Is There Still a Role for Radical Cystectomy?

  • M. BrausiEmail author


Radical cystectomy (RC) with lymph node dissection (eLND) and neoadjuvant chemotherapy still represents the standard treatment for very high-risk non-muscle invasive (NMIBC) and muscle-invasive (MIBC) bladder cancer patients. Radical surgery provides recurrence-free (RFS) and overall survival (OS) rates of 68 and 66% after 5 years and of 60 and 43% after 10 years from RC, respectively. One of the major concerns about radical surgery regards the high morbidity/mortality rates related to the procedure and the consequent decreased patients’ quality of life. Therefore, bladder sparing techniques in a multimodal setting have been proposed and investigated, with promising results. However, to date, long-term oncological outcomes provided by bladder sparing techniques are still lacking. Moreover, patients who will not respond to bladder sparing treatments will, anyway, undergo salvage RC. For these reasons, radical surgery still represents the more convincing options since can provide good long-term outcomes and a decreased risk of local/regional recurrence thanks to the eLND. Moreover, RC is indicated also in locally advanced disease as well as in elderly patients. Finally, the possibility to perform an orthotopic neobladder could improve patients’ acceptability and quality of life.


Radical cystectomy Lymph-node dissection Outcomes Orthotopic neobladder Bladder sparing 


  1. 1.
    Witjes JA, Compérat E, Cowan NC, Gakis G, Hernández V, Lebret T, Lorch A, van der Heijden AG, Ribal MJ. EAU guidelines on muscle-invasive and metastatic bladder cancer. Eur Urol. 2017;65(4):778–92.CrossRefGoogle Scholar
  2. 2.
    Ferlay J, et al. Cancer incidence and mortality patterns in Europe: estimates for 40 countries in 2012. Eur J Cancer. 2013;49:1374. Scholar
  3. 3.
    GLOBOCAN 2012 v1.0. Cancer incidence and mortality worldwide. IARC CancerBase No. 11. International Agency for Research on Cancer.Google Scholar
  4. 4.
    Freedman ND, et al. Association between smoking and risk of bladder cancer among men and women. JAMA. 2011;306:737–45.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Stein JP, et al. Radical cystectomy in the treatment of invasive bladder cancer: long-term results in 1,054 patients. J Clin Oncol. 2001;19:666–75.CrossRefPubMedGoogle Scholar
  6. 6.
    Hautmann RE, et al. Urinary diversion. Urology. 2007;69:17.CrossRefPubMedGoogle Scholar
  7. 7.
    Babjuk M, Burger M, Compérat E, Gontero P, et al. EAU guidelines on non-muscle-invasive bladder cancer (TaT1 and Cis). Eur Urol. 2017;71(3):447–61.CrossRefPubMedGoogle Scholar
  8. 8.
    Mertens LS, et al. Prostate sparing cystectomy for bladder cancer: 20-year single center experience. J Urol. 2014;191:1250–5.CrossRefPubMedGoogle Scholar
  9. 9.
    Stenzl A, et al. Cystectomy—technical considerations in male and female patients. EAU Updat Ser. 2005;3:138–46.CrossRefGoogle Scholar
  10. 10.
    Simone G, et al. Stage-specific impact of extended versus standard pelvic lymph node dissection in radical cystectomy. Int J Urol. 2013;20:390–7.CrossRefPubMedGoogle Scholar
  11. 11.
    Holmer M, et al. Extended lymph node dissection in patients with urothelial cell carcinoma of the bladder: can it make a difference? World J Urol. 2009;27:521–6.CrossRefPubMedGoogle Scholar
  12. 12.
    Poulsen AL, et al. Radical cystectomy: extending the limits of pelvic lymph node dissection improves survival for patients with bladder cancer confined to the bladder wall. J Urol. 1998;160:2015–9.CrossRefPubMedGoogle Scholar
  13. 13.
    Jensen JB, et al. Extended versus limited lymph node dissection in radical cystectomy: impact on recurrence pattern and survival. Int J Urol. 2012;19:39–47.CrossRefPubMedGoogle Scholar
  14. 14.
    Dhar NB, et al. Outcome after radical cystectomy with limited or extended pelvic lymph node dissection. J Urol. 2008;179:873–8.CrossRefPubMedGoogle Scholar
  15. 15.
    Zlotta AR. Limited, extended, superextended, megaextended pelvic lymph node dissection at the time of radical cystectomy: what should we perform? Eur Urol. 2012;61:243–4.CrossRefPubMedGoogle Scholar
  16. 16.
    Zehnder P, et al. Super extended versus extended pelvic lymph node dissection in patients undergoing radical cystectomy for bladder cancer: a comparative study. J Urol. 2011;186:1261–8.CrossRefPubMedGoogle Scholar
  17. 17.
