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PubMed1998

Relationship among cystectomy, microvessel density and prognosis in stage T1 transitional cell carcinoma of the bladder.

PURPOSE: The selection of therapy for stage T1 bladder cancer is controversial, and reliable biomarkers that identify patients likely to require cystectomy for local disease control have not been established. We evaluated our experience with T1 bladder cancer to determine whether early cystectomy improves prognosis, and whether microvessel density has prognostic value for T1 lesions and could be used for patient selection. MATERIALS AND METHODS: We retrospectively reviewed the records of 88 patients with T1 transitional cell carcinoma of the bladder. Patient outcome was correlated with therapeutic intervention. Paraffin embedded tissue from 54 patients was available for factor VIII immunohistochemical staining for microvessel density quantification. RESULTS: Median followup was 48 months (range 12 to 239). Of the patients 34% had no tumor recurrence. The rates of recurrence only and progression to higher stage disease were 41 and 25%, respectively. The survival of patients in whom disease progressed was diminished (p = 0.0002). Grade did not predict recurrence or progression nor did cystectomy provide a survival advantage. Microvessel density did not correlate with recurrence or progression. CONCLUSIONS: Patients with T1 bladder cancer have a high risk of recurrence and progression. Tumor progression has a significant negative impact on survival. Neither grade nor early tumor recurrence predicted disease progression. Because early cystectomy did not improve patient outcome, we suggest reserving cystectomy for patients with progression or disease refractory to local therapy. Microvessel density is not a prognostic marker for T1 bladder cancer and has no value in selecting patients with T1 disease for cystectomy.

Capillaries↗
PubMed1998

Radical cystectomy for invasive bladder cancer--a local experience.

OBJECTIVES: The aim of this study of patients undergoing cystectomy for invasive transitional cell carcinoma of the bladder was to compare clinical and pathological staging and to review factors that predict survival. PATIENTS: Sixty-three patients (73% male) underwent radical cystectomy between January 1988 and February 1994. The mean age was 61 years (range 33-77 years). RESULTS: Of the patients 14% had clinical and 24% pathological stage T1 disease; figures for T2 disease were 24% and 6%, respectively, for T3 disease 46% and 45%, and for T4 disease 16% and 25%. For T1 and T4 disease the clinical stage predicted the pathological stage in over 80% of cases, and for patients with T3 disease the predictive value of clinical staging was 68%; in no patient with clinical stage T2 disease was this confirmed at cystectomy. The prevalence of tumour infiltration of the lymph glands on histological examination of the cystectomy specimen correlated more closely with pathological stage than with clinical stage. For clinical and pathological staging, respectively, the prevalences were 0% and 0%, for T1, 27% and 0% for T2, 20% and 29% for T3, and 40% and 38% for T4. The overall survival rate (life-table method) was 33% at a median follow-up of 42 months in the surviving patients. No patient with tumour infiltration of the lymph glands survived. Survival also correlated more closely with pathological than with histological stage. For clinical and pathological stage T1 disease the 5-year survival rates were 73% and 91%, respectively; for T2 the rates were 27% and 75%, for T3 32% and 31%, and for T4 28% and 29%. The operative mortality rate was 2% and the rate of recurrence of local disease 10%. CONCLUSIONS: Survival after cystectomy correlates more closely with pathological than with clinical stage of disease. The accuracy of clinical staging in T2 disease is poor. Cystectomy is the standard against which other treatments for bladder cancer must be measured.

Adult↗
PubMed1998

Radical cystectomy: extending the limits of pelvic lymph node dissection improves survival for patients with bladder cancer confined to the bladder wall.

