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Surgical Management of Invasive Bladder Cancer

Surgical Management of Invasive Bladder Cancer. Yao Kai. Indications for radical cystectomy. Infiltrating muscle-invasive bladder cancer without evidence of metastasis or with low-volume, resectable locoregional metastases (stage T2-T3b)

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Surgical Management of Invasive Bladder Cancer

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  1. Surgical Management of Invasive Bladder Cancer Yao Kai

  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. 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.

  4. 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

  5. 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 19:666, 2001

  6. Radical CystectomyOUTCOMES Stein JP, et al. J Clin Oncol 19:666, 2001

  7. 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

  8. Standard LND Pelvic Lymphadenectomy common iliac vessel bifurcation Extended LND

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

  10. 100 All Patients 90 80 No. lymph node removed ≥12 n=613 70 60 Bladder Cancer-specific Survival Probability 50 No. lymph node removed <12 n=113 40 30 20 3 yr. ± SE 7 yr. ± SE 10 yr. ± SE No. LN removed ≥1278.1 ±1.9% 71.8 ±2.4% 63.6 ±3.6% No. LN removed <12 59.2 ±5.1% 44.9 ±6.3% 44.9 ±6.3% Log rank test P<0.0001 10 0 4 6 8 10 12 14 16 18 Years after Radical Cystectomy

  11. Number of Nodes Sampled Affects Survival in Both Node Negativeand Node Positive Patients Node negativeNode Positive Herr Urology 61:105, 2003

  12. Two consecutive series of patients treated with radical cystectomy and limited PLND (336; Cleveland Clinic) and extended PLND (322; University of Bern) were analyzed • All cases were staged N0M0 prior to radical cystectomy (without treatment of neoadjuvant therapy) Outcome After Radical Cystectomy With Limited or Extended Pelvic Lymph Node Dissection. J Urol 179, 873-878, March 2008

  13. Using the limited template and with submission as a single packet from each side, a median of 12 nodes were reported per CC patient. Median number of positive nodes was 1 • Using the extended template and submission of 6 packets, a median of 22 nodes were reported per Bern patient. Median number of positive nodes was 2 • The overall lymph node positive rate was 13% for patients with limited and 26% for those who had extended PLND Outcome After Radical Cystectomy With Limited or Extended Pelvic Lymph Node Dissection. J Urol 179, 873-878, March 2008

  14. Recurrence-free survival After Radical Cystectomy With Limited or Extended PLND forpT2+3pN+ Limited PLND Extended PLND Outcome After Radical Cystectomy With Limited or Extended Pelvic Lymph Node Dissection. J Urol 179, 873-878, March 2008

  15. Recurrence-free survival After Radical Cystectomy With Limited or Extended PLND forpT2+3pN0 Limited PLND Extended PLND Outcome After Radical Cystectomy With Limited or Extended Pelvic Lymph Node Dissection. J Urol 179, 873-878, March 2008

  16. Overall survival After Radical Cystectomy With Limited or Extended PLND forpT2pN0-2 and pT3pN0-2 Limited PLND Extended PLND Outcome After Radical Cystectomy With Limited or Extended Pelvic Lymph Node Dissection. J Urol 179, 873-878, March 2008

  17. 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

  18. Types of Urinary Diversion CONTINENT CUTANEOUS RESERVOIR (continent diversion to skin) ORTHOTOPIC NEOBLADDER (continent diversion to urethra) ILEAL CONDUIT (incontinent diversion to skin)

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

  20. 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

  21. 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 Ileal Conduit

  22. 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)

  23. Continent Cutaneous ReservoirINDIANA POUCH Appendix removed Right colon and distal ileum isolated Right colon is opened lengthwise and folded down to create a sphere

  24. Continent Cutaneous ReservoirINDIANA POUCH Ureters attached to back of reservoir (not shown) catheter EFFERENT LIMB (to skin) RESERVOIR Continence maintained by ileocecal valve

  25. Continent Cutaneous ReservoirINDIANA POUCH

  26. 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 Continent Cutaneous Reservoir

  27. Orthotopic Neobladder • Currently the diversion of choice • Hautmann, Studer, T-Pouch,etc. COMPONENTS: • Internal reservoir – detubularized ileum • Connect to urethra (“efferent limb”) • Urethral sphincter provides continence • “Antirefluxing” – ureteral connection • Antirefluxing uretero-intestinal anastomosis(Hautmann ) • Low pressure isoperistaltic limb (Studer)

  28. ADVANTAGES No external bag Urinate through urethra May not need catheterization DISADVANTAGES Incontinence (10-30%) Retention (5-20%) Risk of stones, UTI’s Need to “train” neobladder Orthotopic Neobladder

  29. 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

  30. 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)

  31. 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

  32. Conclusions • Limited PLND is associated with suboptimal staging, poorer outcome for patients with node positive and node negative disease with comparable pT stage and a higher rate of LP • Extended PLND appears not only to allow for more accurate staging but also for improved survival of patients with organ confined, nonorgan confined and LN positive disease

  33. Thank you

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