Bladder Cancer Flashcards
Post TURBT Algorithm NMIBC
Genetic predisposition to NMIBC:
GSTM-1 and NAT-2
The most-studied genes associated with BlCa are N-acetyltransferase 2 and a deletion of glutathione S-transferase µ. Both of these genes are associated with the ability to metabolize aromatic amines and thus play an important role in the subset of individuals with environmental carcinogen exposure.
MSH2 (Lynch Syndrome)
Mismatch repair gene
LOH of ch. 9p, homozygous deletion of CDKN2A and loss of expression of p16
CIS → TP53, RB1, PTEN, oncogenes…
Bladder cancer T staging:
Ta: non-invasive papillary
Tis: CIS
T1: invades lamina propria
T2: invades muscularis propria
T2a: superficial muscularis propria (inner half)
T2b: deep muscularis propria (outer half)
T3: invades perivesical tissue/fat
T3a: invades perivesical tissue/fat microscopically
T3b: invades perivesical tissue/fat macroscopically (extravesical mass)
T4: invades prostate, uterus, vagina, pelvic wall, abdominal wall
T4a: adjacent organs (uterus, ovaries, prostate stroma)
T4b: invades pelvic wall and/or abdominal wall
N and M for bladder cancer
Stages for TNM bladder cancer, 0a - IV b
CSS in high-grade dz:
Ranges 70-85% at 10 years
At time of TURBT, clinicians SHOULD document and perform cystoscopic exam of what? Additionally, they should perform what type of resection?
GUIDELINE STATEMENT 1
Entire urethra and bladder
Document tumor size, location, configuration, number, and mucosal abnormalities
GUIDELINE STATEMENT 2
A complete visual resection when feasable
Define low risk NMIBC
Low risk
LG solitary Ta < 3 cm
PUNLMP
Define intermediate risk NMIBC:
Intermediate risk:
Recurrent w/in 1 year, LG Ta
Solitary LG Ta > 3 cm
LG Ta, multifocal
HG Ta, < 3 cm
LG T1
Define high risk NMIBC:
HG T1
Any recurrent, HG Ta
HG Ta, > 3 cm (or multifocal)
Any CIS
Any BCG failure in HG pt
Any variant histology
Any LVI
Any HG prostatic involvement
Besides resection/cysto, what else SHOULD be performed as part of initial workup of bladder cancer patient?
GUIDELINE STATEMENT 3
Upper tract imaging (tumors <5%)
RGP, CT/MRI urogram, US
Risk stratified and generally w/in 6 mo of dx and every 1-2years (high risk)
What SHOULD a clinician consider in a pt with NMIBC and normal cystoscopy and positive cytology?
GUIDELINE STATEMENT 4
prostatic urethral biopsies and upper tract imaging
consider enhanced techniques (blue light), URS, random bladder bx
At each occurrence/recurrence, clinicians SHOULD:
GUIDELINE STATEMENT 5
assign clinical stage and classify risk category
In variant histology results, what is recommend:
GUIDELINE STATEMENT 6
review of pathology by experience GU pathologist
(micro-papillary, plamacytoid, nested, neuroendocrine, sarcomatoid)
extensive squamous or glandular differentiation or presence of LVI
If pt with variant histology (presumed non-invasive) considering bladder preservation, the clinician SHOULD perform and offer?
GUIDELINE STATEMENT 7
perform re-staging TURBT in 4-6 weeks
*r/o MIBC (high rate upstaging)
GUIDELINE STATEMENT 8
Offer radical cystectomy
Is there a role of urinary biomarkers for surveillance of NMIBC?
GUIDELINE STATEMETN 9
NOT in lieu of cysto
cytology is mainstay despite drawbacks
5 markers are FDA approved
GUIDELINE STATEMENT 10
low risk cancer and normal cysto, do not routinely use biomarker or cytology for surveillance
When are urine biomarkers recommended?
GUIDELINE STATEMENT 11
In NMIBC to assess response to BCG (UroVysion FISH) and to adjudicate equivocal cytology (UroVysion FISH and ImmunoCyt)
What instances get a repeat TURBT?
