Surgery for bladder cancer

Surgical treatment of bladder cancer (Ta, Tl, CIS)

Transurethral resection of the bladder

A thorough examination of the bladder using optics with different angles (always 30°, 70°, rarely 120°) allows not only to identify all tumors (including areas suspicious for CIS), but also to determine the surgical plan.

Transurethral resection of the bladder is performed using 30° optics under continuous irrigation, which prevents bladder overflow. This may lead to thinning of the bladder wall and the risk of perforation. Transurethral resection of the bladder under video monitoring provides for magnification (and improvement) of the image, allows others to observe the operation for training purposes, and allows the entire operation to be documented. First, the endovesical part of the tumor is removed in separate sections, then its base is resected down to the visible muscle tissue. The material is sent for morphological examination in separate containers. Free-floating, highly differentiated tumors can often be and preferably removed (scraped) mechanically with a loop without using electrical energy, which eliminates the risk of perforation. Low-differentiated tumors of solid structure, as well as the base of any tumor, should be removed electrosurgically with subsequent hemostasis. Fulguration impairs the possibility of subsequent morphological examination of the surgical specimen.

After completion of the resection, an additional loop cut or a "cold" biopsy with forceps of the tumor base is performed for morphological determination of tumor invasion into the muscle layer (the preparation is sent for morphological examination separately). The final assessment of the quality of hemostasis is performed under conditions of minimal irrigation or upon its cessation.

Traditionally, transurethral resection of the bladder was performed using sterile water as an irrigant, since saline solutions have electrical conductivity, which leads to dispersion of electrical energy from the monopolar loop of the resectoscope. In recent decades, a glycerol solution has been used more often, which is more expensive, but it has an advantage over water. Currently, resectoscopes with bipolar electroresection have been developed and are increasingly used. The latter allow the operation to be performed using 0.9% sodium chloride solution and reduce the risk of reflex irritation of n. obturatorius, which can lead to a sharp contraction of the adductor muscle of the thigh with possible perforation of the bladder. This rather formidable complication can be prevented by general anesthesia with the introduction of muscle relaxants or local injection of 20-30 ml of lidocaine into the obturator fossa, which is not always reliable.

Removal of a tumor in a bladder diverticulum

In this case, caution is necessary. A diverticulum is a mucosal protrusion (without an underlying muscular layer), so resection almost inevitably leads to perforation of the bladder. However, in highly differentiated tumors, resection and coagulation of the tumor base is possible. In case of perforation, long-term transurethral drainage of the bladder (5 days) ensures healing. In case of poorly differentiated diverticulum tumors, resection of the bladder or radical cystectomy is indicated. Tumors located on the anterior wall or fundus of the bladder may be difficult to access. Minimal filling of the bladder and suprapubic pressure facilitate the removal of such tumors. Very rarely, especially in extremely obese patients, TUR of the bladder is possible only through a temporary urethrostomy.

Removal of tumors in the ureteral orifice

TUR of the bladder requires special caution in case of tumors located in the ureteral orifice. To prevent obstruction of the upper urinary tract due to cicatricial narrowing of the ureteral orifice, only cutting mode should be used; if necessary, resection of the orifice itself is possible. In such cases, temporary drainage of the kidney with a catheter or stent or provision of abundant diuresis in the next 24 hours is preferable. For accurate staging of the disease, the tumor should be removed with the muscle layer for morphological assessment of the degree of invasion. Otherwise, repeated TUR of the bladder is necessary. Minimal bleeding and irritative symptoms are typical for the early postoperative period. Serious complications (significant hematuria, clinical manifestation of bladder perforation) occur in less than 5% of cases, although perforation is detected in most patients during cystography. In most cases, extraperitoneal perforation of the bladder occurs, but intra-abdominal perforation is also possible with tumors located at the bottom of the bladder. In case of extraperitoneal perforation, transurethral drainage of the bladder is sufficiently long (up to 5 days). In case of intra-abdominal perforation, open surgery is often necessary. Careful attention to the technical details of the operation (prevention of overstretching of the bladder, prevention of reflex irritation of the obturator nerve) can significantly reduce the risk of bladder perforation.

Repeat transurethral resection

Sometimes, repeated transurethral resection of the bladder is necessary due to the impossibility of complete tumor removal during the first operation (significant tumor size, anatomical inaccessibility, risk of perforation, forced termination of the operation due to intraoperative complications, etc.). But more often, other reasons (low-differentiated T1 tumors, lack of muscle tissue in the specimen) are indications for repeated transurethral resection of the bladder. During repeated transurethral resection of the bladder, which is performed within 6 weeks after the first operation, residual tumor in the intervention area is detected in 40% of cases.

