Non-Metastatic Muscle-Invasive Bladder Cancer (Surgical aspect)

Wichien Sirithanaphol, MD

Urologic division, Department of surgery

Faculty of medicine, Khon Kaen university

Outlines

• Clinical staging

• Radical cystectomy & urinary diversion

• Oncological Outcomes of Radical cystectomy

Gross hematuria

Imaging & cystoscopy

Bladder tumor

Flexible cystoscopy

Gross hematuria

Imaging & cystoscopy

Bladder tumor

Transurethral Resection of

Bladder Tumor; TUR-BT

Gross hematuria

Imaging & cystoscopy

Bladder tumor

Transurethral Resection of

Bladder Tumor; TUR-BT

Muscle Invasive Bladder Cancer

Clinical staging

Clinical staging

• Exam under anesthesia

• CT abdomen/pelvis, with IV contrast

• Chest imaging (X ray or CT with IV contrast)

Alternatives

o PET scan; equivocal staging exam and/or biopsy not feasible

o Bone scan; elevated ALP and/or pain complaint

o MRI imaging; CT contrast imaging can not be performed

o Non-palpable = T2a

o Induration = T2b

o Mass + mobile = T3a

o Invade adjacent organ = T4a

o Fixed to pelvic side wall = T4b

Bimanual palpation

T2a

T2b

T3a

T3b

T4a

CA bladder in diverticulum

1 2

3

4

CA bladder in Transplant kidney

Radical cystectomy

Indication

• Pathological confirm muscle invasive bladder cancer

• Non-muscle invasive bladder cancer

– High risk of progression

– Lack of response to BCG treatment

– Transurethral uncontrollable NMIBC

Should not performed when

• Bladder is fixed to pelvic side wall

• Tumor is invading rectosigmoid colon

• Evidence of extensive periureteral disease

• LN metastases are unresectable

Pre-operation Incision

Position

Men Bladder, prostate, seminal vesicles

Women Bladder, uterus, anterior vaginal wall

Pelvic lymph node dissection

• Standard PLND

– Common iliac, external iliac, internal iliac, obturator

• Extended PLND

– + presacral region up to aortic bifurcation

• Super-extended PLND

– + up to inferior mesenteric region

Extended PLND

Relationship between the number of lymph nodes removed and the probability

of detecting lymph node metastasis

A recent meta-analysis has shown that an extended PLND increases the probability of detecting positive

nodes at radical cystectomy

Urinary diversion

Urinary diversion

Incontinent

urinary diversion Continent

urinary diversion

Orthotopic

Urinary diversion

(Neobladder) Cutaneous

ureterostomy

Conduit (Ileum, jejunum, colon)

Good renal function (GFR > 35-40)

Urinary diversion

Incontinent

urinary diversion

Cutaneous

ureterostomy

o No anastomosis o No metabolic complication o Short operative time

o High risk stomal stenosis o Difficult to apply appliance (2 stoma) o Replaced by PCN

Advantage Disadvantage

Urinary diversion

Incontinent

urinary diversion

Conduit

(Ileum)

o Quick & easy o Low early complication

o Abdominal stoma o Long term complication

Advantage Disadvantage

Bricker ureterointestinal anastomosis

Wallace ureterointestinal anastomosis

Urinary diversion

Continent

urinary diversion

Orthotopic

Urinary diversion

(Neobladder)

o No stoma (no cost of appliance) o Improve quality of life

o Longer operative time o Longer LOH

o Need self catheter

Advantage Disadvantage

Contraindication • Positive urethral margin • Compromised renal function • Complex urethral stricture

Should caution in • Prior pelvic radiation • Can not self catheter • Short life expectancy • Elderly

Serous-lined, extramural ileal neobladder (Ghoneim) Hautmann ileal neobladder

Studer pouch ileal neobladder Modified Camey II ileal neobladder

Kock ileal neobladder

Mainz ileocolonic neobladder Le Bag ileocolonic neobladder

Sigmoid (Reddy) neobladder

Perioperative complication

Complication of Ileal conduit

Conduit ischemia/gangrene

Wound dehiscence

Parastomal hernia (obstructed)

Parastomal hernia (obstructed)

Ureteroenteric anastomosis stricture

Contrast in conduit (Loopogram) : not seen left ureter left UE anastomosis obstruction

Oncological outcomes of Radical cystectomy

Large surgical series

5-yr disease specific survival rate pT2 = 70-81% pT3 = 40-52% pT4 = 16-44% N –ve = 63-80% N +ve = 21-35%

pT stage & N status = Strongest predictors of recurrence and survival following cystectomy

