Technical considerations for salvage cystectomy

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Experience with 158 patients who had salvage cystectomy performed by urologists at MD Anderson Cancer Center between 1969 and 1987 (114 patients) and between 1993 and 1998 (42 patients), as well as the additional 55 patients shown in Table 5 who had cystectomy between 1993 and 1998, forms the basis of our conclusions on how to avoid some of the surgical complications associated with salvage cystectomy. It is apparent to us that many of the complications are the result of obliterated tissue planes following prior surgery, prior irradiation, prior chemotherapy, or combinations thereof. Some of the dense desmoplastic reaction may be due to obliteration of tumour, some due to healing from prior injury, and some due to ischaemic changes because of injury to small blood vessels.

We believe that the risk of these complications can be reduced by several modifications in technique. First, minimize blunt dissection. Although many surgeons, myself included, are accustomed to opening up tissue planes by finger dissection, with or without using a sponge-stick for assistance, during salvage cystectomy such manoevres are more likely to tear structures randomly, frequently where you don't want them to tear. This may include blood vessels or the rectal wall. Second, be alert to anatomic distortions. The obturator nerve, particularly if the space of Retzius is dissected bluntly, may not be found in its accustomed position on the pelvic sidewall because it may adhere to the bladder wall after

Table 5: Prior therapy in 55 patients who underwent contemporary salvage-equivalent cystectomy after non-definitive therapy or definitive therapy for non-urothelial cancers

Urothelial cancers

23 patients had received neo-adjuvant chemotherapy (two courses) 16 patients had received <50 Gy irradiation (plus chemotherapy in five) Other cancers

10 patients had received >65Gy (plus chemotherapy in three) 6 patients had received chemotherapy (plus <50 Gy in three)

Figure 2: Dissection of the bladder and prostate off the anterior rectal wall.

Figure 2a: Blunt dissection with the surgeon's hand may establish the correct plane in patients without prior treatment.

Figure 2b: In patients undergoing salvage cystectomy, the plane between the posterior bladder wall and the anterior rectal wall is frequently obliterated by a dense desmoplastic reaction. Depress the rectal wall with a sponge-stick and cut immediately adjacent to the bladder wall (small arrow) instead of using blunt dissection.

Handling Cystectomy

prior irradiation, chemotherapy, or surgery, exposing it to risks during the dissection. Third, dissect tissue planes sharply. This is the corollary to minimizing blunt dissection, of course, but it is offered to emphasize the importance of visualizing where you want to dissect and then doing so sharply with scissors or knife. Use counter-traction to help visualize the correct planes. These last two points are illustrated by Figures 2a and 2b.

Although the dissection between the rectum and the posterior bladder wall can frequently be performed bluntly in the patient who has had no prior therapy (as illustrated in Figure 2a), it is much more likely that you will find the posterior bladder wall densely adherent to the rectum, as illustrated in Figure 2b. To minimize the risk of injury to the rectal wall, use a sponge-stick to depress the rectal wall at the same time the bladder is lifted up, and then use scissors to cut immediately adjacent to the posterior bladder wall; then push gently, if possible, to reveal the next point that should be cut. The proper technique requires the surgeon to visualize to the fullest extent possible the juncture of posterior bladder wall and rectum, cut and gently push to see if the dissection proceeds easily, and then repeat the cycle as many times as is necessary. As you approach the prostate itself, it is often easier to complete the dissection following incision of the endopelvic fascia. This may enable you to get down behind the prostate and work in a retrograde manner. It may be optimal to alternate these two approaches: cut and push gently in an antegrade direction, and then try working in a retrograde direction to complete the dissection of the posterior bladder wall and prostate off the rectum.

The distal ureters are frequently very fibrotic because of changes secondary to radiation therapy or chemotherapy. We find it helpful to ligate the ureters as soon as they are cut and to allow them to dilate. Observe the dilation of the ureter. You may find, as illustrated in Figure 3, that a portion of the distal ureter does not dilate. This portion is fibrotic secondary to vascular compromise and should not be used for your urinary diversion. Cut and use only the dilated portion of the ureter to help ensure sufficient blood supply and to minimize the chance that you will get a late stenosis of the anastomosis of the ureter to the bowel.

Chemo Pick Line
Figure 3: The distal ureter may be fibrotic after irradiation. Cut (dotted line) and use only the dilated portion of the ureter.

When selecting bowel for the urinary diversion, avoid unhealthy looking bowel. If portions of the small bowel look very leathery, with multiple adhesions and very friable serosa, consider more proximal segments, since the last 45-60cm of the ileum is usually the worst. To minimize further injury to the bowel, avoid handling tissues unnecessarily. Furthermore, when handling the ureter, do not take even the vascular forceps and grasp the full thickness of the ureteral wall. Try to pick up only adventitia or periureteral tissue so as not to injure already compromised tiny vessels even more. When selecting a segment of bowel, be sure to protect compulsively against injuring the blood supply to the selected segment of bowel. Although it is mostly the small vessels that have been injured by pre-operative therapy, this places increased importance on maintaining a good blood supply with the larger vessels. Avoid injury to any of the vessels at all costs.

Given the high morbidity rate for salvage cystectomies, even with ileal conduits, it should not be surprising that alternative diversions were not recommended until relatively recently. Bochner et al., from the University of Southern California, reported in 1998 that 18 patients had construction of an orthotopic neo-bladder following salvage cystectomy for disease recurrence after receiving at least 60 Gy of radiation for either bladder or prostate cancer.20 They noted good continence during the day and night in 67% and 56% respectively of irradiated patients. Similarly, Gschwend et al., from the University of Ulm, performed orthotopic urinary diversions in 11 patients after high-dose pelvic irradiation, with 'satisfactory results' in seven patients.21 They did see a neovesical-peritoneal fistula in one woman 10 months after surgery, which was repaired during laparotomy, and a neovesical-vaginal fistula that required a supravesical urinary diversion in a second woman. They concluded that high-dose pelvic irradiation should not be a primary contra-indication for orthotopic urinary diversion using segments of small intestine. However, they felt that the indication for orthotopic bladder replacement should be considered critically in patients who undergo combined external and interstitial radiotherapy.

In our experience, we performed either orthotopic neo-bladder diversion or continent cutaneous diversion on 21 of the 97 patients who had had various types of therapy before cystectomy.7,14 Considering only the 42 patients who underwent 'true' salvage cystectomy, 35 had ileal conduits constructed, two had continent cutaneous diversions, and five had Studer ileal neo-bladders constructed. Although one patient undergoing continent cutaneous diversion died post-operatively, this death was attributed to a pulmonary embolus and not urinary diversion. No specific complications were attributable to the urinary diversion, and we believe our experience supports that of others who have concluded that alternatives to ileal conduit can be performed safely in carefully selected patients, despite prior irradiation or chemotherapy, or both.

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