muscle-invasive bladder cancer with clinical evidence of pelvic lymph node metastases. Nat Rev Urol. 2024;21(6):339–356.
https://doi.org/10.1038/s41585-023-00842-y DOI: https://doi.org/10.1038/s41585-023-00842-y
Brierley JD. (ed). TNM classification of malignant tumors. 8th edn. Chichester (UK) : UICC International Union Against Cancer; 2017.
Hautmann RE, de Petriconi RC, Pfeiffer C, et al. Radical cystectomy for urothelial carcinoma of the bladder without neoadjuvant or adjuvant therapy: long-term results in 1100 patients. Eur Urol. 2012;61(5):1039–1047.
https://doi.org/10.1016/j.eururo.2012.02.028 DOI: https://doi.org/10.1016/j.eururo.2012.02.028
Grossman HB, Natale RB, Tangen CM, et al. Neoadjuvant chemotherapy plus cystectomy compared with cystectomy alone for locally advanced bladder cancer. N Engl J Med. 2003;349(9):859–866.
https://doi.org/10.1056/NEJMoa022148 DOI: https://doi.org/10.1056/NEJMoa022148
Sherif A, Holmberg L, Rintala E, et al. Neoadjuvant cisplatinum based combination chemotherapy in patients with invasive bladder cancer: a combined analysis of two Nordic studies. Eur Urol. 2004;45(3):297–303. DOI: https://doi.org/10.1016/j.eururo.2003.09.019
Yin M, Joshi M, Meijer RP, et al. Neoadjuvant chemotherapy for muscle-invasive bladder cancer: a systematic review and two-step meta-analysis. Oncologist. 2016;21(6):708–715.
https://doi.org/10.1634/theoncologist.2015-0440 DOI: https://doi.org/10.1634/theoncologist.2015-0440
Salminen AP, Koskinen I, Perez IM, et al. Neoadjuvant chemotherapy does not increase the morbidity of radical cystectomy: a 10-year retrospective nationwide study. Eur Urol Oncol. 2018;1(6):525–530.
https://doi.org/10.1016/j.euo.2018.06.014 DOI: https://doi.org/10.1016/j.euo.2018.06.014
Shabsigh A, Korets R, Vora KC, et al. Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology. Eur Urol. 2009;55(1):164–174.
https://doi.org/10.1016/j.eururo.2008.07.031 DOI: https://doi.org/10.1016/j.eururo.2008.07.031
Aziz A, May M, Burger M, et al. Prediction of 90-day mortality after radical cystectomy for bladder cancer in a prospective European multicenter cohort. Eur Urol. 2014;66(1):156–163.
https://doi.org/10.1016/j.eururo.2013.12.018 DOI: https://doi.org/10.1016/j.eururo.2013.12.018
Bostrom PJ, Kossi J, Laato M, et al. Risk factors for mortality and morbidity related to radical cystectomy. BJU Int. 2009;103(2):191–196.
https://doi.org/10.1111/j.1464-410X.2008.07889.x DOI: https://doi.org/10.1111/j.1464-410X.2008.07889.x
Daneshmand S, Ahmadi H, Schuckman AK, et al. Enhanced recovery protocol after radical cystectomy for bladder cancer. J Urol. 2014;192(1):50–55.
https://doi.org/10.1016/j.juro.2014.01.097 DOI: https://doi.org/10.1016/j.juro.2014.01.097
Parekh DJ, Reis IM, Castle EP, et al. Robot-assisted radical cystectomy versus open radical cystectomy in patients with bladder cancer (RAZOR): an open-label, randomised, phase 3, non-inferiority trial. Lancet. 2018;391(10139):2525–2536.
https://doi.org/10.1016/S0140-6736(18)30996-6 DOI: https://doi.org/10.1016/S0140-6736(18)30996-6
Oedorf K, Skaaheim Haug E, Liedberg F, et al. Perioperative management of radical cystectomy in the Nordic countries. Scand J Urol. 2019;53(1):51–55.
