Complications of radical cystectomy

Abstract

Radical cystectomy has become a standard and arguably the best definitive form of therapy for high-grade, invasive bladder cancer. Lower urinary tract reconstruction, particularly orthotopic diversion, has been a major component in enhancing the quality of life of patients requiring cystectomy. As with any major surgery, however, complications do arise. It is important for all surgeons to be familiar with the presentation, prevention and treatment of the major causes of morbidity and mortality associated with radical cystectomy and lower urinary tract reconstruction. The complications discussed are among the most common of the complications seen with cystectomy and urinary-intestinal diversion. There are, in fact, many others that may be encountered, as the published literature testifies, and a thorough understanding as to their presentation, prevention and treatment is equally essential for a successful patient outcome. Adherence to proper surgical technique, familiarization with recent data regarding the most successful treatment methods, and attention to detail in the perioperative period are crucial for minimizing complications in any surgical undertaking. Radical cystectomy with orthotopic neobladder as well as total pelvic exenteration and its modifications need to be considered among the treatment options for patients with muscle invasive bladder cancer or advanced pelvic malignancies. Recent advances in patient selection, surgical technique, and perioperative care have led to decreased morbidity. Despite this, these procedure remain complex with the potential for both short and long-term complications. There is abundant evidence that radical cystectomy for bladder malignancies and pelvic exenteration for primary rectal cancer and cervical cancer can lead to meaningful long-term survival; however, the prognosis after pelvic exenteration for recurrent rectal cancer is not as good. The recent introduction of combined chemoradiotherapy is likely to improve local recurrence rates and may translate into more durable long-term survival. Pelvic exenteration continues to have an important role in the multimodality approach to patients with advanced pelvic malignancies. In conclusion, pelvic exenteration appears to be a safe and effective option for an experienced multi specialty surgical team in the treatment of complex locally advanced pelvic malignancy. The success of pelvic exenteration is highly dependent on good patient selection where an en bloc resection may result in prolonged disease-free survival and long term cure. In recent times the morbidity and mortality of this operation has decreased so that palliative exenteration has a role to help improve quality of life for this difficult group of patients.