In the absence of muscle tissue in the surgical specimen, a poorly differentiated stage T1 tumor is classified as stage T2 in most patients after repeated intervention. Repeated transurethral resection of the bladder changes the treatment tactics in a third of patients. It is now generally accepted that patients with stage T1 disease and a poorly differentiated stage Ia tumor require repeated TUR.

Treatment of bladder cancer (stages T2, T3, T4)

Radical cystectomy

Indications for radical cystectomy:

• bladder cancer stage T2-T4a, N0-Nx. M0;
• high-risk oncological tumors (poorly differentiated transitional cell carcinoma stage T1, CIS, tumors resistant to adjuvant immunotherapy);
• non-transitional cell histological tumor types that are insensitive to chemo- and radiation therapy.

“Salvage” cystectomy is indicated when non-surgical treatment (chemotherapy, radiation therapy) or resection of the bladder is unsuccessful.

Preoperative chemotherapy or radiation therapy are not indicated for radical cystectomy.

Contraindications to radical cystectomy

These include serious concomitant diseases and an unacceptably high surgical risk for the patient.

The technique of radical cystectomy involves the removal of the urinary bladder with the surrounding fatty tissue and adjacent organs (prostate and seminal vesicles in men and the uterus with appendages in women). The ureters are cut off in the juxtavesical section and, in case of CIS, their express morphological examination is performed. If the tumor is located in the bladder neck area in women or grows into the prostatic section of the urethra in men, utetrectomy is indicated (simultaneously or as a second stage). In some men, potency can be preserved by preserving the paraprostatic neurovascular bundles (similar to the RPE technique).

Pelvic lymphadenectomy is a mandatory component of radical cystectomy. Affected lymph nodes during radical cystectomy are detected in 10% of patients with stage T1 and in every third patient with stage T3-T4a. Lymph node dissection has great prognostic value, allows determining the need for adjuvant systemic chemotherapy, and in some patients with minimal lymph node involvement improves the results of the operation.

Despite the clear tendency to expand the boundaries of lymphadenectomy from the area of the internal, external, common iliac vessels, the pre-sacral region and to the bifurcation of the aorta, the removal of lymph nodes from the obturator fossa area is currently considered the standard.

Express biopsy of suspicious lymph nodes allows intraoperative determination of a urine diversion plan (if metastases are detected, a simpler and safer type can be selected).

Postoperative complications and mortality in radical cystectomy have decreased significantly over the past 2-3 decades, but still amount to about 30% and 3.7%, respectively. Late complications are usually associated with supravesical urinary diversion. The risk of impotence is high and depends on the age of the patients and the surgical technique.

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Supravesical urinary diversion and bladder substitution

As a result of intensive development of the problem of urine diversion after cystectomy, a large number of different operations have been introduced into clinical practice.

Groups of operations for supravesical urinary diversion and bladder substitution.

• "Wet" cutaneostomy (ureterostomy intestinal conduits).
• "Dry" retaining (continental) cutaneostomies with the creation of low-pressure urinary reservoirs from various parts of the intestine
  (stomach, jejunum, colon).
• Diversion of urine into the intestine (rectal bladder, ureterosigmoidostomy, sigmoidorectal reservoir Mainz-Pouch P).
• Replacement of the urinary bladder (substitution) with a low-pressure reservoir created from various sections of the intestine (ileum, ascending colon, sigmoid colon) and anastomosed with the membranous section of the urethra.

Ureterocutaneostomy, which has been performed up to now, is a forced operation (need to reduce risk). Classical ureterosigmoidostomy is currently practically not used due to the high frequency of urinary infection and the risk of developing adenocarcinoma in the area of the ureteric-intestinal junction.

In the last two decades, operations to form low-pressure intestinal urinary reservoirs have become very popular. The principle of creating low-pressure reservoirs is based on anti-mesenteric dissection of the intestine with subsequent formation of a spherical reservoir. The absence of isotonic contraction of the intestine provides low pressure in the reservoir, and the spherical shape provides its large capacity. Anastomosis of the ureters with the reservoir can be performed using antireflux techniques or without them. Urine retention (continence) occurs due to the submucosal location of the efferent segment of the intestine, brought out to the skin (Mitrofanov principle), its intussusception or the use of a natural valve (Bauhin's valve). The patient performs periodic catheterization of the reservoir independently.

Although most urinary diversion methods provide a good quality of life, bladder substitution has become increasingly popular in recent years.

Radical cystectomy with urinary diversion is a complex procedure, so the operation should be performed only in specialized centers that regularly perform such operations. The final decision on radical cystectomy and the choice of diversion method are made only on the basis of the patient's informed consent.

