Surgical Management of Muscle Invasive Bladder Cancer: A Review of Current Recommendations

ObjectiveTo provide a narrative overview of contemporary surgical management of muscle-invasive bladder cancer with focus on radical cystectomy and urinary tract reconstruction.Data SourcesInternational guidelines and a search for articles in PubMed, Medline, and Cochrane Database for single and collaborative studies on surgical management of muscle-invasive bladder cancer.ConclusionPatients diagnosed with muscle invasive bladder cancer often have complex treatment and care needs. For those who undergo radical cystectomy as the curative treatment, there is a considerable risk of general complications after major surgery and short- and long-term complications specific to reconstruction of the urinary tract after radical cystectomy. Contemporary care focuses on perioperative optimization to lower rates of major complications, enhanced recovery protocols, and focus on rehabilitation and cancer survivorship.Implications for Nursing PracticeNurses are integral members of the multidisciplinary team around patients undergoing surgery for muscle-invasive bladder cancer, and are in a position to coordinate pathways for these patients who often have complex care needs because of preexisting comorbidity and limited personal resources that impede recovery after major surgery and cancer survivorship.     

Current perspectives in bladder cancer management

More than 350,000 new cases of bladder cancer are diagnosed worldwide each year; the vast majority (> 90%) of these are transitional cell carcinomas (TCC). The most important risk factors for the development of bladder cancer are smoking and occupational exposure to toxic chemicals. Painless visible haematuria is the most common presenting symptom of bladder cancer; significant haematuria requires referral to a specialist urology service. Cystoscopy and urine cytology are currently the recommended tools for diagnosis of bladder cancer. Excluding muscle invasion is an important diagnostic step, as outcomes for patients with muscle invasive TCC are less favourable. For non‐muscle invasive bladder cancer, transurethral resection followed by intravesical chemotherapy (typically Mitomycin C or epirubicin) or immunotherapy [bacillus Calmette‐Guérin (BCG)] is the current standard of care. For patients failing BCG therapy, cystectomy is recommended; for patients unsuitable for surgery, the choice of treatment options is currently limited. However, novel interventions, such as chemohyperthermia and electromotive drug administration, enhance the effects of conventional chemotherapeutic agents and are being evaluated in Phase III trials. Radical cystectomy (with pelvic lymphadenectomy and urinary diversion) or radical radiotherapy are the current established treatments for muscle invasive TCC. Neoadjuvant chemotherapy is recommended before definitive treatment of muscle invasive TCC; cisplatin‐containing combination chemotherapy is the recommended regimen. Palliative chemotherapy is the first‐choice treatment in metastatic TCC.     

Urethral recurrence following neobladder in bladder cancer patients

Risk factors of urethral recurrence after neobladder in bladder cancer patients were studied. Between 1977 and 2001, 73 patients (male 58, female 15) underwent neobladder as a treatment for bladder cancer. The observation time after cystectomy ranged from 2 to 254 months (median 60.5). Ten (17.2%) of 58 male patients had urethral recurrence and of the 10, 8 patients had multiple bladder cancers including bladder neck. Urethral recurrence was found by macrohematuria, follow-up cystourethroscopy, and inguinal lymph node swelling. Only one who complained of macrohematuria had positive urinary cytology. Of 58 male patients, 5 underwent total nephroureterectomy for renal pelvic or ureteral cancer before radical cystectomy, and 3 of the 5 had urethral recurrence. Two of 10 patients with urethral recurrence died with cancer, and they had renal pelvic or ureteral cancer. The five-year cause specific survival was 83% for patients with urethral recurrence, and 79% for those without urethral recurrence, respectively. Urethral recurrence did not have a significant effect on survival. The patients with multiple bladder cancers including bladder neck, and renal pelvic or ureteral cancer before radical cystectomy, have high risks for urethral recurrence. Urinary cytology has limited value for the detection of urethral recurrence.     

