Radical cystectomy

Radical cystectomy and urinary diversion

1. RADICAL CYSTECTOMY and URINARY DIVERSION DR BRIGHT SINGH R S MBBS,MS,MCh ( Sur.Onco ), D.Lap,FIAGES,FMAS,FAIS

2. Non muscle invasive Muscle invasive Metastatic disease.

3. Advantages of giving Neo adj chemo Rx over adjuvant chemo Rx? 1. 5 yr survival benefit by 5% (ABC meta analysis) 2. Neo adj chemo Rx early control of micro mets 3. Chemo Rx is better tolerated as neo adj 4. Potential reflection of in- vitro chemo sensitivity 5. 20-25% of clinical T2NoMo are pathologically T3 or N1 disease; so giving neo adj chemo-Rx is advisable. when can you not give neo adj chemo Rx? 1. Poor performance status PS > 2 (ECOG) 2.Impaired renal Function

4. RADICAL CYSTECTOMY INDICATIONS NON MUSCLE INVASIVE T1 with high risk features( size,multifocality,lymphovascular invasion) T1G3 with multiple tumors T1G3 with diverticulum Recurrent T1G3 BCG refractory Diffuse CIS T1G3 involving ureter,prostate Extensive papillary disease that cannot be controlled by TUR and intravesical BCG T1-high grade and incompletely resected Prostrate ductal / acini ( Tis ) Bladder neck and/or urethra( Tis ) in female

5. RADICAL CYSTECTOMY INDICATIONS MUSCLE INVASIVE T2-T4a OTHERS Non urothelial carcinomas( squamous,adeno ) Salvage cystectomy -non responders to conservative therapy Recurrences after bladder sparing treatments Palliative intervension-fistula,pain,recurrent macro haematuria

6. CONTRAINDICATIONS-CYSTECTOMY Un resectable lymph node metastases Bulky lymph node with extensive periurethral disease Bladder is fixed to the pelvic sidewall, or invading the recto sigmoid colon.

7. RADICAL CYSTECTOMY Technique-removal of bladder and adjacent organs Male-removal of prostate, seminal vesicles Female-removal of uterus,cervix,vagina and ovary

8. The inclusion of entire prostate in male patients and extend of urethrectomy and vaginal resection in female patients-has recently been questioned Autopsy studies shows 23-54% incidence of prostatic cancer in cysto prostectomy specimens

9. URETHRECTOMY INDICATIONS Positive margin at the level of urethral dissection Primary tumor is located at bladder neck or in urethra Extensive infiltration of prostate

10. EXTEND OF LYMPHADENECTOMY

11. EXTEND OF LYMPHADENECTOMY T1 – 05% T2 – 20% T3 – 40% T4 – 60% Standard and extended LN dissection Standard LN dissection means removal of hypogastric obturator & ext iliac L.N. Extended LN dissection means removal of pre sacral group and common iliac LN also ( upto bifurcation of aorta) when will you do standard & extended LN dissection? Standard (Marshalls operation) in clinically N o disease Extended (Skinners operation) in clinical N1/N2

12. Consent Pt is explained about his disease and the diagnosis – MIBC; The need for surgery The prognosis (5 yr survival 50-60%) Organ removed – bladder, - prostate, seminal vesicles Pt is explained about ileal conduit & complication VAS deferens ligation Erectile dysfn Gen compln : infn , bleeding, Trauma.

13. Pre Op Prep 1. Blood reservation 2. Only liquid diet from morning on the day before surgery 3. Oval peglec at 12 to noon 4. NBM 12:00 midnight 5. Ileostomy site marking 6. Inform pathology dept for frozen section preparation 7. Part preparation nipple to knee. On the day of sx Morning - serum electrolytes, pulse /BP/RBS - Antibiotics -cephalosporin + Metronidazole

14. MAIN STEPS POSITION INCISION ABDOMINAL EXPLORATION BOWEL MOBILIZATION URETERAL DISSECTION PELVIC LYMPHADENECTOMY LIGATION OF LATERAL VASCULAR PEDICLE LIGATION OF POSTERIOR VASCULAR PEDICLE ANTERIOR APICAL DISSECTION

15. Position Hyper extended supine position with iliac crest located below the fulcrum of operating table The legs are slightly abducted Female patient- lithotomy position- acess to vagina

16. Incision Vertical midline incision Incision should be carried lateral to umbilicus on the contra lateral side of stoma site While opening of posterior rectus sheath ,care should be taken to remove the urachus en bloc with bladder

17. Abdominal Exploration Look for extent and resectability Hepatic metastasis Gross regional and retroperitoneal lymphadenopathy

18. Ureteral resection Ureters are dissected in to deep pelvis(several cm beyond the iliac vessels) and divided between two large hemo clips Proximal cut end of ureteral segment is send for frozen section Leaving the proximal hemo clip on divided ureter allows for hydro static ureteral dialation and facilitates uretero enteric anastomoses

19. Lymphadenectomy Boundaries of Standard LN dissection Superiorly – ureter crossing the iliac vessels Inferior – cooper’s ligament Laterally – genitor femoral nerve Medially – int. iliac artery. Extended LN dissection Up to aortic bifurcation

