Transitional cell carcinoma surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Suveenkrishna Pothuru, M.B,B.S. [2]

Overview

Surgery is the mainstay of treatment for transitional cell carcinoma. The feasibility of surgery depends on the stage of transitional cell carcinoma at diagnosis. Adjunctive chemotherapy, radiation therapy, and immunotherapy may be required.

Surgery

Transitional Cell Cancer of the Bladder

Surgery is the mainstay of treatment for transitional cell carcinoma of the bladder. The type of surgery depend on the stage of the tumor:

Stage	Treatment
Stage 0	Transurethral resection with fulguration followed by an immediate postoperative instillation of intravesical chemotherapy Transurethral resection with fulguration followed by an immediate postoperative instillation of intravesical chemotherapy followed by periodic intravesical instillations of BCG Segmental cystectomy (rarely indicated) Radical cystectomy (in rare, highly selected patients with extensive or refractory superficial high-grade tumors)
Stage I	Transurethral resection with fulguration followed by an immediate postoperative instillation of intravesical chemotherapy Transurethral resection with fulguration Transurethral resection with fulguration followed by an immediate postoperative instillation of intravesical chemotherapy followed by periodic intravesical instillations of Bacillus Calmette-Guérin (BCG) Transurethral resection with fulguration followed by an immediate postoperative instillation of intravesical chemotherapy followed by intravesical chemotherapy Segmental cystectomy (rarely indicated) Radical cystectomy in selected patients with extensive or refractory superficial tumors
Stage II and Stage III	Radical cystectomy Neoadjuvant combination chemotherapy followed by radical cystectomy External beam radiation therapy with or without concomitant chemotherapy Segmental cystectomy (in selected patients) Transurethral resection with fulguration (in selected patients)
Stage T4b, N0, M0 or any T, N1–N3, M0	Chemotherapy alone Radical cystectomy Radical cystectomy followed by chemotherapy Radical cystectomy alone External beam radiation therapy with or without concomitant chemotherapy Urinary diversion or cystectomy for palliation
Stage any T, any N, M1	Chemotherapy alone or as an adjunct to local treatment External beam radiation therapy for palliation Urinary diversion or cystectomy for palliation

• Non-muscle invasive bladder cancer: conservative management may allow the preservation of a functional bladder based upon transurethral resection of bladder tumor (TURBT), potentially combined with adjuvant intravesical therapy
• However, this approach must be balanced against the risk of recurrence or progression.

• Low-risk disease: TURBT alone plus a single dose of perioperative intravesical chemotherapy given in the operating room or within a few hours of tumor resection.

• Intermediate- or high-risk non-muscle invasive bladder tumors: intravesical therapy

• Careful surveillance for recurrent or second primary tumors of the urinary tract is required for both low- and high-risk patients following initial TURBT with or without intravesical therapy.
• Transurethral resection :non-muscle invasive bladder tumors
• Complete TURBT. Some patients with low-grade tumors may require two or more resections in order to remove all visible papillary disease.
• Perioperative single-dose intravesical chemotherapy (usually with mitomycin C) is indicated in patients with low-grade tumors.

• High-risk non-muscle invasive bladder cancer should undergo a repeat cystoscopy and may require reresection of areas of high-grade urothelial cancer prior to initiation of intravesical Bacillus Calmette-Guerin (BCG) therapy.
• Repeat cystoscopy is important, both to eliminate any visible residual disease and to eliminate the risk of understaging. All of the guidelines are consistent with this as a standard of care for patients with high-grade T1 tumors, and this is an option for patients with high-grade Ta tumors.
• Biopsies of normal-appearing mucosa adjacent and remote to the tumor should be done to determine whether CIS is present.

Intravesical therapy:

• Induction (weekly for six weeks) intravesical therapy is indicated in patients with intermediate- and high-risk disease.

• This facilitates delivery of high local concentrations of a therapeutic agent within the bladder, potentially destroying viable tumor cells that remain following TURBT and preventing tumor implantation. This is generally followed by maintenance therapy, and the duration of maintenance therapy is based upon risk stratification.

• Intravesical therapy utilizes large molecular weight compounds, thus limiting transmucosal absorption and systemic toxicity. However, the risk of disseminated infection with BCG or systemic toxicity from chemotherapy is increased in patients who have had extensive transurethral resection with residual denuded mucosal surfaces. Treatment is started one to two weeks after resection, allowing the bladder to heal.