PURPOSE: We assess the influence of the limits of pelvic lymph node dissection on survival following radical cystectomy for bladder cancer. MATERIALS AND METHODS: From January 1990 to September 1997, 194 patients underwent radical cystectomy without prior treatment. Between March 1993 and September 1997, 126 consecutive patients underwent radical cystectomy with extended pelvic lymph node dissection beginning at the bifurcation of the aorta, including the common and external iliac vessels, presacral nodes and obturator fossa. Between January 1990 and March 1993, 68 consecutive patients underwent radical cystectomy, with limited pelvic lymph node dissection beginning at the bifurcation of the common iliac vessels, including the external iliac vessels and obturator fossa. The cystectomy procedure remained unchanged throughout this period and 1 surgeon performed all procedures. RESULTS: A total of 117 patients had tumors confined to the bladder wall (stage pT3a or less) and 77 had tumors penetrating beyond the bladder into perivesical fat or adjacent structures (stage pT3b or greater). The prevalence of patients with tumors penetrating the bladder was higher in the extended dissection group (42.9 versus 33.8% limited dissection). The incidence of lymphatic involvement was 26.2% and slightly higher in the extended than the limited dissection group. There was a modest improvement in the 5-year recurrence-free survival for the extended dissection group (62 versus 56% limited dissection, p = 0.33), and a substantial improvement for the subgroups with tumors confined to the bladder wall (tumor stage pT3a or less) (85 versus 64%, p <0.02) and without lymph node metastasis (stage pT3a or less, pN0) (90 versus 71%, p <0.02). Accordingly, extended pelvic lymph node dissection reduced the 5-year probabilities for pelvic and distant metastasis (2 versus 7% limited dissection, p = 0.17 and 10 versus 21%, p = 0.15, respectively) for patients with tumors confined to the bladder wall (stage pT3a or less). Survival was similar for patients with pT3b or greater tumor. CONCLUSIONS: This retrospective analysis suggests that extending the limits of pelvic lymph node dissection from the bifurcation of the common iliac vessels to the bifurcation of the aorta improves the recurrence-free survival rate for patients undergoing radical cystectomy for bladder cancer confined to the bladder wall (stage pT3a or less).

Adult↗
PubMed1989

Pharmacological responses of rabbit urinary bladder after subtotal cystectomy.

Partial cystectomy is used clinically in specific circumstances. There have been some reports indicating that the bladder following subtotal cystectomy can regenerate to a certain degree. The present study investigates the physiology and pharmacology of bladder regeneration at eight weeks after resection of a major part of the bladder body in rabbits. The following studies were performed on control and cystectomy bladders: 1) in vivo cystometry (prior to and four weeks after the operation, and before the sacrifice at eight weeks); 2) sequential muscle strip study (the strips were obtained by dividing bladder transversely into upper body, lower body, mid-bladder, upper base and lower base); and 3) in vitro whole bladder studies. The results can be summarized as follows: 1) grossly there was no regeneration of the bladder body; the cystometric capacity was increased slowly after the operation primarily due to increased size and capacity of the bladder base. 2) The contractile response of the subtotal cystectomized bladder body to field stimulation and bethanechol stimulation was less than the response of normal bladder body. 3) The contractile response to epinephrine showed that the ratio of alpha/beta adrenergic response was much greater in the cystectomy bladder than in the normal bladder. 4) In the whole bladder study, the intravesical pressure response to field stimulation was about the same in both groups, the response to bethanechol was less for cystectomized bladder, and the response to methoxamine was greater for the cystectomized bladder. 5) The ability of cystectomy bladder to empty in response to both field stimulation and bethanechol was impaired whereas the control bladder fully emptied to both field stimulation and bethanechol. In conclusion, over the eight week period following subtotal cystectomy the capacity increased via distention (and hypertrophy) of the bladder base area as opposed to regeneration of the bladder body.

Adenosine Triphosphate↗
PubMed1980

Salvage cystectomy after irradiation failure.

Recent clinical studies have revealed the superiority of planned preoperative irradiation therapy followed by cystectomy compared to either treatment modality alone. There remains a select group of patients who for personal or medical reasons are not candidates for planned preoperative irradiation and cystectomy, and these patients undergo radical irradiation therapy as the sole treatment modality. Nearly 80% of these patients with invasive bladder cancer treated by definitive irradiation therapy will fail within 5 years, and many of these might become candidates for salvage cystectomy. Our 37 consecutive patients who failed definitive irradiation therapy were treated by salvage cystectomy. The selection for the operative procedure, morbidity and mortality, and survival data are reviewed. The mortality rate for this group was 8.1% and the early complication rate was 24%. However, none of the patients who underwent a 2-stage procedure or who had an early perineal approach died. In addition, only 1 (7%) of the staged patients had an early complication. The over-all survival for the entire group of 37 patients was 38%. However, those patients with pathological stage O or A disease had a 63% survival compared to a dismal 19% for those with stage B or greater disease. Our experience leads us to recommend that salvage cystectomy be performed early after irradiation failure. Selective use of the initial perineal approach in male patients and the use of staged cystectomy after urinary diversion in some of these high risk patients have resulted in a marked decrease in the morbidity and mortality.

