Partial Cystectomy 

Updated: Apr 03, 2019
Author: E Jason Abel, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS 

Overview

Background

Definition

Partial or segmental cystectomy is a bladder-preserving treatment that involves full-thickness surgical removal of the bladder tumor and surrounding bladder wall.[1]

Key points

See the list below:

  • Only 5.8-18.9% of patients with muscle-invasive bladder cancer are suitable candidates for partial cystectomy.

  • Partial cystectomy is indicated in the patient with a normally functioning bladder with good capacity and a solitary tumor located where a 1-cm to 2-cm resection margin is possible.

  • For high-risk tumors, a multimodal approach with neoadjuvant or adjuvant chemotherapy and possible radiotherapy may be needed.

  • Absolute contraindications include carcinoma in situ (CIS) elsewhere in the bladder and multifocal tumors.

  • After surgery, ongoing surveillance, including imaging, cystoscopy, and cytology, is important because the local recurrence rate is high (37-78%).

  • Patients who have undergone partial cystectomy for bladder cancer should have cystoscopy and urinary cytologic examination every 3 months for at least 2 years. Regular CT scans of the pelvis and abdomen are recommended in the first several years of follow-up.

  • With proper patient selection, long-term, bladder-sparing survival rates with partial cystectomy range from 35-70%.

Partial cystectomy is used to treat both malignant and benign conditions of the bladder. Its primary malignant indication is for solitary, primary, muscle-invasive, or high-grade bladder cancer that does not involve specific regions of the bladder such as the bladder trigone, vesical neck, or posterior urethra and that can be resected with adequate surgical margins (1-2 cm). The classically described indication for partial cystectomy is for the removal of an adenocarcinoma or urachal carcinoma that develops in the dome of the bladder.

A better understanding of the natural history of urothelial carcinoma (transitional cell carcinoma) of the bladder has led to more stringent selection criteria for partial cystectomy; consequently, this procedure is being performed less frequently for malignant conditions (see Table 1). For example, the ideal clinical scenario would be if the bladder tumor was in an easily accessible location in the bladder, small in size (< 2cm) and no tumor(s) existed in the rest of the bladder. Partial cystectomy should only be considered if the cancer has not left its site of origin.

Despite advances in transurethral surgery for bladder tumors, some instances exist when the tumor cannot be completely resected and partial cystectomy is not only indicated but the most definitive procedure. For example, the morbidly obese patient with a superficial bladder tumor located in the upper aspect of the posterior bladder wall or dome might require a partial cystectomy because the surgeon was unable to reach the tumor transurethrally. Other indications for partial cystectomy include a need for adequate biopsy of radiation-induced ulcerations, the presence of a tumor in a bladder diverticulum, patient choice, palliation of severe local symptoms, preservation of native bladder function and continence, and poor surgical risk for more aggressive procedures such as radical cystectomy.

A few benign conditions of the bladder can be managed with partial cystectomy. These include resection of bladder diverticula, colovesical fistula repair, vesicovaginal fistula repair and less commonly for cavernous hemangiomas, ulcerative interstitial cystitis, and localized endometriosis of the bladder.

Partial cystectomy has certain advantages over radical cystectomy, such as preserving a functionally continent native urinary reservoir and sparing potency in males. In addition, because a separate urinary diversion procedure (as is necessary in radical cystectomy) is not performed, some surgeons view partial cystectomy as a less morbid operation, suited for high-risk patients and palliative situations. The main disadvantage of partial cystectomy lies in the historically high local recurrence rates of bladder cancer, with only part of a globally diseased urothelium addressed. Although partial cystectomy plays a limited role in the treatment of bladder cancer, in properly selected patients, similar oncologic results can be achieved as seen in patients treated with radical cystectomy. This review focuses on the current applications and indications for partial cystectomy, with an emphasis on the treatment of bladder cancer.

History of the Procedure

Historically, this operation has been performed since the 19th century, when it was thought that many patients with bladder cancer would be ideal candidates. Little was known about how bladder cancer may affect the entire bladder despite the appearance of a solitary tumor. The widespread use of this operation in the mid-1950s led to high local recurrence rates from 37% to 78%.[2, 3] The advent and technical improvements of transurethral resection (TUR) have made it possible to initially resect most bladder tumors.

Table 1. Proportion of Patients With Bladder Cancer Treated With Partial Cystectomy (Open Table in a new window)

Source

Total Patients With Bladder Cancer

Patients Treated With Partial Cystectomy (%)

Utz et al (1973)

3454

199 (5.8)

Brannan et al (1978)

551

49 (7.1)

Faysal and Freiha (1979)

859

117 (13.6)

Merrell et al (1979)

585

54 (9.2)

Ojeda and Johnson (1983)

397

23 (5.8)

Jardin and Vallencien (1984)

475

90 (18.9)

Hayter et al (2000)

20,822

729 (3.5)

Holzbeierlein et al (2004)

935

58 (6.2)

Epidemiology

Frequency

Bladder cancer is the sixth most common type of cancer diagnosed in the United States, representing 4.4% of all new cancer cases. Based on the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Cancer Statistics Review, an estimated 72,570 new cases of bladder cancer were diagnosed in 2013 and 15,210 persons were estimated to die from the disease.

Currently, the overall male-to-female patient ratio is approximately 4:1.

The ratio of bladder cancer in white Americans compared with African Americans is 1.5-2.1:1.

The median age of patients is 73 years at time of diagnosis, with incidence and mortality per pathologic grade increasing as a function of age.

Since 1950, the incidence of bladder cancer has increased by 50%, but the overall mortality rate (primarily in men) has decreased by 33%. More than 560,000 people in the United States are currently living with bladder cancer.

Etiology

The etiology of bladder cancer, a frequent indication for bladder resection, is unknown. Postulated theories include environmental carcinogens (eg, chemicals, ultraviolet light, radiation), aberration of normal cell growth regulation (eg, oncogene induction, suppressor gene negation), and abnormalities in the genetic composition of malignant cells.

Chemical exposures that may increase the risk of bladder cancer include aromatic amines, dietary nitrites, and nitrates. These include aniline dyes (eg, 2-naphthylamine, 4-aminobiphenyl, 4-nitrobiphenyl, 4-4-diaminobiphenyl [benzidine], 2-amino-1-naphthol), combustion gases, coal soot, chlorinated aliphatic hydrocarbons, and acrolein dyes. Smoking is associated with an up to 4-fold increase in the risk of bladder cancer. Other implicated factors include coffee and tea, phenacetin (an analgesic), chronic cystitis, the presence of chronic indwelling catheters, bladder calculi, pelvic irradiation, and exposure to cyclophosphamide. Schistosomiasis of the urinary bladder is associated with a higher incidence of squamous cell carcinoma. Currently, no evidence links bladder cancer to heredity.

