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ABU Oral Boards > Bladder Cancer > Flashcards

Bladder Cancer Flashcards

1
Q

Post TURBT Algorithm NMIBC

A
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2
Q

Genetic predisposition to NMIBC:

A

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…

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3
Q

Bladder cancer T staging:

A

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

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4
Q

N and M for bladder cancer

A
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5
Q

Stages for TNM bladder cancer, 0a - IV b

A
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6
Q

CSS in high-grade dz:

A

Ranges 70-85% at 10 years

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7
Q

At time of TURBT, clinicians SHOULD document and perform cystoscopic exam of what? Additionally, they should perform what type of resection?

A

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

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8
Q

Define low risk NMIBC

A

Low risk

LG solitary Ta < 3 cm

PUNLMP

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9
Q

Define intermediate risk NMIBC:

A

Intermediate risk:

Recurrent w/in 1 year, LG Ta

Solitary LG Ta > 3 cm

LG Ta, multifocal

HG Ta, < 3 cm

LG T1

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10
Q

Define high risk NMIBC:

A

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

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11
Q

Besides resection/cysto, what else SHOULD be performed as part of initial workup of bladder cancer patient?

A

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)

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12
Q

What SHOULD a clinician consider in a pt with NMIBC and normal cystoscopy and positive cytology?

A

GUIDELINE STATEMENT 4

prostatic urethral biopsies and upper tract imaging

consider enhanced techniques (blue light), URS, random bladder bx

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13
Q

At each occurrence/recurrence, clinicians SHOULD:

A

GUIDELINE STATEMENT 5

assign clinical stage and classify risk category

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14
Q

In variant histology results, what is recommend:

A

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

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15
Q

If pt with variant histology (presumed non-invasive) considering bladder preservation, the clinician SHOULD perform and offer?

A

GUIDELINE STATEMENT 7

perform re-staging TURBT in 4-6 weeks

*r/o MIBC (high rate upstaging)

GUIDELINE STATEMENT 8

Offer radical cystectomy

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16
Q

Is there a role of urinary biomarkers for surveillance of NMIBC?

A

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

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17
Q

When are urine biomarkers recommended?

A

GUIDELINE STATEMENT 11

In NMIBC to assess response to BCG (UroVysion FISH) and to adjudicate equivocal cytology (UroVysion FISH and ImmunoCyt)

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18
Q

What instances get a repeat TURBT?

A

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)

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19
Q

In patient with suspected or known low- or intermediate risk bladder cancer, clinicians SHOULD:

A

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)

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20
Q

In high-risk newly dx CIS, HG T1 or high risk Ta, what SHOULD be done:

A

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

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21
Q

In intermediate-risk pt who responds to induction, may utilize:

A

GUIDELINE STATEMENT 19

Maintenance

Monthly for 6-12 mo

GUIDELINE STATEMENT 20

if given BCG and responds → maintenance 1 year (if supply)

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22
Q

In high-risk patients who respond to BCG, maintenance:

A

GUIDELINE STATMENT 21

Continue for 3 years

3 weekly installments at 3, 6, 12, 18, 24, 30, 36 mo

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23
Q

For persistent or recurrent disease or positive cytology following intravesical therapy, clinicians SHOULD consider:

A

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%

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24
Q

Pt with persistent Ta or CIS dz after induction intravesical BCG SHOULD be offered:

A

GUIDELINE STATEMENT 23

A second course of induction

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25
Q

In a patient with persistent/recurrent HG T1 dz after single induction of BCG, SHOULD be offered:

A

GUIDELINE STATEMENT 24

Radical Cystectomy if fit for surgery

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26
Q

When is an additional course of BCG not appropriate?

A

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

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27
Q

What treatment can be offered for persistent or recurrent intermediate- or high-risk NMIBC w/in 12 months of completion of adequate BCG therapy?

A

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

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28
Q

Outline role of cystectomy in NMIBC:

A

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

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29
Q

What is the role of enhanced cystoscopy?

