Transpubic Cystectomy and Ileocecal Bladder Replacement after Preoperative Radiotherapy for Bladder Cancer

0022-534 7/86/1353-04 70$02.00/0 Vol. 135, March

THE JOURNAL OF UROLOGY

Copyright © 1986 by The Williams & Wilkins Co.

Printed in U.S.A.

TRANSPUBIC CYSTECTOMY AND ILEOCECAL BLADDER REPLACEMENT AFTER PREOPERATIVE RADIOTHERAPY FOR BLADDER CANCER KENNETH STEVEN,* PETER KLARSKOV, HENRIK JAKOBSEN, H. BAY-NIELSEN FINN RASMUSSEN

AND

From the Department of Urology, Glostrup Hospital and Herlev Hospital, University of Copenhagen, Copenhagen, Denmark

ABSTRACT

Radical cystectomy was modified by leaving the apical prostatic capsule to facilitate anastomosis of the isolated ileocecal segment to the urethra and to preserve erectile potency. The transpubic approach was used to increase the exposure, and to facilitate dissection and anastomosis. A total of 15 patients with stages Tl to T4 bladder tumors underwent the operation: 13 after preoperative radiotherapy with 4,000 rad and 2 had salvage cystectomy after 6,000 rad. One patient died postoperatively. The remaining 14 patients underwent urodynamic evaluation 3 to 6 months postoperatively. The maximum urine flow rates were almost normal and none of the patients had significant residual urine. Daytime urinary continence was satisfactory in 13 patients and 1 was moderately incontinent. All of the patients were incontinent at night, probably owing to peristaltic contractions in the intestinal bladder and relaxation of the pelvic floor muscles. Preoperatively, 8 patients experienced erections and 7 had intercourse. Postoperatively, erectile potency was preserved in 4 patients and 3 had sexual function. No orthopedic disability occurred postoperatively. The median followup was 20 months, with a range of 3 to 30 months. There have been no local recurrences. A year postoperatively 6 of 9 patients had sterile urine. This technique makes it possible to avoid a urinary stoma, to obtain satisfactory voiding and urinary continence in almost all cases, and to preserve sexual function in some patients after cystectomy. Radical cystectomy requires urinary diversion and almost always results in erectile impotence. 1• 2 Urinary diversion is accomplished most often via an external conduit with an ilea! stoma. To increase the quality of life after radical cystectomy the operation was modified by leaving the apical prostatic capsule. This technique facilitates the anastomosis of an isolated segment of intestine to the urethra, making it possible to create an internal urinary diversion and to retain normal micturition.a---a It also avoids injury to the autonomic innervation of the corpora cavernosa and, thus, preserves erectile potency.9-11 The operation can be performed via a retropubic or transpubic approach. The retropubic approach is more difficult and can be used only in selected cases. 12 The transpubic approach offers excellent exposure, 13- 15 and facilitates dissection and anastomosis. From February 1983 to January 1985, 15 consecutive patients with invasive bladder cancer underwent transpubic radical cystectomy with ileocolic bladder replacement. The surgical technique, clinical results and urodynamic findings are presented. PATIENTS AND METHODS

Patients. Table 1 shows the tumor grade 16 and stage before treatment, and the age of the 15 consecutive men who underwent the operation. Each patient had received preoperative radiotherapy: 12 underwent cystectomy within 4 weeks after receiving 4,000 rad as part of a planned staged treatment, while 2 underwent salvage cystectomy (1 for residual tumor and 1 for recurrence) 1 and 6 months after having received 6,000 rad, respectively, and 1 underwent cystectomy for recurrence and radiation cystitis 5 years after completion of 4,000 rad radioAccepted for publication October 23, 1985. Read at annual meeting of American Urological Association, Atlanta, Georgia, May 12-16, 1985. *Requests for reprints: Department of Urology, Herlev Hospital, DK-2730 Herlev, Denmark. 470

