Radical Cystectomy in Men

One of the first detailed operative descriptions of radical cystoprostatectomy and pelvic lymphadenectomy was probably provided by Marshall and Whitmore in 1949.2 In the 1950s and early 1960s, the operation was attended with significant mortality and morbidity. Although more complex urinary diversions are increasingly employed, contemporary cystectomy is associated with very low mortality. Furthermore, the advent of nerve-sparing cystectomy and orthotopic bladder substitution has significantly reduced functional losses and provided many patients with good locoregional control as well as a good quality of life. The technique, herein described, is based on cumulative experience of more than 20 years during which more than 1,000 cystectomies were carried out at the Department of Urology, Mansoura University, Egypt.

DIAGNOSIS

The diagnosis of transitional-cell carcinoma is generally made by transurethral resection of the tumor in the bladder. Once the diagnosis has been established, it is important to know the histologic stage, particularly if the tumor invades the muscularis propria. Invasion of the muscularis mucosa is not considered as constituting a muscle-invasive tumor. The clinical staging of transitional-cell carcinoma can generally be performed by abdominal and pelvic computerized tomographic (CT) scans. Occasionally radionuclide bone scans are indicated if there is either symptomatic bone pain, abnormalities on the CT scan, or the patient has either an elevated serum calcium or alkaline phosphatase.

INDICATIONS FOR RADICAL CYSTECTOMY IN MEN

The major indication for cystectomy in men is carcinoma of the bladder. In general, the operation is carried out for:

  1. Patients with superficial tumors in whom endoscopic control has failed in spite of adjuvant intravesical chemo- and/or immunotherapy. Although these measures had proved effective in the management of such cases (£T1), an important minority fail. High tumor grade, multifocal lesions, diffuse carcinoma in situ, and involvement of the prostatic urethra were all reported as high-risk factors.

  1. Infiltrating tumor without evidence of distant metastasis. These include tumors infiltrating the muscle layers (P2, P3a) or the perivesical fat short of the pelvic wall (P3b). Infiltration of adjacent organs (P4) or involvement of the regional lymph nodes is not considered as a contraindication for the procedure.

The extent of the radical operation in the male includes the removal of the bladder, its peritoneal covering, the perivesical fat, the lower ureters, the prostate, the seminal vesicles, and the vasa deferentia. In the standard procedure, as much as possible of the membranous urethra is also removed, and total urethrectomy is carried out only if there is involvement of the prostatic urethra.

ALTERNATIVE THERAPY

Alternatives to radical cystectomy include local therapy, partial cystectomy, intravenous chemotherapy, radiation therapy, or a combination of chemotherapy and radiation therapy. Local therapy in invasive disease generally results in progression of the disease and death of the patient within 5 years. Systemic chemotherapy or radiation therapy is associated with a 25% 5-year survival, though the combination of the two modalities results in significant synergy with up to 50% 5-year survival.

SURGICAL TECHNIQUE

Preparation of the Patient

In view of the extent of surgery and the length of the operative time, a thorough medical evaluation and anesthetic consultation are required.

Bowel preparation is necessary before surgery. If it is planned to use the small bowel, oral neomycin and a low-residue diet are all that is needed. More rigorous preparation is required if the colon is utilized. This includes soapsuds enemas until the colonic contents return clear. A neomycin sulfate enema is given on the evening before the day of operation. Intravenous fluids are also administered to maintain hydration.

Patients with histories of thromboembolic disease or varicose veins should receive a prophylactic dose of heparin (5,000 units subcutaneously) the night before the operation and every 12 hours thereafter until ambulation. A parenteral broad-spectrum antibiotic is given just before induction of anesthesia and continued postoperatively for 3 days. The region extending from the midchest to the midthigh should be cleaned and prepared on the night before surgery.

Anesthesia and Instrumentation

Full relaxation of the abdominal muscles by an appropriate anesthetic is necessary throughout the entire procedure. Hypotensive anesthesia would provide an additional advantage and would reduce blood loss.

