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114 Challenging Concepts in Urological Surgery
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Subsequently, a joint patient– clinician decision was made to keep the patient under
clinic review; however, there would be no surveillance cystoscopies unless he became
symptomatic.
A final word from the expert
NMIBC is a challenging condition to manage. The nature of this disease means it is expensive
to manage and burdensome for the patient. For fit patients, with normal life expectancy, the
emphasis must obviously be to prevent disease progression. However, for patients who are unfit,
with reduced life expectancy, a personalized approach must be adopted that strikes a balance
between the risks of diagnosis and/ or treatment and potential symptoms. Increasingly, newer
treatments are being used or being evaluated in clinical trials which will hopefully lead to further
management options for both the fittest and the frailest of patients.
References
1. Antoni S, Ferlay J, Soerjomataram I, Znaor A, Jemal A, Bray F. Bladder cancer incidence
and mortality: a global overview and recent trends. Eur Urol. 2017;71(1):96– 108.
2. Cancer Research UK. Bladder cancer statistics. Cancer Research UK. n.d. https:// www.
cancerresearchuk.org/ health- professional/ cancer- statistics/ statistics- by- cancer- type/
bladder- cancer
3. Cumberbatch MGK, Jubber I, Black PC, et al. Epidemiology of bladder cancer: a systematic
review and contemporary update of risk factors in 2018. Eur Urol. 2018;74(6):784– 795.
4. Brierley J, Gospodarowicz MK, Wittekind C, eds. TNM Classification of Malignant Tumours.
8th ed. Chichester: Wiley- Blackwell; 2017.
5. Au JLS, Jang SH, Wientjes MG. Clinical aspects of drug delivery to tumors. J Control
Release. 2002;78(1– 3):81– 95.
6. Noon AP, Albertsen PC, Thomas F, Rosario DJ, Catto JWF. Competing mortality in patients
diagnosed with bladder cancer: evidence of undertreatment in the elderly and female patients. Br J Cancer. 2013;108(7):1534– 1540.
7. Sylvester RJ, van der Meijden APM, Oosterlinck W, et al. Predicting recurrence and pro-
gression in individual patients with stage Ta T1 bladder cancer using EORTC risk tables: a
combined analysis of 2596 patients from seven EORTC trials. Eur Urol. 2006;49(3):466– 477.
8. National Institute for Health and Care Excellence. Bladder cancer: risk classi-
fication in non- muscle- invasive bladder cancer. National Institute for Health
and Care Excellence. 2015. https:// www.nice.org.uk/ guidance/ ng2/ resources/
nmibc- risk- classification- table- pdf- 3779101
9. Compérat E, Gontero P, Mostafid AH, et al. EAU guidelines on non- muscle- invasive bladder
cancer (TaT1 and CIS). European Association of Urology. 2017. https:// uroweb.org/ wpcontent/ uploads/ EAU- Guidelines- on- Non- muscle- Invasive- Bladder- Cancer- 2020.pdf
10. Mostafid AH, Palou Redorta J, Sylvester R, Witjes JA. Therapeutic options in high- risk non-
muscle- invasive bladder cancer during the current worldwide shortage of bacille CalmetteGuérin. Eur Urol. 2015;67(3):359– 360.
11. Sylvester RJ, van der Meijden APM, Lamm DL. Intravesical bacillus Calmette- Guerin re-
duces the risk of progression in patients with superficial bladder cancer: a meta- analysis of
the published results of randomized clinical trials. J Urol. 2002;168(5):1964– 1970.
12. Liu CY, Chuang CK, Chang YH, et al. Maintenance bacillus Calmette– Guérin therapy pro-
longs recurrence- free survival in non- muscle- invasive bladder cancer: a real- world experience. Urol Sci. 2015;26(2):96– 100.
13. Koya MP, Simon MA, Soloway MS. Complications of intravesical therapy for urothelial
cancer of the bladder. J Urol. 2006;175(6):2004– 2010.
