Radical cystectomy

Radical cystectomy is a standard treatment option for stage II and stage III bladder cancer, and its effectiveness at prolonging survival increases if it is preceded by cisplatin-based multiagent chemotherapy.[1-4] Radical cystectomy is accompanied by pelvic lymph node dissection and includes removal of the bladder, perivesical tissues, prostate, and seminal vesicles in men and removal of the uterus, fallopian tubes, ovaries, anterior vaginal wall, and urethra in women.[5-8] Studies of outcomes after radical cystectomy report increased survival in patients who had more, rather than fewer, lymph nodes resected. It is unknown whether this represents a therapeutic benefit of resecting additional nodes or stage migration.[9] There are no randomized controlled trials evaluating the therapeutic benefit of lymph node dissection in this setting.

Radical cystectomy is a major operation with a perioperative mortality rate of 2% to 3% when performed at centers of excellence.[6-8] Postoperative complications include ileus. Most men have erectile dysfunction after radical cystectomy. Sexual dysfunction after this operation is also common in women.[10-12]

One study of 27 women who underwent radical cystectomy reported diminished ability to have orgasm in 45%, decreased lubrication in 41%, decreased sexual desire in 37%, and pain with vaginal intercourse in 22%. Fewer than one-half were able to have successful vaginal intercourse and most reported decreased satisfaction with their sexual lives after surgery.[12] Studies suggest that radical cystectomy with preservation of sexual function can be performed in some men. In addition, new forms of urinary diversion can obviate the need for an external urinary appliance.[13-16]

In a retrospective analysis from a single institution, older patients (≥70 years) in good general health were found to have clinical and functional results after radical cystectomy similar to younger patients.[17]

After radical cystectomy, however, an approximate 30% to 40% risk of recurrence still exists for patients with muscle-invasive disease, even at centers of excellence.[6-8] The 5-year overall survival (OS) rates range from 50% to 60%, but these rates vary by cancer stage.[4] The addition of preoperative radiation therapy to radical cystectomy did not result in any survival advantage when compared with radical cystectomy alone in a prospective randomized trial.[18]