Aged↗
PubMed2005

Extent of lymphadenectomy in radical cystectomy for bladder cancer.

BACKGROUND: The benefit of pelvic lymphadenectomy in patients with cancer of the urinary bladder remains controversial. Though the inclusion of lymph node dissection in conjunction with radical cystectomy for patients with clinically negative nodes is well accepted, however, the extent of the nodal dissection remains contentious, particularly in patients with gross disease and T1G3 cancer. The extent of the primary bladder tumor, number of lymph nodes removed and the lymph node tumor burden are important prognostic variables in patients undergoing cystectomy. We analyzed the impact of the extent of lymphadenectomy during radical cystectomy on survival in the contemporary literature. METHODS: A Pubmed search was carried out for the literature published over the last 15 years using bladder cancer, radical cystectomy, survival, lymphadenectomy and complications as the key words. We have discussed the extent of lymphadenectomy on survival and its anatomical basis to determine the optimal number of lymph nodes to be removed and the concept of node density. RESULTS: Evidence from contemporary literature indicate significantly increased survival rates after cystectomy in patients with bladder cancer diagnosed with stages III or IV disease who have had relatively more lymph nodes examined, suggesting that even some patients with higher stage disease may benefit from extended pelvic lymphadenectomy at the time of cystectomy. Studies also indicate that more extensive lymphadenectomy significantly improved the prognosis of patients with bladder cancer, not only by providing prognostic information but perhaps it is also due to its inherent therapeutic value. CONCLUSION: Extended lymph node dissection improves local control and survival. However, in the absence of controlled randomized trial this remains a dubitable issue.

Journal Article↗
PubMed1988

[Importance of early cystectomy for the prognosis of cancer of bladder].

Between 1967 and 1985, 246 cystectomies were performed for the treatment of urothelial carcinoma of the bladder. Surgery-related mortality, initially 15%, was equal to 0% in 1985. Preoperative radiation therapy was not given. Despite strictly comparable T and N stages, prognosis was markedly better in patients who had undergone cystectomy as soon as the diagnosis of invasive cancer of the bladder was established than in patients who had undergone cystectomy after one or more recurrences of invasive carcinoma of the bladder and after transurethral resection. Twenty-six patients, undergoing cystectomy because of recurrence after curative radiation therapy, were the group with the worst 5--years survival--less than 10%. These results allow us to conclude that for the prognosis of carcinoma after total cystectomy, it is of the utmost importance to differentiate between an initially invasive tumor and a recurrence of an invasive carcinoma after transurethral resection. If performed immediately after infiltration has been demonstrated, cystectomy may greatly contribute to improving the long-term prognosis. As soon as the tumor extends to the lamina propria (pT1), one can no longer expect transurethral electroresection to suffice as reliable curative treatment of carcinoma of the bladder. As for the argument that the procedure is mutilating, one can counter with the increasing success in the last few years, of urinary derivation with continence, including bladder replacement or even total cystoprostatectomy, which does not result in impotence.

Carcinoma, Transitional Cell↗
PubMed1988

Ovarian cystectomy for serous borderline tumors: a follow-up study of 35 cases.

We have investigated the frequency of persistence or recurrence of tumor in 35 patients with ovarian serous borderline tumors treated by unilateral cystectomy, bilateral cystectomy, or unilateral cystectomy with contralateral oophorectomy or salpingo-oophorectomy. Nineteen of the patients had stage Ia, ten had stage Ib, four had stage Ic, and two had stage III tumors. Tumor persisted or recurred only in the ovary that had been subjected to cystectomy in two (6%) of the 33 patients with stage I tumors, in both the ipsilateral and contralateral ovary in one patient (3%), and in the contralateral ovary only in one patient (3%). The frequency of ipsilateral persistence or recurrence of tumor per ovary subjected to cystectomy in this group of patients was 8%. Both patients with stage III tumors had persistence or recurrence of their tumors. Involvement of the resection margin of the cystectomy specimen and the removal of more than one cyst from an ovary were almost always associated with persistence or recurrence of tumor. Follow-up of the 35 patients showed that despite the occasional complication of persistence or recurrence of tumor, all were alive without evidence of disease 3-18 years after the initial operation, with an average follow-up of 7.5 and a median follow-up of 6.5 years.

