Surgical Management of Bladder Carcinoma

Rafael Carrion, MD, John Seigne, MB

Disclosures

Cancer Control. 2002;9(4) 

In This Article

Open Surgical Management

Radical cystectomy is the most common treatment for invasive bladder cancer in the United States. This approach allows wide excision of the bladder, the surrounding structures, and the draining lymph nodes. Current improvements in surgical technique, urinary reconstruction, and perioperative care have decreased surgical morbidity and mortality and have improved patient quality of life.

Partial Cystectomy

Fewer partial cystectomies are performed today due to the development of improved techniques for TUR of bladder tumors and improved understanding of the natural biology of bladder tumors. Partial cystectomy provides certain intrinsic advantages attractive to patients and physicians alike, including sparing potency in men, leaving a functioning natural reservoir, allowing a full thickness resection of the tumor, and allowing the ability to sample the pelvic nodes. However, the major disadvantage is that the field defect is not treated, thus leading to high tumor recurrence rates ranging from 40% to 80% in some series.[23,24] The high tumor recurrence rate has not only potentially life-threatening consequences for the patient, but also the added burden of requiring frequent cystoscopic (ie, uncomfortable, labor intensive, and costly) follow-up and often adjuvant intravesical therapy.

Less than 10% of patients with invasive bladder cancer are candidates for a partial cystectomy. The lesion should be an initial occurrence and should be solitary with no associated carcinoma in situ (random bladder biopsies are required to confirm this). The tumor must be located in a part of the bladder that allows for complete resection with clean margins and preservation of an adequate bladder capacity. In essence, this excludes patients with lesions around the trigone where the ureteral orifices and bladder neck are in close proximity. Patients with lesions on the dome of the bladder and tumors located in diverticula are good candidates for partial cystectomy.

At the time of surgery, the tumor is excised from the bladder with a 2-cm margin (confirmed by frozen section), and the bladder is then closed in two layers with absorbable sutures. Intraoperatively, care must be taken to prevent spillage of urine due to the risk of tumor cell implantation in the surgical wound. Long-term complications include decreased bladder capacity and tumor recurrence.

Radical Cystectomy

The most common indication for radical cystectomy is a muscle-invasive (T2 or greater) bladder tumor without evidence of distant metastasis. Additional indications include recurrent high-grade Tl or Ta bladder carcinoma despite repeated endoscopic resection and adjuvant intravesical chemotherapy (these patients have a high risk of disease progression) and multiple recurrences of low-grade Ta bladder cancer that cannot be controlled by periodic endoscopic resection. The surgery is performed through a lower midline incision (although perineal cystectomies and laparoscopic cystectomies have been described).[25,26,27] A complete pelvic lymph node dissection is performed (Fig 2). In men, the bladder, peritoneal covering, perivesical fat, lower potion of the ureters, prostate, seminal vesicles, the distal portion of the vasa deferentia, and possibly the urethra are removed (Fig 3). The urinary tract is reconstructed with either an ileal conduit, a continent cutaneous diversion, or a neobladder. In women, the bladder, peritoneal covering, perivesical fat, lower portion of the ureters, uterus, ovaries, fallopian tubes, and possibly the anterior vaginal wall and the urethra are removed. In a fashion similar to that used in men, the urinary tract is reconstructed with either an ileal conduit, a continent cutaneous diversion, or a neobladder.

Figure 2.

Left pelvic lymphadenectomy. The fibrolymphatic tissues surrounding the iliac vessels -- external iliac artery (EIA), internal iliac artery (IIA), external iliac vein (EIV) -- in the pelvis have been removed. The margins of dissection are as follows: superiorly, the common iliac artery (some would say aortic bifurcation); inferiorly, the circumflex iliac vein (CIV); laterally, the genitofemoral nerve (GFN); and medially, the pelvic floor. Care must be taken to correctly identify and preserve the obturator nerve (ON). The ureter (U) can be seen medially.

Figure 3.

Posterior view of a male radical cystectomy specimen. The bladder (BL), peritoneal covering, perivesical fat, lower potion of the ureters (U), prostate (PR), seminal vesicles (SV), and the distal portion of the vasa deferentia (V) have been removed. A probe has been inserted into the urethra (UR) at the tip of the prostate. The urachus (UA) has been excised to the level of the umbilicus. The right (RN) and left (LN) lymph node packets are seen accompanying the cystectomy specimen.