14. Kunieda F, Kitamura H, Niwakawa M, et al. Watchful waiting versus intravesical BCG
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therapy for high- grade pT1 bladder cancer with pT0 histology after second transurethral resection: Japan Clinical Oncology Group Study JCOG1019. Jpn J Clin Oncol.
2012;42(11):1094– 1098.
15. Hernández V, Llorente C, de la Peña E, Pérez- Fernández E, Guijarro A, Sola I. Long- term
oncological outcomes of an active surveillance program in recurrent low grade Ta bladder
cancer. Urol Oncol. 2016;34(4):165.e19– 165.e23.
16. Malmström PU, Sylvester RJ, Crawford DE, et al. An individual patient data meta- analysis
of the long- term outcome of randomised studies comparing intravesical mitomycin
C versus bacillus Calmette- Guérin for non- muscle- invasive bladder cancer. Eur Urol.
2009;56(2):247– 256.
17. Houghton BB, Chalasani V, Hayne D, et al. Intravesical chemotherapy plus bacille CalmetteGuérin in non- muscle invasive bladder cancer: a systematic review with meta- analysis. BJU
Int. 2013;111(6):977– 983.
18. Ye Z, Chen J, Hong Y, Xin W, Yang S, Rao Y. The efficacy and safety of intravesical
gemcitabine vs Bacille Calmette- Guérin for adjuvant treatment of non- muscle invasive
bladder cancer: a meta- analysis. Onco Targets Ther. 2018;11:4641– 4649.
19. Sadée C, Kashdan E. A model of thermotherapy treatment for bladder cancer. Math Biosci
Eng. 2016;13(6):1169– 1183.
20. Tan WS, Palou J, Kelly J. Safety and tolerability analysis of hyperthermic intravesical
mitomycin to mitomycin alone in HIVEC I and HIVEC II: an interim analysis of 307 patients.
Eur Urol Suppl. 2017;16(3):e1150– e1151.
21. Powles T, O’Donnell PH, Massard C, et al. Efficacy and safety of durvalumab in locally
advanced or metastatic urothelial carcinoma: updated results from a phase 1/ 2 open- label
study. JAMA Oncol. 2017;3(9):e172411.
22. De Santis M, Abdrashitov R, Hegele A, et al. A phase III, randomized, open- label,
multicenter, global study of durvalumab and bacillus Calmette- Guérin (BCG) versus BCG
alone in high- risk, BCG- naïve non- muscle- invasive bladder cancer (NMIBC) patients
(POTOMAC). J Clin Oncol. 2019;37(7 Suppl):TPS500– TPS500.
23. Shore ND, Boorjian SA, Canter DJ, et al. Intravesical rAd– IFNα/ Syn3 for patients with
high- grade, bacillus Calmette- Guerin- refractory or relapsed non- muscle- invasive bladder
cancer: a phase II randomized study. J Clin Oncol. 2017;35(30):3410– 3416.
115Case 11 Non-muscle-invasive bladder cancer
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12
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CASE
Muscle- invasive bladder
cancer
Samantha Conroy
Expert commentary James W.F. Catto
Case history
A 71- year- old gentleman, with a solitary right kidney, was reviewed in a haematuria
clinic after being referred by his general practitioner with persistent, asymptomatic,
non- visible haematuria. His medical history included well-controlled hypertension
and hypercholesterolaemia, for which he was taking amlodipine and simvastatin,
respectively. He was a non- smoker and was independent with his daily activities.
On clinical assessment, he was asymptomatic and haemodynamically stable. He
underwent the following investigations:
● Urine dipstick analysis, confirming the presence of non- visible haematuria.
● Baseline blood tests, showing a haemoglobin level of 121 g/ L, a creatinine con-
centration of 79 μmol/ L, an estimated glomerular filtration rate of 89 mL/ min/
1.73 m2, and creatinine clearance of 100 mL/ min.
● Flexible cystoscopy, which identified a large posterior wall bladder tumour, close
to the right ureteric orifice.
