T2 N0 M0 High-grade Urothelial Carcinoma Patient Case Study with Cushingoid Features Undergoing Radical Cystectomy in Neobladder - Makarand Khochikar
August 25, 2020
Makarand Khochikar, MS DNB, Dip Urol, FRCS, FEBU, National delegate for the Indian section of SIU, President of the Urological Society of India – West zone, Chairman of the Department of Uro-oncology at Siddhi Vinayak Ganapati Cancer Hospital, Miraj, India and is also a member of the management committee and Governing council of the hospital.
Ashish Kamat, MD, MBBS, President, International Bladder Cancer Group (IBCG), Professor of Urology & Cancer Research, MD Anderson Cancer Center, Houston, Texas
T2 N0 M0 Muscle-invasive Bladder Cancer Patient Case Study with Malrotation of the Gut Undergoing Radical Cystectomy- Makarand Khochikar
Ashish Kamat: Welcome to UroToday's Bladder Cancer Center of Excellence. I'm Ashish Kamat. I'm a Professor of Urologic Oncology at MD Anderson Cancer Center in Houston, Texas. And it's my great pleasure to once again welcome Dr. Makarand Khochikar to this venue. Dr. Khochikar and I did a bladder cancer case-based panel discussion a few episodes ago. And this was so well received that we've invited him, once again, to partake in that sort of a discussion with us. Today Dr. Khochikar will present a few cases and intraoperative consultations. Dr. Khochikar, the stage is yours.
Makarand Khochikar: Thank you, Dr. Kamat. This was a 66-year-old lawyer who had a high BMI, very short stature, large belly, had cushingoid features. I say cushingoid because all his endocrine workup was normal. ACTH courses were normal. But he was really a man with a high BMI and a short stature. He had a TURBT done offsite, and it showed muscle-invasive bladder cancer. It was T2, N0, M0 urothelial carcinoma high-grade. And he wished, again, to have a radical cystectomy in neobladder, like the last case what we discussed. And he just wanted neobladder only. No other option was acceptable to him. So the rule of preoperative counseling, I'm sure the viewers are familiar about, we usually spend one, two, three sessions, discuss at length with them, not only talk about different operative techniques, what we might have to do during surgery, and sometimes you might have to convert into an ileal conduit and obviously postop complications, like a standard thing.
So the radical cystectomy went off very well. And I was trying to mobilize the small bowel. A thick mesentery we described, very short and bulky. A lot of fat in the mesentery and it was not reaching up to the pelvis. I'm sure all the viewers understand this is a practical difficulty and there are many maneuvers which you can try. And many, many maneuvers, we will discuss it here. And I must say I had a discussion with Dr. Studer a while ago when we had this situation and Richard Hautmann also, a couple of times, what to do. But it's a rarity what they say. Now discussion here is what different things you can do. As it is said in the literature, this was an article which was written by Richard Hautmann, and it does not reach the neobladder in less than 10% of the cases. It's difficult and in his experience of more than a thousand neobladders, only two times he had all the maneuvers tried, nothing worked.
And it is mentioned in this paper here, small, small tricks, like loosening the retractor, straightening the operating table, removing the sacral cushion. But having said that, I never do set up from a jackknife position. I usually do the straight, little bit of head low, neutralizing the extended position, bringing up the perineum with a sponge stick. I don't know whether it works. Freeing the coecum, that was tried, descending colon, like what we do in RPLND. But this was not working. And I knew about this technique. And what is done usually is trying to create a U or some sort of a tube from set up a neobladder and then transfer of the anastomosis to the urethra. But one important caution in this article by Richard Hautmann was any incisions in the mesentery of the neobladder should be avoided. And for obvious reasons, it can have tear blade, metal mark and the valve becomes non-viable.
And just to explain what was done was something like this. Usually, we would have liked to have an anastomosis here. So try and create a tube and join to the intrapelvic portion of the urethra. Now, this was really challenging. And as you have seen in the literature is hardly two cases in 1,000 cystectomies. I would like to ask Dr. Kamat if he experienced anything like this and was there any situation he really couldn't get the neobladder [inaudible 00:04:09]. Dr. Kamat, please?
Ashish Kamat: Absolutely. So this, unfortunately, is a much more common occurrence than has been reported in the literature, especially in populations where the body mass index is higher. And you have patients who might be three, 400 pounds, BMI 35, 40, even 50. The mesentery can often be thickened, the bowel doesn't reach appropriately, et cetera, et cetera. So it's a lot more common nowadays with the rising weight of patients. Preoperative counseling is obviously key because the patient is often made aware that because of certain body habitus, we might have trouble with the neobladder. And, again, Richard and I have had many discussions and I respect him immensely, but I disagree with the fact that you don't or should never do incisions in the mesentery. Because sometimes the only way to get the neobladder down and especially if there's a lot of fat encroaching on the mesentery, is to perform relaxing incisions in the mesentery.
The key there is to not perform them perpendicular to the vessels. Incisions in the mesentery should be parallel to the vessels because if you don't make these incisions parallel to the blood vessels, that's when you can cause all the trouble and issues that our people often talk about. But if you make the incisions parallel to the blood vessels, it can relax the mesentery and have them come down. Clearly the ability to get the neobladder down to the pelvis is paramount. It should never be under tension. And I, again, disagree with the fact that you should use perineal pressure and other things to get the urethra to the neobladder.
Again, it works in his patient population, because they are a lot slender compared to ours. But if you force the anastomosis and you make it happen, but it's under tension, and then the poor patient would end up with a stricture at the anastomosis down the road. And then you are faced with all sorts of problems. So you could say, yes, I got the neobladder down, but then the patient's having a lot of trouble. It's an example and really important for your audience to remember these little tricks.
Makarand Khochikar: Exactly, I agree with you, Ashish. I also agree that any mechanical maneuver, bending the table, or pushing the front perineum it actually doesn't help. Because you don't want to have anastomosis under tension. And the only difficulty is like sort of making an incision to the mesentery. Dr. Studer also once said you can make an incision in the mesentery. The trouble in these patients is to how to visualize the normal results in the mesentery. It's such a big fat. But I agree with experience, you know where to cut and make proper incisions into that. So that was quite interesting.
I think it was wonderful to have your opinion on this and exactly agree with what you have said. All those mechanical maneuvers sometimes really don't help you much. What you said is to have an [inaudible 00:06:54] list and anastomosis is of very paramount importance. Mesenteric incisions do help, so I agree with you. The only problem, in this case, was the mesentery was very thick and to visualize the results sometimes can be tricky, but with the experience, one can do that. But that was a peer message. And I thank you for your expert opinion. Thank you, Dr. Kamat.
Ashish Kamat: Thank you very much, Makarand. These cases were really, really important, practical tips and tricks for our audience. Clearly, those that do these sort of surgeries all the time experience these and are faced with these. But oftentimes we have our colleagues who may not be doing cystectomies or bladder cancer all the time. And learning from the vast experience of cases that you have under your belt is very, very critical. Thank you very much for taking the time and for being part of this important educational activity.