Abstract 152: Innovations in radical cystectomy
Citation: European Journal of Cancer Supplements Volume 3, No. 2, October 2005, Page 40
M. Marberger
University Clinic Vienna, Urology Department, Vienna, Austria
Although bladder-sparing treatment protocols have a growing impact radical cystectomy remains the mainstay and therapy of choice for most patients with muscle-invasive bladder cancer.
The mortality of the procedure has been reduced dramatically in the last 2 decades, so that even octogenarians can be treated in this manner with similar results. Nevertheless, the morbidity of cystectomy both from postoperative complications and a reduction of quality of life as a result of loss of the bladder remains daunting, and the main impetus of innovations is directed at lowering this.
Immediate postoperative morbidity has been shown to correlate to the volume of cases, and it is lower at high experience centers. It is further reduced by generous correction of blood loss (+10%), routinely using epidural catheters for prolonged pain control, avoiding mechanical bowel preps, and commencing early with enteral nutrition. Laparoscopic cystectomy is a most promising approach to a further reduction in morbidity, but at present the need for urinary diversion still presents as a major obstacle to procedures performed completely intracorporeally. Some laparoscopic techniques are already simplifying standard incisional surgery, such as GIA-stapling of the vesico-prostatic pedicles.
The main rehabilitation problems after cystectomy result from urinary diversion and impaired sexuality. Orthotopic continent urinary diversion has become standard in healthy, well informed patients. Adherence to surgical details such as atraumatic dissection of the urethral stump, avoiding all tubularization of the new-bladder at the anastomosis and fixation of the neobladder to the anterior abdominal wall reduce diurnal and nocturial incontinence to ~15% and ~30% respectively.
Nevertheless, a growing body of evidence shows that in elderly, higher risk patients with less pronounced body-image problems simple conduit diversion provides a better quality of life. Nerve-sparing cystectomy continues to provide mixed results only in the effort to retain erectile function but in selected younger patients unilateral nerve preservation in conjunction with supportive measures permits acceptable sexual function. Ongoing attempts of nerve preservation by sparing the prostatic apex, the seminal vesicles and prostatic capsule, and even the entire prostate give better functional results, but are marred by higher rates of local tumor recurrence.
Stage and nodal involvement remain the only independent prognosticators of survival after cystectomy. Negative frozen sections of the distal margin of resection at the prostatic apex or the bladder neck in women are reliable indicators of a low risk of urethral recurrence and hence adequate parameters for urethra-preserving orthotopic bladder substitution.
Magnetic resonance lymphangiography using femomagnetic nanoparticles dramatically improves the reliability of preoperative lymph node staging, but extensive pelvic node dissection has been shown to significantly impact survival rates after cystectomy.
Although in patients with histologically negative nodes this appears to mainly be a function of stage migration, some patients with positive nodes may actually be cured. The optimal template for pelvic node dissection is still at debate, but prospective studies clearly show that all patients need at least a bilateral, complete endopelvic node dissection; dissection limited to the obturator and hypogastric nodes frequently misses isolated positive nodes.
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