    Koppie TM, et al. Standardization of pelvic lymphadenectomy performed at radical cystectomy: can we establish a minimum number of lymph nodes that should be removed? Cancer. 2006;107:2368–74.CrossRefPubMedGoogle Scholar
  18. 18.
    Fleischmann A, et al. Extracapsular extension of pelvic lymph node metastases from urothelial carcinoma of the bladder is an independent prognostic factor. J Clin Oncol. 2005;23:2358–65.CrossRefPubMedGoogle Scholar
  19. 19.
    Wright JL, et al. The association between extent of lymphadenectomy and survival among patients with lymph node metastases undergoing radical cystectomy. Cancer. 2008;112:2401–8.CrossRefPubMedGoogle Scholar
  20. 20.
    Studer UE, et al. Morbidity from pelvic lymphadenectomy in men undergoing radical prostatectomy. Eur Urol. 2006;50:887.CrossRefPubMedGoogle Scholar
  21. 21.
    Gschwend JE, et al. Prospective randomised study comparing limited versus extended lymphadenectomy in patients with bladder cancer. J Clin Oncol. 2016;34(15_suppl):4503.Google Scholar
  22. 22.
    Roth B, Wissmeyer MP, Zehnder P, Birkhäuser FD, Thalmann GN, Krause TM, Studer UE. A new multimodality technique accurately maps the primary lymphatic landing sites of the bladder. Eur Urol. 2010;57(2):205–11.CrossRefPubMedGoogle Scholar
  23. 23.
    Stein JP, et al. Radical cystectomy for invasive bladder cancer: long-term results of a standard procedure. World J Urol. 2006;24:296–304.CrossRefPubMedGoogle Scholar
  24. 24.
    Dalbagni G, et al. Cystectomy for bladder cancer: a contemporary series. J Urol. 2001;165:1111–6.CrossRefPubMedGoogle Scholar
  25. 25.
    Bassi P, et al. Prognostic factors of outcome after radical cystectomy for bladder cancer: a retrospective study of a homogeneous patient cohort. J Urol. 1999;161:1494–7.CrossRefPubMedGoogle Scholar
  26. 26.
    Ghoneim MA, et al. Radical cystectomy for carcinoma of the bladder: critical evaluation of the results in 1,026 cases. J Urol. 1997;158:393–9.CrossRefPubMedGoogle Scholar
  27. 27.
    David KA, et al. Low incidence of perioperative chemotherapy for stage III bladder cancer 1998 to 2003: a report from the National Cancer Data Base. J Urol. 2007;178:451–4.CrossRefPubMedGoogle Scholar
  28. 28.
    Porter MP, et al. Patterns of use of systemic chemotherapy for Medicare beneficiaries with urothelial bladder cancer. Urol Oncol. 2011;29:252–8.CrossRefPubMedGoogle Scholar
  29. 29.
    Advanced Bladder Cancer (ABC) Meta-analysis Collaboration. Neoadjuvant chemotherapy in invasive bladder cancer: update of a systematic review and metaanalysis of individual patient data advanced bladder cancer (ABC) meta-analysis collaboration. Eur Urol. 2005;48:202–5.CrossRefGoogle Scholar
  30. 30.
    Hernández V, Espinos EL, Dunn J, MacLennan S, Lam T, Yuan Y, Compérat E, Cowan NC, Gakis G, Lebrét T, van der Heijden AG, Witjes JA, Ribal MJ. Oncological and functional outcomes of sexual function-preserving cystectomy compared with standard radical cystectomy in men: a systematic review. Urol Oncol. 2017;35(9):539.e17–29. Scholar
  31. 31.
    Ok JH, et al. Medical and surgical palliative care of patients with urological malignancies. J Urol. 2005;174:1177–82.CrossRefPubMedGoogle Scholar
  32. 32.
    Ubrig B, et al. Extraperitoneal bilateral cutaneous ureterostomy with midline stoma for palliation of pelvic cancer. Urology. 2004;63:973–5.CrossRefPubMedGoogle Scholar
  33. 33.
    Zebic N, et al. Radical cystectomy in patients aged > or = 75 years: an updated review of patients treated with curative and palliative intent. BJU Int. 2005;95:1211–4.CrossRefPubMedGoogle Scholar
  34. 34.
    Miller DC, et al. The impact of co-morbid disease on cancer control and survival following radical cystectomy. J Urol. 2003;169:105.CrossRefPubMedGoogle Scholar
  35. 35.
    Figueroa AJ, et al. Radical cystectomy for elderly patients with bladder carcinoma: an updated experience with 404 patients. Cancer. 1998;83:141–7.CrossRefPubMedGoogle Scholar
  36. 36.