The choice of instruments depends mainly on surgeon’s preference. Standard retractors of various sizes and curves as well as long curved and angled scissors are needed. Long curved clamps should also be available. In our practice, we prefer to retract the abdominal wall on the side where the dissection is carried out using one or two ordinary retractors. A ring retractor is applied once the lymphadenectomy is completed.

Position and Initial Exposure

The patient is put in the supine position with a Trendelenberg tilt. Slight bending of the knees would further help in the relaxation of the abdominal muscles, facilitate retraction, and provide a wider exposure. If a total urethrectomy is planned, the patient is put in a slight lithotomy position for access to the perineum.

The surgical area to be sterilized and draped extends from the lower chest down to the root of the penis. A self-retaining catheter is introduced into the bladder and kept indwelling for its evacuation throughout the procedure.

A long, vertical, right paramedian incision extending from the symphysis pubis inferiorly to a point half way between the umbilicus and xyphoid process of the sternum superiorly is generally employed. Alternatively, a midline incision encircling the umbilicus can also be utilized. For obese patients a lower abdominal muscle-cutting transverse incision is preferred. Under such circumstances it provides a wide and direct exposure of the pelvis.

Initially, the abdominal and pelvic cavities are explored. The growth is palpated, its degree of mobility determined, and its relation to the adjacent structures assessed. The endopelvic and aortic lymph nodes are palpated, and frozen sections are taken if necessary. The general peritoneal cavity, omentum, intestinal tract, kidney, spleen, and liver are thoroughly examined. If the decision is to proceed with the radical operation, the intestines are packed out of the pelvis, and the retropubic space is opened by blunt dissection. Any small bleeders are coagulated. This dissection is extended inferiorly and laterally until the ventral surface of the bladder and prostate are exposed. The peritoneal incision is extended inferiorly on either side of the urachal remnant. The urachal remnant is dissected off its attachment with the umbilicus and clamped. In this manner a triangular peritoneal flap with its apex pointing superiorly is raised and will be removed later en bloc with the bladder.

Lymphadenectomy

The peritoneal incision, on either side, is extended posterolaterally along the lateral border of the external iliac and common iliac vessels up to the aortic bifurcation. The vas deferens is identified and ligated near the internal ring. The fascia on the iliopsoas is incised and reflected medially. The triangle of Marceille is exposed by retracting the common and external iliac arteries medially and dissecting the space between these vessels and the medial border of the psoas muscle. Dissection of the fibrolymphatic tissues in this space will expose the obturator nerve as it emerges from the medial border of the psoas muscle. The fibrofascial sheath covering the distal half of the common iliac and the external iliac vessels is then opened and stripped medially to remove the perivascular lymphatics and lymph nodes. The vessels are gently retracted, laterally and immediately below and medial to the cleaned external iliac vein, and the obturator space is entered. By working right on the psoas and obturator muscles, one can strip all the pelvic fascia medially without difficulty. The obturator neurovascular bundle is included in the stripped mass. The obturator nerve is identified and separated from the vessels, which are divided and ligated as they leave the pelvis through the obturator foramen. Dissection is facilitated and the operating time reduced by the use of electrocoagulation to control lymphatic and small blood vessels throughout the lymphadenectomy.

Cystoprostatectomy

The fibrolymphatic mass is now reflected medially. The internal iliac artery is dissected free, and its anterior division is divided and ligated. The ureter is identified where it crosses the common iliac bifurcation, dissected free for 3 to 4 cm, divided, and its distal end ligated. While traction is applied on the ligated ureteric stump of the ureter, finger dissection along its posteromedial border opens the space of Denonvillier laterally. The step greatly helps in the definition of the plane between the bladder and rectum, which will be required at a later stage in the operation.

The endopelvic fascia on either side on the prostate is then opened by the tip of a blunt pair of scissors. The optimal site for the creation of this opening is a white line marking the fusion of the parietal fascia lining the pelvic surface of the levator ani with the visceral fascia covering the lateral surface of the prostate. A right-angled clamp is used to lift the fascia from the underlying venous plexus, and it is further incised medially until the prostatic ligaments are reached. By blunt dissection, this plane is further developed posteriorly on either side of the prostate. Further anterior dissection is deferred to the final stages of the procedure to minimize the possibility of sudden blood losses from inadvertent injury of the prostatic venous plexus.

