Radical Cystectomy with Pelvic Lymph Node Dissection

muscle-invasive bladder cancer to date, the over-

(women). This should be performed only in

all survival at 5 and 10 years was 60% and 43%,

highly selected patients, e.g., relatively young

respectively.46

patients with organ-confined disease. Overall,

Nowadays, in some clinics and in selected

this technique seems effective, with reported

cases, radical cystectomy with pelvic lymph

preservation of sexual function in 75–100% of

node dissection is also performed either com-

patients. Long-term follow-up studies are

pletely (robot) laparoscopic or laparoscopic

required to determine oncological outcomes.53

hand-assisted. Peri-operative complications and

functional outcomes seem to be comparable to

Bladder-Preservation Treatments

open radical cystectomy, but long-term onco-

logic results are still awaited.50

Bladder preservation therapies have been devel-

oped for patients wishing to preserve their

Urinary Diversion Following

bladder and/or patients who are poor candi-

dates for radical surgery. Single modality, organ-

Cystectomy

preserving therapy can either consist of complete

Three modalities can be used to divert the urine:

TUR of the primary tumor, systemic chemo-

therapy, or external beam or interstitial radio-

an incontinent

stoma

(e.g.,

uretero-ileo

therapy. Compared to radical cystectomy, the

(colonic)-cutaneostomy),

a continent urinary

recurrence-free and long-term survival outcome

reservoir to be catheterized or controlled by the

of patients with a muscle-invasive bladder can-

anal sphincter (e.g., ileal or colonic pouch, ure-

cer treated with single modality therapy have

terosigmoidstomy), or an orthotopic bladder

been disappointing.54 Therefore, these single

substitution.51 The latter

is used

increasingly

modality therapies should only be considered in

during the last decade: in some series up to 90%

highly selected patients, unfit for radical surgery

of patients who

undergo a cystectomy.52 An

or multimodality treatment. In a group of highly

advantage of an incontinent stoma is that it is

selected patients (solitary T1–T3 tumors, <5 cm,

easy to construct and that it does not require

good bladder capacity), single modality treat-

patient compliance for

good function, thus

ment using

external beam radiotherapy fol-

upper urinary tracts are “safe.” However, with

lowed by interstitial radiotherapy produced

orthotopic bladder substitution (and to a lesser

good results.55

degree also with continent diversion) the body

Multimodality treatment combines the three

image is not changed, which can have clear psy-

aforementioned single modality interventions

chological benefits.52 When choosing for a type

in an attempt to improve survival outcome. The

of diversion, one has to take into consideration

combination of systemic chemotherapy (mostly

the patient’s age, comorbidity, previous surgery,

cisplatin, methotrexate, and vinblastine (CMV))

and wishes.52 Several segments of the intestinal

and radiotherapy aims at eradicating microme-

tract can be used for urinary diversion: ileum,

tastases whereas complete TUR aims at control-

colon, ileocaecal, and appendix. For all types of

ling local disease. The long-term survival rates

diversion, early

and late complications are

of multimodality therapy series seem to be com-

described.Among these are urine leakage,pouch

parable to radical cystectomy series. However,

rupture, stomal stenosis, stone formation, bacte-

these two treatment modalities have never been

riuria, and metabolic complications (acidosis,

compared in a randomized study and it is sug-

vitamin B12 deficiency).

gested that the encouraging outcomes of the

Sexual Function-Preserving Techniques

multimodality studies are due to selection bias,

e.g., mainly inclusion of patients with favorable

A maximum of 40–60% of patients still have nor-

pathological

characteristics.54

Multimodality

treatment requires compliant patients, good

mal sexual function after radical cystectomy,even

interdisciplinary cooperation,

and thorough

when the operation is performed by experienced

follow-up.

surgeons. Therefore, a modification of cystec-

Partialcystectomyisanotherbladder-preserving

tomy has been developed, with preservation of

treatment that can be an alternative to radical cys-

the vas deferens,prostate or prostatic capsule and

tectomy in highly selected cases.Data on this treat-

seminal vesicles (men) or all internal genitalia

ment modality are sparse and there are no studies

522

Practical Urology: EssEntial PrinciPlEs and PracticE

directly comparing it with radical cystectomy. The

with an excellent performance status and good

location and size of the tumor are important fac-

renal function.61

tors in selecting patients for partial cystectomy.