    Geriatric assessment: methods for clinical decision making. NIH Consensus Statement Online N.I.o. Health, Editor. 1987, U.S. Department of Health & Human Services.Google Scholar
  37. 37.
    Froehner M, Brausi M, Herr HW, Muto G, Studer UE. Complications following radical cystectomy for bladder cancer in the elderly. Eur Urol. 2009;56(3):443–54.CrossRefPubMedGoogle Scholar
  38. 38.
    Fonteyne V, Ost P, Bellmunt J, Droz JP, Mongiat-Artus P, Inman B, Paillaud E, Saad F, Ploussard G. Curative treatment for muscle invasive bladder cancer in elderly patients: a systematic review. Eur Urol. 2017;73(1):40–50.CrossRefPubMedGoogle Scholar
  39. 39.
    Game X, et al. Radical cystectomy in patients older than 75 years: assessment of morbidity and mortality. Eur Urol. 2001;39:525–9.CrossRefPubMedGoogle Scholar
  40. 40.
    Clark PE, Stein JP, Groshen SG, Cai J, Miranda G, Lieskovsky G, Skinner DG. Radical cystectomy in the elderly: comparison of clincal outcomes between younger and older patients. Cancer. 2005;104(1):36–43.CrossRefPubMedGoogle Scholar
  41. 41.
    May M, et al. Results from three municipal hospitals regarding radical cystectomy on elderly patients. Int Braz J Urol. 2007;33:764–73.CrossRefPubMedGoogle Scholar
  42. 42.
    Lughezzani G, et al. A population-based competing-risks analysis of the survival of patients treated with radical cystectomy for bladder cancer. Cancer. 2011;117:103–9.CrossRefPubMedGoogle Scholar
  43. 43.
    Brausi M, Selli C, Rossi A, Gavioli M, De Luca G, Peracchia G, Verrini G, Viola M, Romano A, Simonini G. Radical cystectomy (RC) in octogenarians Long-term experience of two high volume institutions. Eur Urol Suppl. 2015;14(/2):e534.CrossRefGoogle Scholar
  44. 44.
    Shariat SF, et al. Outcomes of radical cystectomy for transitional cell carcinoma of the bladder: a contemporary series from the Bladder Cancer Research Consortium. J Urol. 2006;176:2414–22.CrossRefPubMedGoogle Scholar
  45. 45.
    Madersbacher S, et al. Radical cystectomy for bladder cancer today—a homogeneous series without neoadjuvant therapy. J Clin Oncol. 2003;21:690–6.CrossRefPubMedGoogle Scholar
  46. 46.
    Bruins HM, et al. Clinical outcomes and recurrence predictors of lymph node positive urothelial cancer after cystectomy. J Urol. 2009;182:2182–7.CrossRefPubMedGoogle Scholar
  47. 47.
    Hautmann RE, de Petriconi RC, Pfeiffer C, Volkmer BG. Radical cystectomy for urothelial carcinoma of the bladder without neoadjuvant or adjuvant therapy: long-term results in 1100 patients. Eur Urol. 2012;61:1039–47.CrossRefPubMedGoogle Scholar
  48. 48.
    Hautmann RE, et al. Lessons learned from 1,000 neobladders: the 90-day complication rate. J Urol. 2010;184:990–4.CrossRefPubMedGoogle Scholar
  49. 49.
    Nielsen ME, et al. Association of hospital volume with conditional 90-day mortality after cystectomy: an analysis of the National Cancer Data Base. BJU Int. 2014;114:46–55.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Porter MP, et al. Hospital volume and 90-day mortality risk after radical cystectomy: a populationbased cohort study. World J Urol. 2011;29:73–7.CrossRefPubMedGoogle Scholar
  51. 51.
    Jentzmik F, et al. The ileal neobladder in female patients with bladder cancer: long-term clinical, functional, and oncological outcome. World J Urol. 2012;30:733–9.CrossRefPubMedGoogle Scholar
  52. 52.
    Hautmann RE, et al. ICUD-EAU International Consultation on Bladder Cancer 2012: urinary diversion. Eur Urol. 2013;63:67.CrossRefPubMedGoogle Scholar
  53. 53.
    Corcoran AT, et al. Variation in performance of candidate surgical quality measures for muscleinvasive bladder cancer by hospital type. BJU Int. 2015;115:230.CrossRefPubMedGoogle Scholar
  54. 54.
    Ravi P, et al. Benefit in regionalisation of care for patients treated with radical cystectomy: a nationwide inpatient sample analysis. BJU Int. 2014;113:733.CrossRefPubMedGoogle Scholar
  55. 55.
