PRESENTED BY: DR.

VIKAS KUMAR

MODERATOR : DR.P.K.PURI
(HOD DEPTT. OF UROLOGY,IGMC,
SHIMLA)
 INTRODUTION

•Bladder cancer is the 9th most common cancer overall and 2nd after
prostate ca in genitourinary sys.

Bladder cancer is the 13th most common cause of death worldwide

Sixty-three percent of all bladder cancer cases occur in developed

countries, with 55% from North America and Europe

In North America and Europe, 95% to 97% of cases are urothelial
carcinoma;
 in Africa 60% to 90% are urothelial and 10% to 40% are
squamous cell; and
Egypt has the highest rate of squamous cell carcinoma because of
the endemic infections with Schistosoma species .
 Bladder cancer is 3 times more common in men than in
women.

 Bladder cancer is rare in persons less than the age of 40

years and typically nonaggressive and well differentiated

 The median age of bladder cancer diagnosis is 65 years of

age for men and women, and the incidence and mortality
from the disease increases with age.

 The incidence rate of bladder cancer is decreasing faster in

men than in women because of the recent decrease in the
percent of men smoking compared with women.
ETIOLOGY

I) GENETIC
- The null GSTM1 polymorphism is
associated with an increased bladder risk with
a relative risk of 1.5.
- The slow NAT-2 polymorphism is
related to bladder cancer with an odds ratio of
1.4 compared with the fast polymorphism
II) EXTERNAL RISK FACTORS

i) Smoking – 60-70%

ii) Aromatic amines – 20-27%

iii) Nutritional Factors - fruits and vegetables

protective; salted and barbequed meat, pork, total fat,
pickled vegetables, soy, and spices procarcinogenic
iv) Inflammation/Infection -
Schistosoma hematobium, human papillomavirus,
Escherichia coli,Pseudomonas,and gonorrhea

v) Radiation

vi) Chemotherapy

vii) Heredity
PATHOLOGY
 Histologically, 90% of bladder cancers are of urothelial origin, 5%
are squamous cell carcinomas, and less than 2% are
adenocarcinoma or other variants.

 At initial presentation, 80% of urothelial tumors are non–muscle

invasive.

 There are multiple growth patterns of urothelial cancer, including

flat carcinoma in situ (CIS), papillary tumors that can be low or
high grade, and sessile tumors with a solid growth pattern
WHO Classification of Noninvasive and
Invasive Urothelial Neoplasia
 Noninvasive Urothelial Neoplasia
 Hyperplasia (flat and papillary)
 Reactive atypia
 Atypia of unknown significance
 Urothelial dysplasia (low-grade intraurothelial neoplasia)
 Urothelial carcinoma in situ (high-grade intraurothelial
neoplasia)
 Urothelial papilloma
 Urothelial papilloma, inverted type
 Papillary urothelial neoplasm of low malignant potential
 Noninvasive low-grade papillary urothelial carcinoma
 Noninvasive high-grade papillary urothelial carcinoma

 Invasive Urothelial Neoplasia

 Lamina propria invasion
 Muscularis propria (detrusor muscle) invasion
STAGING
PRIMARY TUMOR (T)
 TX Primary tumor cannot be assessed
 T0 No evidence of primary tumor
 Ta Noninvasive papillary carcinoma
 Tis Carcinoma in situ: “flat tumor”
 T1 Tumor invades subepithelial connective tissue
 T2 Tumor invades muscularis propria
pT2a Tumor invades superficial muscularis propria (inner half)
pT2b Tumor invades deep muscularis propria (outer half)
 T3 Tumor invades perivesical tissue:
pT3a Microscopically
pT3b Macroscopically (extravesical mass)
 T4 Tumor invades any of the following: prostatic stroma, seminal
vesicles, uterus, vagina, pelvic wall, abdominal wall
 T4a Tumor invades prostatic stroma, uterus, vagina
 T4b Tumor invades pelvic wall, abdominal wall
REGIONAL LYMPH NODES (N)

