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Radical Cystectomy

A radical cystectomy is done to treat bladder cancer. This means the surgeon removes the bladder, uterus, ovaries, fallopian tubes, cervix, front wall of the vagina, and the urethra. Although women who have this surgery are often past the age of menopause, many still have active sex lives.

History of the Procedure

The first record of a radical cystectomy dates to the late 1800s. In 1949, Marshall and Whitmore described the basic surgical principles of radical cystoprostatectomy. In 1987, following the neuroanatomic mapping of the pelvic plexus by Schlegel and Walsh, nerve-sparing cystectomy became a surgical option that allowed for preservation of sexual function.[1] For many years, radical cystectomy carried a significant perioperative mortality rate (5%-10%). However, presumably because of improvements in surgical technique, the evolution of intensive care medicine, and the availability of new antibiotics, radical cystectomy is now a common procedure in major medical centers and carries a perioperative mortality rate of approximately 1%-2%.[2] At high-volume centers with postoperative pathway care programs, an ICU stay is no longer routine and the median hospital stay is approximately 7 days.

Bladder cancer can be axiomatically subdivided into nonmuscle invasive and muscle-invasive disease. This article focuses primarily on the management of muscle-invasive transitional cell carcinoma (TCC) and the role of radical cystectomy.

Frequency United States More than 90% of bladder cancers are TCC. Bladder cancer diagnoses increased by 36% from 1984-1993. In the United States, up to 600,000 people have bladder cancer. In 2008, an estimated 68,000 new cases of bladder cancer were diagnosed, and 14,000 persons died of the disease.[3] In 2008, the male-to-female incidence ratio was 2.9:1, and the male-to-female mortality ratio is 2.4:1.[3] Bladder cancer is more common in whites than in African Americans. The average age at diagnosis is 65 years. Screening of asymptomatic individuals is not currently recommended. International In 1996, an estimated 310,000 new cases of bladder cancer were diagnosed worldwide. The incidence rate in Western Europe and North America is higher than in East Asian countries. In developing countries, many bladder cancers are SCCs caused by the parasiteSchistosoma haematobium. In high-prevalence regions, SCC of the bladder has enormous health implications (eg, SCC is the most common solid tumor in Egyptian men).

Environmental risk factors

Smoking Exposure to aromatic amines found in some dyes, paints, solvents, leather dust, inks, combustion products, rubbers, and textiles Prior radiation therapy. Women who have undergone pelvic radiation (eg, for cervical cancer) have a 2- to 4-fold increased incidence rate; survival rates are poorer in men who

have undergone radiation for prostate cancer than in men of similar age and stage who have not undergone radiation. Low daily fluid intake may be a contributing factor. Schistosomiasis caused by the parasite S haematobium can cause SCC; this is common in Egypt and the Nile River Valley. Long-term phenacetin use Long-term placement of indwelling catheters is a risk factor; patients who have indwelling catheters for longer than 10 years should undergo bladder surveillance via cytology and cystoscopy. Artificial sweeteners (saccharin, cyclamate), when administered in high doses to laboratory animals, are risk factors for bladder cancer; no similar evidence has been shown in humans. The use of Aristolochia fangchi, a Chinese herb, has been implicated as a risk factor for both upper and lower tract TCC. Coffee and tea are not risk factors for bladder cancer.

As with most neoplasms, bladder carcinogenesis is a complex multistep process that is not fully understood. Activation of proto-oncogenes, loss or inactivation of tumor suppressor genes, and abnormal growth factor or receptor expression have been implicated. Multiple mutations of chromosome 9 have been identified in superficial bladder cancer cells. Increased expression of the epidermal growth factor receptor and increased mutations of tumor suppressor genes (eg, TP53 and Rb) are common in patients with advanced bladder cancer. Mutations and nuclear accumulation ofTP53 have been correlated with an increased grade, stage, and recurrence risk. The risk of progression to muscle-invasive disease is associated with tumor grade, stage (Ta vs T1), size, number of lesions (solitary vs multiple lesions), previous tumor recurrence, and presence of CIS.

Gross or microscopic hematuria is the initial presenting sign in 80%-90% of patients. Approximately 20% of patients have irritative symptoms such as urinary urgency, dysuria, or frequency. This presentation is typical in patients with diffuse CIS, which can be confused with a urinary tract infection and can result in a delayed diagnosis. With the more routine use of crosssectional imaging, many bladder lesions are incidentally diagnosed. Patients with muscleinvasive disease can present with incidental or symptomatic obstructive hydroureteronephrosis or, less commonly, with metastatic deposits. These factors make bladder cancer a very uncommon incidental finding on autopsy.