Recent investigations have addressed the arsenic content of drinking water. International studies in Taiwan, Chile, and Argentina have suggested that as little as 10.1 mcg/L of arsenic in drinking water increases the risk.[4, 5] In Taiwan, population studies of 8102 residents found that concentrations of 10-50, 50-100, and more than 100 mcg/L of arsenic in drinking water (compared with levels < 10 mcg/L) increase the relative risk of developing transitional cell carcinoma to 1.9, 8.2, and 15.3, respectively.[4] In Chile, studies of arsenic levels from 100-570 mcg/L revealed an elevated standardized mortality ratio of bladder cancer of 6 in men and 8.2 in women.[5] In the United States, it is estimated that 350,000 persons are exposed to arsenic levels of more than 50 mcg/L and that 2.5 million are exposed to levels higher than 25 mcg/L. In one study, the relative risk estimate for an average level of arsenic in US drinking water was 1 in 1000 persons.[6]

Oncogenes and tumor suppressor genes implicated in bladder cancer include TP53, retinoblastoma gene (Rb), p15, and p16. Alterations in TP53, a normal tumor suppressor gene found on chromosome 17p which controls apoptosis, lead to more aggressive bladder cancers. Ongoing studies are exploring the clinical implications of these tumor suppressor genes. Currently, conventional staging and grading are sufficient.

The tumor suppressor gene, Rb, is found on chromosome 13q. A mutated Rb gene or phosphorylated Rb gene leads to dissociation of its product protein, pRB, from the normally complexed transcription factor, E2F. Dissociated E2F drives the transition from G1 to S phase in cellular mitosis.

Two more protein regulators encoded on chromosome 9p, p15 and p16, inhibit nuclear cyclin-dependent kinases from phosphorylating pRB. When p15 and p16 mutate, they can no longer prevent phosphorylation of pRB, resulting in dissociation of the pRB-E2F complex, and free E2F is allowed to stimulate the cell's G1- to S-phase proliferation. Very aggressive high-grade bladder tumors have been associated with alterations in TP53. Mutations in Rb, p15, and p16 have been associated with low-grade superficial tumors.

Bladder cancer often behaves as a field disease; the entire urothelium, from the renal pelvis to the urethra, is susceptible to malignant transformation. Urothelial carcinoma cells may also have the ability to migrate and implant at different sites along the urothelium.

Presentation

A thorough history should be obtained, and a thorough physical examination should be performed. In patients with bladder cancer, the most common presenting symptom is painless hematuria (85%). Hematuria is often intermittent; therefore, a single urinalysis finding may not be significant. Bladder irritability that manifests as urinary frequency, urgency, and dysuria is the second most common symptom. These symptoms rarely occur without hematuria (microscopic or gross). Flank pain due to ureteral obstruction, lower-extremity edema, and pelvic masses are other presenting symptoms. Symptoms of advanced disease, such as weight loss and abdominal or bone pain, are rare because patients usually seek medical attention before these develop.

Indications

Indications for partial cystectomy in malignancy

Urothelial carcinoma (also called transitional cell carcinoma) accounts for the vast majority of bladder cancer in the United States. However, in some countries, squamous cell carcinoma is the dominant subtype of bladder cancer because of chronic infection with Schistosomiasis hematobium.

Partial cystectomy for urothelial carcinoma is recommended in properly selected cases. Suggested selection criteria include the following:

  • No history of multifocal bladder cancer (negative random bladder biopsies)

  • No evidence of metastatic disease

  • Absence of multiple lesions (including carcinoma in situ)

  • Solitary, high grade muscle-invasive tumor located in a position that is amenable to wide resection (ideally achieving 1-2 cm margins)

  • Tumor located away from the ureteral orifices (although resection and re-implantation is possible, but associated with poorer prognosis) and not involving bladder neck or prostate

  • Expectation that the residual postoperative bladder will have adequate capacity and compliance to ensure functionality

As a result of such strict criteria, relatively few patients with muscle invasive bladder cancer are candidates for bladder-sparing surgery.[7] The most common lesions amenable to partial cystectomy are high-grade tumors located in the lateral walls or dome of the bladder.

Cancer in bladder diverticula

Diverticular cancers comprise 1.5-10% of all bladder cancers and are more likely to penetrate the bladder wall because of the relatively thin nature of the wall and its lack of thick muscular layers. Transurethral resection of the tumor may be an option; however, inadvertent perforation is possible because of the paucity of muscle fibers in the diverticulum, which may lead to dissemination of urothelial cancer cells. Urothelial carcinoma in a bladder diverticulum is a common reason for performing partial cystectomy. Historical series suggested a high rate of recurrence and poor prognosis for diverticular tumors, but more contemporary data suggest that complete tumor resection with partial cystectomy results in 5-year disease-specific survival rates of around 70%.[8]

Partial cystectomy for cancers other than urothelial carcinoma

Squamous cell carcinoma has a poor prognosis and is not responsive to chemotherapy and radiation. Although some series describe the feasibility of partial cystectomy, this approach has not been studied extensively because of its low prevalence in the western world (3-7% in the United States).[9] In contrast, 75% of all bladder cancers in Egypt are of squamous cell derivation because of S. hematobium infection. In some reports, bilharzial bladder cancer (bladder cancer associated with Schistosomiasis) has a similar prognosis to transitional cell cancer when compared stage-for-stage, but whether this is true for nonbilharzial squamous cell carcinoma is unclear.

Primary adenocarcinoma of the bladder may be treated with partial cystectomy in select cases. Urachal lesions, which represent 20-40% of all primary bladder adenocarcinomas, are thought to arise from residual transitional cells that line the urachal remnant in the dome of the bladder. Historically, the overall, 5-year survival rate associated with urachal adenocarcinoma has been poor (6-15%).

However, recent evidence has shown that extended partial cystectomy with removal of the bladder segment, posterior rectus fascia, peritoneum, and umbilicus offers the best chance for survival. In a study by Dandekar et al, the 5-year survival rate after partial cystectomy for urachal adenocarcinoma was 56.3%.[10] Herr found that contained urachal adenocarcinomas that were completely resected using extended partial cystectomy had a favorable disease-free rate (77%).[11] Following partial cystectomy, cure rates of well-differentiated urachal adenocarcinomas have been reported to approach 100%.

