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Cystectomy, Partial
Updated: Jan 14, 2008
Introduction
Partial cystectomy, also known as segmental resection of the bladder, is a surgical method of removing a selected full-thickness portion of the bladder wall. Once a more practiced technique, advances in transurethral resection of bladder tumors and accumulated knowledge of the natural history of bladder cancer have resulted in partial cystectomy being performed less frequently (see Table 1).
Partial cystectomy is used to treat both malignant and benign conditions of the bladder. Its primary malignant indication is for solitary, primary, muscle-invasive, or high-grade bladder cancer that does not involve the bladder trigone, vesical neck, or posterior urethra and that can be resected with adequate surgical margins (minimum of 2 cm). Other indications for partial cystectomy include an inability to resect tumors transurethrally, a need for adequate biopsy of radiation-induced ulcerations, the presence of a tumor in a bladder diverticulum, patient choice, palliation of severe local symptoms, preservation of native bladder function and continence, and poor surgical risk for more aggressive procedures such as cystectomy. Adenocarcinomas and urachal carcinomas develop mostly in the dome of the bladder and may be amenable to partial cystectomy.
A few benign conditions of the bladder can be managed with partial cystectomy. These include resection of bladder diverticula, cavernous hemangiomas, ulcerative interstitial cystitis, colovesical fistula, vesicovaginal fistula, and localized endometriosis of the bladder.
Partial cystectomy has certain advantages over radical cystectomy, such as preserving a functional continent native urinary reservoir and sparing of potency in males. In addition, because a separate urinary diversion procedure (as is necessary in radical cystectomy) is not performed, some surgeons view partial cystectomy as a less morbid operation, suited for high-risk patients and palliative situations. The main disadvantage of partial cystectomy lies in the high historical local recurrence rates of bladder cancer, with only part of a globally diseased urothelium addressed. However, in properly selected patients, the results of partial cystectomy rival those of radical cystectomy. This review focuses on the current applications and indications for partial cystectomy, with an emphasis on the treatment of bladder cancer.
History of the Procedure
Table 1. Proportion of Patients With Bladder Cancer Treated With Partial CystectomyOpen table in new window
Table
| Source | Total Patients With Bladder Cancer | Patients Treated With Partial Cystectomy (%) |
| Utz et al (1973) 1 | 3454 | 199 (5.8) |
| Brannan et al (1978) 2 | 551 | 49 (7.1) |
| Faysal and Freiha (1979) 3 | 859 | 117 (13.6) |
| Merrell et al (1979) 4 | 585 | 54 (9.2) |
| Ojeda and Johnson (1983) 5 | 397 | 23 (5.8) |
| Jardin and Vallencien (1984) 6 | 475 | 90 (18.9) |
| Hayter et al (2000) 7 | 20,822 | 729 (3.5) |
| Holzbeierlein et al (2004) 8 | 935 | 58 (6.2) |
| Source | Total Patients With Bladder Cancer | Patients Treated With Partial Cystectomy (%) |
| Utz et al (1973) 1 | 3454 | 199 (5.8) |
| Brannan et al (1978) 2 | 551 | 49 (7.1) |
| Faysal and Freiha (1979) 3 | 859 | 117 (13.6) |
| Merrell et al (1979) 4 | 585 | 54 (9.2) |
| Ojeda and Johnson (1983) 5 | 397 | 23 (5.8) |
| Jardin and Vallencien (1984) 6 | 475 | 90 (18.9) |
| Hayter et al (2000) 7 | 20,822 | 729 (3.5) |
| Holzbeierlein et al (2004) 8 | 935 | 58 (6.2) |
Frequency
Based on the National Cancer Institutes SEER Cancer Statistics Review, 67,160 new cases of bladder cancer will be diagnosed in 2007, and 13,750 persons will die from the disease. Currently, the overall male-to-female patient ratio is approximately 4:1. The ratio of bladder cancer in whites compared with African Americans is 1.5-2.1:1. The median age of patients is 73 years at time of diagnosis, with incidence and mortality per pathologic grade increasing as a function of age. Since 1950, the incidence of bladder cancer has increased by 50%, but the overall mortality rate (primarily in men) has decreased by 33%.
Etiology
The etiology of bladder cancer, a frequent indication for bladder resection, is unknown. Postulated theories include environmental carcinogens (eg, chemicals, ultraviolet light, radiation), aberration of normal cell growth regulation (eg, oncogene induction, suppressor gene negation), and abnormalities in the genetic composition of malignant cells.