GUIDELINE STATEMENT 12
incomplete initial resection (not all visible tumor)
GUIDELINE STATEMENT 13
high risk, HG Ta, consider repeat in 6 weeks (residual tumor up to 50% time, 15% upstaged)
GUIDELINE STATEMENT 14
T1, of primary tumor site to include muscularis propria in 6 weeks (upstage in 40-50% w/o muscle and 15-20% with muscle, improved BCG response, tx with mitomycin → lower recurrence and progression)
In patient with suspected or known low- or intermediate risk bladder cancer, clinicians SHOULD:
GUIDELINE STATEMENT 15
administration of single post operative chemo (Gemzar 2g/100mL, mitomycin)
GUIDELINE STATEMENT 16
Low-risk → NO intravesical induction
GUIDELINE STATEMENT 17
Intermediate-risk → consider 6 week induction (such as mitomycin, gemcitabine, epirubicin, or docetaxel in leiu of BCG due to shortage)
In high-risk newly dx CIS, HG T1 or high risk Ta, what SHOULD be done:
GUIDELINE STATEMENT 18
Induction 6 week BCG
**If not available, these patients and other high-risk patients may be given a reduced 1/2 to 1/3 dose, if feasible, if no supply, omit maintenance or limit to 1 year
Gemcitabine, epirubicin, docetaxel, valrubicin, mitomycin, or sequential gemcitabine/docetaxel or gemcitabine/mitomycin may also be considered with an induction and possible maintenance.
Insufficient evidence to support strain, strength, or combo BCG tx
In intermediate-risk pt who responds to induction, may utilize:
GUIDELINE STATEMENT 19
Maintenance
Monthly for 6-12 mo
GUIDELINE STATEMENT 20
if given BCG and responds → maintenance 1 year (if supply)
In high-risk patients who respond to BCG, maintenance:
GUIDELINE STATMENT 21
Continue for 3 years
3 weekly installments at 3, 6, 12, 18, 24, 30, 36 mo
For persistent or recurrent disease or positive cytology following intravesical therapy, clinicians SHOULD consider:
GUIDELINE STATEMENT 22
prostatic urethral biopsy and upper tract evaluation before repeat intravesical therapy
*UC especially CIS considered “field-change” dz, entire urothelium at risk
Tumor recurrence involves prostatic urethra in 24-30% of NMIBC
Blue light cysto improves CIS detection by 20-40%
Pt with persistent Ta or CIS dz after induction intravesical BCG SHOULD be offered:
GUIDELINE STATEMENT 23
A second course of induction
In a patient with persistent/recurrent HG T1 dz after single induction of BCG, SHOULD be offered:
GUIDELINE STATEMENT 24
Radical Cystectomy if fit for surgery
When is an additional course of BCG not appropriate?
GUIDELINE STATEMENT 25
Intolerance of BCG
Documented recurrence on TURBT of HG dz or CIS w/in 6 mo of 2 courses BCG or induction + maintenance
What treatment can be offered for persistent or recurrent intermediate- or high-risk NMIBC w/in 12 months of completion of adequate BCG therapy?
GUIDELINE STATMENT 26
BCG (2 inductions or induction + maintenance)
radical cystectomy
unwilling or unfit for cystectomy → alternative intravesical agent (valrubicin, gemcitabine, docetaxel, combo)
clinical trials
Systemic immunotherapy with pembrolizumab for CIS
Outline role of cystectomy in NMIBC:
GUIDELINE STATEMENT 27
Ta low- or intermediate- risk dz → DO NOT perform RC until bladder sparing modalities have failed
GUIDELINE STATEMENT 28
Persistent HG T1 on repeat resection, or T1 tumors with CIS, LVI, variant → offer RC
GUIDELINE STATMENT 29
High-risk with persistent or recurrent dz w/in 12 mo of appropriate BCG → offer RC
What is the role of enhanced cystoscopy?