Rhabdomyosarcomas of the bladder comprise 17-50% of all genitourinary rhabdomyosarcomas. These patients have also been successfully treated with partial cystectomy as an alternative to radical cystectomy or chemotherapy. Disease-free survival rates have been reported as high as 78.5% with 2- to 16-year follow-up after partial cystectomy with or without neoadjuvant chemotherapy and radiation. Most of these patients were able to retain functional bladders with minimal lower urinary tract symptoms.[12]

Pheochromocytoma of the bladder is a rare neoplasm, accounting for less than 1% of all bladder tumors. Pheochromocytoma is a tumor of neuroendocrine origin that tends to be functional. Typical presenting symptoms include hematuria and symptoms related to catecholamine secretion, including paroxysmal hypertension and micturition-related headache, palpitations, and syncope. In a recent systematic review, Beilan et al reported that partial cystectomy was the primary treatment for approximately 70% of these tumors, with good symptomatic control and low morbidity. Irrespective of treatment, at a mean follow-up of 35 months, 14.2% had disease recurrence, 9.4% had metastasis, and 56.6% had no evidence of disease. Of note, surgical treatment (whether partial or radical cystectomy) is rarely curative if the disease is metastatic.[13]

Though primarily described in case reports, partial cystectomy has also been used in the treatment of bladder leiomyosarcoma, a rare but aggressive tumor. As with most patients undergoing partal cystectomy, these patients must be followed closely for recurrence or metastasis.[14]

Rectal, colon, prostate, uterus, cervix, or ovarian cancers that are locally advanced can be treated with partial cystectomy in selected cases, although pelvic exenteration may be required. A local recurrence rate of 17% and a 3-year survival rate of 39-74% has been reported with negative surgical margins.[15, 16, 61]

Benign conditions

Nonmalignant conditions of the bladder can also be managed with partial cystectomy. These conditions include bladder diverticula, cystic hydatid disease, cavernous hemangiomas, paraganglioma, leiomyomas, refractory interstitial cystitis, colovesical fistula, vesicovaginal fistula and endometriosis of the bladder.[17, 18]

Relevant Anatomy

The adult bladder is located in the anterior pelvis and is enveloped by extraperitoneal fat and connective tissue. It is separated from the pubic symphysis by an anterior prevesical space known as the retropubic space (of Retzius). The dome of the bladder is covered by peritoneum, and the bladder neck is fixed to neighboring structures by reflections of the pelvic fascia and by true ligaments of the pelvis.

The body of the bladder receives support from the external urethral sphincter muscle and the perineal membrane inferiorly and the obturator internus muscles laterally (see the image below).

Gross anatomy of the bladder. Gross anatomy of the bladder.

For more information about the relevant anatomy, see Bladder Anatomy. See also Female Urethra Anatomy, Female Urinary Organ Anatomy, Male Urethra Anatomy, and Male Urinary Organ Anatomy.

Contraindications

In patients with bladder cancer being considered for partial cystectomy, the entire urothelial tract from the kidneys to the urethra must be evaluated thoroughly. Prior to surgery, no other malignant disease should be anywhere in the urinary tract. The presence of multifocal disease or CIS is considered an absolute contraindication to partial cystectomy.

Other contraindications to partial cystectomy include the following:

  • Cellular atypia in random biopsy specimens

  • Prostatic invasion

  • Bladder neck or trigonal invasion

  • Presence of lymphovascular invasion in biopsy specimen

  • Inability to achieve adequate surgical margins

  • Prior radiation therapy

  • Inadequate bladder volume following resection

  • Evidence of metastatic disease

  • Poor preoperative performance status conveying high surgical risk

 

Workup

Laboratory Studies

Laboratory evaluation is performed for diagnosis and surgical preparation. Diagnostic laboratory evaluation for urothelial cancer may include urinalysis, cytology, and urinary tumor marker levels.

Urinalysis can be used to detect microscopic and gross hematuria.

Conventional microscopic urine cytology may reveal tumor cells. Limitations of cytology include human interpretation and varying sensitivity. Urine cytology relies on a trained pathologist for examination. Thus, low-grade well-differentiated urothelial tumor cells that appear cytologically normal can contribute to a false negative rate of approximately 20%. In addition, well-differentiated tumors are thought to be more cohesive; thus cytology has a lower yield. For these low-grade well-differentiated tumors, cytology sensitivity can range from 35-65%. Conversely, for high-grade urothelial tumors, cytology can be highly specific and have very few false negative results. The false positive rate for urine cytology is approximately 1-12%, mostly due to urothelial atypia, inflammation, or changes associated with chemotherapy or radiation.

The search for more sensitive and specific urothelial tumor markers with the goal of decreasing the need for invasive procedures has led to the development of multiple molecular biology–based tests. These include tests targeting bladder tumor antigen (BTA) (BTA stat test and BTA TRAK test), nuclear matrix protein 22 (NMP-22), fibrin degradation products (FDPs), telomerase, hyaluronic acid and hyaluronidase, cytokeratins, Lewis X antigen, vascular endothelial growth factor (VEGF), soluble Fas, and surviving. Other tests include microsatellite analyses, fluorescent in situ hybridization (FISH) assays, and immunocytologic tests. Of these numerous markers under investigation, 6 are currently FDA approved for bladder cancer surveillance, including BTA, ImmunoCyt, NMP-22, and FISH.

BTA assays are based on an antibody-detectable tumor marker that is used to detect BTA, a basement membrane antigen released when cancer cells are invading and breaking down basement membrane.

The BTA stat test is used to identify a protein similar to human complement factor H. Bladder cancer cells exhibit factor H, which interacts with complement C3b to inhibit the membrane attack complex and protects from immune attack.

NMP-22 is a nuclear matrix protein associated with DNA replication. Higher levels of NMP-22 have been found in the urine of patients with bladder cancer.

Bladder cancer cells produce vascular endothelial growth factor (VEGF) to support angiogenesis. VEGF increases vessel wall permeability of blood and plasma proteins, such as plasminogen, fibrinogen, and other clotting factors. Escaped factors result in a fibrin clot that is broken down into FDPs, which are then released into the urine. Increased urinary FDPs have been observed in patients with bladder cancer.

Multiple chromosome alterations have been associated with bladder cancer. FISH is a technique that involves fluorescently labeled DNA probes to assess cells for chromosomal alterations. FISH can be used to identify cells in the urine that have the chromosomal abnormalities consistent with urothelial cancer.

ImmunoCyt is an immunocytochemistry assay that utilizes a mixture of 3 monoclonal antibodies that can detect bladder tumor cells in the urine.

