Endoscopic
surgery
It
is not acceptable to take a tiny biopsy from the top of a papillary tumour and
apply a fulgurating coagulation current to the rest unless
a small recurrence is being dealt with. The tumour should be carefully resected
in layers using a resectoscope. The base of the tumour is sent separately for
histological examination. Small biopsies are taken near to and distant from
the primary lesion to diagnose unsuspected cis. After removal of the tumour, two
or three further loops of tissue from the base should be sent separately so that
the pathologist can accurately determine whether there is lamina propria or
muscle invasion. The base of the tumour is then coagulated, so achieving
haemostasis. The appearance of pale yellow glistening fat will indicate a
perforation of the bladder. Should this occur before the resection is complete,
it may be prudent to stop the resection and place a catheter in the bladder for
a few days. In this instance
the procedure could be completed some 2 weeks later. The bimanual
examination is repeated at the end of each endoscopic procedure.
Patients
with solid tumours should have adequate material resected for histological
staging and grading. These patients will usually need some other form of
treatment. It is likely that a debulking resection of these tumours is helpful
prior to radiotherapy. Following these procedures an irrigating catheter is left
in situ for 48 hours to prevent clot retention of urine. There is good
evidence that a single dose of mitomycin C (40 mg in 60 ml of fluid)
instilled into the bladder prior to catheter removal decreases the risks of
recurrence in patients with pTa, PT1 grade 1 and 2 disease.
Follow-up.
Most urologists agree that patients with a single, low- or medium-grade pTa
tumour can safely be treated by resection alone and followed up by means of
regular cystoscopies.
The
treatment of patients with multiple low- or medium-grade pTa tumour can be by
either means of resection alone or resection followed by a 6-week course of
intravesical chemotherapy with mitomycin C, adriamycin or epirubicin.
The
treatment of pTl disease is difficult. Many urologists, including many North
American and European urologists, would offer immediate cystectomy to a patient
with a high-grade pTl tumour — particularly if it was multiple or accompanied
by cis, because of the 30—50 per cent risk of progression to muscle invasion.
Others will treat such patients by means of endoscopic treatment followed by
intravesical immunotherapy with intravesical bacille Calmette—Guérin (BCG)
— although there is no firm evidence that this decreases the risk of
progression. The treatment of solitary medium-grade pTl disease remains
uncertain, but a reasonable approach would be endoscopic resection followed
re-resection of the area in 6 weeks followed by intravesical chemotherapy with
BCG.
Follow-up cystoscopies are essential; they may be carried out by means of local anaesthesia with a flexible cystoscope on by means of general anaesthesia if the urologist feels that the patient has a high risk of recurrence. They should initially be performed at 3-monthly intervals over the year; following this the time interval between cystoscopies can be determined according to the presence or absence of further disease. Thirty per cent of patients will never develop another tumour, so that after 2 years if the bladder has remained clear annual inspection may be adequate. For patients who go on to develop multiple recurrences within the bladder at each examination, the cystoscopies need to be maintained at frequent intervals so that the growths can be resected. These patients are at a greater risk from developing progression of their disease; whilst intravesical chemotherapy can decrease the recurrence rate, no reduction in progression rates has been found.
Intravesical
chemotherapy and immunotherapy
Various agents have been used. These include thiotepa (which may be
absorbed because of its low molecular weight and cause blood dyscrasias),
mitomycin C, epirubicin and adriamycin. They are of equal efficacy and the
cheapest should be chosen. They are administered by means of a urethral catheter
and held in the bladder for 1 hour, the patients are turned from side to side
and try to hold their urine for as long as possible. Usually the patients are
treated weekly for 8—10 weeks and then re-cystoscoped. BCG is now frequently
used as intravesical immunotherapy. It carries a greater risk of local side
effects such as ‘cystitis-like’ symptoms and also risks of systemic side
effects — including systemic BCGosis. Nevertheless, it is probably more
effective than intravesical chemotherapy and is the treatment of
choice for cis. Currently, ‘booster’ doses of maintenance BCG
treatment are being given in addition to the initial 6-week course.
Open
surgical excision
This should be totally avoided. If by some error a bladder containing a
tumour is entered, then the tumour may be removed with a diathermy needle and
the base coagulated and the bladder closed. Postoperative radiotherapy to the
wound will diminish the chance of tumour implantation.
Invasive
tumours
The treatment of cancer with proven muscle invasion remains a subject
for debate. Whatever the modality of treatment employed, few centres have 5-year
survival figures of more than 40 per cent. The controversy is centred around
whether primary surgery (radical cystectomy), radical radiotherapy, or a
combination of the two, provides the best result. There is a move towards
primary surgical treatment in most centres. The use of systemic chemotherapy by
means of a combination of agents using cis-platinum, methotrexate, adriamycin
and vinblastine (MVAC) in addition to conventional treatment is presently being
studied. -
Radiotherapy
Deep external beam X-ray therapy. External beam radiotherapy is usually
given by means of high-powered linear accelerators. Radical radiotherapy giving
60 Gy over a 4—6-week period will produce a 40—50 per cent complete
response. The difficulty with radiotherapy is in patients who do not respond at
all or those who have a partial response, having a bladder with pTa or pTl
tumour in it, and who are subject to recurrence. Patients with residual disease
after radiotherapy should be offered ‘salvage cystectomy’ if they are fit.