Adolescent↗
PubMed1987

[Effect of partial cystectomy on BBN-induced rat bladder cancer].

Experimental induction of bladder cancer using N-butyl-N-(4-hydroxybutyl)nitrosamine (BBN) is a well-established technique because of its convenience and reliability. However, most BBN-induced rat bladder tumors are superficial growths and are not usually considered a suitable model for deeply invasive human bladder cancers. We administered rats BBN for 20 weeks by mixing it in the drinking water at a concentration of 0.05%. The tumor which developed in the bladder was mechanically irritated by partial cystectomy, and the tumor was observed at intervals. Deeply invasive tumors developed with a high incidence after 6 weeks (75% 6 weeks after the partial cystectomy, 85% after 8 weeks and 71% after 12 weeks). In contrast, the incidence was 0% in the prepartial-cystectomy group, 8% in the control group and 22% 4 weeks after the partial cystectomy. The tendency for superficial tumors to become deeply invasive after 6 weeks was significant (p less than 0.005). No infiltration was seen in other organs including the prostate. The malignancy of the tumors was G1 and G2 at 0 week after the partial cystectomy, and G2 and G3 at 4, 6, 8, and 12 weeks. The rat bladder cancers induced by BBN in our experimental system seem to be a good model for deeply invasive human bladder cancers in terms of both the depth and malignancy of the cancers. In a clinical study on patients who underwent partial cystectomy, the recurrence rate was high, i.e., 50%, while mortality was as high as 40% or more in the high-stage and high-grade tumor group.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1997

[Partial cystectomy as treatment of infiltrating transitional carcinoma of the bladder].

UNLABELLED: The most widespread opinion, and until recently the only option, is that every vesical transitional cancer invading the muscle is, regardless its extent, candidate for radical cystectomy and that in spite of nobody questioning the advantages of partial cystectomy. MATERIAL AND METHODS: 45 patients with vesical infiltrant cancer T2 or higher, followed between 9 and 258 months and managed with partial cystectomy, were analyzed. Only patients with no radiotherapy were included and only in one patient pre-operative chemotherapy was used. RESULTS: In 8 patients no tumour was found in the specimen (pTO). Tumour grade was pTa in 2; pT1 in 11; pT2 in 5; pT3a in 4; pT3b in 11; and pX in 4 patients. Eight (8) patients had nodal involvement. Twenty-one (21) cases showed bladder relapse. In six (6), vesical infiltrant relapse was associated to metastasis. One case showed vesical relapse, pelvic mass and metastasis, and 4 only metastasis. Extravesical disease-free time and survival are better than in the group treated with radical cystectomy. But this is a highly selected group. CONCLUSIONS: With the same prospects of extravesical disease-free time and survival we offer: shorter, less risky surgery with low post-surgical morbidity and mortality and less hospitalization and proportion of late sequela. Better quality of life, with no skin stoma, incontinence or impotence Although the risk of vesical relapse persists, the procedures required to resolve vesical shunt or replacement complications are more aggressive than TUR sufficient to treat most relapses, and when recurrence is infiltrant radical cystectomy may be used as a rescue measure. This is so even now with the profusion of the so-called "mini-invasive" procedures. We believe that neither radio- and/or chemotherapy combinations contribute nothing to partial cystectomy alone. They may even be harmful and have significant side-effects. It is plain that POs are the result of total removal by TUR. Due to the little reliability when defining T, it is very hard to evaluate the contribution of adjuvant measures. Patients with no vesical tumour (pTOs) or pT1-pT2 tumours, and even up to pT3a, should not be included in protocols to evaluate the efficacy of combined cytostatic agents since their use is superfluous. Radiotherapy makes no contribution to this type of tumour in terms of local relapse and apparently has no effect on the metastasis.

Adult↗
PubMed2000

Predicting the survival of bladder carcinoma patients treated with radical cystectomy.

