The Role of Partial Cystectomy in the Treatment of Muscle-Invasive Bladder Cancer

Abstract

Partial cystectomy has been widely performed in the treatment of muscle-invasive bladder cancer in the 1960s and 70s. During the 1970s and 80s a more aggressive surgical approach was advocated by urologists. However, major complications occurred in 4–25% of patients undergoing radical cystectomy and urinary diversion. The overall survival in patients managed by radical cystectomy has increased during the last decades, but disease-free survival remains the same. This procedure allows excellent loco-regional tumor control, but not changes in the timing of distant metastases and in the failure to control the disease. Recently, multimodal strategies in sparing bladder surgery have been proposed. Neoadjuvant chemotherapy, with or without irradiation, allows bladder sparing surgery in selected patients. A literature review demonstrates a later recurrence in the preserved bladder ranging from 40–75%. One-third of these recurrences required cystectomy and 15–20% of cases with bladder preservation experienced disease progression and died of cancer within 2 yrs. Only 40 and 20% of T2-T3 bladder cancer patients are alive and disease-free at 5 and 10 yrs of follow-up, respectively. In our experience, in selected patients, disease-free survival, overall survival, time to progression and final bladder preservation rate was higher compared to other patients. Bladder sparing in selected patients, i.e. single non-recurrent neoplasm, favorable site, no prostatic or urethral involvement, complete response to neoadjuvant chemotherapy, no P53 overexpression, no previous BCG-failure, is a feasible approach. Cystectomy, possibly with neobladder tailoring, is currently, the standard therapy for muscle-invasive bladder cancer. A better understanding of bladder tumor disease is necessary to choose the optimal treatment and to control each individual patient.