To summarize, it is important to consider the patient’s biological age and cardiorespiratory and vascular status, as bladder cancer patients are elderly and have medical comorbidities. Nutritional aspects should be evaluated in preoperative assessment. Obesity may lead to wound infection, dehiscence, and stomal problems.

Due to advances in anesthesia, intensive care, prevention, and effective management of cardiovascular diseases, there is decreased mortality and morbidity following radical cystectomy [21]. The complication rates following cystectomy approaches 20–30 % in most series (Table 35.2).

Mortality is usually related to the patients’ comorbidities, and it has decreased substantially in the last two to three decades to approximately 1–2 % [22, 23].

Radical cystectomy involves the removal of the entire bladder and urethra with pelvic lymph nodes bilaterally in men, and the removal of the bladder, urethra, uterus, cervix, and cuff of the vagina in women. The procedure is carried out by either a laparoscopic or an open approach. It is an effective curative treatment for muscle-invasive urothelial cancer of the bladder. Excellent local control of the disease can be achieved. It also provides amelioration of local symptoms due to bladder cancer such as hematuria, frequency, dysuria, and clot retention.

In men, radical cystectomy is typically performed as radical cystoprostatectomy with removal of the bladder, prostate, and seminal vesicles en bloc. It maybe performed with or without cavernous-nerve sparing for improved erectile function postoperatively. Prostate-sparing cystectomy has been described to improve the potency rate [24]. However, the chances of incidental prostate cancer is high, around 15–40 %; hence this is not widely practiced. In women, radical cystectomy is typically performed as anterior exenteration consisting of removal of the bladder, uterus, ovaries, fallopian tubes, and part of the anterior vaginal wall. Bilateral pelvic lymphadenectomy involves removal of the obturator, external and internal iliac lymph nodes bilaterally up to the common iliac artery bifurcation. It is always performed in conjunction with radical cystectomy both as a therapeutic and as a staging diagnostic procedure. Occasionally these patients may have prolonged lymphatic leak and lymphocele. Recent data suggest that an extended lymph node dissection (to the bifurcation of the aorta) may also be a therapeutic procedure for patients with minimal lymphadenopathy [25]. Patients with a greater number of removed lymph nodes may have an improved disease-free survival. Most patients with positive lymph nodes require adjuvant chemotherapy. However despite these measures, the 5-year survival is poor at 20 %.

Partial cystectomy has not received adequate recognition it deserves amongst urologists and oncologists. It involves removal of part of the bladder wall that is involved by a discrete lesion. Patients with a solitary muscle-invasive lesion, with no evidence of carcinoma in situ (CIS) or previous history of multiple superficial tumors or metastasis, without involvement of the trigone or posterior urethra, are suitable candidates and it is desirable to have a clear margin of at least 1.5 cm around the tumor. Localised muscle-infiltrating tumours in the fundus or anterior wall are ideal for PC. Other indications include bladder tumors within a diverticulum and urachal adenocarcinoma in the urachus [26].

Before considering the bladder-preserving procedure, the following assessment should be done: (1) bladder mapping: rule out CIS and multifocal lesions by performing systematic bladder biopsies (mapping); (2) bladder capacity should be assessed preoperatively should be adequate to avoid postoperative voiding symptoms due to low bladder capacity. Patients who undergo partial cystectomy require surveillance with cystoscopy and urinary cytology due to an increased risk of recurrence secondary to multifocal nature of urothelial cancer. Bladder capacity can be increased by using a loop of ileum (ileo-cystoplasty). The mean 5-year survival after partial cystectomy for T2 to T3b tumors is 67–80 % [27, 28].

Salvage cystectomy is indicated in intractable haematuria or development of fistula following chemotherapy or radiotherapy or due to severe intractable and disabling urinary symptoms. It is also considered in patients with local recurrence or progression following primary radiotherapy. The operation is usually considered palliative; however, well-selected patients may have significant long-term survival.

Intraoperative blood loss tends to be high, as is the risk of injury to adjacent organs (e.g., rectum, iliac vessels, etc.). Anatomical planes are not well defined in postradiotherapy patients because of desmoplastic reaction. The surgeon should be prepared to perform only a urinary diversion if the bladder cannot be safely removed. Tissue planes are often distorted secondary to radiation. Risks of wound infection and ileus are also increased. Survival rates after salvage cystectomy are quite low [29]. Complication rates are higher with orthotopic bladder reconstruction in these cases.

The ileal conduit is the preferred method of urinary diversion in salvage cystectomy. Risk of incontinence is greater if neobladder reconstruction is attempted secondary to radiation effects on the sphincter. Assessment of the ileum must be made to ensure that there are no radiation-induced injuries, and in such cases other segments of uninvolved bowel should be used.

