World Journal of Urology

, Volume 34, Issue 1, pp 33–39 | Cite as

Open radical cystectomy: still the gold standard for muscle invasive bladder cancer

  • Bernhard Kiss
  • Fiona C. Burkhard
  • George N. ThalmannEmail author
Topic Paper



Muscle invasive bladder cancer is an unforgiving disease, and if untreated, it leads to death within 2 years of the diagnosis in >85 % of the patients. Long-term oncologic efficacy remains the ultimate standard that all procedures have to be measured by. In the past decades, open radical cystectomy (RC), extended pelvic lymph node dissection (PLND), and urinary diversion have been established as the gold standard. In the last few years, however, growing attention has been set on robotic-assisted radical cystectomy (RARC).


Even in the very long term, open RC has good oncological results and if an ileal neobladder is performed excellent functional results. Follow-up of patients after open RC exceeds more than a decade which is unsurpassed by any other technique. Its outcomes have been proven to be durable and cost-effective. Least perioperative complications as well as best oncological and functional results can be achieved if open RC and urinary diversion were performed in a high-volume hospital by high-volume surgeons and an experienced team.


Despite upcoming new technologies such as RARC, open RC following extended (PLND) remains the gold standard treatment for high-grade muscle invasive bladder cancer.


Open radical cystectomy Muscle invasive bladder cancer 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical standards

Ethical committee review was not required as the manuscript is a review of the published literature.


