Nov 26, 2017
November is National Bladder Health Awareness Month. According to the Urology Care Foundation the cost of treating bladder problems in the United States is 70 billion dollars annually. For National Bladder Health Awareness Month, we are talking about bladder cancer. Bladder cancer is the 5th most common non-skin cancer in the United States. It is the 4th most common cancer diagnosed in men and by the Veterans Affairs Health System. Nearly 600,000 Americans live with bladder cancer today and 75-80,000 people will be diagnosed in the United States with bladder cancer this year. An estimated 16-17,00 people will die from bladder cancer this year. In the last episode, we talked about bladder cancer growing as a papillary tumor. It begins on the surface of the bladder, in the lining cells of the bladder called transitional cells. Most bladder cancers then grow into the inside of the bladder on a stalk. As tumors grow, however, they can grow roots and invade into the deeper layers of the bladder. As tumors invade the chance that the cancer metastasizes and spreads to organs beyond the bladder increases. Superficial tumors can be resected from the surface of the bladder as their only treatment. Higher stage and recurrent tumors will need to be treated with other treatments such as instillation of BCG, chemotherapy, or even removal of the bladder. This year the American Urologic Association, in collaboration with other oncologic societies, published guidelines for the treatment of muscle invasive bladder cancer. The guidelines were presented at the 2017 Annual Meeting. You can find the guidelines as well as other AUA guidelines at http://www.auanet.org/guidelines/muscle-invasive-bladder-cancer-new-(2017). Muscle invasive bladder cancer is a challenging problem in urology. The introductory paragraphs of the AUA guidelines gives the scope of the problem that muscle invasive bladder cancer is for patients and physicians: “Although representing approximately 25% of patients diagnosed with bladder cancer, muscle-invasive bladder cancer (MIBC) carries a significant risk of death that has not significantly changed in decades…In patients who undergo cystectomy, systemic recurrence rates vary by stage…Most recurrences will occur within the first two to three years…and…most patients with recurrence after cystectomy are not curable. …There is also a significant impact of treatment choices on outcome with the type and timing of therapy playing an important role.” I am going to repeat that statement. “There is also a significant impact of treatment choices on outcome with the type and timing of therapy playing an important role.” Losing one’s bladder, even if it is lifesaving, causes significant impact in a person’s quality of life, and many patients and physicians choose to delay or defer surgery when it could be curative. Urologists, as we will discover, have always sought ways to restore or retain the quality of life for patients whose bladder must be removed because of cancer. If we choose the right treatment at the right time we can make progress in treating muscle invasive bladder cancer. I am going to go through the AUA guidelines. There are 35 of them. Don’t worry, I will not be going through each guideline individually but rather group them together into brief discussion points that patients who have muscle invasive bladder cancer and their physicians must think about before, during, and after the removal of the bladder. Guidelines 1-5 concern the initial evaluation and counseling. Full history and physical examination should be performed, the patient should have a staging evaluation with imaging and laboratory evaluation, and the patient should have a full discussion of curative treatment options. A complete discussion with regard to implications for quality-of-life should be discussed with the patient, including the type of urinary diversion. A multidisciplinary approach including surgical, chemotherapy and/or radiotherapy options should be discussed with patient. Guidelines 6-9 discuss either preoperative or postoperative chemotherapy. Chemotherapy should be offered to eligible patients prior to radical cystectomy although the best regimen for neo-adjuvant chemotherapy remains undefined. Guidelines 10-12 concern the radical cystectomy operation. Radical cystectomy should be offered to patients along with bilateral lymphadenectomy for surgically eligible patients. Standard radical cystectomy in the males includes removal of the bladder, prostate, and seminal vesicles. In females, the operation includes removal of the bladder, uterus, fallopian tubes, ovaries and anterior vaginal wall. The potential impact of sexual function and other quality of life issues after surgery for both men and women should be discussed prior to the operation. Guidelines 13 and 14 relate to urinary diversion. When the bladder is removed, an alternative to store and drain the urine must be created. Options for urinary diversion after removal of the bladder including ileal conduit, continent cutaneous diversions and ortho-topic neo-bladders. The choice of urinary diversion has a significant impact on long-term quality of life for patients who undergo radical cystectomy. Each type of diversion is associated with its own unique potential complications. Your surgeon will help you decide what type of urine diversion is right for you. I am not trying to be cute here but speaking of diversion, I want to take a step away from the guideline statements at this time and look at one of the articles from the 100th anniversary of the Journal of Urology published this year, a collection of reprints that highlight different eras and advances in Urology over the last 100 years. You can find the articles at JU100.org. I’ve highlighted some of these reprinted articles over my last few episodes. We have also been highlighting how “otherwise cautious urologists are also adventurous surgeons,” a phrase that struck me from the editor’s introduction to the anniversary edition. One of the articles that was reprinted was a 25-year retrospective for one type of procedure for urinary diversion no longer used today called the Camey procedure. The original article was published in the Journal in 1984. Camey began doing his procedure in the late 1950s. The Camey procedure is a type of urinary diversion isolating a 40-cm segment of ileal small bowel, attaching the ureters to either end and sewing the mid-segment of the isolated ileum to the remaining urethra after the bladder is removed. 