Small tumors located in the dome or in a diverticu-

Adjuvant Chemotherapy

lum seem suitable, whereas tumors located in the

lateral wall or trigone seem less appropriate.

Administering chemotherapy after surgery also

Patients with multifocal tumors are at high risk for

has its benefits. Since the histopathological stage

nonmuscle-invasive recurrence and the presence

is known at that time, patients at risk for recur-

of CIS or lymph node metastases is associated with

rence/progression who might benefit from adju-

recurrence of advanced disease.56

vant treatment can be identified, thus reducing

overtreatment. Furthermore, there is no need-

Is There a Role for (Neo)

less delay in surgical treatment, which may

occur in patients not responding to neoadjuvant

Adjuvant Chemotherapy in

chemotherapy.57 One meta-analysis on adjuvant

Muscle-Invasive Bladder Cancer?

chemotherapy for muscle-invasive bladder can-

cer has been published to date based on 6 trials

with only 491 patients available for survival

With radical cystectomy as solitary treatment,

analysis in total. All trials used cisplatin-based

the 5 year survival rates range from 27% to

chemotherapy after cystectomy. An improve-

67%, depending on the histopathological

ment of 9% on survival at 3 years was found

stage.57 In order to improve outcome, in 1985

(95% CI: 1–16%). The authors state that a defini-

the chemotherapy regimen of methotrexate,

tive conclusion on the effect of adjuvant chemo-

vinblastine, doxorubicin, and cisplatin (MVAC)

therapy cannot be drawn due to the limited

was introduced in the management of muscle-

number of trials and patients and they highlight

invasive bladder cancer.57 Since then, several

the need for further appropriately sized ran-

chemotherapeutic regimens have been eva-

domized clinical trials.62

luated, either in neoadjuvant and adjuvant

setting.

Preoperative Radiotherapy

Neoadjuvant Chemotherapy

The aim of radiotherapy prior to cystectomy is

to eradicate microscopic extravesical disease and

Administering chemotherapy before surgery

to prevent seeding of tumor cells during surgery.

has some advantages. The local response to the

There is a lack of evidence for the standard use

agent can be evaluated during surgery, which is

of preoperative radiotherapy. Only a few ran-

a prognostic important issue. Furthermore, sur-

domized trials have been conducted, most of

gery might be more effective after shrinkage of

them with a limited number of patients.63

the tumor. The delay to systemic therapy is less

than in the adjuvant setting and the tolerability

How Should Bladder Cancer

is expected to be better.57 Several randomized

clinical trials have assessed the value of neoad-

Patients Be Followed-up?

juvant chemotherapy for muscle-invasive blad-

der cancer,with conflicting outcomes.Therefore,

three meta-analyses have been undertaken, each

Follow-up After TUR in NMIBC

including 11 trials and more than 2,600 patients.

All show a statistically significant improvement

The high number of recurrence, and progression

in survival of 5–6.5% at 5 years in the cisplatin-

of NMIBC, even in the long term, demand metic-

containing combination chemotherapy trials,

ulous follow-up. Assessment should include a

irrespective of the type of definitive treat-

history with special focus on voiding symptoms

ment.58-60 The question remains whether these

and hematuria, cystoscopy, and cytology. There

results may be generalized to the whole popula-

is no role for urinary markers in the follow-up

tion, since some trials mainly included relatively

since no urinary marker available to date meets

young patients (median age of 63–65 years),

the requirements to replace cystoscopy. Early