  1. 1.
    Ploeg M, Aben KK, Kiemeney LA (2009) The present and future burden of urinary bladder cancer in the world. World J Urol 27(3):289–293PubMedPubMedCentralCrossRefGoogle Scholar
  2. 2.
    Prout GR, Marshall VF (1956) The prognosis with untreated bladder tumors. Cancer 9(3):551–558PubMedCrossRefGoogle Scholar
  3. 3.
    Ghoneim MA, Abdel-Latif M, el-Mekresh M, Abol-Enein H, Mosbah A, Ashamallah A et al (2008) Radical cystectomy for carcinoma of the bladder: 2720 consecutive cases 5 years later. J Urol 180(1):121–127PubMedCrossRefGoogle Scholar
  4. 4.
    Witjes JA, Comperat E, Cowan NC, De Santis M, Gakis G, Lebret T et al (2014) EAU guidelines on muscle-invasive and metastatic bladder cancer: summary of the 2013 guidelines. Eur Urol 65(4):778–792PubMedCrossRefGoogle Scholar
  5. 5.
    Donat SM, Shabsigh A, Savage C, Cronin AM, Bochner BH, Dalbagni G et al (2009) Potential impact of postoperative early complications on the timing of adjuvant chemotherapy in patients undergoing radical cystectomy: a high-volume tertiary cancer center experience. Eur Urol 55(1):177–185PubMedCrossRefGoogle Scholar
  6. 6.
    Roth B, Birkhauser FD, Zehnder P, Burkhard FC, Thalmann GN, Studer UE (2011) Readaptation of the peritoneum following extended pelvic lymphadenectomy and cystectomy has a significant beneficial impact on early postoperative recovery and complications: results of a prospective randomized trial. Eur Urol 59(2):204–210PubMedCrossRefGoogle Scholar
  7. 7.
    Shabsigh A, Korets R, Vora KC, Brooks CM, Cronin AM, Savage C et al (2009) Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology. Eur Urol 55(1):164–174PubMedCrossRefGoogle Scholar
  8. 8.
    Madersbacher S, Hochreiter W, Burkhard F, Thalmann GN, Danuser H, Markwalder R et al (2003) Radical cystectomy for bladder cancer today-a homogeneous series without neoadjuvant therapy. J Clin Oncol Off J Am Soc Clin Oncol 21(4):690–696CrossRefGoogle Scholar
  9. 9.
    Stein JP, Lieskovsky G, Cote R, Groshen S, Feng AC, Boyd S et al (2001) Radical cystectomy in the treatment of invasive bladder cancer: long-term results in 1054 patients. J Clin Oncol Off J Am Soc Clin Oncol 19(3):666–675Google Scholar
  10. 10.
    Bolenz C, Ho R, Nuss GR, Ortiz N, Raj GV, Sagalowsky AI et al (2010) Management of elderly patients with urothelial carcinoma of the bladder: guideline concordance and predictors of overall survival. BJU Int 106(9):1324–1329PubMedCrossRefGoogle Scholar
  11. 11.
    Mayr R, May M, Martini T, Lodde M, Pycha A, Comploj E et al (2012) Predictive capacity of four comorbidity indices estimating perioperative mortality after radical cystectomy for urothelial carcinoma of the bladder. BJU Int 110((6 Pt B)):E222–E227PubMedCrossRefGoogle Scholar
  12. 12.
    Roth B, Thalmann GN (2015) Standard Cystectomy fits all: myth or truth. Transl Androl Urol 4(3):254–260Google Scholar
  13. 13.
    Hautmann RE, Abol-Enein H, Davidsson T, Gudjonsson S, Hautmann SH, Holm HV et al (2013) ICUD-EAU international consultation on bladder cancer 2012: urinary diversion. Eur Urol 63(1):67–80PubMedCrossRefGoogle Scholar
  14. 14.
    Bhatta Dhar N, Kessler TM, Mills RD, Burkhard F, Studer UE (2007) Nerve-sparing radical cystectomy and orthotopic bladder replacement in female patients. Eur Urol 52(4):1006–1014PubMedCrossRefGoogle Scholar
  15. 15.
    Skinner EC, Stein JP, Skinner DG (2007) Surgical benchmarks for the treatment of invasive bladder cancer. Urol Oncol 25(1):66–71PubMedCrossRefGoogle Scholar
  16. 16.
    Turner WH, Studer UE (1997) Cystectomy and urinary diversion. Semin Surg Oncol 13(5):350–358PubMedCrossRefGoogle Scholar
  17. 17.
    Kessler TM, Burkhard FC, Perimenis P, Danuser H, Thalmann GN, Hochreiter WW et al (2004) Attempted nerve sparing surgery and age have a significant effect on urinary continence and erectile function after radical cystoprostatectomy and ileal orthotopic bladder substitution. J Urol 172(4 Pt 1):1323–1327PubMedCrossRefGoogle Scholar
  18. 18.
    Hautmann RE (2003) Urinary diversion: ileal conduit to neobladder. J Urol 169(3):834–842PubMedCrossRefGoogle Scholar
  19. 19.
    Turner JA, Ciol MA, Von Korff M, Berger R (2003) Validity and responsiveness of the national institutes of health chronic prostatitis symptom index. J Urol 169(2):580–583PubMedCrossRefGoogle Scholar
