Muscle Invasive

Bladder Cancer

LEVEL OF EVIDENCE AND

RECOMMENDATION

RADICAL SURGERY AND

URINARY DIVERSION
BACKGROUND
Radical cystectomy standard treatment
for localised MIBC in most western countries
Quality of life (QoL) has increased the trend
toward bladder preservation treatment
modalities, such as radio- and/or
chemotherapy
PS and age influence the choice of primary th/
Controversy remains about age, radical
cystectomy and the type of urinary diversion

RADICAL SURGERY AND

URINARY DIVERSION
TIMING OF SURGERY
A retrospective series of 153 patients, with
a clear indication for radical surgery of
locally advanced bladder cancer, found that
patients treated > 90 days after the
primary diagnosis showed a significant
increase in extravesical disease (81 vs 52%)
Recurrence-free survival and OS were
significantly better in patients treated
before 90 days

RADICAL SURGERY AND

URINARY DIVERSION
INDICATIONS
MIBC T2-T4a, N0-Nx, M0
Other indications
high-risk and recurrent superficial tumours,
BCG-resistant Tis,
T1G3
extensive papillary disease that cannot be controlled
with TURB and intravesical therapy alone
non-responders to conservative therapy,
recurrence after bladdersparing treatment, and
non-urothelial carcinoma
palliative intervention (pain and recurrent hematuria)

RADICAL SURGERY AND

URINARY DIVERSION
MIBC and comorbidity
Complications related to
pre-existing comorbidity
surgical procedure: bowel anastomosis,
urinary diversion

Advanced age as risk factor for

complications (biological age is more
important)
Important evaluation of Comorbidities

RADICAL SURGERY AND

URINARY DIVERSION
Assessment of Comorbidities
Cumulative Illness Rating Scale
(CIRS)
Kaplan-Feinstein index
Charlson Comorbidity Index (CCI)
Index of Coexistent Disease (ICD)
ACE-27
Total Illness Burden Index (TIBI)

RADICAL SURGERY AND

URINARY DIVERSION
Radical cystectomy:
technique and
extent
Male:

bladder,
prostate,
seminal vesicles,
Distal ureters, and
regional lymph nodes

Female:

bladder,
entire urethra,
vagina,
uterus,
distal ureters,
regional lymph
nodes

RADICAL SURGERY AND

URINARY DIVERSION
Controversies in the clinical significance of
lymphadenectomy
Significant correlation between nodal metastases and
concomitant distant metastases
Standard lymphadenectomy involves removal of nodal
tissue cranially up to the common iliac bifurcation
Extended lymphadenectomy includes all lymph nodes in
the region of the aortic bifurcation, and presacral and common
iliac vessels medial to the crossing ureters.
The lateral borders are the genitofemoral nerves,
caudally the circumflex iliac vein, the lacunar ligament and the
lymph node of Cloquet,
A super-extended lymphadenectomy extends cranially to the
level of the inferior mesenteric artery

RADICAL SURGERY AND

URINARY DIVERSION
Progression-free survival as well as OS might be
correlated with the number of lymph nodes
removed during surgery,
Survival rates increase with the number of dissected
lymph nodes
Removal of at least 10 lymph nodes has been
postulated as sufficient for evaluation of lymph node
status, as well as being beneficial for OS in
retrospective studies.
In conclusion, extended LND might have a
therapeutic benefit compared to less-extensive
LND, but due to bias, no firm conclusions can be drawn

RADICAL SURGERY AND

URINARY DIVERSION
Laparoscopic/robotic-assisted
laparoscopic cystectomy
Technically challenging procedure
that requires a high level of skill and
has a long learning curve
Data need to be carefully
intepreted...

RADICAL SURGERY AND

URINARY DIVERSION
Urinary diversion after radical cystectomy
Anatomical standpoint
Abdominal diversion, such as an
uretherocutaneostomy, ileal or colonic conduit, and
various forms of a continent pouch.
Urethral diversion, which includes various forms
of gastrointestinal pouches attached to the urethra
as a continent, orthotopic urinary diversion
(neobladder, orthotopic bladder substitution).
Rectosigmoid diversions, such as uretero(ileo)rectostomy

RADICAL SURGERY AND

URINARY DIVERSION
Preparations for surgery
Length or size of the respective segments
and their pathophysiology when storing
urine must be considered
Formal bowel preparation may not be
necessary
Bowel recovery time has been reduced by
the use of early mobilisation, early
oralisation, and gastrointestinal stimulation
with metoclopramide and chewing gum

RADICAL SURGERY AND

URINARY DIVERSION
Contraindications to more complex forms
of urinary diversion:
debilitating neurological and psychiatric illnesses;
limited life expectancy;
impaired liver or renal function;
transitional cell carcinoma of the urethral margin
or other surgical margins
high-dose preoperative radiotherapy,
complex urethral stricture disease,
severe urethral sphincter-related incontinence

RADICAL SURGERY AND

URINARY DIVERSION
Ureterocutaneostomy
Simplest form and safe procedure
Preferred in older, compromised
Stoma stenosis has been observed more often than in
intestinal stomas
Recent retrospective comparison with short or median
follow-up of 16 months, the diversion-related
complication rate was lower for
ureterocutaneostomy compared to ileal or colon conduit
However, ureter stenosis on skin level and ascending
UTI are more frequent complications in comparison with
those with ileal conduit diversion

RADICAL SURGERY AND

URINARY DIVERSION
Ileal conduit
Up to 48% of patients develop early
complications including UTIs,
pyelonephritis, ureteroileal leakage
and stenosis
However ,ileal conduits had fewer
late complications than continent
abdominal pouches or orthotopic
neobladders