Organ-conserving approaches to muscle-invasive bladder cancer: future alternatives to radical cystectomy

In the USA radical surgery remains the golden standard for invasive bladder cancer. Yet in most other areas of surgical oncology the trend of the 1990s has been towards organ conservation with chemoradiation with or without limited local surgery. Patients with breast, oesophageal, anal, lung and larynx cancer are routinely offered conservative therapies as valid options in the management of their diseases but bladder stands apart from the crowd. Evidence is presented here to show that this need not be the case. Four older randomized trials failed to show a survival advantage when immediate cystectomy was compared with radiation followed by salvage cystectomy, if required. Five and 8-year survival rates for clinically staged patients treated by transurethral resection and chemoradiation (trimodality therapy) in several modern, large and mature series show survival rates comparable to those reported in contemporary radical cystectomy series. Eighty per cent of those alive 5 years after chemoradiation still retain their native bladder. Although superficial relapse occurs in 20% of cases, it remains responsive to BCG (Bacilles bilie de Calmette-Guerin) in the manner of de novo superficial disease. Quality-of-life studies show that the retained bladder functions well. At the Massachusetts General Hospital and in the multicentre prospective trials, less than 1% of patients needed cystectomy for bladder morbidity. It is of note that continent diversions may be performed as salvage after contemporary radiation therapy. Trimodality therapy is a novel and contemporary approach that owes little to the radiation treatment offered in the 1970s. While it will never entirely take the place of radical cystectomy, it should be offered as a reasonable alternative to patients with a new diagnosis of bladder cancer. This multidisciplinary approach will allow uro-oncology to keep in step with the oncological vanguard.     

腹腔镜与开放手术方式根治性膀胱切除术治疗膀胱癌的临床研究

目的通过回顾性分析腹腔镜与开放手术方式根治性膀胱切除术(RC)治疗膀胱癌的临床观察指标,评价腹腔镜技术在RC治疗膀胱癌中的临床价值。方法 2009年10月-2014年8月该院实施RC患者49例,其中腹腔镜组20例(A组)、开放组29例(B组)。收集两组患者的临床资料,采取术中出血量、手术时间、术后胃肠功能恢复时间、术后住院天数和术后并发症等作为观察指标。计量资料采用均数±标准差(x±s)表示,组间比较资料采用t检验,计数资料采用百分率表示,组间比较采用χ2检验,P0.05为差异有统计学意义。结果平均术中出血量A组低于B组[(416.66±232.73)ml vs(964.16±445.73)ml,P0.05];平均术后住院时间A组低于B组[(14.93±2.72)d vs(19.50±3.16)d,P0.05)];术后并发症A组少于B组(P0.05);平均手术时间、平均术后肠功能恢复时间两组间差异无统计学意义。结论通过分析两组临床观察指标,腹腔镜根治性膀胱切除术(LRC)治疗膀胱癌,在手术效果方面与开放手术相似,但其具有创伤小、失血少、恢复快和术后并发症相对较少等优点,是一种安全、有效的手术方法。远期疗效尚需要更多病例术后随访。     

膀胱癌膀胱全切术后继发尿道癌30例

目的:探讨膀胱癌膀胱全切术后继发尿道癌的治疗。方法:回顾性分析30例膀胱癌膀胱全切术后继发尿道癌行全尿道切除术或行局部加热化疗患者的临床资料。结果:24例患者经全尿道切除术均一期愈合,除1例失访、1例因他病死亡外,其余22例随访3～26个月均无瘤生存。6例患者行局部加热化疗后,随访2～3年均无瘤生存。结论:膀胱癌术后尿道癌重在预防;全尿道切除术是膀胱癌行全膀胱切除术后继发尿道癌的有效治疗方法,而局部加热化疗,简便易行,尤其适于手术切除困难者。     

Classification of bladder cancer by microarray expression profiling: towards a general clinical use of microarrays in cancer diagnostics

At present there are no clinically useful markers available for identifying bladder cancer patients with a high risk of disease recurrence or progression. Thus, identification and tailor-suited treatment, for example radical cystectomy and adjuvant therapy, of patients with a poor prognosis is not possible using current methods. The completion of the Human Genome Project and the simultaneous advances in microarray technology have paved the way for performing systematic, full genome screens for prognostic and diagnostic molecular cancer markers. Furthermore, utilization of microarray technology for identifying clinically relevant subclasses of cancer patients and for discovering new potential drug targets seems promising. This article summarizes some of the clinical aspects of bladder cancer and reviews the potential of using tumor expression profiling for the identification of new molecular cancer markers and drug targets, and for generating disease classifiers and outcome predictors using several key gene markers.     

Care of the patient undergoing radical cystectomy with a robotic approach

Radical cystectomy or cystoprostatectomy with urinary diversion is the gold standard for the treatment of muscle-invasive bladder cancer. Cystectomy can be through an open or robotic-assisted laparoscopic approach. Advances in laparoscopy, robotic surgery, and urological oncology have made it possible for select surgeons to perform nerve-sparing robotic-assisted laparoscopic radical cystoprostatectomy. Advantages of robotic surgery may be minimal blood loss, shorter hospital stay, quicker recovery, and possibly more precise and rapid removal of the bladder depending on the experience and expertise of the surgeon. Appropriate patient selection and thorough pre-operative evaluation, however, are key in maximizing positive surgical outcomes. The experience at the University of Virginia with robotic-assisted laparoscopic radical cystectomy will be discussed.     

