Radical cystectomy and lymphadenectomy for invasive bladder cancer: towards the evolution of an optimal surgical standard.

The surgical management of invasive bladder cancer has undergone a significant evolution in technique since its initial introduction. Changes in the extent of surgery have largely reflected a better understanding of the natural history of bladder cancer and the recognized pathways of progression. Incorporation of contemporary surgical techniques that target the perivesical soft tissues, regional lymph nodes, and adjacent organs appear to enhance oncologic outcomes. A growing body of evidence indicates that the quality of radical cystectomy (RC) directly affects patient outcome. Recently, quality of life and functional considerations have led to surgical modifications such as nerve-, prostate-, vaginal wall-, and urethra-sparing approaches. While some modifications in appropriate candidates appear not to decrease cancer control, further studies will be needed to establish their role and safety. This ongoing evolution in the technique of RC and pelvic lymph node dissection (PLND) may help define a new surgical standard that provides optimal benefit in patients with invasive bladder cancer.