GUIDELINE STATEMENT 30
offer blue light cysto at time of TURBT if available → increase detection, decrease recurrence
Hexaminolevulinate (HAL) FDA approved for BLC
GUIDELINE STATEMENT 31
Consider use of narrow band imaging (NBI) to increase detection and decrease recurrence
Discuss surveillance protocol for low- risk patient:
Reminder: LG solitary Ta < 3 cm, PUNLMP
GUIDELINE STATEMENT 32
first cysto in 3-4 mo
GUIDELINE STATEMENT 33
after first surveillance cysto neg, repeat cysto in 6-9 mo, then annually thereafter, after 5 year in absence of recurrence → SDM
GUIDELINE STATEMENT 34
Asx low-risk patient, should Not perform routine surveillance upper tract imaging
GUIDELINE STATEMENT 35
LG Ta and noted sub-cm papillary tumor (s), may consider in-office fulguration
Describe surveillance protocol for intermediate risk dz:
Reminder: Recurrent w/in 1 year LG Ta, Solitary LG Ta > 3 cm, LG Ta, multifocal, HG Ta, < 3 cm, or LG T1
GUIDELINE STATEMENT 36
first surveillance cysto 3 mo
if neg, subsequent cysto and cytology every 3-6 mo for 2 years, q 6-12 mo for years 3-4, then annually after 5 years
GUIDELINE STATEMENT 38
intermediate- or high-risk patients should consider upper tract surveillance imaging at 1-2 year intervals
Describe high-risk surveillance protocol:
Reminder: HG T1, Any recurrent, HG Ta, HG Ta, > 3 cm (or multifocal), Any CIS, Any BCG failure in HG pt, Any variant histology, Any LVI, Any HG prostatic involvement
GUIDELINE STATEMENT 37
first surveillance 3 mo
cystoscopy and cytology q 3-4 mo for 2 years, q 6 mo for years 3-4, and then annually
GUIDELINE STATEMENT 38
intermediate- or high-risk patients should consider upper tract surveillance imaging at 1-2 year intervals
Recurrence rates of bladder cancer by stage:
pT2 → 20-30%
pT3 → 40%
pT2 → 70% (node pos dz)
What is part of workup for suspected MIBC:
GUIDELINE STATEMENT 1
H&P, EUA at time of TURBT
GUIDELINE STATEMENT 2
full staging evaluation → CXR/Chest CT, A/P cross sectional imaging (IV contrast if possible)
Labs CBC, CMP (LFT, ALP, renal function)
Goals of pre-operative imaging in MIBC:
- determine feasibility and safety of removing the bladder
- presence of pelvic LAN
- presence of hydronephrosis
- presence of upper tract dz
- possible visceral/distant mets
What is recommended for pathologic review of MIBC?
GUIDELINE STATEMENT 3
experienced GU pathologist review when variant histology or if muscle invasion is equivocal (e.g. micropapillary, nested, plasmacytoid, neuroendocrine, sarcomatoid, extensive squamous or glandular differentiation)
Prior to treatment at time of dx MIBC, clinicians SHOULD:
GUIDELINE STATEMENT 4
Discuss curative tx options before determining plan based on tumor, comorbidity, include multidisciplinary (chemo, rt, sx)
GUIDELINE STATEMENT 5
counsel patient regarding complications and implications of treatment on QOL (e.g. continence, sexual function, fertility, bowel dysfunction, metabolic problems)
Prior to RC, what is recommended? If not possible due to factors or renal function, what is next recommendation?
GUIDELINE STATEMENT 6
offer cisplatin-based neo-adjuvant chemotherapy
*no validated predictive factors or clinical characteristics associated with response and benefit of NAC
*best regimen and duration not defined
*eligibility for NAC based on comorbidities and performance status, cardiac status and presence of peripheral neuropathy, healing loss, and renal dysfunction
If patient is ineligible for cisplatin-based NAC, and has resectable cT2-T4N0 bladder cancer? is alternative NAC recommended?
GUIDELINE STATEMENT 7
Should NOT prescribe carboplatin-based NAC, if NO cisplatin → just proceed to sx
When is the timing of RC after NAC?