腹腔镜根治性膀胱全切+原位回肠新膀胱术治疗浸润性膀胱癌

目的探讨腹腔镜根治性膀胱全切+原位回肠新膀胱术的手术方法和经验。方法回顾分析2011年3月-2014年10月该院14例浸润性膀胱癌患者的临床资料。结果 13例成功施行了腹腔镜根治性膀胱全切+原位回肠新膀胱术,1例因术中膀胱内肿瘤出血增加术野无法显露而中转开放手术。12例在直视下行新膀胱尿道间断吻合,2例在腹腔镜下采用单针连续缝合法行新膀胱尿道吻合。手术平均时间444 min,术中平均出血量490 ml。术后病理提示12例为膀胱尿路上皮癌,其中1例伴部分鳞状细胞癌,2例为膀胱腺癌。2例患者术后出现尿漏,经保守治疗后治愈,1例术后出现尿失禁。术后随访6~56个月,3例死于肿瘤远处转移,1例目前发生肿瘤颅内转移。其余10例目前仍无瘤生存,其中1例术后1年出现尿道内口狭窄,经行尿道狭窄内切开术后治愈。10例患者目前控尿功能恢复良好,新膀胱容量约300 ml。结论腹腔镜根治性膀胱全切+原位回肠新膀胱术治疗膀胱癌疗效确切、安全、创伤小及术后恢复快,可作为临床浸润性膀胱癌的首选治疗方法。     

A dual-centre, cohort comparison of open, laparoscopic and robotic-assisted radical cystectomy

Introduction: The role of minimally invasive radical cystectomy as opposed to open surgery for bladder cancer is not yet established. We present comparative outcomes of open, laparoscopic and robotic‐assisted radical cystectomy Material and Methods: Prospective cohort comparison of 158 patients from 2003–2008 undergoing open radical cystectomy (ORC) (n = 52), laparoscopic radical cystectomy (LRC) (n = 58) or robotic‐assisted radical cystectomy (RARC) (n = 48) performed by a team of three surgeons at two hospitals. Peri‐operative data, complication rates, length of hospital stay, oncological outcome (including lymph node status) and survival were recorded. Statistical analyses were adjusted to account for potential confounding factors such as ASA grade, gender, age, diversion type and final histology. Results: RARC took longer than LRC and ORC. Patients were about 30 times more likely to have a transfusion if they had ORC than if they had RARC (p < 0.0001) and about eight times more likely to have a transfusion if they had LRC compared with RARC (p < 0.006). Patients were four times more likely to have a transfusion if they had ORC as compared with LRC (p < 0.007). Patients were four times more likely to have complications if they had ORC than RARC (p = 0.006) and about three times more likely to have complications with LRC than with RARC (p = 0.02). Hospital stay was mean 19 days after ORC, 16 days after LRC and 10 days after RARC. Conclusions: Despite study limitations, RARC had the lowest transfusion and complication rates and the shortest length of stay, although taking the longest to perform.     

腹腔镜膀胱癌根治—原位回肠新膀胱术（附5例报告）

目的探讨腹腔镜膀胱癌根治—原位回肠新膀胱术的临床疗效。方法 2008年11月至2011年4月,采用5点穿刺经腹入路,先行腹腔镜下膀胱癌根治,继而体外构建回肠新膀胱,最后腹腔镜下行新膀胱尿道吻合,实施腹腔镜膀胱癌根治—原位回肠新膀胱术5例。皆为男性,平均年龄67岁。结果手术时间420～600min,平均480min,术中失血量350～800ml,平均400ml。术后淋巴结及手术切缘均阴性。随访3～24个月,除1例有轻度夜间尿失禁外,其余患者均昼夜控尿良好。代膀胱充盈良好,容量200～350ml,平均270ml。平均最大尿流率12ml/s。1例出现勃起功能障碍。结论腹腔镜膀胱癌根治—原位回肠新膀胱术创伤小、出血少、并发症少且疗效满意。     

