Cystoprostatectomy

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Cancer of the urinary bladder is the sixth leading cause of cancer death in the United States and the most expensive cancer to manage on a median-cost-per-case basis. According to the American Cancer Society, an estimated 70,000 new diagnoses and 14,000 deaths occurred in 2009. ^[1]

Management of the disease is roughly divided into minimally invasive management of superficial disease via transurethral tumor resection with intravesical immunotherapy and chemotherapy and radical surgery for recurrent high-grade or invasive disease. Conceptually, radical cystoprostatectomy involves wide en bloc excision of all cancer-bearing tissues in the pelvis, including the bladder and prostate, using the musculoskeletal boundaries of the pelvis as the planes of dissection. The aim is removal of all tumor-bearing tissues with a wide negative tumor margin and removal of regional draining lymph nodes.

Attempts at radical cystoprostatectomy date back to 1887, when Bardeneuer of Germany performed the first cystectomy without diversion of the urine, resulting in overwhelming sepsis and death a few days after the surgery. The modern era of cystoprostatectomy dates to the publication of the radical cystectomy series of Marshall and Whitmore in 1962. ^[2] In their series of 230 patients at Cornell Medical Center and Memorial Sloan-Kettering Cancer Center, they observed 5-year survival rates of 21–49% and perioperative mortality of more than 10%. With improved perioperative care reducing the perioperative mortality to less than 5%, ^[3] recent series have shown 10-year cancer specific survival in the 65–78% range. ^[4]

Common indications for radical cystoprostatectomy include recurrent high-grade superficial bladder cancers (stage Ta), invasive bladder cancers (stage T1 and higher), and endoscopically unmanageable bladder cancers. Contraindications include locally unresectable bladder cancers, known active metastatic disease, and medical comorbidities precluding tolerance of a long and complicated operation. Chemotherapy and radiation therapy can play a role in clinically downstaging patients and treating patients unable to tolerate surgery, although these approaches have inferior outcomes when compared to surgery. Neoadjuvant and adjuvant chemotherapy can also play a role in improving survival with patients having stage T2 or higher disease. ^[5]

The anatomy of the bladder forms an extraperitoneal muscular urine reservoir that lies behind the pubic symphysis in the pelvis. A normal bladder functions through a complex coordination of musculoskeletal, neurologic, and psychological functions that allow filling and emptying of the bladder contents. The prime effector of continence is the synergic relaxation of detrusor muscles and contraction of the bladder neck and pelvic floor muscles.

The adult bladder is located in the anterior pelvis and is enveloped by extraperitoneal fat and connective tissue. It is separated from the pubic symphysis by an anterior prevesical space known as the retropubic space (of Retzius). The dome of the bladder is covered by peritoneum, and the bladder neck is fixed to neighboring structures by reflections of the pelvic fascia and by true ligaments of the pelvis.

For more information about the relevant anatomy, see Bladder Anatomy. See also Male Urinary Organ Anatomy and Female Urinary Organ Anatomy.

Prior to surgery, staging with CT scans of the chest, abdomen, and pelvis with intravenous contrast must be performed to rule out metastatic spread and assess local extent of disease. An alternative in the patient with a contrast allergy or calculated glomerular filtration rate of 30–60 mL/min/1.73 m² is a chest radiograph and MR urogram.

Medical optimization prior to surgery includes assessment of comorbidities of heart and lung disease, which are common in this patient population. Laboratory values, including a complete blood count, complete metabolic panel of electrolytes, a prothrombin time and partial thromboplastin time, and blood type and cross-match, should be performed. Finally, preoperative evaluation and counseling by a trained enterostomal therapy nurse is advisable given the challenges of managing a urinary stoma postoperatively and the need for stomal site marking prior to surgery. Preoperative stomal site marking allows for optimal appliance fit and location of the stoma.

The day prior to surgery, the patient is given a clear liquid diet with a mechanical bowel preparation of 4 L of polyethylene glycol 3350 and electrolytes starting the early afternoon the day before surgery. An alternative is to drink 2 bottles of magnesium citrate in the same time frame. The patient is given nothing by mouth after midnight and is given intravenous iso-osmolar crystalloid the morning of surgery. Intravenous antibiotic coverage with broad spectrum antibiotics such as a third-generation cephalosporin and metronidazole are given 1 hour prior to incision. An epidural continuous infusion pain management catheter is placed preoperatively to assist with incisional pain control as both a pre-emptive and postoperative modality.