● Computed tomography (CT) intravenous urography, which confirmed a posterior
bladder mass, but showed no evidence of ureteric obstruction or synchronous
upper tract malignancy.
The working diagnosis was explained to the patient and he was scheduled for an urgent transurethral resection of his bladder tumour (TURBT).
Rigid cystoscopy confirmed a solitary, 4 cm, solid tumour on the right posterior
wall of the bladder. It was close to, but not invading, the right ureteric orifice. The
tumour was resected down to and including detrusor muscle, taking care to avoid the
ureteric orifice.
The histological and radiological findings were discussed at the uro- oncology multidisciplinary team meeting, which confirmed a solitary G3pT2 infiltrating bladder tumour with associated carcinoma in situ (CIS). CT imaging of the thorax, abdomen, and
pelvis identified one 7.8 mm in diameter right- sided, internal iliac lymph node (LN),
which was felt to be at intermediate risk of being a metastasis. No other locoregional
lymphadenopathy or distant metastases were identified.
The outcome of the multidisciplinary team meeting was to proceed with radical
cystoprostatectomy (RC), with extended lymphadenectomy, and to arrange an oncological assessment for neoadjuvant chemotherapy (NAC).
118 Challenging Concepts in Urological Surgery
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Learning point Epidemiology
In 2018, there were 549,393 new cases of bladder cancer (BC) diagnosed worldwide. Over 75% of
these patients were male, making it the sixth most frequently diagnosed cancer, in men, worldwide.1
Most BCs are non- muscle- invasive bladder cancer (NMIBC) tumours confined to the urothelium or
subepithelial tissues. Persons presenting with muscle- invasive bladder cancer (MIBC: approximately,
25% of new cases) or developing invasive cancers after prior NMIBC, need radical treatment to
achieve cure. Despite using radical treatment, around half of patients with MIBC die from this
2
cancer.
Learning point Aetiology
In order to determine significant personal, environmental, and socioeconomic risk factors for BC,
clinicians should obtain a focused history. Known risk factors for BC include3:
● Smoking:
- Greater relative risk for current versus ex- smokers
● Occupational carcinogens:
- Industries such as aluminium, dye, rubber, coal- tar, dry cleaning, hairdressing, printing, and
5
textiles
● Dietary factors and obesity:
- Increases with body mass index
● Increasing age:
- Median age 73 years at diagnosis
● Male sex
● Past medical history of:
- Radiotherapy, diabetes mellitus, schistosomiasis, pioglitazone, and cyclophosphamide use
(conversely, non- steroidal anti- inflammatory drugs and phenobarbital reduce risk)
● Family history of BC
● Socioeconomic status:
- Increased risk in industrialized areas.
4
Expert comment Diagnosis and staging of BC
Typically, patients with suspected BC are referred to urology services because of non- visible
haematuria or visible haematuria in the presence or absence of associated risk factors. They will
undergo a number of investigations including urine cytology, flexible cystoscopy, and urinary tract
imaging (ultrasonography or CT) to identify synchronous upper tract tumours. If a bladder tumour
is identified, the patient will require a formal TURBT to establish a histological diagnosis and to
differentiate between non- muscle- invasive and muscle- invasive disease. MIBC is characterized by
a bladder tumour showing evidence of invasion into the detrusor muscle, histologically defined as
invasion of the muscularis propria (pT2). In conjunction to histological diagnosis, patients must be
evaluated for locoregional or distant metastases.
The tumour, node, metastasis (TNM) system is recommended for staging of BC6:
● Tumour: Tx— unable to assess tumour; T0 no evidence of tumour; Ta— non- invasive papillary
carcinoma; T1— invasion of the lamina propria; T2— invasion of the muscularis propria (2a— inner
50%; 2b— outer 50%); T3— invasion of the perivesical tissue (3a— microscopic invasion; 3b
macroscopic invasion); T4— invasion of surrounding organs/ structures (T4a— invasion of the prostate,
seminal vesicles, uterus, or vagina; T4b— invasion of the pelvic or abdominal wall).