therapy. Three patients were treated with systemic chemotherapy before radiotherapy. Surgical technique. The operation was performed through a left paramedian incision extending down on each side of the penile root (fig. 1). The periosteum was erased from the anterior surface of the symphysis. A wedge of symphysis was excised with the lateral margins at the pubic tubercles superiorly and measuring only 0.5 cm. distally. The bony pelvis was not retracted. Radical cystectomy was performed with the following modification. The prostatic capsule was incised circumferentially along the apex of the gland. The prostate was dissected and the entire gland including the verumontanum was removed. A frozen section was taken from the resection line and the operation was continued only if there was no dysplasia or tumor. The right side of the colon, including the hepatic flexure, was mobilized. The ascending colon was transected above the right colic artery and the ileum was transected 10 to 20 cm. from the ileocolic junction. Intestinal continuity was re-established by an ileocolostomy, The isolated ileocolic segment was rinsed thoroughly with isotonic saline and both ends were closed. The segment was rotated counterclockwise, bringing the cecum down to the urethra without tension. The cecum was incised longitudinally for 2 cm. at a tenia, and was anastomosed to the membranous urethra and prostatic capsule with 2-zero polyglycolic acid. The sutures were left untied and clipped in the Scott retractor until they all had been placed. The ureters were spatulated widely and anastomosed over stent catheters to the entire thickness of the ileum with 4-zero polyglycolic acid. The left ureter usually was brought through the sigmoid mesentery but in cases with a short left ureter as a result of radiation damage the ileal segment was brought through the mesentery instead. In our first 10 cases the ureteral stents and a suprapubic 12F silicone bladder catheter were led out through the appendix stump. In the last 5 patients we have not inserted a suprapubic catheter and have found that the urethral catheter provides sufficient

TRANSPUBIC CYSTECTOMY AND INTESTINAL BLADDER REPLACEMENT

' bladder drainage. The ureteral stents then were brought out alongside the urethral catheter. The pubic periosteum was approximated with polyglycolic acid and closure was done by a standard fashion. Preoperative and postoperative management. The bowel was prepared with whole-gut irrigation. Prophylactic antibiotic therapy was given for 2 to 3 days. The patients were kept in bed for 5 days. Low dose heparin thrombotic prophylaxis was administered until the patients were fully mobilized. Parenteral nutrition was continued until normal bowel function was reestablished. Continuous epidural analgesia was administered. Both bladder catheters were irrigated with saline. Retrograde pyelography was done 10 days postoperatively to assess the

TABLE L Clinical features in 15 patients Pt. Age (yrs.) 59 61 69 67 57 51 67 67 62 72 50 57 68 53 64

Histology

Stage

Pathological Stage

4

T3 T2

PTO pTO

4,000 4,000

3

T4B

pTl

6,000

4

T3

pT3

4,000

3

T3

pT2

4,000

3

T2

pT3

4,000

4

T3

pTO

4,000

Cisplatin

4

T3

pTO

4,000

Methotrexate plus cisplatin

3

T3

pTO

4,000

3

T3

pT2

6,000

4

T2

pTO

4,000

4

T3 T2

pTO pTO

4,000 4,000

3

Tl

pTO

4,000

T4A

pT4A

4,000

Grade

Adenoca. Transitional cell Ca Transitional cell Ca Transitional cell Ca Transitional cell Ca Transitional cell Ca Transitional cell Ca Transitional cell Ca Transitional cell Ca Transitional cell Ca Transitional cell Ca Squamous Ca Transitional cell Ca Transitional cell Ca Squamous Ca

A

Radiotherapy (rad)