Although most of the new tumor markers yield a better sensitivity than conventional urinary cytology, their specificity is not as good as conventional methods. A recent comparison of the urinary markers reported a sensitivity of 12-85% for cytology, 53-78% for BTA-Stat, 51-100% for BTA-TRAK, 50-65% for NMP-22, 50-65% for ImmunoCyt, and 69-100% for FISH.

The same study reported specificity of 78-100% for cytology, 69-87% for BTA-Stat, 73-93% for BTA-Trak, 60-95% for NMP-22, 62-78% for ImmunoCyt, and 65-96% for FISH. Some promising investigational tests are underway for telomerase and BLCA-4. BLCA-4 is a nuclear matrix protein with early reports suggesting it may have both high sensitivity and specificity for bladder cancer (96% and 81-100%, respectively).[19, 20]

New urine tumor markers have shown potential for clinical utility in screening for bladder cancer and potentially even diagnosing or predicting recurrence, but their high cost and lower specificity place them in a limited role. Often they are used in combination with cytology to add diagnostic dimensions, but they have not replaced the need for cystoscopy.

The general preoperative medical condition of the patient and the possible presence of metastatic disease should be assessed.

Serum electrolytes help reveal any concomitant medical condition and assess renal function.

Blood reserves and bleeding risk can be determined by a complete blood count, prothrombin time, and activated partial thromboplastin time.

Presence of infection can be investigated with a white blood cell count, urinalysis, and culture.

Liver function tests and alkaline phosphatase may be suggestive of liver and bone metastases.

A baseline EKG can help identify underlying arrhythmias. For patients at high surgical risk, cardiac clearance may be warranted.

Imaging Studies

Routine studies performed for staging bladder cancer include chest radiography, intravenous pyelography (IVP), CT scan of the abdomen and pelvis, bone scan, and liver function tests. Mandatory preoperative imaging focuses on diagnosing and staging bladder cancer. Staging evaluation is a valuable tool to help determine the probability of extravesical disease.

Intravenous pyelography (IVP)

IVP enables evaluation of the collecting system of the kidneys, ureters, and bladder for any associated tumors for those patients with cystoscopic evidence of bladder cancer. Retrograde pyelography during cystoscopy can serve as an alternative to IVP.

Computed tomography (CT) urography

In recent years, CT urography has become a viable option to image the upper urinary tract. The sensitivity and specificity of CT scans surpass that of IVP. Furthermore, since many patients undergo CT scanning of the abdomen and pelvis for bladder cancer staging, the upper urinary tract can be evaluated in the same setting. CT urography has now become the test of choice for upper urinary tract evaluation in cancer.[21] Attention does need to be paid to the patient’s renal function, however. If intravenous contrast cannot be administered, retrograde pyelography can be used in combination with noncontrast axial imaging.

Magnetic resonance imaging (MRI)

Gadolinium-enhanced and gadolinium-excreted MRI scans have also been used to image the renal pelvis and ureters. Whether MRI is as accurate as IVP or retrograde pyelography is currently under investigation.

MRI generally does not provide more information than a CT scan. If bone metastases are suspected, MRI is more sensitive for detection than a CT scan or a radionucleotide bone scan. In addition, recently published studies using ferumoxtran-10-enhanced MRI suggest that this modality may improve lymph node staging in patients with bladder cancer.

Ureteroscopy

Ureteroscopy can help directly visualize and allow for biopsy of any suspicious lesion in the ureter or renal collecting system. However, ureteroscopy is invasive and is generally not performed without suspicion based on imaging studies.

Computed tomography

CT scanning of the abdomen and pelvis is more helpful in higher stage tumors to provide information regarding depth of tumor invasion, pelvic and paraortic lymphadenopathy, and the presence of liver or adrenal metastases. However, CT scans may fail to detect small nodal metastases in as many as 40% of patients. Liver metastases smaller than 2 cm in diameter are likewise difficult to detect. Also, CT scan is open to interpretation bias and can only estimate extravesical involvement.

CT scanning of the chest is the most sensitive test when evaluating for pulmonary metastases; however, many lesions smaller than 1 cm in diameter that may represent calcified granulomas are incidentally found. Plain radiography of the chest is less sensitive than CT for detection of metastases.

Bone scan

Bone scanning is not commonly performed in patients with normal alkaline phosphatase levels but may be performed as a baseline from which to compare future bone scans.

Positron emission tomography (PET)

Currently, PET scanning plays a limited role in the evaluation of bladder cancer. PET scanning has shown promise in detecting lymph node metastases or distant soft tissue metastases; however, because of the low urinary excretion of commonly used radioisotopes involved in PET scans, they are not yet helpful in the pelvic imaging of bladder cancer.

Diagnostic Procedures

Cystoscopy should be performed in all patients in whom bladder cancer is suggested.

Biopsy samples should be obtained from multiple sites (including the urethra) before partial cystectomy is considered.

Retrograde pyelography can be performed at the same time if findings from an IVP or CT urography are inconclusive to adequately evaluate the upper urinary tracts. With the advances in endoscopic equipment and fiberoptics, ureteroscopy has enabled direct visual inspection of any suspicious upper tract lesions, with the ability to obtain a biopsy specimen and even treat superficial lesions.

Selective saline wash cytologies or brush biopsies may be performed for further evaluation of the upper tract.

Transurethral resection with superficial and deep muscle biopsy is an important tool to evaluate the depth of invasion and tumor pathology. Bladder perforation and possible spillage of tumor cells outside of the bladder should be avoided. However, recent evidence suggests that, even with extraperitoneal or intraperitoneal perforation, the risk of extravesical tumor seeding is low.

Pelvic lymphadenectomy during cystectomy remains the most accurate way of identifying metastatic disease in the lymphatic system. Primary regions of lymphatic spread of bladder cancer include the perivesical, hypogastric, obturator, external iliac, and presacral nodes.

Histologic Findings

Primary solitary bladder cancer is a common indication for consideration of partial cystectomy. More than 90% of bladder cancers are urothelial carcinomas. Of these, 70% are papillary (see the image below), 10% are nodular, and 20% are mixed. When confined to the urothelium, the cancer is called carcinoma in situ. The other 10% of tumors are composed predominantly of squamous cell carcinomas (3-7%) and adenocarcinomas (2%). Secondary metastatic disease in the bladder accounts for less than 1% of all bladder cancers.

Papillary bladder tumors such as this one are typi Papillary bladder tumors such as this one are typically of low stage and grade (Ta-G1). Courtesy of Abbott and Vysis Inc.

