Bladder cancer surgery

Operative 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 detect all tumors (including sites suspected of CIS), but also to determine the plan of the operation.

Transurethral resection of the bladder is performed using optics of 30 ° under conditions of constant irrigation, which prevents its overflow. This can lead to thinning of its walls and risk of perforation. Transurethral resection of the bladder under video monitoring conditions provides an increase (and improvement) in the image, allows you to observe the operation of others for the purpose of training and allows you to document the entire operation. First, the endovezical part of the tumor is removed by separate sections, then its base is resected to the visible muscle tissue. The material is sent to the morphological study in separate containers. Freely flotating highly differentiated tumors is often possible and preferably removed (scraped) by a loop mechanically without the use of electrical energy, which eliminates the risk of perforation. Low-differentiated tumors of solid structure, as well as the bases of any tumor, must be removed electrosurgically with subsequent hemostasis. Fulguration worsens the possibility of a subsequent morphological study of the surgical preparation.

After completion of the resection, an additional loop cut or "cold" biopsy with the base of the tumor is performed for the morphological determination of the tumor invasion into the muscle layer (the drug is referred to the morphological study separately). The final evaluation of the quality of hemostasis is carried out under conditions of minimal irrigation or upon its termination.

Traditionally, transurethral resection of the bladder was performed using sterile water as an irrigation agent, as saline solutions have electrical conductivity, which leads to a dispersion of electrical energy from the monopolar loop of the resectoscope. In recent decades, more often use a solution of glycerol, which is more expensive, but it has an advantage over water. Resectoscopes with bipolar electrodesection have now been developed and are increasingly used. The latter allow performing the operation with the use of 0.9% sodium chloride solution and reduce the risk of reflex irritation n. Obturatorius. Which can lead to a sharp contraction of the adductor muscle of the thigh with possible perforation of the bladder. Prevent this rather formidable complication perhaps through general anesthesia with the introduction of muscle relaxants or by local injection into the occlusal fossa of 20-30 ml of lidocaine, which is not always reliable.

Removal of a tumor in the diverticula of the bladder

In this case, you need to be careful. Diverticulum protrusion of the mucous membrane (without the underlying muscular layer), therefore resection almost inevitably leads to perforation of the bladder. Nevertheless, with highly differentiated tumors, it is possible to perform resection and coagulation of the tumor base. In the case of perforation, prolonged transurethral drainage of the bladder (5 days) provides healing. With low-grade tumors of the diverticulum, resection of the bladder or radical cystectomy is indicated. Tumors located on the front wall or the bottom of the bladder can be difficult to access. Minimal filling of the bladder and suprapubic pressure facilitates the removal of such tumors. Very rarely, especially in excessively obese patients, the TUR of the bladder is possible only through a temporary urethrosis that is applied temporarily.

Removal of tumors in the urethra

Special caution requires TUR of the bladder for tumors located in the mouth of the ureters. To prevent obstruction of the upper urinary tract due to cicatricial narrowing of the ureteral mouth, only the cutting regimen should be used, if necessary, a resection of the mouth itself is possible. In such cases, it is preferable to temporarily drain the kidney with a catheter or stent, or provide an abundant diuresis in the next 24 hours. For precise staging of the disease, the tumor must be removed with a muscle layer for a morphological evaluation of the degree of invasion. Otherwise, a 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 the bladder perforation) occur in less than 5% of cases, although in cystography perforation is detected in most patients. In most cases, extraperitoneal perforation of the bladder occurs, but intraperitoneal perforation is possible in tumors located at the bottom of the bladder. With extraperitoneal perforation, a long (up to 5 days) transurethral drainage of the bladder is sufficient. With intra-abdominal perforation, an open operation is often necessary. Careful attention to the technical details of the operation (prevention of overgrowth of the bladder, prevention of reflex irritation of the nerve) can significantly reduce the risk of perforation of the bladder.

Repeated transurethral resection

Sometimes repeated transurethral resection of the bladder is necessary because of the impossibility of complete removal of the tumor during the first operation (significant tumor size, anatomical inaccessibility, perforation risk, forced discontinuation of surgery due to intraoperative complications, etc.). But more often the indication for repeated transurethral resection of the bladder is other causes (low-grade T1 tumors, the lack of muscle tissue in the drug). With repeated transurethral resection of the bladder, which is performed for 6 weeks after the first operation, the residual tumor in the intervention zone is revealed in 40% of cases.

