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The majority of bladder cancer patients present with superficial disease and are managed with conservative measures. Approximately 20–25% present with muscle-invasive bladder cancer that is potentially life threatening and requires radical treatment. Definitive radiation therapy (RT) has been used for muscle-invasive bladder cancer since the early 1900s and there is evidence that patients can achieve durable local control and maintain a functional bladder without a compromise in the overall survival. 1 However, the standard North American approach to the management of muscle-invasive bladder cancer is radical cystectomy. 2 In the past few decades, radical radiation therapy has been used infrequently and mostly when patients either refused or were not suitable for radical cystectomy. Therefore there is a limited amount of information on the precise role that radiation therapy plays in the management of bladder cancer.

Radical cystectomy is the gold standard of treatment for patients with muscle-invading tumours in most countries. Radiation therapy (RT) is used as primary therapy in only a few countries. Improvements in surgical techniques, peri-operative care, and early diagnosis have led to an increase in survival. This is owing to stage migration of 10–20% per stage. In addition, the frequency of deeply invasive tumours has decreased. The presence of a palpable mass is less, and the incidence of N+ disease has diminished. 1

Recent quality of life studies demonstrated a defi nite advantage of orthotopic neobladders over other forms of continent or incontinent urinary diversion. Satisfactory functional results of an orthotopic bladder replacement require preservation of an adequate segment of the urethra, which in turn should not compromise the oncological outcome of cystectomy.

The American Cancer Society has estimated that there will be 53,200 new cases of bladder cancer diagnosed in the United States this year. 1 Of these, approximately 70% will be of the superficial subtype that can frequently be managed with transurethral resection (TUR), intravesical therapy in selected cases, and careful surveillance for recurrence or progression. The remaining 30% of patients, however, are diagnosed with a far more virulent phenotype of bladder cancer that is invasive into the muscular wall of the bladder, demonstrates significantly increased metastatic potential, and is responsible in large part for the considerable morbidity and mortality associated with the disease. Over 12,200 people are estimated to die from bladder cancer this year, and the overwhelming majority of these patients represent those who present with an invasive phenotype that progresses to metastatic disease. 1

Bladder cancer is an extremely common cancer throughout the world. It is estimated that, per year, there are 261,000 cases of bladder cancer and 115,000 deaths from bladder cancer worldwide. 1 It is the fifth most common cancer in men and the seventh in women, with an annual incidence of approximately 18 cases per 100,000 in the United States. An estimated 54,500 new cases in 1999 led to some 12,000 deaths. 2 The male to female occurrence is three to one. It is primarily a disease of the elderly, with 80% of cases in the 50–79-year age groups, and a peak incidence in the seventh decade.

The subject of invasive transitional cell cancer in the elderly raises several issues. First, what does the diagnosis of invasive transitional cell cancer imply biologically? Second, what is the efficacy of various treatments and what are their risks? Third, how large is the ageing population and what is the magnitude of the problem of invasive transitional cell cancer in this population? Fourth, how do the health of the elderly, the physiology of various organ systems, and their functional reserve during ageing influence the course of disease, the choice of treatment, and the impact of both on the host?

In clinical oncology, health-related quality of life (QL) is defined as a multi-dimensional concept of a cancer patient’s overall wellbeing as seen through his or her eyes. QL is usually evaluated by psychometrically evaluated questionnaires completed by the patients themselves. The use of ad-hoc designed questionnaires should be avoided.

Transitional cell carcinoma primarily involves the bladder, but quite frequently it also involves, either simultaneously or metachronously, the urothelium of the urethra and the upper urinary tract. 1 In fact, transitional cell carcinoma is a multifocal disease and it is well known that the urothelial lining of the pyelocaliceal system, the ureters, and the proximal urethra are at equal risk as the bladder because of a uniform sensitivity of the urothelium to neo-plastic stimuli. Therefore, seeding and implantation of exfoliated cells, as well as lymphatic spread, has been proposed to explain urethral recurrence, although definitive proof of the existence of this pathway is yet to be demonstrated.

During the past century a fascinating development in procedures for lower urinary tract reconstruction has taken place. Within few fields of surgery has greater ingenuity been exercised than in the methods devised for diversion of urine. Since the first report on such a procedure 150 years ago, the urine stream has been conveyed to the outside of the body with the use of an infinite number of surgical techniques. 1 The practicability of the described techniques has often not corresponded to their theoretic advantages, and only a few have been accepted for clinical use. Today the most commonly used methods are conduit diversion, continent cutaneous diversion and orthotopic bladder replacement. For these methods there are now long-term results available with regard to functional outcome, i.e. flow, storage and emptying of urine. Renal function and metabolic consequences of incorporating bowel segments into the urinary tract have been clarified and the impact on patients’ quality of life studied. During the past 10 years, development has concentrated on refining these methods.

The term’ salvage cystectomy’ refers to surgical removal of the urinary bladder in patients who have previously undergone unsuccessful definitive therapy for bladder cancer. Historically, this term was most commonly used when patients underwent radical cystectomy after prior radiation therapy. Salvage cystectomy was considered a formidable surgical procedure with significantly increased morbidity and mortality, and cancer recurrence rates were also very high. 1 – 6 Although this bleak outlook improved a little when reports from the University of Southern California, Memorial Sloan- Kettering Cancer Center, and the University of Texas MD Anderson Cancer Center were published in 1980 and 1981, salvage cystectomy was clearly still a difficult procedure, helpful only in carefully selected patients and probably best reserved for institutions experienced in the management of this type of problem. 7 – 9 Multiple reports since that time have re-affirmed the technical difficulty of salvage cystectomy, with high morbidity and even mortality rates, and its benefit for limited numbers of patients. 10 – 17