Bladder anatomy

• Arterial supply: Superior and inferior vesical arteries (from internal iliac artery)
• Venous return: Vesical venous plexus (will see when bladder is lifted) -> internal iliac veins
• Nerve (sympathetic): sup/inf hypogastric plexus
• Nerve (parasympathetic): inf hypogastric plexus, pelvic splanchnic n.
• Lymphatic drainage
  • Level I: interal iliac, obturator, external iliac
  • Level II: common iliac, presacral
    • 7% of the time bladder cancer can skip to level 2 without level 1 involvement
  • Level III: para-aortic, interaortocaval, paracaval
    • Generally have level I/II involvement as well

Radical cystectomy: Gold standard for muscle-invasive, non-metastatic bladder UC.

• Removal of bladder and pelvic lymph nodes, with prostate+seminal vesicles in men, or +/- anterior vagina+uterus/fallopians/ovaries in women
  • Surgical video - robotic anterior exenteration/cystectomy 
  • Skinner cystectomy
  • Surgical atlas - neobladder (PDF) (W shape Hautman; Skinner does U shape Studer)
    • Studer neobladder: 
      • 
  • Indiana pouch - surgical steps, BCAN patient comments, tips from Indiana
• Indications
  • Muscle-invasive cancer (T2 and above)
  • Recurrent non-muscle-invasive (failed resection/intravesical BCG, esp. if failed 2x)
  • High-grade T1 lesions a/w CIS/LVI/variant histologies (if long life expectancy, or multiple/large tumors)
• Partial cystectomy can be performed if able to achieve negative margins (eg bladder dome or diverticulum), no prior hx of bladder tumors, no prostate involvement
  • **hide**But prostate cancer found in 23-54% of RC specimens; 17-75% had UC involving prostate
  • **hide**Gynecologic UC involvement in < 5%
  • Not recommended if able to have RC
• **hide**Intraoperative frozen-section of ureteral margin - negative margin after positive margin still had higher risk of upper tract recurrence; should still attempt for negative margin

Pelvic lymph node dissection (PLND) should be performed with radical and partial cystectomy.

• Standard PLND - up to level I (external iliac, internal iliac, obturator)
• Extended PLND - up to level II (common iliac, presacral)
• Super-extended PLND - up to level III (para-aortic, interaortocaval, paracaval)
  • Extended/super-extended PLND traditionally thought to improve survival by removing more micrometastatic disease, but recent (2023) SWOG 1011 randomized phase 3 trial showed no survival benefit to extended dissection; increased toxicity (54% vs 44% adverse events, 7% vs 2% death within 90 days).
• Goal - 25-node minimum (75% chance of identifying 1+ LN metastasis; retrospective data)
• 15% of T2 (presumed N0) disease undergoing cystectomy will have node-positive disease

Female anatomy - uterine artery

Internal iliac artery anatomy

 Urinary diversion:

• No overall difference in QoL between methods, but limited data.
• Bowel prep (e.g. Nichols prep) not necessary if using small bowel.
• Ideal reservoir is
  • Non-refluxing
    • Refluxing ureteral anastomosis has lower stricture rate, but recommend anti-refluxing for continent diversion
    • In intermediate term, anti-refluxing does not appear to be necessary for upper tract preservation or UTI prevention
  • Low-pressure (detubularize the bowel)
  • Continent
  • Non-absorptive
• Bricker (independent ureteral anastomosis) vs. Wallace (ureters spatulated and anastomosed together to ileum) : no difference in stricture rate.
• If using ileum, start ~15-20 cm proximal to ileocecal valve to preserve salt absorption.

Complications of bowel in the urinary tract

• Depends on length of conduit, segment of intestine, duration of contact (continent vs non-continent)

Complications of conduit diversion (10-20%)

• Bowel - obstruction, fistula, abscess
• Renal failure
• Recurrent UTI (bowel is chronically colonized), pyelonephritis
• Parastomal hernia or stomal stenosis
• Anastomotic strictures
• Stones from UTI, mucus, acidosis/hypokalemia, dehydration from diarrhea
  • Staple lines can be nidus for stones
  • Mucus: colon > ileum > stomach; increased with dairy
  • Diarrhea after bowel resection; treat with cholestyramine
• Renally excreted drugs can be reabsorbed
  • Methotrexate - drain diversion during chemo; alkalinize the urine and hydrate
• Interesting technical article on PCNUs for conduit leaks

ERAS protocol (Early Recovery after Surgery) - hopsital stay 3-5 d instead of 8-10; early fluids/feeding. Entereg/almivopan - blocks narcotic effect on bowel

Stanford: ***update with new pathway

• Pre-op abx: cefoxitin

• If going home with JP drain - remove if < 100 ml/day

PAVA:

• Pre-op abx: cefoxitin
• Similar to Stanford, just 1 day slower for diet

• Ureteral stents x 1 week

Post cystectomy surveillance

• Years 1-2:
  • LFTs/BMP q3-6 mo
  • CT IVP q3-6 mo
  • CXR/CT chest q3-6 mo
  • Urine cytology q6mo
• Years 3-5: LFTs + B12, CT IVP, CXR/CT chest annually
• Years 5-10: B12, renal US to monitor for hydronephrosis annually
• PET/CT only if metastasis suspected