EAU 2018: Management of Muscle Invasive Bladder Cancer – When Should the Guidelines Be Ignored?

Copenhagen, Denmark (UroToday.com)  Dr. Seth Lerner discussed his experience with radical cystectomy, including several tips and tricks. Dr. Lerner notes that the goals of a radical cystectomy are for (i) local/regional control of invasive bladder cancer and regional lymph node metastases, (ii) accurate pathologic staging, (iii) preservation of volitional control of urination, (iv) preservation of the upper urinary tract, and (v) preservation of sexual function. The goals and anatomic approach for radical cystectomy are the same for open and the robotic assisted approach. 

According to the EAU guidelines, radical cystectomy is the standard of care in most western countries for patients with T2-T4a, N0-Nx, M0 disease. Younger patients with good performance status and minimal comorbidities should undergo a radical cystectomy, and patients >80 years of age may have increased morbidity but only minimally increased risk of mortality. If the patient is not undergoing neoadjuvant chemotherapy, radical cystectomy should be performed within 12 weeks of diagnosis/staging. The AUA guidelines suggest (i) clinicians should offer radical cystectomy with bilateral pelvic lymphadenectomy for surgically curable non-metastatic (M0) disease; (ii) when performing a standard radical cystectomy, clinicians should remove the bladder, prostate and seminal vesicles in a male, and bladder, uterus, fallopian tubes, ovaries and anterior vaginal wall in females; (iii) consider sexual function preserving procedures for patients with organ-confined disease and absence of bladder neck, urethra, and prostate involvement; (iv) urinary diversion – discuss all options and long-term impact on QoL and potential complications. 

According to Dr. Lerner, the treatment process starts with a high-quality TURBT with a bimanual examination under anesthesia. This allows determination of histology, lymphatic/vascular invasion, and depth of penetration – cT stage. A complete resection is not necessary when cystectomy is anticipated and directed biopsies to the bladder neck/urethra should be performed to detect CIS. At the time of radical cystectomy, Dr. Lerner advocates in males towards removal of bladder and perivesical fat, prostate and seminal vesicles; in women – bladder, ovaries, uterus/cervix, anterior vagina, however there is a low incidence of gynecologic organ involvement and there is evidence that preservation of the vagina/uterus provides support for the neobladder and pelvic floor. Nerve-sparing is appropriate in absence of T3/T4 disease and for males is the same technique as a radical prostatectomy and in females one should stay anterior to the vagina. With regards to prostate/seminal vesicle sparing radical prostatectomies, there are reports of carcinomatosis in otherwise curable bladder cancer. In Dr. Lerner’s opinion, the pros are that sparing these organs optimizes continence and potency, however the cons are (i) urothelial carcinoma of the prostate occurs in 40%, (ii) prostatic adenocarcinoma is present in 40% of cases and (iii) >50% of incidental prostate is clinically significant. 

With regards to the urethra, Dr. Lerner rarely performs urethrectomy at the time of cystectomy in men. Indications for a urethrectomy include (i) diffuse CIS/papillary tumor of the prostatic urethra or ducts, (ii) prostatic stromal invasion (T4a), and (iii) CIS or frank tumor at the apical margin (some feel this is the only indication). Urethral preservation in women is contraindicated with cancer involving the bladder neck and urethra or posterior T3 tumors or tumors involving the anterior vaginal wall. 

Dr. Lerner highlighted that atypia and dysplasia do not require action when involving the ureter and that for CIS the aim is for a negative margin, without compromising ureteral length (nephrectomy is not indicated; can reconstruct with a long afferent ileal limb). CIS of the ureter is not independently associated with a worse clinical outcome and recurrence at the anastomosis is rare even with a positive margin. When considering a pelvic lymphadenectomy, the AUA guidelines state that clinicians must perform a bilateral pelvic lymphadenectomy at the time of any surgery with curative intent. Furthermore, when performing bilateral PLND, clinicians should remove at minimum the external and internal iliac and obturator lymph nodes. This identifies >95% of N1 disease and skip metastases rare. An extended lymphadenectomy includes the pre-sacral, common iliac, and distal aorta/IVC lymph nodes – this increases the node yield by 34-40%.

Dr. Lerner concluded with several take-home points:

  • Radical cystectomy is the standard of care for patients with T2-T4a, N0-1, M0 bladder cancer
  • Management co-morbidities and good performance status are required
  • Sex-organ sparing may be appropriate in selected patients
  • Bilateral standard PLND is required for all patients and the role of extended PLND will be defined by an ongoing randomized clinical trial
  • Robotic cystectomy reduces blood loss, but long-term oncologic equivalence is yet to be validated

Presented by: Seth Lerner, Baylor College of Medicine, Houston, TX

Written by: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre, twitter: @zklaassen_md at the 2018 European Association of Urology Meeting EAU18, 16-20 March, 2018 Copenhagen, Denmark