Radical Cystectomy in Women

Total cystectomy is the most effective means of pelvic control of potentially lethal transitional-cell carcinoma (TCC) of the bladder. Bladder cancer is more common in men, and thus, cystectomy is more commonly performed in men than women, generally by a factor of 3:1 or 4:1.2 In some aspects, cystectomy in a woman is easier than in a man because of a larger pelvis and better exposure. However, in many ways the cystectomy is more difficult in women. Urologists have fewer opportunities for familiarity with major pelvic surgery in women than in men. Commonly, the uterus is removed with the bladder, and a hysterectomy is a procedure that urologists do not routinely perform. Bleeding from the paravaginal tissue and venous plexus around the urethra can be brisk and tedious to control. If the urethra is removed entirely, its reconstruction and reconstruction of the vagina can be done in several ways. Finally, orthotopic diversion in women is coming of age; preparation of the urethra for maximum preservation of a normal voiding pattern is different from that done in a male. The challenges of a female cystectomy are unique, and they may be accentuated for the surgeon who uncommonly performs a cystectomy.

DIAGNOSIS

The diagnosis of transitional-cell carcinoma is covered in the chapter on transurethral resection of bladder tumors .

INDICATIONS FOR SURGERY

The broad indication for a cystectomy is an invasive bladder cancer unlikely to be eliminated with transurethral resection and intravesical therapies. On occasion, recurrent, high-grade, noninvasive cancers require a cystectomy to completely eliminate a potentially lethal cancer. The decision on when to proceed with a cystectomy is always difficult for the patient and physician alike. The majority of muscle-invading bladder cancers do so at presentation; occasionally cystectomy is delayed even in this setting because of the risk of the surgery and the negative consequences on urinary function if the bladder is removed. Personally, I believe cystectomy is commonly delayed by either the patient or the physician, and diminished survival after cystectomy may in part be a consequence of this delay. Recent experience suggests that earlier surgery prompted by the availability of orthotopic diversion may translate into an improved outcome. Perhaps our indication for a cystectomy (or an aggressive bladder preservation strategy using chemotherapy and radiation if this proves effective) should be the inability to reliably and completely eliminate a potentially lethal cancer rather than the traditional indication of muscle invasion. A recent review highlighted the frequency of understaging of high-grade minimally invasive or noninvasive tumors. Of 182 patients undergoing a cystectomy for high-grade clinical stage Ta and Tl tumors and CIS, 34% had a higher stage at cystectomy with a subsequent diminished survival.

Orthotopic diversion is an appropriate consideration in the majority of women.9 Currently, the primary contraindication to orthotopic diversion is cancer involving the bladder neck, seen in approximately 25% of women undergoing cystectomy. Based on mapping studies, women without TCC at the bladder neck are unlikely to have urethral TCC.8 In the absence of TCC at the bladder neck, the patient should have an orthotopic diversion provided as a choice. Older patients may have minimal alteration of their life style with an ileal conduit and may prefer this method of diversion.

The experience with orthotopic diversion in women is small, currently at an estimated 100 to 200 cases worldwide. 9,10 As experience accumulates, it is apparent that urinary continence is as good in women as in men. Daytime incontinence in women is extremely rare, and nighttime incontinence may resolve more quickly than in men. A female cystectomy allows preservation of the GU diaphragm and innervation of the external sphincter.7,10 Urinary retention rather than incontinence is seen more commonly in women and may be attributable to a variety of factors as discussed later.

ALTERNATIVE THERAPY

Alternatives to cystectomy include observation, systemic chemotherapy, radiation therapy, or a combination of chemotherapy and radiation. These modalities are generally offered to patients who are a poor surgical risk, who refuse surgery, or who are elderly.

However, cystectomy is often the best option for invasive bladder cancer in the elderly who are otherwise in reasonably good health. Invasive bladder cancer is not an indolent disease, and death from uncontrolled TCC is high in the first 3 to 4 years. Thus, for a healthy 75-year-old, the invasive bladder cancer is the biggest health risk. The morbidity from a cystectomy is substantial, and the risk for complications from the operation is undeniable. However, the risk of radiation therapy and chemotherapy are also substantial, and elimination of the cancer is less likely.4 Unfortunately, a therapeutic strategy considered inadequate in younger patients may be employed in the healthy elderly, often with reduced doses of chemotherapy making the treatment even less likely to be successful. Improved perioperative care allows cystectomy to be done with a low operative mortality, supporting an expedient cystectomy as the overall safest and most effective approach.

SURGICAL TECHNIQUE

Perioperative Care

Life-style factors that contribute to the development of bladder cancer, such as smoking, also contribute to cardiovascular and pulmonary disease. Evaluation and optimization of cardiac and pulmonary function are essential before a cystectomy. Pulmonary toilet, bronchodilators, occasionally steroids, and idealized cardiac function will lessen the risk for perioperative complications.

Preoperative stoma marking by an enterostomal therapist is a necessity. Body habitus and previous surgery may require placement of the stoma in an unusual site. Improper placement of the stoma transforms an otherwise successful operation into a nightmare for the patient.

