Local Treatment, Radical Cystectomy, and Urinary Diversion

Abstract

The open technique of radical cystectomy (RC) has become an efficacious and safe procedure for patients with muscle-invasive or high-risk non-muscle-invasive bladder cancer. Disease-free survival probabilities range from 60% to 70% at 5 years and from 50% to 65% at 10 years. In recent years, more focus has been placed on quality of life after RC. There is evidence that nerve-sparing techniques have a beneficial effect on short- and long-term continence rates in patients with continent urinary diversion. Furthermore, advances in robotic surgery have turned robot-assisted RC (RARC) into a potential alternative to the open procedure. While RARC has not shown benefit in terms of complication outcomes or perioperative morbidity, short-term oncologic data for RARC appear acceptable (bearing in mind that selection bias in most series precludes definitive conclusions). There is general consensus, however, that pelvic lymph node dissection (PLND) should be performed in every case of RC. From observational data, a more extensive PLND template is associated with higher detection rate of lymph node metastasis and lower adjusted risk of mortality. The results of two prospective, randomized trials comparing extended and standard templates are highly anticipated. Following RC, urinary diversion is mandatory. Ileal conduits are most commonly performed, while continent cutaneous urinary diversions represent a valid alternative. Orthotopic bladder substitution allows preservation of an intact body image and normal voiding function and thus of a normal lifestyle, though it requires careful patient selection, meticulous surgical technique, conscientious postoperative patient instruction, and lifelong follow-up.