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Home » Oncology » Oncology – Bladder » Radical cystectomy

Radical cystectomy

Removal of the bladder, surrounding peri-vesical fat, pelvic lymph nodes and

  • Prostate and seminal vesicles in men
  • Uterus, cervix, ovaries, fallopian tubes and anterior vagina in women
  • +/- urethrectomy

 

Timing

  • Meta-analyses have shown delay > 12 weeks between diagnosis of muscle invasion and cystectomy is associated with worse overall survival.
  • After neo-adjuvant chemo, still aim for expedient surgery but enough time to recovery functionally and haematologically after chemo.

 

Technique

Pre-op

  • Stomal therapy and site marked, treat any UTI, medically optimised, ICU bed booked, group and hold, +/- bowel prep, cell saver, headlight

General/men:

  • Supine with both arms out, break at pelvis
  • Lower midline laparotomy to umbilicus
  • Extra-peritoneal approach initially a la radical prostatectomy
  • Develop space of Retzius and de-fat prostate
  • Incise endopelvic fascia
  • Suture ligation of DVC with 0-vicryl sutures and division of DVC
  • Apical dissection, don’t divide urethra until confirmed resectability
  • Retrograde dissection between prostate and rectum along Denonvilliers with Ligasure and clips to posterolateral pedicles
  • Open peritoneum and divide urachus with long tie, develop peritoneal wings each side of medial umbilical ligaments
  • Pack away bowel
  • Open posterior peritoneum over iliacs to expose and sling ureters
  • Ureteric dissection towards to bladder – should come across vas which can be divided
  • Continue ureteric dissection to bladder as far able – divide ureter between two right angles, tie each side (long tie on ureters to find later)
  • Develop lateral bladder pedicles and divide with stapler or Ligasure
  • Join up intraperitoneal and extraperitoneal dissection with hand underneath SVs and divide remaining pedicles
  • Ensure haemostasis DVC and peri-urethral

In females:

  • Similarly can develop Retzius at start but then open peritoneum early and develop wings
  • As follow ureters down will come across round ligament – ligate and divide with long tie
  • Look for gonadal vein in the IP ligament from ovaries – ligate and divide with long tie
  • Add ties to urachal clip and will continue to pull the pelvic organs up and out
  • Continue ureteric dissection coming across uterine pedicles and superior vesical pedicle – ligate with Ligasure/clips/stapler
  • Divide ureters as normal between right angles, with ties and long tail
  • Once all gynae and bladder pedicles, specimen should be lifted up
  • Betadine soaked swab on a stick in vagina to identify cervix and make anterior vaginal wall incision (closed as clamshell / longitudinally)
    • Protect rectum by identifying peritoneum of rectovaginal Pouch of Douglas
  • Urethra will have similar DVC above it which can be controlled similarly by bunching EPF
  • Dissect urethra as much as able aiming for complete excision

 

Lymphadenectomy

  • Bilateral pelvic lymph node dissection is both diagnostic and potentially therapeutic – with patients undergoing PLND shown to have better overall survival cf. cystectomy without LND.
  • 25 % of patients have positive nodes at time of cystectomy.
  • Lymph node status on LND is the most powerful surrogate for recurrence and survival.
  • Nodal spread is generally predictable, with obturator/internal iliac nodes affected first usually.
  • Some studies have suggested > 10 lymph nodes in dissection associated with improved overall survival (depends on pathological analysis, and also autopsy studies show significant inter-individual variations in nodal count). Sending lymph node tissue in separate packets increases nodal count.

