Hemostasis is essential during radical cystectomy, and there are several ways to control the vascular pedicles including clips and sutures, staplers, and bipolar electrocautery devices such as the Ligasure™ (Covidien, Boulder, CO). The use of a stapler is associated with lower blood loss than with the traditional suture and clips technique [87] and the Ligasure appears to be equally effective as a stapler, but more cost efficient [88]. One purported benefit to RARC is decreased intraoperative blood loss [33, 89], and we recently determined that RARC is associated with a lower estimated blood loss and transfusion requirement than ORC (authors data, unpublished). Regardless of the technique used to secure the vascular pedicles, every effort should be taken to avoid excess blood loss given the risks of a blood transfusion and its association with increased mortality after cystectomy [90].

Recently, new techniques have been introduced to manage the prostate and urethra during cystectomy in efforts to improve postoperative functionality and quality of life in men. Historically, urethrectomy was universally recommended at the time of cystectomy, however, given the low risk of urethral recurrence, the popularization of the ONB, and the possible protective effect of ONB on urethral recurrence, patients are now risk stratified to determine if urethrectomy is required [91, 92]. The primary risk factor for anterior urethral recurrence is cancer involvement of the prostate, a finding in upwards of 40 % of cystectomy specimens [91, 93]. Furthermore, CIS, multifocal tumors, and tumors involving the trigone or bladder neck are known to increase the risk of prostatic involvement [93, 94]. Thus, we generally do not perform a urethrectomy in men in the absence of risk factors for urethral recurrence. For those patients not receiving an orthotopic diversion that have a high risk of urethral recurrence, we recommend a urethrectomy at the time of cystectomy.

More recently, a nerve sparing approach to radical cystectomy has been proposed in an attempt to preserve potency and possibly continence with a neobladder. Initially described by Walsh [95], the technique for a nerve sparing radical cystectomy is similar to that of a nerve sparing radical prostatectomy. Some believe that sparing either one or both sets of nerves should be offered to all patients that do not have an oncologic contraindication, whether or not they receive an ONB [96]. Advocates of this approach believe that sparing the neurovascular bundle does not sacrifice the oncologic efficacy of radical cystectomy, as bladder cancer rarely extends through the prostatic capsule [97–99]. Schoenberg et al. presented 10-year data on 101 men who underwent this procedure and demonstrated no positive margins at the site of nerve sparing, survival outcomes similar to that of historic cohorts, and a significant proportion of patients who were able to engage in sexual activity postoperatively [98]. Other series have similarly shown that approximately 80 % of men who were potent prior to cystectomy had good postoperative sexual function with a nerve-sparing procedure [99, 100]. Kessler et al. demonstrated that attempted nerve sparing was associated with improved postoperative erectile function as well as continence with an ONB [101]. Thus, for properly selected sexually active men, nerve-sparing radical cystectomy appears to provide good oncologic control while increasing the likelihood of preserving erectile function and continence. There are no randomized studies of nerve sparing versus non-nerve-sparing cystectomy, thus no firm conclusions regarding these purported functional benefits can be made.

By maximally protecting the neurovascular bundle and rhabdosphincter, a prostate capsule-sparing radical cystectomy is an even more aggressive measure to preserve functionality in patients with an ONB. During this operation, the prostatic urethra, prostatic adenoma, and bladder are removed, a distal urethral frozen section margin is sent, and the prostatic capsule is left in place. Indications for capsule-sparing cystectomy include good preoperative sexual function with tumors that appear to be resectable without requiring a wide periprostatic margin. Contraindications include extravesical tumor extension, bladder cancer involvement of the prostate or bladder neck, CIS, hydronephrosis and biopsy-proven prostate cancer [102, 103]. Clinical staging with transrectal and transurethral evaluation of the prostate and bladder will identify most men that have contraindications to the procedure [104–106].