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

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

Radical cystectomy

Indications for radical cystectomy:

• cancer of the bladder in stage T2-T4a, N0-Nx. M0;
• tumors of high cancer risk (low-grade transitional-cell cancer of stage T1, CIS, resistant to tumor adjuvant immunotherapy);
• non-transient cell histological types of tumor that are insensitive to chemo- and radiotherapy.

"Saving" cystectomy is indicated for unsuccessful nonoperative treatment (chemotherapy, radiation therapy) or unsuccessful resection of the bladder.

In radical cystectomy, preoperative chemo- or radiotherapy is not indicated.

Contraindications to radical cystectomy

These include serious co-morbidities and an unacceptably high operational risk for the patient.

The technique of radical cystectomy involves removal of the bladder from the surrounding fatty tissue and neighboring organs (prostate and seminal vesicles in men and the uterus with appendages in women). The ureters are excised in the juxtavezic department and, under the CIS, perform their morphological express examination. When the tumor is located in the region of the bladder neck in women or in the urethral section of the urethra, men are shown to perform a dissectomy (simultaneously or in the second stage). A part of men can preserve potency by preserving paraprostatic neuromuscular bundles (similar to the RP technique).

Pelvic lymphadenectomy is an obligatory part of radical cystectomy. Affected lymph nodes in radical cystectomy reveal in 10% of patients stage T1 and in every third patient of stage T3-T4a. Lymphadenectomy has a great prognostic value, it allows to determine the need for adjuvant systemic chemotherapy, and in some patients with minimal lesion of lymph nodes improves the results of the operation.

Despite the distinct tendency to widen the boundaries of the lymphadenectomy from the zone of internal, external, common iliac vessels, the precrestal region and to the aortic bifurcation, the removal of lymph nodes from the area of the constriction fossa is now considered the standard.

Express biopsy of suspicious lymph nodes allows intraoperatively to determine the urine derivation plan (in the detection of metastases, a simpler and safer type can be chosen).

Postoperative complications and mortality in radical cystectomy during the last 2-3 decades have significantly decreased, but nevertheless make up about 30 and 3.7%, respectively. Late complications are usually associated with over-tubus urinary diversion. The risk of impotence is high and depends on the age of the patients and the technique of the operation.

[1], [2], [3], [4], [5], [6], [7]

Nasepuzyrnoe urinary diversion and replacement (substitution) of the bladder

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

Groups of operations of the urinary incontinence and replacement (substitution) of the bladder.

• "Wet" kutaneostomy (ureterostomy intestinal conduits).
• "Dry" retention (continent) kutaneostomy with the creation of low-pressure urinary reservoirs from various parts of the intestine.
  (stomach, jejunum, large intestine).
• Removal of urine into the intestine (rectal bladder, ureterosigmostomy, sigmorectal reservoir Mainz-Pouch P).
• Substitution of the bladder (substitution) with a low-pressure reservoir created from various parts of the intestine (iliac, ascending colonic sigmoid colon) and an anastomosed with the membranous urethra.

Ureterocutaneosostomy, which was performed to date, is a forced operation (the need to reduce the risk). Classical ureterosigmostomiyu at the moment is practically not used because of the high frequency of urinary infection and the risk of adenocarcinoma in the area of ureteric-intestinal anastomosis.

In the last two decades, operations on the formation of low-pressure intestinal urinary reservoirs have become very popular. The principle of creating low-pressure reservoirs is based on antisecious dissection of the intestine, followed by the formation of a spherical tank. The absence of isotonic contraction of the gut provides a low pressure in the reservoir, and the spherical shape provides its high capacity. Anastomosing the ureters with the reservoir can be performed with or without antireflux technique. Urinary retention (continence) occurs due to the submucosal location of the efferent segment of the intestine, which is excreted on the skin (Mitrofanov's principle), its invagination, or the use of a natural valve (a buginium valve). Periodic catheterization of the reservoir is performed by the patient independently.

Despite the fact that most methods of urine derivation provide a good quality of life, in recent years, more and more use is found in the replacement (substitution) of the bladder.

