Radical Cystectomy Workup

  • Author: Michael Christopher Large, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS   more...
 
Updated: Mar 8, 2012
 

Laboratory Studies

  • Urinalysis
    • Urinalysis is used to identify or to confirm microscopic or gross hematuria. When hematuria is present along with bacteruria or pyuria, obtain a urine culture to rule out urinary tract infection.
    • Urinalysis may yield false-negative results because hematuria associated with bladder cancer is often intermittent.
  • Urine cytology
    • Exfoliated urothelial cells are viewed using microscopy. In some urothelial cancers, cellular clumping, a high nuclear-to-cytoplasmic ratio, nucleoli, and atypia are seen.
    • Avoid the first morning sample because of cellular degeneration.
    • Cytology is useful for identifying CIS and high-grade tumors but is less useful for low-grade tumors.
    • The sensitivity of cytology for grades 1, 2, and 3 disease is 20%, 50%, and 90%, respectively.
    • Tests that are used to assess for protein (NMP22), nucleic acid, or chromosomal abnormalities (chromosomes 3, 7, 9, 17) are emerging as possible urine-based adjuncts for the diagnosis of bladder cancer.
  • Bladder barbotage
    • Bladder barbotage consists of repeated washings of bladder urothelium with normal saline.
    • This test has better sensitivity than urine cytology because the total yield of cells is higher.
  • Liver function tests and bony fraction of alkaline phosphatase: These tests are used to evaluate for metastatic spread to liver and bone.
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Imaging Studies

  • An appropriate evaluation of hematuria includes radiographic (CT scanning, ultrasonography, retrograde pyelography, intravenous pyelography [IVP]) or direct imaging (cystoscopy, ureteroscopy) of the entire urinary tract. A standard hematuria evaluation includes (1) CT scanning of the abdomen and pelvis, with and without intravenous contrast, often termed CT urography and (2) flexible cystoscopy. If a patient cannot receive intravenous contrast, the evaluation commonly consists of renal ultrasonography, cystoscopy, and retrograde ureteropyelography.
  • CT scanning and ultrasonography can reveal filling defects or masses in the urinary tract; however, they are frequently unable to demonstrate small urothelial tumors.
  • A bone scan is indicated if the patient has symptomatic bone pain, elevated calcium levels, or elevated alkaline phosphatase levels.
  • MRI is used in some centers for evaluation of both local and metastatic disease; however, its staging accuracy is unknown. Therefore, the use of MRI is currently under investigation.
  • Ferumoxtran-10–enhanced MRI and 11C-choline positron emission tomography/CT are under investigation as potential modalities for improving preoperative nodal staging.[6, 7]
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Other Tests

  • Upon recognition of disease that may prove amenable to radical cystectomy, preoperative staging is essential for stratifying the chance of disease eradication and recurrence risk, as well as for identifying patients with metastatic foci who are not candidates for surgery. Preoperative staging involves the following:
    • The patient is examined under anesthesia to determine if the mass is fixed (pT4) or mobile. In women, this includes a bimanual pelvic examination; in men, this includes a bimanual examination with one hand per rectum and the other on the lower abdominal wall.
    • CT scanning of the abdomen and pelvis is performed. Both overstaging (20%) and understaging (50%) are common if only one study is performed.
    • Chest radiography is performed to assess for metastatic deposits.
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Diagnostic Procedures

  • Biopsy - Transurethral resection of bladder tumor
    • The biopsy consists of cystoscopic resection of tumors with biopsy forceps or a resectoscope. Superficial-appearing papillary tumors, as assessed by an experienced urologist, are virtually always noninvasive lesions. As a rule, any lesion that may extend into the lamina propria or deeper should include deep resection specimens that incorporate muscularis propria.
    • The biopsy can be performed in an operating room under general or spinal anesthesia.
    • The site, size, and number of tumors and whether papillary tumors are sessile, solid, nodular, or pedunculated is documented.
    • A biopsy of the prostatic urethra may be considered in patients at high risk for urethral disease (extensive CIS, multifocal high-grade disease, disease at or near the bladder neck, an abnormal-appearing prostate); 10%-40% of patients with bladder cancer have prostatic urethral involvement.
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Histologic Findings

In the United States, 90% of bladder cancers are TCC, 5% are SCC, and 2% are adenocarcinoma. Grades 1, 2, and 3 refer to well, moderately, and poorly differentiated microscopic classifications, respectively. Forty percent of newly diagnosed bladder cancers are high grade, and up to half of these are stage T2 or higher.[8, 9]

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Staging

Upon diagnosis of bladder cancer, accurately staging the cancer is essential for instituting appropriate therapy.

Table 1. Staging of Bladder Cancer (Open Table in a new window)

Disease TypeStageCharacteristics
Superficial diseaseTaConfined to mucosa
T1Involving lamina propria and muscularis mucosa
CISMalignant cells still confined to the flat urothelial layer
Muscle-invasive diseaseT2Invasion of muscularis propria
T3Extension into perivesical fat
T4Invasion of pelvic sidewall or adjacent organs or metastatic disease

Lymph node stages include the following:

  • NX - Unknown lymph node status
  • N0 - No lymph node involvement
  • N1 - One lymph node smaller than 2 cm with disease
  • N2 - One lymph node 2-5 cm with disease or multiple nodes, none larger than 5 cm
  • N3 - Any lymph node larger than 5 cm with disease
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Contributor Information and Disclosures
Author

Michael Christopher Large, MD  Fellow, Urologic Oncology, University of Chicago Hospitals

Michael Christopher Large, MD is a member of the following medical societies: American Urological Association and Endourological Society

Disclosure: Nothing to disclose.

Coauthor(s)

Scott E Eggener, MD  Assistant Professor of Surgery/Urology, University of Chicago Hospitals

Scott E Eggener, MD is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard A Santucci, MD, FACS  Specialist-in-Chief, Department of Urology, Detroit Medical Center; Chief of Urology, Detroit Receiving Hospital; Director, The Center for Urologic Reconstruction; Clinical Professor of Urology, Michigan State University College of Medicine

Richard A Santucci, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, and Société Internationale d'Urologie (International Society of Urology)

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

J Stuart Wolf Jr, MD, FACS  The David A Bloom Professor of Urology, Director, Division of Endourology and Stone Disease, Department of Urology, University of Michigan Medical School

J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology

Disclosure: Nothing to disclose.

Chief Editor

Bradley Fields Schwartz, DO, FACS  Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, and Society of University Urologists

Disclosure: Nothing to disclose.

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Mobilizing the lateral peritoneum after transection of the vas deferens with preservation of the spermatic cord.
Pelvic lymph node dissection with removal of lymphatic tissue from the genitofemoral nerve to the obturator nerve and from the pelvic sidewall to above the bifurcation of the iliac vessels.
Mobilization of the distal ureters into the bladder, taking care to preserve vascular supply. The bladder is lifted to the left; the pouch of Douglas is seen between the bladder and rectum.
Exposure and ligation of the lateral pedicle, which extends from the internal iliac vessels over the distal ureter on its way to the bladder.
Opening the pouch of Douglas between the rectum and posterior bladder wall.
Pelvic ileal neobladder ready for anastomosis to the urethra.
The bowel segment of the Indiana pouch includes the entire ascending colon, a small portion of the transverse colon, and about 7-8 cm of the terminal ileum.
The colon has been opened on its antimesenteric border, and the terminal ileum has been plicated by application of the gastrointestinal anastomosis (GIA) stapler to reduce the lumen to approximately 16F. A 14F catheter is shown traversing the efferent limb. The ileocecal valve also has been bolstered with 2-0 absorbable sutures.
Dissection of the lateral pedicle extending from the internal iliac vessels over the distal ureters. These vessels can be ligated, allowing full mobilization of the ureter down to the bladder.
The posterior peritoneum has been entered, and the rectum is retracted to the right. The posterior plane between the bladder and prostate anteriorly and the rectum posteriorly can then be entered using a combination of sharp and blunt dissection; this defines the posterior pedicles.
The rectum is retracted down and to the left, and the articulating stapler is applied to the posterior pedicle. Three such applications of the stapler typically advance the dissection all the way to the lateral endopelvic fascia. The apex can then be addressed in a manner similar to a radical prostatectomy.
The ureters are anastomosed to the posterior wall of the pouch and are shown from behind the pouch. They are brought through the wall and sutured to the pouch with interrupted absorbable 4-0 sutures. An antirefluxing anastomosis has traditionally been recommended, using the LeDuc technique. Both anastomoses are stented.
Table 1. Staging of Bladder Cancer
Disease TypeStageCharacteristics
Superficial diseaseTaConfined to mucosa
T1Involving lamina propria and muscularis mucosa
CISMalignant cells still confined to the flat urothelial layer
Muscle-invasive diseaseT2Invasion of muscularis propria
T3Extension into perivesical fat
T4Invasion of pelvic sidewall or adjacent organs or metastatic disease
Table 2. Advantages and Disadvantages of Intestinal Segments Used for Urinary Diversion
SegmentAdvantagesDisadvantages
StomachCan be used in patients with renal failure, hepatic failure, acidosis, and pelvic radiation; no mucus productionHypokalemic hypochloremic metabolic alkalosis, hematuria dysuria syndrome due to acid irritation of the urothelium, concern for increased secondary malignancy
JejunumN/AHyperkalemic hypochloremic metabolic acidosis, hyponatremia, osteomalacia (Avoid if at all possible.)
IleumFamiliarity to urologistsHypokalemic hyperchloremic metabolic acidosis, vitamin B-12 deficiency, fat malabsorption, diarrhea, osteomalacia (not a good option following pelvic radiation)
ColonTransverse colon can be used in patients who have had pelvic radiation.Hypokalemic hyperchloremic metabolic acidosis, osteomalacia; most mucus production of all intestinal segments
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