 NX Lymph nodes cannot be assessed

 N0 No lymph node metastasis

 N1 Single regional lymph node metastasis in the

true pelvis (hypogastric, obturator, external
iliac, or presacral lymph node)

 N2 Multiple regional lymph node metastasis in

the true pelvis (hypogastric, obturator,
external iliac, or presacral lymph node metastasis)

 N3 Lymph node metastasis to the common iliac lymph

nodes
Distant Metastasis (M)
 M0 No distant metastasis

M1 Distant metastasis
Anatomic Stage

Group T N M

 Stage 0a Ta N0 M0
 Stage 0is Tis N0 M0
 Stage I T1 N0 M0
 Stage II T2a N0 M0
T2b N0 M0
 Stage III T3a N0 M0
T3b N0 M0
T4a N0 M0
 Stage IV T4b N0 M0
Any T N1-3 M0
Any T Any N M1
DISSEMINATION
A) Angiolymphatic Invasion : seen in approximately 25% of invasive
urothelial carcinoma.

B) Pagetoid Spread : Pagetoid spread occurs when cancer cells grow

underneath a layer of normal-appearing surface urothelium.

-Pagetoid spread of urothelial cancer can occur into the prostatic

urethra and distal ureters.

-Biopsies of normal-appearing prostatic urothelium are needed

in the evaluation of patients with positive urine cytology and yet
endoscopically normal bladder

C) Direct Extension : Direct extension of tumors into the basal lamina,

connective tissue, and, ultimately, the angiolymphatic system is
caused by genetic and epigenetic changes.
DETECTION OF UROTHELIAL
CARCINOMA
 Gross, painless hematuria is the primary
symptom in 85% of patients

 Fifty percent of patients with gross hematuria will

have a demonstrable cause, 20% will have a
urologic malignancy, and 12% will have a bladder
tumor

 The AUA guidelines for microscopic hematuria

evaluation include a cystoscopy, upper tract
imaging, and urine cytology
INVESTIGATIONS
1) URINE CYTOLOGY
-Positive urine cytology is virtually
diagnostic of a bladder tumor

-the gold standard urinary marker

against which other markers are held

- the sensitivity and specificity for

cytology in detecting bladder cancer is 40% to
62% and 94% to 100%, respectively.
1) 2) CYSTOSCOPY

A) White light cystoscopy (WLC) is the gold standard.

- White light cystoscopy has an excellent sensitivity of 87% and

specificity of 85% for papillary tumors but is relatively poor for CIS
(15%).

B) Blue light cystoscopy : Porphyrin-induced fluorescence

cystoscopy uses photoactive porphyrins, such as hexaminolevulinate,

that accumulate preferentially in neoplastic tissue and emit red

fluorescence under blue-wavelength light.

-This may improve the detection of small papillary lesions and CIS.

- Blue light cystoscopy detected 58% of CIS ; and sensitivity of 87%

C) Narrow-band imaging (NBI) is an endoscopic optical image
enhancement technique that enhances the contrast between mucosal
surfaces and microvascular structures without the use of dyes.
- vascular structures appear dark brown or green against a pink
or white mucosal background.
- sens. 100% and sp.82%

-NBI more accurately detects tumor recurrence after BCG

therapy than do urine cytology or white light cystoscopy,
3) RANDOM BLADDER BIOPSY
-Random bladder biopsies are
recommended to detect unsuspected CIS or small
papillary tumors in endoscopically normal urothelium.

- Overall, there is a 2.5% detection rate of

CIS or small papillary tumors in random biopsies of
patients with known or suspected bladder tumors.

-It is reasonable to perform random

biopsies in high-risk individuals, such as for those given
postintravesical therapy or for those with a positive
cytology and an endoscopically negative bladder.
4) URINE MARKERS

-There are various urine markers that evaluate

secreted proteins or shed cells in the hope of noninvasively
detecting bladder cancer.

