Simple and Partial Cystectomy

SIMPLE  CYSTECTOMY

Simple cystectomy is defined as removal of the bladder without removal of adjacent structures or organs and is infrequently performed today. In the man, this would mean leaving behind the prostate, urethra, and seminal vesicles with the advantage that potency is conserved. However, in the impotent male in whom the urinary diversion is not expected to be reversed, removal of these structures adds little morbidity to the operation. In the woman, this means leaving behind the urethra, uterus, and anterior wall of the vagina. Simple cystectomy also implies that there is no dissection of the pelvic lymph nodes.

Indications for Surgery

Upper tract diversion has been a popular treatment alternative for a range of benign lower tract pathology and upper tract obstruction since the development of ureteroilieal cutaneous diversion in the 1950s. The indications for supravesical diversion are varied and include radiation cystitis after treatment of pelvic malignancies, interstitial cystitis, cyclosphosphamide cystitis, severe incontinence, neurogenic bladder, severe urethral trauma, and obstruction of the upper tracts. Initially, simple cystectomy was not routinely included during supravesical diversion because of the increased morbidity involved in simple cystectomy. However, complications from the retained bladder occur in up to 80% of patients undergoing supravesical diversion without simple cystectomy and include pyocystis, hemorrhage, sepsis, pain, vesicocutaneous fistula, colovesical fistula, feelings of incomplete emptying, and development of cancer in the retained bladder. Indeed, the rate of secondary cystectomy approaches 20% in some series. Because of the high complication and reoperation rate, we recommend simple cystectomy as a part of upper tract diversion in any patient whose urinary diversion is not expected to be reversed, and especially in patients who have some component of bladder outflow obstruction.

Alternative Therapy

Other alternatives to simple cystectomy include conservative management, total cystoprostatectomy, radical cystectomy, and partial cystectomy. With the recent advances in laparoscopic technology and laparoscopic surgical techniques, laparoscopic simple cystectomy has become a potential treatment alternative, with several centers reporting success with the procedure as well as shortened postoperative convalescence times.

Surgical Technique

A male patient is prepped and draped in the standard position as for radical cystectomy, in a supine position with the legs apart with gentle hyperextension. A female patient is placed in a lithotomy position for access to the perineum. This operation can be performed entirely extraperitoneally if prior upper tract urinary diversion has already taken place. This is preferred because it obviates the need for lysis of adhesions, which can be numerous in a patient who has had prior intra-abdominal surgery and/or radiation therapy. Obviously, if urinary diversion is to take place at the same time, an intraperitoneal approach is used.

In the extraperitoneal approach, we use a lower midline incision extending from the pubis to immediately lateral to the umbilicus. The space of Retzius is entered by dividing the rectus abdominis in the midline. The retropubic space is developed down to the bladder, using a combination of blunt and sharp dissection to separate the parietal peritoneum from the dome and posterior wall of the bladder. It is important to repair with 3-0 or 4-0 chromic any tears made in the parietal peritoneum, as the parietal peritoneum provides an important boundary between the peritoneal contents and the raw surface of the pelvis after simple cystectomy. During dissection of the parietal peritoneum in the man, the vas deferens are encountered. If we are going to leave the seminal vesicles and prostate, we do not sacrifice the vas but instead dissect it posteriorly. If the seminal vesicles and prostate are to be sacrificed, we divide the vas. During the dissection of the parietal peritoneum posteriorly, the superior vesical pedicle is encountered. At this point it is clamped and divided between 2-0 silk ties.

After control of the superior vesical pedicles bilaterally, the ureters are identified where they enter the bladder. In patients who have had prior upper tract diversion, the ureters are dissected proximally to the point where they were divided previously in order to ensure complete excision of the distal ureters. In patients who are to undergo urinary diversion at the same time, we use an intraperitoneal approach and divide the ureters close to the bladder wall.

