The role of surgery in the multimodality treatment of bladder cancer.

There has been little change in bladder cancer survival for more than 40 years, although earlier diagnosis is now detecting more cases at an early, potentially curable stage. Radical cystectomy remains the most effective single treatment, although in the past the morbidity and mortality of treatment and the age of patients made it less favoured as primary treatment. Progress in continent bladder reconstruction is changing attitudes. However, because tissue damage from preoperative radiation, particularly when combined with chemotherapy, makes such operations less safe in patients with advanced disease, reconstruction is primarily of value in high risk superficial and early invasive cancers, though there remains a need for randomized trials or immediate vs deferred use of these operations to establish when they give most benefit. With new knowledge about the role of trauma released tissue repair cytokines and immunosuppressive effect of prolonged anaesthesia on increasing tumour recurrence after surgery, new approaches such as treatment with TNFA, anti-EGF antibody or neoadjuvant chemo/immunotherapy before TURBT to improve on the benefits of surgery need to be explored in randomized trials in both advanced invasive and early superficial disease. With progress in vaccine and gene therapy on the horizon, the central role of the urologist in both harvesting tumours for molecular diagnosis and monitoring response of local disease to treatment is undisputed. The relative underusage and value of bladder washings cytology to provide cells for such studies is also highlighted.