-To date, none of these markers have a high

enough sensitivity or specificity to replace office cystoscopy.
MARKER MEDIAN SENSITIVITY (%) MEDIAN SPECIFICITY (%)

 BTA stat 70 75
 BTAtrak 69 65
 NMP22 73 80
 FDP 61 79
 ImmunoCyt 83 80
 Cytometry 60 80
 Quanticyt 59 79
 Hb-dipstick 52 82
 Lewis X 83 85
 FISH 84 95
 Telomerase 75 86
 Microsatellite 91 94
 CYFRA21-1 94 86
 UBC 78 91
 Cytokeratin 20 91 84
 BTA 50 86
 TPS 72 78
NON–MUSCLE-INVASIVE BLADDER
CANCER

 DEF : malignant urothelial tumors that have not

invaded the detrusor are more appropriately
termed non–muscle invasive traditionally known
as superficial bladder cancer .

 Approximately 70% are non–muscle invasive at

presentation. Of these, 70% present as stage Ta,
20% as T1, and 10% as CIS
 Stage Ta tumors are usually low grade. Although
recurrence is common, especially in the setting of
multiplicity, progression is rare .

 Between 40% and 83% of patients with CIS will

develop muscle invasion if untreated.

 T1 tumors are usually papillary. Deep penetration

into the lamina propria, especially if involving
muscularis mucosae, increases the risk of
recurrence and progression
Non-Muscle Invasive Bladder Cancer
Carcinoma in Situ
 There is significant potential for
understaging in patients with high-grade,
apparently non–muscle-invasive tumors,
especially for those that appear to be
stage T1.

 one third of patients believed to have

non–muscle-invasive disease at the time
of cystectomy were found to actually have
muscle invasion, only half of which were
organ confined. Metastases were already
present in 8% of these patients.
NMIUC Prognosis correlates with:
 Tumor grade

 +/- CIS

 Tumor Size

 Multiplicity

 Papillary vs Sessile

 +/- Lymphovascular Invasion

 ENDOSCOPIC SURGICAL
MANAGEMENT
 TUR of bladder tumor (TURBT)
under regional or general
anesthesia is the initial treatment
for visible lesions and is performed
to
(1) remove all visible tumors
and
(2) provide specimens for
pathologic examination to
determine stage and grade.

 Bimanual examination of the

bladder should be performed
under anesthesia before
prepping and draping unless the
tumor is clearly small and
noninvasive, and it should be
repeated after resection.
 Fixation or persistence of a palpable mass after resection
suggests locally advanced disease.

 Friable, low-grade tumors can often be removed without the use

of electrical energy

 If a tumor appears to be muscle invasive, biopsies of the borders

and base in order to establish invasion may be performed in lieu
of complete resection, because cystectomy will likely follow based
on confirmatory biopsies

 Consensus is that patients with pT1 and high-grade Ta tumors

merit repeat resection after 2 to 3 weeks
A, Broad-based papillary lesion. B, Resection of lesion with loop
electrocautery. C, Depth of resection to detrusor muscle.
Complications of Transurethral
Resection of Bladder Tumor
- Minor bleeding
- irritative symptoms
- uncontrolled hematuria
- clinical bladder perforation
-TUR Syndrome
-UO Obstruction
 Why Do Patients Recur?

 Nature of the tumor…

 Missed tumors at TURBT

 Incomplete TURBT resection

 Implantation of shed tumor cells at

TURBT
Perioperative Intravesical Therapy to Prevent
Tumor Implantation

 It is believed that tumor cell implantation

immediately after resection is responsible for
many early recurrences and this has been used to
explain the observation that initial tumors are
most commonly found on the floor and lower side
walls of the bladder, whereas recurrences are
often located near the dome.

