eMedicine Specialties > Urology > Cancer, Bladder, Penis, and Urethra
Cystectomy, Partial: Treatment
Updated: Jan 14, 2008
Treatment
Medical Therapy
Bladder-sparing options other than partial cystectomy include monotherapy and multimodality protocols. Monotherapy consists of complete transurethral resection with or without repeat resections, systemic chemotherapy, or external beam radiation (XRT). Multimodality bladder-sparing therapy includes an initial transurethral resection followed by induction chemoradiation, repeat urological evaluation (biopsies or repeat transurethral resection), and, afterwards, consolidation chemoradiation. Salvage cystectomy is offered if no response to induction therapy is observed.
Table 2. Comparison of Studies and Their Treatment Regimens and Results
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Table
| Study | Number of Patients | Induction Therapy | % Complete Response | Consolidation Therapy | % Overall Survival (years) | % Overall Survival with Bladder Intact (years) |
|---|---|---|---|---|---|---|
| Housset et al 15 | 120 | Bifractionated XRT + concurrent cisplatin + 5-fluorouracil | 77 | Bifractionated XRT + concurrent 5-fluorouracil + cisplatin | 63 (5) | |
| Sauer et al 16 | 184 | 45-54 Gy XRT + concurrent cisplatin or carboplatin | 80 | None | 56 (5) | 41 (5) |
| Fellin et al 17 | 56 | 2 cycles MCVa, 40 Gy XRT + concurrent cisplatin | 50 | 24 Gy XRT + concurrent cisplatin | 55 (5) | 41 (5) |
| Tester et al 18 | 49 | 40 Gy XRT + concurrent cisplatin | 66 | 24 Gy XRT + concurrent cisplatin | 60 (4) | 42 (4) |
| Tester et al 19 | 91 | 2 cycles MCV, 39.6 Gy XRT + concurrent cisplatin | 75 | 25.2 Gy XRT + concurrent cisplatin | 62 (4) | 44 (4) |
| Shipley et al 20 | 61 | 2 cycles MCVa, 39.6 Gy XRT + concurrent cisplatin | 61 | 25.2 Gy XRT + concurrent cisplatin | 48 (5) | 36 (5) |
| Shipley et al 21 | 62 | 39.6 Gy XRT + concurrent cisplatin | 55 | 25.2 Gy XRT + concurrent cisplatin | 49 (5) | 40 (5) |
| Kachnic et al 22 | 106 | 2 cycles MCV, 40 Gy XRT + concurrent cisplatin | 66 | 24.8 Gy XRT + concurrent cisplatin | 52 (5) | 43 (5) |
| Zietman et al 23 | 18 | Bifractionated XRT + concurrent cisplatin + 5-fluorouracil | 78 | Bifractionated XRT + concurrent cisplatin + 5-fluorouracil + 3 cycles MCV | 83 (3) | 78 (3) |
| Study | Number of Patients | Induction Therapy | % Complete Response | Consolidation Therapy | % Overall Survival (years) | % Overall Survival with Bladder Intact (years) |
|---|---|---|---|---|---|---|
| Housset et al 15 | 120 | Bifractionated XRT + concurrent cisplatin + 5-fluorouracil | 77 | Bifractionated XRT + concurrent 5-fluorouracil + cisplatin | 63 (5) | |
| Sauer et al 16 | 184 | 45-54 Gy XRT + concurrent cisplatin or carboplatin | 80 | None | 56 (5) | 41 (5) |
| Fellin et al 17 | 56 | 2 cycles MCVa, 40 Gy XRT + concurrent cisplatin | 50 | 24 Gy XRT + concurrent cisplatin | 55 (5) | 41 (5) |
| Tester et al 18 | 49 | 40 Gy XRT + concurrent cisplatin | 66 | 24 Gy XRT + concurrent cisplatin | 60 (4) | 42 (4) |
| Tester et al 19 | 91 | 2 cycles MCV, 39.6 Gy XRT + concurrent cisplatin | 75 | 25.2 Gy XRT + concurrent cisplatin | 62 (4) | 44 (4) |
| Shipley et al 20 | 61 | 2 cycles MCVa, 39.6 Gy XRT + concurrent cisplatin | 61 | 25.2 Gy XRT + concurrent cisplatin | 48 (5) | 36 (5) |
| Shipley et al 21 | 62 | 39.6 Gy XRT + concurrent cisplatin | 55 | 25.2 Gy XRT + concurrent cisplatin | 49 (5) | 40 (5) |
| Kachnic et al 22 | 106 | 2 cycles MCV, 40 Gy XRT + concurrent cisplatin | 66 | 24.8 Gy XRT + concurrent cisplatin | 52 (5) | 43 (5) |
| Zietman et al 23 | 18 | Bifractionated XRT + concurrent cisplatin + 5-fluorouracil | 78 | Bifractionated XRT + concurrent cisplatin + 5-fluorouracil + 3 cycles MCV | 83 (3) | 78 (3) |
a Methotrexate, cisplatin, and vinblastine24