GUIDELINE STATEMENT 8
ASAP following completion and recovery (ideally w/in 12 weeks if medically advisable)
Patient s/p RC with pT2/T3 and/or N+ dz, who did not receive NAC, what is option?
GUIDELINE STATEMENT 9
Eligible patients who did not receive NAC s/p RC with non-organ confined dz → offer cisplatin-based adjuvant chemotherapy
For MIBC who should be offered RC?
GUIDELINE STATEMENT 10
non-metastatic MIBC → RC and b/l PLND to eligible surgical candidates with resectable M0
What is included in a radical cystectomy?
GUIDELINE STATEMENT 11
standard RC with curative intent remove: bladder, prostate, and SVs; female consider removal of adjacent reproductive organs base on dz and need for R0
(anterior vaginal wall, uterus, cervix, fallopian tubes, ovaries)
invasive cancer at margin → urethrectomy (immediate or delayed men, always women unless neobladder)
GUIDELINE STATEMENT 12
discuss and consider sexual function preservation in organ-confined dz and absence of bladder neck, urethral, and prostate (male) involvement
*nerve sparing, vagina sparing
Which urinary diversions should be discussed? What are limitations/contraindications of certain types?
GUIDELINE STATEMENT 13
RC, discuss IC, continent cutaneous, and orthotopic neobladder diversions pros and cons
Contraindications to continent diversion:
- insufficient bowel length
- inadequate motor function or psych issue that limit self-cath
- inadequate renal or hepatic function increasing risk of metabolic abnormalities (GFR <45)
- cancer at urethral margins
- significant urethral stricture dz that is not correctable
GUIDELINE STATEMENT 14
orthotopic urinary diversion, must verify negative urethral margins
*in patients with palpable masses (_>_T3b) on bimanual, intraoperative frozen urethral and vaginal margins if considering neobladder
Some key elements of pre-operative management for RC:
GUIDELINE STATEMENT 15
Optimize patient performance status (nutrition, smoking cessation, data shows no need for mechanical bowel prep, carb loading)
GUIDELINE STATEMENT 16
Peri-operative pharmacologic thromboembolic ppx given during RC (SCD, heparin)
prior to anesthesia and up to 4 weeks post op
GUIDELINE STATEMENT 17
ų -opioid antagonist therapy to accelerate GI recovery decrease LOS
GUIDELINE STATEMENT 18
Should received detailed teaching on care of diversion prior to d/c
Discuss PLND during RC:
GUIDELINE STATEMENT 19
Clinicians should perform b/l PLND at time of sx with curative intent
GUIDELINE STATEMENT 20
B/L PLND should remove at minimum external, internal iliac, and obturator LN (goal >12)
Discuss MIBC bladder preservation approach:
GUIDELINE STATEMENT 21
for new dx MIBC, pts who wish to retain bladder or w/comorbidities for whom RC is not tx not an option → bladder preserving tx (max TURBT, partial cystectomy and LND, primary RT, and multimodal tx)
GUIDELINE STATEMENT 22
pts considering bladder preservation → max debulking TURBT and assessment of multifocal dz or CIS should be performed
GUIDELINE STATEMENT 23
pts with MIBC who are medically fit and consent to RC SHOULD NOT undergo partial cystectomy or max TURBT as primary curative therapy
Selection criteria for partial cystectomy or max TURBT:
accessible tumor location
size < 3 cm
no multi-focal CIS
no hydronephrosis
adequate bladder function
no residual T1 or higher dz
Primary radiation for MIBC?
GUIDELINE STATEMENT 24
for patient with MIBC, SHOULD NOT offer radiation alone as curative tx
Define multimodal bladder preserving therapy
GUIDELINE STATEMENT 25
MIBC → max TURBT, chemotherapy + EBRT
planned cystoscopic re-evaluation (mid course to ID non-responders)
*cytotoxic agents may sensitize tumor cells to RT, kills in synergistic fashion
GUIDELINE STATEMENT 26
Radiation sensitizing chemo should be included with curative intent
(cisplatin +/- 5FU, mitomycin C?, gemcitabine)
After bladder preserving therapy, what should follow up be:
GUIDELINE STATEMENT 27
regular surveillance cystoscopy q 3 mo first year, q 4-6 the 2nd year q6-12 mo thereafter
CT scans (q6 mo for 1st year) and urine cytology
Bladder preserving treatment failure options: residual or recurrent MIBC? non MIBC?