 Thus intravesical chemotherapy to kill such cells

before implantation has been used
 Mitomycin C (MMC) appears to be the most effective
adjuvant intravesical chemotherapeutic agent
perioperatively.

 a single dose administered within 6 hours lessens

recurrence rates, whereas a dose 24 hours later does not

 Recurrence dropped from 48.4% to 36.7%

 Destroys residual microscopic tumor at the TURBT site

 Used to prevent tumor implantation

 Perforation is absolute contraindication

 IMMUNOTHERAPY
 Goal of immunotherapy is to
 Augment cancer cell recognition

 Promote tumor cell-specific cytotoxicity

 Recruit tumor cells that have evaded the immune system

“onto the radar”
 Intravesical immunotherapy results in a massive local
immune response characterized by induced expression
of cytokines in the urine and bladder wall and by an
influx of granulocytes, mononuclear, and dendritic cells

1) Bacillus Calmette-Guérin

- BCG is an attenuated mycobacterium

developed as a vaccine for tuberculosis that has
demonstrated antitumor activity in several different
cancers including UC

-BCG is stored in refrigeration and

reconstituted from a lyophilized powder.
 Use in CIS
 CIS is often diffuse preventing complete tumor
resection
 80% response rate
 50% durable at 4 yrs and 30% at 10 yrs
 Higher efficacy compared with intravesical
chemo
 Use in residual tumor
 Effectively treats Ta papillary lesions, but not a surgical
substitute
 TURP + delayed BCG to prostatic urethra is effective treatment
for prostatic CIS

 Use as prophylaxis for 6 weeks after TURBT

 Induction decreased recurrence by up to 40% for T1 lesions
compared to TUR alone
 Induction + Maintenance can reduce progression by 20-30% in
HG tumors
 Maintenance is thought to provide long-term
immunostimulation
BCG SCHEDULING
-Treatments are generally begun 2 to
4 weeks after tumor resection, allowing time for
re-epithelialization, which minimizes the potential
for intravasation of live bacteria

-The vaccine (80-120 mg) is

reconstituted with 50 mL of saline and should be
administered through a urethral catheter under
gravity

-In the event of a traumatic

catheterization, the treatment should be delayed
for several days to 1 week, depending on the
extent of injury.
 After instillation, the patient should retain the
solution for at least 2 hours

 Patient should turn from side to side to bathe the

entire urothelium

 Fluid, diuretic, and caffeine restriction before

instillation is essential to limit dilution of the
agent with urine and to facilitate retention of the
agent for 2 hours
 6 week induction alone is insufficient to achieve optimal
response
 Lamm and SWOG Maintenance
– (after 6 week induction)
 @ 3 months- 3 weekly instillations
 @ 6 months- 3 weekly instillations
 then every 6 months for 3 yrs

 Quinolones may affect the viability of BCG and

should be avoided if possible during the course of
BCG treatments
CONTRAINDICATIONS
 Absolute Contraindications
 Immunosuppressed and
immunocompromised patients
 Immediately after transurethral resection
on the basis of the risk of intravasation
and septic death
 Personal history of BCG sepsis
 Gross hematuria (intravasation risk)
 Traumatic catheterization (intravasation
risk)
 Total incontinence (patient will not retain
agent)
 Relative Contraindications
 Urinary tract infection (intravasation risk)
 Liver disease (precludes treatment with
isoniazid if sepsis occurs)
 Personal history of tuberculosis (risk theorized
but unknown)
 Poor overall performance status
 Advanced age
 No or Insufficient Data on Potential Need
for Contraindications
 Patients with prosthetic materials
 Ureteral reflux
 Anti–tumor necrosis factor medications
(theoretically predispose to BCG sepsis)
SIDE EFFECTS
Grade 1: Moderate Symptoms <48 Hr
 Mild/moderate irritative voiding symptoms, mild hematuria, fever
<38.5° C

 ASSESSMENT
 Possible urine culture to rule out bacterial urinary tract infection

 SYMPTOM MANAGEMENT

 Anticholinergics, analgesics, nonsteroidal anti-inflammatory drugs

Grade 2: Severe Symptoms and/or >48 Hr

Severe irritative voiding symptoms, hematuria, or symptoms lasting

>48 hr
All maneuvers for grade 1, plus the following:

ASSESSMENT
Urine culture, chest radiograph, liver function tests

MANAGEMENT
Consult immediately with physician experienced in
management of mycobacterial infections/complications.

Consider dose reduction to one half to one third of dose

when instillations resume.

