Editing Cystectomy (section)

== Intra-operative Decision Making ==

=== Clinical T4b ===
* '''Biopsy can be performed to confirm histology. If positive for urothelial carcinoma, chemotherapy should be initiated followed by consideration of radical cystectomy'''

=== Grossly positive nodes ===
* '''If adenopathy is encountered at the time of cystectomy, a frozen section should be taken to confirm metastasis, and radical cystectomy with extended lymph node dissection and should be completed when feasible'''
** '''Cystectomy is not performed when'''
**# '''Lymph node metastases are unresectable (because of bulk)'''
**# '''Extensive periureteral disease'''
**# '''Bladder is fixed to the pelvic sidewall'''

=== Intraoperative ureteral tumor ===
* '''The finding of a papillary lesion at the ureteral margin requires on-the-table flexible ureteroscopy to fully ascertain the extent of tumors in the system prior to planning the correct therapy.'''
** If only CIS or dysplasia is present, intraoperative endoscopy is not indicated, because visual identification of CIS is unlikely.
** If on-the-table ureteroscopy shows no additional tumors, resect until negative margins are obtained. Nephroureterectomy and extensive ureteral resection would only be performed if the ureteroscopy demonstrated tumors at more proximal location.

=== Intraoperative Frozen Sections of the Ureter ===
* '''The distal ureter is involved with tumour on final pathology ≈6-8% at the time of radical cystectomy'''
* '''Intraoperative frozen-section analysis of the ureters at the time of cystectomy remains controversial. Patients with ureteral disease at the time of cystectomy experience an increased risk of upper tract recurrence regardless of margin status, but this risk can be partially mitigated by achieving a negative margin'''
** Final ureteral margin status has proven to be an independent predictor of upper tract recurrence following cystectomy. However, the overall incidence of upper tract recurrence following cystectomy is a relatively rare event ranging from 2-8%.
*** Risk factors for upper tract recurrence following cystectomy:
**** Bladder CIS
**** Distal ureteral involvement with tumor
**** High-grade pTa-T1 disease.
* There is no definitive recommendation for the length of the distal ureter that should be removed at the time of surgery

=== Urethrectomy ===

==== Urethral Involvement ====
*'''<span style="color:#ff0000">Males</span>'''
**'''<span style="color:#ff0000">Urethral recurrence</span>'''
***Epidemiology
****Overall risk of urethral recurrence following cystectomy is ≈7% at 5 years and 9% at 10 years.
****Recurrences are observed at a median of 2 years after cystectomy (range 0.2-13 years)
*** '''<span style="color:#ff0000">Risk factors</span>'''
****'''<span style="color:#ff0000">Involvement of the prostatic urethra</span>''' 
*****Absolute risk increase 6% at 5 years (11% men with any prostate involvement vs. 5% men without any prostate tumour involvement
****** '''Patients with documented prostatic mucosal, ductal, or stromal invasion [found at TURBT of the primary tumour] should be counselled about the increased risk of urethral recurrence if the urethra is left in situ to help them weigh that risk against any perceived advantage of an orthotopic diversion'''
*****'''Extent of prostatic tumor involvement correlates with the risk of subsequent urethral recurrence.'''
****** 5-year risk of urethral recurrence 18% pT2 (stromal invasion) vs. 12% CIS or pT1 (mucosa and ductal prostatic urethral involvement)
******* Isolated prostatic stromal involvement is unusual in the absence of nodal disease
******'''In general, those with prostatic stromal invasion are counseled to undergo neoadjuvant chemotherapy'''
*******In those who are not candidates for neoadjuvant chemotherapy or who have persistent prostatic urethral involvement, at surgery a concomitant urethrectomy and cutaneous form of diversion are recommended. 
**** Other risk factors with mixed results
*****Presence of papillary tumours
*****Multifocality
*****Trigone or bladder neck involvement
*****CIS 
******'''The presence of [bladder] CIS or a multifocal tumor should not preclude orthotopic diversion'''
**** '''Some evidence suggests that orthotopic diversion itself may provide some protection against urethral recurrence'''
*****Close surveillance of the urethra is mandatory if a neobladder procedure is performed, with periodic urethral wash cytology and urethroscopy as indicated.
* '''<span style="color:#ff0000">Females</span>'''
** '''<span style="color:#ff0000">Risk factors for urethral involvement (3):</span>'''
**# '''<span style="color:#ff0000">Tumour involving bladder neck</span>'''
**#* In one study, ≈50% of women with bladder neck tumors had a normal (tumor-free) proximal urethra. No patient with a normal bladder neck demonstrated tumor involvement of the urethra. In all cases, intraoperative frozen-section analysis of the proximal urethra correlated with and was correctly confirmed by final permanent section. These results suggest that one may depend on the intraoperative frozen section to determine the feasibility of orthotopic diversion.
**# '''<span style="color:#ff0000">Tumour invading anterior vaginal wall</span>'''
**#* '''Vaginal wall involvement is best evaluated on bimanual examination under anesthesia at the time of TURBT or cystectomy.'''
**#* Anterior vaginal wall involvement by a posterior-based bladder tumor or bladder neck or urethra involvement is a contraindication to urethra sparing and orthotopic bladder replacement because one cannot get an adequate distal vaginal margin and urethra margin
**#'''<span style="color:#ff0000">Inguinal lymphadenopathy</span>'''