基于“三线五面”膜解剖的腹腔镜根治性膀胱切除术治疗男性膀胱癌的疗效观察（附34例报告）

目的探讨基于"三线五面"膜解剖的腹腔镜根治性膀胱切除术治疗男性膀胱癌的安全性、疗效与优势。方法选取2018年1月-2020年4月郴州市第一人民医院泌尿外科收治的34例男性膀胱癌患者,均实施腹腔镜下根治性膀胱切除术。患者年龄54~83岁,平均(66.6±7.9)岁;多发肿瘤12例,单发肿瘤22例,其中位于三角区3例,左侧壁6例,右侧壁7例,底部4例,顶部2例;肿瘤直径1.5~7.5 cm,平均(3.6±1.6) cm;术前临床分期:cT₂N₀M₀20例,cT₃N₀M₀10例,cT_4aN₀M₀4例。手术均由同一高年资医师完成,按照"三线五面"("三线"即三条主线:输尿管、输精管和脐内侧韧带;"五面"即五个无血管平面:输尿管鞘平面、直肠前平面、脐动脉外侧平面、骨盆侧壁平面、耻骨后平面)的手术思路,运用膜解剖技术精准分离,先行根治性膀胱切除术,再行盆腔淋巴结清扫,最后行尿流改道。结果34例患者均顺利完成手术,根治性膀胱切除及盆腔淋巴结清扫术时间为160~240 min,平均(185.6±20.3) min,术中出血量200~500 mL,无输血病例。术后病检结果:pT₁N₀M₀2例,pT₂N₀M₀18例,pT₃N₀M₀11例,pT_4aN₀M₀3例;低级别尿路上皮癌4例,高级别尿路上皮癌30例,其中高级别尿路上皮癌伴肉瘤样癌1例;手术切缘均为阴性。术后肠道功能恢复时间(2.8±0.6) d,术后出现1例粘连性肠梗阻,经非手术治疗后肠道功能恢复,术中术后无严重并发症,术后住院时间10~15 d,平均(12.5±2.6) d,术后疼痛评分1~5分,平均(3.1±1.1)分,术后随访6~28个月,平均(12.5±7.8)个月,暂无局部复发与远处转移。结论按照"三线五面"手术思路,运用膜解剖技术实施腹腔镜根治性膀胱切除术,术中解剖标志清晰、组织层次分明,并发症可控,手术安全性高,疗效满意,值得临床推广运用。     

腹腔镜下全膀胱切除原位回肠新膀胱术（附16例报告）

目的探讨在基层医院采用腹腔镜下全膀胱切除原位回肠新膀胱术的临床应用。方法对15例浸润性膀胱尿路上皮细胞癌Ⅱ～Ⅲ级、1例鳞状细胞癌患者行腹腔镜下全膀胱切除加原位回肠代膀胱术,观察手术时间、术中出血量、术后肠道功能恢复情况及术后并发症等手术效果。结果 16例患者膀胱根治均切除成功,手术时间240～320min。腹腔镜下失血量为100～500ml,平均为230ml。2例输浓缩红细胞2个单位。术后3d恢复肠蠕动并拔除耻骨后引流管,4d后开始进食。2周后拔除输尿管支架管。随访4～26个月,1例有排尿困难,5例术后早期出现轻微尿失禁,所有病例术后3个月均可完全控制排尿,5例男性患者有勃起功能障碍。16例均无复发。结论该术式具有微创、出血少、恢复快等特点,将成为治疗浸润性膀胱癌的安全、有效的方法之一,有可能在具有一定腹腔镜手术操作基础的基层医院逐步开展。     

Staging bladder carcinoma by three-dimensional ultrasound rendering

Organ-confined staging for bladder cancer has major impact on further treatment. Most imaging techniques for this purpose are insufficient. We, therefore, assessed the value and the limitations of a new diagnostic tool, the 3-D ultrasound (US) rendering, to distinguish invasive from noninvasive bladder cancers. A total of 63 patients underwent 3-D US of the bladder before transurethral resection or radical cystectomy. The US findings were compared with the pathologic stages of the transurethral resection material or the cystectomy specimens. Superficial (pTa) carcinomas were correctly staged in 66% by 3-D US. Lamina propria infiltrating (pT1) were correctly staged in 83% and the quota of correct staging of infiltrating carcinomas (>pT1) by 3-D rendering was 100%. The overall accuracy was 79%. Three-dimensional US rendering is most valuable to discriminate between superficial stages pT1. This new technique might improve staging of bladder cancer.     