The specimen is now lifted ventrally by applying traction on the median umbilical ligament (urachus). The two planes developed along the posteromedial borders of the ureter on either side are easily joined together by blunt dissection. As a result, the peritoneal reflection from the anterior surface of the rectum to the back of the bladder could be stretched and safely incised by diathermy. The potential space between the rectum posteriorly and the bladder, seminal vesicles, and prostate anteriorly is opened by blunt dissection. As the prostatic apex is reached, this space becomes obliterated as a result of fusion of the two layers of the fascia of Denonvillier. This cul-de-sac is opened by the blunt tip of long angled scissors. Once this is completed, the tip of the surgeon’s forefinger would readily feel the apex of the prostate as well as the catheter in the urethra in the midline. Alternatively, if it is directed laterally, it would appear through the previously created openings on either side of the prostate .

In this manner, a thick and wide fascial band is created on either side, connecting the bladder, vesicles, and prostate anteriorly with the pararectal fascia posteriorly (the vesicoprostatopelvic fascia). This is divided piecemeal between clamps, which are underrun by 2-0 polyglactin sutures.

The bladder is now free laterally and posteriorly, and the mass is left to drop in the pelvis. Attention is now focused on the anterior and final phase of the procedure. The puboprostatic ligaments are identified by applying traction on the prostate in a cephalad and posterior direction. These ligaments are carefully severed at the point of their insertion in the pubic bone. The prostatic venous plexus is controlled by one or two sutures of 3-0 polygalactic acid placed near the prostatic apex. A transverse incision is made proximal to these sutures with a long scalpel and extended with sharp dissection by scissors, exposing the urethra, within which the catheter can be palpated (Fig. 23-6). The catheter is then withdrawn; the urethra is clamped and transected; the distal end is ligated; and the specimen is removed. Final hemostasis is achieved by inserting deep 2-0 polyglactin sutures between the edges of the levator ani muscles on either side (Fig. 23-7). No attempt is made to reperitonealize the pelvis. Two tube drains are placed in the pelvic cavity and brought out through separate incisions in the abdominal wall. The wound is closed in layers with particular attention for careful closure of the anterior rectus sheath. This is closed with interrupted sutures of nylon with the knots tied to the inside.

Variations on a Theme

One-Stage Cystoprostatourethrectomy

Urethrectomy is indicated in a subpopulation of patients with multifocal tumors, diffuse carcinoma in situ, or tumor involving the bladder neck and/or the prostate. Following incision of the puboprostatic ligaments and control of the prostatic venous plexus described, traction is applied on the cystectomy specimen in a cephalad direction. The urethra is dissected from the urogenital diaphragm with a long pair of dissecting scissors. In this manner, 2 to 3 cm of the membranous urethra can be mobilized. The pelvis is temporarily acked with gauze, and further steps are carried out perineally without urethral transaction.

A midline incision in the perineum is usually employed. The skin, subcutaneous tissue, and the bulbocavernosus muscle are incised in the midline. The Foley catheter can now be palpated in the urethra. The urethra is dissected sharply from the overlying corpora cavernosus. Further dissection is carried out in the direction of the glans penis. Traction on the urethra results in inversion on the penis, allowing dissection of the urethra as far as the coronal sulcus. The penis is then allowed to restore its normal position. The urethral meatus is circumscribed sharply, and the glans penis is incised in the midline to allow dissection of the fossa navicularis. The entire penile urethra is now free. The glans penis is reconstructed by a few sutures of interrupted 3-0 chromic catgut.

Attention is now focused on dissection of the bulbar urethra. The relatively avascular tissues ventral to the bulbar urethra and beneath the symphysis pubis are dissected first. Thus, the corresponding part that had been previously dissected in the pelvis can be reached, and the pelvic and perineal exposures joined. Dissection is further developed laterally and posteriorly with control of the bulbar urethral arteries. In this manner the urethra is freed totally, and the whole specimen is removed in one block.

