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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) - PowerPoint PPT Presentation
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Surgical Surgical Management of Management of Invasive Bladder Invasive Bladder
CancerCancerYao Kai Yao Kai
Indications for radical Indications for radical cystectomycystectomy
Infiltrating muscle-invasive bladder cancer without Infiltrating muscle-invasive bladder cancer without evidence of metastasis or with low-volume, evidence of metastasis or with low-volume, resectable locoregional metastases (stage T2-T3b) resectable locoregional metastases (stage T2-T3b)
Superficial bladder tumors characterized by any of Superficial bladder tumors characterized by any of the following: the following: Refractory to cystoscopic resection and intravesical Refractory to cystoscopic resection and intravesical
chemotherapy or immunotherapy chemotherapy or immunotherapy Extensive disease not amenable to cystoscopic resection Extensive disease not amenable to cystoscopic resection Invasive prostatic urethral involvementInvasive prostatic urethral involvement
Stage-pT1, grade-3 tumors unresponsive to Stage-pT1, grade-3 tumors unresponsive to intravesical BCG vaccine therapy intravesical BCG vaccine therapy
CIS refractory to intravesical immunotherapy or CIS refractory to intravesical immunotherapy or chemotherapy chemotherapy
Palliation for pain, bleeding, or urinary frequency Palliation for pain, bleeding, or urinary frequency Primary adenocarcinoma, SCC, or sarcomaPrimary adenocarcinoma, SCC, or sarcoma
Radical cystectomy: Radical cystectomy: evolutionevolution
More than removing just the bladder More than removing just the bladder (simple cystectomy)(simple cystectomy)
First performed in 1800s for bladder First performed in 1800s for bladder cancercancer
1948, landmark report showed a 47% 1948, landmark report showed a 47% incidence of local recurrence within 1 year incidence of local recurrence within 1 year and 33% mortality after recurrent disease and 33% mortality after recurrent disease within 1-2 yearswithin 1-2 years
Overall outcomes of patients undergoing Overall outcomes of patients undergoing simple cystectomies were poor. simple cystectomies were poor.
Modern Radical CystectomyModern Radical Cystectomy Radical CystectomyRadical Cystectomy
Removal of bladder with surrounding fatRemoval of bladder with surrounding fat Prostate/seminal vesicles (males)Prostate/seminal vesicles (males) Uterus/fallopian tubes/ovaries/cervix (females)Uterus/fallopian tubes/ovaries/cervix (females) ++ Urethrectomy Urethrectomy
Pelvic LymphadenectomyPelvic Lymphadenectomy More is betterMore is better
Urinary DiversionUrinary Diversion Ileal conduitIleal conduit Continent cutaneous reservoirContinent cutaneous reservoir Orthotopic neobladderOrthotopic neobladder
Radical CystectomyRadical CystectomyOUTCOMESOUTCOMES
• 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
Radical CystectomyRadical CystectomyOUTCOMESOUTCOMES
Stein JP, et al. J Clin Oncol 19:666, 2001
Impact of Surgical Impact of Surgical Technique on OutcomesTechnique on Outcomes
More extended lymph nodes More extended lymph nodes dissection = better outcomes dissection = better outcomes
More lymph nodes removed = better More lymph nodes removed = better outcomesoutcomes
Lower positive margin rate = better Lower positive margin rate = better outcomesoutcomes
More experienced surgeons = better More experienced surgeons = better outcomesoutcomes
Standard Standard LNDLND Extended Extended
LNDLND
Pelvic LymphadenectomyPelvic Lymphadenectomy
common iliac vessel bifurcation
Pelvic LymphadenectomyPelvic Lymphadenectomy
~25%~25% have LN involvement at cystectomy have LN involvement at cystectomy
Accurate stagingAccurate staging Assessment of prognosisAssessment of prognosis Adjuvant therapies (chemotherapy, clinical trials)Adjuvant therapies (chemotherapy, clinical trials)
Therapeutic benefitTherapeutic benefit Removal of micrometastatic diseaseRemoval of micrometastatic disease
Bla
dd
er C
ance
r-sp
ecif
ic S
urv
ival
Pro
bab
ilit
y
Years after Radical Cystectomy
100
90
80
70
60
50
40
18
30
20
16148
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 <12 59.2 ±5.1% 44.9 ±6.3% 44.9 ±6.3%
10
0
4 6 10 12
No. lymph node removed ≥12 n=613
No. lymph node removed <12 n=113
Log rank test
P<0.0001
All Patients
Number of Nodes Sampled Affects Number of Nodes Sampled Affects Survival in Both Node NegativeSurvival in Both Node Negative and and
Node Positive PatientsNode Positive Patients
Node negative Node Positive
Herr Urology 61:105, 2003
Outcome After Radical Cystectomy With Limited or Extended Pelvic Lymph Node Dissection. J Urol 179, 873-878, March 2008