Chemical exposures that may increase the risk of bladder cancer include aromatic amines, dietary nitrites, and nitrates. These include aniline dyes (eg, 2-naphthylamine, 4-aminobiphenyl, 4-nitrobiphenyl, 4-4-diaminobiphenyl [benzidine], 2-amino-1-naphthol), combustion gases, coal soot, chlorinated aliphatic hydrocarbons, and acrolein dyes. Smoking is associated with an up to 4-fold increase in the risk of bladder cancer. Other implicated factors include coffee and tea, phenacetin (an analgesic), chronic cystitis, the presence of chronic indwelling catheters, bladder calculi, pelvic irradiation, and exposure to cyclophosphamide. Schistosomiasis of the urinary bladder is associated with a higher incidence of squamous cell carcinoma. Currently, no evidence links bladder cancer to heredity.
Recent investigations have addressed the arsenic content of drinking water. International studies in Taiwan, Chile, and Argentina have suggested that as little as 10.1 mcg/L of arsenic in drinking water increases the risk.9,10 In Taiwan, population studies of 8102 residents found that concentrations of 10-50, 50-100, and more than 100 mcg/L of arsenic in drinking water (compared with levels <10 mcg/L) increase the relative risk of developing transitional cell carcinoma to 1.9, 8.2, and 15.3, respectively.9 In Chile, studies of arsenic levels from 100-570 mcg/L revealed an elevated standardized mortality ratio of bladder cancer of 6 in men and 8.2 in women.10 In the United States, estimates indicate that 350,000 persons are exposed to arsenic levels of more than 50 mcg/L and that 2.5 million are exposed to levels higher than 25 mcg/L. In one study, the relative risk estimate for an average level of arsenic in US drinking water was 1 in 1000 persons.11
Oncogenes and tumor suppressor genes implicated in bladder cancer include TP53, retinoblastoma gene (Rb), p15, and p16. Alterations in TP53, a normal tumor suppressor gene that is found on chromosome 17p and that controls apoptosis, lead to more aggressive bladder cancers. Ongoing studies are exploring the clinical implications of these tumor suppressor genes. Currently, conventional staging and grading are sufficient.
The tumor suppressor gene Rb is found on chromosome 13q. A mutated Rb gene or phosphorylated Rb gene leads to dissociation of its product protein, pRB, from the normally complexed transcription factor, E2F. Dissociated E2F drives the transition from G1 to S phase in cellular mitosis.
Two more protein regulators encoded on chromosome 9p, p15 and p16, inhibit nuclear cyclin-dependent kinases from phosphorylating pRB. When p15 and p16 mutate, they can no longer prevent phosphorylation of pRB, resulting in dissociation of the pRB-E2F complex, and free E2F is allowed to stimulate the cell's G1- to S-phase proliferation. Very aggressive high-grade bladder tumors have been associated with alterations in TP53. Mutations in Rb, p15, and p16 have been associated with low-grade superficial tumors.
Bladder cancer often behaves as a field disease; the entire urothelium, from the renal pelvis to the urethra, is susceptible to malignant transformation. Transitional carcinoma cells may also have the ability to migrate and implant at different sites along the urothelium.
Presentation
A thorough history should be obtained, and a thorough physical examination should be performed. In patients with bladder cancer, the most common presenting symptom is painless hematuria (85%). Hematuria is often intermittent; therefore, a single urinalysis finding may not be significant. Bladder irritability that manifests as urinary frequency, urgency, and dysuria is the second most common symptom. These symptoms rarely occur without hematuria (microscopic or gross). Flank pain due to ureteral obstruction, lower-extremity edema, and pelvic masses are other presenting symptoms. Symptoms of advanced disease, such as weight loss and abdominal or bone pain, are rare because patients usually seek medical attention before these develop.
Indications
Indications for Malignancy
Bladder cancer
Partial cystectomy is suitable to treat tumors that meet strict criteria, including (1) no prior history of bladder cancer, (2) no malignancy (eg, carcinoma in situ or papillary tumors) distant from the known bladder cancer, (3) a solitary muscle-invasive tumor located well away from the ureteral orifices that is amenable to partial cystectomy (ie, 2 cm of normal bladder around the lesion), (4) a reasonable expectation that the residual postoperative bladder will have adequate capacity and compliance to ensure functionality, and (5) ideally, partial cystectomy should be used for T1-T2b tumors. Additionally, higher-stage tumors with deeper invasion (eg, T3 and above) found during surgery may benefit from complete resection if negative surgical margins can be obtained. Adjuvant chemotherapy (eg, cisplatin-based) and/or radiation (currently up to 65 Gy) may provide additional local control for T3b tumors or tumors that have been found to penetrate through perivesical fat.
