260 CHAPTER 6 Urological neoplasia

Muscle-invasive bladder cancer: surgical management of localized (pT2/3a) disease

This is a dangerous disease; untreated 5-year survival is 3%. In the absence of prospective randomized trials comparing the surgical and nonsurgical treatments, the options for a patient with newly diagnosed confined mus- cle-invasive bladder cancer are as follows.

Bladder preservation

•Radical transurethral resection of bladder tumor (TURBT) plus systemic chemotherapy, mostly done in setting of clinical trial at present or in patients clearly unfit for radical cystectomy. With hydronephrosis, bladder preservation relative contraindication.

•Palliative TURBT palliative radiotherapy (RT): for elderly/unfit patients

•Partial cystectomy in highly selected patients without evidence of CIS

•TURBT plus definitive RT (see p. 264): poor options for SCC and adenocarcinoma as they are seldom radiosensitive

Radical cystectomy with:

•Ileal conduit urinary diversion

•Continent urinary diversion (orthotopic neoblader or catherizable stoma)

•Neoadjuvant chemotherapy: some evidence of benefit (see p. 264)

•Neoadjuvant RT: no evidence of benefit

Partial cystectomy

A good option for well-selected patients with small solitary disease located near the dome, and for urachal carcinoma. Morbidity is less than with radical cystectomy.

The surgical specimen should be covered with perivesical fat, with a 1.5 cm margin of macroscopically normal bladder around the tumor. There should be no biopsy evidence of CIS elsewhere in the bladder.

The bladder must be closed without tension and catheterized for 7–10 days to allow healing. Subsequent review cystoscopies ensure no tumor recurrence.

Radical cystectomy with urinary diversion

This is the most effective primary treatment for muscle-invasive UC, SCC, and adenocarcinoma, and can be used as salvage treatment if bladder preservation has failed. It is also a treatment for G3T1 UC and CIS, refractory to BCG.

However, this is a major undertaking for the patient and surgeon, requiring support from cancer specialist nurse, stoma therapist, or continence advisor.

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The procedure

Some centers are exploring laparoscopic radical cystectomy with urinary diversion. However, it is not currently considered the standard of care. Standard open surgical radical cystectomy is described.

Through a midline abdominal transperitoneal approach, the entire bladder is excised along with perivesical vascular pedicles, fat, and urachus, plus the prostate or anterior vaginal wall. The anterior urethra is not excised unless there is prior biopsy evidence of tumor at the female bladder neck or prostatic urethra (when recurrence occurs in 37%).

The ureters are divided close to the bladder, ensuring their disease-free status by frozen-section histology if necessary, and anastomosed into the chosen urinary diversion (see p. 266).

A bilateral pelvic lymphadenectomy is undertaken at the time. The extent and completeness of the lymphadenectomy can have important therapeutic implications.

Node burden (>8 positive) and node density, the ratio of involved nodes to total lymph nodes (>20%) has worse prognosis

Major complications

Affect 25% of cystectomy patients. These include perioperative death (1%), re-operation (10%), bleeding, thromboembolism, sepsis, wound infection/ dehiscence (10%), intestinal obstruction or prolonged ileus (10%), cardiopulmonary morbidity, and rectal injury (4%).

Erectile dysfunction is likely in men after cystectomy due to cavernosal nerve injury.

The complications of urinary diversion are discussed on p. 266.

Postoperative care

Monitoring in the intensive care unit for 24 hours is considered standard at most centers.

Daily clinical evaluation, including inspection of the wound (and stoma if present), plus monitoring of blood count and creatinine/electrolytes, is mandatory. Broad-spectrum antimicrobial prophylaxis and thromboembolic prophylaxis with TED stockings, pneumatic calf compression, and subcutaneous heparin are standard.

Assisted ambulation after 24 hours is ideal. Chest physiotherapy and adequate analgesia is especially important in smokers and patients with chest comorbidity. Oral intake is restricted until bowel sounds are present; some patients may require parenteral nutrition in the presence of gastrointestinal complications.

Drains are usually placed in the pelvis or near the ureterodiversion anastomosis. Ureteral catheters passing from the renal pelves through the diversion and exiting percutaneously or through the stoma are used. If a continent diversion is performed, a catheter draining the diversion will be exiting urethrally or suprapubically.

Most patients are hospitalized 7–10 days.

262 CHAPTER 6 Urological neoplasia

Salvage radical cystectomy is technically a more difficult and slightly more morbid procedure. Relatively few patients who have failed primary RT and chemotherapy are suitable for this second chance of a cure.

Efficacy of radical cystectomy 5-year survival rates are as follows:

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Muscle-invasive bladder cancer: radical and palliative radiotherapy

Radical external beam radiotherapy (RT)

This is a good option for treating muscle-invasive (pT2/3/4) UC in patients who are not healthy or unwilling to undergo cystectomy. The 5-year survival rates are inferior to those of surgery, but the bladder is preserved and the complications are less significant.

Typically, a total dose of 70 Gy is administered in 30 fractions over 6 weeks. Higher-grade tumors tend to do less well, perhaps because of the undetected presence of disease outside the field of irradiation. Beyond this, prediction of radiotherapy response remains difficult, relying on fol- low-up cystoscopy and biopsy. CIS, SCC, and adenocarcinoma are poorly sensitive to radiotherapy.

Neoadjuvant or adjuvant cisplatin-based combination chemotherapy with RT is used in locally advanced (pT3b/4) disease (see p. 264) and is more commonly performed than RT monotherapy.

Complications

These occur in 70% of patients; they are self-limiting in 90% of cases. Complications include radiation cystitis (LUTS and dysuria) and proctitis (diarrhea and rectal bleeding). These effects usually last only a few months.

Refractory radiation cystitis and hematuria may rarely require measures such as intravesical alum, formalin, hyperbaric oxygen, iliac artery embolization, or even palliative cystectomy.

Efficacy of RT monotherapy

5-year survival rates are as follows:

If disease persists or recurs, salvage cystectomy may still be successful in appropriately selected patients; 5-year survival rates are 30–50%.

Otherwise, cytotoxic chemotherapy (see p. 265) and palliative measures may be considered.

Palliative treatment

This includes radiotherapy for metastatic bone pain (30 Gy) or to palliate symptomatic local tumor (40–50 Gy). Intractable hematuria may be controlled by intravesical formalin or alum, hyperbaric oxygen, bilateral internal iliac artery embolization or ligation, or palliative cystectomy.

Ureteral obstruction may be relieved by percutaneous nephrostomy and antegrade stenting (see p. 456). Involvement of a palliative care team can be very helpful to the patient and family.