Disease Characteristics. Blaaskanker. Blaaskanker. Blaaskanker. Blaaskanker UROBEL

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1 Bricker - Vervangblaas Disease Characteristics Steven Joniau Hein Van Poppel UZ Gasthuisberg KU Leuven Cancer Prostatic urethral disease Locally advanced / nodal disease Low tumours in women Urethrectomy / anterior exenteration Inflammatory TB, Radiotherapy, Interstitial Cystitis IS THE URETHRA AVAILABLE? UROBEL Blaaskanker Algemene informatie en epidemiologie > 90% TCC (Transitioneel Cel Carcinoma) 70-80% oppervlakkig, 20-30% invasief bij eerste diagnose Man/vrouw = 3/1 Etiologie Blaaskanker Roken: 50% van TCC bij man, 31 % van TCC bij vrouw Toxines Chronische irritatie Diagnose en stagering Blaaskanker Hematurie of irritatieve mictie zonder UWI Echografie IVP Cystoscopie (CT) (Botscan) Diagnose en stagering Blaaskanker TNM classificatie WHO differentiatie graden

2 Behandeling Blaaskanker Oppervlakkige tumoren TURBlaas Eventueel aanvullend chemostatischeinstillaties (MMC, Epirubicine, BCG ) Carcinoma in Situ BCG-instillaties Cystectomie Blaaskanker Invasieve tumoren Blaaskanker Cystoprostatectomie/voorste exenteratie Aanleggen van Bricker-stoma Neo-blaas Bladder Cancer Second urinary-tract neoplasm Fourth killer by cancer Nasty neoplasm when invasive disease Around 12,000 deaths in Europe per year! Bij ingroei in omliggende organen, lymfeklieraantasting of metastasen: chemotherapie Populations at risk for TCC Long-term tobacco use Analgesic use Pelvic irradiation Cyclophosphamide Occupational exposure (aniline dyes and aromatic amines)! Familial history

3 New cases of bladder cancer: Percentage of invasive disease Superficial bladder cancer Years % invasive disease 27% 29% 130,000 new cases per year observed in the US and 5 European Union countries Lifetime cost per patient of 58,000 Euros (twice the amount or lung cancer) 2 million related cystoscopies, endoscopic resections and instillation cycles per year! % Lamm et al Superficial bladder cancer Two distinct forms of so-called "superficial papillary" urothelial cancers coexist. 1. Ta is associated with a high rate of recurrence (50 to 75%) but little likelihood of progression (< 5%) - CATS 2. Higher-grade papillary tumors which infiltrate the lamina propria (T1) often associated with cis with a substantially higher likelihood of progression (30 to 50%) -TIGERS Both forms initially develop in a form that is confined to the mucosa but express very different behavioral patterns. Bladder cancer:diagnosis Diagnosis Cystoscopy TUR BT Histological Analysis Post TURBT cytology Cystoscopy TUR BT Histological Analysis Post TURBT cytology Diagnosis 3 Month Review Cystoscopy 3 Month Review Cystoscopy

4 A good TURBT is of utmost importance Good anesthesia!! Excellent equipment Good lens (30-70 sometimes 110 ) Maintain bladder not overdistended Hemostasis is critical Plan the procedure upfront Video and review your own resections! Superficial TCC: Risk Stratification Low Risk pta Small (<3cms Grade 1-2 High Risk Any Grade 3 pt1 CIS Intermediate Risk The rest Bladder Cancer:Staging Invasive bladder cancer staging IMAGING Radical Cystectomy for Invasive Bladder Cancer: Long-Term Results Stein et al., J. Clin. Oncol., 19: 666, patients Radical cystectomy Median follow-up: 10 yrs Recurrence free survival (10 yrs): Organ confined -82% Extravesical -58% Lymph node (+) -34%