In the operating room, a general anesthetic with muscle relaxation is necessary for a case that typically lasts 3–5 hours. Care is taken to pad pressure points due to the length of the operation. The patient is positioned in the supine position with approximately 15 º of flexion at the level of the pelvic brim (anterior superior iliac spines), and the incision is made in the midline from the level of the umbilicus to the pubis (see the image below). The abdomen is prepared with a 10% povidone-iodine solution from below the xiphoid process to the upper thighs, with the perineum and inner thigh prepared as well.

Once the incision is made, the underlying subcutaneous tissues and midline fascia are incised and opened. Below this level, the peritoneum is visualized with the embryologic urachus present in the midline (see the image below).

This is tied off with 0 silk sutures at the level of the umbilicus and divided, allowing for division of the peritoneum on either side of the urinary bladder (see the first image below). Placement of a Bookwalter self-retaining retractor at this point assists with retraction and exposure. The vas deferens is then identified on either side of the bladder and doubly ligated with 0 silk sutures and divided laterally proximal to the level where they enter the internal inguinal rings bilaterally (see the second image below).

Below the level of the vas deferens, the ureter can then be visualized distal to the point where it crosses the common iliac artery, which is an easily identifiable landmark from which the ureter can be identified. The peritoneum overlying the ureter is then divided (see the first image below), and the ureter is then encircled with a vessel loop. Proximal and distal dissection of the ureter is then performed (see the second image below), and then the ureter is divided at the level of the vascular pedicle of the bladder, applying 2-0 silk ties to the distal end to prevent retrograde urine leakage.

At this point, the lateral vascular pedicles of the bladder are easily identifiable (see the first image below) and are either divided between titanium clips (see the second image below), electrocautery vascular sealing device, or endovascular stapler. The vascular pedicles include the superior, middle, and inferior vesical arteries and veins that predominantly arise from the internal iliac vessels, as well as some branches of the of the obturator and pudendal vessels. The anatomy is shown in the third image below. The pedicle division is performed bilaterally, and then the space of Retzius is developed, thus exposing the prostate.

Once the space of Retzius is opened, the endopelvic fascia on either side of the prostate is divided, and the dorsal venous complex of the prostate is oversewn with a 0 Vicryl suture. The urethra is then divided, and a Foley catheter can be used for outward retraction of the prostate (see image below). At this point, careful apical dissection can facilitate standard cavernous nerve preservation along the lateral boundaries of the prostate, as well as preservation of the urethral stump if an orthotopic neobladder is to be implanted into the stump for urinary control. Using cavernous nerve sparing techniques, Schoenberg and colleagues demonstrated preservation in 62% of men less than 50 years old, 47% for those age 50–60, and 20% over 60 years old. ^[6]

The peritoneal reflection in the cul-de-sac is then divided, and the specimen is then removed for pathologic analysis (see the image below). Copious irrigation with sterile water is then performed, and remaining visualized bleeding is treated with cautery, suturing, or titanium clips. Attention is then turned to the regional lymph node dissection, which in a standard dissection removes nodes in the external iliac, obturator, and common iliac distributions. Extended dissections also include presacral, paracaval, and paraortic nodes as well.

Radical cystectomy in the female presents some variation in anatomic landmarks. Initially, the gonadal vessels are ligated and divided proximal to the ovaries (see the first image below). Division of the round ligaments is then performed, and the posterior aspect of the cervix is exposed at its insertion into the vagina (see the second image below). The posterior vagina is then incised onto sponge stick, and the vaginal vault is entered (see the third image below).

A circumferential incision is then made around the cervix, and the uterus is then detached from the vagina (see the first image below). The vagina is then closed in a single layer using 0 Vicryl suture (see the second image below). An incision is then made in the peritoneum overlying the pelvic portion of the ureter (see the third image below), and then the ureter is isolated using vessel loops (see the fourth image below).

The space of Retzius is then opened and developed, exposing the endopelvic fascia on either side of the bladder and urethra. This is then incised sharply, revealing the underlying bladder anatomy abutting the vagina (see the first image below).The urethra is then incised and opened, and the posterior urethral and bladder attachments are dissected free from the anterior vaginal wall (see the second image below). Then, working in a retrograde fashion, the vascular pedicles of the bladder are encountered and ligated using titanium clips, cautery, or staples (see the third image below). Once the specimen is removed, the remaining preserved vaginal vault and urethra is copiously irrigated with warm sterile water and all remaining bleeding is cauterized or clipped.

