Partial cystectomy as a bladder-sparing option for the treatment of muscle-invasive bladder cancer can be very appealing to many urologists, as relative to radical cystectomy with urinary diversion it has less morbidity, is less technically demanding and is amenable to minimally invasive approaches (figs. 1 and 2). This procedure, however, must be used very cautiously in carefully selected and surveilled patients, as it leaves patients at risk of intravesical recurrence and progression.¹ Furthermore, many have raised concerns about inappropriate use of partial cystectomy at centers that are unable or unwilling to perform radical cystectomy with urinary diversion. Overutilization of this procedure has been seen among vulnerable populations such as those living in rural areas and African American patients, potentially disproportionately negatively impacting their oncologic outcomes.²

Figure 1. Intraoperative photo of minimally invasive partial cystectomy prior to excision.

Figure 2. Intraoperative photo of minimally invasive partial cystectomy after excision.

While the AUA Non-Metastatic Muscle Invasive Bladder Cancer Guideline recommends against the routine use of partial cystectomy in patients who are medically fit and willing to undergo radical cystectomy, in the appropriately selected patient it can represent a treatment option.³ Data from Memorial Sloan Kettering and MD Anderson, which have been incorporated into the AUA guidelines, identified the ideal candidate for partial cystectomy as a patient with a solitary tumor, ideally less than 3 cm, that is in an amenable location to complete resection with a healthy margin, such as the dome and anterior bladder. Patients with hydronephrosis or other features concerning for T3 or T4 disease are poor candidates for partial cystectomy, and it should not be performed in those patients. Critically, carcinoma in situ must be excluded with modalities such as random biopsies with or without blue light cystoscopy, as the presence of carcinoma in situ has been shown to drastically increase the risk of advanced recurrence and progression.^1,4 It is also important that these patients are evaluated preoperatively for adequate bladder function, as inadequate preoperative bladder capacity could lead to quality of life impairments after partial cystectomy that would necessitate completion radical cystectomy. Indications and contraindications for partial cystectomy are summarized in the table.

In patients with solitary, less than 3 cm, technically resectable tumors without concomitant carcinoma in situ or features concerning for T3 or T4 disease, long-term oncologic outcomes between partial and radical cystectomy, including distant recurrence-free survival and cancer specific survival, have been shown to be relatively similar.⁵ Despite relatively similar survival in appropriately selected patients, the 5-year risk of recurrence after partial cystectomy has been shown to be as high as 61%, with 16% ultimately undergoing completion radical cystectomy, underscoring the need for close long-term cystoscopic surveillance in these patients.⁴

Given the risk of intravesical recurrence and need for long-term surveillance, before committing a patient to partial cystectomy, surgically or medically complex patients thought to be poor surgical candidates should be referred to a high-volume center and carefully evaluated for candidacy for radical cystectomy. Healthier patients who are hesitant to undergo radical cystectomy should be counseled on and offered orthotopic and continent cutaneous reconstruction as well as nerve-sparing surgery when appropriate. Another option would be trimodality therapy with maximal transurethral resection of bladder tumor followed by external beam radiation therapy and radiation sensitizing chemotherapy, which is an alternative bladder preserving option with similar eligibility criteria, and can also be used in patients with multifocal tumors and tumors in locations inaccessible to partial cystectomy, as long as they are completely resectable transurethrally. While a recent study of the Surveillance, Epidemiology, and End Results program database found improved overall survival with partial cystectomy relative to trimodality therapy, with a hazard ratio of 0.72,⁶ there is a paucity of high-level evidence comparing these treatment options, and currently the AUA guidelines recommend trimodality therapy as the preferred bladder preserving therapy option.³

Bilateral pelvic lymphadenectomy at the time of partial cystectomy for invasive bladder cancer has been shown to improve cancer-specific mortality and should be performed in all patients undergoing this procedure.⁷ Despite this, concomitant pelvic lymphadenectomy is performed in only 50% of partial cystectomies, highlighting a particular area of need for education and improvement.⁷ Cisplatin based neoadjuvant chemotherapy should also be administered when medically feasible, as it has been shown to improve advanced recurrence-free survival with a hazard ratio of 0.18 (p=0.03), although an impact on overall survival was not seen.⁴

The use of partial cystectomy for urachal adenocarcinoma is much less controversial, with partial cystectomy representing the first line treatment option for urachal adenocarcinoma in patients where a complete resection is feasible, with equivalent long-term oncologic outcomes to radical cystectomy.⁸ The use of partial cystectomy for other non-urothelial bladder malignancies including non-urachal adenocarcinoma, squamous cell carcinoma and neuroendocrine carcinoma has been associated with higher cancer-specific mortality relative to patients undergoing partial cystectomy for urothelial carcinoma, with a hazard ratio of 1.4.⁹ While this is likely more attributable to the aggressiveness of these disease processes than the surgical approach, given the poor prognosis associated with variant histologies, the use of partial cystectomy or other bladder sparing treatment modalities should be avoided whenever possible in these patients.

Overall, partial cystectomy is an option for select patients with invasive bladder cancer who are poor candidates for or are unwilling to undergo radical cystectomy and have a less than a 3 cm, solitary tumor in a resectable location without carcinoma in situ or features concerning for T3 or T4 disease and who have appropriate bladder function. It is important to note, however, that despite only 6%–10% of patients with invasive bladder cancer meeting these qualifications, it has been demonstrated that up to 18%–20% of patients needing extirpative surgery for bladder cancer undergo partial cystectomy,² indicating that many of these patients are likely poor candidates for partial cystectomy and at risk for adverse oncologic outcomes. It is critical that urologists understand when and for whom partial cystectomy is the correct treatment choice.