Carcinoma in situ

Carcinoma in situ consists of poorly differentiated transitional cell carcinoma cells confined to the urothelium. Carcinoma in situ may be papillary or flat in architecture. These cells demonstrate poor intercellular cohesiveness; thus, urine cytopathology is a very sensitive test. Carcinoma in situ may be present in more than 25% of patients with high-grade superficial tumors and, thus, can exist concurrently with cancer found elsewhere in the bladder. When found, partial cystectomy is contraindicated.

Urothelial carcinoma (transitional cell carcinoma)

At a consensus conference, pathologists of the WHO and ISUP preferred the name urothelial carcinoma to describe tumors formerly known as transitional cell carcinoma.[22] Histopathology is used to grade bladder cancer tumors. Although no uniform grading system exists, most grading systems are based on the degree of anaplasia of the tumor cells. Tumor grade strongly correlates with stage and prognosis. The most commonly accepted system[22] is presented below.

  • Papilloma (former grade 0) - Fewer than 7 epithelial cell layers and no abnormalities in histology, these tumors are considered benign

  • Papillary urothelial tumors of unknown malignant potential (former grade I) - Well-differentiated thin fibrovascular stalks with a thickened urothelium that contain more than 7 cell layers and exhibit slight anaplasia and pleomorphism; possible increased nuclear-to-cytoplasmic ratio and prominence of nuclear membrane; rare mitotic figures, some association with higher concurrent tumors

  • Low grade urothelial carcinoma (former grade II) - Moderately differentiated, wider fibrovascular core, greater cell disturbance with loss of cellular polarity, higher nuclear-to-cytoplasmic ratio, nuclear pleomorphism and prominent nucleoli, and more frequent mitotic figures

  • High grade urothelial carcinoma (former grade III) - Poorly differentiated, marked pleomorphism, high nuclear-to-cytoplasmic ratios, and frequent mitotic figures; cells that remain undifferentiated from basement membrane to surface

Squamous cell carcinoma

Histologically, squamous cell carcinomas are composed of keratinized islands that show various degrees of differentiation. Eccentric cellular aggregates known as squamous pearls also exist. Urinary cytopathology is less sensitive in detecting squamous cell carcinoma. Histologic tumor differentiation is less predictive of overall prognosis than it is for transitional cell carcinomas, although tumor stage shows a strong correlation with prognosis.

Adenocarcinoma

All histologic variants of enteric adenocarcinoma, including signet-ring and colloid variants, can be found in the bladder. Most adenocarcinomas are mucin-producing and are either papillary or solid in architecture. Signet-ring adenocarcinoma can produce linitis plastica of the bladder. Most adenocarcinomas are poorly differentiated and invasive upon presentation.

Staging

The American Joint Committee has designated staging based on the tumor, node, and metastases (TNM) classification.

  • The TNM system for the primary tumor (T) is as follows:

    • Stage TX - Primary tumor cannot be assessed

    • Stage T0 - No evidence of primary tumor

    • Stage Ta - Noninvasive papillary carcinoma

    • Stage Tis - Carcinoma in situ

    • Stage T1 - Invades subepithelial connective tissue

    • Stage T2a - Invades superficial muscle (inner half)

    • Stage T2b - Invades deep muscle (outer half)

    • Stage T3a - Microscopic invasion of perivesical tissue

    • Stage T3b - Macroscopic invasion of perivesical tissue

    • Stage T4a - Invades stroma of the prostate, uterus, and/or vagina

    • Stage T4b - Invades pelvic sidewall or abdominal wall

  • The following is the TNM system for the regional lymph nodes (N). Note that regional lymph nodes are in the pelvis; all others are considered distant lymph nodes.

    • Stage NX - Regional lymph nodes cannot be assessed

    • Stage N0 - No regional lymph node metastasis

    • Stage N1 - Metastasis to a single lymph node in the true pelvis

    • Stage N2 - Metastasis to 2 or more lymph nodes in the true pelvis

    • Stage N3 - Metastasis to lymph nodes that lie along the common iliac artery

  • The TNM system for distant metastasis (M) is as follows:

    • Stage MX - Distant metastasis cannot be assessed

    • Stage M0 - No distant metastasis

    • Stage M1 - Metastasis to distant lymph nodes, organs or tissues (i.e. bones. lungs or liver)

While overstaging is relatively uncommon, clinical understaging occurs in as many as 53% of patients.

 

Treatment

Medical Therapy

Bladder-sparing options other than partial cystectomy

In the United States, most young healthy patients with urothelial carcinoma are treated with radical cystectomy as the criterion standard treatment because of survival advantages seen in large series.[23]

Several other studies have been published using treatment protocols involving systemic chemotherapy or external beam radiation (XRT). Multimodality bladder-sparing therapy usually includes complete transurethral resection followed by induction chemotherapy/radiation, repeat urological evaluation (biopsies or repeat transurethral resection), and, afterwards, consolidation chemotherapy/radiation. Salvage cystectomy is offered to patients without response to induction therapy or if recurrence is detected.

Table 2. Options Other than Partial Cystectomy (Open Table in a new window)

Study

Number of Patients

Induction Therapy

% Complete Response

Consolidation Therapy

% Overall Survival (years)

% Overall Survival with Bladder Intact (years)

Housset et al

120

Bifractionated XRT + concurrent cisplatin + 5-fluorouracil

77

Bifractionated XRT + concurrent 5-fluorouracil + cisplatin

63 (5)

 

...

Sauer et al

184

45-54 Gy XRT + concurrent cisplatin or carboplatin

80

None

56 (5)

41 (5)

Fellin et al

56

2 cycles MCVa, 40 Gy XRT + concurrent cisplatin

50

24 Gy XRT + concurrent cisplatin

55 (5)

41 (5)

Tester et al

49

40 Gy XRT + concurrent cisplatin

66

24 Gy XRT + concurrent cisplatin

60 (4)

42 (4)

Tester et al

91

2 cycles MCV, 39.6 Gy XRT + concurrent cisplatin

75

25.2 Gy XRT + concurrent cisplatin

62 (4)

44 (4)

Shipley et al

61

2 cycles MCVa, 39.6 Gy XRT + concurrent cisplatin

61

25.2 Gy XRT + concurrent cisplatin

48 (5)

36 (5)

Shipley et al

62

39.6 Gy XRT + concurrent cisplatin

55

25.2 Gy XRT + concurrent cisplatin

49 (5)

40 (5)

Kachnic et al

106

2 cycles MCV, 40 Gy XRT + concurrent cisplatin

66

24.8 Gy XRT + concurrent cisplatin

52 (5)

43 (5)

Zietman et al

18

Bifractionated XRT + concurrent cisplatin + 5-fluorouracil

78

Bifractionated XRT + concurrent cisplatin + 5-fluorouracil + 3 cycles MCV

83 (3)

78 (3)

a Methotrexate, cisplatin, and vinblastine[24]

Multimodality bladder-sparing approaches other than partial cystectomy yield 5-year overall survival rates of 48-56%, with 5-year bladder survival rates of 36-43%. Comparison between approaches is difficult because of the multiple variables which may affect survival differ significantly between study populations. To date, no prospective randomized studies among modalities have been performed, so data must be interpreted accordingly.