Two consecutive series of patients treated with Two consecutive series of patients treated with radical cystectomy and limited radical cystectomy and limited PLND PLND (336; (336; Cleveland Cleveland ClinicClinic)) and extended and extended PLND PLND (322; (322; University of BernUniversity of Bern)) were were analyzedanalyzed
All cases were staged N0M0 prior to radical All cases were staged N0M0 prior to radical cystectomycystectomy
(without treatment of neoadjuvant therapy)(without treatment of neoadjuvant therapy)
Outcome After Radical Cystectomy With Limited or Extended Pelvic Lymph Node Dissection. J Urol 179, 873-878, March 2008
Using the limited template and with Using the limited template and with submission as a single packet from each side, submission as a single packet from each side, a median of 12 nodes were reported per CC a median of 12 nodes were reported per CC patient. Median number of positive nodes patient. Median number of positive nodes was 1 was 1
Using the extended template and submission Using the extended template and submission of 6 packets, a median of 22 nodes were of 6 packets, a median of 22 nodes were reported per Bern patient. Median number of reported per Bern patient. Median number of positive nodes was 2 positive nodes was 2
The overall lymph node positive rate was 13% The overall lymph node positive rate was 13% for patients with limited and 26% for those for patients with limited and 26% for those who had extended PLNDwho had extended PLND
Outcome After Radical Cystectomy With Limited or Extended Pelvic Lymph Node Dissection. J Urol 179, 873-878, March 2008
Recurrence-free survival Recurrence-free survival After Radical Cystectomy With Limited or Extended PLND
for pT2+3pN+
Limited PLND Extended PLND
Outcome After Radical Cystectomy With Limited or Extended Pelvic Lymph Node Dissection. J Urol 179, 873-878, March 2008
Recurrence-free survival Recurrence-free survival After Radical Cystectomy With Limited or Extended PLND
for pT2+3pN0
Limited PLND Extended PLND
Outcome After Radical Cystectomy With Limited or Extended Pelvic Lymph Node Dissection. J Urol 179, 873-878, March 2008
Overall survival Overall survival After Radical Cystectomy
With Limited or Extended PLND for pT2pN0-2 and pT3pN0-2
Limited PLND Extended PLND
Urinary DiversionUrinary Diversion
Use of Use of intestinal segmentintestinal segment to bypass/ reconstruct/ to bypass/ reconstruct/ replace the normal urinary tractreplace the normal urinary tract
Goals: Goals: Storage of urineStorage of urine without absorption without absorption Maintain low pressureMaintain low pressure even at high volumes to allow even at high volumes to allow
unobstructed flow of urine from kidneysunobstructed flow of urine from kidneys Prevent refluxPrevent reflux of urine back to the kidneys of urine back to the kidneys Socially-acceptable Socially-acceptable continencecontinence EmptiesEmpties completely completely
““Ideal” diversion has yet to be discoveredIdeal” diversion has yet to be discovered
Types of Urinary DiversionTypes of Urinary Diversion
ILEAL CONDUIT(incontinent
diversion to skin)
CONTINENT CUTANEOUS RESERVOIR
(continent diversion to skin)
ORTHOTOPIC NEOBLADDER
(continent diversion to urethra)
Ileal ConduitIleal Conduit
15-20 cm of small 15-20 cm of small intestine (ileum) is intestine (ileum) is separated from the separated from the intestinal tractintestinal tract
Intestines are sewn Intestines are sewn back together (re-back together (re-establish intestinal establish intestinal continuity)continuity)
Ileal ConduitIleal Conduit
Ureters are attached to Ureters are attached to one end of the segment one end of the segment of ileum of ileum
Natural peristalsis of Natural peristalsis of intestine propels urine intestine propels urine through the segmentthrough the segment
Other end is brought Other end is brought out through an opening out through an opening on the abdomenon the abdomen
ureterureter
Ileum
Ileal ConduitIleal Conduit
ADVANTAGESADVANTAGES Simplest to performSimplest to perform Least potential for Least potential for
complicationscomplications No need for intermittent No need for intermittent
catheterizationcatheterization Less absorption of urineLess absorption of urine
DISADVANTAGESDISADVANTAGES Need to wear an external Need to wear an external
collection bagcollection bag Stoma complicationsStoma complications
Parastomal herniaParastomal hernia Stomal stenosisStomal stenosis
Long-term sequelaeLong-term sequelae PyelonephritisPyelonephritis Renal deteriorationRenal deterioration
Continent Cutaneous ReservoirContinent Cutaneous Reservoir Many variations (same theme)Many variations (same theme)
Indiana Pouch, Penn Pouch, Kock Pouch…Indiana Pouch, Penn Pouch, Kock Pouch… All use various parts of the intestineAll use various parts of the intestine
