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

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r-sp

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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