Chemotherapy Cisplatin

integrity of the anastomoses before removal of the ureteral stents and suprapubic catheter. The urethral catheter was kept in place for approximately 14 days. If suprapubic leakage occurred after its removal a catheter was reinserted and left in place for 2 to 3 weeks. Urodynamic studies. Urodynamic evaluation was done 3 to 6 months postoperatively and began with a 60-minute provocative incontinence test. 17 Uroflowmetry then was performed, followed by urethral catheterization and assessment of residual urine. A 14F Foley catheter with a ring electrode mounted 1 to 2 cm. below the balloon was used. The sensory thresholds of the penile skin and posterior urethra were determined by increasing the current of 0.2 msec. square wave current pulses at 2 Hz. The current was read in milliamperes and the mean of 3 readings was used. To examine sphincter electromyographic activity and sacral evoked responses a concentric needle electrode was inserted into the external anal sphincter or bulbocavernosus muscle. The latency of the bulbocavernosus reflex was measured with stimuli delivered to the penile skin and posterior urethra with intensities 2 to 3 times that of the sensory thresholds. Medium-fill cystometry was performed with saline at 37C and a filling rate of 50 ml. per minute. The urethral catheter was withdrawn and pressure-flow electromyographic studies were performed. To measure the cecal bladder pressure a 3.5F infant feeding tube was inserted suprapubically in 8 patients and a 5F infant feeding tube was placed transurethrally in 4. To record the abdominal pressure an 8F balloon catheter was placed in the rectum. These values were subtracted to calculate the pressure generated by the cecal bladder. Measurements were repeated until they could be reproduced. To examine the pathogenesis of nocturnal incontinence the urethral closure pressure was monitored with the patient awake and asleep via 2 microtip pressure transducers. Measurements were made with the Neuromatic 2000 and 2100 Uro-system.* The methods, definitions and units conform to the standards recommended by the International Continence Society. 18• 19 Sexual function. Sexual activity was evaluated by interviews with the patient and his wife. Penile blood pressure was measured with a 2.5 X 12.5 cm. cuff and a 8 MHz. Doppler ultrasound * DISA/Dantec, Copenhagen, Denmark.

,.•'

..·····

Bladder~~~~-

......··::./

471

Ureter

',,

Prostate ~---

FIG. 1. Surgical technique. Structures indicated by broken line are excised and those within hatched lines remain

472

STEVEN AND ASSOCIATES TABLE 2.

Operative mortality and complications No.

Operative mortality Major complications Ureteroileal anastomotic leakage (percutaneous nephrostomy) U reteroileal anastomotic stricture (reoperation) Enterocutaneous fistula (parenteral nutrition) Intestinal obstruction (reoperation) Pelvic abscess Minor complications: Cecourethral anastomotic leakage (closed spontaneously) Leakage at suprapubic catheter drainage site (urethral catheter) Low pack pain (physiotherapy)

1/15 2

1 1 1 1* 2

5 8

* Postoperative death. TABLE 3. Results of medium fill cystometry in 13 patients with ileocecal bladder substitutes examined 3 to 6 months postoperatively

Median (range) First sensation to void, 7 pts. (ml.) Maximum cystometric capacity (ml.) Empty resting pressure (cm. water) Full resting pressure (cm. water) Maximum amplitude of peristaltic contractions (cm. water)

65 (40-225) 275 (100-650) 5 (5-20) 25 (5-55) 40 (15-160)

detector. The brachial arterial pressure was recorded simultaneously and the penile-brachial arterial pressure ratio was calculated. RESULTS