5 Disease Characteristics Cancer Prostatic urethral disease Locally advanced / nodal disease Low tumours in women Urethrectomy / anterior exenteration Inflammatory TB, Radiotherapy, Interstitial Cystitis IS THE URETHRA AVAILABLE? PAINFUL BLADDER /IC Supratrigonal Substitution Van Ophoven series > 10 patients. N = 148 Success in 55-83% Beware; trigonal disease urethral pain capacity > 300 mls neuropathic pain NEUROPATHY Priorities in Neuropathy Maintenance of renal function The context of disease

6 Radical cystectomy Radical cystectomy Male: radical cystoprostatectomy ± urethrectomy Female: anterior exenteration (hysterectomy, ovariectomy, anterior colpectomy and cystourethrectomy Both: lymph node dissection Note: - nerve sparing cystoprostatectomy - prostate sparing cystectomy? Indications for cystectomy 1. TCC = T2 GI-III T1GIII and TIS failing BCG (Ta failing endoscopic treatment) 2. Primary adenocarcinoma Squamous cell carcinoma Bladder sarcoma 3. Salvage cystectomy: relapse after RT 4. Palliative cystectomy: - local symptoms (even in M+ pts) - non-functioning bladder after TUR, instillation, RT

7 Lymphadenectomy in bladder cancer Routinely combined with radical cystectomy Provides important informations for prognosis Help identify patients in need of adjuvant therapy But how extensive? Pelvic Iliac Lymphadenectomy Pelvic Iliac Lymphadenectomy 2 cm above aortic bifurcation Pelvic Iliac Lymphadenectomy 2 cm above aortic bifurcation Genitofemoral nerve

8 Pelvic Iliac Lymphadenectomy 2 cm above aortic bifurcation Pelvic Iliac Lymphadenectomy 2 cm above aortic bifurcation Lymph node of Cloquet Lymph node of Cloquet * * Genitofemoral nerve Genitofemoral nerve Obturatorfossa Pelvic Iliac Lymphadenectomy 2 cm above aortic bifurcation Morbidity of extended lymph node * Lymph node of Cloquet Bern: 2.4% Leissners: 2% UCLA: 1.1% Genitofemoral nerve Obturatorfossa Presacral lymph nodes Indications for urethrectomy TIS Multifocal TCC Bladder neck TCC Upper tract TCC Prostatic TCC - mucosa - duct - STROMA Management of the urethra 1. Cutaneous diversion - simultaneous urethrectomy (perineal or prepubic) 2. Orthotopic bladder replacement - frozen section of margin Management of the ureter Frozen section is standard but not proven benefit

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10 Early complications 1. Mortality 1-2% 2. Morbidity of cystectomy - hemorrhage - rectal injury - major vascular injury 3. Morbidity of diversion - bowel obstruction - intestinal fistula - urinary fistula 4. Morbidity of surgery - pulmonary embolism, cardiac problems Urinary diversion Ideal 1. Easy to perform with minimal morbidity-mortality 2. Protect the upper tract 3. Well perceived by the patient Urinary diversion External - incontinent: conduit - continent: umbilical or abdominal Internal - ureterosigmoidostomy - bladder replacement

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12 Ileum conduit (Bricker) Easiest and least complicated diversion Stomal problems: peristomitis, hernia, stenosis Deterioration of upper tracts - When urethrectomy is mandatory - Less fit patients

13 Ureterosigmoidostomy Coffey, Goodwin, Mainz Upper tract deterioration Metabolic disorders Colon adenocarcinoma Anal problems

14 Reservoir diversions Bladder replacement Continent stoma Ileum, colon, ileocaecal Detubularisation Confection of pouch Connection to the urethra to the skin (continence mechanism) Implantation of the ureter. Leduc Hautmann. Studer

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18 Reservoir diversions More complications Upper tract deterioration Electrolyte disturbances Diarrhea Lithiasis

19 Bladder replacement Advantages - voiding through natural urethra - better QoL Disadvantages - (incontinence) - hypercontinence - enuresis nocturna