BACKGROUND: Clinical outcomes vary for patients treated with radical cystectomy. The authors sought to identify factors associated with the survival of patients treated with radical cystectomy for urothelial carcinoma of the urinary bladder. METHODS: The authors studied 218 patients treated with radical cystectomy for urothelial carcinoma between 1980 to 1984. Patient ages ranged from 41 to 78 years (mean, 64 years). Using the 1997 TNM system, T classifications were Ta (17 patients), T1 (44), T2 (71), T3a (42), T3b (14), T4a (28), and T4b (2). Thirty-two patients had lymph node metastasis at the time of surgery. Histologic grade was determined according to the newly proposed World Health Organization and International Society of Urological Pathology grading system; tumor was low grade in 43 patients and high grade in 175. The male-to-female ratio was 4.9 to 1. The mean follow-up of patients still alive was 13.1 years (median, 13.8 years; range, 30 days to 18 years). Cox proportional hazards models were used to determine the impact of numerous clinical and pathologic findings on survival. RESULTS: Ten-year local recurrence free, distant metastasis free, cancer specific, and all-cause survival were 71%, 73%, 67%, and 41%, respectively. In univariate analysis, cancer size, T classification, and lymph node status were associated with distant metastasis free, cancer specific, and all-cause survival. Histologic grade and surgical margin status were significantly associated with worse cancer specific and all-cause survival, but not with distant metastasis free survival. In multivariate analysis, cancer size, margin status, T classification, and lymph node status were identified as significantly associated with cancer specific survival after adjustment for age and gender. CONCLUSIONS: Long term survival is achieved in a significant number of patients treated with radical cystectomy. In this study, patients with organ-confined (< or = pT2) and small size (< or = 3 cm) cancer had favorable 10-year distant metastasis free (93%) and cancer specific survival (88%) after cystectomy. Tumor size, margin status, extravesical involvement, and lymph node metastasis are important pathologic factors and should be considered as stratification variables in identifying patients for whom adjuvant chemotherapy should be evaluated in clinical trials.

Adult↗
PubMed2005

Radical cystectomy in the elderly: Comparison of survival between younger and older patients.

BACKGROUND: The authors reported their experience with radical cystectomy for transitional cell carcinoma (TCC) of the bladder. They compared pathologic features and survival rates between older and younger patients. METHODS: The authors retrospectively reviewed the records of 1054 patients who underwent radical cystectomy for bladder TCC between 1971 and 1997. Four age groups were compared: < 60 years old at the time of cystectomy (n = 310), 60-69 years old (n = 381), 70-79 years old (n = 313), and >/= 80 years old (n = 50). RESULTS: There were no significant differences in pathologic features among the groups regarding frequency of carcinoma in situ, high-grade disease, p53 status, and lymph node positivity. However, in the age groups < 60, 60-69, 70-79, and >/= 80, 45%, 49%, 51%, and 72% of patients, respectively, had extravesical TCC (P=0.004). Significant differences also were seen in the proportion of patients who received adjuvant chemotherapy (26%, 26%, 15%, and 6%, respectively; P < 0.001). The 5-year overall survival rates for patients < 60, 60-69, 70-79, and >/= 80 years old were 72%, 58%, 54%, and 33%, respectively (P < 0.001). The 5-year disease recurrence-free survival rates were 75%, 65%, 68%, and 45%, respectively (P = 0.003). The elderly had a lower probability of receiving adjuvant chemotherapy. CONCLUSIONS: Elderly patients undergoing cystectomy for TCC had similar pathologic features (except for disease stage) as younger patients. In the current series, elderly patients undergoing cystectomy had a higher pathologic stage and were less likely to receive adjuvant chemotherapy. The elderly had worse disease recurrence-free survival rates. Further work is needed to identify the causes for this and to develop strategies to improve cancer control in elderly patients.

Age Factors↗
PubMed2005

Radical cystectomy in the elderly: comparison of clincal outcomes between younger and older patients.

BACKGROUND: The authors report their experience with radical cystectomy for transitional cell carcinoma (TCC) of the bladder comparing clinical outcomes, including complication rates, among older patients versus younger patients in a high-volume center specializing in the treatment of patients with advanced carcinoma of the urinary bladder. METHODS: A retrospective review was undertaken of 1054 patients who underwent radical cystectomy for bladder TCC from 1971 through 1997. Four age groups were compared; < 60 years at the time of cystectomy (n = 309 patients), age 60-69 years (n = 381 patients), age 70-79 years (n = 314 patients), and age > or = 80 years (n = 50 patients). RESULTS: The median length of hospital stay in patients ages < 60 years, 60-69 years, 70-79 years, and > or = 80 years was 10 days, 10 days, 11 days, and 11 days, respectively (P < 0.001). The corresponding rates of overall early complications were 24%, 25%, 37%, and 30%, respectively (P = 0.002); whereas the corresponding late complication rates were 36%, 30%, 22%, and 14%, respectively (P < 0.001). The rate of early diversion-related complications did not differ significantly (11%, 8%, 12%, and 6%, respectively; P = 0.14). The operative mortality rates were 1%, 3%, 4%, and 0%, respectively (P = 0.14). There was no difference with respect to early complications, early diversion-related complications, late complications, or operative mortality comparing patients age > 70 years who underwent ileal conduit versus orthotopic urinary diversion (P = 0.20, P = 0.61, P = 0.53, and P = 0.78, respectively). CONCLUSIONS: Elderly patients who underwent cystectomy for TCC had similar mortality and early diversion-related complication rates. Carefully selected elderly patients safely can be offered an orthotopic urinary diversion. Chronological age, per se, is not a contraindication for radical cystectomy in the setting of invasive bladder carcinoma.

