The Role of Surgery in the Potentially Curative Treatment of Bladder Carcinoma

Summary

The surgical procedures that carry the potential for cure for the patient with invasive bladder carcinoma are transurethral resection, segmental resection, various types of cystectomy, and, occasionally, cystostomy with suprapubic fulguration. The success of transurethral resection depends entirely on local ablation, and the reported survival rates suggest that anything more than scant muscle invasion is associated with marked decrease in survival. Segmental resection of invasive tumors suitably placed on the bladder wall are reported to give survival rates equivalent to those for cystectomy. The latter procedure has, in addition to the prevention of further bladder carcinoma, at least the theoretical advantage of removal of the tumor and associated lymphatics. Radical cystectomy, which implies pelvic lymphadenectomy as well, seems to offer a small but definable improvement in survival when a limited number of pelvic nodes are involved. This procedure has been linked to preoperative adjuvant radiotherapy in recent years, and comparisons of survival with historical controls suggest improvement over cystectomy alone. This improvement may be associated with ill-defined factors such as better patient selection, better patient care, and better operative techniques as well as adjuvant radiotherapy. One group of patients that seems singularly advantaged is that in which the adjuvant radiotherapy has left the bladder tumor free. A randomized, controlled study demonstrates improved but not statistically significant survival for the entire group of preoperatively irradiated patients, but analyses support the above: down-staging to absence of tumor provides the greatest success rate. Failures are due to the subsequent appearance of distant metastases in the majority of patients. The lungs and bones seem to be favored sites for the lesions. The evidence suggests that invasion with lymphatic and vascular permeation provides for dissemination of tumor in the majority of patients; thus, invasive bladder carcinoma should be perceived as a systemic disease, and new treatment strategies, including effective systemic chemotherapy and/or immunotherapy, should be given high priority for development.