20. Pelvic Dissection Blood supply of bladder lateral pedicle- Superior vesicle - Inferior vesicle Posterior pedicle Superior & inferior vesicle arteries are B/O anterior division of IIA. Posterior pedicle is branch of posterior division of IIA

21. Control DVC vicryl 1-0 or 1 number and apply “figure of eight suture” on DVC complex and fix it to pubic symph y sis

22. Urinary diversion after radical cystectomy Orthotopic Orthotopic bladder substitution Heterotopic Continent Right colonic pouches- Indiana,Florida,Miami,Penn Ileal pouches- Kock,Mainz Caecum & ascending colon-Mainz I Non continent Ileal /colonic conduit Cutaneous ureterostomy Diversion in to GIT Uretrosigmoidostomy /Rectal bladder- Manz II,Mansuora rectal bladder

23. Orthotopic neobladder CRITERIA Sphincter mechanism must remain intact to provide a continent means of storing urine Margins should not be compromised TYPES - Hautmann pouch - Studer pouch - Camey II -Le Bag pouch -T pouch - Abol Enein Ghoneim modification of W pouch -Reverse S- Podua ileal pouch -Sigmoid( Reddy) neobladder Advantages Able to empty the pouch of urine similar to normal voiding pattern No stoma required No catheter required Less effect on physical image Better post op sexual function Disadvantages Longer surgery time Potential for incontinence for small percentage of patients Some patients may have to perform intermittent catheterization Complications from urinary waste product reabsorption

24. RECONSTRUCTION OF NEO BLADDER The type of the intestinal segment and the construction type. Ileum, colon and sigmoid are commonly used intestinal segments . Terminal ileum is more favoured among the three because it is more distensible and has larger capacity therefore it stores urine at lower pressures and less risk of causing high-pressure damage to the kidneys. It also experiences more mucosal atrophy in the long term which leads to reduced risk of metabolic consequences and less electrolyte exchange across the mucosa. The second consideration is the type of construction. Intestinal segments are naturally cylindrical in shape but according to Laplace law this is not the best shape to maintain a low pressure in the reservoir. Due to the smaller radius in a cylindrical reservoir, there will be higher intraluminal pressures at lower volumes. Detubularized bowel may be refashioned to a spherical reservoir; however, the larger radius enables it to contain higher volumes at lower intraluminal pressures.The sphere has the smallest surface area for the same volume meaning: This has the smallest risk of metabolic consequences secondary to electrolyte exchange across the gut mucosal lining in the neo bladder and a minimal length of intestinal segment is required to form a sphere

25. Hautmann pouch

26. Studer pouch

27. Camey II pouch

28. Continent urinary reservoir Right colonic pouches - Indiana,Florida,Miami , Penn Ileal pouches - Kock,Mainz Caecum & ascending colon -Mainz I Advantages Normal or near normal urinary continence No nocturnal incontinence No need for stoma bag Less effect on physical image Disadvantages Technically more difficult surgery Stomal complications- parastomal hernia Complications associated with intermittent catheterization(4-6 hrs)- pouchitis Complications from urinary waste product reabsorption

29. Continent urinary reservoir Contraindications Renal impairment Hepatic impairment Bowel dysfunction Short bowel syndrome (<1.5m) Inflammatory bowel syndrome Previous pelvic radiotherapy Long-term chemotherapy*/disease modifying drugs (e.g. methotrexate ) Psychiatric disorder Unable or unwilling to perform CISC Possibly age > 65 years (higher nocturnal eneuresis with orthotopics )

30. Non continent urinary reservoir Ileal /colonic conduit Cutaneous ureterostomy Advantages Simple surgery Fewer complications No bladder training No nocturnal incontinence Disadvantages Risk of stomal complications- parastomal hernia,stenosis Urinary incontinence Increase expenses for stoma care

31. Ileal conduit urinary diversion Originally described by Zaayer in 1911, popularised by Bricker in early 1950s Reliable, easily performed procedure which has stood test of time Typically 10-15 cm of ileum, 10-15cm from ileocaecal valve Contraindications: Short bowel syndrome Inflammatory bowel disease Pelvic irradiation

32. Diversion in to GIT Uretrosigmoidostomy Rectal bladder- Manz II,Mansuora rectal bladder

33. Contraindications Poorly functioning anal sphincter (neuropathy, prolapse etc) Pelvic radiotherapy Severe sigmoid diverticulosis

34. COMPLICATIONS OF URINARY DIVERSION Metabolic Neuro -mechanical Surgical

35. Metabolic complications Electrolyte abnormalities Altered sensorium Abnormal drug metabolism Osteomalasia Growth retardation Persistent and recurrent infections Formation of renal and reservoir calculi Problems ensuing from removal of portion of gut Development of cancer

36. Neuro -mechanical complications Two types Atonic Hyperperistaltic

37. Surgical complications Pulmonary embolus Wound dehiscence Pneumonia Atelectasis

38. THANK YOU