Surgical Management of Invasive Bladder Cancer

1
Surgical Management of Invasive Bladder Cancer

• Ganesh V. Raj MD, PhD

2
Indications for radical cystectomy

• Infiltrating muscle-invasive bladder cancer
  without evidence of metastasis or with
  low-volume, resectable locoregional metastases
  (stage T2-T3b)
• Superficial bladder tumors characterized by any
  of the following
• Refractory to cystoscopic resection and
  intravesical chemotherapy or immunotherapy
• Extensive disease not amenable to cystoscopic
  resection
• Invasive prostatic urethral involvement
• Stage-pT1, grade-3 tumors unresponsive to
  intravesical BCG vaccine therapy
• CIS refractory to intravesical immunotherapy or
  chemotherapy
• Palliation for pain, bleeding, or urinary
  frequency
• Primary adenocarcinoma, SCC, or sarcoma

3
(No Transcript)
4
Radical cystectomy evolution

• More than removing just the bladder (simple
  cystectomy)
• First performed in 1800s for bladder cancer
• 1948, landmark report showed a 47 incidence of
  local recurrence within 1 year and 33 mortality
  after recurrent disease within 1-2 years
• Overall outcomes of patients undergoing simple
  cystectomies were poor.

5
Modern Radical Cystectomy

• Radical Cystectomy
• Removal of bladder with surrounding fat
• Prostate/seminal vesicles (males)
• Uterus/fallopian tubes/ovaries/cervix (females)
• Urethrectomy
• Pelvic Lymphadenectomy
• More is better
• Urinary Diversion
• Ileal conduit
• Continent cutaneous reservoir
• Orthotopic neobladder

6
(No Transcript)
7
Radical Cystectomy

• Midline incision
• Thorough intraabdominal exploration (rule out
  metastatic disease)
• Assess resectability of bladder

8
Radical cystectomy made ridiculously simple 8
easy steps
9
Step 1 mobilize the urachus from the umbilicus
10
Step 2 mobilize the bladder from the bowel
11
Step 3 isolate and transect ureters
12
Step 4 complete lymph node dissection
13
Step 5 separate bladder from sigmoid colon
14
Step 6 complete posterior dissection and cut off
bladder blood supply
15
Step 7 complete anterior dissection and isolate
urethra
16
Step 8 transect urethra and remove specimen
17
Radical CystectomyOUTCOMES

• 35-40 will develop a recurrence after surgery
• Most recur within first 3 yrs after surgery
• Usually at a distant site
• Almost all will eventually die from their disease

Stein JP, et al. J Clin Oncol 19666, 2001
18
Radical CystectomyOUTCOMES
Stein JP, et al. J Clin Oncol 19666, 2001
19
Impact of Surgical Technique on Outcomes

• More extended lymph nodes dissection better
  outcomes
• More lymph nodes removed better outcomes
• Lower positive margin rate better outcomes
• More experienced surgeons better outcomes

20
(No Transcript)
21
Pelvic Lymphadenectomy
Extended LND
22
Pelvic Lymphadenectomy

• 25 have LN involvement at cystectomy
• Accurate staging
• Assessment of prognosis
• Adjuvant therapies (chemotherapy, clinical
  trials)
• Therapeutic benefit
• Removal of micrometastatic disease

23
Pelvic Lymphadenectomy
24
100
All Patients
90
80
No. lymph node removed 12 n613
70
60
Bladder Cancer-specific Survival Probability
50
No. lymph node removed lt12 n113
40
30
20
3 yr. SE 7 yr. SE 10 yr.
SE No. LN removed 12 78.1 1.9 71.8
2.4 63.6 3.6 No. LN removed lt12 59.2
5.1 44.9 6.3 44.9 6.3
Log rank test Plt0.0001
10
0
18
16
14
8
4
6
10
12
Years after Radical Cystectomy
25
Number of Nodes Sampled Affects Survival in Both
Node Negative and Node Positive Patients
Node negative
Node Positive
Herr Urology 61105, 2003
26
Modifications in technique

• Nerve sparing for potency
• Prostate sparing
• Gynecologic organ sparing
• Anterior vaginal wall sparing
• Urethral sparing in women
• Urethral sparing in men

27
Role of neoadjuvant chemotherapy

• Highly recommended
• But chemo has toxicity
• Do all patients with T1 bladder cancer need
  neoadjuvant chemotherapy?
• Do all patients with T2 bladder cancer need
  neoadjuvant chemotherapy?
• Do all patients with T3 bladder cancer need
  neoadjuvant chemotherapy?

