Cystoprostectomy-Grossing

Anatomy

• Shape: Tetrahedral

• Base (fundus)

• Neck

• Apex

• Superior surface

• Two inferolateral surfaces

Base

• Triangular

• Posteroinferiorly

• Related to the rectum

• Separated above by the rectovesical pouch

• Below by the seminal vesicle and vas deferens on each side and Denonvillier’s fascia

Neck

• Most fixed

• lies most inferiorly

• 3–4 cm behind the lower part of the symphysis pubis

• Bladder neck is essentially the internal urethral orifice, which lies in a constant position

• direct continuity with the base of the prostate

Apex

• apex faces towards the upper part of the symphysis pubis

• Attached to the median umbilical ligament

Superior surface

• Completely covered by peritoneum

Bladder interior

• Vesical mucosa:

• Attached loosely to the muscle

• Folds when bladder is empty

Bladder interior

• Trigone:

• Always smooth

• Anteroinferiorly: Internal uretheral orifice

• Posterolaterally: Ureteric orifices

Prostate

• Base

• Apex

• Anterior surface

• Posterior surface

• Inferolateral surfaces

Prostate

• Superiorly the base is largely contiguous with the neck of the bladder

• The apex is inferior, surrounding the junction of the prostatic and membranous parts of the posterior urethra

• The anterior surface lies in the arch of the pubis and is transversely narrow and convex extending from the apex to the base

• The inferolateral surfaces are related to the muscles of the pelvic sidewall

• The posterior surface of the prostate is transversely flat and vertically convex

• Near its superior (juxtavesical) border is a depression where it is penetrated by the two ejaculatory ducts

• The urethra enters the prostate near its anterior border and usually passes between its anterior and middle thirds

• The ejaculatory ducts pass anteroinferiorly through its posterior region to open into the prostatic urethra

Zonal anatomy of prostate

• Transitional zone (5% by volume)

• Central zone (25% by volume)

• Peripheral zone (70% by volume)

Transition zone

• Just proximal to the apex of the central zone and the ejaculatory ducts

Central zone

• Surrounds the ejaculatory ducts, posterior to the urethra, and is conical in shape with its apex at the verumontanum

Peripheral zone

• cup-shaped and encloses the central transitional zone except the preprostatic urethra anteriorly

Peripheral zone

• Fills the space anterior to the preprostatic urethra

Radical cystoprostectomy

• Bladder cancer

• Tumour has invaded the muscularis propria

• Large tumour size

• Recurrent high grade malignancies not amenable to intra-vesical BCG therapy

• Aim: To ascertain extent of invasion and assessment of ureteric and urethral cut margins

Fixation

• There are two ways in which cystectomy specimens may be fixed.

• First involves opening the urinary bladder when received fresh, then immersed in large volumes of fixative for 24-48 hrs.

• Alternately, the intact specimen is infused with formalin through Foley's catheter and kept for overnight fixation in a container of formalin.

Steps in grossing

• Orient the radical cystectomy specimen.• identify the seminal vesicles, vas deferens and

the ureter, all of which are present on the posterior surface of the bladder

• Ink the entire external surface of bladder along with prostate.

• Document the size of the bladder, ureteric stumps, seminal vesicles, prostate and urethra.

• The bladder is probed through the urethral orifice and cut open anteriorly to expose the tumour.

• The ureters are opened from the point of their resection margin up to their opening in to the bladder.

• The tumour is then examined in relation to:

• Size (including the transmural thickness)

• Location (anterior wall, posterior wall, trigone and base)

• Shape of the tumour (papillary or ulcerated)

• Presence of multifocal lesions

• Cut surface of tumour

• Depth of invasion into bladder wall

• Extension into perivesical tissue

Sections

• Resection margins:

• Prostatic urethra cut margin

• Right ureteric cut margin

• Left ureteric cut margin

• Vas deferens cut margins

• Take at least 4 sections of the tumour including the adjoining bladder mucosa.

• Sections should include full thickness of the tumour infiltrating the bladder wall with perivesicle fat and inked resection margin

• to assess the exact depth and plane of invasion

• Sections from ureteric orifices

• Section from bladder neck, one section each from trigone, anterior and posterior wall and bladder dome

• Any abnormal looking area also has to be sectioned

• One section from each seminal vesicle also has to be submitted

• The prostate is submitted entirely to look for involvement by bladder tumour or for a co-existing prostatic adenocarcinoma.

Staging

Primary Tumour (pT)

Regional lymph nodes (pN)

Distant Metastasis (pM)

Prostatic invasion

• Involvement of the prostate gland may occur in several different patterns

• Tumours (flat carcinoma in situ, papillary or invasive carcinoma) can first spread along the prostatic urethral mucosa and prostate glands and subsequently invade prostatic stroma (transurethral mucosal route)

• Tumours may also invade through the bladder wall and the base of the prostate directly into the prostate gland

• Tumours can also invade into extravesical fat and then extend back into the prostate gland

• The latter two routes are considered direct transmural invasion

• In patients who have a large urinary bladder carcinoma that has invaded through the full thickness of the bladder wall and thereby secondarily involves the prostatic stroma, a T4 stage should be assigned per urinary bladder staging

• In other circumstances in which involvement by urothelial carcinoma is seen in both sites, separate urinary bladder and prostatic urethral staging should be assigned

• Transmucosal route into prostatic stroma from a bladder cancer without transmural prostatic stromal invasion is now categorized as pT2 and the concomitant bladder proper cancer is given a separate stage category

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