GUIDELINE STATEMENT 28
patients medically fit recurrent or residual MIBC → RC + b/l PLND
GUIDELINE STATEMENT 29
local measures (TURBT with intravesical tx) OR RC + b/l PLND
Surveillance and f/up s/p RC for MIBC?
GUIDELINE STATEMENT 30
Chest and cross sectional A/P CT/MRI q 6-12 mo for 2-3 years, then annually
Evaluate: upper tract cancer, mc recurrence, progression, mets (pelvis, RP, liver, lungs, bones), and urinary diversion concerns like hydro
GUIDELINE STATEMENT 31
electrolytes and renal function q 3-6 mo interval for 2-3 years, then annually (hypokalemia, hyponatremia and/or hypokalemic hyperchloremic metabolic acidosis, B12)
GUIDELINE STATEMENT 32
Monitor urethral remnant for recurrence
Guidelines in regards to survivorship:
GUIDELINE STATEMENT 33
discuss how patients are coping and recommend cancer support group or individual counseling
GUIDELINE STATEMENT 34
encourage pts to adopt healthy lifestyle habits, smoking cessation, exercise, healthy diet to improve long term health and quality of life
What about variant histology f/up:
GUIDELINE STATEMENT 35
Unique clinical characteristics may require divergence from standard evaluation and management
what is rationale for intravesical tx after TURBT?
recommended to reduce risk of recurrence (reduction 17%)
option for patients with papillary appearing tumor but no pathologic dx yet
destruction of residual microscopic tumor at site of TURBT and circulating cells, preventing re-implantation
Mitomycin C → alkylating agent inhibits DNA replication
Little systemic circulation
a/e dermatitis and irritative voiding sxs
Risk factors for bladder cancer:
- tobacco
- Male > Female (3:1)
- Age (90% > 55 yo)
- Radiation
- chemical/occupational exposure → aromatic compounds (paint, dye, metal/petroleum)
- Phenacetin → analgesic
- Cyclophosphamide
- Pioglitazone (actos)
- Schistosomiasis (SCC)
- Chronic cystitis (SCC) → chronic UTI, foley, CIC, stones
natural history of non MIBC? Ta, T1, CIS?
Ta → 50-70% recurrence, < 5 % progression
T1 → 70-80% recurrence, 50% progression
CIS → 80% recurrence after TURBT, 20-30% recurrence after BCG, 20% progress after complete BCG response
factors that influence recurrence of non MIBC?
number of tumors
tumor grade and stage
tumor size > 3 cm
concomitant CIS
prior recurrence rate
tumor present at 3 mo cysto
What factors influence muscle invasion for superficial UC (CIS, Ta, T1)?
tumor grade and stage
CIS
Tumor size > 3 cm
*if intravesical therapy fails, early cystectomy warranted
What is the role of cytology in initial workup of microhematuria?
symptomatic (irritative voiding sxs in absence of infx)
risk factors for UC (smoking, dyes, exposures)
What is the theory of BCG efficacy?
attenuated strain of mycobacterium bovis → immune response causes intense local inflammatory reaction of the bladder, activates T cells to attack abnormal urothelium and causes release of cytokines
Why should BCG be postponed? When is it contrainidcated?
Postpone: recent resection (4 weeks), traumatic catheter, gross hematuria, cystitis, UTI/fever
contra: immunosuppression (HIV, lymphoma, leukemia, steroids), prior hypersensitivity rxn/sepsis, NOT if positive PPD
What is an extended and a standard PLND?
