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.