https://doi.org/10.1080/21681805.2019.1583686 DOI: https://doi.org/10.1080/21681805.2019.1583686
Nikulainen I, Salminen AP, Högerman M, Seikkula H, Boström PJ, The Finnish National Cystectomy Database Research Group. Neoadjuvant chemotherapy in muscle-invasive bladder cancer: a nationwide analysis of eligibility, utilization, and outcomes. Cancers (Basel). 2025;17(3):505. https://doi.org/10.3390/cancers17030505 DOI: https://doi.org/10.3390/cancers17030505
Jerlström T, Gårdmark T, Carringer M, et al. Urinary bladder cancer treated with radical cystectomy: perioperative parameters and early complications prospectively registered in a national population-based database. Scand J Urol. 2014;48(4):334–340.
https://doi.org/10.3109/21681805.2014.909883 DOI: https://doi.org/10.3109/21681805.2014.909883
Bagi P, Nordsten CB, Kehlet H. Cystectomy for bladder cancer in Denmark during the 2006-2013 period. Dan Med J. 2016 Apr;63(4):A5217.
Kwok KHM, Abbadi A, Côté S, et al. Characterization of treatment patterns and outcomes in muscle-invasive bladder cancer patients in Sweden. Scand J Urol. 2025;60:108–114.
https://doi.org/10.2340/sju.v60.43875 DOI: https://doi.org/10.2340/sju.v60.43875
Ullén A, Aljabery F, Dahlman P, et al. Swedish national guidelines on urothelial carcinoma: 2024 update on advanced and metastatic disease. Scand J Urol. 2025;60:76–82.
https://doi.org/10.2340/sju.v60.43236 DOI: https://doi.org/10.2340/sju.v60.43236
Charlson ME, Pompei P, Ales KL, et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–383. DOI: https://doi.org/10.1016/0021-9681(87)90171-8
Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap) – a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–381.
https://doi.org/10.1016/j.jbi.2008.08.010 DOI: https://doi.org/10.1016/j.jbi.2008.08.010
Harris PA, Taylor R, Minor BL, et al. The REDCap consortium: building an international community of software platform partners. J Biomed Inform. 2019;95:103208. DOI: https://doi.org/10.1016/j.jbi.2019.103208
Khetrapal P, Wong JKL, Tan WP, et al. Robot-assisted radical cystectomy versus open radical cystectomy: a systematic review and meta-analysis of perioperative, oncological, and quality of life outcomes using randomized controlled trials. Eur Urol. 2023;84(4):393–405.
https://doi.org/10.1016/j.eururo.2023.04.004 DOI: https://doi.org/10.1016/j.eururo.2023.04.004
Crozier J, Hennessey D, Sengupta S, et al. A systematic review of ileal conduit and neobladder outcomes in primary bladder cancer. Urology. 2016;96:74–79. DOI: https://doi.org/10.1016/j.urology.2016.06.034
Mastroianni R, Ferriero M, Tuderti G, et al. Open radical cystectomy versus robot-assisted radical cystectomy with intracorporeal urinary diversion: early outcomes of a single-center randomized controlled trial. J Urol. 2022;207(5):982–992.
https://doi.org/10.1097/JU.0000000000002422 DOI: https://doi.org/10.1097/JU.0000000000002422
Aman H, Hamza M, Ramzan A, et al. Standard Versus Extended Pelvic Lymphadenectomy in Patients With Bladder Cancer: A Systematic Review and Meta-analysis. Am J Clin Oncol. 2025 Oct 1;48(10):479-487. DOI: https://doi.org/10.1097/COC.0000000000001206
Lerner SP, Tangen C, Svatek RS, et al. Standard or extended lymphadenectomy for muscle-invasive bladder cancer. N Engl J Med. 2024;391(13):1206–1216.
https://doi.org/10.1056/NEJMoa2401497 DOI: https://doi.org/10.1056/NEJMoa2401497
Fahmy O, Khairul-Asri MG, Schubert T, et al. A systematic review and meta-analysis on the oncological long-term outcomes after trimodality therapy and radical cystectomy with or without neoadjuvant chemotherapy for muscle-invasive bladder cancer. Urol Oncol. 2018;36(2):43–53.
