Bladder cancer surgical management

🔬 Diagnosis - Staging the Splash Zone

• Initial Evaluation: Gold standard is cystoscopy for direct visualization of bladder lesions. Urine cytology is an adjunct, high specificity but low sensitivity for low-grade tumors.
• Definitive Staging: Transurethral Resection of Bladder Tumor (TURBT) is the cornerstone.
  • Provides tissue for histopathology (grade & stage).
  • Determines depth of invasion (T-stage).
  • Must include detrusor muscle in the specimen.

⭐ The single most important prognostic factor is invasion into the muscularis propria (detrusor muscle). This differentiates Non-Muscle Invasive (NMIBC: Ta, Tis, T1) from Muscle-Invasive Bladder Cancer (MIBC: ≥T2).

• Metastatic Workup: For MIBC, CT/MRI of abdomen/pelvis assesses nodal (N) and distant metastatic (M) disease.

🔪 Management - The Superficial Shave

• Primary Approach: Transurethral Resection of Bladder Tumor (TURBT) is the initial diagnostic and therapeutic step for non-muscle invasive bladder cancer (NMIBC).
• Procedure: A resectoscope is inserted via the urethra to resect the tumor from the bladder wall.
• Goal: Complete resection of all visible tumors.
• Adjuvant Therapy: Often followed by a single, post-op dose of intravesical chemotherapy (e.g., Mitomycin C) within 24 hours to reduce recurrence.
• High-Risk NMIBC: May require intravesical Bacillus Calmette-Guérin (BCG) immunotherapy.

⭐ Crucial for Staging: The TURBT specimen must contain detrusor muscle to rule out muscle-invasive disease (T2 or higher). Absence of muscle in a high-grade tumor specimen necessitates a repeat TURBT.

🔪 Management - Going Deep, Bladder's Out

• Non-Muscle Invasive (Ta, T1, CIS):

  • Primary: Transurethral Resection of Bladder Tumor (TURBT) for diagnosis & therapy.
  • Adjuvant: Intravesical Bacillus Calmette-Guérin (BCG) or chemotherapy (e.g., Mitomycin C) to ↓ recurrence.

• Muscle-Invasive (≥T2):

  • Standard: Radical Cystectomy (RC) with Pelvic Lymph Node Dissection (PLND).
  • Urinary Diversion Post-RC:
    • Ileal Conduit: Incontinent diversion (stoma bag). Most common.
    • Neobladder: Continent, orthotopic reservoir from ileum.

⭐ For muscle-invasive disease, radical cystectomy is standard. The extent of pelvic lymph node dissection is a key prognostic and therapeutic factor.

🌊 Management - Rerouting the River

• Post-Radical Cystectomy: Urinary diversion is necessary.
• 1. Ileal Conduit (Incontinent):
  • Most common. A segment of ileum channels urine from ureters to an abdominal stoma.
  • Requires a permanent external urostomy bag.
  • Lower operative complexity.
• 2. Orthotopic Neobladder (Continent):
  • Intestinal segment (ileum) fashioned into a reservoir, connected to the urethra.
  • Allows volitional voiding (Valsalva).
  • ⚠️ Higher risk of nighttime incontinence & urinary retention.

⭐ A key long-term complication of using intestinal segments is hyperchloremic, non-anion gap metabolic acidosis.

• Caused by reabsorption of urinary ammonium ($NH_4^+$) and chloride ($Cl^−$).

⚠️ Complications - The Post-Op Perils

• TURBT:
  • Immediate: Hematuria, bladder perforation, UTI.
  • Late: Urethral stricture.
• Radical Cystectomy & Urinary Diversion:
  • General: DVT/PE, infection, prolonged ileus, urine leak.
  • Urinary Diversion (Ileal Conduit) Specific:
    • Uretero-intestinal stricture → hydronephrosis.
    • Parastomal hernia, stomal stenosis.
    • Sexual dysfunction (ED, vaginal shortening).
    • Vitamin B12 deficiency (long-term).

⭐ High-Yield: An ileal conduit can cause a hyperchloremic, non-anion gap metabolic acidosis. This occurs because the intestinal segment reabsorbs urinary chloride in exchange for bicarbonate.

⚡ Biggest Takeaways

• Non-muscle-invasive (NMIBC): Managed with TURBT (transurethral resection). High-risk tumors receive adjuvant intravesical BCG to prevent progression.
• Muscle-invasive (MIBC): Standard of care is neoadjuvant cisplatin-based chemotherapy followed by radical cystectomy.
• Radical cystectomy includes pelvic lymph node dissection and requires permanent urinary diversion (e.g., ileal conduit).
• An ileal conduit is the most common incontinent diversion; a neobladder is a continent, orthotopic option.
• Partial cystectomy is a rare, bladder-sparing surgery for select solitary tumors.