Five-year survival rates following partial cystectomy vary from 35-80% (see Survival). Five-year survival rates following contemporary radical cystectomy are 50-60%. Multimodality bladder-sparing approaches yield 5-year survival rates of 48-56%, with 5-year bladder survival rates of 36-43%. These numbers, and particularly a direct comparison between the bladder-sparing approaches versus radical surgery, should be evaluated with caution because of patient-selection variables and a lack of prospective randomized trials.
Another concern with bladder-sparing protocols is that delaying cystectomy may risk disease progression. In addition, salvage radical cystectomy was eventually performed in 34-45% of cases,20,22 with salvage cystectomy being a more difficult procedure than radical cystectomy without comorbid chemotherapy and pelvic radiation. Morbidity and quality-of-life concerns regarding chemotherapy and radiation must be weighed against those of radical cystectomy. Partial cystectomy, if successful, would have a theoretical upper hand over radical cystectomy or bladder-sparing chemoradiation protocols because it has the advantage of retaining the native bladder with none of the toxicities of chemotherapy or radiation. Urinary diversion after radical cystectomy also has advanced, with choices ranging from an ileal conduit to neobladders and continent catheterizable pouches.
The most important factors for bladder-sparing therapies include appropriate patient selection and long-term surveillance. Patient factors that increase risk of failure in transurethral resection/chemoradiation protocols include clinical stage higher than T2, associated ureteral obstruction with hydroureteronephrosis, incomplete initial transurethral resection, and lack of response to induction chemoradiation. Local recurrence rates for such protocols vary from 20-30%. Partial cystectomy also requires proper patient selection and long-term surveillance (see Indications and Recurrence).
Surgical Therapy
Choices in the surgical management of bladder cancer include bladder-sparing or radical surgery. Bladder-sparing surgery includes techniques such as transurethral resection of bladder tumors (TURBT), with or without fulguration of such tumors, and partial cystectomy with or without pelvic lymph node dissection. Radical cystectomy involves more than just bladder excision. In men, it involves removal of the pelvic peritoneum, prostate, and seminal vesicles. In women, the urethra, uterus, broad ligaments, and anterior third of the vaginal wall are removed. Pelvic lymphadenectomy and urinary diversion are also performed. The remainder of this article discusses only partial cystectomy.
Preoperative Details
In preparation for partial cystectomy, the bladder lesion is confirmed pathologically with initial transurethral resection. During resection, a thorough cystourethroscopy is performed and necessary biopsy samples collected to ensure that no other portions of the lower urinary tract contain disease. Appropriate imaging staging studies are performed (see Imaging Studies) to ensure that no disease exists elsewhere. Preoperative history, physical examination, medical assessment, and necessary laboratory evaluation (see Lab Studies) are also performed.
Intraoperative Details
The patient is usually placed supine in a slight Trendelenburg position. Bimanual examination under anesthesia is performed to determine suitability for resection. A catheter is inserted through the urethra, and the bladder is irrigated with sterile water to decrease local tumor spillage. The bladder is left partially expanded by clamping the catheter, which facilitates dissection.
Generally, the partial cystectomy is approached in one of two different approaches—transperitoneal or extraperitoneal. The transperitoneal approach may be more suitable for tumors located posteriorly. Both approaches involve a lower midline or paramedian incision.