The bladder is then divided from the prostate at the prostatovesical junction using electrocautery starting anteriorly at the bladder neck and working laterally on both sides until the posterior bladder neck is reached. If the patient has significant prostatic hypertrophy, which will impede adequate closure of the bladder neck, then a suprapubic prostatectomy is performed with rigorous attention to hemostasis afterward because a Foley catheter can not be used to help control hemorrhage. The posterior bladder wall is then divided from within using electrocautery until the ampulla of the vasa are seen. The base of the bladder is then bluntly dissected off the seminal vesicles and ampulla of the vas. During this dissection, the lateral vascular pedicles are identified and divided between 2-0 silk ties. The bladder is now removed from the operative field. The prostate is then oversewn with a double layer of 0 chromic catgut.

In women, after development of the retropubic space, the parietal peritoneum is dissected off the dome and posterior wall of the bladder until the anterior vaginal fornix is reached. The superior vesical pedicles are divided as in a man. The ureters are handled the same way as in a man, with care taken not to injure the uterine artery during their dissection. A sponge on a stick placed in the vagina is used for cephalad traction, and the plane between the bladder and anterior vaginal wall is developed. During dissection of this plane, the lateral bladder pedicles are divided between 2-0 silk ties as they are encountered. Once the urethra is reached, the Foley catheter is removed, and the urethra is divided and oversewn with 0 chromic catgut suture. If simple cystectomy is being performed for interstitial cystitis, it is important to remove the entire urethra and external rethral meatus because failure to do so may result in persistent symptoms.

If an upper tract urinary diversion is to be performed at the same time, an intraperitoneal approach is used with an incision from the symphysis pubis to a point midway between the xyphoid process and the umbilicus. Our approach for simple cystectomy in this case is the same, with the parietal peritoneum carefully preserved as a boundary between the peritoneal contents and the raw pelvic surfaces.

Postoperatively, a drain is left in the pelvic space if the operation was performed in the presence of pyocystis. We rarely find it necessary to leave this drain more than 48 hours. Otherwise, we do not routinely leave a pelvic drain unless the patient will have placement of an orthotopic bladder.

PARTIAL CYSTECTOMY

Partial cystectomy has had a role in the management of bladder cancer for many years, though its exact role today is not well defined. The advent of improved means of transurethral resection of bladder tumors plus an improved understanding of the natural biology of bladder tumors has ensured that partial cystectomy today is a much less practiced procedure than in the past. There are certain advantages to partial cystectomy, such as sparing potency in men, retaining a functioning urinary reservoir, and the ability to achieve full thickness resection of bladder tumors and sample perivesical nodal tissue. This makes partial cystectomy an attractive procedure in selected patients. The major drawback in the use of partial cystectomy in the treatment of bladder cancer lies in the high tumor recurrence rates, which range from 40% to 80% in the reported series. Though this ensures that partial cystectomy is an uncommonly performed procedure, we believe it is an important part of the urologic surgeon’s repetoire.

Indications for Surgery

Certain criteria must be met before a patient can be considered for partial cystectomy. The tumor must be a solitary, primary lesion located in a part of the bladder that allows for complete excision with adequate margins. We feel that margins of at least 3 cm are necessary for adequate resection.

Other indications for partial cystectomy include patients who are not candidates for a complete transurethral resection of a bladder tumor because of a combination of patient body habitus, hypomobility of the hips secondary to osteoarthritis, or a fixed prostatic urethra. In this case, partial cystectomy may be required for complete diagnosis. It has also been recommended that tumors located in bladder diverticuli be managed with partial cystectomy. This is because bladder diverticuli have attenuated walls that may easily be perforated with transurethral resection, allowing for tumor spillage into the perivesical space. Other indications for partial cystectomy are in the management of genitourinary sarcomas in adults and children, the management of urachal carcinomas involving the dome of the bladder, involvement of the bladder by tumors in adjacent organs, and in the palliation of severe local symptoms. Nonmalignant indications for partial cystectomy include the management of colovesical or vesicovaginal fistulas and the management of localized endometriosis of the bladder. Few other indications for partial cystectomy exist.

