Cystectomy: Difference between revisions
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=== Clinical T4b === | === Clinical T4b === | ||
* '''Biopsy can be performed to confirm histology. If positive for urothelial carcinoma, chemotherapy should be initiated followed by consideration of | * '''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 === | === Grossly positive nodes === | ||
* '''If adenopathy is encountered at the time of cystectomy, a frozen section should be taken to confirm metastasis, and | * '''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''' | ** '''Cystectomy is not performed when''' | ||
**# '''Lymph node metastases are unresectable (because of bulk)''' | **# '''Lymph node metastases are unresectable (because of bulk)''' | ||
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=== Intraoperative Frozen Sections of the Ureter === | === Intraoperative Frozen Sections of the Ureter === | ||
* '''The distal ureter is involved with tumour on final pathology ≈6-8% at the time of | * '''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''' | * '''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%. | ** 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%. | ||
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**# '''<span style="color:#ff0000">Local recurrence is clinically obvious in the perineum or penis</span>''' | **# '''<span style="color:#ff0000">Local recurrence is clinically obvious in the perineum or penis</span>''' | ||
== | == Adverse Events == | ||
=== <span style="color:#ff0000">Intra-operative</span> === | === <span style="color:#ff0000">Intra-operative</span> === | ||
# Risks of general anesthesia (stroke, myocardial infraction, thrombosis) | # '''Risks of general anesthesia (stroke, myocardial infraction, thrombosis)''' | ||
# Injury to adjacent organ (nerves, bowel, rectum) | # '''Injury to adjacent organ (nerves, bowel, rectum)''' | ||
# Bleeding +/- transfusion | # '''Bleeding +/- transfusion''' | ||
=== <span style="color:#ff0000">Early post-operative</span> === | === <span style="color:#ff0000">Early post-operative</span> === | ||
# Gastrointestinal (29%)[https://pubmed.ncbi.nlm.nih.gov/33853799/] | # '''Gastrointestinal (29%)[https://pubmed.ncbi.nlm.nih.gov/33853799/]''' | ||
## Ileus (16%) | ## '''Ileus (16%)''' | ||
## Small bowel obstruction (5%) | ## '''Small bowel obstruction (5%)''' | ||
## Constipation (3%) | ## '''Constipation (3%)''' | ||
## Clostridium difficile colitis (2%) | ## '''Clostridium difficile colitis (2%)''' | ||
## Anastamotic bowel leak (1%) | ## '''Anastamotic bowel leak (1%)''' | ||
# Infection (26%)[https://pubmed.ncbi.nlm.nih.gov/33853799/] | # '''Infection (26%)[https://pubmed.ncbi.nlm.nih.gov/33853799/]''' | ||
## UTI/pyelonephritis (14%) | ## '''UTI/pyelonephritis (14%)''' | ||
## Sepsis (4$) | ## '''Sepsis (4$)''' | ||
## Pelvic/intra-abdominal abscess (2.4%) | ## '''Pelvic/intra-abdominal abscess (2.4%)''' | ||
# Ureteric anastamotic leak (3%)[https://pubmed.ncbi.nlm.nih.gov/33853799/] | # '''Ureteric anastamotic leak (3%)[https://pubmed.ncbi.nlm.nih.gov/33853799/]''' | ||
# Wound (13%)[https://pubmed.ncbi.nlm.nih.gov/33853799/] | # '''Wound (13%)[https://pubmed.ncbi.nlm.nih.gov/33853799/]''' | ||
## Dehiscence (4%) | ## '''Dehiscence (4%)''' | ||
## Fascial dehiscence (1.6%) | ## '''Fascial dehiscence (1.6%)''' | ||
## Infection (10%) | ## '''Infection (10%)''' | ||
# Need for secondary procedure | # '''Need for secondary procedure''' | ||
#Mortality | #'''Mortality''' | ||
#*'''2.4% (range 0.9–4.7) inpatient mortality rate and a 4.7% (range 0.0–7.0) 90-day mortality rate following radical cystectomy[https://pubmed.ncbi.nlm.nih.gov/33853799/]''' | #*'''2.4% (range 0.9–4.7) inpatient mortality rate and a 4.7% (range 0.0–7.0) 90-day mortality rate following radical cystectomy[https://pubmed.ncbi.nlm.nih.gov/33853799/]''' | ||
#** Mortality after radical cystectomy is typically < 5%, but may increase substantially in the elderly with 90-day mortality rates over 10% in patients > 75 years of age and almost 20% in octagenarians. | #** Mortality after radical cystectomy is typically < 5%, but may increase substantially in the elderly with 90-day mortality rates over 10% in patients > 75 years of age and almost 20% in octagenarians. | ||
=== <span style="color:#ff0000">Late post-operative</span> === | === <span style="color:#ff0000">Late post-operative</span> === | ||
# Failure to cure | # '''Failure to cure''' | ||
# Metabolic consequences of diversion | # '''Metabolic consequences of diversion''' | ||
# Ureteral stricture | # '''Ureteral stricture''' | ||
# Hernia | # '''Hernia''' | ||
# Erectile dysfunction | # '''Erectile dysfunction''' | ||
# Infection | # '''Infection''' | ||
== Post-operative care == | == Post-operative care == | ||
* '''<span style="color:#ff0000">Extended (4 weeks) venous thromboembolism prophylaxis should be considered in all radical cystectomy cases</span>''' | === Venous Thromboembolism === | ||
*'''<span style="color:#ff0000">Extended (4 weeks) venous thromboembolism prophylaxis should be considered in all radical cystectomy cases</span>''' | |||
**'''The incidence of symptomatic venous thromboembolism in short-term follow-up after radical cystectomy is 3-12%''', of which > 50% of cases will occur after hospital discharge. | **'''The incidence of symptomatic venous thromboembolism in short-term follow-up after radical cystectomy is 3-12%''', of which > 50% of cases will occur after hospital discharge. | ||
*** Meta-analyses of clinical trials in patients undergoing major abdominal oncologic operations suggest a decreased risk of venous thromboembolisms for patients receiving '''extended (4 weeks) venous thromboembolism prophylaxis.''' | *** Meta-analyses of clinical trials in patients undergoing major abdominal oncologic operations suggest a decreased risk of venous thromboembolisms for patients receiving '''extended (4 weeks) venous thromboembolism prophylaxis.''' | ||
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== Answers == | == Answers == | ||
#What organs are removed at the time of radical cystectomy? | |||
# What are the primary lymphatic drainage sites in bladder cancer? | |||
# What are the boundaries of lymph node dissection in bladder cancer? | |||
# What are the indications for urethrectomy at the time of radical cystectomy? | |||
== References == | == References == | ||