完全腹腔镜下根治性膀胱全切除回肠原位膀胱术后新膀胱功能锻炼的循证护理

目的探讨完全腹腔镜下根治性膀胱全切除回肠原位膀胱术后新膀胱功能锻炼的循证护理方法。方法选择15例完全腹腔镜下根治性膀胱全切除回肠原位膀胱术后进行新膀胱功能锻炼的患者,对其实施循证护理。结果 15例患者手术均获成功,术后住院时间(25.0±4.1)d,术后随访7~38个月,2例患者出现轻度尿失禁(夜间睡眠中尿失禁),其余患者均能定时排尿,无明显残余尿。结论将循证护理运用于完全腹腔镜下根治性膀胱全切除回肠原位膀胱术后进行新膀胱功能锻炼的患者,能使可控性的尿流改道技术最大限度接近患者的生理状态,使患者尽可能恢复正常排尿功能并显著改善患者的生活质量。     

全膀胱切除原位新膀胱术患者的护理

笔者报道全膀胱切除原位新膀胱术患者的护理。通过对63例根治性膀胱全切除、回肠／结肠原位新膀胱术患者的护理,提出护理重点在于术前肠道护理,术后原位新膀胱冲洗,预防吻合口瘘,各种管道的护理,新膀胱功能训练。     

新辅助化疗联合高-低氧吸入放射治疗浸润性膀胱癌的研究

目的评估新辅助化疗联合高-低氧吸入放射治疗浸润性膀胱癌的疗效及安全性。方法对31例无法耐受或拒绝接受膀胱全切手术的浸润性膀胱癌患者进行保留膀胱治疗,先给予新辅助化疗2周期,然后给予盆腔适形放疗,放疗过程中先后吸入高低浓度氧。对肿瘤部分缓解及复发患者行保留膀胱的手术。结果肿瘤完全缓解率为71．0％（22／31）,部分缓解率29．0％（9／31）。9例部分缓解的患者接受了保留膀胱的手术治疗,4例复发患者接受了再次手术治疗。结论新辅助化疗联合高-低氧吸入放疗为部分无法耐受或拒绝接受膀胱全切术的浸润性膀胱癌患者提供了一种有效的治疗方法。     

手助腹腔镜根治性膀胱切除术（附31例报告）

目的探讨手助腹腔镜根治性膀胱切除术的临床应用价值。方法采用手助腹腔镜行根治性膀胱切除术31例,其中利用手助操作通道的切口行回肠膀胱术24例,原位回肠新膀胱术7例;并观察围手术期的恢复情况及近期疗效。结果31例手助腹腔镜下根治性膀胱切除均获成功,手术时间245-530min,平均365．7min出血量100-500ml,平均250．9ml。其中3例需输血,输血率为9．7％。术后进食时间为2～15d,平均4．3d。住院时间平均19．7d（9～83d）。术后6例发生围手术期并发症,占19．4％。31例患者均获随访,平均18个月（1～38个月）,2例回肠膀胱切口疝,1例输尿管新膀胱吻合口狭窄。肺部转移及局部复发并全身转移各1例,带瘤生存。肿瘤转移死亡1例,猝死1例。其余27例无瘤存活。结论手助腹腔镜根治性膀胱切除术是安全、可行的,尤其在复杂的根治性膀胱切除术中可以减少手术出血,降低手术难度,有效防止并发症的发生。     

膀胱非尿路上皮癌的诊断与治疗

目的探讨膀胱非尿路上皮癌的发病特点,总结其诊治经验。方法回顾分析2001年1月至2009年12月收治的59例膀胱非尿路上皮癌的临床资料。其中男37例,女22例,平均年龄72.6岁;临床主要表现为无痛性肉眼血尿和膀胱刺激症状;辅助检查包括B超、盆腔CT及膀胱镜检＋活检。另选同期膀胱尿路上皮癌51例作为对照。比较两组患者围手术期治疗,术后1、3和5年生存率等差异。结果 59例膀胱非尿路上皮癌患者,术后病理检查证实膀胱腺癌13例、膀胱鳞癌10例、膀胱小细胞癌5例、膀胱平滑肌肉瘤2例、副神经节瘤4例和混合癌肿25例。其中行全膀胱切除术41例,膀胱部分切除术6例,经尿道膀胱肿瘤电切术（TUBRT）12例。术前新辅助治疗4例,术后辅助放疗14例,术后辅助化疗35例。有效随访53例,术后1、3和5年生存率分别为83.1%、54.7%和28.3%。51例膀胱尿路上皮癌术后均经病理证实诊断,其中行全膀胱切除术12例,膀胱部分切除术3例,TUBRT36例。术后成功随访43例,术后1、3和5年生存率分别为81.8%、76.7%和72.7%。结论膀胱非尿路上皮癌临床少见,恶性程度较高,预后较差。根治性膀胱全切除术是首选手术方法,结合不同肿瘤类型的病理特点,辅助或新辅助放、化疗可望提高疗效。