84 patients were reviewed by Camey in his 25 year-experience. Dr. Camey’s review paper is fascinating to read. In his paper Dr. Camey gives details about his experience, both his success as well as his failures. Let’s hear him tell us about his first five patients. “The historical evolution of the current technique of bladder replacement can be divided into intervals of error, analysis, and correction. The first patient bladder replacement was attempted achieved continence. The second patient, operated upon a few days after the first, died within 15 days postoperatively…. The first functional enterocystoplasty in which total continence was a seen was performed in 1959 (patient #3). Pelvic lymphadenectomy revealed positive nodes and the patient died of carcinoma in 18 months… In an attempt to minimize infection, foreign body reaction and so forth, ureteral were not used in patient number four. This procedure proved disastrous when the patient became anuric secondary to edematous obstruction of the bilateral implants. As a consequence, bilateral ureteral stents delivered through the urethra and held in place by attachment to an indwelling urethrovesical 22 French straight catheter sutured to the penis have been used in all subsequent procedures. As a consequence of patient 5 the final U-shaped enterocystoplasty emerged. The error in this case was a graph design in which both ureters where anastomosed to the isoperistaltic end of the ileal loop with the distal end anastomosed to the urethra. This procedure resulted in peristaltic waves abutting against the urogenital diaphragm causing urinary frequency and leakage. Despite this deficiency the patient was the first long-term survival (15 years) with preservation of excellent renal function and electrolyte balance.” I will stop reading from Camey’s article. It just gives us some idea of how this otherwise cautious urologist needed to be an adeventurous surgeon to make his breakthrough. As I said, the Camey procedure is no longer performed. This has been replaced by other types of urinary diversion and neo-bladder with other names such as Indiana, Hauttman, Studer, and Koch. The newer diversions use de-tubularized segments of bowel. The bowel is designed to contract in a coordinated peristalsis and move contents through it. Because of the coordinated peristalsis the pressures within a tubular segment of bowel will push urine through it rather than store the urine. By de-tubularizing the bowel, we disrupt the peristaltic waves of the bowel and it begins to store the urine under low pressure. The different types of diversion deserve a whole podcast to themselves. Let’s return to this podcast and the guidelines. Guidelines 15-18 relate the perioperative management of patients. Optimization of patient performance status and health prior to cystectomy and optimized recovery pathway protocols will enhance recovery. Guidelines 19 and 20 discuss the role of extended lymphadenectomy during the procedure. Guidelines 21through 29 discuss bladder sparing protocols for those patients not eligible for radical cystectomy or who choose to keep their bladder. For these patients, maximal trans-urethral resection of the bladder tumor should be performed. This is typically combined with a combination of radiation along with chemotherapy and close follow-up. Recurrences after bladder sparing techniques should be treated aggressively. Guidelines 30-34 relate to patient surveillance and long-term quality of life issues. Frequent imaging and laboratory assessment are appropriate for those who have undergone treatment to check for recurrence. For those patients struggling with their diagnosis there are number of bladder cancer support groups that would love to speak with you. The last guideline number 35 relates to unique, less common cancer types that may require variance from any of the above guidelines. Your surgeon will help you understand if you fall into one of these categories. The radical cystectomy, lymphadenectomy and the urinary diversion is one of the longest and most complicated procedures that a urologist does. In his conclusion, Dr. Camey wrote, “As a cautionary note the successful performance of this operation depends on an unusual degree of commitment to meticulous technique. The procedure is tedious and stressfully long, and requires a team approach that is logistically complex and not universally feasible.” Dr. Camey’s operations routinely took 9 hours. He employed two sets of surgeons for the operation, one to remove the bladder and the other to do the urinary diversion. As urologists have gained surgical experience, operative times have improved. For my partners and I it takes 2-4 hours to remove the bladder, perform the lymphadenectomy, and create the simplest urinary diversion, the ileal conduit. The current standard in my practice is to perform the removal of the bladder robotically using the daVinci system. But the urologic oncologist’s long-term success and survival for patients with muscle invasive bladder cancer have not changed in the last 30 years. In his conclusion Dr. Camey writes, “The ancillary modalities, such as chemotherapy, immunotherapy, radiotherapy, antibiotic prophylaxis and nutritional supplementation, which may improve survival further must be perfected….” By creating the guidelines listed above the AUA and other various societies have for the first time come to an agreement about the best approach for these patients to give the highest chance of long-term success. I will end with some of the websites where you can find more information or support if you find yourself with this disease. Helpful websites include the Bladder Cancer Advocacy Network (http://www.bcan.org), Cancer Support Community (https://www.cancersupportcommunity.org), Cancer Care (https://www.cancercare.org), the American Bladder Cancer Society (https://bladdercancersupport.org), the American Cancer Society (https://www.cancer.org), and the Urology Care Foundation (http://urologyhealth.org). Support groups help reduce the three most significant stressors associated with cancer: unwanted aloneness, loss of control, and loss of hope. For those patients who are not interested in a support group, individual counseling may be available through an oncology social worker, psychologist, or local religious organizations. Lastly, if you have any questions, need my support, or have any feedback you can contact me at firstname.lastname@example.org.