Bladder Neoplams- MIBC

Question 1

Bladder cancer hematogenous metastasis

Answer 1

Both lymphatic and hematogenous metastasis occur. About 33% of pts who die of metastatic bladder cancer have negative pelvic nodes. Common hematogenous locations- liver (38%), lung (36%), bone, adrenal, intenstine.

Question 2

Bladder cancer lymphatic metastasis

Answer 2

Level I nodes: internal and external iliac and obturator
Level II nodes: common iliac and sacral
Level III nodes: paraortic, paracaval, and interaortocaval
note: in 7% of cases level II is involved even though level I is not; III is never involved without lower levels

Question 3

Clinical staging factors

Answer 3

Takes into acct. pathologic staging of TURBT, bimanual exam, and imaging. Do CT A/P w/ and w/o and CT chest (or at least CXR).

Question 4

PET scan for bladder cancer

Answer 4

PET scan for bladder cancer- sens. 82%, spec. 89%

Question 5

Radical cystectomy- male

Answer 5

Radical cystectomy in the male patient includes removal of the bladder, the perivesical fat, the prostate, seminal vesicles and pelvic lymph nodes. Urethrectomy is rarely performed at time of RCP; do interval urethrectomy if final path shows +urethral margin.

Question 6

Radical cystectomy- female

Answer 6

removal of the bladder, the perivesical fat, the pelvic lymph nodes, the uterus, cervix, fallopian tubes, ovaries and the anterior vagina- consider vaginal sparing surgery for pts with low stage disease

Question 7

Boundaries of lymphadenectomy for RCP

Answer 7

Superior- common iliac vessels
Inferior- inguinal ligament
Medial- bladder
Lateral- pelvic sidewall and genitofemoral nerve

Question 8

MIBC survival

Answer 8

Overall 5yr survival of 36-48%

for T3, T4, or node positive drops to 30%

Question 9

Neoadjuvant chemotherapy for MIBC

Answer 9

5-7% improvement in survival
MVAC followed by cystectomy had median survival of 77mos vs. 46mos for cystectomy alone.
GC is sometimes used in place to avoid morbidity.

Question 10

Adjuvant chemotherapy for MIBC

Answer 10

Adjuvant chemo (after cystectomy but before recurrence) has not been shown to be beneficial

Question 11

Complications following cystectomy

Answer 11

64% have at least one perioperative complication within 90d, 13% have grade III or higher complication

Question 12

Ileal conduit complications

Answer 12

upper tract deterioration, urinary tract infections, stomal or parastomal hernia, and peri-stoma skin irritation

Question 13

Orthotopic diversion contraindication

Answer 13

Positive urethral margin, extensive extravesical disease, pubic bone involvement, plans for radiation, urethral strictures, bowel disease, renal or hepatic insufficiency

Question 14

Incontinence after orthotopic diversion

Answer 14

10-15% daytime incontinence

20-30% nighttime incontinence

Question 15

Partial cystectomy

Answer 15

Consider for isolated tumor at dome or tumor in diverticulum