(i) Radical cystectomy Radical cystectomy with simultaneous pelvic lymph node dissection is the standard treatment for muscle invasive bladder cancer and is an effective treatment to improve the survival rate of patients with invasive bladder cancer and to avoid local recurrence and distant metastasis. This procedure needs to be selected according to the pathological type, stage, grading of the tumor, the site of tumor occurrence, and the presence or absence of involvement of adjacent organs, combined with the patient’s general condition. The literature reports that the possibility of pelvic lymph node metastasis in patients with invasive bladder cancer is 30% to 40%. The scope of lymph node dissection should be decided according to the extent of tumor, pathological type, depth of infiltration and patient’s condition.
1. Indications for radical cystectomy: The basic surgical indications for radical cystectomy are T2-T, N0-x, M0 invasive bladder cancer, other indications include high-risk non-muscle invasive bladder cancer T1G3 tumors, Tis where BCG treatment is ineffective, recurrent non-muscle invasive bladder cancer, extensive papillary lesions that cannot be controlled by conservative treatment, etc., and preservation of the bladder Those with ineffective non-surgical treatment or tumor recurrence after surgery and non-uroepithelial carcinoma of the bladder.
The above surgical indications can be used independently or in combination. However, those with serious comorbidities (heart, lung, liver, brain, kidney, etc.) that cannot tolerate radical cystectomy should be excluded.
2. Matters related to radical cystectomy: The scope of radical cystectomy includes the bladder and surrounding fatty tissue, the distal ureter, and pelvic lymph node dissection; men should include the prostate and seminal vesicles, and women should include the uterus, adnexa and anterior vaginal wall. If the tumor involves the urethra of the prostate in men or the bladder neck in women, total urethrectomy should be considered. In China, some scholars believe that if the tumor involves the prostate, bladder neck, triangle, or multiple tumors or carcinoma in situ, total urethrectomy should be performed. It has also been reported that the distal urethral cut edge is sent for rapid pathological examination to clarify whether there is tumor involvement to decide whether urethrectomy should be performed at the same time. In younger male patients with normal sexual function, intraoperative protection of the peripheral neurovascular can prevent sexual function in more than half of the patients, but close postoperative follow-up of tumor recurrence and PSA changes is required, and long-term patient regression needs to be further confirmed.
The current radical cystectomy approach can be divided into open surgery and laparoscopic surgery. Compared with open surgery, laparoscopic surgery has the characteristics of less blood loss, less postoperative pain and faster recovery, but the operation time is not significantly better than that of open surgery, and laparoscopic surgery requires higher operator skills. Recently, robot-assisted laparoscopic radical cystectomy allows for more precise and rapid surgery with reduced bleeding.
Lymph node dissection is not only a therapeutic tool, but also provides important information for prognostic determination. There are currently three main types of lymph node dissection: local lymph node dissection, conventional lymph node dissection, and expanded lymph node dissection. Local lymph node dissection only removes lymph nodes and fatty tissue in the foramen ovale; extended lymph node dissection includes the aortic bifurcation and common iliac vessels (proximal), genitofemoral nerve (lateral), spinocerebral vein and Cloquet’s lymph node (distal), internal iliac vessels (posterior), including the foramen ovale, both sides of the anterior sciatic and presacral lymph nodes, and dissection reaches up to the level of the inferior mesenteric artery; conventional lymph node dissection The rest is the same as the expanded lymph node dissection. It has been suggested that extended lymph node dissection is beneficial and may improve the 5-year survival rate after surgery, but this approach remains controversial. The proportion of positive lymph nodes to intraoperative resected lymph nodes (lymph node density) may be one of the important prognostic indicators for patients at high risk for positive lymph nodes.
3, Survival rate of radical cystectomy: With the improvement of surgical techniques and follow-up methods, the survival rate of patients with invasive bladder cancer has improved considerably [24]. The perioperative mortality rate for radical cystectomy is 1,8 9/6 to 2,5%, and the main causes of death are cardiovascular complications, sepsis, pulmonary embolism, liver failure, and hemorrhage. The overall 5-year survival rate of patients is 54,5% to 68%, and the 10-year survival rate is 66%. If the lymph nodes were negative, the 5-year and 10-year survival rates were 89% and 78% for stage T2, 87% and 76% for stage T3a, 62% and 61% for stage T3b, and 50% and 45% for stage T4, respectively. In contrast, the 5- and 10-year survival rates for patients with positive lymph nodes were only 35% and 34%.
(ii) Bladder-preserving surgery For patients with invasive bladder cancer who are physically unable to tolerate radical cystectomy or who do not wish to undergo radical cystectomy, bladder-preserving surgery may be considered. Patients undergoing bladder-sparing surgery need to be carefully selected, the nature of the tumor and the depth of infiltration should be evaluated, and the correct bladder-sparing surgery should be selected, and postoperative radiation therapy and chemotherapy should be supplemented with close postoperative follow-up.
There are two types of bladder preservation surgery for invasive bladder cancer: transurethral resection of bladder tumor (TURBT) and partial cystectomy. For most patients with bladder-preserving invasive bladder cancer, the tumor can be removed by the transurethral route. However, partial cystectomy should be considered for some patients: those with tumors located within the bladder diverticulum, around the ureteral opening or in the blind area of the transurethral surgical operation, those with severe urethral strictures and those who cannot tolerate the amputation position. Recently, it has been suggested that for patients with stage T2, a repeat TUR-BT within 4-6 weeks after the initial TUR-BT combined with chemotherapy and radiotherapy can help preserve the bladder.
The 5-year survival rate for patients with invasive bladder cancer who undergo bladder preservation surgery is 58.5%-69%, the 3-year survival rate for stage T2 is 61.2%, and the 3-year survival rate for stage T3 is 49.1%.
Recommendation: 1. Radical cystectomy is preferred for muscle-infiltrating uroepithelial carcinoma of bladder, and lymph node dissection is performed at the same time.
2.The decision of whether to perform urethrectomy can be made according to the specimen margin.
3.Surgery to preserve the bladder in special cases must be carefully selected and should be supplemented with radiotherapy and chemotherapy, and closely followed up.