    Irwin BH, Gill IS, Haber GP, Campbell SC. Laparoscopic radical cystectomy: current status, outcomes, and patient selection. Curr Treat Options Oncol. 2009;10(3–4):243–55.CrossRefPubMedGoogle Scholar
  56. 56.
    Wilson TG, et al. Best practices in robot-assisted radical cystectomy and urinary reconstruction: recommendations of the Pasadena Consensus Panel. Eur Urol. 2015;67:363.CrossRefPubMedGoogle Scholar
  57. 57.
    Bochner BH, Dalbagni G, Sjoberg DD, et al. Comparing open radical cystectomy and robot-assisted laparoscopic radical cystectomy: a randomized clinical trial. Eur Urol. 2015;67(6):1042–50.CrossRefPubMedGoogle Scholar
  58. 58.
    Cohen SA, Mirheydar HS, Parsons JK, et al. Minimally invasive cystectomy is associated with improved perioperative patient safety outcomes compared with open cystectomy in a national cohort. Urology. 2014;84(2):314–9.CrossRefPubMedGoogle Scholar
  59. 59.
    Novara G, Catto JW, Wilson T, et al. Systematic review and cumulative analysis of perioperative outcomes and complications after robotassisted radical cystectomy. Eur Urol. 2015;67(3):376–401.CrossRefPubMedGoogle Scholar
  60. 60.
    Gandaglia G, Karl A, Novara G, De Groote R, Buchner A, D’Hondt F, Montorsi F, Stief C, Mottrie A, Gratzke C. Perioperative and oncologic outcomes of robot-assisted vs. open radical cystectomy in bladder cancer patients: a comparison of two high-volume referral centers. Eur J Surg Oncol. 2016;42(11):1736–43.CrossRefPubMedGoogle Scholar
  61. 61.
    Hussein AA, Saar M, May PR, Wijburg CJ, et al. Early oncologic failure after robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium. J Urol. 2017;197(6):1427–36.CrossRefPubMedGoogle Scholar
  62. 62.
    Karam JA, Sagalowsky AI. Minimally invasive radical cystectomy for bladder cancer? Lancet Oncol. 2008;9:317.CrossRefPubMedGoogle Scholar
  63. 63.
    Jacobi CA, Wenger FA, Ordemann J, et al. Experimental study of the effect of intraabdominal pressure during laparoscopy on tumour growth and port site metastasis. Br J Surg. 1998;85:1419.CrossRefPubMedGoogle Scholar
  64. 64.
    Stolla V, Rossi D, Bladou F, et al. Subcutaneous metastases after coelioscopic lymphadenectomy for vesical urothelial carcinoma. Eur Urol. 1994;26:342.CrossRefPubMedGoogle Scholar
  65. 65.
    Tsivian A, Sidi AA. Port site metastases in urological laparoscopic surgery. J Urol. 2003;169:1213.CrossRefGoogle Scholar
  66. 66.
    Ost MC, Patel KP, Rastinehad AR, et al. Pneumoperitoneum with carbon dioxide inhibits macrophage tumor necrosis factor-alpha secretion: source of transitional-cell carcinoma portsite metastasis, with prophylactic irrigation strategies to decrease laparoscopic oncologic risks. J Endourol. 2008;22:105–12.CrossRefPubMedGoogle Scholar
  67. 67.
    Hewett PJ, Thomas WM, King G, et al. Intraperitoneal cell movement during abdominal carbon dioxide insufflation and laparoscopy. An in vivo model. Dis Colon Rectum. 1996;39:S62.CrossRefPubMedGoogle Scholar
  68. 68.
    El-Tabey NA, Shoma AM. Port site metastases after robot-assisted laparoscopic radical cystectomy. Urology. 2005;66:1110.PubMedGoogle Scholar
  69. 69.
    Gakis G, Efstathiou J, Lerner SP, Cookson MS, Keegan KA, Guru KA, et al. International Consultation on Urologic Disease-European Association of Urology Consultation on Bladder Cancer 2012. ICUD-EAU International Consultation on Bladder Cancer 2012: radical cystectomy and bladder preservation for muscle-invasive urothelial carcinoma of the bladder. Eur Urol. 2013;63:45–57.CrossRefPubMedGoogle Scholar
  70. 70.
    Siegel R, Naishadham D, Jemal A. Cancer statistics, 2012. CA Cancer J Clin. 2012;62:10–29.CrossRefGoogle Scholar
  71. 71.
    Monteiro LL, Kassouf W. Radical cystectomy is the best choice for most patients with muscle-invasive bladder cancer? Opinion: yes. Int Braz J Urol. 2017;43(2):184–7.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of UrologyB. Ramazzini HospitalCarpi-ModenaItaly

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