  20. 20.
    Eichelberg C, Erbersdobler A, Michl U, Schlomm T, Salomon G, Graefen M et al (2007) Nerve distribution along the prostatic capsule. Eur Urol 51(1):105–110 (discussion 10-1)PubMedCrossRefGoogle Scholar
  21. 21.
    Sievert KD, Hennenlotter J, Laible I, Amend B, Schilling D, Anastasiadis A et al (2008) The periprostatic autonomic nerves-bundle or layer? Eur Urol 54(5):1109–1116PubMedCrossRefGoogle Scholar
  22. 22.
    Walsh PC, Donker PJ (1982) Impotence following radical prostatectomy: insight into etiology and prevention. Eur Urol 128(3):492–497Google Scholar
  23. 23.
    Rao GN, Drew PJ, Lee PW, Monson JR, Duthie GS (1996) Anterior resection syndrome is secondary to sympathetic denervation. Int J Colorectal Dis 11(5):250–258PubMedCrossRefGoogle Scholar
  24. 24.
    Birkäuser FD (2015) Seminal vesicle-sparing cystoprostatectomy: what can be expected? In: Studer UE (ed) Keys to Successful Orthotopic bladder Sustitution, pp 85–92. doi: 10.1007/978-3-319-12382-0_5
  25. 25.
    Birkhauser FD, Schumacher C, Seiler R, de Meuron L, Zehnder P, Roth B et al (2012) Occlusion of seminal vesicles increases sexual activity in a mouse model. Eur Urol 62(5):855–862PubMedCrossRefGoogle Scholar
  26. 26.
    Ong CH, Schmitt M, Thalmann GN, Studer UE (2010) Individualized seminal vesicle sparing cystoprostatectomy combined with ileal orthotopic bladder substitution achieves good functional results. J Urol 183(4):1337–1341PubMedCrossRefGoogle Scholar
  27. 27.
    Stein JP, Hautmann RE, Penson D, Skinner DG (2009) Prostate-sparing cystectomy: a review of the oncologic and functional outcomes. Contraindicated in patients with bladder cancer. Urol Oncol 27(5):466–472PubMedCrossRefGoogle Scholar
  28. 28.
    Studer UE, Burkhard FC, Schumacher M, Kessler TM, Thoeny H, Fleischmann A et al (2006) Twenty years experience with an ileal orthotopic low pressure bladder substitute-lessons to be learned. J Urol 176(1):161–166PubMedCrossRefGoogle Scholar
  29. 29.
    Kefer JC, Voelzke BB, Flanigan RC, Wojcik EM, Waters WB, Campbell SC (2005) Risk assessment for occult malignancy in the prostate before radical cystectomy. Urology 66(6):1251–1255PubMedCrossRefGoogle Scholar
  30. 30.
    Pettus JA, Al-Ahmadie H, Barocas DA, Koppie TM, Herr H, Donat SM et al (2008) Risk assessment of prostatic pathology in patients undergoing radical cystoprostatectomy. Eur Urol 53(2):370–375PubMedCrossRefGoogle Scholar
  31. 31.
    Revelo MP, Cookson MS, Chang SS, Shook MF, Smith JA Jr, Shappell SB (2004) Incidence and location of prostate and urothelial carcinoma in prostates from cystoprostatectomies: implications for possible apical sparing surgery. J Urol 171(2 Pt 1):646–651PubMedCrossRefGoogle Scholar
  32. 32.
    Weizer AZ, Shah RB, Lee CT, Gilbert SM, Daignault S, Montie JE et al (2007) Evaluation of the prostate peripheral zone/capsule in patients undergoing radical cystoprostatectomy: defining risk with prostate capsule sparing cystectomy. Urol Oncol 25(6):460–464PubMedCrossRefGoogle Scholar
  33. 33.
    Valette TN, Antunes AA, Leite KM, Srougi M (2015) Probability of extraprostatic disease according to the percentage of positive biopsy cores in clinically localized prostate cancer. Int Braz J Urol Off J Braz Soc Urol 41(3):449–454CrossRefGoogle Scholar
  34. 34.
    Schilling D, Horstmann M, Nagele U, Sievert KD, Stenzl A (2008) Cystectomy in women. BJU Int 102(9 Pt B):1289–1295PubMedCrossRefGoogle Scholar
  35. 35.
    Chen ME, Pisters LL, Malpica A, Pettaway CA, Dinney CP (1997) Risk of urethral, vaginal and cervical involvement in patients undergoing radical cystectomy for bladder cancer: results of a contemporary cystectomy series from M. D. Anderson Cancer Center. J Urol 157(6):2120–2123PubMedCrossRefGoogle Scholar
  36. 36.
    Varkarakis IM, Pinggera G, Antoniou N, Constantinides K, Chrisofos M, Deliveliotis C (2007) Pathological review of internal genitalia after anterior exenteration for bladder cancer in women. Evaluating risk factors for female organ involvement. Int Urol Nephrol 39(4):1015–1021PubMedCrossRefGoogle Scholar
  37. 37.
    Skinner DG (1982) Management of invasive bladder cancer: a meticulous pelvic node dissection can make a difference. J Urol 128(1):34–36PubMedGoogle Scholar