High-grade lesions can be managed with partial cystectomy if they meet the above criteria. The most common lesions amenable to partial cystectomy include grade II and III tumors located away from the base and trigone of the bladder (ie, on the lateral walls or dome of the bladder). A bimanual examination should be performed under anesthesia to confirm resectability.
Cancers in bladder diverticula
Diverticular cancers comprise 1.5-10% of all bladder cancers are more likely to penetrate the bladder wall because of the relatively thin nature of the wall and its muscular layers. Transurethral resection of the tumor, if possible, is a viable option. However, inadvertent perforation of the diverticulum is a definite risk because of the paucity of muscular fibers in the diverticulum and may lead to dissemination of urothelial cancer cells. Bladder diverticula are usually resected with partial cystectomy. Previous reports suggested a high rate of recurrence and poor prognosis for diverticular tumors. However, more recent data suggest that complete tumor excision via conservative means with or without adjuvant intravesical therapy carries a 5-year disease-specific survival rate of 70%. This is much better than previously reported.
Partial cystectomy and other cancers
In appropriate cases, cancer that invades the bladder from the nearby rectum, colon, prostate, uterus, cervix, or ovaries has been treated with partial cystectomy. Locally invasive colorectal carcinoma that involves the bladder has traditionally been treated with total pelvic exenteration; when possible, bladder-sparing techniques, such as partial cystectomy, have yielded a local recurrence rate of 17% and a 3-year survival rate of 39-74%, provided surgical margins are clear of disease.
Adenocarcinoma of the bladder, which includes urachal cancers, is often treated with partial cystectomy. Urachal lesions (20-40% of adenocarcinomas) are thought to arise from residual transitional cells that line the urachal remnant. The overall 5-year survival rate associated with urachal adenocarcinoma is poor (6-15%); however, recent evidence has shown that extended partial cystectomy with removal of the bladder segment, posterior rectus fascia, peritoneum, and umbilicus offers the best chance for survival. In a study by Dandekar et al, the 5-year survival rate after partial cystectomy of urachal adenocarcinoma was 56.3%.12 Herr found that contained urachal adenocarcinomas that were completely resected using extended partial cystectomy had a favorable disease-free result rate (77%).13 Following partial cystectomy, cure rates of well-differentiated urachal adenocarcinomas approach 100%.
Rhabdomyosarcomas of the bladder comprise 17-50% of all genitourinary rhabdomyosarcomas, with nearly all embryonal subtypes occurring in children. These patients have also been successfully treated with partial cystectomy as an alternative to radical cystectomy or primary chemotherapy with local radiation. Disease-free survival rates have been found to be as high as 78.5% with a 2- to 16-year follow-up following partial cystectomy with or without neoadjuvant chemotherapy and radiation. Most of these patients were able to retain functional bladders, with minimal lower urinary tract symptoms.
Indications for Benign Conditions
A few benign conditions of the bladder can be managed with partial cystectomy. They include bladder diverticula (which are resected), cystic hydatid disease, cavernous hemangiomas, refractory interstitial cystitis, colovesical fistula, vesicovaginal fistula, and localized endometriosis of the bladder.
Contraindications
In patients with malignancy, the entire urothelial tract must be evaluated before a partial cystectomy is performed. No evidence of disease elsewhere in the urinary tract must be demonstrated, including carcinoma in situ, transitional cell carcinoma, adenocarcinoma, squamous cell carcinoma, and severe urothelial dysplasia. This requires investigation of not only the bladder but also the kidneys and ureters.
Other contraindications to partial cystectomy include cellular atypia, prostatic or trigonal invasion, an inability to obtain adequate surgical margins, prior radiation therapy, inadequate bladder volume following resection, evidence of metastasis, and poor surgical risk. Some surgeons feel that partial cystectomy is associated with less morbidity than radical cystectomy because operating time is decreased, a urinary diversion with bowel manipulation is not necessary, and an extraperitoneal technique is possible in some cases. Some patients who cannot undergo radical cystectomy can undergo partial cystectomy. Others cannot undergo surgery of any type. These decisions are based on individual medical and surgical judgments and are tempered by patient choice.
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Keywords
bladder cancer, partial cystectomy, cystectomy, transitional cell carcinoma, bladder sparing, urachal carcinoma, bladder diverticula, cystic hydatid disease, cavernous hemangioma, interstitial cystitis, colovesical fistula, vesicovaginal fistula, bladder endometriosis, urothelial cancer, urothelial malignancy, bladder carcinoma, segmental resection of the bladder
