Partial Cystectomy Treatment & Management

Updated: Apr 03, 2019
  • Author: E Jason Abel, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Treatment

Medical Therapy

Bladder-sparing options other than partial cystectomy

In the United States, most young healthy patients with urothelial carcinoma are treated with radical cystectomy as the criterion standard treatment because of survival advantages seen in large series. [23]

Several other studies have been published using treatment protocols involving systemic chemotherapy or external beam radiation (XRT). Multimodality bladder-sparing therapy usually includes complete transurethral resection followed by induction chemotherapy/radiation, repeat urological evaluation (biopsies or repeat transurethral resection), and, afterwards, consolidation chemotherapy/radiation. Salvage cystectomy is offered to patients without response to induction therapy or if recurrence is detected.

Table 2. Options Other than Partial Cystectomy (Open Table in a new window)

Study

Number of Patients

Induction Therapy

% Complete Response

Consolidation Therapy

% Overall Survival (years)

% Overall Survival with Bladder Intact (years)

Housset et al

120

Bifractionated XRT + concurrent cisplatin + 5-fluorouracil

77

Bifractionated XRT + concurrent 5-fluorouracil + cisplatin

63 (5)

 

...

Sauer et al

184

45-54 Gy XRT + concurrent cisplatin or carboplatin

80

None

56 (5)

41 (5)

Fellin et al

56

2 cycles MCVa, 40 Gy XRT + concurrent cisplatin

50

24 Gy XRT + concurrent cisplatin

55 (5)

41 (5)

Tester et al

49

40 Gy XRT + concurrent cisplatin

66

24 Gy XRT + concurrent cisplatin

60 (4)

42 (4)

Tester et al

91

2 cycles MCV, 39.6 Gy XRT + concurrent cisplatin

75

25.2 Gy XRT + concurrent cisplatin

62 (4)

44 (4)

Shipley et al

61

2 cycles MCVa, 39.6 Gy XRT + concurrent cisplatin

61

25.2 Gy XRT + concurrent cisplatin

48 (5)

36 (5)

Shipley et al

62

39.6 Gy XRT + concurrent cisplatin

55

25.2 Gy XRT + concurrent cisplatin

49 (5)

40 (5)

Kachnic et al

106

2 cycles MCV, 40 Gy XRT + concurrent cisplatin

66

24.8 Gy XRT + concurrent cisplatin

52 (5)

43 (5)

Zietman et al

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 vinblastine [24]

Multimodality bladder-sparing approaches other than partial cystectomy yield 5-year overall survival rates of 48-56%, with 5-year bladder survival rates of 36-43%. Comparison between approaches is difficult because of the multiple variables which may affect survival differ significantly between study populations. To date, no prospective randomized studies among modalities have been performed, so data must be interpreted accordingly.

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, multiple tumors, and lack of response to induction chemoradiation. Local recurrence rates for such protocols vary from 20-30%. A recent editorial estimated that the mortality risk of certain bladder sparing procedures was between 7-16%. [25]

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Preoperative Details

Initial TURBT should confirm that the patient is a good candidate for partial cystectomy (absence of multifocal tumors, no carcinoma in situ, good bladder capacity.) During TURBT, a thorough inspection 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 in the upper urinary tracts or outside the bladder. Preoperative history, physical examination, medical assessment, and necessary laboratory evaluation (see Lab Studies) are also performed.

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Intraoperative Details

The patient may be placed in the supine or low-lithotomy position with a slight amount of Trendelenburg positioning. Bimanual examination under anesthesia is performed to determine suitability for resection. A catheter is inserted through the urethra, and the bladder is instilled with Mitomycin C (1 mg/mL) to decrease local tumor spillage. The Foley catheter is clamped so that the intravesical chemotherapy remains inside the bladder, and the bladder is allowed to partially expand, which facilitates dissection.

The surgical approach is either transperitoneal or extraperitoneal through a lower midline incision. The transperitoneal approach may be more suitable for tumors located posteriorly. Pelvic lymph node dissection can be performed before or after partial cystectomy. In urothelial carcinoma, it is known that improved survival can be achieved with extended pelvic lymph node dissection. [26]

After completing the pelvic lymph node dissection, the Mitomycin C is drained from the bladder into a contained Foley bag system and discarded according to biohazard principles. Next a combined endoscopic and open approach is utilized to ensure resection of the mass with adequate tumor margins. A flexible cystoscope is introduced via the urethra into the bladder. While the assistant surgeon displays the location of the mass on the video monitor with the cystoscope, the primary surgeon can now see exactly where to place four sutures (inferior, superior, medial, lateral) strategically into the detrusor muscle of the bladder, to outline the exact area to be resected.