• Intravesical immunotherapy with BCG, a live attenuated form of Mycobacterium bovis, is the treatment of choice for patients with high-risk disease (Ta, Tis, T1). A number of other intravesical agents have been compared with BCG, but none has proved consistently superior. Alternatives to BCG include several chemotherapy agents, such as mitomycin C, epirubicin, and gemcitabine

Transurethral resection of the bladder (TURB)

• A transurethral resection is also called a cystoscopic resection or a transurethral resection of bladder tumor (TURBT).
• Cancerous bladder tissue is removed through the urethra.
• Transurethral resection is used as the first treatment for all bladder cancers.
• It may be the only treatment needed for bladder cancer that hasn’t grown into the muscle layer of the bladder wall.
• For bladder cancer that has grown deeper into the bladder wall, a transurethral resection usually removes most of the tumor and also acts as a biopsy before other treatment is given.

Partial Cystectomy

• If the initial TURBT identifies muscle invasive (T2) disease, definitive therapy is generally indicated.
• Cystectomy may also play a role in the management of patients with non-muscle invasive bladder cancer.

• Any of the following represents a strong indication to proceed to cystectomy:

• T1 tumors with lymphovascular invasion

• Variant histologies, including micropapillary transitional cell carcinoma, sarcoma, squamous cell carcinoma, or adenocarcinomas

• T1, grade 3 tumors that were incompletely resected

• Prostatic duct/acinar CIS

• Relative indications :

• Ta or T1 high-grade plus CIS; T1b tumors (ie, deep involvement of lamina propria)

• Persistent T1, grade 3 tumors identified on reresection

• Recurrent or persistent disease within 6 to 12 months of initiating treatment with BCG

• Large-volume Ta, low-grade disease
• Women with bladder neck and/or urethra CIS
• However, decisions regarding cystectomy should be individualized based on the surgical risks of the patient
• Partial cystectomy is a segmental cystectomy removes the tumor and part of the bladder.
• Partial cystectomy may be an option if:

• The patient has a small tumor that can easily be removed with clear margins.
• The tumor is in an abnormal pouch on the bladder wall.
• The patient isn't healthy enough to have more extensive surgery.

MUSCLE INVASIVE DISEASE

Radical Cystectomy

• Radical cystectomy involves removal of the bladder, adjacent organs, and regional lymph nodes.
• In men, radical cystectomy generally includes removal of the prostate and seminal vesicles as well as the urinary bladder.
• In women, removal of the uterus, cervix, ovaries, and anterior vagina is usually performed en bloc with the bladder.

• Radical cystectomy is minimally invasive laparoscopic approach.
• Patients who have undergone radical cystectomy for urothelial bladder cancer are at risk for the development of distant metastases as well as second primary urothelial tumors in the renal pelvis, ureters, or urethra.

Urinary diversion

Surgery may also be done to drain urine after the bladder is removed. This may include:

Urinary diversion surgery
Ileal conduit
Continent urinary reservoir
Orthotopic neobladder

Ileal conduit

• A small urine reservoir is surgically created from a small piece of bowel.
• The ureters that drain urine from the kidneys are attached to one end of the bowel segment.
• The other end is brought out through an opening in the skin (a stoma).
• The stoma allows the patient to drain the collected urine out of the reservoir.

Continent urinary reservoir

• A pouch to collect urine is created inside the body using a piece of your colon.
• You will need to insert a tube into an opening in your skin (stoma) into this pouch to drain the urine.

Orthotopic neobladder

• This surgery is becoming more common in patients who had their bladder removed.
• A part of the bowel is folded over to make a pouch that collects urine.
• It is attached to the place in the body where the urine normally empties from the bladder.
• This procedure allows you to maintain some normal urinary control.

Transitional Cell Cancer of the Renal Pelvis and Ureter

Localized Transitional Cell Cancer of the Renal Pelvis and Ureter

Standard treatment options for localized transitional cell cancer of the renal pelvis and ureter may include:

• Nephroureterectomy with cuff of bladder
• Segmental resection of ureter

Nephroureterectomy

• This is the most common surgery for cancer of the renal pelvis or ureter.
• Removes all of the kidney, the layer of fat around the kidney, all of the ureter, and the tissue where the ureter enters the bladder (called the bladder cuff).
• With large tumors, the renal vein and parts of the large vein in the abdomen (vena cava) may be removed.

Segmental resection of ureter

• This surgery removes the part of the ureter with the tumor in it.
• A segmental resection is usually only used to remove tumors in the lower third of the ureter.
• The surgeon will remove a margin of healthy tissue above the tumor and all of the ureter below the tumor to the bladder.
• The ureter is then usually reattached, or reimplanted, to the bladder (called ureteroneocystostomy).
• In rare cases, a segmental resection is done for tumors higher in the ureter.
• The surgeon removes the tumor with some healthy tissue above and below it.
• The two remaining ends of the ureter are joined together.