Table 2 shows the operative mortality and complications. Operative mortality. A 65-year-old man in poor general condition with a stage T3 tumor that did not respond to radiotherapy died of septicemia owing to pelvic abscesses. Early complications. Leakage from the ureteroileal anastomosis occurred in 2 high risk patients: 1 after salvage cystectomy for an actively bleeding stage pT2 tumor, and 1 after multiple operations because of a childhood accident with pelvic fractures, disruption of the membranous urethra and a rectourethral fistula. Bilateral nephrostomy was successful in both patients. No late strictures have occurred. An early stricture at the ureteroileal anastomosis occurred in our first patient and reoperation was successful. A split cuff ureteral nipple technique 20 was used for the initial anastomosis. As a consequence the method for ureteroileal anastomosis was altered to the technique described by Skinner and Richie,2 1 and no strictures have occurred. A small bowel fistula developed after a salvage cystectomy and closed after 3 weeks of parenteral nutrition. Leakage from the cecourethral anastomosis occurred in 2 patients and ceased spontaneously after 1 week. Suprapubic urinary leakage from the catheter drainage site occurred in 5 of our first 10 patients and was treated by urethral catheter drainage for 2 to 3 weeks. This complication was avoided by not inserting a suprapubic catheter in the last 5 patients. Symptomatic urinary tract Candida infections were seen in 8 patients and were treated successfully with 5-fluorocytocin. Asymptomatic bacterial infections have occurred in most cases. Low back pain occurred in 8 patients and disappeared with physiotherapy in each case. The median followup for the 14 initially surviving patients is 20 months (range 3 to 30 months). Four patients died of distant metastases at 3, 7, 13 and 26 months, respectively. There have been no local recurrences. Seven of 9 patients had sterile urine at 1 year. Urodynamic studies. Urodynamic evaluation was performed in all but 3 patients: 1 refused instrumentation for urodynamic purposes, and underwent the incontinence test, uroflowmetry and determination of residual urine by ultrasound only, 1 had

multiple metastases 2 months postoperatively, and underwent uroflowmetry and cystometry only, and 1 died postoperatively. Cystometry. Each patient experienced a sense of bladder distension associated with rhythmic contractions of the intestinal bladder (table 3). A first sensation of filling was felt by only 7 patients but all had a well defined maximum cystometric capacity. The values for the resting bladder pressure and maximum capacity were almost normal. Micturition. None of the patients had hesitancy or stranguria. The flow curves were normal in 7 patients and fluctuated in 7. The maximum flow rates were almost normal in all patients (median 14 ml. per second) and none had significant residual · urine (fig. 2) (median 5 ml.). The pressure-flow electromyographic studies showed that voiding was initiated by relaxation of the external sp}i.incter (fig. 3). Five patients voided by straining alone (median maximum pressure 90 cm. water, with a range of 80 to 195 cm. water). In 5 cases cecal bladder contractions and straining contributed about equally to the voiding pressure (median maximum pressures 50 and 40 cm. water, with ranges of 20 to 60 and 20 to 70 cm. water, respectively). Two patients voided by cecal bladder contractions alone with maximum pressures of 55 and 150 cm. water. Continence. Continence improved during the first 3 inonths postoperatively. Clinically, 13 patients were continent when awake on scheduled voiding with intervals ranging from 1½ to 3 hours. The patient who had undergone multiple operations as a result of a childhood accident was moderately incontinent, probably as a result of a deficient external sphincter. At the incontinence test 9 patients were dry and 4 had losses of 1, 4, 7 and 30 gm., respectively (fig. 4). The 30 gm. loss occurred in the clinically incontinent patient. The 7 gm. loss occurred in a patient who had been continent clinically but who at the time of testing had become urge incontinent as a result of peritoneal carcinomatosis without a local recurrence. All of the patients were incontinent at night. To examine the mechanism of nocturnal incontinence the urethral closµre pressure was monitored in 4 patients during sleep (fig. 5). The peristaltic contractions continued when the patients fell asleep, causing urinary incontinence probably as a result of relaxation of the pelvic floor muscles. Furthermore, the median value of the mean urethral pressures decreased from 49 (range 54 to 42) to 42 (range 49 to 32) cm. water. Urethral sensitivity and evoked potentials. The electrical perception threshold was increased above normal in the posterior urethra (median 45, range 7 to 100 and normal range 5 to 15 ma.) but was normal on the penile skin (median 5, range 3 to

A

•••••la 0

5

10

15

• 20

••• 25

30 ml/s

B

iI• 0

•

• 25

50ml

FIG. 2. Maximum urine flow rates and residual urine after ileocecal bladder replacl!lnent.