Radical cystectomy in Srinagarind Hospital 56 patients (2007-2016)

Age • 63 yr (min 33, max 83 yr, SD 11.7)

Gender • Male 54 cases (96%) • Female 2 cases (4%)

Presentation • Hematuria 56 cases (100%) • Obstructive uropathy 5 cases (9%)

Aim of Operation • Curative 48 cases (85%) • Palliative 7 cases (13%) • Salvage 1 cases (2%)

Urinary diversion • Ileal conduit 41 cases (73%) • Ileal neobladder 11 cases (20%) • Ureterostomy 3 cases (5%) • ESRD + bilateral nephrectomy 1 cases (2%)

Overall survival

Months

Survival & p-staging

Months

Stage I

Stage II

Stage III

Stage IV

Survival & T-stage

Months

T1-2

T3-4

p = 0.01

Survival & N-stage

Months

N0

N+

p = 0.009

Survival & Age

Months

<65 yr

>65 yr

Survival & GFR

Months

≥60

<60

p = 0.01

Survival & Pre-op albumin level

Months

≥3.6

<3.6

p = 0.02

Age

<65 yr 65-75 yr >=75 yr

Mean age

52.7 69.4 77.6

GFR < 60

(32/56 )

10/26

(38%)

15/21

(71%)

7/9

(77%)

pT3-4

(28/56)

10/26

(38%)

14/21

(66%)

4/9

(44%)

N+

(19/56)

5/26

(19.2%)

10/21

(47.6%)

4/9

(44.4%)

Death within 90 days

(5/56)

2/26

(7.7%)

1/21

(4.7%)

2/9

(22.2%)

Radical cystectomy in Srinagarind Hospital 56 patients (2007-2016)

Cystectomy vs Neoadjuvant CMT

• Answer

– Neoadjuvant chemotherapy

Advantage

1. Systemic CMT is often better tolerated before surgery than after surgery

2. Micrometastatic will receive therapy when burden of disease is low

3. Potential to downstage bulky and locally advanced tumor

4. Allow clinician to access each individual response to therapy

Disadvantage

1. Delay in definitive local therapy for patient who do not response to CMT

Problems of neoadjuvant CMT in clinical practice

1. Symptomatic patient

• Hematuria, Irritative voiding symptoms

• Urinary tract obstruction

2. Insufficient renal function for Cisplatin based CMT

• GFR < 60

• In our series • 32/56 cases (57%) GFR < 60

• 5/56 (9%) obstructive uropathy (need PCN)

3. Patient compliance

4. Toxicity of systemic chemotherapy

Neoadjuvant CMT

Randomized Trials of Neoadjuvant chemotherapy

Neoadjuvant CMT

2017

Neoadjuvant CMT

Neoadjuvant CMT

Neoadjuvant CMT

Cystectomy in elderly

Overall survival

cT2

Cancer specific survival

cT2

Multivariate analysis

Increasing age is significantly associated with worse survival for patients > 70 yr

Multivariate analysis

Cancer specific survival not able to demonstrate worse outcome for age > 70 yr However, age > 80 yr remains a significant predictor for CSS

Overall perioperative mortality and early mortality is increased in older patients (Incidence of perioperative mortality : < 70 yr = 1-6%, > 70 yr = 0-15%)

A syndrome of decreased physiologic reserve component (Comorbidities, physical function, nutrition, dependency, cognitive function, mood)

Eila Skinner at 2016 ASCO Annual Meeting

Eila Skinner at 2016 ASCO Annual Meeting

Conclusion

• Frailty does not directly relate to Age

• Formal frailty assessment can help us identify the patients at highest risk of surgical complication

• Ideal measure for radical cystectomy patients has not been identified yet

Curative Treatment for MIBC in Elderly patient

There is a need for Geriatrics assessments to select those patients that will benefit from curative treatment

Life expectancy Harm & benefit of curative treatment

Trimodal Therapy vs

Cystectomy

Trimodal Therapy

• Reasonable option in highly selected patient

• Ideal candidate – Good baseline bladder function

– Have a complete resection of all visible tumor endoscopically

– Have small solitary tumors with limited CIS

– No evidence of hydronephrosis

Trimodal Therapy

Major Prospective Trimodal Bladder Preservation Studies

2017

Trimodal Therapy

Trimodal Therapy

Thank You