Further management of bladder cancer

Recommendations for monitoring patients with superficial bladder tumors after their removal (TUR of the bladder) depend on the stage and degree of differentiation of the tumor, as well as other risk factors.

Superficial bladder cancer (Ta, Tl, CIS)

For follow-up examination of patients with superficial bladder tumors, cystoscopy, ultrasonography, intravenous urography, and multiple biopsies of the bladder mucosa can be performed. Cystoscopy is the "standard" for monitoring patients after TUR of the bladder, and is performed on all patients after 3 months.

In highly differentiated stage Ta tumors (about 50% of all patients), cystoscopy should be performed after 3 and 9 months and then annually for 5 years. The morphological characteristics of these tumors in case of recurrence remain the same in 95% of patients.

High-risk patients (15% of all patients) require cystoscopy every 3 months for 2 years, then every 4 months for the third year after surgery, and then every six months for 5 years. In addition, annual intravenous urography is indicated (5 years).

In patients with an average degree of oncological risk, the tactics of cystoscopic observation are of an intermediate nature and depend on the previously mentioned prognostic signs.

If standard treatment of bladder cancer is unsuccessful (recurrence, progression), a new tactic is chosen. If the superficial tumor progresses with invasion into the muscular layer of the bladder wall, radical cystectomy is indicated. Standard treatment of bladder cancer should be considered ineffective with disease progression (primary tumor Ta - relapse T1), the appearance of poorly differentiated cells or the development of CIS. If a relapse (even at the same stage of the disease) develops early after TUR (after 3-6 months), bladder cancer treatment should also be considered ineffective. In some patients, changing immunotherapy to chemotherapy can lead to remission, but in the case of poorly differentiated tumors, radical cystectomy is preferable due to the high risk of tumor invasion into the muscular layer with the development of metastases. Even with “favorable” tumors, repeated TUR with intravesical chemo- or immunotherapy leads to a decrease in bladder capacity, significant disturbances in the act of urination, which makes radical cystectomy more preferable.

Recurrent tumors are most often detected in the first 2 years of observation. With each relapse of the disease, the frequency of cystoscopic observation begins again. The possibility of recurrence remains after 10-12 years, and patients with relapses of the disease during the first 4 years should be under cystoscopic control for life, or they undergo cystectomy.

In the case of a single, highly differentiated stage Ta tumor and no recurrence, observation can be stopped after 5 years. In other cases, it is necessary for 10 years, and in patients with a high oncological risk - for life.

Ultrasonography cannot replace cystoscopy. Urine cytology is of little use in highly differentiated tumors, but is considered a valuable observation method for poorly differentiated tumors (especially CIS).

Repeated bladder mucosal biopsies are indicated only in the case of visual abnormality or positive cytology results in patients with CIS.

Invasive bladder cancer (stages T2, T3, T4)

Patients after radical cystectomy and radiation therapy must be monitored for the earliest possible detection of disease progression (local relapse, metastasis). If necessary, they undergo additional treatment measures (salvage cystectomy if radiation therapy is ineffective, urethrectomy or nephroureterectomy for oncological lesions of the urethra or ureter, systemic chemotherapy).

Of no less importance is the monitoring of possible side effects and complications of supravesical urinary diversion and their timely elimination.

After radical cystectomy, the first control examination is performed 3 months after surgery. It includes a physical examination, determination of serum creatinine level and acid-base balance, urinalysis, ultrasonography of the kidneys, liver and retroperitoneum. Chest X-ray. Such a control examination should be performed every 4 months. In the presence of lymph node metastases (pN+), pelvic CT and bone scintigraphy are additionally necessary. Patients with CIS additionally require regular examination of the upper urinary tract. If the urethra was not removed during cystectomy, urethroscopy and cytological examination of the urethral washings should also be performed.

After radiation therapy for bladder cancer, in addition to the above studies, CT of the pelvic organs, cystoscopy, and cytological examination of urine are also indicated, since the greatest danger lies in local progression of the disease.

Prognosis for bladder cancer

Five-year survival of patients depends on the stage of the disease and is 75% at stage pT1, 63% at pT2, 31% at stage pT3, and 24% at pT4. The second factor determining the results of bladder cancer treatment is the presence of metastases in the lymph nodes.

Radiation therapy for invasive bladder tumors (stages T2, T3, T4)

Five-year survival rate for bladder cancer at stages T2 and T3 is 18-41%. Local relapses develop in 33-68% of patients. Success in the treatment of bladder cancer is possible only with close cooperation of doctors of different specialties (urologist, radiation therapist, chemotherapist, morphologist), and careful monitoring is necessary for timely "saving" cystectomy in the absence of the effect of radiation therapy.