Age Factors↗
PubMed1994

Total cystectomy after intravesical bacillus Calmette-Guérin (Tokyo strain) therapy for superficial bladder cancer: experience in Japan.

To clarify which patients might most require total cystectomy after intravesical bacillus Calmette-Guérin (BCG) therapy, we reviewed data for 111 individuals with superficial bladder cancer. Of the 111 patients, 73 received the BCG treatment for prophylaxis of intravesical recurrence after transurethral resection (group 1), 24 therapeutically for Ta or T1 tumours (group 2), and 14 for eradicating carcinomas in situ (CIS, group 3). Although the BCG therapy significantly reduced frequencies of recurrence in group 1, 27 patients (37%) did develop tumours again. Tumours disappeared in 18 of 24 patients (75%) in group 2, and in 11 of 14 (79%) in group 3. The rate of disease progression was 6% for all 111 patients: 3% (2/73) for group 1, 17% (4/24) for group 2, and 7% (1/14) for group 3. A total of 16 of the 111 patients (14%) underwent total cystectomy, the respective figures being 7% in group 1, 29% in group 2, and 29% in group 3. Indications for total cystectomy were progression in 7, recurrent multiple tumours in 5, persistent CIS in 2, a contracted bladder in 1, and occurrence of bilateral renal pelvic cancer in 1. Thus, 4 of 6 patients (67%) who had tumours unresponsive to BCG therapy in group 2 demonstrated progression and necessitated total cystectomy. Because tumours persisting after BCG therapy are frequently of the muscle-invasive type, such cases should be regarded as candidates for immediate total cystectomy.

Administration, Intravesical↗
PubMed2004

[Tips and tricks for nerve-sparing cystectomy].

The aim of radical cystectomy with subsequent urinary diversion is to combine a safe oncological outcome with a satisfactory lower urinary tract function. Recent findings on the anatomy, physiology and nerve supply of the pelvis have resulted in a modified nerve-sparing cystectomy technique. A number of studies have shown that the oncological outcome is not compromised by such a technique; in particular the rate of local recurrences is not enhanced. Nerve-sparing cystectomy is of importance for the lower urinary tract function, including continence status after orthotopic bladder substitution and erectile function. Prerequisites for a nerve-sparing technique are a profound knowledge on the nerve supply of the pelvic organs and a subtle surgical technique. Recent surgical developments, for example in prostate and seminal vesicle sparing cystectomy techniques, indicate that it will be feasible to restore lower urinary tract and also sexual function after radical cystectomy and orthotopic bladder substitution.

Cystectomy↗
PubMed2002

Urinary diversion after radical cystectomy.

At most centers with experience in urinary diversion, an orthotopic urinary reservoir is the diversion of choice after radical cystectomy for bladder cancer. The paradigm has shifted in the past 10 years from actively looking for reasons to do an orthotopic diversion to carefully considering why a patient cannot undergo reconstruction to their native urethra. In our institution, any patient who is to undergo a radical cystectomy for bladder cancer is a potential candidate for orthotopic diversion provided they do not have chronic renal insufficiency. In addition, they must have a negative urethral margin on frozen section at the time of cystectomy, and have the mental and physical capacity to understand what is required to manage the reservoir after surgery. Proper patient selection is the key to success. Notably, chronologic age is not an absolute contraindication to orthotopic diversion. Instead, careful consideration of the patient's comorbid conditions should guide eligibility. In addition, locally advanced disease is not a contraindication to an orthotopic diversion. To have the flexibility to manage whatever situation presents itself intraoperatively, the surgeon performing a urinary diversion after radical cystectomy must be facile with several diversion techniques. At the very least, the surgeon must be comfortable with one type of each major form of urinary diversion, a conduit (incontinent) diversion, a continent cutaneous diversion, and an orthotopic diversion. As a result, radical cystectomy and urinary diversion should be performed at centers with significant experience in all three types of diversions.