==== Indications ====

===== AUA =====
*'''<span style="color:#ff0000">2020 AUA MIBC guidelines:[https://pubmed.ncbi.nlm.nih.gov/28456635/]</span>'''
*# '''<span style="color:#ff0000">Males with invasive cancer at the apical urethral margin'''
*#'''<span style="color:#ff0000">All females not receiving neobladder</span>''' to reduce risk of positive surgical margin or tumor recurrence (different than CUA)
*#

===== CUA =====
*'''<span style="color:#ff0000">2019 CUA MIBC guidelines:</span>[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6737737/]'''
*# '''<span style="color:#ff0000">Positive urethral margin</span>'''
*# '''<span style="color:#ff0000">Males with:</span>'''
*## '''<span style="color:#ff0000">High grade or invasive urethral disease distal to the prostatic urethra</span>'''
*## '''<span style="color:#ff0000">Suspected prostatic stromal involvement</span>'''
*# '''<span style="color:#ff0000">Females with bladder neck tumours</span>''' (note CUA does not include tumour invading anterior vaginal wall)

===== Campbell’s =====
* '''Males'''
** '''Absolute (2):'''
**# '''Positive urethral margin'''
**#* '''If a frozen section of the urethral margin is positive, an orthotopic neobladder is contraindicated'''
**#** '''When an orthotopic neobladder is to be constructed, frozen sections need to be done at the level of the urethral section margin in males and females. Conversion to a cutaneous diversion with immediate urethrectomy is mandatory if the frozen sections turn out to be positive§'''
**#* '''While preoperative evaluation of the prostatic urethra via transurethral biopsy can be performed''' (TUR biopsies of the prostate, preferably at the 5- and 7-o’clock positions lateral to the verumontanum, at the time of TURBT of the primary bladder tumor) to further characterize the risk of urethral recurrence and help dictate intraoperative management of the distal urethra and choice of urinary diversion, '''the sensitivity and specificity of transurethral biopsy is moderate with a relatively low positive predicate value compared to final cystoprostatectomy specimens'''.
**# '''Presence of CIS or urothelial carcinoma in the prostatic urethra, glands or stroma [different than CUA Guidelines]'''
** '''Relative (1):'''
**# '''Patients that undergo other types of diversions (incontinent, continent cutaneous), even when no poor prognostic factors are present because the risk of urethral recurrence is always present'''
* '''Females'''
** Unless indicated, a complete urethrectomy can be omitted at the time of cystectomy allowing for orthotopic bladder substitution in women
** '''Absolute (3):'''
**# '''Positive urethral margin'''
**#* Frozen-section analysis of the distal urethra has demonstrated high correlation with final urethral margin and should be performed in all women in which orthotopic bladder substitution is being considered
**# '''Tumour involving bladder neck'''
**#* Although tumor presence at the bladder neck is significantly associated with urethral involvement, ≈60% of patients with tumors in this location will not have a tumor in the urethra on final pathology and therefore controversy exists with regard to an absolute need for complete urethrectomy in this setting
**# '''T4 tumors involving the urethra and/or vagina [different than CUA Guidelines]'''

==== Approach ====
*Urethrectomy is ideally done through a prepubic approach

==== Delayed urethrectomy ====
* '''<span style="color:#ff0000">Absolute indications (3):</span>'''
*# '''<span style="color:#ff0000">Urethral cytology washing becomes positive</span>'''
*# '''<span style="color:#ff0000">A patient develops bloody discharge</span>'''
*# '''<span style="color:#ff0000">Local recurrence is clinically obvious in the perineum or penis</span>'''