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Ostomytalk10 12

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wocn-ci oct 2, 2012 springfield, il

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Ostomytalk10 12

  1. 1. Surgical Management of Bladder Cancer: 2012 Alex Gorbonos, MDAssistant Professor, Division of Urology Director, Robotic Surgery SIU School of Medicine October 2, 2012
  2. 2. Outline Overview of bladder cancer Radical cystectomy  Past  Present  Future
  3. 3. EPIDEMIOLOGY  5th most common cancer  4th most common in men  Cancer most likely to recur  2nd most common urologic cancer ACS, 2012
  4. 4. EPIDEMIOLOGY Median age at diagnosis: 68 3-4 times more common in men More aggressive in blacks and women  Longer time to diagnosis  Access to care
  5. 5. HISTOLOGY Most common primary histology in USA  Urothelial (transitional) cell  Urothelium: lines collecting system of the kidney, ureters, bladder and most of urethra Most common primary histology in world  Squamous cell  Spinal cord injury, recurrent UTIs/stones, catheter use Other histologies:  Adenocarcinoma (bladder augmentation, urachus, GI) http://en.wikipedia.org/wiki/File:Urinary_system.svg
  6. 6. ETIOLOGY Environmental exposures  Tobacco (nitrosamine, 2-naphthylamine, 4- aminobiphenyl): x 2-6 increased risk  Occupational (aromatic amines, aniline dyes)  Factories dealing with organic dyes  Truck drivers/autoworkers  Plumbing No strong hereditary link Chronic bladder infections/irritation  squamous cell carcinoma  Schistosomiasis
  7. 7. PRESENTATION Hematuria, gross painless: 80-90% Irritative lower urinary tract symptoms Systemic complaints in metastatic disease
  8. 8. DIAGNOSIS Cystosopy CT Urogram Cytology Bladder tumor
  9. 9. STAGING TURBT Bladder biopsy
  10. 10. PRESENTATION Non-muscle invasive (cis, Ta, T1)  75 to 85%  25% subsequently progresses to invasive disease Muscle-invasive (T2-4)  15 to 25% Metastatic  5%
  11. 11. Treatment TUR (transurethral resection) Intravesical therapy  BCG, MMC, Thiotepa, Gemcitabine, IFN Radical cystectomy Chemotherapy  Neoadjuvant  Adjuvant Radiation
  12. 12. Radical Cystectomy Gold standard for surgical management of  Invasive bladder carcinoma  Intravescical therapy-refractory non-muscle invasive carcinoma  High-volume or unresectable non-invasive disease Males: removal of the bladder, prostate Female: removal of the bladder, uterus/ovaries
  13. 13. http://upload.wikimedia.org/wikipedia/commons/0/03/Gray1135.png
  14. 14. http://upload.wikimedia.org/wikipedia/commons/0/06/Gray1139.png
  15. 15. Radical Cystectomy Males Females Radical cystectomy+/-  Radical cystectomy+/- urethrectomy urethrectomy Radical prostatectomy  TAH-BSO Pelvic lymphadenectomy
  16. 16. First Radical Cystecomy Bernhard Bardenheuer (1839-1913)  Prussian surgeon who performed first complete cystectomy on January 13, 1887  Der extraperitoneale Explorativschnitt. Die differentielle Diagnostik der chirurgischen Erkrankungen und Neubildungen des Abdomens. Stuttgart, Enke, 1887. 748 pages. p. 273  Theodor Baum, 57 yo carpenter’s assistant, from Cologne had advanced bladder tumor involving both ureters  Operation lasted 75min  Ureters were left unimplanted  Patient died POD#14 days from uremia and hydronephrosis Pannek and Senge, History of Urinary Diversion, Urol Int; 1996, 60: 1-10 Moll et al, Bardenheuers contribution to the development of modern urology, J Med Bio; 1998, 6: 11-14
  17. 17. FIRST RADICAL CYSTECTOMY 1899 – Fedor Krause performed first successful total cystectomy and ureterosigmoidostomy for bladder cancer  Ureters connected to sigmoid colon to use anal sphincter as a continence mechanism Pannek and Senge, History of Urinary Diversion, Urol Int; 1996, 60: 1-10
  18. 18. Radical Cystectomy – 19th Century Mortality due to sepsis from peritonitis and pyelonephritis limited widespread practice of cystectomy  Lack of antibiotics  Post-op urinary leak  Antiquated surgical principles Pannek and Senge, History of Urinary Diversion, Urol Int; 1996, 60: 1-10