 

Boundaries of pelvic lymph node dissection:

  • Inferiorly
    • Cloquet’s node / inguinal ligament
  • Medially
    • Bladder and ureter
  • Laterally
    • Pelvic side wall and genitofemoral nerve
  • Cranially
    • Standard – bifurcation of common iliac
    • Extended – aortic bifurcation (including pre-sacral nodes)
    • Super-extended – IMA

Recommended nodal dissection is controversial:

  • At least a standard LND should include obturator, internal iliac and common iliac nodes
  • Some studies suggest a cancer specific and overall survival with extended and super-extended dissections, but these studies have inconsistency in techniques and results and both EAU and AUA guidelines suggest “methodological limitations” and “study bias”

 

Bowel prep

  • No strong evidence that it either increases or reduces complications
  • Omitted in ERAS packages

 

Open vs robotic

  • Robotic cystectomy prevalence increasing
  • Cochrane review of 5 RCTs – no difference in oncological outcomes, no difference in rate of major or minor complications, no difference in patient reported quality of life
  • Less blood loss and transfusion with robotic surgery
  • Reduction in hospital stay
  • Longer OT time with robotic surgery
  • Surgeon and institution volume is probably more important that technique specifically

 

Urethrectomy

  • Risk factors for urethral involvement or recurrence is extent of CIS and bladder neck and prostatic urethral involvement, prostatic stromal invasion and multifocal disease
  • 4 – 17 % urethral recurrence rate.
  • Negative urethral margin is usually obtained in men
  • Women often undergo essentially near complete urethrectomy at time of cystectomy (except if planning neobladder)
  • Delayed urethrectomy is an acceptable option if positive urethral margin at time of cystectomy in men

 

Organ sparing

Prostate sparing or prostate capsule / nerve sparing in men:

  • Aiming to preserve potency
  • More common in neobladder
  • 20 – 25 % men will have prostate cancer on cystoprostatectomy specimen

 

Gynaecological organ sparing:

  • Risk of pelvic organ involvement is less than 10 %
    • Usually direct invasion into vaginal wall
  • Consider vaginal sparing in sexually active women, if oncologically appropriate
  • Consider ovarian sparing in premenopausal women
    • If hereditary risk of breast or ovarian cancer (BRCA), oophorectomy should be done
  • Must be no concern for T4 disease or concern in area of organ being spared
  • EAU – do not offer pelvic organ preserving radical cystectomy to women as standard therapy
  • AUA – may be considered as long as complete tumour resection can be achieved (no disease at bladder neck or trigone)

 

Frozen sections:

  • Need to do frozen sections of urethral margin if doing neobladder
  • Distal ureteric margins on surgeon preference
    • Upper tract disease following cystectomy is rare, < 10 %
    • Skip ureteric lesions are well described
    • Higher risk of UTUC or positive margins with CIS
    • Positive frozen section may predict risk of upper tract involvement in future
    • But, sequential clearance to a negative margin has not been shown to impact recurrence or survival (and risk compromising ureteric length)

 

ERAS

  • Package of interventions, adopted from colorectal surgery, including:
    • No bowel prep
    • Carbohydrate drinks pre-operatively
    • Spinal and regional anaesthesia
    • Opioid sparing analgesia
    • No nasogastric tube
    • Early feeding
    • Aggressive ambulation
    • Mu opioid antagonists (alvimopan)
    • Aggressive stomal therapy

 

Evidence for ERAS in cystectomy:

  • Alvimopan shows definite reduction in ileus and length of stay
  • Package of interventions generally reduces length of stay and ileus rates
  • Effect on complication rate and readmission rates unclear or not changed
  • Difficult to ascertain which interventions are responsible for improvements seen
  • ERAS protocols may increase administration burden and ‘box-ticking’
  • May limit flexibility and patient focussed or individualised care
  • Patient satisfaction may be higher
  • Often limited by logistics and practicalities – weekend staffing, safe discharge destination
  • Requires buy-in from multiple disciplines – surgeons, anaesthetics, nursing, allied health, administration
  • Reduction in ileus and LOS associated with cost savings

 

VTE risk in radical cystectomy

  • 5 – 10 % risk of VTE/PE within 30 days.
  • 28 days of post-operative clexane reduces risk of VTE.
  • VTE risk is higher in patients who receive neoadjuvant chemotherapy.
  • EAU strong recommendation for 4 weeks post-operative clexane.

