Surgical Management of
Invasive Bladder Cancer
Yao Kai
Indications for radical cystectomy
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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:
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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
Radical cystectomy: evolution
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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.
Modern Radical Cystectomy
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Radical Cystectomy
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Pelvic Lymphadenectomy
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Removal of bladder with surrounding fat
Prostate/seminal vesicles (males)
Uterus/fallopian tubes/ovaries/cervix (females)
+ Urethrectomy
More is better
Urinary Diversion
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Ileal conduit
Continent cutaneous reservoir
Orthotopic neobladder
Radical Cystectomy
OUTCOMES
• 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 Cystectomy
OUTCOMES
Stein JP, et al. J Clin Oncol 19:666, 2001
Impact of Surgical Technique on
Outcomes
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More extended lymph nodes dissection = better
outcomes
More lymph nodes removed = better outcomes
Lower positive margin rate = better outcomes
More experienced surgeons = better outcomes
Pelvic Lymphadenectomy
common iliac vessel bifurcation
Standard LND
Extended LND
Pelvic Lymphadenectomy
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~25% have LN involvement at cystectomy
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Accurate staging
Assessment of prognosis
 Adjuvant therapies (chemotherapy, clinical trials)
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Therapeutic benefit
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Removal of micrometastatic disease
Bladder Cancer-specific Survival Probability
100
All Patients
90
80
No. lymph node removed ≥12
n=613
70
60
50
40
No. lymph node removed <12
n=113
30
20
10
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%
Log rank test
P<0.0001
0
4
6
8
10
12
Years after Radical Cystectomy
14
16
18
Number of Nodes Sampled Affects Survival in
Both Node Negative and Node Positive Patients
Node negative
Node Positive
Herr Urology 61:105, 2003
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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
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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
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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
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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
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 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 After Radical Cystectomy With Limited or
Extended PLND for pT2pN0-2 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
Urinary Diversion
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Use of intestinal segment to bypass/ reconstruct/
replace the normal urinary tract
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Goals:
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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
Types of Urinary Diversion
ILEAL CONDUIT
(incontinent
diversion to skin)
CONTINENT
CUTANEOUS
RESERVOIR
(continent diversion
to skin)
ORTHOTOPIC
NEOBLADDER
(continent diversion
to urethra)
Ileal Conduit
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15-20 cm of small
intestine (ileum) is
separated from the
intestinal tract
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Intestines are sewn
back together (reestablish intestinal
continuity)
Ileal Conduit
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Ureters are attached to
one end of the segment
of ileum
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Natural peristalsis of
intestine propels urine
through the segment
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Other end is brought
out through an opening
on the abdomen
Ileum
ureter
ureter
Ileal Conduit
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ADVANTAGES
Simplest to perform
Least potential for
complications
No need for intermittent
catheterization
Less absorption of urine
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DISADVANTAGES
Need to wear an external
collection bag
Stoma complications
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Parastomal hernia
Stomal stenosis
Long-term sequelae
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Pyelonephritis
Renal deterioration
Continent Cutaneous Reservoir
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Many variations (same theme)
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All use various parts of the intestine
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ileum, right colon most commonly
Reservoir
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Indiana Pouch, Penn Pouch, Kock Pouch…
“Detubularized” intestine- low pressure storage
Continence mechanism
Ileocecal valve (Indiana)
 Flap valve (Penn, Lahey)
 Intussuscepted nipple valve (Kock)
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Continent Cutaneous Reservoir
INDIANA POUCH
Appendix
removed
Right colon
and distal
ileum isolated
Right colon is
opened
lengthwise and
folded down to
create a
sphere
Continent Cutaneous Reservoir
INDIANA POUCH
Ureters attached to back of reservoir (not shown)
catheter
RESERVOIR
EFFERENT LIMB
(to skin)
Continence maintained
by ileocecal valve
Continent Cutaneous Reservoir
INDIANA POUCH
Continent Cutaneous Reservoir
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ADVANTAGES
No external bag
Stoma can be covered
with bandaid
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DISADVANTAGES
Most complex
Need for regular
intermittent
catheterization
Potential complications:
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Stoma stenosis
Stones
Urine infections
Orthotopic Neobladder
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Currently the diversion of choice
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Hautmann, Studer, T-Pouch,etc.
COMPONENTS:
 Internal reservoir – detubularized ileum
 Connect to urethra (“efferent limb”)
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Urethral sphincter provides continence
“Antirefluxing” – ureteral connection
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Antirefluxing uretero-intestinal anastomosis(Hautmann )
Low pressure isoperistaltic limb (Studer)
Orthotopic Neobladder
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ADVANTAGES
No external bag
Urinate through
urethra
May not need
catheterization
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DISADVANTAGES
Incontinence (10-30%)
Retention (5-20%)
Risk of stones, UTI’s
Need to “train”
neobladder
Choice of Urinary Diversion
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Disease Factors
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Urethral margin
Patient Factors
Kidney function / liver function
 Manual dexterity
 Preoperative urinary continence/ urethral
strictures
 Motivation
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Surgeon Factors
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Familiarity with various types of diversions
Urinary Diversions
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Enterostomal therapist is CRITICAL for
success
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Urinary diversions require lifelong follow-up
Imaging (kidneys/ureters/diversion)
 Labs (electrolytes, acid-base, B12 levels)
 Cancer follow-up (surveillance imaging, cytology)
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Conclusions
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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
Conclusions
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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
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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
Thank you