Editing Cystectomy (section)

== Radical Cystectomy ==

=== Radical vs. Simple Cystectomy ===
* '''<span style="color:#ff0000">Simple cystectomy involves removal of the bladder only'''
* '''<span style="color:#ff0000">Radical cystectomy involves removal of the bladder (cystectomy) along with the organs at highest risk of harboring tumors that extend beyond the bladder'''
**'''<span style="color:#ff0000">Radical cystectomy traditionally includes excision of perivesical soft tissue and:</span>'''
*** '''<span style="color:#ff0000">Males (2):</span>'''
***# '''<span style="color:#ff0000">Prostate</span>'''
***# '''<span style="color:#ff0000">Seminal vesicles</span>'''
*** '''<span style="color:#ff0000">Females (4):</span>'''
***# '''<span style="color:#ff0000">Ovaries</span>'''
***# '''<span style="color:#ff0000">Fallopian tubes</span>'''
***# '''<span style="color:#ff0000">Uterus with cervix</span>'''
***# '''<span style="color:#ff0000">Anterior vagina</span>'''
** In male patients, a nerve-sparing procedure can be safely offered to select patients interested in preserving sexual function.
** '''<span style="color:#ff0000">Female organ-sparing cystectomy'''
***'''<span style="color:#ff0000">Preserves uterus, ovaries and/or vagina'''
***'''<span style="color:#ff0000">Indications'''
****'''<span style="color:#ff0000">In select females with''' 
****#'''<span style="color:#ff0000">Early stage disease AND'''
****#'''<span style="color:#ff0000">Desire to preserve sexual and/or reproductive function'''

=== Bilateral pelvic lymph node dissection ===
* '''≈25% of patients will have pathologic lymph node metastases at the time of cystectomy, and lymph node status is the most powerful surrogate for long-term recurrence-free and overall survival following radical cystectomy'''

==== Lymphatic Drainage ====
*'''Primary lymphatic drainage sites for bladder cancer (4):'''
*# '''Obturator'''
*# '''Internal iliac'''
*# '''External iliac'''
*# '''Presacral lymph nodes'''
* Secondary lymphatic drainage sites
*# Common iliac
*# Para-aortic
*# Interaortocaval
*# Paracaval lymph nodes

==== Indications ====

===== AUA =====

* '''<span style="color:#ff0000">2020 AUA Guidelines on Muscle-Invasive Bladder Cancer'''
** '''<span style="color:#ff0000">Absolute (1):'''
**# '''<span style="color:#ff0000">Any surgery with curative intent'''

==== Template ====
* '''<span style="color:#ff0000">Bilateral pelvic lymph node dissection should be performed with removal, at minimum, of the (3)</span>'''
*#'''<span style="color:#ff0000">Obturator lymph nodes</span>'''
*#'''<span style="color:#ff0000">Internal iliac lymph nodes</span>'''
*#'''<span style="color:#ff0000">External iliac lymph nodes</span>'''

===== Boundaries =====
* '''<span style="color:#ff0000">Superiorly: ureter/bifurcation of the common iliac artery</span>'''
* '''<span style="color:#ff0000">Inferiorly: circumflex iliac vein and Cloquet’s node/Cooper ligament at the femoral canal</span>'''
* '''<span style="color:#ff0000">Laterally: genitofemoral nerve</span>'''
* '''<span style="color:#ff0000">Medially: bladder and internal iliac artery</span>'''
* '''<span style="color:#ff0000">Posteriorly: obturator nerve/fossa</span>'''

===== Extended lymph node dissection =====
*Many retrospective studies have suggested a survival benefit of extending the cystectomy lymph node dissection boundaries to a level as high as the inferior mesenteric artery.
*Randomized trials (SWOG S1011 and LEO AUO AB 25/02) suggest no significant benefit (see [[Muscle-Invasive Bladder Cancer|Muscle-Invasive Bladder Cancer Chapter Notes]])

===== <span style="color:#ff0000">Lymph node count</span> =====
* '''<span style="color:#ff0000">To facilitate adequate staging, a standard lymphadenectomy </span>(bilateral external iliac, internal iliac and obturator lymph nodes), <span style="color:#ff0000">at a minimum, needs to be completed with >12 lymph nodes evaluated.</span>[https://www.auanet.org/guidelines/guidelines/bladder-cancer-non-metastatic-muscle-invasive-guideline]'''
*'''Absolute number of nodes removed has been shown to provide important prognostic information and staging accuracy both in lymph node positive and lymph node negative patients'''
** Removing > 10 nodes is recommended ['''AUA MIBC Guidelines say >12'''] based on observational studies evaluating node count and survival

=== Approach ===

==== Options ====

#'''Open'''
#'''Laparoscopic/robotic'''

===== Comparison of Approach =====

*Both laparoscopic/robotic and open approaches are acceptable methods to perform radical cystectomy with comparable cancer outcomes.

====== <span style="color:#ff00ff">RAZOR (Lancet 2018)</span> ======
* '''Population: 360 patients''' with T1–T4, N0–N1, M0 bladder cancer or refractory carcinoma in situ
* '''Randomized to robotic vs. open radical cystectomy'''
*'''Primary outcome: 2-year progression-free survival'''
* '''Results:'''
** '''Primary outcome: robotic cystectomy was non-inferior to open on 2-year PFS [similar results at 3 years]'''
** Secondary outcomes
***Adverse event were not significantly different between groups (67% robotic vs. 69% open)
**** No difference in risk of post-operative ileus (22% robotic vs. 20% open)
*[https://pubmed.ncbi.nlm.nih.gov/29976469/ Parekh, Dipen J., et al.] "Robot-assisted radical cystectomy versus open radical cystectomy in patients with bladder cancer (RAZOR): an open-label, randomised, phase 3, non-inferiority trial." ''The Lancet'' 391.10139 (2018): 2525-2536.