ileum, right colon most commonlyileum, right colon most commonly ReservoirReservoir
““Detubularized” intestine- low pressure storageDetubularized” intestine- low pressure storage Continence mechanismContinence mechanism
Ileocecal valve (Indiana)Ileocecal valve (Indiana) Flap valve (Penn, Lahey)Flap valve (Penn, Lahey) Intussuscepted nipple valve (Kock)Intussuscepted nipple valve (Kock)
Continent Cutaneous ReservoirContinent Cutaneous ReservoirINDIANA POUCHINDIANA POUCH
Appendix removed
Right colon and distal
ileum isolated Right colon is opened lengthwise and folded down to create a sphere
Continent Cutaneous ReservoirContinent Cutaneous ReservoirINDIANA POUCHINDIANA POUCH
RESERVOIREFFERENT LIMB
(to skin)
catheter
Ureters attached to back of reservoir (not shown)
Continence maintained by ileocecal valve
Continent Cutaneous ReservoirContinent Cutaneous ReservoirINDIANA POUCHINDIANA POUCH
Continent Cutaneous ReservoirContinent Cutaneous Reservoir
ADVANTAGESADVANTAGES No external bagNo external bag Stoma can be covered Stoma can be covered
with bandaidwith bandaid
DISADVANTAGESDISADVANTAGES Most complexMost complex Need for regular Need for regular
intermittent intermittent catheterizationcatheterization
Potential complications:Potential complications: Stoma stenosisStoma stenosis StonesStones Urine infectionsUrine infections
Orthotopic NeobladderOrthotopic Neobladder
Currently the diversion of choiceCurrently the diversion of choice Hautmann, Studer, T-Pouch,etc.Hautmann, Studer, T-Pouch,etc.
COMPONENTSCOMPONENTS:: Internal reservoirInternal reservoir – detubularized ileum – detubularized ileum Connect to urethra (“efferent limb”)Connect to urethra (“efferent limb”)
Urethral sphincter provides continenceUrethral sphincter provides continence ““Antirefluxing”Antirefluxing” – ureteral connection – ureteral connection
Antirefluxing uretero-intestinal anastomosis(Hautmann )Antirefluxing uretero-intestinal anastomosis(Hautmann ) Low pressure isoperistaltic limb (Studer)Low pressure isoperistaltic limb (Studer)
Orthotopic NeobladderOrthotopic Neobladder
ADVANTAGESADVANTAGES No external bagNo external bag Urinate through Urinate through
urethraurethra May not need May not need
catheterizationcatheterization
DISADVANTAGESDISADVANTAGES Incontinence (10-30%)Incontinence (10-30%) Retention (5-20%)Retention (5-20%) Risk of stones, UTI’sRisk of stones, UTI’s Need to “train” Need to “train”
neobladderneobladder
Choice of Urinary DiversionChoice of Urinary Diversion
Disease FactorsDisease Factors Urethral marginUrethral margin
Patient FactorsPatient Factors Kidney function / liver functionKidney function / liver function Manual dexterityManual dexterity Preoperative urinary continence/ urethral Preoperative urinary continence/ urethral
stricturesstrictures MotivationMotivation
Surgeon FactorsSurgeon Factors Familiarity with various types of diversionsFamiliarity with various types of diversions
Urinary DiversionsUrinary Diversions
Enterostomal therapist is Enterostomal therapist is CRITICALCRITICAL for for successsuccess
Urinary diversions require lifelong follow-up Urinary diversions require lifelong follow-up Imaging (kidneys/ureters/diversion)Imaging (kidneys/ureters/diversion) Labs (electrolytes, acid-base, B12 levels)Labs (electrolytes, acid-base, B12 levels) Cancer follow-up (surveillance imaging, cytology)Cancer follow-up (surveillance imaging, cytology)
ConclusionsConclusions
Surgery is the cornerstone of treatment for Surgery is the cornerstone of treatment for invasive bladder cancerinvasive bladder cancer
Accurate staging (after surgery) is the most Accurate staging (after surgery) is the most important determinant of prognosisimportant determinant of prognosis
A properly performed lymph node A properly performed lymph node dissection makes a differencedissection makes a difference
Choice of urinary diversion must be Choice of urinary diversion must be individualized for optimal outcomesindividualized for optimal outcomes
ConclusionsConclusions Limited PLND is associated with suboptimal staging, Limited PLND is associated with suboptimal staging,
poorer outcome for patients with node positive and poorer outcome for patients with node positive and node negative disease with comparable pT stage and node negative disease with comparable pT stage and a higher rate of LPa higher rate of LP
Extended PLND appears not only to allow for more Extended PLND appears not only to allow for more accurate staging but also for improved survival of accurate staging but also for improved survival of patients with organ confined, nonorgan confined and patients with organ confined, nonorgan confined and LN positive diseaseLN positive disease
Thank you