Overview
In the United States, there are 60,000 new cases of bladder cancer each year, 25% of which have infiltrated the bladder muscle at the time the patient is seen, while the remaining 75% have more superficial lesions, but 10-15% of this group of patients also develop invasive cancer. In Europe and the United States, bladder cancer is the 4th most common tumor in men and the 8th most common tumor leading to death; it is the 8th most common tumor in women and the 10th most common tumor leading to death. In China, bladder cancer is also the most common genitourinary tumor. Bladder cancer ranks 8th in men in China and after 12th in women. The standardized incidence rate: 6.7/100,000 for men and 2.7/100,000 for women.
For muscle invasive bladder cancer with regional lymph node metastasis, it is possible to be cured if treated promptly and appropriately. Some patients have superficial but highly invasive bladder cancer and may eventually die from metastases despite total bladder removal surgery. In situ neobladder surgery is feasible for most patients who must have their bladder removed, whether male or female. Patients with in situ neobladder have a relatively high quality of life; therefore, for some patients with highly invasive superficial bladder cancer, total cystectomy is a reasonable option that is not limited to conservative therapies.
Smoking ranks first among the risk factors for bladder cancer, including secondhand smoke. There are a number of occupations that require long-term exposure to chemicals containing aromatic hydrocarbons, which also increase the risk of bladder cancer, typically in the dye, leather, paint and aluminum industries. Other risk factors include specific drugs, especially cyclophosphamide. A recent epidemiological survey showed that the use of hair dyes (especially for hairdressers) is a risk factor for the development of bladder cancer. The staging, treatment and prognosis of bladder cancer depend on the depth of bladder infiltration. At the time of diagnosis, 75% of bladder cancers are superficially located (invading only the mucosal layer of the bladder surface), and most of these patients have a low risk of tumor progression and metastasis. However, in about 25% of patients, the bladder cancer has already infiltrated the muscular layer of the bladder at the time of the first visit, and the ideal treatment is complete removal of the bladder and surrounding lymph nodes, i.e., radical cystectomy combined with expanded lymph node dissection.
We also have considerable experience in urinary tract reconstruction and can offer all forms of urinary diversion for patients to choose from. The large number of cases not only gives us a high level of surgical expertise, but also provides us with a large number of samples to study the biological characteristics of the tumor. At BYUH, we have urologists, radiologists, oncologists and pathologists in the treatment of bladder cancer, allowing for multidisciplinary collaboration to provide comprehensive care.
In addition, we are convinced that enough time should be spent with patients and their families to discuss the diagnosis of their cancer and the treatment options available to them. This is because the support of the family is very important in the choice of treatment decisions. When presenting the patient with their condition, we not only draw on imaging data, but also bring out anatomical atlases and explain the extent of the lesion in detail. We believe that the patient’s understanding of urinary tract reconstruction is the key to the success of the reconstructive surgery. It is also important for patients to understand the complications and side effects of each method, which is the only way to guarantee the patient’s right to informed consent.
Types of bladder cancer
There are 3 main pathological types of bladder cancer: metastatic cell carcinoma (over 90%); squamous cell carcinoma (3-8%), where schistosomiasis, chronic infection and inflammation are risk factors for the development of squamous carcinoma; and adenocarcinoma (1-2%), which has a morphology very close to intestinal tumors and therefore needs to be differentiated from intestinal metastases. Both squamous and adenocarcinoma show almost invasive growth at the time of diagnosis. The prognosis of adenocarcinoma is worse than that of metastatic cell carcinoma. Neuroendocrine tumors of the bladder are rare, accounting for 1% of cases, and are histologically differentiated between large cell and small cell, with a mixture of both in half of cases; even with aggressive surgical treatment and chemotherapy, the prognosis is poor.
Staging of bladder cancer
The staging of bladder cancer depends mainly on the specimen obtained at TURBT (transurethral resection of bladder tumor). Treatment options depend on the malignancy of the tumor (pathologic grading) and the level of bladder invasion (pathologic staging). In order to determine the presence of muscle infiltration, the muscle below the base of the tumor must be accessed during resection. What we often call “superficial” or non-invasive bladder cancer occurs in the mucosal layer (or innermost layer) of the bladder wall and can usually be completely removed by TURBT.
The picture shows superficial bladder cancer
If the tumor invades the connective tissue below the mucosal layer, the lamina propria (stage T1), then special attention is needed, as 30% of these tumors will reveal a muscular infiltrate upon re-excision. Intravesical perfusion chemotherapy can be used as long as there is sufficient myxoid tissue in the specimen to confirm the absence of myxoid infiltration. The gold standard of treatment for bladder cancer with muscle infiltration is radical cystectomy as opposed to bladder cancer without muscle infiltration, which is completely different. Radical cystectomy provides accurate staging of bladder cancer and tumor-associated regional lymph node conditions with the best local tumor control and long-term tumor-free survival; it also helps to accurately assess the risk and the need for adjuvant chemotherapy. Chemotherapy and radiation therapy are primarily used to treat patients who have been lost to surgery.