Treat culture results as appropriate.

 ANTIMICROBIAL AGENTS

 Administer isoniazid and rifampins, 300 mg/day and 600 mg/day,

orally until symptom resolution.
 Do not use monotherapy.
 Observe for rifampin drug-drug interactions (e.g., warfarin).

Grade 3: Serious Complications (Hemodynamic Changes,

Persistent High-Grade Fever)
 ALLERGIC REACTIONS (JOINT PAIN, RASH)
 Perform all maneuvers described for grades 1 and 2, plus the
following:
 Isoniazid, 300 mg/day, and rifampin, 600 mg/day, for 3-6
months depending on response
SOLID ORGAN INVOLVEMENT (EPIDIDYMITIS, LIVER, LUNG, KIDNEY,
OSTEOMYELITIS, PROSTATE)

• Isoniazid, 300 mg/day, rifampin, 600 mg/day, ethambutol, 15

mg/kg/ day single daily dose for 3-6 months

•Cycloserine often causes severe psychiatric symptoms and is to be

strongly discouraged.

•BCG is almost uniformly resistant to pyrazinamide, so this drug has

no role.

•Consider prednisone, 40 mg/day, when response is inadequate or

for septic shock (never given without effective antibacterial therapy).
2) INTERFERON
-Interferons have multiple antitumor activities
* inhibition of nucleotide synthesis;
*upregulation of tumor antigens,
*antiangiogenic properties; and
*stimulation of cytokine release with enhanced T and B cell
activation, as well as enhanced natural killer cell activity.

-Interferon as a solitary agent is more expensive

and less effective than BCG or intravesical chemotherapy in
eradicating residual disease, preventing recurrence of papillary
disease, and treating CIS

-Combination of BCG and interferon is superior

3) NEWER IMMUNOTHERAPEUTIC AGENTS

 Keyhole-limpet hemocyanin (KLH) from the

hemolymph of the mollusk Megathura crenulata

 Bropirimine

 Mycobacterial cell wall DNA extract

 Thiosulfinate extracts of garlic

 Interleukin-12
INTRAVESICAL CHEMOTHERAPY
 INDICATIONS

 Low grade tumor

 Multifocal tumor

 Recurrences > 4

 CIS
 Intravesical chemotherapy has a clear impact on tumor
recurrence when immediately instilled after TURBT and in
the adjuvant setting.

 There is no clear evidence of an impact on progression.

 Combinations of various chemotherapeutic agents and

chemotherapy combined with BCG have not demonstrated
major benefit combined with single-agent treatment, with
the exception of interferon

 Given for 6-8 wks post op. but response not better than
BCG
 Various chemotherapeutic agents
include:
 Mitomycin C
 Doxorubicin and Its Derivatives
 Thiotepa
 Gemcitabine and
 Taxanes
EARLY CYSTECTOMY
• Should be considered in patients

-Micropapillary Variant
– Do not tolerate intravesical therapy
– Failed attempts at disease control with TURBT +IVT
– Lesions not amenable to endoscopic resection
– Failure of TURBT and intravesical therapy
• Recurrence at higher grade and multifocality
• Progression on intravesical therapy (Grade Progression)
• Invasion into detrusor (T progression)
• Especially in HGTa or CIS
RADIATION THERAPY

• Has not been studied extensively in NMI

Urothelial Ca
• Initial very good response, short term
• Not effective long term for Ta or CIS
– 90% recur in 5 years
AMERICAN UROLOGICAL ASSOCIATION 2007
GUIDELINES FOR NON–MUSCLE-INVASIVE BLADDER
CANCER

 Index Patient #1: Abnormal Urothelial “Growth”

but Not Proven Cancer
 Standard: Obtain biopsy to confirm grade
for all index patients
 If possible, eradicate all visible tumors
 If cancer, periodic cystoscopy
 Option: Single dose of postoperative
intravesical chemotherapy
 Index Patient #2: Small-Volume, Low-Grade
Ta
Recommendation: Single dose of postoperative
intravesical chemotherapy