● Node: Nx— unable to assess LN status; N0— no regional LN metastases; N1— single LN metastasis in
true pelvis; N2— multiple LN metastases in true pelvis; N3— common iliac LN metastases.
● Metastasis: M0— no distant metastases; M1— metastases present (M1a— LN metastases outside of the
pelvis; M1b— metastases present in other organs or parts of the body).
Around 33– 55% of patients found with pT1 (NMIBC) disease on initial TURBT, have persistent disease
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on re- resection and up to 25% are upstaged to pT2 disease (MIBC)7 These figures highlight the need
for accurate and timely staging.
Clinical tip Pathology subtypes
Histological classification of BC plays an important role in determining future management. Around
90% of all BCs are urothelial cell carcinomas (UCCs), thus, only a small proportion of BCs are nonurothelial histological subtypes; these include squamous, adenocarcinoma, small cell, sarcoma, and
melanoma. The outcomes and systemic regimens for non- urothelial BCs differ and so care should be
adapted accordingly.
Almost all MIBCs are high- grade UCCs. Therefore, histological and/ or radiological stage have greater
prognostic value than grade. However, some morphological subtypes of UCCs behave differently
to pure UCCs in terms of treatment response and prognosis; these variants include micropapillary,
small cell (neuroendocrine), lymphoepithelioma, nested, plasmacytoid, and those with squamous
components, and should be considered when making decisions about patient care.
119Case 12 Muscle-invasive bladder cancer
Expert comment Current challenges in BC pathological staging
The under- staging of MIBC is a particular concern for patient care. This most commonly arises when
at TURBT a cancer is staged as NMIBC (and invasive components are not apparent). To clarify the
diagnosis, a re- resection TURBT, ideally within 6 weeks of the initial resection, is advocated for patients
with high risk of upstaging (e.g. high- grade NMIBC, stage T1, lack of detrusor muscle in TURBT
specimen, CIS).9 Disease that progresses from NMIBC to MIBC has a worse cancer- specific survival
than for cancers that present as de novo MIBC.
10
This raises two important questions;
1. Are we staging high- risk NMIBC appropriately— or should pT1 disease be subclassified?
2. Do we need to treat high- risk NMIBC more aggressively in the first instance?
Evidence base BRAVO randomized controlled trial
Radical cystectomy against intravesical BCG immunotherapy for high- risk non- muscle- invasive
bladder cancer (BRAVO) was a multicentre, parallel- group, randomized controlled feasibility
study to evaluate acceptability and feasibility of a phase III randomized controlled trial comparing
maintenance BCG with radical cystectomy for high- risk NMIBC.
11,12
Recruitment to the study
was challenging, attributable to multiple factors including patient preference, lack of clinician
equipoise, and logistical difficulties. The study highlighted the challenges in managing this cohort of
patients: around 10% of all new high- risk NMIBCs harboured lethal disease, and thus may benefit
from primary RC; but a significant proportion successfully underwent bladder- preserving therapy
while maintaining pre- diagnosis quality of life. Hence, clinicians must use risk- adapted and patientcentred strategies.
11
Future directions Subcategorization of pT1 tumours
Predicting the progression and response of pT1 tumours (currently classified as high- risk NMIBC) is
challenging, hence, a second TURBT within 6 weeks of the original resection is recommended.
13
More recently, the American Joint Committee on Cancer have recommended sub- classification of pT1
disease into those that have minor or extensive invasion of the lamina propria, however, do not yet
have a validated method of doing so.14 Future subcategorization of pT1 disease may provide a more
effective risk stratification system for those with ‘borderline’ muscle- invasive disease.
Future directions Genetic
subclassification
Advances in our molecular
understanding of BC has also
allowed genetic subclassification
of tumours into luminal, luminal
papillary, luminal unstable,
stromal rich, basal/ squamous, and
neuroendocrine like.8 In the future,
these molecular characteristics may
aid clinical decision- making and
play a role in targeted therapy.