Modified pelvic lymph node dissection can be performed prior to partial cystectomy. This is usually approached from the obturator fossa to the iliac vessel bifurcation. The bladder is mobilized with the vas deferens and the obliterated hypogastric artery, and the superior vesical artery is divided and ligated. The superior vesical artery division is especially helpful in the lateral mobilization of the bladder to expose a posteriorly located lesion. The tumor is excised with a 2-cm margin, and perivesical fat and the overlying peritoneum are removed, if necessary, with care to protect both ureters and the rectum. If a 2-cm margin cannot be obtained from any ureter, radical cystectomy is suggested rather than ureteral reimplantation. Frozen sections of the specimen are sent for analysis to ensure negative surgical margins.
An alternative method of excision involves placement of a Satinsky clamp around the portion that contains the tumor, excision of the segment, and cauterization of the wound edges.
The bladder is closed in a 2-layer inverting fashion, and drains are placed in the perivesical space. A suprapubic tube is avoided because of possible tumor spread. Bladder drainage is managed with a temporary Foley catheter. Tumor spillage is detrimental and can be prevented via preoperative flushing of the bladder with sterile water, careful draping, isolation, and manipulation of the tumor. This protects wound edges, and the wound is copiously irrigated with sterile water prior to closure. Concurrent procedures, such as prostatic adenoma enucleation or transurethral incisions of the bladder neck for bladder outlet obstruction, should be avoided because of the risk of tumor implantation in the prostatic bed.
Postoperative Details
Maintaining perivesical drainage facilitates visualization and aids in healing any urine leak from the bladder suture line. Drainage, either via an open Penrose drain or a closed Jackson-Pratt drain, is maintained until such leakage has stopped. A 20-22F urethral catheter is maintained postoperatively. This catheter serves to protect against urinary leakage and allows the bladder suture line to heal by maintaining low vesical pressures. It also provides access to the bladder, which allows for monitoring urine output and detecting any postoperative hematuria. This catheter is usually left in place for 7 days. Postoperative cystography prior to Foley removal is unnecessary.
Severe intravesical bleeding may result in urinary clot retention and may require gentle bladder irrigation to evacuate clots.
Wound and prevesical space infection may lead to abscesses that may require open or percutaneous drainage. Ureteral obstruction should be suspected if the patient reports flank pain. IVP or ultrasonography can be used to confirm this diagnosis, and percutaneous nephrostomy can temporarily divert urine in the hope that the obstruction is temporary.
Postoperative ureteral orifice edema may lead to an obstruction; however, this is only transient in nature. Incontinence due to altered bladder compliance and uninhibited bladder contractions usually improves with time and anticholinergic medications.
Follow-up
Bladder carcinoma is a recurrent disease. Careful monitoring of all patients is mandatory. Even superficial (Ta) high-grade (III) disease that has been successfully treated has shown a risk of eventual recurrence and progression, with 15-year progression-free and disease-specific survival rates of 61% and 74%, respectively. Those with low grade I superficial (Ta) lesions have a 15-year progression-free survival rate of 95%. Routine cystoscopy, initially every 3 months after resection, with voided urine cytologies should be performed.
Upper urothelial tract imaging with IVP, CT urography, or retrograde pyelography is are needed, although the upper tract requires less frequent monitoring than the lower urinary tract. Certainly, patients with T1 or more advanced disease and those with Ta high-grade disease must be monitored for disease recurrence and progression for life.
For excellent patient education resources, visit eMedicine's Cancer and Tumors Center. Also, see eMedicine's patient education article Bladder Cancer.
Complications
The overall complication rate of partial cystectomy is reported as 11-29%. Common complications of partial cystectomy include bleeding, infection, reduction of bladder capacity, and urinary extravasation. Other complications include fistulas (vesicocutaneous, vesicovaginal, colovesical), myocardial infarctions, pulmonary embolus, congestive heart failure, upper gastrointestinal hemorrhage, and death. Perioperative mortality rates once approached 10%; however, contemporary studies have not reported this rate. Local recurrences in the wound or suprapubic tract are worrisome complications that have been reported in 0-18% of patients.
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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