 Index Patient #3: Multifocal or Large Low-

Grade Ta, or Recurrent Low-Grade Ta

 Recommendation: Intravesical BCG or MMC—

goal to prevent/delay recurrence
 Option: Maintenance BCG or MMC

 Index Patient #4: High-Grade Ta, T1, or CIS

 Standard: If T1 disease, but no muscularis in specimen,
repeat resection
 Recommendation: Intravesical BCG with maintenance
therapy
 Option: Consider cystectomy for select patients
 Index Patient #5: High-Grade Ta, T1, and/or CIS
Following Prior Intravesical Therapy
 Standard: T1 disease but no muscularis in
specimen, repeat resection
 Recommendation: Consider cystectomy as
therapeutic alternative
 Option: Further intravesical therapy may be
considered
INVASIVE BLADDER CANCER

DEF. : It includes T2 and beyond bladder cancer

 The majority (80%) of patients with bladder cancer present de

novo with muscle-invasive disease as its first manifestation.

 The remaining 15% to 20% progress from non–muscle-invasive

cancer after treatment with intravesical therapy.

 Deaths due to bladder cancer invariably occur as a result of

distant metastases present at the time of loco-regional therapy.

 Progression of cancer after definitive loco-regional therapy

commonly occurs within the first 2 years after treatment
STAGING AND EVALUATION
 Laboratory testing at a minimum
should include
 complete hemogram,
 blood urea,

 creatinine,

 electrolytes,

 liver function tests

 IMAGING STUDIES:

 CXR

 CT Abd & pelvis

 CT Chest

 Bone scan

 MRI

 PET

 Tumor markers- CEA,CA19.9,CA 125

MANAGEMENT
 I) SURGICAL
 II) NEOADJUVANT CHEMOTHERAPY
 III)ADJUVANT CHEMOTHERAPY
SURGICAL
 I) RADICAL CYTECTOMY

 II) BLADDER PRESERVATION

SURGERY
Indications for radical cystectomy
 Infiltrating muscle-invasive bladder cancer without
evidence of metastasis or with low-volume, resectable
locoregional metastases (stage T2-T3b)

 Superficial bladder tumors characterized by any of the

following:
 Refractory to cystoscopic resection and intravesical
chemotherapy or immunotherapy
 Extensive disease not amenable to cystoscopic
resection
 Invasive prostatic urethral involvement

 Primary adenocarcinoma, SCC, or sarcoma

 Stage-pT1, grade-3 tumors unresponsive to intravesical
BCG vaccine therapy

 CIS refractory to intravesical immunotherapy or

chemotherapy

 Palliation for pain, bleeding, or urinary frequency

RADICAL CYSTECTOMY
 Radical Cystectomy
 Removal of bladder with surrounding fat
 Prostate/seminal vesicles (males)
 Uterus/cervix/fallopian tubes/ovaries /ant. Vault of vagina
(females)
 + Urethrectomy
 Pelvic Lymphadenectomy
 More is better
 Urinary Diversion
 Conduit urinary diversion
 Continent cutaneous reservoir
 Orthotopic neobladder
Radical Cystectomy

 Midline incision
 Thorough intraabdominal exploration (rule out
metastatic disease)
 Assess resectability of bladder
Step 1: mobilize the urachus from the umbilicus
Step 2: mobilize the bladder from the bowel
Step 3: isolate and transect ureters
Step 4: complete lymph node dissection
Step 5: separate bladder from sigmoid colon
Step 6: complete posterior dissection and cut off bladder blood supply
Step 7: complete anterior dissection and isolate urethra
Step 8: transect urethra and remove specimen
Cystectomy is not performed when

(1)lymph node metastases are unresectable because of

bulk or proximal extent above the common iliac
vessels;

(2) there is evidence of extensive periureteral disease;

(3) the bladder is fixed to the pelvic sidewall; or

(4) tumor is invading the rectosigmoid colon.

