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- 1. Surgical Management of Bladder Cancer: 2012 Alex Gorbonos, MD Assistant Professor, Division of Urology Director, Robotic Surgery SIU School of Medicine October 2, 2012
- 2. Outline Overview of bladder cancer Radical cystectomy Past Present Future
- 3. EPIDEMIOLOGY 5th most common cancer 4th most common in men Cancer most likely to recur 2nd most common urologic cancer ACS, 2012
- 4. EPIDEMIOLOGY Median age at diagnosis: 68 3-4 times more common in men More aggressive in blacks and women Longer time to diagnosis Access to care
- 5. HISTOLOGY Most common primary histology in USA Urothelial (transitional) cell Urothelium: lines collecting system of the kidney, ureters, bladder and most of urethra Most common primary histology in world Squamous cell Spinal cord injury, recurrent UTIs/stones, catheter use Other histologies: Adenocarcinoma (bladder augmentation, urachus, GI) http://en.wikipedia.org/wiki/File:Urinary_system.svg
- 6. ETIOLOGY Environmental exposures Tobacco (nitrosamine, 2-naphthylamine, 4- aminobiphenyl): x 2-6 increased risk Occupational (aromatic amines, aniline dyes) Factories dealing with organic dyes Truck drivers/autoworkers Plumbing No strong hereditary link Chronic bladder infections/irritation squamous cell carcinoma Schistosomiasis
- 7. PRESENTATION Hematuria, gross painless: 80-90% Irritative lower urinary tract symptoms Systemic complaints in metastatic disease
- 8. DIAGNOSIS Cystosopy CT Urogram Cytology Bladder tumor
- 9. STAGING TURBT Bladder biopsy
- 10. PRESENTATION Non-muscle invasive (cis, Ta, T1) 75 to 85% 25% subsequently progresses to invasive disease Muscle-invasive (T2-4) 15 to 25% Metastatic 5%
- 11. Treatment TUR (transurethral resection) Intravesical therapy BCG, MMC, Thiotepa, Gemcitabine, IFN Radical cystectomy Chemotherapy Neoadjuvant Adjuvant Radiation
- 12. Radical Cystectomy Gold standard for surgical management of Invasive bladder carcinoma Intravescical therapy-refractory non-muscle invasive carcinoma High-volume or unresectable non-invasive disease Males: removal of the bladder, prostate Female: removal of the bladder, uterus/ovaries
- 15. Radical Cystectomy Males Females Radical cystectomy+/- Radical cystectomy+/- urethrectomy urethrectomy Radical prostatectomy TAH-BSO Pelvic lymphadenectomy
- 16. First Radical Cystecomy Bernhard Bardenheuer (1839-1913) Prussian surgeon who performed first complete cystectomy on January 13, 1887 Der extraperitoneale Explorativschnitt. Die differentielle Diagnostik der chirurgischen Erkrankungen und Neubildungen des Abdomens. Stuttgart, Enke, 1887. 748 pages. p. 273 Theodor Baum, 57 yo carpenter’s assistant, from Cologne had advanced bladder tumor involving both ureters Operation lasted 75min Ureters were left unimplanted Patient died POD#14 days from uremia and hydronephrosis Pannek and Senge, History of Urinary Diversion, Urol Int; 1996, 60: 1-10 Moll et al, Bardenheuer's contribution to the development of modern urology, J Med Bio; 1998, 6: 11-14
- 17. FIRST RADICAL CYSTECTOMY 1899 – Fedor Krause performed first successful total cystectomy and ureterosigmoidostomy for bladder cancer Ureters connected to sigmoid colon to use anal sphincter as a continence mechanism Pannek and Senge, History of Urinary Diversion, Urol Int; 1996, 60: 1-10
- 18. Radical Cystectomy – 19th Century Mortality due to sepsis from peritonitis and pyelonephritis limited widespread practice of cystectomy Lack of antibiotics Post-op urinary leak Antiquated surgical principles Pannek and Senge, History of Urinary Diversion, Urol Int; 1996, 60: 1-10
- 19. Conclusion Not enough to be able to remove the organ, but it is necessary to reconstruct the urinary tract GI tract “mobilized”
- 20. Goals Extirpation Reconstruction SAFE EFFECTIVE ACCEPTABLE DURABLE EVOLVING