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Clinical tip Accurate
histological staging of BC
Accurate histological staging is
essential and clinicians must be
aware of how surgical technique
impacts on tissue analysis.
● Surgical factors that may
interfere with analysis include
cautery or thermal damage to
tissues and tangential tissue
segmentation, making it difficult
to orientate.
● Therefore, ‘en bloc’ resection
of small tumours and fractional
resection of larger tumours is
recommended.
● Detrusor muscle should always
be obtained for analysis, and
where possible, sent as a
separate sample to the tumour.
14
Shortly after the multidisciplinary team meeting, the patient was reviewed by a urooncologist with the view to starting NAC as soon as possible, as to not delay RC. As
part of the assessment, repeat baseline blood tests were requested. His repeat urea and
electrolyte results showed a significant rise in creatinine concentration (104 μmol/ L from
79 μmol/ L) with an associated reduction in his estimated glomerular filtration rate (65
mL/ min/ 1.73 m2 from 89 mL/ min/ 1.73 m2) and creatinine clearance (73 mL/ min from
100 mL/ min).
In the context of the patient’s solitary kidney and the proximity of the resected
infiltrating tumour to the right UO, the clinicians were concerned about potential malignant ureteric obstruction. He was fully assessed for evidence of pre- renal and renal
causes of his acute kidney injury, but none were identified. Post- renal obstruction,
therefore, was the most likely cause.
Clinically, he was euvolaemic, systemically well, and had no signs or symptoms
of coexisting urinary tract infection. An urgent, non- contrast CT scan was performed,
showing mild to moderate right- sided hydroureteronephrosis, traceable down to the
right vesicoureteric junction.
Having confirmed the ureteric obstruction, a joint decision was made to site a
percutaneous nephrostomy (PCN), with the goal of facilitating temporary urinary diversion and preserving renal function to facilitate NAC.
Expert comment Options for acute urinary diversion
Two methods commonly used for acute urinary diversion are ureteric stents and PCN. The modality
of diversion is dependent on the aetiology, urgency, technical expertise required for diversion and
bladder function/ capacity, as well as patient choice. Although there is no consensus between stenting
and PCN in BC, PCN is preferred in the neoadjuvant setting because it offers more definitive urinary
drainage and lower rates of tumour seeding to the upper tracts.
Temporizing PCN provides an option for preserving renal function in the neoadjuvant setting to
optimize patients prior to NAC and RC. PCN may be regarded as a potential infective focus during
chemotherapy, but this is counter- balanced by assisting in the resolution of urinary stasis and
associated urinary tract sepsis, as well as contributing towards improving renal function, minimizing
the delay to definitive surgery.
15
Within 72 hours of PCN insertion, the patient’s estimated glomerular filtration rate
had increased to baseline. He was re- reviewed by the oncology team, who were now
happy for him to proceed with NAC. He completed four cycles of systemic cisplatin
and gemcitabine without significant side effects or complications.
The patient’s definitive treatment was open RC with ileal conduit formation and extended lymphadenectomy. The procedure was uneventful, with no immediate anaesthetic or surgical complications. A total of 465 mL of blood was lost intraoperatively.
Because he had a very good postoperative urine output via the ileal conduit, and now
had ureteroileal anastomotic stents (placed intraoperatively), the right PCN was removed on table at the end of surgery.
121Case 12 Muscle-invasive bladder cancer
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The prognosis of patients with MIBC undergoing RC remains poor.2 NAC has been shown to
improve 5- year survival rates by around 5%
13,16
and so is recommended for platinum- eligible
patients with T2– T4a cN0M0 disease. Table 12.1 describes the potential benefits and risks of NAC
in MIBC.
Cisplatin- based combination chemotherapy is the optimal NAC regimen in MIBC. Cisplatin can be
combined with either gemcitabine or with methotrexate, vinblastine, and doxorubicin (Adriamycin®)
(MVAC). Gemcitabine is more commonly used, as comparative trials suggest gemcitabine is less
toxic and has similar efficacy to MVAC.17 Carboplatin may be used as an alternative in patients with
contraindications to cisplatin.