The most important factors for bladder-sparing therapies include appropriate patient selection and long-term surveillance. Patient factors that increase risk of failure in transurethral resection/chemoradiation protocols include clinical stage higher than T2, associated ureteral obstruction with hydroureteronephrosis, incomplete initial transurethral resection, multiple tumors, and lack of response to induction chemoradiation. Local recurrence rates for such protocols vary from 20-30%. A recent editorial estimated that the mortality risk of certain bladder sparing procedures was between 7-16%.[25]

Preoperative Details

Initial TURBT should confirm that the patient is a good candidate for partial cystectomy (absence of multifocal tumors, no carcinoma in situ, good bladder capacity.) During TURBT, a thorough inspection is performed and necessary biopsy samples collected to ensure that no other portions of the lower urinary tract contain disease. Appropriate imaging staging studies are performed (see Imaging Studies) to ensure that no disease exists in the upper urinary tracts or outside the bladder. Preoperative history, physical examination, medical assessment, and necessary laboratory evaluation (see Lab Studies) are also performed.

Intraoperative Details

The patient may be placed in the supine or low-lithotomy position with a slight amount of Trendelenburg positioning. Bimanual examination under anesthesia is performed to determine suitability for resection. A catheter is inserted through the urethra, and the bladder is instilled with Mitomycin C (1 mg/mL) to decrease local tumor spillage. The Foley catheter is clamped so that the intravesical chemotherapy remains inside the bladder, and the bladder is allowed to partially expand, which facilitates dissection.

The surgical approach is either transperitoneal or extraperitoneal through a lower midline incision. The transperitoneal approach may be more suitable for tumors located posteriorly. Pelvic lymph node dissection can be performed before or after partial cystectomy. In urothelial carcinoma, it is known that improved survival can be achieved with extended pelvic lymph node dissection.[26]

After completing the pelvic lymph node dissection, the Mitomycin C is drained from the bladder into a contained Foley bag system and discarded according to biohazard principles. Next a combined endoscopic and open approach is utilized to ensure resection of the mass with adequate tumor margins. A flexible cystoscope is introduced via the urethra into the bladder. While the assistant surgeon displays the location of the mass on the video monitor with the cystoscope, the primary surgeon can now see exactly where to place four sutures (inferior, superior, medial, lateral) strategically into the detrusor muscle of the bladder, to outline the exact area to be resected.

Next, the bladder is mobilized while dividing the vas deferens and the obliterated hypogastric artery. A portion of the ipsilateral vascular pedicle including the superior vesical artery is divided and ligated. The superior vesical artery division is especially helpful in the lateral mobilization of the bladder to expose a posteriorly located lesion. The tumor is excised with a 1-cm to 2-cm margin. The perivesical fat and the overlying peritoneum are removed, if necessary, with care to protect both ureters and the rectum. Frozen sections of the specimen are sent for analysis to ensure negative surgical margins.

An alternative method of excision involves placement of a Satinsky clamp around the portion that contains the tumor, excision of the segment, and cauterization of the wound edges.

The bladder is closed in 2-layers, and drains are placed in the perivesical space. A suprapubic tube is avoided because of possible tumor spread. Bladder drainage is managed with a temporary Foley catheter. Tumor spillage is detrimental and can be prevented via instillation of intravesical chemotherapy into the bladder prior to making the lower midline incision, careful draping, and meticulous isolation and manipulation of the tumor. The wound edges should be protected and the wound copiously irrigated with sterile water prior to closure. Concurrent procedures, such as prostatic adenoma enucleation or transurethral incisions of the bladder neck for bladder outlet obstruction, should be avoided because of the risk of tumor implantation in the prostatic bed.

Partial cystectomy can also be performed laparoscopically or robotically with similar technique to open procedures.[27, 28] The patient is placed in the extreme Trendelenburg position with his or her legs abducted in Allen stirrups. A 5-mm port may be used for a transperitoneal approach. The camera port is positioned at least 2-3 cm above the umbilicus to facilitate adequate mobilization of the urachal remnant. The peritoneum is incised lateral to each medial umbilical ligament, and the urachus and peritoneum along with the surrounding pre-peritoneal fat are widely mobilized en bloc. Alternatively, some advocate that leaving the bladder attached to the anterior abdominal wall whenever possible while the remainder of the bladder is mobilized aids in laparoscopic exposure.[29]  

Once the space of Retzius is fully developed and the bladder is completely mobilized, the tumor is typically identified. A circumferential cystotomy is made under simultaneous cystoscopic guidance (with or without cystoscopic tattooing) at a distance of 2 cm from the tumor to provide an adequate margin. The surgical specimen is then immediately placed into an EndoCatch bag (USCC, Norwalk, CT).

Bladder margins are sent for frozen section analysis and the bladder is then closed in 2 layers. The retrieval bag is removed through an extension of the camera trocar site, and a Jackson Pratt drain is positioned in the prevesical space through one of the previous trocar sites. In selected patients, with skilled surgeons, laparoscopic or robotic approaches can afford the patient a shorter recovery time and hospital stay.[30, 31, 29]

Postoperative Details

Placement of a drain in the perivesical space and maintaining a large caliber urethral catheter helps facilitate healing of the suture line where the bladder has been repaired. Ideally, the bladder is kept decompressed and any initial urine leakage is drained to allow healing of the bladder suture line. A urethral catheter also allows monitoring of urine output and detection of hematuria. This catheter is usually left in place for 7-14 days postoperatively. A cystogram may be obtained prior to catheter removal to ensure that the bladder suture line has healed.

Rarely, intravesical bleeding may result in urinary clot retention and may require gentle bladder irrigation to evacuate clots. Postoperative wound infection or abscesses may require open or percutaneous drainage. Ureteral obstruction should be suspected if the patient reports flank pain. IVP or ultrasonography can be used to confirm this diagnosis, and percutaneous nephrostomy may be used to temporarily divert urine in the hope that the obstruction is temporary. Incontinence due to altered bladder compliance and uninhibited bladder contractions usually improves with time and anticholinergic medications.