https://doi.org/10.1016/j.urolonc.2017.10.002 DOI: https://doi.org/10.1016/j.urolonc.2017.10.002
Hamid A, Ridwan FR, Parikesit D, et al. Meta-analysis of neoadjuvant chemotherapy compared to radical cystectomy alone in improving overall survival of muscle-invasive bladder cancer patients. BMC Urol. 2020;20(1):158.
https://doi.org/10.1186/s12894-020-00733-z DOI: https://doi.org/10.1186/s12894-020-00733-z
Petrelli F, Coinu A, Cabiddu M, et al. Correlation of pathologic complete response with survival after neoadjuvant chemotherapy in bladder cancer treated with cystectomy: a meta-analysis. Eur Urol. 2014;65(2):350–357.
https://doi.org/10.1016/j.eururo.2013.06.049 DOI: https://doi.org/10.1016/j.eururo.2013.06.049
Macleod LC, Yabes JG, Yu M, et al. Trends and appropriateness of perioperative chemotherapy for muscle-invasive bladder cancer. Urol Oncol. 2019;37(7):462–469.
https://doi.org/10.1016/j.urolonc.2019.04.006 DOI: https://doi.org/10.1016/j.urolonc.2019.04.006
Pfister C, Gravis G, Flechon A, et al. Dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin or gemcitabine and cisplatin as perioperative chemotherapy for patients with nonmetastatic muscle-invasive bladder cancer: results of the GETUG-AFU V05 VESPER Trial. J Clin Oncol. 2022;40(18):2013–2022.
https://doi.org/10.1200/JCO.21.02051 DOI: https://doi.org/10.1200/JCO.21.02051
Pfister C, Gravis G, Flechon A, et al. Perioperative dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin in muscle-invasive bladder cancer (VESPER): survival endpoints at 5 years in an open-label, randomised, phase 3 study. Lancet Oncol. 2024;25(2):255–264.
https://doi.org/10.1016/S1470-2045(23)00587-9 DOI: https://doi.org/10.1016/S1470-2045(23)00587-9
Powles T, Catto JWF, Galsky MD, et al. Perioperative durvalumab with neoadjuvant chemotherapy in operable bladder cancer. N Engl J Med. 2024;391(19):1773–1786.
https://doi.org/10.1056/NEJMoa2408154 DOI: https://doi.org/10.1056/NEJMoa2408154
Liedberg F, Hagberg O, Aljabery F, et al. Cystectomy for bladder cancer in Sweden – short-term outcomes after centralization. Scand J Urol. 2024;59:84–89.
https://doi.org/10.2340/sju.v59.40120 DOI: https://doi.org/10.2340/sju.v59.40120
Catto JWF, Khetrapal P, Ricciardi F, et al. Effect of robot-assisted radical cystectomy with intracorporeal urinary diversion vs open radical cystectomy on 90-day morbidity and mortality among patients with bladder cancer: a randomized clinical trial. JAMA. 2022;327(21):2092–2103. DOI: https://doi.org/10.1016/j.eururo.2022.08.035
https://doi.org/10.1001/jama.2022.7393 DOI: https://doi.org/10.1001/jama.2022.7393
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Copyright (c) 2026 Tiia Venhomaa, Ilkka Nikulainen, Johannes Bobjer, Mats Bläckberg, Lasse Bro, Simone Buchardt Brandt, Otto Ettala, Knud Fabrin, Sigurdur Gudjonsson, Erik Skaaheim Haug, Mikael Högerman, Josephine M. Hyldgaard, Tomas Jerlström, Peter Kirrander, Ilmari Koskinen, Gitte Lam, Markku J. Leskinen, Fredrik Liedberg, Astrid Helene Livbjerg, Heikki Seikkula, Katharina Skovhus, Viveka Ströck, Grazvydas Tuckus, Ville Virta, Marie-Louise Vrang, Jørgen Bjerggaard Jensen, Peter J. Boström
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