At one time, partial cystectomy was offered to patients who were considered to be poor cardiopulmonary risks. However, improvements in surgical technique, perioperative care, and postoperative care have markedly reduced the operative mortality so that this is no longer considered an indication for partial cystectomy.

Contraindications to partial cystectomy include patients with multiple lesions, recurrences, or tumors located on the trigone, where adequate excision is not possible because of the proximity of the ureteral orifices and bladder neck. In addition, patients must have biopsy-proven absence of cellular atypia or CIS in the remainder of the bladder and prostatic urethra. If there is evidence of fixation of the tumor to adjacent pelvic structures, or if segmental resection of the tumor would require removal of so much of the bladder as to necessitate augmentation cystoplasty, then a partial cystectomy should not be performed.

These criteria, therefore, limit the number of patients who are candidates for partial cystectomy to 6% to 19% of patients who present with bladder cancer. The ideal candidate for partial cystectomy is a patient with a solitary primary lesion located on the dome of the bladder with no evidence of diffuse involvement of the urothelium.

Alternative Therapy

Other potential therapies include transurethral resection of bladder tumors, laser ablation of bladder tumors, intravesical chemotherapy, and radical cystectomy. There are several problems associated with the performance of partial cystectomy in the treatment of bladder cancer. After this operation, it can be difficult to treat tumor recurrence, and the operation cannot be repeated. There is also the real risk of tumor implantation in the wound, which is both difficult to treat and implies a poor prognosis for the patient. Several authors have advocated the use of perioperative radiotherapy to the incision to minimize the chance of tumor seeding. Perhaps the greatest contraindication to partial cystectomy lies in its questionable efficacy in the treatment of bladder cancer. Though randomized trials comparing partial cystectomy with other surgical therapies stage for stage in the treatment of bladder cancer are lacking, recurrence rates ranging from 40% to 80% have been reported.

Surgical Technique

The patient is placed on the operating room table in the supine position and is sterilely prepped and draped. The sterile field includes the penis in men and vulva and vagina in women. This allows for sterile insertion of a Foley catheter into the bladder after resection of the tumor and before closure of the incision.

We prefer a lower midline incision to a transverse suprapubic incision because it allows for easier access to the peritoneal cavity if needed. We position the patient on the table such that the break in the table is at the anterior superior iliac spine, which allows for adequate flexion of the patient and elevation of the bladder into the wound. The standard incision extends from the pubic symphysis to the level of the umbilicus. The rectus abdominis is divided in the midline, and the space of Retzius is entered. The patient is then placed in the Trendelenburg position to elevate the abdominal contents out of the pelvis.

Depending on the location of the tumor in the bladder, we proceed with either an extraperitoneal or an intraperitoneal approach. For tumors located on the dome or anterior part of the bladder, we prefer an extraperitoneal approach. For tumors located on the posterior aspect of the bladder, an intraperitoneal approach is preferred.

Extraperitoneal Partial Cystectomy

For our extraperitoneal approach, we expose the anterior surface of the bladder through the space of Retzius, mobilizing the peritoneum where it is readily separable from the bladder. A bilateral pelvic lymph node dissection with the boundaries from the bifurcation of the common iliac artery superiorly to Cooper’s ligament inferiorly and from the external iliac artery laterally to the internal iliac artery medially. The bladder is freed laterally and posteriorly well beyond the site of the tumor. The fat over the site of the tumor is left attached to the bladder, and the superior vesicle pedicle can be divided if necessary.

Several stay sutures are then placed in the bladder at a site known from cystoscopy to be distant from the tumor. The wound edges are packed away from the bladder with laparotomy pads or plastic drapes, and the bladder is entered between the stay sutures using electrocautery, taking care to minimize the amount of spillage of urine in order to minimize the risk of tumor implantation. The incision is extended for several centimeters anteriorly and posteriorly to allow for adequate visualization of the tumor and its relationship to the ureteric orifices and bladder neck. The tumor is then excised, with care taken to leave a 3-cm margin of normal-appearing bladder surrounding the tumor. The tumor should be removed en bloc with the overlying perivesical fat and peritoneum using electrocautery or sharp dissection. If the tumor lies less than 3 cm from the ureteric orifice, sacrifice the ureteric orifice and perform a ureteral reimplantation. If enough ureter remains, a Leadbetter–Politano reimplantation is preferred, though a nonrefluxing ureteroneocystostomy or simple nipple reimplantation is acceptable. If excision of the tumor involves the bladder neck, it is possible to excise the bladder neck and the surrounding prostatic capsule after enucleation of the prostate gland. We do not recommend excising any portion of the bladder neck in women in order to avoid incontinence.

After removal of the tumor, the bladder should be closed in two layers using a 3-0 Vicryl suture to close the urothelium and a 2-0 Vicryl to close the muscular layer. A suprapubic cystostomy catheter is contraindicated in these patients because of the risk of tumor spillage, so it is essential that a wide-bore Foley catheter be used. We drain the perivesical space only if there is concern about the adequacy of bladder closure or a lymphadenectomy has been performed. The abdominal wall is then closed in the standard fashion.

Postoperatively the urethral catheter should be left in place for 7 to 10 days. If there is any doubt as to the integrity of the repair, a gentle gravity cystogram may be performed. If perivesical drains are placed, they may be removed when drainage is minimal, usually on the third or fourth postoperative day.

Intraperitoneal Partial Cystectomy

For posteriorly located tumors, we take an intraperitoneal approach. After dividing the rectus abdominis muscles in the midline, we open the peritoneum in the midline. We then put the patient in the Trendelenburg position and pack the abdominal contents out of the pelvis with laparotomy pads. The peritoneum over the iliac vessels is incised, and we proceed with our bilateral pelvic lymph node dissection as described previously. We follow the obliterated hypogastric artery to the takeoff of the superior vesical artery, which we clamp and divide.

The bladder is then freed posteriorly as needed, and stay sutures are then placed in the bladder, and the bladder is opened as described previously. Removal of the bladder tumor including the perivesical fat and peritoneum, reimplantation of the ureters, closure of the bladder, management of urethral catheters and perivesical drains, and wound closure are all handled as described previously.

OUTCOMES

Complications

The perioperative and early post operative complications of partial cystectomy and simple cystectomy include hemorrhage and infection. In patients undergoing partial cystectomy, urinary extravasation is also a possible complication.

Long-term complications of partial cystectomy include reduced bladder capacity and recurrence of the tumor in the pelvis or in the incision. This latter complication may be prevented by 2,000 cGy external beam therapy given immediately preoperatively.

Results

When utilized for interstitial cystitis with a substitution of bowel for reconstruction, partial (subtotal) cystectomy results in relief of pain and return of voiding ability in approximately two-thirds of patients. When utilized for superficial transitional cell carcinoma, the results are comparable to transurethral resection of superficial bladder tumors, but in invasive tumors, the results are inferior to those of radical cystectomy. Pathologic examination of the specimen will reveal the grade and stage of the tumor. If perivesical fat or pelvic lymph nodes are involved, it is recommended that the patient receive three courses of MVAC. Follow-up includes an IVP 3 months after surgery. Cystoscopies should be performed with bladder washings every 3 months for 2 years, then every 6 months for 2 years, and every year thereafter. With careful selection of the case, the reduction in bladder volume should not be so great as to cause urinary frequency. It is surprising how much of the bladder may be removed without causing urinary frequency. Even if postoperative frequency does occur, in the majority of cases it resolves spontaneously within 6 months.

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