Материал: Oxford American Handbook of Urology ( PDFDrive )

MANAGEMENT OF SUPERFICIAL UC 259

BCG infection (BCGosis), especially if BCG is administered in a setting of recent surgery or traumatic catheterization, can be seen in a small percentage of patients. They develop a high, persistent fever, requiring antituberculous therapy for up to 6 months with isoniazid and pyridoxine, or standard triple therapy (rifampicin, isoniazid, and ethambutol) in critically ill patients. Granulomatous prostatitis and epididymo-orchitis are rare complications.

Contraindications to intravesical BCG

•Immunosuppressed patients

•Pregnant or lactating women

•Patients with hematological malignancy

•After a traumatic catheterization

•Active UTI

Cystoscopy done too early after BCG can produce alarming-looking effects because of the generalized inflammatory response. Follow-up cystoscopy and biopsy 3 months after BCG may still reveal chronic granulomatous inflammation.

Maintenance BCG (e.g., treatment every 3 months and then every 6 months for 3 years after the initial 6-week course or monthly regimen) demonstrated a benefit for superficial UC, excluding CIS, compared with a single 6-week course.

Maintenance may be associated with a higher risk of side effects.

Recurrent G3T1 UC or CIS

A second course of BCG could be offered; 50% of patients will respond. Otherwise, proceed without delay to radical cystectomy. The latter has a cure rate of 90%.

260 CHAPTER 6 Urological neoplasia

Muscle-invasive bladder cancer: surgical management of localized (pT2/3a) disease

This is a dangerous disease; untreated 5-year survival is 3%. In the absence of prospective randomized trials comparing the surgical and nonsurgical treatments, the options for a patient with newly diagnosed confined mus- cle-invasive bladder cancer are as follows.

Bladder preservation

•Radical transurethral resection of bladder tumor (TURBT) plus systemic chemotherapy, mostly done in setting of clinical trial at present or in patients clearly unfit for radical cystectomy. With hydronephrosis, bladder preservation relative contraindication.

•Palliative TURBT palliative radiotherapy (RT): for elderly/unfit patients

•Partial cystectomy in highly selected patients without evidence of CIS

•TURBT plus definitive RT (see p. 264): poor options for SCC and adenocarcinoma as they are seldom radiosensitive

Radical cystectomy with:

•Ileal conduit urinary diversion

•Continent urinary diversion (orthotopic neoblader or catherizable stoma)

•Neoadjuvant chemotherapy: some evidence of benefit (see p. 264)

•Neoadjuvant RT: no evidence of benefit

Partial cystectomy

A good option for well-selected patients with small solitary disease located near the dome, and for urachal carcinoma. Morbidity is less than with radical cystectomy.

The surgical specimen should be covered with perivesical fat, with a 1.5 cm margin of macroscopically normal bladder around the tumor. There should be no biopsy evidence of CIS elsewhere in the bladder.

The bladder must be closed without tension and catheterized for 7–10 days to allow healing. Subsequent review cystoscopies ensure no tumor recurrence.

Radical cystectomy with urinary diversion

This is the most effective primary treatment for muscle-invasive UC, SCC, and adenocarcinoma, and can be used as salvage treatment if bladder preservation has failed. It is also a treatment for G3T1 UC and CIS, refractory to BCG.

However, this is a major undertaking for the patient and surgeon, requiring support from cancer specialist nurse, stoma therapist, or continence advisor.

MUSCLE-INVASIVE BLADDER CANCER 261

The procedure

Some centers are exploring laparoscopic radical cystectomy with urinary diversion. However, it is not currently considered the standard of care. Standard open surgical radical cystectomy is described.

Through a midline abdominal transperitoneal approach, the entire bladder is excised along with perivesical vascular pedicles, fat, and urachus, plus the prostate or anterior vaginal wall. The anterior urethra is not excised unless there is prior biopsy evidence of tumor at the female bladder neck or prostatic urethra (when recurrence occurs in 37%).

The ureters are divided close to the bladder, ensuring their disease-free status by frozen-section histology if necessary, and anastomosed into the chosen urinary diversion (see p. 266).

A bilateral pelvic lymphadenectomy is undertaken at the time. The extent and completeness of the lymphadenectomy can have important therapeutic implications.

Node burden (>8 positive) and node density, the ratio of involved nodes to total lymph nodes (>20%) has worse prognosis

Major complications

Affect 25% of cystectomy patients. These include perioperative death (1%), re-operation (10%), bleeding, thromboembolism, sepsis, wound infection/ dehiscence (10%), intestinal obstruction or prolonged ileus (10%), cardiopulmonary morbidity, and rectal injury (4%).

Erectile dysfunction is likely in men after cystectomy due to cavernosal nerve injury.

The complications of urinary diversion are discussed on p. 266.

Postoperative care

Monitoring in the intensive care unit for 24 hours is considered standard at most centers.

Daily clinical evaluation, including inspection of the wound (and stoma if present), plus monitoring of blood count and creatinine/electrolytes, is mandatory. Broad-spectrum antimicrobial prophylaxis and thromboembolic prophylaxis with TED stockings, pneumatic calf compression, and subcutaneous heparin are standard.

Assisted ambulation after 24 hours is ideal. Chest physiotherapy and adequate analgesia is especially important in smokers and patients with chest comorbidity. Oral intake is restricted until bowel sounds are present; some patients may require parenteral nutrition in the presence of gastrointestinal complications.

Drains are usually placed in the pelvis or near the ureterodiversion anastomosis. Ureteral catheters passing from the renal pelves through the diversion and exiting percutaneously or through the stoma are used. If a continent diversion is performed, a catheter draining the diversion will be exiting urethrally or suprapubically.

Most patients are hospitalized 7–10 days.