  38. 38.
    Roth B, Wissmeyer MP, Zehnder P, Birkhauser FD, Thalmann GN, Krause TM et al (2010) A new multimodality technique accurately maps the primary lymphatic landing sites of the bladder. Eur Urol 57(2):205–211PubMedCrossRefGoogle Scholar
  39. 39.
    Dhar NB, Klein EA, Reuther AM, Thalmann GN, Madersbacher S, Studer UE (2008) Outcome after radical cystectomy with limited or extended pelvic lymph node dissection. J Urol 179(3):873–878 (discussion 8)PubMedCrossRefGoogle Scholar
  40. 40.
    Zehnder P, Studer UE, Skinner EC, Dorin RP, Cai J, Roth B et al (2011) Super extended versus extended pelvic lymph node dissection in patients undergoing radical cystectomy for bladder cancer: a comparative study. J Urol 186(4):1261–1268PubMedCrossRefGoogle Scholar
  41. 41.
    Bruins HM, Veskimae E, Hernandez V, Imamura M, Neuberger MM, Dahm P et al (2014) The impact of the extent of lymphadenectomy on oncologic outcomes in patients undergoing radical cystectomy for bladder cancer: a systematic review. Eur Urol 66(6):1065–1077PubMedCrossRefGoogle Scholar
  42. 42.
    Shariat SF, Karakiewicz PI, Palapattu GS, Lotan Y, Rogers CG, Amiel GE et al (2006) Outcomes of radical cystectomy for transitional cell carcinoma of the bladder: a contemporary series from the Bladder Cancer Research Consortium. J Urol 176(6 Pt 1):2414–2422 (discussion 22)PubMedCrossRefGoogle Scholar
  43. 43.
    Hautmann RE, de Petriconi RC, Pfeiffer C, Volkmer BG (2012) Radical cystectomy for urothelial carcinoma of the bladder without neoadjuvant or adjuvant therapy: long-term results in 1100 patients. Eur Urol 61(5):1039–1047PubMedCrossRefGoogle Scholar
  44. 44.
    Hautmann RE, Gschwend JE, de Petriconi RC, Kron M, Volkmer BG (2006) Cystectomy for transitional cell carcinoma of the bladder: results of a surgery only series in the neobladder era. J Urol 176(2):486–492 (discussion 91-2)PubMedCrossRefGoogle Scholar
  45. 45.
    Zehnder P, Studer UE, Skinner EC, Thalmann GN, Miranda G, Roth B et al (2013) Unaltered oncological outcomes of radical cystectomy with extended lymphadenectomy over three decades. BJU Int 112(2):E51–E58PubMedCrossRefGoogle Scholar
  46. 46.
    Leow JJ, Reese SW, Jiang W, Lipsitz SR, Bellmunt J, Trinh QD et al (2014) Propensity-matched comparison of morbidity and costs of open and robot-assisted radical cystectomies: a contemporary population-based analysis in the United States. Eur Urol 66(3):569–576PubMedCrossRefGoogle Scholar
  47. 47.
    Ng CK, Kauffman EC, Lee MM, Otto BJ, Portnoff A, Ehrlich JR et al (2010) A comparison of postoperative complications in open versus robotic cystectomy. Eur Urol 57(2):274–281PubMedCrossRefGoogle Scholar
  48. 48.
    Pruthi RS, Wallen EM (2007) Robotic assisted laparoscopic radical cystoprostatectomy: operative and pathological outcomes. J Urol 178(3 Pt 1):814–818PubMedCrossRefGoogle Scholar
  49. 49.
    Wang GJ, Barocas DA, Raman JD, Scherr DS (2008) Robotic versus open radical cystectomy: prospective comparison of perioperative outcomes and pathological measures of early oncological efficacy. BJU Int 101(1):89–93PubMedGoogle Scholar
  50. 50.
    Bochner BH, Dalbagni G, Sjoberg DD, Silberstein J, Keren Paz GE, Donat SM et al (2015) Comparing open radical cystectomy and robot-assisted laparoscopic radical cystectomy: a randomized clinical trial. Eur Urol 67(6):1042–1050PubMedCrossRefGoogle Scholar
  51. 51.
    Khan MS, Gan C, Ahmed K, Ismail AF, Watkins J, Summers JA et al (2015) A single-centre early phase randomised controlled three-arm trial of open, robotic, and laparoscopic radical cystectomy (CORAL). Eur Urol. doi: 10.1016/j.eururo.2015.07.038
  52. 52.
    Novara G, Catto JW, Wilson T, Annerstedt M, Chan K, Murphy DG et al (2015) Systematic review and cumulative analysis of perioperative outcomes and complications after robot-assisted radical cystectomy. Eur Urol 67(3):376–401PubMedCrossRefGoogle Scholar
  53. 53.
    Raza SJ, Wilson T, Peabody JO, Wiklund P, Scherr DS, Al-Daghmin A et al (2015) Long-term oncologic outcomes following robot-assisted radical cystectomy: results from the international robotic cystectomy consortium. Eur Urol 68(4):721–728PubMedCrossRefGoogle Scholar
  54. 54.