  19. 19. Conclusion Not enough to be able to remove the organ, but it is necessary to reconstruct the urinary tract GI tract “mobilized”
  20. 20. Goals Extirpation  Reconstruction SAFE EFFECTIVE ACCEPTABLE DURABLE EVOLVING
  21. 21. 20th Century – First Half Ureterosigmoidostomy was the operation of choice using the Coffey method of anastomosis 1936 – Hinman and Weyrauch reviewed 740 ureterosigmoidostomies  Perioperative mortality was 30%  50% - cancer causes  20% - non-cancer causes Cutaneous ureterostomy was thought to offer best chance of survival Pannek and Senge, History of Urinary Diversion, Urol Int; 1996, 60: 1-10
  22. 22. 20th Century – 2nd Half Diversion field boom Mortality decreases  Antibiotics introduction  Improvement in anesthesia and critical care  Surgical technique continues to evolve 1950 – Ferris and Oedel demonstrate hyperchloremic metabolic acidosis in ureterosigmoidostomy patients due to absorptive capacity of bowel mucosa  Ureterosigmoidostomy moves to the background Pannek and Senge, History of Urinary Diversion, Urol Int; 1996, 60: 1-10
  23. 23. Ileal Conduit 1911 – first described by Zaayer in 2 patients  1st patient – died of cancer POD#11  2nd patient – died of peritonitis POD#6 1927 – Bollman and Mann created conduits in animals  High mortality from electrolyte disturbances because they were creating long conduits  Hypokalemic hyperchloremic metabolic acidosis Pannek and Senge, History of Urinary Diversion, Urol Int; 1996, 60: 1-10
  24. 24. Ileal Conduit 1950 – Eugene Bricker published a landmark paper on his experience with ileal conduit  “Surg Clin N Am 1950; 30: 1511-21”  10 patients with follow-up of 2 mo (4) to 4 years  Metabolic complications not recognized  12.4% mortality in 307 cases; 3.4% directly related to diversion Bricker conduit:  Refluxing anastomosis  Simple stoma, without a bud Perez & Webster, “History of Urinary Diversion Techniques,” in Urinary Diversion, Webster and Goldwasser, eds., 1995
  25. 25. Eugene M. Bricker (1909- 2000) “We ourselves are pleased with the procedure because we feel it is the acme of simplicity…At the present time we are ready to drop the project of trying to develop a continent intra-abdominal urinary pouch in favor of this method…” General SurgeonPerez & Webster, “History of Urinary Diversion Barnes Hospital, St. LouisTechniques,” in Urinary Diversion, Webster andGoldwasser, eds., 1995
  26. 26. Ileal Conduit - Modifications 1966 – Wallace of London modified ileal conduit by joining ureters together prior to anastomosis to the ileal segment end 1975 – Turnbull, general surgeon from Cleveland Clinic, introduced loop stoma technique for obese patients  Decreased stomal stenosis Perez & Webster, “History of Urinary Diversion Techniques,” in Urinary Diversion,  Higher parastomal hernia rate Webster and Goldwasser, eds., 1995
  27. 27. Robotic Cystectomy Radical cystectomy with pelvic lymphadenectomy: First performed robotically in 2003 Urinary Diversion performed intra- or extra- corporeally
  28. 28. Robotic Radical Cystectomy Males Females Radical cystectomy+/-  Radical cystectomy+/- urethrectomy urethrectomy Radical prostatectomy  TAH-BSO Pelvic lymphadenectomy  Pelvic Lymphadenectomy
  29. 29. Robotic Cystectomy with Neobladder
  30. 30. Robotic Cystectomy with Ileal Conduit
  31. 31. Robotic Radical Cystectomy Decreased blood loss Less evaporative fluid losses Reduced manipulation of GI tract, quicker return of bowel function Equivalent oncologic outcomes Better cosmesis Less pain Quicker recovery The Journal of Urology Vol 183, Issue 2, Pages 510-515, February 2010
  32. 32. Future of Diversion?  Anthony Atala et al: Tissue-engineered autologous bladders for patients needing cystoplasty Lancet. 2006 Apr 15;367(9518):1241-6  Autologous engineered bladder tissues used for reconstruction in 7 myelomeningocele patientsConstruction of engineered bladderScaffold seeded with cells (A) and engineered bladder anastamosed to nativebladder with running 4–0 polyglycolic sutures (B). Implant covered with fibrin glueand omentum (C).

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