Lymphadenectomy

Bilateral pelvic lymphadenectomy is important for the staging and treatment of invasive bladder carcinoma.[28] This entails removing the fibrolymphatic tissues surrounding the iliac vessels in the pelvis. The margins of dissection are proximally from the common iliac artery (some would say the aortic bifurcation) to the circumflex iliac vein distally and laterally from the genitofemoral nerve superiorly to the pelvic floor inferiorly. Care must be taken to correctly identify and preserve the obturator nerve as it emerges from the medial border of the psoas muscle[29] (Fig 2). There is some controversy as to how extensive the lymph node dissection should be, whether it should be obtained en bloc or submitted separately, whether the node dissection has any therapeutic as opposed to just prognostic value, and whether cystectomy in the face of positive lymph nodes provides any survival advantage. Several recent reports have clarified some of these issues. Herr and colleagues[30] examined whether the number of nodes removed would affect outcomes after radical cystectomy. These investigators found that a minimum of 9 nodes needed to be examined to accurately assess nodal status. They also found that survival improved in both node-positive and node-negative patients as the number of nodes removed increased. Although it cannot be concluded from this report that the extent of the node dissection generated the improved survival (because of multiple confounding influences such as adjuvant treatment decisions and more accurate staging), it is likely that it was a contributing factor. The same investigators evaluated the impact of submitting nodes en bloc or as separate packages and suggested that submitting nodes as separate packages not only is easier but also optimizes the evaluation and number of the lymph nodes retrieved.[30,31]

There is no doubt that a pelvic lymphadenectomy has significant prognostic importance. Patients with positive nodes are clearly at increased risk of failure and are candidates for adjuvant chemotherapy, which has the potential to provide a survival advantage (again, a controversial issue).[30,32] Whether the node dissection itself provides a survival advantage in patients with positive nodes is less clear. Certainly, some studies indicate that lymphadenectomy, in combination with radical cystectomy, can cure a small fraction of node-positive patients.[32] The subset of patients benefiting most from lymphadenectomy and cystectomy in the face of positive nodes appear to be those with a low-stage primary tumor.

Based on this information, we proceed with radical cystectomy when we discover positive nodes (either grossly or on frozen section) at the time of surgery in the following circumstances: (1) when the patient has substantial local symptoms from the tumor, (2) when the local stage of the tumor is low, and (3) when cystectomy can be performed easily with minimal morbidity to the patient (to allow for prompt initiation of chemotherapy). We are reluctant to perform continent urinary diversion to the urethra in these circumstances due to the risk of pelvic recurrence and the necessity for subsequent therapy.

Urethrectomy

Over the past 10 years, the indications for total urethrectomy at the time of cystectomy have undergone substantial modification. The overall risk of urethral recurrence after cystectomy is approximately 10%.[33] Historically, urethrectomy was performed in patients with multifocal tumors, diffuse carcinoma in situ, and prostatic urethral involvement. More recent studies have identified prostatic stromal invasion or diffuse carcinoma in situ of the prostatic urethra as the primary risk factor, conferring a 25% to 35% risk of urethral recurrence.[34] Two studies have found a less than 5% incidence of urethral recurrence in patients undergoing ileal neobladder replacement despite the postoperative identification of prostatic stromal involvement.[35] Based on these two large series, we no longer perform routine preoperative prostatic urethral biopsies prior to cystectomy, but instead we rely on frozen section analysis of the urethral margin to decide whether to proceed with neobladder construction or perform a urethrectomy and continent cutaneous diversion. In patients who are not candidates for a neobladder and have known prostatic stromal involvement by tumor, we perform an en bloc urethral resection. For patients who have had a cutaneous diversion and are discovered on final pathology sto have prostatic stromal involvement, we recommend ag delayed urethrectomy after they have completed adjuvant chemotherapy.

In women, a classical radical cystectomy includes removal of the urethra and anterior vaginal wall since case series have reported urethral and vaginal involvement by transitional cell carcinoma in approximately 13% of cystectomies.[36,37] However, careful histological studies have documented a low incidence of urethral tumor involvement (0% to 20%) in the absence of tumor at the bladder neck. Currently, in women who are candidates for neobladders, we perform cystoscopy and preoperative bladder neck biopsies combined with intraoperative frozen section of the bladder neck margin prior to proceeding with neobladder construction.[36,37] We routinely resect the urethra and anterior vaginal wall in women who are not candidates for a neobladder.

Management of the Ureter

A small subgroup of patients (1% to 9%) are found to have carcinoma in situ at the distal ureteral margin at the time of frozen section during a cystectomy. Resection of sufficient ureter to obtain a negative margin may result in substantial ureteral shortening. In such a situation, the ureter may no longer reach the necessary distance into the pelvis to perform a tension-free anastomosis to an orthotopic neobladder. Certain continent diversions (eg, the Studer pouch and the modified Hautmann neobladder) have long afferent limbs that can bridge moderate ureteral gaps.[38,39] In cases where we are unable to obtain a margin clear of carcinoma in situ and the patient has good ipsilateral renal function, we will cut the ureter "comfortably" short and perform the urinary diversion. Several studies have shown a low incidence of ipsilateral tumor recurrence in these circumstances.[40,41]

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