    Patel R, Szymaniak J, Radadia K, Faiena I, Lasser M (2015) Controversies in robotics: open versus robotic radical cystectomy. Clin Genitourin Cancer 13(5):421–427PubMedCrossRefGoogle Scholar
  55. 55.
    Nguyen DP, Al Hussein Al Awamlh B, Wu X, O’Malley P, Inoyatov IM, Ayangbesan A et al (2015) Recurrence patterns after open and robot-assisted radical cystectomy for bladder cancer. Eur Urol 68(3):399–405PubMedCrossRefGoogle Scholar
  56. 56.
    Lee R, Ng CK, Shariat SF, Borkina A, Guimento R, Brumit KF et al (2011) The economics of robotic cystectomy: cost comparison of open versus robotic cystectomy. BJU Int 108(11):1886–1892PubMedCrossRefGoogle Scholar
  57. 57.
    Smith A, Kurpad R, Lal A, Nielsen M, Wallen EM, Pruthi RS (2010) Cost analysis of robotic versus open radical cystectomy for bladder cancer. J Urol 183(2):505–509PubMedCrossRefGoogle Scholar
  58. 58.
    Yuh B, Wilson T, Bochner B, Chan K, Palou J, Stenzl A et al (2015) Systematic review and cumulative analysis of oncologic and functional outcomes after robot-assisted radical cystectomy. Eur Urol 67(3):402–422PubMedCrossRefGoogle Scholar
  59. 59.
    Smith ND, Castle EP, Gonzalgo ML, Svatek RS, Weizer AZ, Montgomery JS et al (2015) The RAZOR (randomized open vs. robotic cystectomy) trial: study design and trial update. BJU Int 115(2):198–205PubMedCrossRefGoogle Scholar
  60. 60.
    Hautmann RE, Abol-Enein H, Lee CT, Mansson W, Mills RD, Penson DF et al (2015) Urinary diversion: How experts divert. Urology 85(1):233–238PubMedCrossRefGoogle Scholar
  61. 61.
    Gore JL, Saigal CS, Hanley JM, Schonlau M, Litwin MS (2006) Urologic Diseases in America P. Variations in reconstruction after radical cystectomy. Cancer 107(4):729–737PubMedPubMedCentralCrossRefGoogle Scholar
  62. 62.
    Dutta SC, Chang SC, Coffey CS, Smith JA Jr, Jack G, Cookson MS (2002) Health related quality of life assessment after radical cystectomy: comparison of ileal conduit with continent orthotopic neobladder. J Urol 168(1):164–167PubMedCrossRefGoogle Scholar
  63. 63.
    Gerharz EW, Mansson A, Hunt S, Skinner EC, Mansson W (2005) Quality of life after cystectomy and urinary diversion: an evidence based analysis. J Urol 174(5):1729–1736PubMedCrossRefGoogle Scholar
  64. 64.
    Steers WD (2000) Voiding dysfunction in the orthotopic neobladder. World J Urol 18(5):330–337PubMedCrossRefGoogle Scholar
  65. 65.
    Ali-el-Dein B, Shaaban AA, Abu-Eideh RH, el-Azab M, Ashamallah A, Ghoneim MA (2008) Surgical complications following radical cystectomy and orthotopic neobladders in women. J Urol 180(1):206–210 (discussion 10)PubMedCrossRefGoogle Scholar
  66. 66.
    Canda AE, Atmaca AF, Altinova S, Akbulut Z, Balbay MD (2012) Robot-assisted nerve-sparing radical cystectomy with bilateral extended pelvic lymph node dissection (PLND) and intracorporeal urinary diversion for bladder cancer: initial experience in 27 cases. BJU Int 110(3):434–444PubMedCrossRefGoogle Scholar
  67. 67.
    Satkunasivam R, Santomauro M, Chopra S, Plotner E, Cai J, Miranda G et al (2015) Robotic intracorporeal orthotopic neobladder: urodynamic outcomes, urinary function, and health-related quality of life. Eur Urol. doi: 10.1016/j.eururo.2015.06.041
  68. 68.
    Hautmann RE, Herr HW, Pruthi RS, Aron M (2014) Robotic radical cystectomy-is the diversion the Achilles’ heel? J Urol 192(6):1601–1603PubMedCrossRefGoogle Scholar
  69. 69.
    Abol-Enein H, Ghoneim MA (2001) Functional results of orthotopic ileal neobladder with serous-lined extramural ureteral reimplantation: experience with 450 patients. J Urol 165(5):1427–1432PubMedCrossRefGoogle Scholar
  70. 70.
    Hautmann RE, de Petriconi R, Gottfried HW, Kleinschmidt K, Mattes R, Paiss T (1999) The ileal neobladder: complications and functional results in 363 patients after 11 years of followup. J Urol 161(2):422–427 (discussion 7-8)PubMedCrossRefGoogle Scholar
  71. 71.
    Stein JP, Dunn MD, Quek ML, Miranda G, Skinner DG (2004) The orthotopic T pouch ileal neobladder: experience with 209 patients. J Urol 172(2):584–587PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  • Bernhard Kiss
    • 1
  • Fiona C. Burkhard
    • 1
  • George N. Thalmann
    • 1
    Email author
  1. 1.Department of UrologyUniversity of BernBernSwitzerland

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