Is Exam under Anesthesia Still Necessary for the Staging of Bladder Cancer in the Era of Modern Imaging?

BACKGROUND: The ability to accurately determine tumor stage in bladder cancer is critical because it impacts the management paradigm and overall prognosis. There is often discrepancy between clinical and pathologic staging. Historically, exam under anesthesia (EUA) has been recommended to assist in the staging of bladder cancer. OBJECTIVE: In this era of modern imaging technology, we sought to determine if EUA still contributes meaningfully to the local staging of bladder cancer. METHODS: We retrospectively reviewed the charts of 1898 patients from 1994–2013 in our radical cystectomy database at MD Anderson Cancer Center. There were 414 patients that had complete information including EUA and whose surgery was performed by one of two surgeons and included in the final analysis. Univariate and multiple logistic regression models were generated to determine the ability of EUA, imaging, and other patient characteristics to predict pathological fat extension at the time of cystectomy. RESULTS: 38% of patients had≥pT3 disease at the time of cystectomy. 30.9% of patients had findings on EUA suggestive of T3 disease and 28.7% had radiologic findings suggestive of T3 disease. In a model including age, BMI, ethnicity, year of operation, and neoadjuvant chemotherapy among other factors, the only factors predictive of pT3 disease were EUA and imaging (p = 0.002). The combination of EUA and imaging improved the accuracy of clinical staging compared to either modality alone. CONCLUSIONS: Despite modern advances in imaging, EUA contributes meaningfully to accurate determination of local bladder cancer stage.