Page 106 - Read Online

Page 2 of 11 Cicione et al. Mini-invasive Surg 2021;5:47 https://dx.doi.org/10.20517/2574-1225.2021.52

Keywords: Salvage radical cystectomy, bladder cancer, radiotherapy, hematuria

INTRODUCTION
Nowadays, the improvements in medical, surgical, and anesthetic techniques have dramatically reduced the
morbidity and mortality associated with radical cystectomy (RC), but it is still considered a major surgery
with a 0.7%-42% risk of developing high-grade complications (defined as Clavien-Dindo Grade ≥ 3) and
[1]
0.4%-7% mortality rate .
RC is the standard treatment for muscle invasive bladder cancer (MIBC) recommended for T2-4a, N0-
NxM0 MIBC, in the case of T1 bladder cancer not responsive to BCG treatment or not controllable by
[2]
TURB . In addition to the surgical skill required to perform RC, one of the challenges regarding this
surgery is related to the patient’s medical condition. Surgery is generally performed in frail elderly patients,
with several comorbidities, intractable gross hematuria and anemia, and some of them (about 10%-15%) are
metastatic .
[2]

The term “salvage radical cystectomy” (SRC) initially referred to RC performed after bladder radiotherapy
and implied an unfavorable meaning for the more elevated skill required to accomplish the procedure as
well as its higher morbidity and mortality rate. Nowadays, SRC term is largely used when the bladder is
removed in patients affected of MIBC who previously underwent unsuccessful initial trimodal treatment
(TMT) or when RC is carried out for a purely palliative purpose aimed at treating only fatal disease-related
complications and symptoms without a true oncologic intent.

We performed a literature review with the aim of summarizing the current role of salvage radical
cystectomy in those two clinical settings of MIBC, after a failed initial treatment or as a palliative surgery.

METHODS
In January 2021, a literature research on PubMed/Medline, Scopus, and Google Scholar databases was
performed by using the following keywords: bladder cancer, muscle invasive bladder cancer, bladder
preservation, radiotherapy, pelvic irradiation, and salvage cystectomy. The title and the abstract of the
retrieved studies were assessed for their relevance and, subsequently, their reference lists were screened to
identify further studies. No time limit was applied to the research strategy, however English language
restriction was used and no abstracts were included. In particular, two authors (Cicione A and Lombardo R)
selected studies which included patients affected by MIBC who underwent salvage cystectomy as a
subsequent treatment for supplementary control of disease and studies where RC was carried out only for a
[3]
symptom-control purpose. Moreover, only studies using the Clavien-Dindo Classification System were
used to assess surgery complications of SRC.

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines
were respected in the preparation of this scoping review [Figure 1].
[4]

RESULTS
Salvage radical cystectomy after trimodal therapy: oncological outcomes
Most of the retrieved studies reporting survival rates after SRC referred to cystectomy performed after
preserving bladder treatment for MIBC [Table 1] [5-18] . Moreover, there are no completed randomized trials
comparing the oncological outcomes of preserving bladder treatment with RC , whereby the current
[2]
oncological benefit of SRC after a bladder preserving treatment is based mainly on surgical series. At