- 21. 20th Century – First Half Ureterosigmoidostomy was the operation of choice using the Coffey method of anastomosis 1936 – Hinman and Weyrauch reviewed 740 ureterosigmoidostomies Perioperative mortality was 30% 50% - cancer causes 20% - non-cancer causes Cutaneous ureterostomy was thought to offer best chance of survival Pannek and Senge, History of Urinary Diversion, Urol Int; 1996, 60: 1-10
- 22. 20th Century – 2nd Half Diversion field boom Mortality decreases Antibiotics introduction Improvement in anesthesia and critical care Surgical technique continues to evolve 1950 – Ferris and Oedel demonstrate hyperchloremic metabolic acidosis in ureterosigmoidostomy patients due to absorptive capacity of bowel mucosa Ureterosigmoidostomy moves to the background Pannek and Senge, History of Urinary Diversion, Urol Int; 1996, 60: 1-10
- 23. Ileal Conduit 1911 – first described by Zaayer in 2 patients 1st patient – died of cancer POD#11 2nd patient – died of peritonitis POD#6 1927 – Bollman and Mann created conduits in animals High mortality from electrolyte disturbances because they were creating long conduits Hypokalemic hyperchloremic metabolic acidosis Pannek and Senge, History of Urinary Diversion, Urol Int; 1996, 60: 1-10
- 24. Ileal Conduit 1950 – Eugene Bricker published a landmark paper on his experience with ileal conduit “Surg Clin N Am 1950; 30: 1511-21” 10 patients with follow-up of 2 mo (4) to 4 years Metabolic complications not recognized 12.4% mortality in 307 cases; 3.4% directly related to diversion Bricker conduit: Refluxing anastomosis Simple stoma, without a bud Perez & Webster, “History of Urinary Diversion Techniques,” in Urinary Diversion, Webster and Goldwasser, eds., 1995
- 25. Eugene M. Bricker (1909- 2000) “We ourselves are pleased with the procedure because we feel it is the acme of simplicity…At the present time we are ready to drop the project of trying to develop a continent intra-abdominal urinary pouch in favor of this method…” General Surgeon Perez & Webster, “History of Urinary Diversion Barnes Hospital, St. Louis Techniques,” in Urinary Diversion, Webster and Goldwasser, eds., 1995
- 26. Ileal Conduit - Modifications 1966 – Wallace of London modified ileal conduit by joining ureters together prior to anastomosis to the ileal segment end 1975 – Turnbull, general surgeon from Cleveland Clinic, introduced loop stoma technique for obese patients Decreased stomal stenosis Perez & Webster, “History of Urinary Diversion Techniques,” in Urinary Diversion, Higher parastomal hernia rate Webster and Goldwasser, eds., 1995
- 27. Robotic Cystectomy Radical cystectomy with pelvic lymphadenectomy: First performed robotically in 2003 Urinary Diversion performed intra- or extra- corporeally
- 28. Robotic Radical Cystectomy Males Females Radical cystectomy+/- Radical cystectomy+/- urethrectomy urethrectomy Radical prostatectomy TAH-BSO Pelvic lymphadenectomy Pelvic Lymphadenectomy
- 29. Robotic Cystectomy with Neobladder
- 30. Robotic Cystectomy with Ileal Conduit
- 31. Robotic Radical Cystectomy Decreased blood loss Less evaporative fluid losses Reduced manipulation of GI tract, quicker return of bowel function Equivalent oncologic outcomes Better cosmesis Less pain Quicker recovery The Journal of Urology Vol 183, Issue 2, Pages 510-515, February 2010
- 32. Future of Diversion? Anthony Atala et al: Tissue-engineered autologous bladders for patients needing cystoplasty Lancet. 2006 Apr 15;367(9518):1241-6 Autologous engineered bladder tissues used for reconstruction in 7 myelomeningocele patients Construction of engineered bladder Scaffold seeded with cells (A) and engineered bladder anastamosed to native bladder with running 4–0 polyglycolic sutures (B). Implant covered with fibrin glue and omentum (C).