Bladder cancer Flashcards
1
Q
presentation - musc vs non musc inv, vs metastatic
A
75% non musc, 20% musc, 5% metastatic
2
Q
cigaretter smoking dose threshold
A
dose dependent but 40 pk yrs is esp important. no risk plateau
3
Q
4 things assd w bilateral upper tract ca
A
arsenic, balken nephropathy, bracken fern, aristolochia fangchi
4
Q
2 polymorphisms confering higher suceptibility to environmental carcinogens
A
- slow acetylators, 2. glutathione s transferase M1 null
5
Q
congential condition w higher risk of adnenoca
A
extrophy
6
Q
iatrogenic condition w higher risk of adnenoca
A
ureterosigmoidostomy
7
Q
signet cell adenoca significance
A
very bad
8
Q
small cell/neuroendocrine markers - 3
A
synaptophysin, chromogranin, neuron speciic enolase
9
Q
tx for small cell
A
VP-16 then cystectomy for ANY stage
10
Q
3 premalignant lesions
A
- leikoplakia (20% risk of SCC), 2. cystitis glandularis (adenoca), 3. inverted papilloma (assd w TCC elsewhere)
11
Q
benign lesions - 5
A
squamous metaplasia (50% females), nephrogenic adenoma (turbt), cystis cystica / follicularis, pseudosarcoma (spindle cell tumor), malacoplakia (rxn to chronic UTI)
12
Q
significance of 9q loss
A
low grade tcc
13
Q
significance of high p53, KI 67, matril metaloprotease
A
high grade
14
Q
what is KI 67
A
marker of proliferation
15
Q
tetraploidy significance
A
normal - found in umbrella cells
16
Q
sig of low RB, e-cadgerin, p27
A
high grade
17
Q
what is RB
A
“cell cycle brake” - loss promotes cancer proliferation
18
Q
sig of high urokinase type pasminogen activator
A
high grade
19
Q
nephrogenic adenoma sx
A
hematuria, dysuria, frequency
20
Q
clinical stage for fixed vs palpable mass after turbt
A
fixed - T4, palpable - ct3
21
Q
rate of understaging if no muscle in T1 specimen
A
50%
22
Q
chance understaging in T1 with muscle in specimen or chance of leaving tumor behind
A
10-20% understaging, 30-50% residual tumor behind
23
Q
retur?
A
all high grade T1 reduces understaging to < 10%
24
Q
tumor in diverticulum - Ta vs T1
A
Ta - can be safely removed, T1 - may need partial cystectomy
25
2 situations where intraperitoneal perf can be managed conservatively
1. small and late in TUR - switch to glycine, 2. large/ assd w bleeding or early in TUR - stop and retuen another time
26
absolute indication to e-lap in intraperitoneal bladder injury
bowel injury
27
LVI in T1 - prognostic sig - 3
88% chanc of understaging, increased occult LN mets, decreased survival
28
LVI mgmt in T1 - 2
early cystectomy with neoadjuvant chemo
29
risk of recurrence at 2 yrs vs 4 yrs for HG TCC
80% vs 20%
30
things primarily affecting recurrence - 4
prior recurrence > 1x/yr, multifocality, tumor > 3 cm, recurrence at 3 mo cysto
31
things affecting progression
CIS, stage (T1/CIS)
32
low risk bca - 3
low grade, solitary, Ta
33
progression risk for low risk
<5% @5 yrs
34
intermediate risk - 2
recurrent OR multifocal Ta/T1 low grade
35
progression risk for intermediate risk
10% at 5 yrs
36
high risk
any high grade (CIS, Ta, T1)
37
highest risk
multifocal T1G3+CIS
38
progression risk for high risk
25-50% @ 5 yrs
39
post TUR agents - 3
mitomicin, thiotepa, doxorubicin
40
when to give post TUR chemo
within 6 hrs
41
dwell time for post tur agents
30-60 minutes
42
what agent does not cause severe local tissue reaction/peritonitis with perforation
thiotepa
43
thiotepa risk with perf
myelosupression (lowest molecular weight)
44
benefit of post chemo agent
25-50% relative risk of recurrence, 15% absolute risk reduction
45
techniques for optimization of intravesical chemo (delayed) - 4
1. relative dehydration, 2. empty bladder prior to instillation, 3. increase concentration (40 mg in 20 cc water), 4. alkalinize urine with po bicarb (reduces mitomicin degradation)
46
mitomycin toxicity
hypersensitivity, palmar rash, bladder contracture
47
thiotepa toxicity
myelpsupression- have to check weekly CBC
48
who is intravesical chemo best for
intermediate risk papillary, or if BCG is contraindicated
49
effect of intravesical chemo
recurrence only, no effect on progression
50
limitations of multidose chemo -3
1. reduces recurrence only, 2. ineffective if prior bcg failure, 3. failure of 1 chemo agent increases failure likelyhood of another chemo agent
51
contraindications to BCG dose - 4
1. traumatic cath, 2. recent gross hematuria, 3. unresolved UTI, 4. significant immunosupression or autoimmune disease
52
what are not contraindications to BCG - 4
1. reflux, 2. hx treated TB, 3. positive PPD, 4. prosthetic devices
53
benefit to BCG
30% reduction in recurrence and progression
54
BCG MOA - 2