TRANSPUBIC CYSTECTOMY AND INTESTINAL BLADDER REPLACEMENT

Sexual function. Preoperatively, 8 of the 14 patients experienced erections and 7 had intercourse regularly. Postoperatively, erectile potency was preserved in 4 patients and 3 had sexual intercourse. The interval from the operation to the first intercourse was 1 month in 2 patients and 8 months in 1. The penile-brachial artery pressure ratio was recorded in 7 patients before and after the operation. The postoperative values (median 0. 76, range 0.50 to 0.86) were slightly lower than preoperatively (median 0.83, range 0.67 to 1.4) but most were within the normal range (more than 0.7). 22

Anal sphincter EMG

80 Subtracted pressure

40

DISCUSSION

0 40

0 100

50

0 30

Urinary flow rate

mils

265ml

15 0 0

15

30

45

60

75

sec.

FIG. 3. Pressure-flow electromyography study. Cecal bladder was filled suprapubically with isotonic saline resulting in peristaltic contraction. Patient felt desire to void but remained continent as result of increased external sphincter activity. Voluntary voiding was initiated by relaxation of external sphincter and was followed by almost normal flow curve. Peristaltic pressure iri cecal bladder and straining contributed about equally to voiding pressure.

•• 0

473

• 25

50 g/h

FIG. 4. Urinary continence after ileocecal bladder replacement. Results of 60-minute provocative incontinence test.

10 and normal range 3 to 10 ma.). The electromyographic patterns of the bulbocavernosus muscle, and external urethral and anal sphincters were all normal as was the latency of the bulbocavernosus reflex (penile skin stimulation median 37, range 30 to 60 and normal range 30 to 45 msec., posterior urethral stimulation median 69, range 57 to 100 and normal range 55 to 90 msec.). Renal function. The 51chromium-ethylenediaminetetraacetic acid (51 Cr-EDTA) clearance values were almost the same preoperatively (median 79, range 58 to 102 ml. per minute) and 3 months postoperatively (median 70, range 38 to 89 ml. per minute). Unobstructed upper urinary tracts were demonstrated 3 months postoperatively in 13 patients by diuresis renography and in 1 by excretory urography after reoperation for a ureteroileal stricture. No electrolyte disturbances have been recorded. Cystography revealed ileal reflux in 5 of 8 patients in whom it was done.

Our results agree with most earlier studies showing satisfactory micturition and perfect daytime continence but nocturnal incontinence after cystectomy and intestinal bladder replacement.4-8·23-29 The urodynamic functions also agree with the observations of others, that is the maximum urine flow rates were almost normaF· 27·28 and residual urine was insignificant. 7· 24'28· 30 At cystometry each patient experienced a sense of bladder distension associated with peristaltic contractions with amplitudes increasing in proportion to the degree of bladder filling. 7·24· 30 The maximum bladder capacity was similar to that of a normal bladder. The increases in bl.adder pressure associated with the peristaltic contractions were similar to those recorded in the ileocecal bladder reservoir31 and slightly higher than the pressure amplitudes of 35 cm. water recorded in the Kock reservoir. 32 Continence after intestinal bladder replacement is maintained by the distal sphincter mechanism: at rest most likely by a sustained contraction of the intrinsic rhabdosphincter and during the peristaltic contractions of the intestinal bladder by the periurethral pelvic floor musculature. Nocturnal incontinence probably occurs because relaxation of the pelvic floor muscles during sleep makes it impossible to increase the urethral pressure in response to the peristaltic activity of the intestinal bladder substitute. Our finding of a reduced urethral pressure during sleep agrees with the results of Bhatia and associates in normal men. 33 The 51 Cr-EDTA clearance values were slightly reduced postoperatively, which is in agreement with the observations of others showing excellent long-term preservation of renal function. 7·8• 23·24 Also, no electrolyte disturbances were found. 5·7·8·24·26 Cystography was performed in 8 patients and demonstrated reflux in 5. The incidence of ureteral reflux also is known to be high after ileal and sigmoid bladder replacement when the ureters are implanted directly. 8·23 ' 24·34 Reflux may be more severe after ileal loop than after ileocecal bladder replacement because the intestinal peristalsis will cause reflux after the former but not after the latter procedure. 23 ·34 Renal function is preserved after intestinal bladder replacement despite the occurrence of reflux, possibly because it occurs at low pressure and usually with uninfected urine. 8·23 ·24·34 Therefore, we did not perform an antireflux procedure, since we assumed that the risk of stricture owing to the procedure might outweigh the advantage gained. Preoperatively, 50 per cent of our patients were sexually active, which is slightly less than the approximately 65 per cent expected for this age group. 35·36 Radical cystectomy is known to cause erectile impotence in almost all cases, most likely as a result of injury to the autonomic nerves to the corpora cavernosa.10· 37 To avoid injury to these nerves the surgical technique was modified by leaving the apical prostatic capsule, which made it possible to preserve erectile potency in about 50 per cent of the sexually active men. This finding corroborates the results of others using this technique. 9Furthermore, Walsh and associates altered the techniques of radical retropubic prostatectomy and cystoprostatectomy to avoid autonomic nerve injury, and have shown that it is possible to preserve sexual potency in about 85 per cent of the patients. 38·39 The transpubic approach facilitated the radical cystectomy