● Cisplatin mechanism of action:
- Alkylating agent.
- Interferes with DNA replication and repair.
● Action recommendation:
- Cisplatin- based NAC should be offered to those with MIBC who have no evidence of
locoregional or distant metastases.
● Contraindications:
- Eastern Cooperative Oncology Group (ECOG) score ≥2.
- Poor renal function (creatinine clearance <60 mL/ min).
- Evidence of heart failure (≥ class III New York Heart Association heart failure).
- Evidence of neuropathy (≥ grade 2).
- Hearing impairment (≥ grade 2).
● Adverse effects18:
- Common: nephrotoxicity, ototoxicity, bone marrow suppression, nausea/ vomiting, diarrhoea, fatigue.
- Uncommon: neurotoxicity, allergic reactions, cardiac arrhythmias.
Table 12.1 Advantages and disadvantages of NAC in patients with MIBC
Learning point Neoadjuvant chemotherapy
Advantages of NAC Disadvantages of NAC
Better compliance and tolerated
pre- cystectomy than after
Treatment for metastatic disease at low
volume. Metastases are the cause of
death in most MIBC patients
Potentially delays definitive treatment for those
with tumours that are not chemosensitive
Potential to over- treat those who have not been
staged by conventional TURBT and imaging
Side effect profile
Can identify in vivo sensitivity of
tumour to NAC
Clear evidence that it does not increase
surgical morbidity
Clinical tip Management of MIBC
Radical treatment (RC or radiotherapy) is the main curative treatment for MIBC. The choice between
surgery or radiotherapy reflects disease factors (stage, hydronephrosis, presence of CIS), patient factors
(fitness, comorbidities), bladder function (capacity and compliance), and patient preference. Optimal
factors for bladder- sparing radiotherapy are unclear but may include low- volume or unifocal disease
(and clearance at TURBT), good bladder capacity, lack of CIS, and a good response to NAC. Most
RCs are performed with a curative intent. However, in certain cases palliative cystectomy may be
performed for symptomatic relief.
The timing of RC is important. Studies have shown that delaying RC for >90 days may significantly
impact survival, particularly in those with pT2 disease.19 Therefore, patients ideally should be
optimized for surgery within this time frame, to avoid unnecessary disease progression which may
affect prognosis and survival (Figure 12.1).
122 Challenging Concepts in Urological Surgery
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Flexible cystoscopy +/– upper
tract imaging
TURBT +/– staging CT/MRI if
suspected muscle invasion
Re-TURBT if muscle absent in
specimen/pT1 disease
(within 42 days)
Radical cystectomy +
lymphadenectomy (should
not exceed 90 days)
0 90 days
Discuss at urooncology MDT
if required
Figure 12.1 Timeline of events to radical cystectomy.
Expert comment Lymphadenectomy during RC
Many authorities advocate pelvic lymph node dissection (LND) at the time of RC. LND has a role
in staging the cancer and may have a therapeutic benefit. However, the procedure lengthens the
duration of surgery and can slow patient recovery (lymphatic fluid may prolong ileus and may require
drainage). Conventionally, pelvic LND includes removal of LNs up to the ureteric crossing of the
common iliac vessels (namely the internal iliac, presacral, obturator, and external iliac nodes). More
extensive LND approaches are practised, with extended lymphadenectomy including LNs up to the
aortic bifurcation and super- extended lymphadenectomy including LNs up to the inferior mesenteric
artery. The optimal extent of LND required in MIBC is debatable.
LND staging
Preoperative imaging (CT or MRI) should identify enlarged LNs with a diameter of >8 mm in the pelvis
and 10 mm in the abdomen, which in the context of a known pelvic malignancy, should be treated
as suspicious for malignant deposits.13 However, not all malignant LNs are enlarged and, conversely,
some enlarged LNs are inflamed. As such, lymphadenectomy clarifies the stage and this can be used
to stratify the need for adjuvant treatment and predict recurrence.