The second portion of the procedure involves the urinary diversion. The options include incontinent and continent diversions. The most commonly performed urinary diversion is an incontinent diversion, the ileal conduit. In this procedure, a 10–15 cm segment of distal ileum is harvested approximately 15 cm from the ileocecal junction (see the first image below). The bowel is reanastomosed in a standard side-to-side fashion. The ureters are anastomosed to the proximal end of the conduit in a standard spatulated Bricker anastomoses using dissolvable running or interrupted 4-0 Vicryl suture or 5-0 PDS suture (see the second image below).

Permanent suture should not be used given the potential for that suture to be a nidus for stone formation. The distal-most end of the conduit can then be delivered through the fascia underlying a previously marked stoma location, typically on the right side of the midline incision, taking care to deliver it through the rectus muscle without dividing it. The stoma is then matured to the skin either as an end stoma (see the image above) or as a Turnbull loop stoma (see the image above).

The end stoma is preferable in a thin patient with easy reach of the stoma to the level of the skin because this has a lower parastomal hernia risk. The loop stoma, on the other hand, provides an improved blood supply to the distal portion of the conduit by delivering mesenteric blood supply with the distal end, at the cost of increasing the parastomal hernia risk. This should be used in select obese patients and those in which the tension to the distal most end of the stoma may contribute to ischemia and stomal stenosis.

A completed Turnbull loop ileal conduit can be seen in the first image below. Other portions of bowel that can be used as an incontinent urinary diversion include a sigmoid colon conduit (see the image below) and a transverse colon conduit (see the image below).

A transverse colon conduit may be useful in patients with prior pelvic radiation exposure because this segment of bowel is often spared of radiation exposure and related enteritis. Ileal and colon conduits can lead to electrolyte derangement, namely hyperchloremic metabolic acidosis. Avoidance of the use of jejunum in the urinary diversion is preferable because use of this bowel segment can lead to jejunal conduit syndrome. This derangement leads to a hyponatremic, hypochloremic, hyperkalemic metabolic acidosis with symptoms including lethargy, nausea, vomiting, dehydration, weakness, and fever. Treatment involves hydration and sodium replacement.

Continent urinary diversions may be used in patients with normal renal function (with a glomerular filtration rate > 60 ml/min/1.73 m²) and good performance status. One alternative is a continent cutaneous urinary pouch.

The Indiana pouch is a reservoir created by harvesting the right colon and distal ileum, relying on the distal arcade of the superior mesenteric artery with the right colic artery as the blood supply (see the image below). The right colon is detubularized, and the ureters are spatulated and anastomosed to the right colon in a standard Bricker fashion (see the image below). The pouch is then sewn in a clamshell fashion by folding the right colon on itself (see the image below), and the efferent limb is created using the distal ileum. The ileocecal valve provides continence, and it is buttressed with nonabsorbable 3-0 silk sutures, and the lumen of the ileum is narrowed via antimesenteric stapling of the segment (see the image below).This contributes to the continence of the pouch.

The distal end is then matured at the skin either in the right lower quadrant or umbilicus flush with the skin. This stoma is then either left uncovered or covered in a small bandage, and a catheter is then passed several times daily to empty the pouch.

The third option for urinary diversion is a continent orthotopic ileal neobladder, including diversions such as the Studer pouch. With this type of diversion, a longer segment of distal ileum is harvested, approximately 55–60 cm. The bowel is then opened on its antimesenteric side, preserving intact the most proximal 10 cm of bowel as an afferent chimney. The diversion is then constructed into a watertight pouch, and then the ureters are anastomosed to the afferent chimney using standard Bricker-type anastomoses. The afferent chimney provides an antirefluxing mechanism for urine delivered to the pouch due to forward peristalsis of the limb. An opening is created in the dependent most portion of the pouch, allowing for anastomosis of the pouch to the remaining urethral stump. With appropriate preservation of the urethral stump and membranous urethra with its surrounding muscular external striated sphincter, continence may be preserved.

Postoperative management of the patient includes placement of a closed suction – type drain for management of urinary and lymphatic leakage use of a nasogastric tube to limit abdominal distension due tom ileus in the first several days postoperatively. In the recovery room, complete blood count and complete metabolic panel are checked, and derangements such as anemia, thrombocytopenia, and electrolyte imbalance may be replaced. Close supervision of fluid intakes and outputs should be monitored.