Poor nutrition is an important risk factor for perioperative complications. Routine perioperative parental nutrition is not necessary in the well-nourished patient; however, if a complication does occur that delays prompt resumption of eating, there should be no hesitation to institute enteral or parenteral feeding. In our experience, approximately 10% to 15% of patients need postoperative nutritional support.

Either GOLYTELY (Braintree Laboratory, Braintree, MA) or Phosphosoda (Fleet Corporation, Lynchburg, VA) solutions are used as a single-day bowel prep. Perioperative antibiotics for wound prophylaxis relies on a second-generation cephalosporin. Patients without medical problems requiring special monitoring are admitted to the hospital the same day as the surgery.

Intraoperative anesthesia monitoring allows prompt recognition of hypoxemia or hypovolemia during the case. Epidural analgesia, patient-controlled analgesia (PCA), and nonsteroidal anti-inflammatory agents are useful adjuncts to provide better postoperative pain control, which translates into better pulmonary hygiene, ambulation, and return of bowel function.

Intermittent compression stockings are currently used for deep venous thrombosis (DVT) prophylaxis. Early ambulation and a high index of suspicion for DVT are important.

Establishment of a “care” or “critical” pathway is useful for cystectomy patients.4 Compliance with the ideal postoperative course is difficult after cystectomy because of a high frequency of comorbid disease and complications, which may delay discharge even if they are not life-threatening. Nonetheless, the pathway provides a target for the patient, physicians, and nursing staff for anticipated events during the hospital course.

Operative Technique

Access to the urethra and vagina is necessary during a female cystectomy. A modified lithotomy position is used with either Allen or Lloyd–Davies stirrups. Careful padding to prevent pressure points, which may cause a perineal nerve compression or anterior compartment syndrome, is important. The vagina and perineum must be well prepped.

A vertical midline incision gives ideal exposure. The urachal remnant provides a convenient handle for traction on the bladder. The peritoneum is divided along the lateral umbilical ligaments, and the round ligament is clipped and divided. Usually, the fallopian tubes and ovaries are present but nonfunctional and thus are removed with the uterus and bladder after dividing the gonadal vessels above the ovaries. The ureters are mobilized with a large amount of periureteral adventitial tissue to preserve optimal blood supply and divided. Typically, a pelvic lymphadenectomy is performed with the following boundaries: the lateral limit is the genitofemoral nerve, the superior limit is the bifurcation of the common iliac artery, the inferior limit is the inguinal ligament, and the medial limit is the perivesical tissue. The following maneuver isolates the lateral blood supply to the bladder and uterus coursing from the internal iliac artery and vein: expose the endopelvic fascia and the perirectal “fat pad”; with medial traction on the bladder and ureter, develop bluntly with the index finger a plane just medial to the well-defined superior vesicle artery, aiming obliquely toward the perirectal tissue. This will isolate the superior vesicle artery, which needs to be ligated separately, and many small arteries and veins, which are controlled with Ligaclips “marching down” the lateral pedicle under direct vision. Medical traction on the bladder with fingers above and below the pedicles enhances exposure.

After division of the lateral pedicles on each side, the technique is modified depending on the amount of perivesical soft tissue to be removed with the bladder. In a classical anterior pelvic exenteration, the bladder, uterus, bilateral fallopian tubes and ovaries, anterior vaginal wall, and urethra are removed en bloc. This is warranted for an invasive posterior bladder wall cancer in which orthotopic urinary diversion is not planned.

After division of the lateral pedicles on both sides, an incision is made in the peritoneum down to the rectal vaginal cul-de-sac. Blunt dissection in the midline mobilizes the posterior vaginal wall; this mobility will allow the posterior vaginal wall to be rolled anteriorly for vaginal reconstruction.

A Betadine-soaked sponge is placed in the vagina, elevating the apex of the vagina just posterior to the cervix. Cautery is used to open the apex of the vagina in the midline; this incision is carried laterally down the anterior vaginal wall on each . Venous bleeding from the incised vaginal wall and adjacent tissue may be heavy, and multiple suture ligatures with 2-0 Vicryl provide for hemostasis . This dissection continues to near the bladder neck. The endopelvic fascia is not opened now; the dissection moves to the perineum after reasonable homeostasis has been ensured in the pelvis.

The labia are retracted laterally with suture ligatures. Army–navy retractors or a self-retaining retractor provides exposure to the urethral meatus. An inverted U-shaped incision is made around the urethra and the urethra is mobilized anteriorly and laterally. Returning to the pelvic approach, the endopelvic fascia is incised on each side. Suture ligatures are placed in the venous plexus anterior to the urethra, analogous to control of the dorsal venous plexus in men. Then, from below, the anterior vaginal wall posterolateral to the urethra is divided to connect with the pelvic dissection, which allows removal of the entire specimen.

The vagina is reconstructed by rotating the apex of the posterior vaginal wall anteriorly to create a foreshortened vagina that maintains the previous width. A stay suture in the apex of the posterior vaginal wall brings the vaginal wall to the perineum; this flap of vagina is sutured to the periurethral vaginal tissue anteriorly in the midline and then sequentially on each side. After two to three interrupted sutures are placed on each side from the perineum, additional sutures higher up on the vaginal wall are more easily placed from the pelvic exposure. A watertight closure provides optimal homeostasis of the paravaginal tissue. Closed-suction drains are left in the pelvis and brought out through separate stab wounds on the abdominal wall. A vaginal pack soaked in Betadine is left in the vagina for 24 hours.

For a tumor located high on the posterior wall, and when orthotopic diversion is anticipated, the uterus may be removed en bloc with the bladder, but the anterior vaginal wall need not be removed. For a non- or minimally invasive cancer in the bladder and planned orthotopic diversion, the uterus need not always be removed, and a plane can be established between the posterior bladder wall and the anterior vaginal wall. Care must be taken to enter the proper plane adhering to the anterior vaginal wall. Dissection too close to the bladder causes additional bleeding.

If the urethra is to be used for reconstruction, the above dissection must be modified. The key points are: (a) do not open the endopelvic fascia and thus avoid disruption of the support of the external sphincter; (b) avoid dissection of the lateral wall of the vagina to prevent injury to the neurogenic innervation of the rhabdoid sphincter; and (c) remove the bladder neck entirely to minimize postoperative urinary retention.

Once the bladder has been mobilized off the vagina down to the bladder neck, fine sutures are used anteriorly in the periurethral tissue as necessary for homeostasis of the venous plexus. The urethra is amputated sharply at the junction with the bladder neck, avoiding distal mobilization or dissection of the urethra (Fig. 24-10). After the bladder has been removed, exposure is ideal for the enterourethral anastomosis, using fine absorbable sutures with small bites on the urethra; eight to ten sutures are generally necessary using 3-0 Monocryl. Mobility of the intestinal reservoir to the urethra is not a problem in the woman as it may be in the man.

In the initial experience with orthotopic diversion, the concern for stress incontinence was such that anterior urethral fixation sutures were placed to prevent hypermobility of the urethra. This maneuver is not only not necessary (unless documented stress incontinence from hypermobility is evident preoperatively) but is probably counterproductive by contributing to increased urinary retention or “hypercontinence.”

A possible additional mechanism for postoperative urinary retention may be exacerbation of a preexisting but previously insignificant cystocele. After the cystectomy, the urethra is fixed anteriorly, and the patient voids by Valsalva maneuver after relaxing the external sphincter. If a cystocele is present, the increased abdominal pressure needed for voiding across the fixed urethra and bladder neck could be blunted by the cystocele. This particular circumstance has been noted as a possible contributing factor for urinary retention in two of our first eight female patients undergoing orthotopic diversion. Confirmation of the pathophysiology, appropriate preoperative recognition, and preventative measures useful at the time of reconstruction are lacking.

Postoperative Care

Excellent pain control, early ambulation, judicious use of diuretics as needed to combat fluid retention, and pulmonary toilet are important. If a conduit has been used for the diversion, the conduit is kept decompressed with a catheter for 6 to 7 days. If a neobladder or continent cutaneous diversion is used, the catheter is left indwelling for 3 weeks and is removed in the outpatient area. A cystogram is no longer routinely obtained. Education of the inpatient nursing staff and the patient on frequent irrigation of the catheter to prevent plugging by mucus is crucial.

OUTCOMES

Complications

A cystectomy is a difficult operation. Under the 1995 relative value (RVU) scale rating, cystectomy and continent diversion are ranked as the most difficult procedures in urology, ranked at 75.44 RVUs compared with 54.27 for radical retropubic prostatectomy and 40.80 for radical nephrectomy. A mortality rate of 1% to 2% is feasible and should be a standard to strive for. Twenty to thirty percent of patients will have a complication delaying discharge. Currently, our mean and median length of stay for 15 women undergoing cystectomy in 1995 and 1996 was 9.4 and 8.5 days, respectively (range 7 to 16 days), including six with an orthotopic diversion. Many of the specific complications after a cystectomy are a consequence of the urinary diversion and thus beyond the specific scope of this chapter. Complications from the cystectomy include bleeding and subsequent coagulation abnormalities and rectal injury. In my experience, female cystectomies tend to be associated with more blood loss than those in men, and although special blood products such as platelets and fresh frozen plasma are rarely needed, they may be lifesaving. A rectal injury should be extremely rare in women and seen only in association with previous surgery or radiation therapy. The postoperative care after cystectomy requires a diligence over and above that seen with other urologic procedures. Some complications are preventable. A regimented, reproducible “game plan” for the technique of cystectomy and diversion is enormously helpful to prevent errors during a 4 to 6 hour operation. Some complications are not preventable, but recognition early in their evolution may drastically minimize the negative consequences, and a high index of suspicion is essential. Early recognition of a complication may prevent a cascade of other successive complications, which may ultimately lead to more morbidity or the patient’s death.

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: