PRELIMINARY EXPERIENCE WITH RADICAL CYSTECTOMY AND W–ILEAL POUCH FOR MUSCLE INVASIVE TRANSITIONAL CELL BLADDER CARCINOMA

Abstract

Background

Radical cystectomy and bilateral pelvic lymphadenectomy is considered the treatment of choice for patients with muscle invasive transitional cell bladder cancer. Following radical cystectomy the surgeon would choose an appropriate modality of urinary diversion from a plethora of methods. Radical cystectomy with any type of diversion remains a complication-prone surgery. This study aims at reviewing the peri-operative challenges and morbidities experienced with radical cystectomy and W-ileal pouch urinary diversion in a tertiary hospital in Nigeria.

Aims & Objective

To report experience with radical cystectomy and W-ileal pouch construction in patients with muscle invasive transitional cell urinary bladder carcinoma.

Patients & Methods

The case notes of patients diagnosed with muscle invasive transitional cell bladder carcinoma (T2/3N_oM_o) who underwent radical cystectomy and W-ileal pouch construction from December 2006 to December 2011 at the Jos University Teaching Hospital, Jos, Nigeria were retrospectively studied. Patients were evaluated for age, sex, duration of surgery, estimated blood loss, duration of hospital stay, and complications after surgery.

Results

Six patients had their records reviewed. Mean age was 55.8 years (range 32 – 66years). Male to female ratio was 5:1. Mean hospital stay was 31 days, with all of the patients requiring intensive care for a mean of 24 hours (range 24-72 hours). Mean hospital stay was 31 days (range 21-40 days). Mean estimated blood loss was 891 ml (range 720-1500ml). Mean duration of surgery was 10.3 hours (range 8-12 hours). Commonest complication was urine retention secondary to mucus plug in 50%. Operative mortality was 16.7%.

Conclusion

Radical cystectomy and W-ileal pouch construction due to its technical complexity and challenging postoperative management necessitates a team approach with experienced surgeons, anesthetists, intensivists and stoma care specialist, among others.

Introduction

Radical cystectomy is currently the treatment of choice for patients with muscle invasive transitional cell carcinoma of the urinary bladder provided they are fit and willing to undergo such extensive surgery1. Radical cystectomy is a technically challenging operation hence prompt postoperative recovery, short hospital stay and reduction in morbidity and mortality are difficult to achieve2,3,4.

Following the radical cystectomy is the dilemma of choosing a suitable mode of urinary diversion.

Historically, the overwhelming majority of patients received an ileal conduit, in which a tube of ileum connects the urine draining from the kidneys to a cutaneous stoma, and the urine collects in an external bag. Over the last two decades, techniques designed to improve the quality of life of patients after radical cystectomy have obviated the need for external appliances. These continent urinary tract reconstructions involve creation of a spherical neobladder from bowel that is connected either to the urethra to replicate volitional voiding, or to a small skin opening that requires intermittent catheterization to empty the reservoir. Advantages of the ileal conduit include a shorter operative time and relative ease of the surgical technique. Advantages of the neobladder include continence and preserved body image. Thus far no single urinary diversion technique has been shown to be ideal. The decision for any type of urinary diversion following radical cystectomy is based on patients’ renal function, individual anatomy and personal preference.

The ileal neobladder is an intentionally large capacity and low-pressure reservoir fashioned with the aim of eliminating night time incontinence. The reservoir is spherically configured from a W- shaped arrangement of a cross folded detubularised ileal segment. The ureters are implanted into the lateral limbs of the W of the reservoir using the serous-lined extramural tunnel principle with the aim of achieving an anti-reflux mechanism5, 6.

In 1994, Hautmann, after publishing results of more than 200 ileal neobladders using W fashioned ileum, concluded that ileal neobladder is the treatment of choice for male patients after radical cystectomy for the treatment of invasive bladder cancer7.

The W-ileal pouch is a form of continent urinary diversion in use at the Jos University Teaching Hospital, and this study retrospectively reviewed the perioperative challenges and morbidities experienced with its use in the past 5 years.

Reports

PATIENTS AND METHODS

Data from patients with histologically confirmed muscle invasive transitional cell bladder carcinoma (T2/3 N_oM_o) who underwent radical cystectomy with W-ileal pouch construction from December 2006 until December 2011 at Jos University Teaching Hospital, Jos, Nigeria was retrospectively analyzed. Patients who had had radiation and/or chemotherapy were excluded from the study. Data regarding gender distribution, age at surgery, duration of surgery, estimated blood loss, duration of hospital stay and complications were analysed using means and percentages.

RESULTS

Six (6) patients had their records analysed. . Male to female ratio was 5:1.The characteristics of the patients and other parameters analysed are presented in a table (Table 1) as means and percentages.

The age range was 32-66 years with a mean of 55.8 years. Duration of surgery ranged from 8-12 hours with a mean of 10.3 hours. One patient (16.7%) had surgery for 12 hours due to difficult dissection of extra-organ disease and difficulty in controlling the dorsal venous complex.

Mean blood loss was 891 ml (range 720-1500ml).

Urine retention secondary to mucus plug was the commonest complication occurring in 50% of patients. Mean hospital stay was 31 days with a range of 21-40 days. Two (33.3%) patients had wound infection. One of these two patients had superficial wound dehiscence.

There was one perioperative death from acute myocardial infarction. Only 1(16.7%) patient is currently alive 5 years after surgery. Two (33.3%) patients who were placed on adjuvant Cisplatin and Gemcitabine due to node positive disease have succumbed to the disease. Two (33.3%) others have been lost to follow up

Table 1: Clinical characteristics of 6 patients who had radical cystectomy and W-ileal pouch

Characteristic				Number				Percentage
Age(years)
<54			1			16.7
55-59			2			33.3
60-64			2			33.3
65-70			1			16.7
Duration of surgery (hours)
<5			-			-
5-10			3			50
>10			3			50
Estimated blood loss(ml)
500-1000			5			83.3
>1000			1			16.7
Duration of hospital stay (days)
21-30			3			50
31-40			3			50
>40			-			-
Complications
Wound infection			2			33.3
Burst Abdomen			1			16.7
Mucus plug retention			3			50
Perioperative death			1			16.7

Figure 1:

Long lower midline incision

Figure 2:

Complete skeletonisation of the pelvic vessels during lymphadenectomy

Figure 3:

The urinary bladder about to be excised after being freed from the lateral pedicle

Figure 4:

Constructed W-ileal pouch using the serous-lined tunnel principle5

Conclusions

Radical cystectomy and W-ileal pouch construction is dogged by intra-operative and post-operative challenges. It is recommended that experienced urologist should adopt a team approach to reduce the peri–operative and post-operative morbidity of this procedure.

Discussion

Over the past decade, continent urinary diversion has become increasingly popular following radical cystectomy for bladder cancer as urologists strive to create a reservoir that will as much as possible functionally resemble the native bladder.

Age range of patients was 32-66 years with a mean of 55.8 years .This presentation of bladder carcinomas is similar to 58 years described in Pakistan by Rafique et al9, and also agrees with earlier reports from Jos of a second peak of incidence in the sixth decade of life10. An age of more than 70 years and being a female have been labeled as higher risk factors in radical cystectomy and urinary diversion 11,12,13. Proper selection and risk balancing, however improve the outcome.

The mean surgical time of 10.3 hrs was longer than the reported 6.5hrs by Strunmbakis et al14. Their cohort included patients who had ileal conduit as a means of urinary diversion which reduces operative time. The surgical learning curve being overcome would explain the longer duration of surgery reported in this study. Hand- sewn enteric anastomosis due to lack of staplers in our centre would have also contributed to the prolonged operation time. In the past few years there has been some debate on the issue of surgical learning curve in radical cystectomy both at personnel and institutional levels vis–a-vis surgical volume15,16,17,18. Although still a contentious issue, it is acceptable that an individual or institution which handles 10 radical cystectomies per year and has facilities for major surgeries can continue to undertake radical cystectomies 19,20_.

Mean estimated blood loss of 891 ml falls in the range of 750-1500ml recorded by Jagdeesh20 . Acute blood loss is common during or after radical cystectomy and it is difficult to predict21. In the authors’ experience the division of the dorsal venous complex was the step where most of the blood loss occurred. Recently Chang et al. in a prospective trial reported reduction of the blood loss with use of stapler device for controlling dorsal venous complex and bladder pedicles; others have advocated the use of the harmonic scalpel or ligasure22. These new devices have cost constraints. In a recent review, laparoscopic radical cystectomy or robot-assisted laparoscopic radical cystectomy has been shown to reduce the operative blood loss significantly and also the operating time23. The authors believe that increasingly these approaches will continue to expand and will be the preferred methods in radical cystectomy.

In a review of 261 patients who had radical cystectomy, hospital stay ranged from 15-60 days with a median of 18 days20. A mean stay of 31 days found in this study is not unrelated to the perioperative and post operative challenges experienced such as wound infection and wound dehiscence.

Urine retention secondary to mucus plug was the commonest complication in this study as it was the case in 50% of the patients.The bowel mucosa secretes mucus made up of glycoprotein core24 . About 35g/day of mucus is produced in continent urinary diversion25. A sudden increase in mucus production may be an early sign of urinary tract infection26 . Aside from periodic catheter irrigation and mucus evacuation, oral or instillation therapy with N-acetyl cysteine or urea is reported to be helpful24, 25, 27.

Two (33.3%) patients had wound infection which is higher than the wound infection rate of 13.5% noticed by Stroumbakis14. The debility of bladder carcinoma in these patients, the blood loss and subsequent transfusion as well as prolonged hospital stay could be reasons for this significant morbidity.

The treatment goal in any cancer surgery is to cure the primary neoplasm and preserve quality of life. In the index study, five years after surgery only one (16.7%) patient was alive the rest either having died or been lost to follow up. The tenets of modern management of muscle-invasive transitional cell bladder cancer include consideration of combining perioperative chemotherapy with surgery to improve patient survival28. Although the treatment of organ-confined bladder cancer with radical cystectomy alone can lead to durable results, early dissemination of occult micro-metastases is a significant source of failure28. The rates of 5-year recurrence after surgery alone range from 20-30% in pT1 and pT2 disease to 50-90 % in pT3-4 disease28, 29, 30.

Two patients (33.3%) were placed on adjuvant Cisplatin and Gemcitabine; however, our setting is such that multiagent chemotheraupeutic agents are scarce and expensive; radiotherapy services are still difficult to access thus making compliance erratic.

This study is limited by its relatively small patient series and retrospective nature. It however brings to fore the challenges of surgical management of patients with muscle invasive transitional cell carcinoma of the urinary bladder in a resource-constrained setting.