Although most studies are relatively small and nonrandomized, the functional outcomes with capsule-sparing cystectomy and ONB appear encouraging. Vallancien et al. reported that of 100 capsule-sparing cystectomy patients, over 80 % of previously sexually active men were able to have intercourse postoperatively [105]. In another series, Nieuwenhuijzen et al. reported 78 % of their 44 patients had satisfactory postoperative sexual function [107]. Postoperative daytime and nighttime continence in patients with ONBs also appear to be quite high with this procedure [102]. Still, capsule-sparing cystectomy is controversial given the oncologic concerns of leaving prostatic tissue behind and any conclusions regarding functional and oncological outcomes relative to traditional radical cystectomy are inferences, as no comparative studies exist.

Although urethral and prostatic fossa recurrences in capsule-sparing cystectomy series are low, the risk is cause for concern [105]. Urothelial carcinoma involvement of the prostate may be as high as 40 %, with an increased likelihood in patients with CIS or trigonal tumors [93, 94, 103, 108]. While most of these tumors can be identified preoperatively [106], urothelial carcinoma involving the prostatic capsule and periprostatic tissue (areas not well sampled during clinical staging) has been identified in cystectomy specimens [109]. Thus, advocats of this technique advise urethral and prostatic surveillance as would normally be done with an ONB, and to treat any such recurrences either endoscopically or with undiversion, if necessary [110].

Incidental prostatic adenocarcinoma can be identified in approximately 30 % of cystectomy specimens, up to one quarter of which are clinically significant, and some are located in areas that would be left behind with a capsule-sparing procedure [109, 111–115]. While there is a report of prostate cancer metastasis after radical cystectomy [116], the risk of prostate cancer-specific mortality and biochemical recurrence is low [117–120]. There are no reports of prostate cancer deaths in capsule-sparing cystectomy patients found to harbor occult prostate cancer, and most could be effectively treated, if required [121, 122].

Most importantly, oncologic outcomes with capsule-sparing cystectomy appear comparable to that of traditional radical cystectomy. In one of the largest series of capsule-sparing cystectomy patients, Rozet et al. reported a 4.7 % and 34 % rate of local and distant recurrence, respectively [122]. Despite these encouraging results, some argue that leaving the prostatic capsule is inappropriate, distant failure with capsule-sparing cystectomy is higher than would be expected, and the supporting data are limited by selection bias [123, 124]. Therefore, for properly motivated patients, capsule-sparing cystectomy with ONB may help preserve continence and sexual function, but the risk of residual or recurrent cancer must be understood and, until large randomized studies with extended follow-up exist, it cannot be considered oncologically equal to traditional radical cystectomy [124].

With the increasing use of ONBs in women [125], the preferred management of the urethra at the time of cystectomy has been called into question. While there is a relatively low risk of female urethral involvement (<10 %) by bladder cancer, patients with bladder neck and trigonal tumors are at higher risk [126–128]. In women at low risk for urethral involvement that have a negative intraoperative urethral frozen section analysis, the risk of urethral recurrence can be considered minimal and an ONB may be safely fashioned [129]. Otherwise, urethrectomy is generally performed along with radical cystectomy.

In an effort to improve functionality after cystectomy, some have recommended sparing the gynecologic organs. As vaginal shortening can lead to significant sexual dysfunction, young, sexually active women who desire ONBs and have minimal risk for vaginal wall involvement may be candidates of vaginal wall-sparing cystectomy [130]. Sparing the anterior vaginal wall and maximally preserving paravaginal and periurethral supporting tissues may decrease the risk of pelvic organ prolapse, maintain vaginal length, and reduce the risk of neobladder–vaginal fistula. Chang et al. demonstrated that preservation of the anterior vaginal wall in women with ONBs was associated with a low rate of complications and resulted in satisfactory functional voiding outcomes [131]. Furthermore, sparing the uterus is associated with improved incontinence in women with ONBs, further supporting the utility of preserving uninvolved gynecologic organs [132]. Importantly, sparing these organs does not appear to sacrifice the oncologic efficacy of radical cystectomy. Pathologic analysis of gynecologic organs taken during radical cystectomy demonstrated that, in the absence of gross tumor extension, they are unlikely to be involved by bladder cancer [133]. Ali-El-Dein et al. noted a 2.6 % prevalence of gynecologic organ involvement in cystectomy specimens, with a higher risk in women that had aggressive tumor characteristics [134]. Thus, it does not appear necessary to routinely remove all female gynecologic organs during radical cystectomy.

