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Ostomytalk10 12
1. Surgical Management of
Bladder Cancer: 2012
Alex Gorbonos, MD
Assistant Professor, Division of Urology
Director, Robotic Surgery
SIU School of Medicine
October 2, 2012
3. EPIDEMIOLOGY
5th most common
cancer
4th most common
in men
Cancer most likely
to recur
2nd most common
urologic cancer
ACS, 2012
4. EPIDEMIOLOGY
Median age at diagnosis: 68
3-4 times more common in men
More aggressive in
blacks and women
Longer time to diagnosis
Access to care
5. HISTOLOGY
Most common primary histology in USA
Urothelial (transitional) cell
Urothelium: lines collecting system of the
kidney, ureters, bladder and most of urethra
Most common primary histology in world
Squamous cell
Spinal cord injury, recurrent UTIs/stones, catheter use
Other histologies:
Adenocarcinoma (bladder augmentation, urachus, GI)
http://en.wikipedia.org/wiki/File:Urinary_system.svg
12. Radical Cystectomy
Gold standard for surgical management of
Invasive bladder carcinoma
Intravescical therapy-refractory non-muscle
invasive carcinoma
High-volume or unresectable non-invasive disease
Males: removal of the bladder, prostate
Female: removal of the bladder, uterus/ovaries
16. First Radical Cystecomy
Bernhard Bardenheuer (1839-1913)
Prussian surgeon who performed first complete
cystectomy on January 13, 1887
Der extraperitoneale Explorativschnitt. Die differentielle Diagnostik der
chirurgischen Erkrankungen und Neubildungen des Abdomens.
Stuttgart, Enke, 1887. 748 pages. p. 273
Theodor Baum, 57 yo carpenter’s assistant,
from Cologne had advanced bladder
tumor involving both ureters
Operation lasted 75min
Ureters were left unimplanted
Patient died POD#14 days from uremia and
hydronephrosis
Pannek and Senge, History of Urinary Diversion,
Urol Int; 1996, 60: 1-10
Moll et al, Bardenheuer's contribution to the development of
modern urology, J Med Bio; 1998, 6: 11-14
17. FIRST RADICAL CYSTECTOMY
1899 – Fedor Krause performed first successful
total cystectomy and ureterosigmoidostomy for
bladder cancer
Ureters connected to sigmoid colon to use anal
sphincter as a continence mechanism
Pannek and Senge, History of Urinary
Diversion, Urol Int; 1996, 60: 1-10
18. Radical Cystectomy – 19th Century
Mortality due to sepsis from peritonitis and
pyelonephritis limited widespread practice of
cystectomy
Lack of antibiotics
Post-op urinary leak
Antiquated surgical principles
Pannek and Senge, History of Urinary
Diversion, Urol Int; 1996, 60: 1-10
19. Conclusion
Not enough to be able to remove the organ, but
it is necessary to reconstruct the urinary tract
GI tract “mobilized”
21. 20th Century – First Half
Ureterosigmoidostomy was the operation of choice
using the Coffey method of anastomosis
1936 – Hinman and Weyrauch reviewed 740
ureterosigmoidostomies
Perioperative mortality was 30%
50% - cancer causes
20% - non-cancer causes
Cutaneous ureterostomy was thought to offer best
chance of survival
Pannek and Senge, History of Urinary
Diversion, Urol Int; 1996, 60: 1-10
22. 20th Century – 2nd Half
Diversion field boom
Mortality decreases
Antibiotics introduction
Improvement in anesthesia and critical care
Surgical technique continues to evolve
1950 – Ferris and Oedel demonstrate
hyperchloremic metabolic acidosis in
ureterosigmoidostomy patients due to absorptive
capacity of bowel mucosa
Ureterosigmoidostomy moves to the background
Pannek and Senge, History of Urinary
Diversion, Urol Int; 1996, 60: 1-10
23. Ileal Conduit
1911 – first described by Zaayer in 2 patients
1st patient – died of cancer POD#11
2nd patient – died of peritonitis POD#6
1927 – Bollman and Mann created conduits in
animals
High mortality from electrolyte disturbances
because they were creating long conduits
Hypokalemic hyperchloremic metabolic acidosis
Pannek and Senge, History of Urinary
Diversion, Urol Int; 1996, 60: 1-10
24. Ileal Conduit
1950 – Eugene Bricker published a
landmark paper on his experience with
ileal conduit
“Surg Clin N Am 1950; 30: 1511-21”
10 patients with follow-up of 2 mo (4) to 4
years
Metabolic complications not recognized
12.4% mortality in 307 cases; 3.4% directly
related to diversion
Bricker conduit:
Refluxing anastomosis
Simple stoma, without a bud
Perez & Webster, “History of Urinary Diversion
Techniques,” in Urinary Diversion, Webster and
Goldwasser, eds., 1995
25. Eugene M. Bricker (1909-
2000)
“We ourselves are pleased
with the procedure because
we feel it is the acme of
simplicity…At the present time
we are ready to drop the
project of trying to develop a
continent intra-abdominal
urinary pouch in favor of this
method…”
General Surgeon
Perez & Webster, “History of Urinary Diversion Barnes Hospital, St. Louis
Techniques,” in Urinary Diversion, Webster and
Goldwasser, eds., 1995
26. Ileal Conduit - Modifications
1966 – Wallace of London
modified ileal conduit by
joining ureters together
prior to anastomosis to the
ileal segment end
1975 – Turnbull,
general surgeon from
Cleveland Clinic, introduced loop stoma technique for
obese patients
Decreased stomal stenosis Perez & Webster, “History of Urinary
Diversion Techniques,” in Urinary Diversion,
Higher parastomal hernia rate Webster and Goldwasser, eds., 1995
27. Robotic Cystectomy
Radical cystectomy with pelvic
lymphadenectomy:
First performed robotically in 2003
Urinary Diversion performed intra- or extra-
corporeally
31. Robotic Radical Cystectomy
Decreased blood loss
Less evaporative fluid losses
Reduced manipulation of GI tract, quicker return of
bowel function
Equivalent oncologic outcomes
Better cosmesis
Less pain
Quicker recovery
The Journal of Urology Vol 183, Issue 2,
Pages 510-515, February 2010
32. Future of Diversion?
Anthony Atala et al: Tissue-engineered autologous
bladders for patients needing cystoplasty
Lancet. 2006 Apr 15;367(9518):1241-6
Autologous engineered bladder tissues used for
reconstruction in 7 myelomeningocele patients
Construction of engineered bladder
Scaffold seeded with cells (A) and engineered bladder anastamosed to native
bladder with running 4–0 polyglycolic sutures (B). Implant covered with fibrin glue
and omentum (C).