A

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

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30
Q

Discuss surveillance protocol for low- risk patient:

A

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

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31
Q

Describe surveillance protocol for intermediate risk dz:

A

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

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32
Q

Describe high-risk surveillance protocol:

A

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

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33
Q

Recurrence rates of bladder cancer by stage:

A

pT2 → 20-30%

pT3 → 40%

pT2 → 70% (node pos dz)

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34
Q

What is part of workup for suspected MIBC:

A

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)

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35
Q

Goals of pre-operative imaging in MIBC:

A
  1. determine feasibility and safety of removing the bladder
  2. presence of pelvic LAN
  3. presence of hydronephrosis
  4. presence of upper tract dz
  5. possible visceral/distant mets
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36
Q

What is recommended for pathologic review of MIBC?

A

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)

37
Q

Prior to treatment at time of dx MIBC, clinicians SHOULD:

A

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)

38
Q

Prior to RC, what is recommended? If not possible due to factors or renal function, what is next recommendation?

A

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

39
Q

If patient is ineligible for cisplatin-based NAC, and has resectable cT2-T4N0 bladder cancer? is alternative NAC recommended?

A

GUIDELINE STATEMENT 7

Should NOT prescribe carboplatin-based NAC, if NO cisplatin → just proceed to sx

40
Q

When is the timing of RC after NAC?

A

GUIDELINE STATEMENT 8

ASAP following completion and recovery (ideally w/in 12 weeks if medically advisable)

41
Q

Patient s/p RC with pT2/T3 and/or N+ dz, who did not receive NAC, what is option?

A

GUIDELINE STATEMENT 9

Eligible patients who did not receive NAC s/p RC with non-organ confined dz → offer cisplatin-based adjuvant chemotherapy

42
Q

For MIBC who should be offered RC?

A

GUIDELINE STATEMENT 10

non-metastatic MIBC → RC and b/l PLND to eligible surgical candidates with resectable M0

43
Q

What is included in a radical cystectomy?

A

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

44
Q

Which urinary diversions should be discussed? What are limitations/contraindications of certain types?

A

GUIDELINE STATEMENT 13

RC, discuss IC, continent cutaneous, and orthotopic neobladder diversions pros and cons

Contraindications to continent diversion:

  1. insufficient bowel length
  2. inadequate motor function or psych issue that limit self-cath
  3. inadequate renal or hepatic function increasing risk of metabolic abnormalities (GFR <45)
  4. cancer at urethral margins
  5. 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

45
Q

Some key elements of pre-operative management for RC:

A

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

46
Q

Discuss PLND during RC:

A

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)

47
Q

Discuss MIBC bladder preservation approach:

A

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

48
Q

Selection criteria for partial cystectomy or max TURBT:

A

accessible tumor location

size < 3 cm

no multi-focal CIS

no hydronephrosis

adequate bladder function

no residual T1 or higher dz

49
Q

Primary radiation for MIBC?

A

GUIDELINE STATEMENT 24

for patient with MIBC, SHOULD NOT offer radiation alone as curative tx

50
Q

Define multimodal bladder preserving therapy

A

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)

51
Q

After bladder preserving therapy, what should follow up be:

A

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

52
Q

Bladder preserving treatment failure options: residual or recurrent MIBC? non MIBC?

A

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

53
Q

Surveillance and f/up s/p RC for MIBC?

A

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

54
Q

Guidelines in regards to survivorship:

A

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

55
Q

What about variant histology f/up:

A

GUIDELINE STATEMENT 35

Unique clinical characteristics may require divergence from standard evaluation and management

56
Q

what is rationale for intravesical tx after TURBT?

A

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

57
Q

Risk factors for bladder cancer:

A
  1. tobacco
  2. Male > Female (3:1)
  3. Age (90% > 55 yo)
  4. Radiation
  5. chemical/occupational exposure → aromatic compounds (paint, dye, metal/petroleum)
  6. Phenacetin → analgesic
  7. Cyclophosphamide
  8. Pioglitazone (actos)
  9. Schistosomiasis (SCC)
  10. Chronic cystitis (SCC) → chronic UTI, foley, CIC, stones
58
Q

natural history of non MIBC? Ta, T1, CIS?