The neurovascular bundles that provide autonomic innervation to the vagina, clitoris, and proximal urethra run lateral to the vaginal walls and damage can result in sexual and urinary dysfunction [96, 135–137]. With an interest in improving postoperative quality of life in women, some have suggested preservation of these bundles [138, 139]. Several small case–series suggest that, in properly selected patients, sparing one or both of these nerve bundles may help preserve postoperative sexual function and urinary continence in women with ONBs [125, 140, 141]. Vaginal wall and gynecologic organ-sparing procedures may help avoid damage to these nerves.

Postoperative care is an essential element to any operation, no more so than with radical cystectomy. At our institution, we pioneered a collaborative care pathway for cystectomy patients, which incorporates evidence-based guidelines and standardizes patients’ hospital course (Appendix). As a result, the cost and length of hospital stay after cystectomy decreased significantly with no impairment in quality of care [142, 143]. Part of this pathway was exclusion of routine postoperative surgical intensive care unit placement. While it is important to have the resources available to admit a cystectomy patient to an intensive care unit, it is not routine practice. In fact, with the use of a collaborative care pathway, only 6.5 % of radical cystectomy patients required postoperative intensive care unit admission [144].

Another component to postoperative patient care is patient disposition at the time of hospital discharge. With shorter lengths of inpatient stay, there is an increasing use of postoperative home healthcare services and rehabilitation facilities [145]. Aghazadeh et al. recently reported that approximately a third of cystectomy patients are discharged home with services and 9 % to an inpatient facility [146]. In fact, older age, lower preoperative albumin, being unmarried, and a higher Charlson comorbidity index (CCI) were independently associated with discharge to home with services, while older age, poor preoperative exercise tolerance, and a longer hospital stay were associated with discharge to a rehabilitation facility. It is important to educate patients preoperatively that only half are discharged home without services and patients at higher risk of requiring postdischarge care should be appropriately counseled.

Due to the substantial perioperative morbidity of radical cystectomy (Table 2.1), surgeons must be familiar with all possible complications and be prepared to recognize and manage them expediently. Importantly, patients should be counseled about the prevalence and spectrum of these risks preoperatively.

Historically, perioperative complications were reported within 30 days of cystectomy. One large series reported 30-day morbidity, readmission, and mortality rates of 45 %, 18 %, and 1.7 %, respectively [3]. However, given the considerable risk of additional complications in the months following surgery, there has been a trend to report up to 90 days postoperatively. Stimson et al. identified increases in readmission and mortality rates to 27 % and 7 %, respectfully, when following patients to 90 days [147]. Given the nonstandardized methods for reporting complications, it is difficult to compare different series and accurately define the morbidity of radical cystectomy [148]. Thus, using stringent criteria [149] to report 90-day complications, there was a 64 % prevalence of any complication, 26 % risk of readmission, and 2.7 % mortality rate (Table 2.2) [150]. Gastrointestinal, infectious, and wound complications were the most common diagnoses and 11 % required an interventional radiology procedure.

While studies reporting perioperative morbidity after RARC are limited by patient numbers and procedural selection bias, there appears to be a similar rate of complications. Hayn et al. reported perioperative complications on 156 RARC patients and found that 52 % of patients experienced at least one complication within 90 days of surgery [151]. Gastrointestinal, infectious, and genitourinary were the most common types of complications and 21 %, 8.3 %, and 5.8 % of patients were readmitted, required an interventional radiology procedure, and died, respectively. Thus, despite the purported benefits of RARC, it is clearly associated with a similar frequency and spectrum of complications as ORC (Table 2.2).