 PELVIC LYMPHADENECTOMY
 ~25% have LN involvement at cystectomy

 25 nodes be the minimum number to be

removed
 Accurate staging
 Assessment of prognosis
 Adjuvant therapies (chemotherapy, clinical trials)

 Therapeutic benefit
 Removal of micrometastatic disease
Pelvic Lymphadenectomy

Standard LND Extended

LND
 Urinary Diversion
 Use of intestinal segment to bypass/ reconstruct/
replace the normal urinary tract
 Goals:
 Storage of urine without absorption
 Maintain low pressure even at high volumes to allow
unobstructed flow of urine from kidneys
 Prevent reflux of urine back to the kidneys

 Socially-acceptable continence

 Empties completely

 “Ideal” diversion has yet to be discovered

 Types of Urinary Diversion

ILEAL CONDUIT CONTINENT ORTHOTOPIC

(incontinent CUTANEOUS NEOBLADDER
diversion to RESERVOIR (continent
skin) (continent diversion to
diversion to urethra)
skin)

Figures from www.clevelandclinic.org/health/health-info/docs

Ileal Conduit
 15-20 cm of small
intestine (ileum) is
separated from the
intestinal tract

 Intestines are sewn

back together (re-
establish intestinal
continuity)
 Ileal Conduit
 Ureters are attached to
one end of the segment
of ileum

 Natural peristalsis of
intestine propels urine
through the segment Ileum

ureter
 Other end is brought ureter
out through an opening
on the abdomen
 Ileal Conduit
ADVANTAGES DISADVANTAGES
 Simplest to perform  Need to wear an external
 Least potential for collection bag
complications  Stoma complications
 No need for intermittent  Parastomal hernia
catheterization  Stomal stenosis

 Less absorption of urine  Long-term sequelae

 Pyelonephritis
 Renal deterioration
 Continent Cutaneous Reservoir
 Many variations (same theme)
 Indiana Pouch, Penn Pouch, Kock Pouch…
 All use various parts of the intestine
 ileum, right colon most commonly
 Reservoir
 “Detubularized” intestine- low pressure storage
 Continence mechanism
 Ileocecalvalve (Indiana)
 Flap valve (Penn, Lahey)
 Intussuscepted nipple valve (Kock)
 Continent Cutaneous Reservoir
INDIANA POUCH

Appendix
removed
Right colon
and distal
ileum Right colon is
isolated opened
lengthwise
and folded
down to
create a
sphere
 Continent Cutaneous Reservoir
INDIANA POUCH

Ureters attached to back of reservoir (not shown)

catheter

EFFERENT LIMB
RESERVOIR (to skin)
Continence
maintained by
ileocecal valve
 Continent Cutaneous Reservoir
ADVANTAGES DISADVANTAGES
 No external bag  Most complex
 Stoma can be covered  Need for regular
with bandaid intermittent
catheterization
 Potential complications:
 Stoma stenosis
 Stones

 Urine infections
 Orthotopic Neobladder
 Currently the diversion of choice
 Studer, T-Pouch, Hautmann, Ghoniem, etc.

COMPONENTS:
 Internal reservoir – detubularized ileum

 Connect to urethra (“efferent limb”)

 Urethral sphincter provides continence
 “Afferent Limb” – ureteral connection
 Antirefluxing (T-Pouch, Kock)
 Low pressure isoperistaltic limb (Studer)
 Orthotopic Neobladder

Ureters
attache
d

15-20 cm

44 cm Ileum
detubularize
d Reservoir
Connect to urethra

STUDER ILEAL NEOBLADDER

Orthotopic Neobladder
Isolation of ileal segment

22 cm

22 cm
15-20 cm
 Orthotopic Neobladder
Afferent Limb

Detubularization of ileum
Orthotopic Neobladder

Afferent Limb Reservoir

Opening to
urethra
Orthotopic Neobladder

ADVANTAGES DISADVANTAGES
 No external bag  Incontinence (10-

 Urinate through 30%)

urethra  Retention (5-20%)