A

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

59
Q

factors that influence recurrence of non MIBC?

A

number of tumors

tumor grade and stage

tumor size > 3 cm

concomitant CIS

prior recurrence rate

tumor present at 3 mo cysto

60
Q

What factors influence muscle invasion for superficial UC (CIS, Ta, T1)?

A

tumor grade and stage

CIS

Tumor size > 3 cm

*if intravesical therapy fails, early cystectomy warranted

61
Q

What is the role of cytology in initial workup of microhematuria?

A

symptomatic (irritative voiding sxs in absence of infx)

risk factors for UC (smoking, dyes, exposures)

62
Q

What is the theory of BCG efficacy?

A

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

63
Q

Why should BCG be postponed? When is it contrainidcated?

A

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

64
Q

What is an extended and a standard PLND?

A

Extended: common iliac, external iliac, obturator, hypogastric, and presacral LN (may include nodes up tot he level of the IMA if necessary)

Boundaries

  1. Genitofemoral nerves → lateral
  2. Bladder → medial
  3. Common iliac artery → proximal
  4. Femoral canal → distal

Standard: external iliac, obturator, hypogastric LNs

65
Q

Name the metabolic abnormalities for the various bowel segments that are used for diversion:

A

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

66
Q

How do you treat BCG sepsis?

A

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

67
Q

What are other side effects of BCG besides irritative voiding and BCG sepsis?

A

Granulomatous prostatitis: asx - no tx; sxs-tx INH/Rifampin 3-6 mo

Granulomatous orchitis/epididymitis

Cystitis: causes delay and dropout

68
Q

Describe regimens for multi-agent Cisplatin based chemotherapy and their major side effects:

A

GC (Gemcitibine, Cisplatin)

  1. Gemcitibine: thrombocytopenia and anemia
  2. Cisplatin: nephrotoxicity

(Older regimens)

MVAC (Methotrexate, Vinblastine, Doxorubicin, Cisplatin) *higher rate of neutropenia, sepsis, mucositis, alopecia, and fatigue

  1. Methotrexate: mucositis, myelosuppression
  2. Vinblastine: cardiotoxicity
  3. Doxorubicin: cardiotoxicity
  4. Cisplatin: nephrotoxicity
69
Q

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?

A

FOBT if + needs colonoscopy prior to considering diversion/tx

70
Q

What if grossly enlarged nodes are found at time of RC/PLND?

A
  1. Is it resectable? If yes, proceed with extended PLND, recommend adjuvant chemotherapy
  2. Abort case when:
    1. Bulk LAN not resectable
    2. Demoplastic peri-ureteral mets
    3. Rectal wall invasion
    4. Bladder fixed and unresectable
71
Q

Describe cystoprostatectomy in males?

A
  1. Midline incision
  2. Divide urachus and vasa
  3. Take down lateral pedicles of bladder and prostate
  4. Incise the peritoneum in the rectovesical cul-de-sac
  5. Incise the endopelvic fascia
  6. Preserve the neurovascular bundles
  7. Ligate the DVC
  8. Transect the urethra
72
Q

Likely sources of bleeding during RC?

A

DVC

Branches of internal iliac artery such as superior and inferior vesical arteries

External lilac and obturator vessels

pelvic sidewall

73
Q

What are QOL implications for RC?

A

Issue with continence

ED

Metabolic problems

Bowel dysfunction

Fertility

74
Q

Describe creation of neobladder (Orthotopic-Studer)

A
  1. 50-55 cm of ileum, 15-20 cm proximal to ileocecal junction
  2. 10-15 cm proximal end for ureteral reimplant
  3. Place single J stents
  4. Open anti-mesenteric side of distal 40 cm
  5. fold into sphere
  6. suprapubic tube is option
  7. anastomose to prostatic urethra
  8. place pelvic drain
75
Q

Describe creation of a continent reservoir (i.e. Indiana pouch):

A
  1. Right colon and 10 cm distal ileum
  2. Appendectomy
  3. Narrow catheterizable ileal segment with GIA stapler
  4. Imbricate or reinforce ileocecal valve with silk Lembert sutures or cecal wrap
  5. Colon folded into U-shaped segment and detubularized
  6. Ureteral-colonic anastomosis
  7. Place single J stents
  8. Sew catheterizable channel to abdominal wall and ensure easy passage of catheter
  9. Place pelvic drain
76
Q

Describe an anterior exenteration for females:

A
  1. Midline incision
  2. Divide urachus
  3. Take down lateral pedicles of bladder
  4. Ligate superior vesical artery
  5. Divide ovarian vessels (infundibulopelvic ligament)
  6. Divide cardinal and ureterosacral ligaments
  7. Incise the peritoneum in the pouch of Douglas
  8. Divide ureters at the level of the bladder
  9. Divide the urethra at bladder next and send margin for frozen
77
Q

Describe creation of an Ileal Conduit:

A
  1. Harvest 12-15 cm length of terminal ileum at least 15-20 cm from ileocecal valve
  2. Maintain vascular supply
  3. Perform enteroenterostomy
  4. Close mesenteric trap above conduit
  5. Pass left ureter behind sigmoid mesentery
  6. Close butt end of loop
  7. Ureteroileal anastamosis
  8. Tack butt end to RP ?
  9. Place single J ureteral stents
  10. Mature stoma
  11. Place pelvic drain
78
Q

What are indications for partial cystectomy?

A
  1. single primary tumor, no CIS (mapping bx)
  2. location suitable for bladder preservation (away from UOs, i.e. dome)
  3. High grade, focal, MIBC w/complete or partial response to chemo
  4. tumor amenable to complete excision with neg margins
  5. tumor only in diverticulum
  6. urachal adenocarcinoma → resect posterior rectus sheath, urachus, and dome (en-bloc)
  7. patients who have sufficient bladder capacity after sx (cystogram first)

**must perform b/l PLND

79
Q

Complications of partial cystectomy:

A

Tumor recurrence

Vesicocutaneous fistula

Ureteral obstruction

Urine leak

Reduced bladder capacity

Urge incontinence

80
Q

Discuss bladder preserving tx, components, amount, f/up?

A

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

81
Q

Poor prognostic features for MIBC, when considering bladder sparing tx?

A

hydronephrosis

cT3b, cT4

low Hgb

CIS (does not respond to XRT)

residual dz after TURBT

82
Q

If you have a leak from a neobladder early post op, what is first steps? part of initial PE, labs, imaging?

A
  1. See patient, flush stents, foley, SPT (if present)
  2. UA, UCX, CBC, BMP, JP Cr
  3. Pouchogram and stentogram
  4. If leak, take JP off suction, manipulate away from anastomosis
  5. Consider PCNs
  6. If persistent, re-explore and repair
83
Q

List Intraop complications of RC?

A

hemorrhage

tumor spillage

rectal injury

vascular injury

nerve injury (obturator)

84
Q

List Post op complication of RC?

A

prolonged ileus

wound infection

urine leak

SBO

DVT/PE

intestinal leak

wound dehiscence

fistula

hemorrhage

urinary/renal obstruction

pyelonephritis

85
Q

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?

A

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

86
Q

what are risk factors for urethral recurrence s/p RC?

A

multifocal NMIBC

CIS

Bladder cancer stage

history of urothelial carcinoma of prostate

non-orthotopic urinary diversion

87
Q

What are indications for urethrectomy?

A

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)

88
Q

What are some metabolic complications of post-cystectomy urinary diversion?

A

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

89
Q

How would you educate patients regarding incontinence following orthotopic urinary diversion?

A

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

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