Technical Advances in Bladder Cancer Patient Care: Progress or Promise?

Abstract

The radical resection of the bladder and perivesical tissues and regional pelvic lymph node dissection (PLND) have emerged as the most effective local-regional therapy for invasive bladder cancer (BCa). The techniques for radical cystectomy (RC) and the associated PLND have been refined over many decades, taking into account the recognized pathways for progression of invasive BCa. RC and PLND alone will cure the majority of patients with localized invasive disease as well as a significant minority of patients with regionally metastatic disease. Following removal of the native bladder, all patients undergoing RC will also require some form of simultaneous reconstruction of the urinary tract, adding to the technical challenges of the procedure and to patient recovery. BCa is a disease of the elderly, with approximately two-thirds of all cases occurring in patients aged >65. Additionally, transitional cell cancer of the bladder is a smoking-related tumor typically arising after many years of tobacco exposure. The procedure is unquestionably a formidable undertaking for patients, many of whom are now pretreated with systemic chemotherapy prior to surgery. The combination of advanced age at diagnosis and significant prior smoking exposure contributes to the extensive list of comorbidities exhibited by most BCa patients presenting in need of RC. Performing extensive pelvic surgery with reconstruction of the urinary tract in an older, sicker population of patients largely explains the observed perioperative morbidity and mortality. Although RC and urinary diversion can be performed safely in the vast majority of patients, 2–2.5% perioperative mortality has been reported [1,2]. Overall morbidity associated with open RC, PLND, and urinary diversion ranges from 28% to 64%, depending on the method of reporting, the definition of complications, and the extent of the postoperative time period evaluated [1,3]. In a series of 1142 patients undergoing open RC, PLND, and urinary diversion at Memorial Sloan-Kettering Cancer Center, an aggressive prospective effort to record all complications out to 90 d after surgery revealed that 64% of patients experienced some degree of morbidity [1]. The system for collecting complications included the use of an established five-grade modification of the original Clavien system with further subclassification into 11 different categories. High-grade complications (defined as grade 3–5) were experienced by 8.3% of patients. Overall, 87% of all complications were considered grade 1–2, and the 90-d mortality observed was 2.7%. Gastrointestinal-related complications (most commonly ileus) were most prevalent, followed by infectious and wound-related issues, all of which contributed to the 9-d median length of stay for this series. The well-documented morbidity and mortality in the open RC literature has firmly established our current perioperative outcomes in the BCa patient population. Fueled by great expectations and many recent technological advances, minimally invasive surgery (MIS) has rapidly been incorporated into the care of the oncology patient. Most tumor sites now have MIS techniques described for their management. The acceptance of this technology rests on the expectations of clinicians and patients that ‘‘less invasive’’ surgery will reduce perioperative complications and improve patient recovery while maintaining the same level of oncologic efficacy established with open techniques. MIS techniques for performing RC were initiated with the desire to reduce the level of morbidity associated with the open procedure. The initial