Radical Cystoprostatectomy with Orthotopic Bladder Substitution

A standard radical cystoprostatectomy is performed except that the final stages of the operation must be done with attention to detail to avoid damage to the urethra and periurethral musculature. The integrity of these structures has a central role in the functional success of orthotopic substitution. Following lymphadenectomy and control of the pedicles, the endopelvic fascia on either side of the prostate is opened by the tip of a blunt pair of scissors. A right-angled clamp is used to lift the fascia from the underlying venous plexus, and then it is further incised medially until the puboprostatic ligaments are reached. These ligaments are carefully severed at the point of their insertion in the pubic bone. The prostatic venous plexus is controlled by one or two suture ligatures of 3-0 polyglactin just distal to the vesicoprostatic junction. A transverse incision is made proximal to these sutures and extended by sharp dissection with scissors toward the apex of the prostate. The catheter is palpated in the urethra, the anterior wall of which is then incised just distal to the prostatic apex. The exposed Foley catheter is transected, clamped, and held for traction. At this point, three stay sutures of 4-0 polyglactin are placed through the urethra at the 3-,9-, and 12-o’clock positions, incorporating the mucosa as well as the periurethral musculature. These sutures prevent retraction of the urethra following its complete transection and are used later for the urethroileal anastomosis. The posterior urethral wall is then incised to expose the dorsal fibrous raphe formed by the fascia of Denonvillier, which is lifted from the anterior surface of the rectum by a right-angled clamp and divided. The divided fascia is then included in two posterior stay sutures at the 5- and 7-o’clock positions for its later incorporation in the urethrointestinal anastomosis.

Radical Cystoprostatectomy with Nerve Sparing

This procedure was initially described by Schlegel and Walsh.5 It can be carried out in an antegrade or a retrograde manner, though in our practice we prefer the antegrade approach. During radical cystectomy there are two points where the neurovascular bundle could be injured: (a) posterolateral to the prostate and (b) behind the seminal vesicles. If the extent of the pathology allows the surgeon to avoid these areas, potency could be preserved.

Bilateral lymphadenectomy with creation of the space between the rectum posteriorly and the bladder, seminal vesicles, and prostate anteriorly is carried out as previously described. By a combination of blunt and sharp dissection, the lateral surface of the seminal vesicles is freed from the medial aspect of the vesicoprostatopelvic fascia. This allows the control of these ligaments at a more ventral plane. As a result, the neurovascular pathway behind the seminal vesicles is avoided. These pedicles are controlled by a series of simple interrupted sutures of 3-0 Vicryl. The use of heavy clamps, clips, and diathermy should be avoided. The dorsal vein complex is now controlled, and the urethra isolated carefully from the adjacent fascia. The urethra is then transected, and the Foley catheter is clamped and held for traction. The prostate can thus be elevated superiorly. A right-angle clamp is used to identify branches of the neurovascular bundle to the prostate. These are ligated and divided, freeing the prostate from all its lateral attachments.

Postoperative Management

Intravenous alimentation and nasogastric suction are maintained until normal bowel activity is resumed. Systemic antibiotics are continued for 3 days postoperatively. Chest exercises and physiotherapy to the lower limbs should be carried out. Subcutaneous heparin should be administered if indicated. The tube drains are removed when drainage becomes less than 100 ml/day. It is advisable to estimate the creatinine content of the fluid to ensure that it is not the result of a urinary leak. Patients with an ileal conduit can be discharged on the 10th to the 12th postoperative day. Following orthotopic substitution, patients are usually kept in the hospital for 3 weeks. Before discharge, a pouchography is carried out to make sure that there are no leaks from the neobladder or from the urethroileal anastomosis.