Cystectomy↗
PubMed2004

A meta-analysis of randomised trials suggests a survival benefit for combined radiotherapy and radical cystectomy compared with radical radiotherapy for invasive bladder cancer: are these data relevant to modern practice?

OBJECTIVE: Treatment options for muscle-invasive bladder cancer include radical cystectomy or radical radiotherapy, and the prevailing choice varies by country. The ideal treatment would be a bladder-preserving therapy without compromising survival. The objective of this review was to compare the overall survival after radical surgery (cystectomy) with radical radiotherapy in patients with muscle-invasive cancer. MATERIALS AND METHODS: We searched the Cochrane Controlled Trials Register, Medline, EMBASE, Cancerlit, Healthstar and the Database of Abstracts of Reviews of Effectiveness. Authors of unpublished data were contacted. Randomised trials comparing surgery (alone or with preoperative radiotherapy) with radiotherapy were eligible for assessment. Three reviewers assessed trial quality based on the Cochrane Guidelines. Data were extracted from the text of the article or extrapolated from the Kaplan-Meier plot. The Peto odds ratio was determined to compare the overall survival and disease-specific survival. Analysis was performed on an intention-to-treat basis and treatment actually received. RESULTS: No randomised trials comparing surgery alone with radiotherapy alone were identified. Three randomised trials comparing preoperative radiotherapy followed by radical cystectomy (surgery) versus radical radiotherapy with salvage cystectomy (radical radiotherapy) were eligible for assessment. These trials represented a total of 439 patients, 221 randomised to surgery and 218 to radical radiotherapy. Three trials were combined for the overall survival results, and one was evaluable for the disease-specific survival analysis. The mean overall survival (intention-to-treat analysis) at 3 and 5 years were 45% and 36% for surgery, and 28% and 20% for radiotherapy, respectively. Peto odds ratio (95% confidence interval [CI]) analysis consistently favoured surgery in terms of overall survival. The results were significantly in favour of surgery at 3 years (OR = 1.91, 95% CI 1.30-2.82) and at 5 years (OR = 1.85, 95% CI 1.22 -2.82). On a treatment-received basis, the results were significantly in favour of surgery at 3 years (OR 1.84, 95% CI 1.17-2.90) and 5 years (OR 2.17, 95% CI 1.39-3.38) for overall survival, and at 3 years (OR 1.96, 95% CI 1.06-3.65) for disease-specific survival. CONCLUSIONS: The analysis of this review suggests that there is an overall survival benefit with combined preoperative radiotherapy plus radical surgery compared with radical radiotherapy plus salvage cystectomy in patients with muscle-invasive bladder cancer. However, it must be considered that only three trials were included for analysis, the patient numbers were small and that many patients did not receive the treatment they were randomised to. It must also be noted that many improvements in radiotherapy and surgery have taken place since the initiation of these trials; therefore, the data may not be readily extrapolated to modern practice. Ideally, a new trial comparing modern bladder-sparing therapy with the latest surgical approach to this disease is required.

Cystectomy↗
PubMed2006

What is the significance of pT0 at cystectomy?

The current treatment for muscle invasive bladder cancer is radical cystectomy. However, this approach leads to significant changes in the patient's quality of life, as well as potential treatment failure. And so, with the introduction of alternative and neoadjuvant therapies available, the presence of pT0 tumour at cystectomy confers a number of issues. The variability in numbers of pT0 tumours at cystectomy highlights the importance of adequate clinical staging, as well as the increasing successful use of neoadjuvant chemotherapy. Although current literature is limited, patients with prior clinical stage of muscle-invasive but node-negative disease are likely to demonstrate the most improvement in survivability if they subsequently develop pT0 at cystectomy. This review also highlights the importance of response to chemotherapy as an indicator of subsequent prognosis. With increasing numbers of pT0 tumours seen at radical cystectomy, it is suggested that more conservative measures, such as re-staging following neoadjuvant chemotherapy and even 'selective bladder preservation' treatment, may be the future for the management of muscle invasive bladder cancer.

Cystectomy↗