What are the considerations and recommendations for a cystectomy with diversion in an adult patient over 50 years old with a history of bladder cancer or severe bladder dysfunction?

Cystectomy with Urinary Diversion: Evidence-Based Recommendations

Primary Recommendation

For adults over 50 with muscle-invasive bladder cancer, radical cystectomy with bilateral pelvic lymphadenectomy followed by urinary diversion is the standard definitive treatment, with neoadjuvant cisplatin-based chemotherapy strongly recommended for T2-T4a disease to improve survival. 1

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Surgical Approach and Extent

Standard Radical Cystectomy Technique

In men, remove the bladder, prostate, seminal vesicles, proximal vas deferens, and proximal urethra. 1

In women, remove the bladder, uterus, fallopian tubes, ovaries, anterior vaginal wall, and urethra. 1

• The surgery can be performed via open or robotic approach. 1
• Nerve-sparing procedures should be discussed with patients who have organ-confined disease without bladder neck, urethral, or prostatic involvement to preserve sexual function. 1

Mandatory Pelvic Lymph Node Dissection

At minimum, remove the external iliac, internal iliac, and obturator lymph nodes (standard lymphadenectomy). 1

• More extensive dissection including common iliac or lower para-aortic/paracaval nodes yields more nodes, increases detection of positive nodes, and is associated with better survival and lower pelvic recurrence rates. 1
• Patient factors that may preclude lymphadenectomy include severe scarring from previous treatments, advanced age with severe comorbidities, though these should be carefully weighed against oncologic benefit. 1

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Neoadjuvant Chemotherapy: Critical for Survival

Offer cisplatin-based neoadjuvant chemotherapy to all eligible patients with T2-T4a muscle-invasive disease before cystectomy. 1

• Neoadjuvant MVAC (methotrexate, vinblastine, doxorubicin, cisplatin) increases median survival from 46 to 77 months compared to surgery alone. 1
• Meta-analysis of 3,005 patients demonstrates 5% absolute improvement in 5-year overall survival and 9% improvement in disease-free survival. 1
• Neoadjuvant chemotherapy reduces residual disease rates from 38% to 15% without increasing perioperative morbidity or mortality. 1
• Common pitfall: Only 17% of eligible patients receive neoadjuvant chemotherapy even at academic centers, representing a significant missed opportunity. 1

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Urinary Diversion Selection Algorithm

First-Line Option: Orthotopic Neobladder

Orthotopic neobladder is the preferred diversion for appropriately selected patients, providing bladder function closest to native bladder. 2, 3, 4

Mandatory requirements for orthotopic diversion:

• Negative urethral margin on intraoperative frozen section. 1, 5
• Absence of carcinoma in situ (Tis) in prostatic ducts or positive urethral margin. 1
• Patient must have adequate manual dexterity and cognitive function for self-catheterization if needed. 2, 5
• Patient must be motivated and committed to neobladder training and management. 5

Expected outcomes:

• Increased risk of nighttime incontinence compared to native bladder. 1
• May require intermittent self-catheterization for urinary retention. 1
• Urethral recurrence rates are low at less than 4% in properly selected patients. 5

Important caveat: Chronologic age alone is NOT a contraindication; instead, evaluate comorbid conditions and functional status. 3

Second-Line Option: Continent Cutaneous Diversion

Consider continent cutaneous reservoir (continent pouch with abdominal wall drainage) when urethral involvement precludes orthotopic diversion but patient desires continence. 1, 4

• Requires obligate self-catheterization. 4
• Preserves body image by avoiding external appliance. 6, 4
• More technically demanding than ileal conduit. 4

Standard Alternative: Ileal Conduit

The ileal conduit remains the most commonly performed, fastest, easiest, and least complication-prone urinary diversion. 2, 4

Ideal for patients who:

• Would benefit from less morbid surgical procedure. 6, 4
• Cannot or will not perform self-catheterization. 6, 4
• Have significant comorbidities limiting operative time tolerance. 2
• Are elderly with limited life expectancy. 2

Critical preoperative step: All patients considering ileal conduit must meet with an enterostomal therapist before surgery to mark optimal stoma site. 1, 2

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Partial Cystectomy: Highly Selective Use Only

Partial cystectomy is appropriate in less than 5% of cases and should be reserved for solitary lesions on the bladder dome without carcinoma in situ elsewhere. 1

Specific criteria:

• Adequate margin of soft tissue and minimum 2 cm of uninvolved urothelium can be removed. 1
• No associated Tis in other urothelial areas. 1
• Lesions in trigone or bladder neck are relative contraindications. 1
• Ideal candidates include cancer in a diverticulum or patients with significant medical comorbidities precluding radical cystectomy. 1

Partial cystectomy is NOT considered the gold-standard surgical treatment of muscle-invasive bladder cancer. 1

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Perioperative Management Essentials

Patient Education and Preparation

All patients must receive detailed preoperative education about all three urinary diversion options (orthotopic, continent cutaneous, ileal conduit) unless specifically contraindicated. 1, 5

Patients must receive detailed teaching regarding urinary diversion care prior to hospital discharge. 1

• For neobladder or continent catheterizable diversions, verify patient possesses sufficient manual dexterity and willingness to catheterize postoperatively. 1, 2
• Even patients choosing neobladder should be marked for stoma site in case intraoperative findings necessitate ileal conduit. 1

Perioperative Optimization

Administer perioperative prophylactic antibiotics (second or third-generation cephalosporins) within 60 minutes of incision, with intraoperative redosing after 2 half-lives, and discontinue within 24 hours. 1, 2

Implement deep vein thrombosis prophylaxis due to high risk in this population. 2

• Enhanced recovery after surgery (ERAS) protocols are associated with decreased narcotic usage, lower postoperative ileus incidence, and shorter hospital stays. 1
• Ureteral stenting at time of surgery improves upper tract drainage, enhances bowel recovery, and reduces metabolic acidosis. 2

Critical Intraoperative Decision

For patients receiving orthotopic diversion, verify negative urethral margin on frozen section before proceeding with urethral anastomosis. 1, 5

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Common Pitfalls and How to Avoid Them

Understaging is frequent: 42% of patients are upstaged following cystectomy despite preoperative cystoscopy, examination under anesthesia, TURBT, and cross-sectional imaging. 1

Inadequate lymphadenectomy: Ensure at minimum a standard template (external iliac, internal iliac, obturator nodes); more extensive dissection improves outcomes. 1

Missed neoadjuvant chemotherapy opportunity: Despite level 1 evidence, only 17% of eligible patients receive neoadjuvant chemotherapy. 1

Inadequate patient education: Failure to discuss all diversion options and provide enterostomal therapy consultation leads to poor postoperative adjustment. 1, 2

Inappropriate patient selection for orthotopic diversion: Proceeding without confirming negative urethral margin or adequate patient functional capacity leads to poor outcomes. 5, 3

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Long-Term Surveillance

Monitor annually for vitamin B12 deficiency if continent diversion was created. 1

Perform urethral wash cytology every 6-12 months, particularly if Tis was found in bladder or prostatic urethra. 1

Obtain baseline postoperative CT scan to define revised pelvic anatomy, then repeat every 3-6 months for 2 years if high recurrence risk, then annually. 1