20 Continent stoma Advantages: - no bag - better QoL? Disadvantages: - autocatheterisation - leakage - catheterisation difficulties - reoperations 10% Patient related factors determining the choice of diversion type 1. Age 2. Preference (body image) 3. Intelligence and dexterity 4. Compliance to adjuvant medical therapies 5. Sexual, sportive and social activities Medical factors determining the choice of diversion type 1. Cancer stage 2. Antecedents: intestinal diseases previous RT or surgery 3. Kidney function 4. Natural sphincteric function Urologist s preference and competence

21 What type of diversion after CEC for bladder cancer? Whenever possible and feasible: bl. replacement NOT: - poor performance status - TCC in prostate stroma When urethrectomy mandatory: cutaneous diversion - conduit: most pts - continent stoma: selected pts by experienced urologists Invasive bladder cancer. Surgery and combination therapy Radical cystectomy is the mainstay of invasive bladder cancer treatment Lymph node dissection is part of radical cystectomy Urethrectomy is mandatory when the prostate is invaded Diversion type must be individualized Combination and alternative treatments need further exploration Reconstructions in UK (n = 1691 cystectomies) Neobladders Median 4 pa Continent Diversion Median 3 pa Ileal conduits Median 10 pa 699 Office of National Statistics BAUS Section of Female and Reconstructive Urology Yong et al 2002 / 2004 Yong et al 2002 / 2004 Comparison of Ileal Conduit to Orthotopic Bladder and Cont Diversion Early complications Upper tract preservation UTI Quality of Life 18 trials 2 RCTs addressing selected criteria 1 RCT no numbers! 2 RCTs addressing unselected criteria 13 non randomised trials

22 Yong et al 2002 / 2004 Quality of Life Neobladder v Conduit 18 trials Author Year N Outcome 2 RCTs addressing selected criteria 1 RCT no numbers! 2 RCTs addressing unselected criteria 13 non randomised trials Mansson Bjerre McGuire Fujisawa NS NS Better NS Hobisch Better No differences found! Protogerou NS Better sex QOL (Hobisch2001 Sem Urol Onc ) Continence? Orthotopic Conduit 75% 33% Felt safe 1.5% 48% Wet clothes 97% 36% Recommend to friend Daytime Continence Nocturnal continence Rate Author N Rate Author N 96% Hautmann % Hautman % Verleyen 51 80% Verleyen 51 94% Abol Enein % Abol Enein % Chen 20 88% Chen 20 67% Lee % Lee 130

23 QOL. Continent Diversion Conclusions Author Gerharz Kitamura Hardt Year N Op CD/IC CD/IC/NB CD/IC Outcome Better NS Better The evidence is weak - however Some advantages to neobladder Complications are early for neobladders and late for ileal conduit Choice of pouch makes little difference Continent diversion has high complication rates in best hands Mainz 2 Rectosigmoid pouch is a viable alternative Cystectomy and substitution still has a role for painful bladder syndrome Hart CD/IC/NB NS Guidance Blaasaugmentatie en Continente Stomata Surgeon must be able to perform full range of reconstructive techniques But ought to stick to the one he knows best Must know own outcomes Should be encouraged to take part in group audit or research Steven Joniau UZ Gasthuisberg KU Leuven UROBEL Indicaties voor augmentatie Indicaties en technieken van blaasaugmentatie Doel van de ingreep: LAGE DRUK RESERVOIR VOLUME Indicaties Therapieresistente detrusoroveractiviteit Schrompelblaas undiversion

24 Reservoir problemen Reservoir problemen Persiterend hoge drukken initieel door denervatie darm lagere drukgolvenin ileum, hogere drukgolven in colon correcte reconfiguratie als preventie Metabole problemen door ionentransport colon>ileum milde metabole acidose R/ bicarbonaat geen continent reservoir bij GFR <40-50ml/min Belang van detubulariseren Belang van detubulariseren Lage druk tijdens blaasvulling en volume afhankelijk van gebruikte lengte en configuratie Bolvorm W-vorm S-vorm U-vorm Niet gedetubulariseerd Belang van residuele detrusoroveractiviteit Oplossingen voor residuele detrusoroveractiviteit