Indications for radical cystectomy include the following: Infiltrating muscle-invasive bladder cancer without evidence of metastasis or with lowvolume, resectable locoregional metastases (stage T2-T3b) Superficial bladder tumors characterized by any of the following: o Refractory to cystoscopic resection and intravesical chemotherapy or immunotherapy (Up to 71% of these patients may progress to stage T2 within 5 years of initial recurrence.) o Extensive disease not amenable to cystoscopic resection o 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

Indications for urethrectomy include the following: Tumor in the anterior urethra Prostatic stromal invasion that is noncontiguous with the primary Positive urethral margin during radical cystectomy Diffuse CIS of bladder, prostatic ducts, or prostatic urethra (a relative indication)

Anatomy and Physiology

The anatomy of the bladder forms an extraperitoneal muscular urine reservoir that lies behind the pubic symphysis in the pelvis. A normal bladder functions through a complex coordination of musculoskeletal, neurologic, and psychological functions that allow filling and emptying of the bladder contents. The prime effector of continence is the synergic relaxation of detrusor muscles and contraction of the bladder neck and pelvic floor muscles.

Gross anatomy of the bladder.

The normal adult bladder accommodates 300600 mL of urine; a central nervous system (CNS) response is usually triggered when the volume reaches 400 mL. However, urination can be prevented by cortical suppression of the peripheral nervous system or by voluntary contraction of the external urethral sphincter.

Contraindications to radical cystectomy include (1) bleeding diathesis, (2) evidence of gross, unresectable metastatic disease (unless performed for palliation), and (3) medical comorbidities that preclude operative intervention (eg, advanced heart disease, poor pulmonary mechanics, advanced age).

Medical Therapy
Alternative therapy for mscle-invasive disease Transurethral resection of bladder tumor (TURBT) alone: Risks include incomplete resection, a high rate of disease recurrence, and the potential for disease progression. Systemic chemotherapy in combination with TURBT This regimen has historically included methotrexate, vinblastine, doxorubicin (Adriamycin), and cisplatin (MVAC). A doublet of gemcitabine and cisplatin has shown similar response rates to MVAC in the metastatic setting and is easier to tolerate; therefore, this regimen is often considered the first-line therapy. Primary radiation therapy: This therapy is more commonly used in countries outside the United States for patients with T2 and T3 cancer. The 5-year survival rate is 20%-40% (less than radical cystectomy). Bladder-sparing multimodality therapy Transurethral resection plus radiation therapy and concomitant cisplatin-based chemotherapy carries a 3- to 5-year estimated survival rate of 45%-64%. Delayed cystectomy is often required for palliation of symptoms or for recurrent disease. At 5 years following treatment, approximately 40% of patients are disease-free with their native bladder. No significant improvement over up-front cystectomy has been shown, and the burden of therapy is often greater in patients who undergo multimodal therapy. This therapy is considered only in patients who are highly motivated to preserve their bladder and reliably adhere to the rigorous surveillance protocol required.

Partial cystectomy: Partial cystectomy is for highly selected patients with a single tumor at a single point in time in a surgically amenable location who have no associated CIS and a bladder volume capable of tolerating a partial resection. Patients must be willing to accept the risk of local recurrence within the retained bladder and the risk of disease progression.

Surgical Therapy
Patients who undergo radical cystectomy may benefit from a cancer-specific survival advantage when neoadjuvant chemotherapy is given prior to surgery. The rationale of preoperative chemotherapy includes treatment of micrometastatic disease and pathologic downstaging. However, some patients with node-negative disease are needlessly treated with chemotherapy; in addition, surgery is significantly delayed. A recent meta-analysis of 11 trials showed an overall survival rate benefit of 6.5% among patients who received neoadjuvant chemotherapy. If locally advanced TCC is suspected based on clinical staging, the rationale for neoadjuvant chemotherapy prior to cystectomy is even stronger.

Preoperative Details
Prehospital Consideration of neoadjuvant chemotherapy for stage pT2 disease or higher: Adequate renal function (estimated glomerular filtration rate >60 mL/min) is required to administer cisplatinbased regimens (MVAC or gemcitabine/cisplatin). Cisplatin-based neoadjuvant chemotherapy is the preferred standard when possible, as it has been shown to improve survival rates. Neoadjuvant chemotherapy is preferred over adjuvant chemotherapy because of improved patient tolerance. Evaluation and optimization of cardiopulmonary disease Stoma marking and counseling, if necessary Autologous blood donation, if desired Bowel preparation, with surgeon's choice of clear-liquid diet, magnesium citrate, Phosphosoda, GoLYTELY, or enemas Confirmation of urine sterility Smoking cessation In-hospital Adequate intravenous hydration Nasogastric tube placed intraoperatively (Many centers remove gastric suction at the end of surgery.) Antibiotics with bowel flora coverage Subcutaneous heparin or pneumatic compression stockings Operating room Paralytic anesthetic agent Long, curved, and angled instruments; self-retaining retractor Supine position in men (For concomitant urethrectomy, lithotomy is needed.) Modified lithotomy position with Allen or Lloyd-Davies stirrups in women Sterile preparation and drape from mid chest to mid thigh, including the genitalia and perineum Bladder catheter

