Radical Cystectomy - Definition, Indications, and Complications

What Is Radical Cystectomy (RC)?

Radical cystectomy is a surgery done primarily for muscle-invasive bladder cancer (MIBC) and, at times, for refractory non-muscle invasive bladder cancer (NMIBC). The procedure comprises two steps- radical cystectomy and urinary diversion. The surgeon removes the entire bladder and surrounding lymph node (to prevent metastasis); in men, it is followed by the removal of the prostate and seminal vesicles, and in women, the uterus, ovaries, fallopian tubes, and part of the vagina are removed after bladder resection.

The second step of the procedure is the urinary diversion; this is done to create an artificial outlet to store and expel urine. It can be done by creating an artificial opening in the wall of the patient's belly (stoma), or the surgeon can fashion out an artificial bladder from the patient's intestine.

Radical cystectomy is the mainstay in the management of MIBC and NMIBC and is always combined with perioperative chemotherapy and lymphadenectomy (removal of surrounding lymph nodes). New developments in the procedure include minimally-invasive laparoscopic RC and robot-assisted RC, which have a significant upper hand when it comes to short-term outcomes but is yet to be determined in terms of their long-term impact.

What Are the Indications for Radical Cystectomy?

It is indicated in patients with the following conditions:

• Urinary bladder cancer has invaded the muscular layer but is still confined within the bladder.

• In patients with advanced colon cancer, prostate, or endometrium, the bladder is removed to prevent further spread.

• It is done in patients with severe intestinal cystitis, which does not respond to conventional treatments.

• It is done in patients with developmental anomalies in their bladder.

• A bladder diverticulum is a condition where the inner wall of the bladder forms an outward bulge that looks like a pouch. It is not dangerous by itself, but often in a few patients, it can get infected or can be the site for transitional cell carcinoma that can be treated only by an RC.

• In patients with a fistula between the colon and the bladder or the vagina and the bladder.

• For localized endometriosis of the bladder.

• In the case of cavernous hemangioma with severe hematuria (blood in the urine).

• Other conditions include pheochromocytoma (neuroendocrine tumor), schwannoma (a rare type of nervous system tumor), and endocervicitis (an inflammatory process that involves cervical tissues).

What Happens During Radical Cystectomy?

Prior to the procedure, the surgeon requests a couple of tests to diagnose the condition and plan the surgery. These are divided into the following groups:

• Laboratory Tests- These include urinalysis to identify and confirm hematuria, urine cytology to identify cancer cells, bladder barbotage for better sensitivity, liver function, and a bone fraction of alkaline phosphatase to evaluate metastasis (spread of cancer cells from its origin to other parts of the body)).

• Imaging Tests- After confirming hematuria and probable cancer cells, the next step is a radiographic evaluation which is done by computed tomographic (CT) scanning, ultrasound, retrograde pyelography, and intravenous pyelography (IVP), or by direct imaging like a cystoscopy and ureteroscopy that visualize the entire bladder.

Any one of the above-mentioned or in combination can be used for investigative purposes.

• Other Tests- Once the condition leading to radical cystectomy is identified, the clinician performs a bimanual pelvic exam to determine if the tumor in the bladder is fixed or movable. A chest radiograph is also performed to assess metastatic deposits.

• Biopsy- This is done when all the before-mentioned tests indicate bladder cancer. A section of the tumor is surgically resected with a resectoscope under general or spinal anesthesia. An experienced urologist then assesses the sample and determines the size, site, and number of lesions.

• Staging- Once the cancer is diagnosed, staging is done to plan the surgery. For example, in a T0 stage cancer where the tumor is confined to the mucosa (inner lining) of the bladder, the surgeon opts for partial cystectomy, whereas for patients with T1 and T2 stage cancer, radical cystectomy or total cystectomy is an ideal approach.

Once the necessary workup is done, the next is comprehensive preoperative counseling which motivates the patient, improves recovery and reduces complications. The next step is the actual cystectomy; it can be done in different ways; they are as follows:

1. Open Radical Cystectomy (ORC) With Intracorporeal Urinary Diversion- After anesthesia, the surgeon accesses the bladder and surrounding lymph nodes with one long incision in the abdomen; adequate exposure is crucial to optimize surgical insufficiency. This is followed by the removal of the bladder, in men, the prostate and the seminal vesicles are also removed (parts of the male reproductive system), and in women, the uterus, fallopian tubes, ovaries, cervix, and occasionally part of the vagina (parts of the female reproductive system) are resected. The specimen is then sent for histopathological examination; the next procedure is the dissection of the associated lymph nodes (lymphadenectomy) to prevent metastasis (spread of cancer). Urinary diversion is the last step in the process; it can be done by three methods, they are:

• Ileal Conduit- The surgeon then disconnects a part of the small intestine called the ileum and attaches both the ureters (thin tubes through which urine travels from the kidneys to the bladder) to one end of it. The other end of the ileum is attached to the stoma (an artificial opening created by the surgeon in the abdominal wall). The open ends of the intestine are anastomosed with sutures. Externally a plastic ostomy bag is attached to the stoma. When the kidney produces urine, it travels to the ureter, gets collected in the ileum (but not stored), and then passes through the stoma into the ostomy bag.

