Partial cystectomy Yair Lotan, David A Swanson, Arthur I Sagalowsky

Introduction Bladder cancer is the fourth most common cancer in men (6%) and the tenth most common cancer in women (2%), accounting in men for 3% of cancer deaths in the year 2004 in the US.1 On average, 15% to 30% of all patients with bladder cancer are diagnosed with muscle-invasive tumors and radical cystectomy represents the gold standard therapy.2 In an effort to reduce the morbidity of radical cystectomy, attempts have been made to utilize bladder-preserving therapy such as aggressive transurethral resection (TUR) followed by combined chemotherapy/radiotherapy or partial cystectomy. The advantage of partial cystectomy over TUR is that it allows for complete pathologic staging of the tumor and pelvic lymph nodes with preservation of normal bladder and sexual function. The popularity of this procedure peaked in the 1950s and 1960s, but reports in the 1970s emphasized the problems, particularly high recurrence rates. Unfortunately, partial cystectomy virtually disappeared thereafter, despite the fact that good results are possible, even with T2 and T3 tumors. Many of the recurrences were due, not to incomplete removal of tumor, but to the appearance of new tumors, suggesting that patient selection is critically important to the potential for success of partial cystectomy.3-7 Although partial cystectomy can be performed when adequate transurethral biopsy cannot be confidently performed because of location or other considerations, and it may be appropriate as palliative therapy in highly selected patients instead of radical cystectomy, our discussion in this chapter will focus on its potential to provide definitive therapy for transitional carcinoma of the bladder. Indications As stated, the most important factor in performing a successful partial cystectomy is proper patient selection. Bladder cancer is an aggressive disease that places the entire urothelium at risk. Once it metastasizes, treatment options such as radical cystectomy, radiotherapy, and systemic chemotherapy do not significantly change the overall survival rates.8,9 Accordingly, the best opportunity to cure patients of their disease is offering the appropriate treatment at the start of therapy. In fact, a review of the literature concluded that only 5.8% to 18.9% of patients with muscle-invasive bladder cancer were suited for partial cystectomy, and that would be considered too permissive by many.10 Another study evaluating initial management of all stages of bladder cancer in Canada found that only 3.5% of cases underwent partial cystectomy or open excision as their initial treatment.11 At The University of Texas M.D. Anderson Cancer Center,

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