105.Part 2 Surgeries of Bladder Cancer.pptx

bladder surgeries

1. SURGERIES OF BLADDER CANCER DEPARTMENT OF SURGERY JNMC Sawangi ( Meghe ), Wardha.

2. Competetncy Competency Number Competency. SU29.8 Describe the clinical features, investigations and principles of management of bladder cancer

3. Learning objectives Students should be able to Enumerate Surgical management Know complications of surgery

4. Purpose Statement The purpose of this seminar is that at the end, student should know the different types of surgeries performed for bladder carcinoma and its complications in brief.

5. Surgery Radical cystectomy Good long term survival rates Lowest local recurrences Accurate pathological staging & nodal status Timing – delay > 3 months after TURBT undermines patient survival PLND Urinary diversions

6. Radical cystectomy En bloc removal of pelvic organs anterior to rectum Men – bladder, urachus, prostate, seminal vesicles & visceral peritoneum Women - bladder, urachus, ovaries, fallopian tubes, uterus, cervix, vaginal cuff & anterior pelvic peritoneum Lymphadenectomy Extended lymphadenectomy is beneficial Bilaterally all obsturator, hypogastric, presciatic & presacral LN >15 LNs sufficient

7. Urinary diversions Incontinent – standard Continent Incontinent Conduit derived from distal ileum → Ureter anastomosed → Anterior abdominal wall stoma Continent To retain continence Abdominal – stomal reservoir Orthotopic neobladders anastomosed to remaing distal urethra

8. Complication Metabolic complications Acidosis Vit B12 malabsorption (loss of distal ileum) Neuromechanical Urinary retention – atonic segment Surgical Urine leak Fecal leak Pyelonephritis Renal failure

9. Recurrence following RC Pelvic Within the soft tissue field of exenteration 6-9% Distant Outside the pelvis 20-35% Urethral recurrence New primary tumor occurring in the retained urethra

10. North America model Trimodality therapy Maximal TURBT Chemotherapy Radiotherapy Split course RT 40Gy with synchronous CT → interval cystoscopy → total dose of 64-68Gy Selective bladder preservation Exit to surgery

11. Contraindications to Bladder Preservation Hydronephrosis Multifocal CIS Incomplete TURBT Non-TCC histology Poor bladder capacity/function Inability to tolerate chemotherapy

12. N A C T To down size & down stage the tumors Occult micro mets in muscularis propria Standard of care in T3/T4 or node positive disease MVAC CMV dd MVAC (dense dose) Accelerated MVAC/high dose MVAC Compressed schedule over 14 days NCCN 2018 Category 1 recommendation T2 – T4a dd MVAC CMV GC

13. Adjuvant CT More accurate selection of patients (p stage) Two settings Following bladder sparing chemoradiation Following radical cystectomy Regimens MCV GC Paclitaxel Standard recommendation Positive nodes High p Stage T3 T4 LVI

14. Metastatic Bladder Cancer MVAC 28 day cycles Mtx 30mg/m2 Days 1, 15, 22 Vinblastine 3mg/m2 Days 2, 15, 22 Doxorubin 30mg/m2 Day 2 Cisplatin 70mg/m2 Day 2 CMV Omits Doxorubicin GC Gemcitabine 1000mg/m2 Days 1, 8, 15 Cisplatin 70mg/m2 Day 2 Less toxic, improved tolerability

15. Toxic effects of MVAC Neutropenia Anemia Thrombocytopenia Stomatitis

16. Palliative RT 35Gy/10# - 71% symptomatic improvement 21Gy/3# - 64%

17. Treatment Recurrent superficial cases : TUR and intravesical BCG (6 weekly applications), Radical cystectomy may be performed after the 3rd recurrence

18. Pathological exam of cystoscopic biopsy should include: Tumor growth pattern Grade Evidence of muscle invasion Multifocality Presence of associated carcinoma in situ or cell nests of Brunn .

19. The pathological examination of the cystectomy specimen should include: Tumor type transitional, squamous or adeno . Ca. Tumor size and multifocality . Tumor P-stage (TNM, 1997). Associated conditions Ca. in situ, bilharzial affection. Number of examined nodes (not less than 10) and number of infiltrated nodes.

20. Follow-up * Every 2 months in the first year, every 3 months in the 2nd & every 6 months thereafter. * CXR and CT abdomen & pelvis are performed every year. * Bone scan to be performed whenever necessary.

21. Follow up: - At every follow up visit the physician should be able to evaluate: Tumor response: No evidence of disease, site & size of recurrence; local, bone, chest, liver, …etc. Immediate & late treatment morbidity including surgery, radiotherapy, chemotherapy or the combination.

22. Summary. Surgiers for Bladder Carcinoma: Radical cystectomy - Good long term survival rates PLND Radical cystectomy Urinary diversions Incontinent – standard Continent Neo-Adjuvant Chemotherapy: To down size & down stage the tumors, Occult micro mets in muscularis propria, Standard of care in T3/T4 or node positive disease. Adjuvant Chemotherapy: given in two seetings Following bladder sparing chemoradiation Following radical cystectomy

23. Questions. Enumerate Surgical management What are the complications of the surgeries?

24. References S R B’ s MANUAL OF SURGERY _ Sriram Bhat Text book of surgery _ Roshan lall Gupta Bailey & Love’s Short practice of surgery _ N. S. Williams Schwartz’s principles of surgery _ F. Charles Bunicardi Sabiston text book of surgery.

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