Follow-up

Careful monitoring of all patients with bladder cancer is mandatory as bladder cancer frequently recurs. Cystoscopy should be performed every three months initially with voided urine cytology and frequent imaging.

Upper urothelial tract imaging with IVP, CT urography, or retrograde pyelography is also necessary although recurrence in the upper tract is less common. A precise surveillance schedule should be determined on an individual basis, and patients with high-grade tumors should be monitored for disease recurrence and progression for life.

For excellent patient education resources, see eMedicineHealth's patient education article Bladder Cancer.

Surgery: partial cystectomy

Initial transurethral resection of bladder tumor (TURBT) is essential for adequate staging in order to make an informed decision about future therapy. In general, partial cystectomy involves removing the segment of diseased bladder and repairing the defect with or without performing pelvic lymph node dissection. Radical cystectomy involves removal of the bladder, prostate and seminal vesicles in men. In women, along with the bladder, the urethra, uterus, broad ligaments, and anterior third of the vaginal wall may be removed. Pelvic lymphadenectomy is performed and a urinary diversion is created which may include ileal conduit, neobladder or continent pouch. The remainder of this article discusses details for partial cystectomy only.

Complications

Excluding recurrence of malignant disease, the overall complication rate of partial cystectomy is reported as 11-29%, with recent literature suggesting lower complication and mortality rates at higher-volume centers.[32] Common complications of partial cystectomy include: bleeding, infection, reduction of bladder capacity, and urinary extravasation. Less commonly, some patients develop fistulas (vesicocutaneous, vesicovaginal, colovesical). Other complications include those that are possible in any major surgery: myocardial infarction, pulmonary embolus, congestive heart failure, upper gastrointestinal hemorrhage, and death. 

The application of laparoscopic and robotic surgical approaches to partial cystectomy represents a significant advancement and promises to further reduce length of hospital stay, surgical morbidity, and complication rates.[60] Although large series of robotic partial cystectomy are lacking, Golombos et al recently reported their experience of 29 patients. While this series included a heterogenous patient population, they reported a median hospital length of stay of one day and overall 90 day complication rate of 24.1% (all Clavien I-II) following robotic partial cystectomy; which are concordant with other series.[29, 33]  

 

Perioperative mortality rates once approached 10%, although more recent studies have reported rates of 1-2%.

Outcome and Prognosis

Recurrence

The major disadvantage of partial cystectomy compared with radical cystectomy is an increased bladder recurrence rate in addition to metastatic recurrence. Recurrence also implies a risk of disease progression, metastasis, and death from cancer. In many patients, salvage with radical cystectomy is not possible, and some series report high death rates in patients who recur. Recurrence rates associated with partial cystectomy have been reported as 19-78%. Relapses seem to be influenced by tumor stage T3b, poorly differentiated (grade III) tumors, and tumor size (>4 cm). Various studies and their corresponding recurrence rates are as follows:

Table 3. Various Studies and Their Corresponding Recurrence Rates (Open Table in a new window)

Studies

Recurrence rates

Resnick and O'Connor (1973)

76%

Evans and Texter (1975)

40%

Novick and Stewart (1976)

50%

Peress et al (1977)

54%

Cummings et al (1978)

49%

Schoborg et al (1979)

70%

Faysal and Freiha (1979)

78%

Jardin and Vallencien (1984)

78%

Lindahl et al (1984)

58%

Kaneti (1986)

38%

Dandekar et al (1995)

43%

Holzbeierlein et al (2004)

19%

Kassouf et al (2006)

49%

Knoedler et al (2012)

43%

 

Peress et al noted that preoperative grade is an important prognostic factor in determining the risk of recurrence after partial cystectomy.[34] They studied 61 patients with stage A transitional cell carcinoma and found that 54% of patients with high-grade lesions experienced recurrence after partial cystectomy and eventually died of their disease. Kassouf et al have shown that a higher pathological stage at time of partial cystectomy was associated with shorter recurrence-free survival. Smaldone et al found that only tumor size at time of partial cystectomy was associated with tumor recurrence.[35] Older studies by Resnick and O'Connor and by Faysal and Freiha have also confirmed these findings.[36, 37]

These high local recurrence rates reflect the natural history of bladder cancer. Urothelial carcinoma of the bladder may affect the urothelium globally in some patients. Recurrences and survival outcomes depend on tumor stage and grade. Conservative management of Ta-T2 disease with transurethral resection alone results in a 60% recurrence rate. Those patients with history of previous tumors have an 84% recurrence rate, with nearly half of all tumor recurrences being multifocal. At initial presentation, two thirds of urothelial cancer patients have superficial (Ta, T1) disease, and two thirds of these patients experience recurrence (with 20% of the recurrences being of a higher grade). Death from urothelial carcinoma occurs in 5% of patients with grade 1 disease, 16% of patients with grade II disease, 28-35% of patients with grade III/stage Ta disease, and 83% of patients with grade III/stage T2 disease.

Recurrent local disease may be treated with transurethral resection, intravesical chemotherapy, radiotherapy, repeat partial cystectomy, and radical cystectomy. Of all patients who undergo partial cystectomy as original therapy, 4-15% eventually undergo radical cystectomy. Salvage radical cystectomy may confer prolonged survival, though prognosis is largely related to pathological tumor stage and nodal status.[38]

Survival

Many studies have examined the survival of patients with bladder cancer after partial cystectomy. Survival is influenced by tumor stage, grade, and histology. Accurately interpreting the impact of partial cystectomy on overall survival and comparing to results of radical cystectomy data is difficult. Most partial cystectomy series are small (usually < 50 patients) compared to radical cystectomy series of more than 1000 patients. Also, many partial cystectomy series are carefully selected for lower risk tumors prior to surgery, which may influence survival. Furthermore, pelvic lymph node dissection, which has been shown to have a significant survival benefit,[26] is frequently underutilized in partial cystectomy series.[39]

Data from Kassouf et al showed that patients undergoing partial cystectomy who had a prior history of superficial tumors had a decreased overall and advanced recurrence-free survival.[40] This finding is not surprising given that these patients have already demonstrated evidence of a global field effect within the urothelium

When comparing results for a given stage or grade of urothelial bladder cancer, survival outcomes for partial cystectomy series have been worse compared with radical cystectomy series. Five-year survival rates vary from 35-70%, compared with the reported 50-88% survival rate of contemporary radical cystectomy series. However, a recent matched case-control analysis (with patients matched based on age, sex, pathological T stage, and receipt of chemotherapy) showed no difference in metastasis-free or cancer-specific survival when comparing patients undergoing partial cystectomy with those undergoing radical cystectomy, although partial cystectomy patients remain at high risk for recurrence.[41]

Neoadjuvant chemotherapy has been shown in randomized trials to improve overall survival in patients undergoing radical cystectomy[42] although it is unclear whether adjuvant therapy would be equally effective.[43] Adjuvant chemotherapy should be considered in patients with extravesical extension or pelvic lymph node metastases who undergo partial cystectomy.