Next, the bladder is mobilized while dividing the vas deferens and the obliterated hypogastric artery. A portion of the ipsilateral vascular pedicle including 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 1-cm to 2-cm margin. The perivesical fat and the overlying peritoneum are removed, if necessary, with care to protect both ureters and the rectum. 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 2-layers, 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 instillation of intravesical chemotherapy into the bladder prior to making the lower midline incision, careful draping, and meticulous isolation and manipulation of the tumor. The wound edges should be protected and the wound 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.

Partial cystectomy can also be performed laparoscopically or robotically with similar technique to open procedures. [27, 28] The patient is placed in the extreme Trendelenburg position with his or her legs abducted in Allen stirrups. A 5-mm port may be used for a transperitoneal approach. The camera port is positioned at least 2-3 cm above the umbilicus to facilitate adequate mobilization of the urachal remnant. The peritoneum is incised lateral to each medial umbilical ligament, and the urachus and peritoneum along with the surrounding pre-peritoneal fat are widely mobilized en bloc. Alternatively, some advocate that leaving the bladder attached to the anterior abdominal wall whenever possible while the remainder of the bladder is mobilized aids in laparoscopic exposure. [29]  

Once the space of Retzius is fully developed and the bladder is completely mobilized, the tumor is typically identified. A circumferential cystotomy is made under simultaneous cystoscopic guidance (with or without cystoscopic tattooing) at a distance of 2 cm from the tumor to provide an adequate margin. The surgical specimen is then immediately placed into an EndoCatch bag (USCC, Norwalk, CT).

Bladder margins are sent for frozen section analysis and the bladder is then closed in 2 layers. The retrieval bag is removed through an extension of the camera trocar site, and a Jackson Pratt drain is positioned in the prevesical space through one of the previous trocar sites. In selected patients, with skilled surgeons, laparoscopic or robotic approaches can afford the patient a shorter recovery time and hospital stay. [30, 31, 29]

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Postoperative Details

Placement of a drain in the perivesical space and maintaining a large caliber urethral catheter helps facilitate healing of the suture line where the bladder has been repaired. Ideally, the bladder is kept decompressed and any initial urine leakage is drained to allow healing of the bladder suture line. A urethral catheter also allows monitoring of urine output and detection of hematuria. This catheter is usually left in place for 7-14 days postoperatively. A cystogram may be obtained prior to catheter removal to ensure that the bladder suture line has healed.

Rarely, intravesical bleeding may result in urinary clot retention and may require gentle bladder irrigation to evacuate clots. Postoperative wound infection or abscesses 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 may be used to temporarily divert urine in the hope that the obstruction is temporary. Incontinence due to altered bladder compliance and uninhibited bladder contractions usually improves with time and anticholinergic medications.

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Follow-up

Careful monitoring of all patients with bladder cancer is mandatory as bladder cancer frequently recurs. Cystoscopy should be performed every three months initially with voided urine cytology and frequent imaging.

Upper urothelial tract imaging with IVP, CT urography, or retrograde pyelography is also necessary although recurrence in the upper tract is less common. A precise surveillance schedule should be determined on an individual basis, and patients with high-grade tumors should be monitored for disease recurrence and progression for life.

For excellent patient education resources, see eMedicineHealth's patient education article Bladder Cancer.

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Surgery: partial cystectomy

Initial transurethral resection of bladder tumor (TURBT) is essential for adequate staging in order to make an informed decision about future therapy. In general, partial cystectomy involves removing the segment of diseased bladder and repairing the defect with or without performing pelvic lymph node dissection. Radical cystectomy involves removal of the bladder, prostate and seminal vesicles in men. In women, along with the bladder, the urethra, uterus, broad ligaments, and anterior third of the vaginal wall may be removed. Pelvic lymphadenectomy is performed and a urinary diversion is created which may include ileal conduit, neobladder or continent pouch. The remainder of this article discusses details for partial cystectomy only.