Extended: common iliac, external iliac, obturator, hypogastric, and presacral LN (may include nodes up tot he level of the IMA if necessary)
Boundaries
- Genitofemoral nerves → lateral
- Bladder → medial
- Common iliac artery → proximal
- Femoral canal → distal
Standard: external iliac, obturator, hypogastric LNs
Name the metabolic abnormalities for the various bowel segments that are used for diversion:
Stomach: hypochloremic hypokalemic metabolic alkalosis
Jejunum: hyponatremic hypochloremic hyperkalemic metabolic acidosis; tx: oral NaCL, HCO3, fluids
Ileum, Colon, Sigmoid: hyperchloremic hypokalemic metabolic acidosis; tx: oral Cl restriction, HCO3, oral/IV hydration, drain in cath
How do you treat BCG sepsis?
After tx, high fever, shaking chills, hypotension
Admit right away
Early use of steroids, IVF, anti-Tb meds ASAP (UCx, BCx → bacteria, AFB), broad spectrum Abx (FQ)
INH 300 mg/day, pyridoxine (Vit B6 daily)
Rifampin 600 mg /day
Ethambutol 1200 mg/day
6 mo course of tx (check LFTs during INH tx)
NEVER give BCG again
What are other side effects of BCG besides irritative voiding and BCG sepsis?
Granulomatous prostatitis: asx - no tx; sxs-tx INH/Rifampin 3-6 mo
Granulomatous orchitis/epididymitis
Cystitis: causes delay and dropout
Describe regimens for multi-agent Cisplatin based chemotherapy and their major side effects:
GC (Gemcitibine, Cisplatin)
- Gemcitibine: thrombocytopenia and anemia
- Cisplatin: nephrotoxicity
(Older regimens)
MVAC (Methotrexate, Vinblastine, Doxorubicin, Cisplatin) *higher rate of neutropenia, sepsis, mucositis, alopecia, and fatigue
- Methotrexate: mucositis, myelosuppression
- Vinblastine: cardiotoxicity
- Doxorubicin: cardiotoxicity
- Cisplatin: nephrotoxicity
When a patient has MIBC and family hx of colon cancer? What test is part of metastatic post TURBT workup? What other testing is indicated in further planning?
FOBT if + needs colonoscopy prior to considering diversion/tx
What if grossly enlarged nodes are found at time of RC/PLND?
- Is it resectable? If yes, proceed with extended PLND, recommend adjuvant chemotherapy
- Abort case when:
- Bulk LAN not resectable
- Demoplastic peri-ureteral mets
- Rectal wall invasion
- Bladder fixed and unresectable
Describe cystoprostatectomy in males?
- Midline incision
- Divide urachus and vasa
- Take down lateral pedicles of bladder and prostate
- Incise the peritoneum in the rectovesical cul-de-sac
- Incise the endopelvic fascia
- Preserve the neurovascular bundles
- Ligate the DVC
- Transect the urethra
Likely sources of bleeding during RC?
DVC
Branches of internal iliac artery such as superior and inferior vesical arteries
External lilac and obturator vessels
pelvic sidewall
What are QOL implications for RC?
Issue with continence
ED
Metabolic problems
Bowel dysfunction
Fertility
Describe creation of neobladder (Orthotopic-Studer)
- 50-55 cm of ileum, 15-20 cm proximal to ileocecal junction
- 10-15 cm proximal end for ureteral reimplant
- Place single J stents
- Open anti-mesenteric side of distal 40 cm
- fold into sphere
- suprapubic tube is option
- anastomose to prostatic urethra
- place pelvic drain
Describe creation of a continent reservoir (i.e. Indiana pouch):
- Right colon and 10 cm distal ileum
- Appendectomy
- Narrow catheterizable ileal segment with GIA stapler
- Imbricate or reinforce ileocecal valve with silk Lembert sutures or cecal wrap
- Colon folded into U-shaped segment and detubularized
- Ureteral-colonic anastomosis
- Place single J stents
- Sew catheterizable channel to abdominal wall and ensure easy passage of catheter
- Place pelvic drain
Describe an anterior exenteration for females:
- Midline incision
- Divide urachus
- Take down lateral pedicles of bladder
- Ligate superior vesical artery
- Divide ovarian vessels (infundibulopelvic ligament)
- Divide cardinal and ureterosacral ligaments
- Incise the peritoneum in the pouch of Douglas
- Divide ureters at the level of the bladder
- Divide the urethra at bladder next and send margin for frozen
Describe creation of an Ileal Conduit:
- Harvest 12-15 cm length of terminal ileum at least 15-20 cm from ileocecal valve
- Maintain vascular supply
- Perform enteroenterostomy
- Close mesenteric trap above conduit
- Pass left ureter behind sigmoid mesentery
- Close butt end of loop
- Ureteroileal anastamosis
- Tack butt end to RP ?