1. T-helper type 1 immune response (inc IL2 and interferon gamma), 2. opposed by T helper type 2 response (increased IL-4 and IL-10)
55
1st steps to improve BCG tolerance
sx relieving drugs - antichol, pyridium
56
alternate methods of improving BCG toelrance - 3
1. BCG dose reduction, 2. space tx out to 2 wks apart, 3. decrease dwell time to 30 mins
57
BCG sepsis meds - 2 steps
3-6 months with INH, or triple therapy (INH, ethambutol, rifampin) if severe case + steroids(!) in acute phase
58
supplementation with INH
B6, pyridoxine
59
mgmt of BCG prostatitis
anti tb meds
60
most common cause of BCG sepsis
traumatic catheterization
61
low, intermediate, high risk and chemo/BCG
low - postop chemo only, intermediate/high - postop chemo + 6 wk chemo or BCG + maintenance
62
indications for upfront cystectomy in nonmuscle invasive disease - 7
unfavorabel histology, LVI, bulky/incompletely resectable T1 HG, BCG failure x 2 in T1HG, prostatic stromal invasion, HGT1 in bladder diverticulum, bladder cripple with recurrent disease
63
unfavorable histology qualifying for upfront cystectomy
SCC, small cell, adenoca, nested or plasmacytoid, micropapillary
64
relative indications for RC
T1HG after repeat TUR, T1HG after BCG x 1, multifocal T1HG + CIS at presentation
65
upper tract studies - low risk, multifocal low risk, high risk
low risk - initial study only, multifocal low risk, every 2 yrs, high risk - q 1-2 yrs
66
delay in tx of small Ta with hx low/intermediate risk disesae
safe - 2 mm growth per mo
67
when is selective positive upper tract cytology unreliable
visible bladder tumor or bx + CIS - contamination
68
in female, if bladder workup negative for positive cytology
check gyn source
69
outcome if initial workup of positive cytology is negative
bladder source eventually in 80%
70
bcg failure vs chemo failure
bcg failure responds to 2nd line bcg (30-50% response) but not to chemo, chemo failure responds to bcg like untreated patient
71
most common cause of death in bladder ca
distant mets at the time of locoregional tx
72
what timeframe does progression of cancer happen after locoregional tx
within 2 yrs
73
small cell associated paraneoplastic syndromes - 3
ectopic ACTH, hypercalcemia, hypophosphatemia
74
T2a/b
Ta2 - inner muscle, b - outer muscle
75
T4a
t4b - prostate stroma (via SV, urethra, or bladder neck), vag, uterus, rectum. mobile. T4b - pelvic side wall, fixed
76
CIS of prostatic urethra or ducts and stage?
does not upstage as outcome is determined by primary bladder ca
77
most significant pathologic risk for progression
LN status
78
% upstaging from T1 at TUR to T2 at RC
40%
79
hydro on preop workup and cT stage
cT3
80
prostate prior to RC
always do prostate biopsies at 5/7 oclock. if neg, dont need to send urethral margin at RC
81
when to absolutely get CT chest other than abn cxr
T4, N+ on c stage
82
when to preserve uterus/vagina in F
better support when considering neobladder
83
when can a female not have orthotopic diversion
anterior vaginal wall invovlement b/c have to remove urethra
84
when not to preserve urethra in F and mgmt
poster based invasice ca. have to include a small strip of anterior vag for margin.
85
prostate/SV sparing RC
investigational as prostate is involved 40% of the time
86
extended LN dissection and survival
no current evicence extended LN dissection (to IMA) improves survival.
87
extended LN dissection and tumor involvement
involved in upto 50% of T3/4
88
4 situations to abort cystectomy
1. LN disease unresectable, 2. extensive periureteral disease, 3. fixation to pelvic side wall, 4. invading rectum
89
when can you keep the urethra if there is tumor involvement
small, papillary tumors that have been resected
90
recurrent urethral TCC risk and diversion type
lower with orthotopic vs cutaneous diversion
91
how to preserve urethral innervation in female
limit dissection to above endopelvic fascia
92
nerve sparin cystectomy?
only if no evidence of local extension intraoperatively. 40% achieve erections. age dependent
93
CIS of ureter or prostate and outcome
not associated with poor outcome
94
noncontiguous vs contiguous involvement of prostate and outcome
contiguous = very bad, T4 disease
95
all of the following surgical LN characteristics impact survival: 5
LN, # LN positive, % LN positive, path stage of tumor, extranodal extension
96
death and women
upto 50% higher risk of death
97
timeframe to recurrence
most within 1st 3 yrs
98
who needs annual upper tract monitoring post cystectomy - 3
urethral margin, + ureteral margin, CIS
99
tumor location for partial cystectomy
dome of the bladder, away fro ureteral orifaces
100
partial cystectomy outcome
poorer outcome.