Table 4. Survival Rates by Tumor Grade (Open Table in a new window)

Source

Five-year Survival (%)

Ten-year Survival (%)

Grade I

Grade II

Grade III/IV

Grade I

Grade II

Grade III/IV

Magri (1962)

 

88

33

34

-

-

-

Utz et al (1973)

100

48

39

-

-

-

Novick and Stewart (1976)

100

75

40

0

67

8

Brannan et al (1978)

50

62

55

50

33

30

Cummings et al (1978)

100

96

32

-

-

-

Schoborg et al (1979)

75

62

26

50

28

4

Faysal and Freiha (1979)

100

53

30

25

20

8

Merrell et al (1979)

78

56

22

83

32

0

Kaneti (1986)

75

46

46

-

-

-

Dandekar et al (1995)

100

94.4

53.5

-

-

-

Table 5. Survival Rates by Tumor Stage (Open Table in a new window)

Source

Five-year Survival (%)

Ten-year Survival (%)

T0

T1

T2

T3

T4

Overall

T0

T1

T2

T3

T4

Overall

Magri (1962)

-

80

38

26

0

42

-

-

-

-

-

-

Long et al (1962)

80

67

43

9

0

-

-

-

-

-

-

-

Cox et al (1969)

-

-

20

16

-

-

-

-

-

-

-

-

Resnick and O'Connor (1978)

75

71

77

12.5

20

35

-

-

-

-

-

-

Utz et al (1973)

-

68

47

29

0

39

-

-

-

-

-

-

Evans and Texter (1975)

-

69

43

14

0

0

-

-

-

-

-

21

Novick and Stewart (1976)

-

67

53

20

-

46

-

67

44

-

-

36

Brannan et al (1978)

100

69

54

33

0

57

-

31

36

11

-

32

Cummings et al (1978)

-

79

80

6

-

60

-

-

-

-

-

-

Schoborg et al (1979)

69

69

29

12

100

43

-

37

0

0

0

12

Faysal and Freiha (1979)

75

58

29

7

0

40

21

15

13

7

0

9

Merrell et al (1979)

100

100

67

25

-

48

-

100

33

0

0

32

Lindahl et al (1984)

-

59

38

-

-

42

-

48

25

-

0

38

Kaneti (1986)

-

68

40

33

0

48

-

-

-

-

-

-

Smaldone et al (2008)

-

-

-

-

-

70

 

 

 

 

 

 

a Stage T3a/T3b

Future and Controversies

Partial cystectomy offers potential quality of life advantages over radical cystectomy and may be appropriate in selected patients with cancer or certain benign conditions.

In patients with urothelial cancer, partial cystectomy will probably continue to play a limited role in the absence of quality comparative studies demonstrating equivalent survival results to radical cystectomy. The improved quality of life and fewer complications seen in patients undergoing partial cystectomy must be carefully weighed against the increased risk of cancer death.

Patients should be appropriately counselled by experienced surgeons when considering partial cystectomy.

 

Questions & Answers

Overview

What is partial cystectomy?

What are the clinical applications of partial cystectomy?

When was partial cystectomy first performed?

What is the prevalence of bladder cancer?

What causes bladder cancer?

Which clinical history findings are characteristic of bladder cancer?

When is partial cystectomy indicated in the treatment of urothelial carcinoma?

When is partial cystectomy indicated in the treatment of cancer in bladder diverticula?

What is the role of partial cystectomy in the treatment of squamous cell carcinoma of the bladder?

What is the role of partial cystectomy in the treatment of primary adenocarcinoma of the bladder?

What is the role of partial cystectomy in the treatment of rhabdomyosarcomas of the bladder?

What is the role of partial cystectomy in the treatment of pheochromocytoma of the bladder?

What is the role of partial cystectomy in the treatment of bladder leiomyosarcoma?

What is the role of partial cystectomy in the treatment of locally advanced rectal, colon, prostate, uterus, cervix, or ovarian cancers?

Which benign bladder conditions are treated with partial cystectomy?

What is the anatomy of the bladder relevant to partial cystectomy?

What are the contraindications to partial cystectomy?

Workup

What is the role of lab tests in the preoperative workup of partial cystectomy?

What is the role of imaging studies in the preoperative workup of partial cystectomy?

What is the role of IV pyelography (IVP) in the preoperative workup of partial cystectomy?

What is the role of CT urography in the preoperative workup of partial cystectomy?

What is the role of MRI in the preoperative workup of partial cystectomy?

What is the role of ureteroscopy in the preoperative workup of partial cystectomy?

What is the role of CT scanning in the preoperative workup of partial cystectomy?

What is the role of bone scanning in the preoperative workup of partial cystectomy?

What is the role of PET scanning in the preoperative workup of partial cystectomy?

What is the role of cystoscopy in the preoperative workup of partial cystectomy?

What is the role of biopsy in the preoperative workup of partial cystectomy?

What is the role of retrograde pyelography in the preoperative workup of partial cystectomy?

What is the role of transurethral resection in the preoperative workup of partial cystectomy?

What is the role of pelvic lymphadenectomy in partial cystectomy?

Which histologic findings are characteristic of primary bladder cancer?

Which histologic findings are characteristic of bladder carcinoma in situ?

Which histologic findings are characteristic of urothelial carcinoma (transitional cell carcinoma)?

Which histologic findings are characteristic of bladder squamous cell carcinoma?

Which histologic findings are characteristic of bladder adenocarcinoma in partial cystectomy?

How is bladder cancer staged?

Treatment

What are the alternatives treatments to partial cystectomy for bladder cancer?

What is included in preoperative care prior to partial cystectomy?

How is partial cystectomy performed?

What is included in postoperative care following partial cystectomy?

What is included in long-term monitoring following partial cystectomy?

What is the difference between partial and radical cystectomies?

What are the possible complications of partial cystectomy?

What is the recurrence rate of bladder cancer after partial cystectomy?

What are the survival rates for bladder cancer after partial cystectomy?

What are the advantages of partial cystectomy over radical cystectomy?