474

STEVEN AND ASSOCIATES 100

Bladder pressure

100

Urethral pressure

50

Urethral 0 closure pressure -SO

1----s""1min

FIG. 5. Influence of sleep on urethral closure pressure. Continuous measurements of cecal bladder and maximum urethral pressures were made while patient fell asleep. Peristaltic contractions of intestinal bladder continued during sleep, causing incontinence. Resting urethral closure pressure decreased as result of reduced urethral pressure. Arrows indicate periods with negative closure pressure. and the cecourethral anastomosis, thus, making it possible to perform the operation on all patients who otherwise would have undergone cystectomy and ileal conduit diversion. Low back pain was noted in half of our patients but persisted for only a few weeks. Resection of the symphysis as an aid to cystectomy and radical prostatectomy was described almost a century ago. 40 - 42 More recently, Waterhouse, 13 Morales 14 and Patil1 5 and their associates advocated its use in pelvic operations. Transitory pelvic girdle pain occurred in only 1 of their 24 patients undergoing either cystectomy or radical prostatectomy. The early postoperative death was probably a result of poor surgical judgment. The preoperative general condition of the patient was so poor that the correct treatment should have been cystectomy and a simple method of urinary diversion, such as cutaneous ureterostomy. Most complications occurred in high risk cases. The small bowel fistula and 1 of the 2 leakages at the ureteroileal anastomosis were seen after salvage cystectomy, which is known to be associated with a high incidence of fistulas. 8 • 43 - 46 The other ureteroileal leakage occurred in a patient who previously had undergone multiple operations on the bladder and urethra. Leakage from the cecourethral anastomosis was a smaller problem than reported in earlier studies 7• 23 • 24 • 26 and may be the result of our use of the transpubic approach, which made it possible to perform the anastomosis accurately. Over-all, these results suggest that the mortality and morbidity rates associated with radical cystectomy and intestinal bladder replacement should not be higher than after cystectomy and external conduit diversion. The use of intestinal bladder replacement as an acceptable alternative to an external conduit after cystectomy for bladder cancer can be established only on the basis of long-term preservation of renal and voiding functions, a low risk for urethral recurrence and a similar survival rate as found after external conduit diversion. The results of earlier studies indicate that each of these conditions can be met. Long-term preservation of renal8 • 23 • 24 and bladder8 • 24 function has been reported, the risk for urethral recurrence is low8 • 24 • 26 and excellent long-term survival rates have been noted. 8 • 24- 26 Furthermore, internal urinary diversion facilitates the followup for urethral recurrence by making it possible to perform routine urine cytology. Our results show that it is possible to achieve satisfactory micturition and daytime continence in almost all patients and to preserve sexual function in some. The psychological impact of a stoma2 is avoided as are the frequently associated problems with urinary leakage and skin irritation. 47 ·

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TRANSPUBIC CYSTECTOMY AND INTESTINAL BLADDER REPLACEMENT

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33.

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