European Journal of Cancer vol:47 issue:1 pages:S50
ECCO edition:16 location:Stockholm date:23-27 September 2011
Radical cystectomy and pelvic lymph node dissection provides the best cancer speciﬁc survival for muscle invasive urothelial cancer and is the standard treatment with 10 year recurrence free survival rates of 50 to 60% and overall survival rates of around 45% . Radical cystectomy with urinary diversion is a procedure in which reduction of morbidity, rapid postoperative rehabilitation, limited length of hospital stay and cost containment are difﬁcult to achieve. From a technical point of view, a radical cystectomy is a well established procedure . A more debated topic is the issue of lymphadenectomy in patients in whom radical cystectomy is undertaken with curative intent. In all large radical cystectomy series about 25% of patients have node positive disease. We believe today that these patients have a chance for cure as long as the nodal invasion is limited and when in some cases adjuvant treatment is considered . The indications for simultaneous “prophylactic urethrectomy” in male patients seem to be limited to those patients where invasion by TCC is present in the prostatic stroma while those with multifocal tumours, carcinoma in situ and even urothelial invasion of the prostatic urethra are not considered to absolutely indicate urethrectomy. New techniques including prostate or seminal vesicles sparing cystec- tomies, aiming at preserving sexual function, are proposed but are by most not considered to be appropriate. Only single center series have shown the feasibility and sometimes also oncological safety. With the advent of robotic assisted surgery also cystectomy has been done this way in a couple of expert centers. It remains unproven whether it is clever to do so and whether this is oncologically as safe both from an oncological point of view as when it comes to duration of the cystectomy and the urinary diversion [4,5]. While preoperative chemotherapy has shown to beneﬁt to patients with more advanced stages, it is today not clear if all patients undergoing cystectomy for muscle invasive bladder cancer should be considered candidates for neoadjuvant chemotherapy. Deﬁnitely in patients with clinically obvious nodal disease chemotherapy is the primary (and sometimes only) treatment, but in some cases when an excellent response to chemotherapy is obtained, consolidation radiation treatment or surgery can be considered. Most complications after cystectomy and urinary diversion are not due to the cystectomy but to the urinary diversion. While the postoperative mortality has been reduced to extremely rare cases in most expert centers, the morbidity of the procedure still remains high. There is certainly a relation between morbidity and surgical volume although not only surgical skills but also the availability of an integrated multidisciplinary surgical- anesthesiological team is needed . The urinary diversion type should be discussed with the patient and depends on general condition, the underlying disease stage, the wish of the patient and the available surgical expertise. While bladder substitution could be considered in virtually all patients that can safely undergo a cystectomy, cutaneous diversion remains often applied in older patients where the reeducation of the bladder substitution is anticipated to be more difﬁcult. Continent cutaneous diversion were pretty popular many years ago while today more surgeons will either go for a bladder replacement or a cutaneous Bricker diversion. Diversions of the uretero-sigmoidostomy type have become less and less popular due to many complications with ascending infections, electrolyte disturbance, anal problems and development of adenocarcinoma of the colon.