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Complications

Excluding recurrence of malignant disease, the overall complication rate of partial cystectomy is reported as 11-29%, with recent literature suggesting lower complication and mortality rates at higher-volume centers. [32] Common complications of partial cystectomy include: bleeding, infection, reduction of bladder capacity, and urinary extravasation. Less commonly, some patients develop fistulas (vesicocutaneous, vesicovaginal, colovesical). Other complications include those that are possible in any major surgery: myocardial infarction, pulmonary embolus, congestive heart failure, upper gastrointestinal hemorrhage, and death. 

The application of laparoscopic and robotic surgical approaches to partial cystectomy represents a significant advancement and promises to further reduce length of hospital stay, surgical morbidity, and complication rates. [60] Although large series of robotic partial cystectomy are lacking, Golombos et al recently reported their experience of 29 patients. While this series included a heterogenous patient population, they reported a median hospital length of stay of one day and overall 90 day complication rate of 24.1% (all Clavien I-II) following robotic partial cystectomy; which are concordant with other series. [29, 33]  

 

Perioperative mortality rates once approached 10%, although more recent studies have reported rates of 1-2%.

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Outcome and Prognosis

Recurrence

The major disadvantage of partial cystectomy compared with radical cystectomy is an increased bladder recurrence rate in addition to metastatic recurrence. Recurrence also implies a risk of disease progression, metastasis, and death from cancer. In many patients, salvage with radical cystectomy is not possible, and some series report high death rates in patients who recur. Recurrence rates associated with partial cystectomy have been reported as 19-78%. Relapses seem to be influenced by tumor stage T3b, poorly differentiated (grade III) tumors, and tumor size (>4 cm). Various studies and their corresponding recurrence rates are as follows:

Table 3. Various Studies and Their Corresponding Recurrence Rates (Open Table in a new window)

Studies

Recurrence rates

Resnick and O'Connor (1973)

76%

Evans and Texter (1975)

40%

Novick and Stewart (1976)

50%

Peress et al (1977)

54%

Cummings et al (1978)

49%

Schoborg et al (1979)

70%

Faysal and Freiha (1979)

78%

Jardin and Vallencien (1984)

78%

Lindahl et al (1984)

58%

Kaneti (1986)

38%

Dandekar et al (1995)

43%

Holzbeierlein et al (2004)

19%

Kassouf et al (2006)

49%

Knoedler et al (2012)

43%

 

Peress et al noted that preoperative grade is an important prognostic factor in determining the risk of recurrence after partial cystectomy. [34] They studied 61 patients with stage A transitional cell carcinoma and found that 54% of patients with high-grade lesions experienced recurrence after partial cystectomy and eventually died of their disease. Kassouf et al have shown that a higher pathological stage at time of partial cystectomy was associated with shorter recurrence-free survival. Smaldone et al found that only tumor size at time of partial cystectomy was associated with tumor recurrence. [35] Older studies by Resnick and O'Connor and by Faysal and Freiha have also confirmed these findings. [36, 37]

These high local recurrence rates reflect the natural history of bladder cancer. Urothelial carcinoma of the bladder may affect the urothelium globally in some patients. Recurrences and survival outcomes depend on tumor stage and grade. Conservative management of Ta-T2 disease with transurethral resection alone results in a 60% recurrence rate. Those patients with history of previous tumors have an 84% recurrence rate, with nearly half of all tumor recurrences being multifocal. At initial presentation, two thirds of urothelial cancer patients have superficial (Ta, T1) disease, and two thirds of these patients experience recurrence (with 20% of the recurrences being of a higher grade). Death from urothelial carcinoma occurs in 5% of patients with grade 1 disease, 16% of patients with grade II disease, 28-35% of patients with grade III/stage Ta disease, and 83% of patients with grade III/stage T2 disease.

Recurrent local disease may be treated with transurethral resection, intravesical chemotherapy, radiotherapy, repeat partial cystectomy, and radical cystectomy. Of all patients who undergo partial cystectomy as original therapy, 4-15% eventually undergo radical cystectomy. Salvage radical cystectomy may confer prolonged survival, though prognosis is largely related to pathological tumor stage and nodal status. [38]

Survival

Many studies have examined the survival of patients with bladder cancer after partial cystectomy. Survival is influenced by tumor stage, grade, and histology. Accurately interpreting the impact of partial cystectomy on overall survival and comparing to results of radical cystectomy data is difficult. Most partial cystectomy series are small (usually < 50 patients) compared to radical cystectomy series of more than 1000 patients. Also, many partial cystectomy series are carefully selected for lower risk tumors prior to surgery, which may influence survival. Furthermore, pelvic lymph node dissection, which has been shown to have a significant survival benefit, [26] is frequently underutilized in partial cystectomy series. [39]