RADICAL SURGERY AND

URINARY DIVERSION
Continent cutaneous urinary diversion
Low-pressure detubularised ileal reservoir
can be used as a continent cutaneous
urinary diversion for selfcatheterisation
Stomal stenosis was seen in 23.5% of
patients with an appendix stoma and 15%
of those with an efferent intussuscepted
ileal nipple
Stone formation in the pouch occurred in
10% of patients

RADICAL SURGERY AND

URINARY DIVERSION
Ureterocolonic diversion
Oldest and most common form of
ureterocolonic
High incidence of upper UTIs and the
longterm risk of developing colon
cancer

RADICAL SURGERY AND

URINARY DIVERSION
Orthotopic neobladder
Now commonly used both in men and women
Diversion of choice for most patients
undergoing cystectomy in several centers
Terminal ileum is the segment most often
used
Long-term complications included diurnal (810%) and nocturnal (20-30%) incontinence,
ureterointestinal stenosis (3-18%), metabolic
disorders, and vitamin B12 deficiency

RADICAL SURGERY AND

URINARY DIVERSION
Morbidity and mortality
Perioperative mortality was reported
as 1.2-3% at 30 days and 2.3-5.7% at
90 days
Early complications (within 3 months
of surgery) in 58% of patients
Late morbidity is usually due to the
type of urinary diversion

RADICAL SURGERY AND

URINARY DIVERSION
SURVIVAL
5-year recurrence-free survival was 58% and the cancerspecific survival was 66%
The 5-year recurrence-free survival in node-positive patients
who underwent cystectomy was considerably less at 34-43%
In a surgery only study, the 5-year recurrence-free survival was
76%
74%
52%
36%

in patients with pT1 tumours,

for pT2,
for pT3, and
for pT4 (59).

Another study reported 10-year disease-specific survival and

OS rates of 72.9% versus 49.1% for organ-confined disease
(defined as pT < 3a), and 33.3% versus 22.8% for nonorganconfined disease

RADICAL SURGERY AND

URINARY DIVERSION

RADICAL SURGERY AND

URINARY DIVERSION

RADICAL SURGERY AND

URINARY DIVERSION

NON RESECTABLE TUMOR

Palliative cystectomy for muscleinvasive bladder carcinoma
T4b, invading the pelvic or abdominal
wall with debilitating symptoms
Those patients are suggested
palliative radioth/
Cystectomy with urinary diversion is
the most invasive treatment

NON RESECTABLE TUMOR

NON RESECTABLE TUMOR

Supportive care
For Obstruction of UUT
Unilateral (best kidney) or bilateral nephrostomy tubes provide the
easiest
patients find the tubes are inconvenient and prefer ureteral stenting

Bleeding and pain

Screen for coagulation and anticoagulant drugs
Intravesical rinsing of the bladder with 1% silver nitrate or 1-2%
alum
Instillation of formalin (2.5-4% during 30 minutes) requiring general
or regional anaesthesia, side effect bladder fibrosis
Radiation therapy
Embolization
Radical surgery

PRE-OPERATIVE RADIOTHERAPY IN
MUSCLE-INVASIVE BLADDER CANCER
RCT in 100 patients, comparing preoperative versus post-operative radiotherapy
and radical cystectomy, showed
comparable OS, DFS and complication rates
Retrospective study in 2009, which
compared the long-term outcome of preoperative (n=90) versus no pre-operative
(n=97) radiotherapy and cystectomy
Down staging and significant longer
disease-specific survival

PRE-OPERATIVE RADIOTHERAPY IN
MUSCLE-INVASIVE BLADDER CANCER

BLADDER-SPARING TREATMENTS FOR

LOCALIZED DISEASE
TURB
TURB alone is only possible as a therapeutic
option if tumour growth is limited to the
superficial muscle layer and if re-staging
biopsies are negative for residual tumour
TURB alone should only be considered as a
therapeutic option when the patient is unfit
for cystectomy or a multimodality bladderpreserving approach, or refuses open
surgery

BLADDER-SPARING TREATMENTS FOR

LOCALIZED DISEASE
External beam radiotherapy (EBRT)
Target field comprises the bladder only, with a
safety margin of 1.5-2 cm to allow for
unavoidable organ movements
60-66 Gy
The daily dose is usually 1.8-2 Gy and the course
of radiotherapy should not extend beyond 6-7
weeks to minimize the repopulation of cancer
cells
Late morbidity of the urinary bladder or bowel in
less than 5% due to modern standard od Radioth/

BLADDER-SPARING TREATMENTS FOR

LOCALIZED DISEASE

important prognostic factors for

radioth/ outcome include
tumour size;
hydronephrosis;
Completeness of the initial TURB.

External radiotherapy can be an

alternative treatment in patients
unfit for radical surgery

BLADDER-SPARING TREATMENTS FOR

LOCALIZED DISEASE
Chemotheraphy
Chemotherapy alone rarely produces
durable CRs
Neoadjuvant chemotherapy with 2-3 cycles
of methotrexate, vinblastine, adriamycin
plus cisplatin (MVAC) or cisplatin,
methotrexate plus vinblastine (CMV) has
led to a down-staging of the primary
tumour in different prospective series

BLADDER-SPARING TREATMENTS FOR

LOCALIZED DISEASE

Chemotheraphy

BLADDER-SPARING TREATMENTS FOR

LOCALIZED DISEASE
Multimodality bladder-preserving treatment
Combine TURB, chemotherapy and radiation
local tumour control : TURB and radiation
eradication of micrometastasis : Chemoth/

TURB + Chemoradioth/ Is BETTER than TURB +

Radioth/
A bladder-preserving multimodality strategy
requires very close multidisciplinary cooperation and a high level of patient
compliance

BLADDER-SPARING TREATMENTS FOR

LOCALIZED DISEASE

Multimodality bladder-preserving treatment