When to Perform Radical Cystectomy versus Partial Cystectomy
Radical cystectomy is the standard treatment for muscle-invasive bladder cancer (cT2-cT4a), while partial cystectomy is reserved exclusively for highly selected patients with solitary cT2 lesions in anatomically favorable locations (typically the dome), without carcinoma in situ, and amenable to resection with adequate margins. 1
Indications for Radical Cystectomy
Radical cystectomy/cystoprostatectomy is indicated for:
- Primary treatment of cT2, cT3, and cT4a muscle-invasive disease 1
- Residual high-grade cT1 or muscle-invasive disease at re-resection in non-muscle invasive disease 1
- Highly select cT4b disease that responds to primary treatment 1
- Persistent tumor after adequate trial of intravesical agents in conjunction with endoscopic resection 2
- Tumor extension into prostatic ducts or prostatic substance 2
Critical Timing and Adjuvant Therapy
- Cystectomy should be performed within 3 months of diagnosis if no neoadjuvant therapy is given 1
- Neoadjuvant cisplatin-based combination chemotherapy should be administered before cystectomy for cT2-cT4a disease (Category 1 recommendation) 1, 3
- Bilateral pelvic lymphadenectomy is mandatory, including at minimum common, internal iliac, external iliac, and obturator nodes 1, 3
Indications for Partial Cystectomy
Partial cystectomy is appropriate only when ALL of the following strict criteria are met:
Anatomic Requirements
- Solitary cT2 muscle-invasive lesion in a location amenable to segmental resection with adequate margins 1
- Minimum 2 cm margin of noninvolved urothelium can be achieved 1
- Lesion typically located on the dome of the bladder 1, 4
- Not involving the trigone or bladder neck (relative contraindications) 1
Pathologic Requirements
- No carcinoma in situ as determined by random biopsies 1
- No multifocal disease confirmed by mapping biopsies or blue light cystoscopy 4
- Negative prostatic urethral biopsy 4
Surgical Requirements
- Neoadjuvant cisplatin-based combination chemotherapy should be administered 1
- Bilateral pelvic lymphadenectomy must be performed with the same nodal stations as radical cystectomy 1
- Ability to preserve continence and avoid significant reduction in bladder capacity 1
Outcomes and Surveillance Considerations
Partial Cystectomy Outcomes
- 5-year recurrence-free survival: 39-67% 4, 5
- 5-year cancer-specific survival: 62-84% 4
- 5-year overall survival: 45-70% 4
- 51% of patients have no tumor recurrence, 24% have superficial recurrence successfully treated, and 24% develop advanced disease 5
Critical Surveillance After Partial Cystectomy
- Cystoscopy and urinary cytology every 3 months for first 24 months, then every 6 months for years 3-4, then yearly for life 4
- Cross-sectional imaging every 3-6 months for first 2-3 years, then annually for 5 years 4
- Late recurrence can occur (documented at 41,44, and 138 months), making lifelong surveillance essential 5
Common Pitfalls and Caveats
Patient Selection Errors
- Partial cystectomy is appropriate in fewer than 5% of muscle-invasive bladder cancer cases 1
- Understaging is frequent (42% of patients are restaged after cystectomy), making clinical staging unreliable 3
- Higher pathological stage is associated with shorter recurrence-free survival (HR 3.4, p=0.04) 5
Technical Considerations
- If intraoperative findings preclude partial cystectomy, proceed immediately to radical cystectomy 1
- Ureteral reimplantation is not an absolute contraindication to partial cystectomy 1
- Partial cystectomy offers lower complication rates and shorter length of stay compared to radical cystectomy 4