 May not need  Risk of stones,

catheterization UTI’s
 Need to “train”
neobladder
 Choice of Urinary Diversion
 Disease Factors
 Urethral margin
 Patient Factors
 Kidney function / liver function
 Manual dexterity
 Preoperative urinary continence/ urethral strictures
 Motivation

 Surgeon Factors
 Familiarity with various types of diversions
 Urinary Diversions
 Enterostomal therapist is CRITICAL for success

 Urinary diversions require lifelong follow-up

 Imaging (kidneys/ureters/diversion)
 Labs (electrolytes, acid-base, B12 levels)

 Cancer follow-up (surveillance imaging, cytology)

BLADDER PRESERVATION
APPROACHES
1) Radical Transurethral Resection of
Bladder Tumor (TURBT)
 Criteria
a) initial occurrence of bladder cancer;
b) no CIS;
c) size less than or equal to 3 cm;
d) stage T2 (no palpable mass); and
e) not in the dome or high posterior wall because of the risk
of bowel injury
2) Partial Cystectomy

 Criteria
a) Same as for TURBT plus

b) Located at dome and away from the ureteral orifices.

Bilateral pelvic lymphadenectomy is performed at the time of

surgery for pathologic staging of the nodes
3) Trimodality Therapy

TURBT + CHEMO + RT

Criteria
a) clinical stage (organ-confined),
b) tumor size less than 3 to 5 cm,
c) absence of hydronephrosis,
d) absence of a palpable mass, and
e) unifocal disease
Role of neoadjuvant
chemotherapy
 Chemotherapy before surgery has several advantages.

 Therapy is better tolerated before surgery or radiation.

 Chemotherapy-related toxicities are considerably less in patients

with localized disease than in those with metastatic disease on
the basis of performance status.

 Patients are often able to tolerate a greater dose intensity and

more cycles of chemotherapy preoperatively than postoperatively.

 Neoadjuvant chemotherapy allows in vivo drug sensitivity testing

that may provide useful information for later therapy.
 The primary tumor can be evaluated for response, which also has
major prognostic significance.

 In addition, preoperative chemotherapy may down-stage tumors,

potentially allowing for technically easier surgery

 DISADVANTAGE

 delay in definitive local therapy in patients who do not respond or

whose disease progresses.

 An interval longer than 12 weeks between the diagnosis of muscle

invasion and cystectomy has even been associated with a poorer
outcome.

 increase in the incidence of perioperative morbidity.

ADJUVANT CHEMOTHERAPY
 In patients with pT3-4 and/or N+M0 disease, 5-year survival after
radical cystectomy is only 25% to 35% at best.

 As a result, adjuvant chemotherapy has been advocated for high-

risk patients in an effort to delay recurrence and prolong survival

 ADVANTAGES

 An adjuvant approach allows selection of patients at highest risk

of metastatic or recurrent disease on the basis of an accurate
pathologic evaluation.

 Surgery is performed without delay, and the advent of orthotopic

neobladders and continent urinary diversions has improved
quality of life in patients after cystectomy, favoring immediate
cystectomy.
 There is evidence that delaying cystectomy can be detrimental (,
and no time is wasted in those patients who do not respond to
chemotherapy.

 The availability of sufficient tissue for increasingly sophisticated

analysis of molecular prognostic and predictive markers is also a
potential advantage.

 If micrometastases are present, they can be treated with

chemotherapy when at a low volume, rather than after there is
overt metastatic disease.
 DISADVANTAGES

 bladder is not preserved and that there is a delay in

starting systemic therapy for occult metastases
while the focus is first on the primary tumor.

 Response cannot be easily evaluated, and the only

clinical end point that can be assessed is the time to
tumor recurrence

 difficulty in administering chemotherapy to those

with surgical morbidities following cystectomy.
ROBOTIC AND LAP. RADICAL
CYSTOPROSTATECTOMY
 Robotic-assisted and lap. radical
cystectomy represents an evolving field in
urology.

 It is certainly one tool that can be used in

the treatment of invasive bladder cancer.

 Morbidity is limited, operative time is

comparable, and long-term oncologic
outcomes are awaited.