LND therapy
The therapeutic benefit from lymphadenectomy is unclear. Proponents report patients with nodal
metastasis who are cured from MIBC and non- randomized data suggesting better outcomes with
lymphadenectomy.
recent comparisons of limited versus extended LND show no difference in survival.
Therefore, when deciding on the need for and extent of lymphadenectomy, one should consider the
likely disease burden, patient fitness, and technical implications for the surgical procedure.
20,21
However, there are no randomized data comparing LND to no LND, and
Offer neoadjuvant
chemotherapy in
selected cases
21,22
Evidence base Extended versus limited lymphadenectomy for MIBC
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A prospective, phase III, multicentre trial evaluated extended LND versus limited LND in patients
undergoing RC for high- risk NMIBC and MIBC.22 A total of 401 patients were randomized with the primary
endpoint being recurrence- free survival and secondary endpoints including cancer- specific and overall
survival. This trial showed no statistically significant benefit of extended over limited LND for the primary
or secondary endpoints described. However, it did suggest that 11% of patients would have had metastatic
LNs left behind had they undergone limited rather than extended LND. Extended LND may therefore play a
role in a selected cohort with more aggressive and radiologically node- negative disease (pT2– 4N0).
123Case 12 Muscle-invasive bladder cancer
The main routes of urinary diversion are:
1. Incontinent: ileal conduit or ureterocutaneostomy
2. Continent: orthotopic neobladder (ileal or ileal/ caecal) or continent cutaneous diversion
3. Rectosigmoid: such as a Mainz or Mansoura pouch.
The choice of urinary diversion includes patient, oncological, and surgical factors.
Learning point Urinary diversion during RC
Patient factors
● Patient fitness (ileal conduit is faster and less complicated).
● Comorbidities (various neobladder exclusions such as renal impairment, Crohn’s disease, etc.).
● Life expectancy (neobladders are better with longer recovery).
● Insight and engagement, pre- existing benign urethral disease, or incontinence.
Oncological factors
● Evidence of UCC at a surgical margin.
● Coexisting urethral tumours or N2– 3 disease (all of which exclude an orthotopic reconstruction).
Surgical/ institutional factors
● Centre volume, surgeon experience, and surgeon preference.
Postoperatively, the patient was initiated on the Enhanced Recovery After Surgery
(ERAS; see ‘Learning point’ box on postoperative care) protocol, and made good progress with pain control, mobilization, oral intake, and stoma care on the ward. His
postoperative blood investigations were unremarkable. He was discharged 5 days after
his surgery with 28 days of low- molecular- weight heparin and continued to make a
good recovery in the community.
Learning point Postoperative care
Expert comment Palliative
cystectomy in locally advanced BC
Although the primary aim of RC
is for curative intent, this is not its
sole purpose. Palliative cystectomy
and urinary diversion may be
offered on a case- by- case basis
(e.g. symptomatic tumour, upper
tract obstruction, low metastatic
burden, high performance status),
to patients with symptomatic
disease, without alternative options.
The aim of postoperative care is to enable patients to reach complete recovery, as soon as possible, to
their preoperative state. A multidisciplinary approach should be used to determine the most suitable
location for postoperative recovery on a case- by- case basis, which in some, may require higher level
care in the initial stages.
More recently, there has been a push to improve perioperative and postoperative outcomes from RC.
ERAS protocols have been implemented to good effect in many non- urological specialities for major
surgery; the principles of ERAS are as follows23:
1. Appropriate preoperative assessment, optimization, caloric loading with avoidance of bowel
preparation, and prolonged fasting.
2. Perioperative standardized anaesthetic protocols.
3. Early postoperative oral feeding, mobilization, and drain/ catheter removal where appropriate.
Specific adaptations of ERAS protocols for RC are described in Table 12.2.24 In a recent, single- centre
randomized controlled trial, patients who underwent RC followed by ERAS (when compared to
controls) had the following benefits23:
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