Indications for early cystectomy

Treatment goals for superficial bladder cancer are two-fold: (1) reducing tumor recurrence and the subsequent need for additional therapies (cystoscopy, transurethral resection, intravesical therapy) and the morbidity associated with these treatments; and (2) preventing tumor progression and the subsequent need for more aggressive therapy. The administration of intravesical therapy has become an important component in these treatment goals; however, there remains a group of patients with superficial bladder cancer that are at risk of disease progression, metastases, and death from their disease. The treating urologist must be extremely active and diligent when treating patients with superficial bladder cancer. An understanding of tumor biology and current intravesical therapies is important. Furthermore, and perhaps most important, the timely decision to abandon conservative therapy and proceed with radical cystectomy and urinary diversion should be kept in mind to prevent the potentially lethal sequelae of invasive bladder cancer. In view of the potential for recurrence, stage progression, and significant clinical understaging of patients with superficial bladder cancer, and the fact that radical cystectomy provides excellent results with regard to prevention of local recurrence and overall survival, radical cystectomy should be considered in patients with high-risk factors. Radical cystectomy may also provide important prognostic information and influence the decision for adjuvant therapy based on pathologic criteria. Finally, definite improvements in lower urinary tract reconstruction and nerve-sparing techniques have decreased the social implications of cystectomy for both men and women.