 

Complications of cystectomy

60 % of patients have a complication

 

General/anaesthetic risks

  • DVT/PE, CVA, MI, positioning, anaphylaxis, pneumonia

 

Intraoperative risks

  • Bleeding
    • DVC, iliacs, mesenteric, pedicles
  • Rectal injury
    • General surgeon, 2 layered closure + omentum vs end colostomy diversion (size of injury, nutritional status of patient, radiation all important factors)
  • Conduit won’t reach
    • Ensure harvest appropriate length, optimise fascial opening and left ureteric mobility, avoid or divide anchoring retroperitoneal suture, further mobilise right colon and caecum, relaxing incisions in peritoneum of mesentery, deepen mesenteric incisions, Turnbull loop, incise mesentery at stoma end to free up the stoma end, start again or harvest another segment and add on
  • Injury to other structures
    • Obturator nerve – reapproximate
    • Bowel injury – oversew in 2 layers with Heineke Mikulicz principle
  • Fixed tumour to side wall or pelvis
    • Abandon +/- diversion only

 

Early post-operative

  • Ileus / SBO
    • Start TPN day 7 if no significant oral intake
  • Lymphocele
  • Wound infection
  • Fascial dehiscence
  • Stoma necrosis
  • Sepsis or infection
  • Bowel leak
    • Take back to theatre with general surgeon, washout, +/- repair or resect +/- divert
  • Urine leak
    • Poor technique, poor healing, radiation, intra-abdominal or pelvic collection or haematoma
    • If presents delayed at 1-2 weeks consider ischaemic ureter
    • Elevated serum Cr, drain outputs, reduced urine output, prolonged ileus, fevers or flank pain
    • Most commonly left side
    • CT to ensure no large urinoma which needs drainaing
    • CT IVP or loopogram to determine point of leak
    • Initially manage conservative – stent or nephrostomy, drain urinoma off suction, optimise nutrition, catheter in conduit
    • Repair/re-do if not responding to conservative – timing dependent on patients condition
  • Peri-operative death
    • 1 – 2 %

 

Late complications

  • Ureteroileal stricture
  • Renal failure
  • Metabolic complications of diversion
    • Hyperchloraemic hypokalemic metabolic acidosis, B12 deficiency, bone loss
  • Stomal issues – retraction, parastomal hernia
  • Neobladder issues – retention, incontinence, rupture, stones
  • Sexual dysfunction

 

Outcomes after radical cystectomy

5 year survival:

  • pT0 – 85 %
  • pT2 – 65 %
  • pT3/4 – 50 %
  • pN1 – 30 %

 

Choice of diversion

  • Incontinent diversion
    • Ileal conduit (or colonic conduit)
  • Continent orthotopic
    • Neobladder
  • Continent cutaneous
    • Indiana pouch

 

 

Follow up after cystectomy

  • Local recurrence
    • Poor prognosis – median survival up to 8 months
  • Distant or nodal recurrence
    • More common in pN+ patients
    • Most likely sites are nodes, lung, liver and bone
    • 90 % of distant recurrences occur within first 3 years, mainly in first two years
    • Median survival with cisplatin chemotherapy 1 – 2 years
  • Urothelial recurrences
    • 5 % risk of urethral recurrence – higher risk if bladder neck / prostatic urethral involvement
    • Survival benefit if urethral recurrence detected asymptomatically vs symptomatically – so worth monitoring those at risk
      • Rx BCG vs urethrectomy
    • 4 – 10 % risk of upper tract recurrence – more common after 3 years
      • Quite often diagnosed symptomatically cf. by surveillance
    • Complications of diversion
      • B12 deficiency
      • Metabolic acidosis
      • Renal function deterioration
      • Recurrent infections
      • Hydronephrosis and ureteroileal strictures
      • Stones
      • Stomal complications – parastomal hernia, retraction
      • Neobladder complications – incontinence, retention

 

My regime:

  • CT C/A/P (or IVP) every 6 months for 3 years then annual CT/USS
  • B12 annually with bloods
  • Urethroscopy and washings annually (or PRN if any symptoms)
  • AUA – limited role for urine cytology – detection of upper tract cancers is inferior to CT and may be confusing due to desquamated intestinal epithelial cells – CT IVP probably better.