101
poor pronostic features in EBRT of bladder - 4
anemia, T3a> or T4, hydronephrosis, CIS (radioresistant)
102
benefit of neoadjuvant chemo
5% overall survival benefit
103
who benefits most from adjuvant
residual micromets
104
FGFR3 mutation and tcc type
Ta papillary
105
P53 chromosome location
short arm of 17
106
P53 pathway
DNA damage --> inc P53 --> P21 --> cell cycle arrest (G1-S)
107
RB gene location
chr 13q
108
where are mets most likely after chemo and why
cns - privelaged site
109
positive prognostic factors for chemo in mets - 2
LN only mets, asymptomatic
110
mgmt of solitary mets post chemo
resect
111
(absolute) criteria for neobladde - 5
live expectancy > 1 yr, manual dexterity (need for CIC), cr cl > 50 or cr < 2, normal bowel function, urethra not involved by cancer
112
study to do before using colon in reservoir
colonoscopy
113
who is not excluded from orthotopic neobladder - 3
> 80 yo, locally advanced disease, prior pelvic rsadiation
114
absolute contraindication for neobladder in F
ca at bladder neck or posterior bladder. must retain distal 2/3 urethra for nl urinary function
115
signifance of urinary retention in men post nb
likely suggests recurrence
116
bowel segment to use for cutaneous diversion if prior pelvic radiation
transverse colon
117
use fo turnbull stoma
eliminates risk of stomal stenosis
118
what is hematuria/dysuria syndrome
reduced HCL secretion = loss of feedback on gastrin secretion --> peptic ulcers, hematuria
119
cause of diarrhea after urinary diversion and mgmt
fat malabsorbtion and bile salt irritation of colon.
120
mgmt of persistent diarrhea after colon conduit
metamucil --> antimotility drugs --> cholestyramine
121
pathophys of increased renal calculi in diversion
decreased bile acids --> fat malabsorbtion and ca binding --> increased oxalate
122
Post TURBT Algorithm NMIBC
123
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…
124
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
125
N and M for bladder cancer
126
Stages for TNM bladder cancer, 0a - IV b
127
CSS in high-grade dz:
Ranges 70-85% at 10 years
128
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
129
Define low risk NMIBC
Low risk
LG solitary Ta _\<_ 3 cm
PUNLMP
130
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
131
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
132
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)
133
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
134
At each occurrence/recurrence, clinicians SHOULD:
GUIDELINE STATEMENT 5
assign clinical stage and classify risk category
135
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
136
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
137
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
138
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)
139
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)
140
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)
141
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
142
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)
143
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
144
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%
145
Pt with persistent Ta or CIS dz after induction intravesical BCG SHOULD be offered:
GUIDELINE STATEMENT 23
A second course of induction
146
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
147
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
148
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
149
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
150
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
151
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
152
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
153
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
154
Recurrence rates of bladder cancer by stage:
pT2 → 20-30%
pT3 → 40%
pT2 → 70% (node pos dz)
155
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)
156
Goals of pre-operative imaging in MIBC:
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
157
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)
158
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)
159
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
160
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
161
When is the timing of RC after NAC?
GUIDELINE STATEMENT 8
ASAP following completion and recovery (ideally w/in 12 weeks if medically advisable)
162
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
163
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
164
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
165
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:
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
166
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
167
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)
168
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
169
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
170
Primary radiation for MIBC?
GUIDELINE STATEMENT 24
for patient with MIBC, SHOULD NOT offer radiation alone as curative tx
171
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)
172
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
173
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
174
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
175
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
176
What about variant histology f/up:
GUIDELINE STATEMENT 35
Unique clinical characteristics may require divergence from standard evaluation and management
177
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
178
Risk factors for bladder cancer:
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
179
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
180
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
181
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
182
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)
183
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
184
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
185
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
1. Genitofemoral nerves → lateral
2. Bladder → medial
3. Common iliac artery → proximal
4. Femoral canal → distal
Standard: external iliac, obturator, hypogastric LNs
186
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
187
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
188
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
189
Describe regimens for multi-agent Cisplatin based chemotherapy and their major side effects:
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
190
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
191
What if grossly enlarged nodes are found at time of RC/PLND?
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
192
Describe cystoprostatectomy in males?
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
193
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
194
What are QOL implications for RC?
Issue with continence
ED
Metabolic problems
Bowel dysfunction
Fertility
195
Describe creation of neobladder (Orthotopic-Studer)
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
196
Describe creation of a continent reservoir (i.e. Indiana pouch):
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
197
Describe an anterior exenteration for females:
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
198
Describe creation of an Ileal Conduit:
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
199
What are indications for partial cystectomy?
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
200
Complications of partial cystectomy:
Tumor recurrence
Vesicocutaneous fistula
Ureteral obstruction
Urine leak
Reduced bladder capacity
Urge incontinence
201
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
202
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
203
If you have a leak from a neobladder early post op, what is first steps? part of initial PE, labs, imaging?
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
204
List Intraop complications of RC?
hemorrhage
tumor spillage
rectal injury
vascular injury
nerve injury (obturator)
205
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
206
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
207
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
208
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)
209
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
210
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
