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Surgery of bladder cancer

Transurethral resection of bladder (TUR-B)

The tumor localization must be described and a bimanual exploration should be performed on the patient before and after a TUR-B to determine the T-stage.

If there is CIS in areas of the urinary bladder, verified with biopsies or supplemented with fotodynamic diagnostics (PDD), it is agreed upon that a TUR-B alone is not adequate treatment. In such cases, local immunological treatment with BCG instillation in the bladder is recommended. For primary Tis, there is an 80% cancer reduction (normal cytology) after BCG instillation. If pT ≥ 2 or if a WHO grade 3 is present regardless of T-stage, additional treatment should be discussed and planned for.  

YAG laser

Laser destruction of superficial tumors can be performed as an alternative to TUR-B or electrocoagulation. The advantage of laser is that cells are destroyed deeper into the tissue. The disadvantage is that a pathology assessement of the radicality of the treatment cannot be performed. 

Radical cystectomy

If the tumor infiltrates the bladder wall musculature (pT ≥ 2) and TUR-B is the only treatment, experience shows that the prognosis will be poor. In most cases, a radical cystectomy with urine diversion is recommended. This operation is a mutilating surgery, and in elderly patients with a statistically short expected survival time and solitary tumor, a bladder resection can be chosen as suboptimal treatment, possibly in combination with radiation therapy. Significant contraindications against a cystectomy should be present to choose organ-sparing surgery in case of a muscle-infiltrating tumor.

In principle, a radical cystectomy with regional lymphadnectomy is the correct treatment for muscle-infiltrating urothelial cancer of the urinary bladder. This treatment should also be considered for superficial high risk cancers (multifocal WHO grade 3, possibly combined with CIS).

During a radical cystectomy on a man, the following organs are removed: the urinary bladder, prostate, vesicles, and distal ureters en bloc. In women, the following are removed: the bladder, distal ureters, urethra, uterus, and anterior vaginal wall. In postmenopausal or menopausal women, the ovaries are also removed. 

Principles for urinary diversion

There exist different methods for urinary diversion, ranging from a simple pyelostomy to complicated continent diversions. A clear goal for the choice of method must be that later urine collection must occur in a safe way that is easily maintained and will protect the kidneys. 

  • A pyelostomy catheter/cutaneous ureterostomy are very simple diversions. They are simple to carry out, but not much protective of the kidneys, and should therefore only by chosen as palliative treatment in patients with short expected survival, or with severe contraindications against safer alternatives. 
  • Cutaneous ureterileostomy ad modum Bricker is a simple diversion of urine and protects the kidneys. For the patient, the diversion is compatible with a good quality of life, as long as the surgeon constructs a nipple that functions well.
  • To avoid external collection into a urostomy bag, different methods for intraabdominal collection of urine have been developed over the years. Many different variations have been attempted including use of the small intestine (Studer) and large intestine (Lundiana). All of the methods are encumbered with a significant re-operation frequency. Therefore, these procedures should be used on patients with favorable prognoses. Such procedures should preferably not be used in patients who have previously irradiation to the pelvis/abdomen. 
  • An orthotopic bladder is a reconstructed bladder using tissue from either the large intestine or small intestine, which is connected to the urethra where it empties, either by abdominal pressure or using a catheter. There are multiple techniques for constructing an orthotopic bladder including Studer.   

The surgeon must always keep in mind the patient's quality of life and kidney function when choosing a method for urinary diversion. If the patient must be on dialysis after 5-20 years, the method of choice was not optimal.

Contraindications for continent urostomy and bladder substitution 

  • Neurological disease (must have help for catheterization)
  • Psychiatric disease
  • Short survival expectancy
  • Reduced kidney and liver function
  • Chronic diarrhea and malabsorption conditions
  • Previous irradiation of pelvis/abdomen
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