The protagonists of radiotherapy would claim that for most patients it saves the
need to remove the bladder and allows men to retain potency. Radiotherapy is not
always without complications, and during the course of treatment will cause
urinary frequency and also diarrhoea. Late complications can leave the bladder
contracted and fibrosed, in which case the bladder may need to be removed for
palliative reasons. Late complications affecting the rectum should be uncommon,
especially if lateral fields of irradiation are employed.
Local
radiotherapy. For small invasive lesions, local radiotherapy can be delivered by
open placement of a radioactive tantalum wire (iB2Ta) or iridium wire
or the implantation of gold grains (t98Au). It is used infrequently
today.
Surgery
Partial cystectomy. This should be limited to the treatment of small
adenocarcinomas of the bladder.
Radical
cystectomy and pelvic lymphadenectomy. This is now standard treatment for
localised pT2—pT3 disease without evidence of secondary spread or of cis
which has nor responded to BCG. Before contemplating radical surgery to remove
the bladder, it is important to have evidence that surgical cure is attainable.
A CT scan of the pelvis may over-stage the bladder if a recent resection has
been carried out, although the finding of grossly enlarged pelvic, iliac or para
aortic
nodes on liver metastases will alter the decision for cystectomy. A bone scan
[technetium-99m (S9mTc)] will help to show whether there is spread to
bone.
Operation
Alternative
drainage for the urine is necessary following removal of the bladder. The
standard procedure is to perform an ileal conduit. Patients should be counselled
about the onset of erectile impotence and absent ejaculation following the
operation; they should also be told about alternative forms of urinary diversion
which include continent urinary diversions and orthotopic bladder replacement.
Patients
should be seen by a stoma care therapist who will help to advise the patient and
will try different ileostomy bags to ensure that the correct site is chosen
avoiding skin creases so that one does not end up with the disaster of a leaking
urinary ileostomy. A decision is made about whether the male urethra is to be
removed (depending on the estimated risk of recurrence within the urethra); a
urethrectomy is usually indicated in patients with primary cis or those with
tumour invading the prostate stroma. Many surgeons are now offering total
replacement of the bladder after cystectomy (Fig.
65.53).
Preoperatively,
the bowel is prepared with a balanced solution of polyethylene glycol (Golytely
or Kleanprep). The patient should receive prophylactic antibiotics including
metronidazole, cefuroxime and amoxycillin, and low-dose heparin.
The
abdomen is opened through a long lower midline incision extending down to the
symphysis pubis. The liver and the retroperitoneum are checked for evidence of
metastases and the operability of the bladder is assessed. A bilateral pelvic
lymphadenectomy is performed removing external iliac nodes, internal iliac nodes
and the nodes in the obturator fossae. The vessels passing to the bladder from
the side wall are ligated in continuity; these include the obliterated
hypogastric vessels, the superior vesical artery, the middle vesical veins, and
the inferior vesical arteries and veins. The ureters are then divided. The
posterior ligaments extending from the pararectal area to the back of the
bladder are ligated and divided, and the layer posterior to Denonvillier’s
fascia is opened up. The endopelvic fascia is then divided on each side and the
puboprostatic ligaments are divided. A ligature is passed between the dorsal
vein complex and the urethra, and the former is ligated and divided. The urethra
is then mobilised and divided. The ligaments lateral to the prostate are divided
and the bladder is removed. In women, the uterus and anterior vaginal wall need
to be included. Women must be counselled about the loss of ovarian and
uterine function. -
An
isolated loop of ileum is then prepared on its own mesentery, and continuity of
the small bowel restored. The ureters are then implanted into the bowel and the
ileostomy is created. Meticulous care must be taken to close all mesenteric
windows, thus avoiding internal hernias. If the bladder is to be replaced
orthotopically, a reservoir made from detubularised bowel (usually an ileocaecal
segment or ileum) is created and anastomosed to the urethra after implantation
of the ureters.
The
operative mortality associated with cystectomy used to be considerable, but
should be in the order of 2 per cent. Late complications include urethral
recurrence (about 5—8 per cent) which is increased in the presence of
multifocal tumours, cis and, particularly, invasion of prostatic stroma (Fig.
65.54).
Leukoplakia
This condition is simply squamous metaplasia of the bladder. Profuse production of keratin may result in the passing of white particles in the urine. It cannot be treated easily. Localised areas may be resected endoscopically. Diffuse leucoplakia of the bladder is premalignant and results in squamous bladder cancer. Careful cystoscopic assessment is required. The condition may require cystectomy.
Endometriosis
Endometriosis within the bladder wall is rare, but can have the
appearance of a vascular bladder tumour or a tumour which contains chocolate-coloured
or bluish cysts. The swelling enlarges and bleeds during menstruation. If
medical management fails, by means of danazol or luteinising hormone-releasing
agonists (LHRH), further treatment is usually by means of partial cystectomy or
full-thickness endoscopic resection, depending on its site. The condition may be
part of more widespread disease. Endometriosis is also a cause of ureteric
stricture.