Editorial: cystectomy for bladder cancer.

The article from a single university in Italy by Colombo et al (page 1819) in this issue of The Journal describes 27 men with superficial high risk or muscular invasive bladder cancer who underwent radical “nerve and seminal sparing cystectomy” with ileo-capsular anastomosis. Prostate sparing cystectomy is much more popular in Europe than in the United States. These authors rightly suggest that our usual intent to perform nerve sparing cystoprostatectomy in such patients results in no better than a 50% probability of potency and a rather constant 33% incidence of nocturnal incontinence. In this modest treatment trial no patient required any pads 15 days after catheter removal. There was nearly a 100% satisfactory sexual function outcome, as measured by preoperative and postoperative International Index of Erectile Function scores. In fact, many of the men could actually achieve harvesting of sperm-containing urine which was able to be retrieved and used for fertilization, although no patient has accomplished fathering as yet. Although the results of this brief followup period suggest no adverse effects on cancer management, further experience with this type of procedure is required before recommending that prostate sparing cystectomy is a viable option in the management of muscle invasive or high grade, noninvasive bladder cancer. Herr et al (page 1823) in this issue of The Journal speaks to standardization of radical cystectomy and pelvic lymph node dissection (PLND) for bladder cancer. This was an effort put forth by a multi-institutional group (Bladder Cancer Collaborative Group). This group consisted of a number of individuals reporting from Memorial Sloan-Kettering Cancer Center, University of Michigan, Vanderbilt University and Baylor College of Medicine, wherein the 16 surgeons of those institutions reported a total of 1,091 cystectomy cases from 2000 to 2002. Patient, tumor and surgical variables of margin status, extent of pelvic node dissection, number of nodes examined and surgeon volume associated with bladder cancer outcomes were reported. Unfortunately, this study was not as informative as the smaller Italian study. It is difficult to understand how the authors reached conclusions that they cited. First, the question of how many cystectomies should surgeons perform is not really well addressed. The authors suggest that “at least 10 per year are required to maintain proficiency” but 4 of their “expert” surgeons performed fewer than 10 cystectomies annually. What are the acceptable limits of pelvic lymph node dissection? A standard PLND or greater is advised in at least 75% to 80% of patients undergoing cystectomy but the article does not suggest which patients should be subjected to more limited node dissections or else none at all! Clearly, patients who have had prior therapy (chemotherapy or other) were less likely to undergo standard or extended lymph node dissection but the variation in lymph nodes resected was so high as not to seem important. Regardless of surgeon volume of cystectomy, no lymph node dissection at all was performed in 8% to 13% of cases, a limited node dissection was done in 8% to 13% a standard lymph node dissection was performed in 53% to 76% and extended dissection was done in 11% to 26% (all without much relation to surgical volume). The number of nodes harvested actually was higher, on average, for surgeons who had less than 50 cases of experience, and the range of nodes harvested was 0 to 70 overall, 0 to 70 for the less experienced surgeons, 0 to 48 for the intermediate experienced surgeon and 0 to 70 for the most experienced surgeon.