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Radical cystectomy with construction of orthotopic bladder substitution ad modum Studer


Medical editor Bjørn Brennhovd MD
Urologist

Oslo University Hospital

General

A radical cystectomy is standard treatment for muscle infiltrating urothelial cancer in the bladder. This operation is also relevant for certain high risk groups of superficial tumors.  

Orthotopic bladder substitute

An orthotopic reconstruction using intestinal tissue connected to the urethra has been implemented mostly on male patients, but in later years, the operation has been increasingly used on female patients. The reconstruction is performed using a 50-60 cm long isolated intestinal segment. The intestinal reservoir is emptied using abdominal pressure, relaxation of the pelvic floor, or intermittent catheterization. The majority of patients will experience encumbant nighttime incontinence and lacking or incomplete emptying. In the long term, many develop difficulties emptying the bladder and require self catheterization.  

Contraindications for an orthotopic bladder substitution are tumor involvement of the prosthatic urethra, extenstive Tis, high preoperative radiation dose to the pelvis, and longer urethral strictures. A bladder substitution is contraindicated if the patient is not willing to accept that self catheterization may be necessary as well as the risk of urinary incontinence.

Indications

The indications for a radical cystectomy are: 

  • T1 tumor with deep infiltration of lamina propria
  • T1 tumors with accompanying carcinoma in situ
  • Extensive T1 tumors
  • Recurring T1 tumors
  • Muscle-infiltrating urothelial cancer without detectable lymph node metastasis or distant metastasis 

Goal

  • Curative treatment

Equipment

  • Surgical laparotomy tray
  • Bookwalters retractor 
  • Pigtail catheters Ch. 7–9, x 2
  • Optionally robot



Preparation

  • Antibiotic prophylactic
  • Thrombosis prophylactic
  • Preoperative hair removal for abdominal incision

Preoperative preparation in the operating theatre

  • Operating table appropriate for patient and type of surgery
    • Men: square drape, penis free
    • Women: back/leg supports
  • Diathermy
  • Suction
  • Installation of catheter

Implementation

  • The abdominal cavity is opened using a long midline incision, or the operation is performed with a robot with removal of the urinary bladder and lymph nodes before urinary diversion.  
  • The bowels are displaced cranially.
  • The ureters are identified on both sides and clamped towards the bladder.
  • Biopsies of both ureters are sent for frozen sectioning.
  • The peritoneum is opened around the bladder.
  • Proceed to the midline and identify the layer between the bladder and the rectum.
  • The vesicle arteries are clamped and divided.
  • Proceed to the front and open the endopelvic fascia.

Removal of the primary specimen 

  • In men, the neurovascular bundle is cut on both sides of the prostate using a sharp scissors, and the nerves are spared as much as possible to preserve erectile function.  
  • In women, the length of the vagina is spared as much as possible.
  • Proceed back to the urinary bladder. Maintain a good margin until the specimen is removed. 
  • Take a biopsy of the urethra and put it in formalin.

Iliacal bilateral lymph node dissection

  • First, empty the obturator space bilaterally.
  • Proceed in front of and lateral to the iliacal vessels out towards the ilioinguinal nerve. 
  • Isolate the internal and common iliac arteries up to the level of the aortic bifurcation. 

Construction of the reservoir (ad modum Studer)

  • Tunnel the left ureter and attach it the right.
  • Isolate about 55 cm of distal small intestine. The anal division should be about 30 cm from the coecal opening. 
  • First, split the mesentery at the anal end of the instestinal segment.
  • Measure the correct length.
  • Split the mesentery at the oral end before the bowel is closed and divided at both ends with a suture apparatus. 
  • Restore the intestinal continuity with side-to-side anastomosis with a suture apparatus.
  • Invaginate the clips with suture.
  • Attach the ureters to the isolated intestinal segment and insert pigtail catheters to the renal pelvis on both sides.
  • Invaginate 45 cm (distale) of the removed intestinal segment.
  • Construct a reservoir ad modum Studer with continuous sutures.
  • Prepare an anastomosis between the urethral stump and the most caudal point of the reservoir with interrupted sutures over a Foley catheter nr. 18. 
  • Test the anastomosis for possible leakage using a 60 ml syringe with sodium chloride 9 mg/ml.
  • Insert a drain in the abdomen and lay the pigtail catheters out.
  • Close the abdominal cavity with monofilament continuous sutures.

Follow-up

  • Remove pigtail catheter to the kidneys after 10 days
  • Foley catheter is removed after three weeks 

The patient should be trained for self-catheterization before being discharged.

Follow-up

The risk of tumor progression after a radical cystectomy depends very much on the histopathological T stage. The risk gradually increases with tumor stage.

Recommended follow-up routines

A follow-up by a specialist should be performed 3 and 6 months after the operation. Thereafter, the patient should be monitored every 6 months for a period of 5 years. After 5 years, further follow-up can be done by a primary care doctor.

Evaluation should include:

  • Physical examination with palpation of the abdomen and transrectal exploration.
  • Blood tests: Hb, creatinine, ALP, venous acid-base determination (should be followed closely for tendency of elevated creatinine), vitamin B12 (should be followed from 2 years)
  • Thoracic X-ray (after 2 years, once annually)
  • CT urography is performed after 3 months and 1 year. If these are satisfactory, CT urography is done later upon indication (hematuria, clinical UVI, flank pain). Somewhat more liberal CT urography is performed for Tis. For monitoring of hydronephrosis, ultrasound of the kidneys is an alternative. 
  • Endoscopy of urethra and bladder substitute should be performed once annually and possibly supplemented with "wash cytology". 
  • Measurement of residual urine in bladder substitute.
  • Endoscopy of remaining urethra in risk patients once annually if a urethraectomy was not performed.

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