Frequent complications include bowel ileus, which can be reduced via the use of a perioperative epidural analgesic to reduce narcotic usage and early ambulation. Diet is advanced with the passage of flatus. Deep venous thrombosis and pulmonary embolism are other frequent serious complications, and prophylaxis with intermittent pneumatic compression stockings is used. In patients with stable hemoglobin and hematocrit lab values, subcutaneous low molecular weight heparin can be used as well.

In a prospective series of complications recorded at a busy bladder cancer referral center (Memorial Sloan-Kettering Cancer Center), 64% of patients undergoing radical cystectomy had at least one perioperative complication within 90 days of surgery, of which 13% were high grade (Clavien grade 3 or higher). ^[3] Most of the complications were gastrointestinal (29%), with infectious (25%) and wound-related complications (15%) also being common. The 30-day all-cause mortality rate was 1.5%. Another study confirmed that in patients older than 70 years, the complication rate increase to 72%, with 17% high-grade complications (Clavien grade 3 or higher), with a 3.4% 30-day mortality rate. ^[7]  A multicenter study by Pignot et al found that the rate of incidentally diagnosed prostate cancer in radical cystoprostatectomy specimens was 21.7%. ^[8]

A study by Fahmy et al that included data from 13,140 patients who underwent radical cystoprostatectomy for bladder cancer with no previous history of prostate cancer reported that incidental prostate cancer was detected in 24.4% of the patients and was significantly associated with greater age, lymphovascular invasion of bladder cancer and lower 5-year overall survival. ^[9]

Jemal A, Siegel R, Ward E, Hao Y, Xu J, Thun MJ. Cancer statistics, 2009. CA Cancer J Clin. 2009 Jul-Aug. 59(4):225-49. [Medline].

WHITMORE WF Jr, MARSHALL VF. Radical total cystectomy for cancer of the bladder: 230 consecutive cases five years later. J Urol. 1962 Jun. 87:853-68. [Medline].

Shabsigh A, Korets R, Vora KC, et al. Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology. Eur Urol. 2009 Jan. 55(1):164-74. [Medline].

Shariat SF, Karakiewicz PI, Palapattu GS, et al. Outcomes of radical cystectomy for transitional cell carcinoma of the bladder: a contemporary series from the Bladder Cancer Research Consortium. J Urol. 2006 Dec. 176(6 Pt 1):2414-22; discussion 2422. [Medline].

Milowsky MI, Stadler WM, Bajorin DF. Integration of neoadjuvant and adjuvant chemotherapy and cystectomy in the treatment of muscle-invasive bladder cancer. BJU Int. 2008 Nov. 102(9 Pt B):1339-44. [Medline].

Schoenberg MP, Walsh PC, Breazeale DR, Marshall FF, Mostwin JL, Brendler CB. Local recurrence and survival following nerve sparing radical cystoprostatectomy for bladder cancer: 10-year followup. J Urol. 1996 Feb. 155(2):490-4. [Medline].

Froehner M, Brausi MA, Herr HW, Muto G, Studer UE. Complications following radical cystectomy for bladder cancer in the elderly. Eur Urol. 2009 Sep. 56(3):443-54. [Medline].

Pignot G, Salomon L, Neuzillet Y, Masson-Lecomte A, et al. Clinicopathological characteristics of incidental prostate cancer discovered from radical cystoprostatectomy specimen: a multicenter French study. Ann Surg Oncol. 2014 Feb. 21 (2):684-90. [Medline].

Fahmy O, Khairul-Asri MG, Schubert T, Renninger M, Stenzl A, Gakis G. Clinicopathological Features and Prognostic Value of Incidental Prostatic Adenocarcinoma in Radical Cystoprostatectomy Specimens: A Systematic Review and Meta-Analysis of 13,140 Patients. J Urol. 2017 Feb. 197 (2):385-390. [Medline].

Stein JP, Lieskovsky G, Cote R, et al. Radical cystectomy in the treatment of invasive bladder cancer: long-term results in 1,054 patients. J Clin Oncol. 2001 Feb 1. 19(3):666-75. [Medline].

Ryan K Berglund, MD Assistant Professor of Surgery (Urology), Cleveland Clinic Glickman Urological and Kidney Institute, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University School of Medicine

Ryan K Berglund, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Endourological Society, Ohio State Medical Association, Society of Laparoendoscopic Surgeons, Society of Urologic Oncology, American Association of Clinical Urologists

Disclosure: Nothing to disclose.

Edward David Kim, MD, FACS Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, Sexual Medicine Society of North America, Tennessee Medical Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Endo, Avadel.

Cystoprostatectomy

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