Intraoperative Details
Continent cutaneous urinary diversions In 1987, Rowland and associates introduced the Indiana pouch, which is the most commonly used continent cutaneous diversion technique. Approximately 30-40 cm of cecum and ascending colon are isolated with approximately 10 cm of terminal ileum. The colon is detubularized. The terminal ileum is plicated to the size of a 14F catheter with a GIA stapler. The ileocecal valve is buttressed and imbricated as a continence mechanism. The cecum is folded down, shaped into a spherical

reservoir, and closed with 2-0 running absorbable suture. The ureterointestinal anastomoses are placed on the posterior colonic wall and stented perioperatively. A cecostomy tube is placed to drain the pouch and to provide for postoperative irrigation, as needed. The estimated rate of daytime continence is 93% and nocturnal continence, 76%.

Postoperative Details

Optional use of nasogastric suction and stress gastritis prophylaxis Bowel-spectrum antibiotics for 1-2 days Deep vein thrombosis (DVT) prophylaxis - Includes serial compression devices, subcutaneous unfractionated heparin, or low molecular weight heparin Incentive spirometry and chest physiotherapy Removal of Jackson-Pratt drains when less than 150 mL per day accumulates

Common complications include ileus, atelectasis, DVT, and wound infection. Less common complications include rectal injury, ureteroileal anastomotic leaks, and bowel obstruction.

Nursing Care
Potential long-term sequela and complications for these surgically unique patients do not differ based on approach, robotic versus open. There are several potential complications and issues as a result of cystectomy with urinary diversion. The potential of ureteral anastomosis stricture, urethral stricture (with neobladder), and reservoir rupture (neobladder or Indiana pouch) are rare but must be discussed pre-operatively and taken into account as patient and surgeon discuss options for urinary diversion (personal communication, D. Theodorescu, May 2005). Metabolic complications are monitored with regular lab work and are managed with medications as appropriate. If the patient is undergoing surgery for cancer, the potential for recurrence must be monitored vigilantly. Ideally, this should be by the urologist who performed the surgery for continuity. In continence, as a result of a failed pouch sphincter or neobladder sphincter, can be an outcome that is frustrating for patients and caregivers. Often incontinence can be addressed surgically but must be evaluated carefully. If the incontinence arises in the face of an intact sphincter with poor pouch emptying, then the urologist may implement a regimen of clean intermittent catheterization to allow for consistent reservoir decompression and hopefully return of reservoir tone (personal communication, D. Theodorescu, May 2005). Sexuality for both men and women is often affected with cystectomy surgery. For women, it can affect sexual function since usually the uterus and ovaries are removed with cystectomy. This may lead to menopausal symptoms such as hot flashes or vaginal dryness. If part of the vagina is removed during surgery, then sexual intercourse may be difficult. For men, surgery may damage the nerves that control erections resulting in erectile dysfunction. Fortunately, there are treatments available to address these problems. Patients should be encouraged to discuss their feelings and explore available options with their health care providers. Skin issues are rare but bothersome for patients with an ileal conduit, ileocecal, or Indiana pouch. With the ileal conduit, pouch changes can lead to skin excoriation and tears. Education about proper skin care regimens is important pre and postoperatively, and on return clinic visits. This is

often done by the nurse practitioner or WOC nurse. Since the ileocecal pouch may produce a small amount of mucous at the exit site, a small adhesive bandage or gauze dressing can be placed over the stoma to prevent leakage on clothing. Many patients use mineral oil to keep the stoma moist between catheterizations. Signs and symptoms of urinary tract infection should be taught to patients and caregivers. These are rare but can occur. Fevers and flank pain can be signs of pyelonephritis or pouchitis. Abdominal pain can indicate a sign of infection that may or may not be localized to the urinary reservoir. Urine collected for laboratory assessment will have bacterial colonization due to the use of bowel for reservoir construction. If urine is needed, a double catheterization method can be used to secure a more accurate upstream specimen that can have culture and sensitivity evaluated. Treatment should be guided by culture and sensitivity results.