• Continuous Cutaneous Diversion- This is similar to the ileal conduit, but a larger portion of the intestine is sectioned and attached to the ureters. This acts as a reservoir and collects and stores the urine. The other end of the reservoir is connected to the stoma; the stored urine in the reservoir gets emptied through the stoma with a catheter instead of an ostomy bag.

• Neobladder- The surgeon fashions a reservoir from the intestine and attaches it to the ureters on one end and the urethra (it is the tube through which urine leaves the body) on the other end. There is no need for a stoma, an ostomy bag, or a catheter; urine travels from the kidneys to the ureters, gets collected in the reservoir, and then emptied through the urethra.

2. Robot-assisted Radical Cystectomy (RARC) With Intracorporeal Urinary Diversion- This is a minimally-invasive technique that uses a laparoscope attached to a robotic system (da Vinci Xi); the entire system is operated by the surgeon from the control room. After anesthesia, the surgeon places six small incisions (two of them measuring 12 mm, the other two around eight millimeters, and the remaining two sound five millimeters) below the belly in a crescent shape. The laparoscope (a fiber-optic instrument with a light and camera attached to it) is then inserted through one of the incisions. Once inserted, the laparoscope live-streams the underlying organs and tissues. The surgeon then inserts specialized surgical instruments using the da Vinci XI through the remaining five small incisions. The next steps are similar to that of open surgery; they are as follows:

• Mobilization and division of the ureters at the UVJ or ureterovesical junction (it is an area where the tube (ureters) that helps in draining urine from the kidneys meet the bladder.

• Mobilization of bilateral seminal vesicles (glands that produce semen) in men and anterior vaginal resection, salpingectomy, and hysterectomy in women.

• Dissection of lateral pedicles (lateral and posterior blood supply of the bladder) with a laparoscopic stapler.

• Division of the dorsal venous plexus (blood supply of the prostate) and membranous urethra (middle section of the urethra).

• Specimen entrapment in an endo catch bag.

• Extended lymphadenectomy.

• Urinary division through a small-midline incision.

ORC is considered the gold standard for treating bladder cancers due to its long-term survival rate, RARC is superior when it comes to short-term outcomes, but its long-term effectiveness is yet to be determined.

What Are the Interim Outcomes of RARC?

Below are the immediate effects of RARC:

• Decreased blood loss.

• Decreased postoperative pain.

• Faster recovery.

• Better cosmetic results.

• A shorter learning curve when compared to ORC.

• Decreased hospital stay.

• Enhanced visibility of vital structures.

• Three-dimensional visualization.

• Extended degrees of freedom.

• Precise apical dissection.

• Decreased bowel exposure outside the body.

• Superior ergonomics for the primary surgeon.

• Decreased intracorporeal suturing time.

Even with the never-ending list of positive short-term outcomes, RARC does have its pitfalls that can be overcome with time; they are:

• No long-term oncological data. The procedure is less than twenty years old, and very few studies have been done on this procedure, which explains why there is no established data regarding its long-term survival rate and remission.

• High initial and procedural costs.

• Longer operative time.

• Lack of tactile feedback.

• Limited instrumentation.

• Longer setup times initially.

What Are the Complications of Radical Cystectomy?

As with any major surgical procedure, RC also has a few complications and risks; they are:

• Bleeding.

• Blood clots.

• Infection.

• Organ damage.

• Reaction to anesthesia.

• Erectile dysfunction in men.

• Sexual side effects in women.

RC is a complex procedure that needs enhanced recovery surgery protocols postoperatively; they include optimization of nutrition, standardized analgesic and anesthetic regime, and early patient mobilization. Nutritional optimization includes avoiding mechanical preparation, limited perioperative fasting, carbohydrate loading, and early oral feeding postoperatively. Incorporation of enhanced recovery programs after surgery has been shown to promote recovery, reduce hospital stay, and promote the faster return of bowel function.

Conclusion:

Radical cystectomy is a major procedure with high morbidity and mortality rates; it is performed only when the life of the patient is at stake and the benefits outweigh the complications. The success of the procedure depends on multidisciplinary coordination and active engagement of the patient by counseling, which helps them to make informed decisions regarding their treatment.