25 Gouden standaard: Clam cystoplastie Indicaties en technieken van continente stomata Bramble 1982 Continentiemechanismen Outlet -problemen Flap Valve Nipple Valve Flap-valve technieken Incontinentie revisie en reïmplantatie bulking agents? Catheterisatieproblemen stenose richting dundarmplooien bv. bij tapered ileum Nipple valve technieken Incontinentie slipping van de instulping Catheterisatieproblemen richting dundarmplooien instulping steenvorming op sutuurmateriaal Outlet -problemen A. Mitrofanoff Continent appendico-vesicostomie Kinderen Neurogeen blaaslijden 1980 Serie 17 patienten

26 Eenvoudige procedure F.U. 20 jaar Continentie : % Stenose : 7 24 % B. Yang-Monti TRANSV. GEMODELL. ILEUM Yang Monti stoma Continent stoma CIC 1997 Ileo-vesicostomie Getubulariseerd ileum Flap valve Navel / re fossa Historiek Serie Resultaten Besluit TRANSV. GEMODELL. ILEUM Goede 2de optie > blaasaugmentatie Continentie ratio s Complicatie ratio s TRANSV. GEMODELL. ILEUM Full Monti Chapple modification THE FULL MONTY

27 TRANSV. GEMODELL. ILEUM Full Monti Chapple modification TRANSV. GEMODELL. ILEUM Full Monti Chapple modification TRANSV. GEMODELL. ILEUM TRANSV. GEMODELL. ILEUM Full Monti Chapple modification Resultaten Mitrofanoff / Monti C. Alternatieven Kinderen : succes! Perfecte continentie Weinig complicaties VOLWASSENEN? URETER Origineel Mitrofanoff Meer stenosen

28 GETUBULARISEERDE BLAAS Grote blaascapaciteit GETUBULARISEERDE MAAG Na RT in kleine bekken Geen ileo-caecaal segment Huid irritatie LONG. GEMODELL. ILEUM 6 10 cm terminaal ileum Minder continent CIC problemen II. SERIE A. Wie? Sedert patienten 18 vrouwen / 7 mannen jaar ( gem. 43 jaar) F.U. : 2 m 65 m ( gem. 2 jaar 5 maand). A. Wie? B. Wat? 6 dwarslaesie 5 MS 4 spina bifida 2 Fowler 2 rec. gynaec. Ca 2 ideopathische 1 DM neuropathie 1 na HRT. 1 chondrosarcoma 1 CNI (urethraklep) 5 appendico-vesicostomie (Mitrofanoff) 5 single Monti 14 Full-Monti 1 vesicostomie met blaaslapje

29 B. Wat? + 14 ileale blaasaugmentatie + 3 MACE + 2 sluiten BH III. RESULTATEN A. Continentie Droog : 17 / 25 ( 68 %) Man : 57 % Vrouw : 72 % B. Stenose 4 / 25 (16 %) C. Revisies OPEN INGREPEN : 13 / 25 ( 52 %) 7 x afbraak Monti (4 x Bricker) 5 x revisie Monti (2 x fundiplicatio ) C. Revisies OPEN INGREPEN : 13 / 25 ( 52 %) C. Revisies MINIMALE INGREPEN : 5 / 25 ( 20 %) 2 dilatatie Monti voor stenose 1 lasering Monti voor poliepje 2 TVT

30 8 voor lekkage 3 voor stenosen C. Revisies Concept : mooi IV. BESLUIT Voordelen patient : evident Chirurgie : mooi, plezant Ideale pnt : droog, patent, geen compl. : 7/25 ( 28 %) IV. BESLUIT Patient, arts : fit and forget procedure Complicaties Continentie Goede follow-up Patient begeleiding! >> volwassenen Historiek Serie Film Serie Film Besluit