Radical cystectomy with urinary diversion is a complex intervention, therefore the operation must be performed only in specialized centers where such operations are performed regularly. The final decision on radical cystectomy and the choice of the method of derivation are carried out only on the basis of informed consent of the patient.

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 cancer of the bladder (Ta, Tl, CIS)

For the control examination of patients with superficial tumors of the bladder, cystoscopy and ultrasonography can be performed. Intravenous urography and multiple biopsies of the mucosa of the bladder. Cystoscopy is the "standard" of monitoring patients after TUR of the bladder, and after 3 months it is performed by all patients.

With highly differentiated tumors of stage Ta (about 50% of all patients) it is necessary to perform cystoscopy at 3 and 9 months and then annually for 5 years. Morphological characteristics of these tumors in case of recurrence remain the same in 95% of patients.

Patients at high risk (15% of all patients) need cystoscopy every 3 months for 2 years, then every 4 months during the third year after surgery and then every six months for 5 years. In addition, annual intravenous urography (5 years) is shown.

In patients with an average degree of cancer risk, the tactic of cystoscopic observation is intermediate in nature and depends on the prognostic features given earlier.

If the 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 in the progression of the disease (primary tumor Ta - relapse T1). The appearance of low-grade cells or the development of CIS. If relapse (even in the same stage of the disease) develops early in the post-TUR period (after 3-6 months), treatment of bladder cancer should also be considered ineffective. In some patients, a change in immunotherapy for chemotherapy can lead to remission, but in low-grade tumors, radical cystectomy is preferred because of the high risk of tumor invasion into the muscle layer with the development of metastases. Even with "favorable" tumors, repeated TURs with intravesical chemotherapy or immunotherapy lead to a decrease in the capacity of the bladder, a significant violation of the act of urination, which makes the radical cystectomy more preferable.

Recurrent tumors are most often detected in the first 2 years of follow-up. With each relapse of the disease, the count of the frequency of cystoscopic observation begins from the beginning. The possibility of recurrence persists even after 10-12 years, and patients with relapses of the disease during the first 4 years should be under cystoscopic control all their lives, or they perform a cystectomy.

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

Ultrasonography can not replace cystoscopy. Cytological examination of urine is poorly informative for highly differentiated tumors, but it is considered a valuable observation method for low-grade tumors (especially CIS).

Repeated biopsies of the bladder mucosa are indicated only in cases of visual abnormality or positive results of cytological examination in patients with CIS.

Invasive bladder cancer (stage T2, T3, T4)

Patients after radical cystectomy and radiation therapy must be observed for the earliest possible detection of the progression of the disease (local relapse, metastasis). If necessary, they are given additional therapeutic measures ("saving" cystectomy with ineffective radiation therapy, urethrectomy or nephroureterectomy in case of cancer of the urethra or ureter, systemic chemotherapy).

Equally important is the observation of possible side effects and complications of the tuberculosis of urine and their timely elimination.

After radical cystectomy, the first control study is performed 3 months after the operation. It includes physical examination, determination of serum creatinine level and assessment of acid-base balance, urine analysis, ultrasonography of kidneys, liver and retroperitoneal space. Chest x-ray. Such a control examination should be performed every 4 months. In the presence of metastases in the lymph nodes (pN +), it is additionally necessary to perform CT of pelvic organs and bone scintigraphy. Patients with CIS need additional regular examination of the upper urinary tract. If cystectomy has not removed the urethra, it is also necessary to perform urethroscopy and cytological examination of flushing from the urethra.

After radiotherapy for bladder cancer, along with the above studies, CT scan, cystoscopy, and cytological examination of urine have also been shown, since the greatest danger lies in the local progression of the disease.

Prognosis for bladder cancer

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

Radiation therapy of invasive neoplasms of the bladder (stages T2, T3, T4)

The five-year survival rate for bladder cancer in stages T2 and T3 is 18-41%. Local relapses develop in 33-68% of patients. Achievement of success in the treatment of bladder cancer is possible only with close cooperation of physicians of different specialties (urologist, radiotherapist, chemotherapist, morphologist), and careful observation is necessary for timely "saving" cystectomy in the absence of the effect of radiation treatment.