Surgical treatment
For high-grade invasive bladder cancer, the standard treatment is radical bladder resection plus bilateral pelvic and iliac vascular lymph node dissection. Most studies have shown that for muscle-invasive bladder cancer, bladder-preserving treatments (transurethral electrodesiccation, chemotherapy, and radiation therapy) are less effective than radical cystectomy in terms of local recurrence and survival. With improvements in surgical techniques and postoperative treatment measures, surgical mortality and complications (e.g., sexual dysfunction) have decreased significantly. Male patients require complete removal of the bladder, prostate, seminal vesicles, and pelvic lymph nodes. For female patients, traditional radical cystectomy (or anterior pelvic organ resection) requires complete removal of the bladder, uterus, fallopian tubes, ovaries and anterior vaginal wall and is still required for some patients. In contrast, some patients can have their pelvic organs and vagina preserved while ensuring that cancer control is not compromised. Radical cystectomy to treat muscle-invasive bladder cancer has the highest survival rate and lowest local recurrence rate. The progression-free survival rate and overall survival rate of bladder cancer are significantly correlated with the pathological stage of the tumor.
The 5-year overall survival rate was about 50%. Patients with no lymph node metastasis and tumors confined to the bladder have a 5-year survival rate of about 80%, compared to 35-58% if the tumor breaks through the bladder into the peribladder fat or if there is lymph node metastasis. It is worth emphasizing that for patients with lymph node metastases, radical cystectomy and expanded pelvic lymph node dissection can result in long-term survival in 35%.
Survival advantages of lymph node dissection
The first place where bladder cancer metastasizes is in the pelvic lymph nodes. Although the extent of expanded lymph node dissection is not clearly defined, a growing body of data suggests that patients who are candidates for surgery should undergo more extensive lymph node dissection. Expanded lymph node dissection should include not only the distal para-aortic and inferior vena cava lymph nodes, but also the presacral lymph nodes, which anatomically also receive bladder lymphatic drainage and therefore have the potential for tumor metastasis to this area. Expanded lymph node dissection can improve survival in patients with/without lymph node metastases without significantly increasing surgical complications and mortality. In patients with total bladder dissection with lymph node metastases, the extent of the primary bladder tumor (p-stage), the number of lymph nodes removed, and the metastasis of the lymph nodes are important indicators of prognosis.
Urinary diversion
Ileal cystectomy
Ileal substitution cystectomy involves the creation of a urinary flow channel with a segment of small intestine and an incision in the skin of the abdominal wall. The ureter is anastomosed directly to the selected segment of bowel and urine can be easily channeled through this segment of small bowel into an external storage device (ostomy bag) that can be emptied at intervals. This is the easiest urinary diversion procedure and is used in most medical facilities. This urinary diversion is recommended for patients with combined renal insufficiency or who are not candidates for in situ bladder for other reasons.
Internal morphology of the abdominal cavity and appearance of the abdominal wall in ileal cystoplasty
In situ neocystectomy
There are various forms of in situ bladder, but usually a section of small bowel is used to create a bladder substitute. The selected small bowel is made spherical to increase the volume and also to reduce the pressure to 1/4 to 1/3 of the original bowel cavity. it is then connected to the urethra so that the patient can urinate autonomously from the urethra. This procedure is usually used for male patients because it was previously thought that the female urethra should be cut out to prevent the cancer from recurring. However, recent studies have found that the urethra can be completely preserved as long as no tumor is found at the urethral cut edge during surgery. In addition, studies have demonstrated that most women have an in situ bladder that is able to control urination. Urination requires relaxation of the pelvic floor muscles while increasing abdominal pressure (Valsalva maneuver). Roughly 90% of patients have good control of urination during the day and more than half of patients can control urination throughout the night. Patient satisfaction with this type of diversion procedure is also quite high. It is currently the predominant type of urinary diversion in larger medical centers in Europe and the United States for appropriate patients of both sexes.
A 54-60 cm long terminal ileum is separated to create an in situ bladder. By detubularization, the bowel is re-sutured into a spherical shape and anastomosed to the remaining urethra.
Controlled urinary diversion
Patients who are unable to undergo in situ cystectomy because of urethral injury, incontinence, or cancer at the urethral incisional margin and do not want to carry a urine collection bag can have a storage sac made from the colon with a catheterizable stoma.13 The patient has a catheter inserted into the stoma every 4-6 hours to empty the urine. This one-way valve mechanism allows the patient to drain and empty urine through a small stoma in the abdominal wall (usually in the umbilicus) and to store urine temporarily when not catheterized. Usually the appendix is used to make a catheterizable access, or if the appendix is absent or not applicable, a cut section of ileum can be used. This type of urinary diversion is more technically demanding and also requires more patient involvement. Since being able to catheterize themselves is a key ability for patients with controlled urinary diversion, patients must be able to take care of themselves to have the opportunity to have this procedure done.
Part of the right colon and ileum is used to create a new bladder. The appendix is used as an access point through the catheter to connect to the supraumbilical stoma.
The in situ bladder has little impact on the patient’s appearance (no skin stoma or stoma device is required) and allows the patient to complete a more natural urination process through the urethra. However, the patient’s own feelings are a very personal and subjective matter, and in fact, most patients are more satisfied with their choice of urinary diversion, whether it is controlled or uncontrolled. All patients who require total cystectomy need to be aware of these options available to them. Although there are specific contraindications to controlled urinary diversion and some patients may be better suited for ileal replacement cystectomy, most patients undergoing radical cystectomy now have the opportunity for controlled urinary diversion and this should be made known to the patient prior to surgery. We believe that every patient who needs a urinary diversion should have a thorough conversation with the surgeon to discuss the pros and cons of each approach. The Department of Urology at BYUH is currently able to offer all forms of urethral diversions.