Various specialist centers in Europe and the United States have described conservative procedures involving bladder removal with pelvic lymph node dissection and preservation of the vasa deferentia, prostate, and seminal vesicles in males, and all internal genitalia in females. This is followed by an ileal neobladder reconstruction and its anastomosis to the margins of the prostate in males and urethra in females. Indications for this type of surgery are T1 to T3 BC with no tumor in the bladder neck and prostate in males and absent tumor in the trigone in females [24]. These patients need to undergo preoperative assessment and investigations for neoplasia of the prostate (prostate-specific antigen (PSA) and transrectal Ultrasound), uterus, and cervix (colposcopy and cytology), and erectile dysfunction in men. The results are encouraging, but long-term follow-up results are still awaited [30].

Radical cystectomy and urinary diversion may be complicated by significant intraoperative blood loss. The operation can be lengthy (3–6 h), and patients would have also typically undergone complete bowel preparation for 1 or 2 days prior to the operation. Patients may also be chronically anemic secondary to gross hematuria. Therefore, intraoperative and postoperative fluid management is critical.

Intraoperative monitoring entails the following:

Postoperative care entails the following:

Bowel preparation reduces the risk of infection and provides the surgeon greater visibility in performing an ureterointestinal anastomosis. Mechanical bowel preparation combined with antibiotics is the preferred option. However, there are studies that failed to show any benefit with mechanical bowel preparation.

The typical bowel preparation includes the following:

Virtually every possible type of bowel segment has been utilized in the creation of both urinary conduits and urinary diversions. Ileum is currently the preferred choice of bowel for conduits due to its low risk of metabolic abnormalities, ease of use, and length of mesentery [31]. Jejunum is rarely used because of its greater risk of metabolic complications. Transverse colon is typically second choice if ileum is not available or diseased secondary to prior pelvic radiation.

The bowel must be handled gently. The “butt” end of the conduit is usually oversewn with nonabsorbable sutures if metallic staples are used to divide the bowel. The ureterointestinal anastomosis must be widely spatulated to prevent anastomotic strictures [32]. Anastomosis performed over 7-Fr stents. Alternately a T-tube can be used as a splint with horizontal limbs of T in each ureter and vertical limb in the lumen of ileaum. Mesenteric defect should be re-approximated with nonabsorbable sutures to prevent internal herniation.

Stomal stenosis (5–15 %) can be exacerbated by poorly fitting appliances [32, 33]. Uretero-intestinal anastomotic stricture is seen in 5–15 %, and when present it is important to rule out malignancy. Chronic pyelonephritis and renal failure are seen in 15 % of cases on long-term followup. Parastomal hernia (5 %) and conduit calculi (5–20 %) are also seen.

Metabolic complications include the following:

Orthotopic bladder substitutions are being increasingly offered to patients undergoing cystectomy due to documented improvement in the quality of life, our increased understanding of pelvic anatomy, and advances in the surgical techniques [34]. The pelvic anatomy should be favorable and should not compromise the functional and oncological outcomes. Meticulous preservation of the external sphincter mechanism is essential. The distal urethra should be free of malignancies and strictures. Locally advanced disease is not a strict contraindication for bladder substitution, and the decision to perform bladder substitution should be individualized. Adjuvant and neoadjuvant chemotherapy are safe in these patients, and hence orthotopic bladder substitution should not be denied unfairly to patients who may require chemotherapy [35]. Detailed preoperative discussion with the patient regarding bladder substitution is essential. Patients should always be counseled for alternate urinary diversion options, such as ileal conduit preoperatively in case the neobladder formation is not feasible. Enterostomal therapists play a pivotal role in patient-education both pre- and postoperatively.

The long-term outcome is dependent on careful patient selection, meticulous postoperative care, and follow-up.

Renal insufficiency increases the chances of complications such as metabolic acidosis and electrolyte imbalances. In patients with serum creatinine levels >2.0 mg/L, bladder substitution should be avoided. However, if the renal insufficiency is due to ureteral obstruction that can be reversed during surgery and bladder substitution should be considered.

A history of previous bowel resection, inflammatory bowel disease, and radiation therapy increases the chances of postoperative bowel dysfunction. These patients should be fully evaluated and counseled regarding the bowel dysfunction. An attempt should be made to preserve the terminal ileum and ileocecal valve to minimize bowel dysfunction and maintain vitamin B12 and bile salt metabolism.

Patients with liver dysfunction are at a higher risk for hyperammonemia following neobladder formation, particularly if the patient develops infection with urease-splitting organisms.

In patients with significant sphincter deficiency and stress incontinence, neobladder reconstruction should be avoided.

It is imperative that the urethral margins at the anastomotic level be negative for malignancy to avoid tumor recurrences. The presence of carcinoma in situ, multifocal disease and prostatic urethral involvement increases the chances of tumor recurrence, but they are not absolute contraindications for reconstructive procedures.