- Place single J ureteral stents
- Mature stoma
- Place pelvic drain
What are indications for partial cystectomy?
- single primary tumor, no CIS (mapping bx)
- location suitable for bladder preservation (away from UOs, i.e. dome)
- High grade, focal, MIBC w/complete or partial response to chemo
- tumor amenable to complete excision with neg margins
- tumor only in diverticulum
- urachal adenocarcinoma → resect posterior rectus sheath, urachus, and dome (en-bloc)
- patients who have sufficient bladder capacity after sx (cystogram first)
**must perform b/l PLND
Complications of partial cystectomy:
Tumor recurrence
Vesicocutaneous fistula
Ureteral obstruction
Urine leak
Reduced bladder capacity
Urge incontinence
Discuss bladder preserving tx, components, amount, f/up?
medically unfit or refuse RC
complete TURBT, chemo, RT
XRT w/radio-sensitizing chemo (Cisplatin, 5FU)
45-55 Gy to bladder and LN with 20 Gy to tumor
22-47% proceed to RC
Poor prognostic features for MIBC, when considering bladder sparing tx?
hydronephrosis
cT3b, cT4
low Hgb
CIS (does not respond to XRT)
residual dz after TURBT
If you have a leak from a neobladder early post op, what is first steps? part of initial PE, labs, imaging?
- See patient, flush stents, foley, SPT (if present)
- UA, UCX, CBC, BMP, JP Cr
- Pouchogram and stentogram
- If leak, take JP off suction, manipulate away from anastomosis
- Consider PCNs
- If persistent, re-explore and repair
List Intraop complications of RC?
hemorrhage
tumor spillage
rectal injury
vascular injury
nerve injury (obturator)
List Post op complication of RC?
prolonged ileus
wound infection
urine leak
SBO
DVT/PE
intestinal leak
wound dehiscence
fistula
hemorrhage
urinary/renal obstruction
pyelonephritis
What’s the treatment of choice for a 2 cm recurrence at the distal uretero-ileal anastamosis of an IC wit hydronephrosis? what if urethral cytology is positive?
PCN
Antegrade nephrostogram and stent, send cytology
Re-operation with excision of left distal ureter and re-anastomosis with negative urethral margins (consider URS and nephroureterectomy if multifocal)
urethrectomy
what are risk factors for urethral recurrence s/p RC?
multifocal NMIBC
CIS
Bladder cancer stage
history of urothelial carcinoma of prostate
non-orthotopic urinary diversion
What are indications for urethrectomy?
Men: diffuse CIS of prostatic urethra or ducts, tumor invasion to prostatic stroma, CIS or frank tumor at apical margin
Women: CIS or tumor at bladder neck/urethra, multifocal CIS, tumor involving anterior vaginal wall (T4)
What are some metabolic complications of post-cystectomy urinary diversion?
Electrolyte abnormalities
AMS → increase ammonia levels
Altered hepatic metabolism
Pyelonephritis → proteus or pseudomonas MC
Metabolic acidosis → osteomalacia
Renal and reservoir calculi → struvite stones; mc associated with hyperchloremic metabolic acidosis
Adenocarcinoma → ureterosigmoidostomy ureteral anastomosis site at risk
Short bowel syndrome → B12 (neuro defects), bile salts, calcium and folic acid malabsorption
How would you educate patients regarding incontinence following orthotopic urinary diversion?
80-90% continent during day
55-65% continent during night
Incontinence rate higher > 65 yo
Increased nocturnal incontinence is due to loss of afferent input from detrusor to the CNS, which perviously resulting in corresponding increase in urethral resistance with filling