Although there have been vast improvements in the management of patients with bladder cancer, differences still exist in the quality of surgery delivered. Quality surgical care can be analyzed within the Donabedian framework of structure, process, and outcome [152]. While the components of this framework are interrelated, structural aspects (physical facilities, hospital/surgeon volume) help drive clinical processes (adequacy of lymphadenectomy, use of ONB), which, in turn, are related to outcomes (perioperative morbidity and mortality) [153]. Though certain outcomes may be impacted by patient factors, such as comorbidity and disease severity, some potentially modifiable surgical factors may also impact outcomes. Currently, there are no accepted quality of care indicators for radical cystectomy, thus proxies must be used to estimate surgical quality.

Urothelial carcinoma is a chemosensitive malignancy and data over the past decade has solidified the use of chemotherapy in its management. Given the high rate of distant recurrences, there is no question that systemic therapy plays a role in the management of bladder cancer [164]. Chemotherapy can either be administered preoperatively or postoperatively, and there are advocates for each approach [165]. While neoadjuvant chemotherapy can allow for tumor downstaging, provide early treatment for systemic micrometastasis, is delivered to the tumor with an intact vasculature and may be tolerated better, it also may lead to overtreatment and unintentionally delay cystectomy. Adjuvant chemotherapy can be used selectively for high-risk patients and allows for immediate cystectomy but may be poorly tolerated and delays administration of systemic therapy to patients who may fail surgery due to distant recurrences [166].

Current level 1 data clearly demonstrates a survival benefit of neoadjuvant chemotherapy [167]. Based on a meta-analysis of over 3,000 patients from 11 randomized control trials, the use of multiagent cisplatin neoadjuvant therapy resulted in a 14 % relative risk reduction in mortality and a 22 % reduction in disease specific mortality at 5 years [168]. Patients with a good performance status and clinical factors concerning for high-risk and locally advanced disease are the best candidates for neoadjuvant chemotherapy [169]. However, despite supporting data, neoadjuvant chemotherapy remains relatively underutilized, providing a target for improvement in the quality of care delivered to cystectomy patients [170, 171]. While adjuvant chemotherapy may be beneficial, its use is not strongly supported based on a recent meta-analysis [172, 173]. Because there are no trials directly comparing adjuvant and neoadjuvant chemotherapy, the relative benefit of one over another is speculative.

The last element to a successful cystectomy is survivorship care. One such element of survivorship is cancer surveillance. At 5 years approximately 30–40 % of patients experience a recurrence, but most occur within 2 years of surgery [68, 174, 175]. Depending on pathologic risk factors, there is a small risk of urethral recurrence [91, 176] and an even smaller risk of upper tract recurrence [177]. Boorjian et al. demonstrated that post-cystectomy patients experienced improved survival if their recurrence was detected asymptomatically through routine surveillance imaging, and patients who presented symptomatically fared poorer, supporting the value in routine postoperative surveillance imaging [178]. Unfortunately, there are no set guidelines about the recommended frequency and method for postoperative surveillance and there remains tremendous variation in how patients are monitored [179]. At our institution we image the abdomen and pelvis, typically using CT with intravenous contrast, every 6 months for the first 2 years and then annually thereafter. We do not routinely screen for urethral recurrences in patients with incontinent diversions and retained urethras [180, 181].

Other elements of survivorship include management of late treatment effects, quality of life issues, and physical and psychosocial rehabilitation [169]. As these issues are unquestionably important to cystectomy patients and their families, instituting multidisciplinary survivorship programs continues to be a growing effort among urologists.

Radical cystectomy is the gold-standard treatment for high-risk bladder cancer and a successful result is dependent on multiple patient, surgeon, and institutional factors. The outcome of radical cystectomy can be optimized through proper patient selection, adherence to surgical principles, the use of adjunctive treatments, and regular postoperative follow-up. Regardless of the surgical approach chosen, these principles must be followed as they undoubtedly translate to improved surgical quality.