28
(No Transcript)
29
(No Transcript)
30
(No Transcript)
31
Urinary Diversion

• Use of intestinal segment to bypass/ reconstruct/
  replace the normal urinary tract
• Goals
• Storage of urine without absorption
• Maintain low pressure even at high volumes to
  allow unobstructed flow of urine from kidneys
• Prevent reflux of urine back to the kidneys
• Socially-acceptable continence
• Empties completely
• Ideal diversion has yet to be discovered

32
Types of Urinary Diversion
CONTINENT CUTANEOUS RESERVOIR (continent
diversion to skin)
ORTHOTOPIC NEOBLADDER (continent diversion to
urethra)
ILEAL CONDUIT (incontinent diversion to skin)
Figures from www.clevelandclinic.org/health/health
-info/docs
33
Ileal Conduit

• 15-20 cm of small intestine (ileum) is separated
  from the intestinal tract
• Intestines are sewn back together (re-establish
  intestinal continuity)

34
Ileal Conduit

• Ureters are attached to one end of the segment of
  ileum
• Natural peristalsis of intestine propels urine
  through the segment
• Other end is brought out through an opening on
  the abdomen

Ileum
ureter
ureter
35
Ileal Conduit
36
Ileal Conduit
37
Ileal Conduit

• ADVANTAGES
• Simplest to perform
• Least potential for complications
• No need for intermittent catheterization
• Less absorption of urine

• DISADVANTAGES
• Need to wear an external collection bag
• Stoma complications
• Parastomal hernia
• Stomal stenosis
• Long-term sequelae
• Pyelonephritis
• Renal deterioration

38
Continent Cutaneous Reservoir

• Many variations (same theme)
• Indiana Pouch, Penn Pouch, Kock Pouch
• All use various parts of the intestine
• ileum, right colon most commonly
• Reservoir
• Detubularized intestine- low pressure storage
• Continence mechanism
• Ileocecal valve (Indiana)
• Flap valve (Penn, Lahey)
• Intussuscepted nipple valve (Kock)

39
Continent Cutaneous ReservoirINDIANA POUCH
Appendix removed
Right colon and distal ileum isolated
Right colon is opened lengthwise and folded down
to create a sphere
40
Continent Cutaneous ReservoirINDIANA POUCH
Ureters attached to back of reservoir (not shown)
catheter
EFFERENT LIMB (to skin)
RESERVOIR
Continence maintained by ileocecal valve
41
Continent Cutaneous ReservoirINDIANA POUCH
42
Continent Cutaneous Reservoir

• ADVANTAGES
• No external bag
• Stoma can be covered with bandaid

• DISADVANTAGES
• Most complex
• Need for regular intermittent catheterization
• Potential complications
• Stoma stenosis
• Stones
• Urine infections

43
Orthotopic Neobladder

• Currently the diversion of choice
• Studer, T-Pouch, Hautmann, Ghoniem, etc.
• COMPONENTS
• Internal reservoir detubularized ileum
• Connect to urethra (efferent limb)
• Urethral sphincter provides continence
• Afferent Limb ureteral connection
• Antirefluxing (T-Pouch, Kock)
• Low pressure isoperistaltic limb (Studer)

44
Orthotopic Neobladder
Ureters attached
15-20 cm
44 cm
Ileum detubularized
Reservoir
Connect to urethra
STUDER ILEAL NEOBLADDER
45
Orthotopic Neobladder
Isolation of ileal segment
22 cm
22 cm
15-20 cm
46
Orthotopic Neobladder
Afferent Limb
Detubularization of ileum
47
Orthotopic Neobladder
Afferent Limb
Reservoir
Opening to urethra
48
Orthotopic Neobladder
49
Orthotopic Neobladder

• ADVANTAGES
• No external bag
• Urinate through urethra
• May not need catheterization

• DISADVANTAGES
• Incontinence (10-30)
• Retention (5-20)
• Risk of stones, UTIs
• Need to train neobladder

50
Choice of Urinary Diversion

• Disease Factors
• Urethral margin
• Patient Factors
• Kidney function / liver function
• Manual dexterity
• Preoperative urinary continence/ urethral
  strictures
• Motivation
• Surgeon Factors
• Familiarity with various types of diversions

51
Urinary Diversions

• Enterostomal therapist is CRITICAL for success
• Urinary diversions require lifelong follow-up
• Imaging (kidneys/ureters/diversion)
• Labs (electrolytes, acid-base, B12 levels)
• Cancer follow-up (surveillance imaging, cytology)

52
Conclusions

• Surgery is the cornerstone of treatment for
  invasive bladder cancer
• Accurate staging (after surgery) is the most
  important determinant of prognosis
• A properly performed lymph node dissection makes
  a difference
• Choice of urinary diversion must be
  individualized for optimal outcomes

53
New Frontiers

• Laparoscopic cystectomy
• Robotic cystectomy with intracoporeal diversion