OUTCOMES

Complications

The two most serious complications that may occur during the procedure are excessive blood loss or rectal perforation. Sudden massive bleeding is usually venous in origin, arising from tributaries of the external iliac vein during the lymphadenectomy: the deep circumflex iliac vein laterally and an abnormal obturator vein medially. Since both are located near the inguinal ligament, good retraction, illumination and suction are needed. A laceration of the external iliac vein is then sutured with 5-0 Prolene.

Another source of bleeding is in relation to the dorsal vein complex. Dissection of this area has to be deferred to the final phase of the procedure. This venous complex is usually injured when the puboprostatic ligaments are incised. Compression of the bleeding area by a piece of gauze (4×8) and the tip of a long thin blade of a Deaver’s retractor are necessary until the dissection of the urethra is completed. Thereafter, bleeding is controlled by one or two interrupted 3-0 sutures of polyglactin acid placed between the two medial borders of the levator ani muscles.

However, the most serious source of bleeding is from the internal iliac vein or one of its tributaries. Sudden excessive bleeding occurs from the depth of a narrow deep recess. Blind attempts to control the bleeding with clamps usually fail and result in more damage. In our experience, one has to achieve an initial temporary control by packing. One or two 4×8 pieces of moist gauze are sufficient. The pack is tightly and constantly compressed for a few minutes and then is left in place. The operator should proceed with further operative steps until the specimen is removed. Now, the working space is wide enough to allow manipulations under vision. The ipsilateral external iliac and common iliac veins as well as the main stem of the internal iliac artery are controlled by bulldog clamps. The gauze pack is then removed. There will still be some back bleeding, but with the help of a little suction, the bleeding vessels are readily located and easily secured by suture ligation using 4-0 silk.

The other serious intraoperative complication is rectal perforation. This usually takes place during the final phase of the operation if the space between the prostate and rectum was not adequately and completely opened. Under such circumstances, traction on the specimen will lead to tenting of the anterior wall of the rectum. Sharp dissection with scissors or application of clamps would result in an injury of the anterior wall of the rectum well below the peritoneal reflection. If this injury is recognized, the tear is meticulously repaired. The edges are trimmed and closed in two layers using 3-0 polyglactin acid: the first through and through, and the second inverting as a fascia muscular layer (Lembert technique). An omental flap is raised, brought down to the pelvis and sutured over the repair for additional security. The pelvic cavity is then thoroughly irrigated with 1% solution of kanamycin in saline. At the end of surgery, while the patient is still under anesthesia, anal dilation is carried out up to three to four fingers to establish adequate decompression. Generally, by following these principles, one can avoid the need of a temporary proximal colostomy.

The postoperative mortality following contemporary cystectomy is 2% or less.6 The most common postoperative complication is prolonged ileus. This is treated by nasogastric suction, intravenous alimentation, and hyperalimentation if necessary. Septic complications including abdominal and/or pelvic abscesses, wound sepsis, and septicemia are not uncommon. These are treated by the appropriate antibiotics and drainage of the infected collection. This is best achieved by ultrasound-guided aspiration and/or insertion of a percutaneous tube drain. Wound dehiscence should be immediately repaired by proper closure using tension sutures. Urinary collections (urinoma) are drained under ultrasound guidance. If the source of leak is the ureterointestinal anastomosis, a percutaneous nephrostomy tube is inserted until healing is achieved and checked with an antegrade study.

Results

Radical cystectomy has evolved as the standard therapeutic modality for muscle-invasive bladder cancer. It can be accomplished with very low mortality, and technical innovations with nerve sparing and orthotopic substitution can provide many patients with a good quality of life with minimal functional losses.

All contemporary series demonstrate that radical cystectomy can result in a substantial rate of cure with overall survival ranges between 48% and 53%.1,8 For tumors with low stage (<P2), the survival could be as high as 75%. With further stage progression, the survival expectancy is decreased. Radical cystectomy with pelvic lymphadenectomy also provides a survival advantage for cases with nodal disease (5-year survival in the range of 20%). Evidence has also been provided that adjuvant cisplatin-based polychemotherapy improves the chances of survival among patients with advanced locoregional disease.

Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: