9th International EAUN Meeting

Metastatic Urological Cancers

28 March 2008

9th International EAUN Meeting

Urothelial Cell Cancer

State of the Art

Laparoscopic Cyst(oprostat)ectomy with

Bricker urinary derivation  Dr. L. Fossion, M.D., urologist, FeBU

Maxima Medical Center, Veldhoven, The Netherlands

ContentIntroduction: Urothelial Cell Cancer (UCC) = bladder cancer

Indications for surgery

Surgical procedure: Open Radical Cyst(oprostat)ectomy (ORC) Laparoscopic Radical Cyst(oprostat)ectomy (LRC)

Advantages of laparoscopy

Results

Complications

Follow up

Szent GyorgiNobel price of medecine 1953

There is only one way to avoid mistakes, it is to do nothing or at least to avoid doing something

new.State of the Art

Laparoscopic Cyst(oprostat)ectomy

with Bricker urinary derivation  Dr. L. Fossion, M.D., urologist, FeBU

Urothelial Cell Cancer (UCC)

• Frequency: 5th malignancy in Europe.• In Western World ~ in 95% UCC.• Intermittent, silent haematuria in 85-90%.• ♂ / ♀ : 2,5 / 1.• Typicaly in the 6th and 7th decade.• Before the 5th decade ~ good prognosis.

Introduction: Bladder Cancer

Risk Factors

• Sigarets(25-60%).• Carcinogen-exposure(20-25%): chemicals,

rubber, textile, hair dyes, mineworkers, painters and

truckdrivers. Analgetics(phenacetine), ifosfamide and

cyclofosfamide. High doses saccharine and

cyclamate (= artificial sweeteners).

• Previous pelvic radiotherapy.• Hereditary. • Schistosomiasis (bilharziasis)

< in the Middle-East and Africa.

Technical Examinations

• Urine analysis• Urine cytology• US kidneys and bladder• Cystoscopy• CT-scan uro• X-ray Tx or CT Tx• Bone scan

Trans-Urethral Resection of Tumor

T-stageHistologic gradeType of tumorMetastases

TNM-Classification

The penetration depth of the tumor in the bladder wall is

prognostic the main factor for urothelial cell carcinoma(UCC).

Histopathologic grade:G1 : Well differentiated

G2 : Moderately differentiated

G3 : Poorly differentiated

CIS: Carcinoma in situ

+

Therapeutic options for UCC

Non-invasive UCC

TURT40 mg MMC bladder instillation

Second (re-)TURT

Follow-upMaintenance: MMC or BCG

Invasive UCC

TURT

Cystectomy

Radiotherapy

Chemotherapy

EORTC 30994

Indications for Radical Cystectomy

Tumorinvasion in the detrusor, UCC - T2 G I-II

Recurrent, high grade, non-invasive tumor - T1 G III

Multiple, recurrent non-invasive UCCCIS resistent to BCGCIS in the prostatePrimary adenoca, squameuscellca, sarcoma, μ-papillary UCC

Salvage cystectomy post-radiotherapyCystectomy as palliation in symptomatic patientsRadiocystitis or interstitial cystitis

Prognosis

Tumor stage pTa pT1 pT2 pT3 N+

5 yrs survival 88-90% 90% 46-78% 18-58% 50%

Stage, tumor ø and multifocality ~ recurrence and progression.

CAVE tumors > T2 in 30-80% occult metastases.

Types of Urinary Derivations

• Incontinent:– Nephrostomy– Ureterocutaneostomy with 1 or 2 stoma’s– Uretero-ileostomy or Bricker urostoma

• Continent:– Kock pouch = uretero-ileo-sigmoidostomy– Benchekroun pouch– Mainz pouch = ileocaecal pouch with ileal nipple– Indiana pouch = appendico-ileocaecal segment– Mitrovanoff = appendicovesicostomy– Neobladder with urethro-neovesical anastomosis:

• Mansoura• Hautmann• Studer

Ileal Conduit Indiana Pouch Reservoir Neobladder + Urethral-anastomose

Catheterisable

ContinentIncontinent Continent

Urinary Derivations

Orthotopic NeobladderHeterotopic Urinary Derivation

Open Radical Cystectomy

Median LaparotomyOpening cavum Retzius

Clipping the bladder and the prostatic pedicles

= posterior dissection

Urethral dissection

Anterior dissection of the bladder

Lap. Radical CystoprostatectomyThe new golden standard?

Lap. Radical Cystoprostatectomy

Laparoscopic part: placement of the ports intraperitoneally• Opening of the peritoneal fold + perform a bilateral ext. PLND• Dissection till you see the pelvic floor (muscles)• Divide the hypogastric vessels/arteries and both ureters• Connecting the posterior peritoneal fold 2 cm above the Douglas pouch• Search for the 2 vasa deferentiae and seminal vesicles on the midline• Prevesical clipping of the ureter, but not intramural• Transection/sealing of both the vesical and the prostatic pedicles• Creation of the extraperitoneal space (Retzius) with the balloon• Transection of the urachus + umbilical cords + anterior peritoneal fold• Apical prostatectomy and clipping of the urethra

Open part:• Extraction of the specimen in the endobag• Connection of both infra-and supra-umbilical scars = mini-laparotomy• Creation of Bricker urostoma

Videofragment LRC

Advantages & disadvantages of LRCOutcome Criteria Lap Rad Cystectomy Open Rad Cystectomy

Blood Loss Decreased (~300 ml) Significant (1500–

1800 mL)

Perop fluid loss Decreased Significant

Postop pain Decreased Can be significant

Bowel functions Quick return Prolonged ileus

Postop recovery Days Weeks

Return to full activity Weeks Months

Operative time 5-13 hours 3-5 hours

Technical difficulty Highly advanced Advanced

Cost Expensive Relatively cheaper

Long term outcome Promissing to be equal Proven

Cosmetic Smaller scars Laparotomy

Results

Fossion L. et al Ileal conduit 10 Assisted 7,4 800 4 14 1 uretero-ileal stricture + 1 wound herniation + 1 gastric necrosis

But…

TrainingProblem solving

Postoperative complications

• Mortality: 1-2%• Morbidity from cystectomy:

– Blood loss– Rectal injury– Vascular injury

• Morbidity from urinary derivation:– Intestinal obstruction: bowel ileus– Intestinal or urinary fistula

• Morbidity from surgery:– Lung emboly– Cardiac ischemia– Renal insufficiency

Physiology

Creation of a neobladder using bowel: if the segment > 60 cm: Increase of bowel transit Malabsorption of bilary salts Steatorrhea, diarrhea Bacterial overgrowth Prolonged contact of hypo-osmolary urine with the reservoir

Hypovolaemic salt loosing Deshydratation Reabsorption of ammonium and chloride

Hyperchloraemic, hypokaliaemic metabolic acidosis

Results of metabolic acidosis:• Buffering of the skeleton (Ca2+)• Impairment of Vit D-synthesis• Increase of osteoclastic activation bone pain• Alk Fosfatasis

Bone disorders

Late complications

• Steatorrhea < bilary salt and fat malabsorption• Vit B-12 malabsorption pernicious anemia• Metabolic acidosis• Elektrolyte disorders• Renal insufficiency

– Reflux nephropathy– Stenosis at the ureteroneovesical level

obstructive nephropathy• Stone formation < mucus, UTI and stasis• Enuresis nocturna & hypercontinent neobladder

Some facts…

• 50-70% of all stoma-patients will have to deal with peristomal problems…

• Continent stomas are continent in 95%

• 40% of all continent stomas need surgical correction

• In 5% of all reservoirs a neoformative cancer occurs < nitrosamines

Follow-up after Urinary Derivation

• Annual renal function evaluation• Labo: Hb, Hct, leuco’s, creat, Na, K, Cl, venous BG, Vit B-12,

AF, Ca2+, P, PTH

• US kidneys to exclude hydronephrosis• Urinary culture in case of fever• X-ray abdomen if suspect for urolithiasis / ileus• Encourage your patient to drink• Annual CT abdomen + X-ray Tx

oncological follow-up

Take home messages

Maxima Medical Center, VeldhovenThe Netherlands

Conclusion

• Laparoscopic cystectomy is the future• Advantages in this group of patients is

obvious• Advanced laparoscopic skills are

mandatory• Derivation: keep it simple!• Centralisation in specialised centers• Surgery = teamwork• Patient Care = teamwork• Encourage the younger generation!

9th International EAUN Meeting

Urothelial Cell Cancer

State of the Art

Laparoscopic Cyst(oprostat)ectomy with

Bricker urinary derivation  Dr. L. Fossion, M.D., urologist, FeBU

Maxima Medical Center, Veldhoven, The Netherlands