Data from Kassouf et al showed that patients undergoing partial cystectomy who had a prior history of superficial tumors had a decreased overall and advanced recurrence-free survival. [40] This finding is not surprising given that these patients have already demonstrated evidence of a global field effect within the urothelium

When comparing results for a given stage or grade of urothelial bladder cancer, survival outcomes for partial cystectomy series have been worse compared with radical cystectomy series. Five-year survival rates vary from 35-70%, compared with the reported 50-88% survival rate of contemporary radical cystectomy series. However, a recent matched case-control analysis (with patients matched based on age, sex, pathological T stage, and receipt of chemotherapy) showed no difference in metastasis-free or cancer-specific survival when comparing patients undergoing partial cystectomy with those undergoing radical cystectomy, although partial cystectomy patients remain at high risk for recurrence. [41]

Neoadjuvant chemotherapy has been shown in randomized trials to improve overall survival in patients undergoing radical cystectomy [42] although it is unclear whether adjuvant therapy would be equally effective. [43] Adjuvant chemotherapy should be considered in patients with extravesical extension or pelvic lymph node metastases who undergo partial cystectomy.

Table 4. Survival Rates by Tumor Grade (Open Table in a new window)

Source

Five-year Survival (%)

Ten-year Survival (%)

Grade I

Grade II

Grade III/IV

Grade I

Grade II

Grade III/IV

Magri (1962)

 

88

33

34

-

-

-

Utz et al (1973)

100

48

39

-

-

-

Novick and Stewart (1976)

100

75

40

0

67

8

Brannan et al (1978)

50

62

55

50

33

30

Cummings et al (1978)

100

96

32

-

-

-

Schoborg et al (1979)

75

62

26

50

28

4

Faysal and Freiha (1979)

100

53

30

25

20

8

Merrell et al (1979)

78

56

22

83

32

0

Kaneti (1986)

75

46

46

-

-

-

Dandekar et al (1995)

100

94.4

53.5

-

-

-

Table 5. Survival Rates by Tumor Stage (Open Table in a new window)

Source

Five-year Survival (%)

Ten-year Survival (%)

T0

T1

T2

T3

T4

Overall

T0

T1

T2

T3

T4

Overall

Magri (1962)

-

80

38

26

0

42

-

-

-

-

-

-

Long et al (1962)

80

67

43

9

0

-

-

-

-

-

-

-

Cox et al (1969)

-

-

20

16

-

-

-

-

-

-

-

-

Resnick and O'Connor (1978)

75

71

77

12.5

20

35

-

-

-

-

-

-

Utz et al (1973)

-

68

47

29

0

39

-

-

-

-

-

-

Evans and Texter (1975)

-

69

43

14

0

0

-

-

-

-

-

21

Novick and Stewart (1976)

-

67

53

20

-

46

-

67

44

-

-

36

Brannan et al (1978)

100

69

54

33

0

57

-

31

36

11

-

32

Cummings et al (1978)

-

79

80

6

-

60

-

-

-

-

-

-

Schoborg et al (1979)

69

69

29

12

100

43

-

37

0

0

0

12

Faysal and Freiha (1979)

75

58

29

7

0

40

21

15

13

7

0

9

Merrell et al (1979)

100

100

67

25

-

48

-

100

33

0

0

32

Lindahl et al (1984)

-

59

38

-

-

42

-

48

25

-

0

38

Kaneti (1986)

-

68

40

33

0

48

-

-

-

-

-

-

Smaldone et al (2008)

-

-

-

-

-

70

 

 

 

 

 

 

a Stage T3a/T3b

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Future and Controversies

Partial cystectomy offers potential quality of life advantages over radical cystectomy and may be appropriate in selected patients with cancer or certain benign conditions.

In patients with urothelial cancer, partial cystectomy will probably continue to play a limited role in the absence of quality comparative studies demonstrating equivalent survival results to radical cystectomy. The improved quality of life and fewer complications seen in patients undergoing partial cystectomy must be carefully weighed against the increased risk of cancer death.

Patients should be appropriately counselled by experienced surgeons when considering partial cystectomy.

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