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Webinar | Revealing the Surgical Journey: Understanding the Anatomy of a Cystectomy

This webinar explores the intricate world of bladder removal surgery known as a radical cystectomy, a surgical procedure designed to address high grade non-muscle invasive or muscle invasive bladder cancer. Urologist Dr. Matthew Mossanen unravels the complexities and sheds light on the various aspects of radical cystectomy, from the differences between open and robotic cystectomy procedures to the step-by-step surgical procedures involved in bladder removal and construction of a urinary diversion.

With Dr. Matthew Mossanen

Year: 2024

Part 1. Introduction to a Cystectomy: Removal of the Bladder and Lymph Nodes

Transcript (PDF)

Part 2. Reconstruction of a Urinary Diversion

Transcript (PDF)

Part 3. Types of Urinary Diversions

Transcript (PDF)

Part 4. Q&A on Understanding the Anatomy of a Cystectomy

Transcript (PDF)

Stephanie Chisolm:

Welcome to today’s program, Revealing the Surgical Journey, Understanding the Anatomy of a Cystectomy.

For many with bladder cancer diagnosis, the standard of care or best practice recommendations involve the intricate world of bladder removal surgery known as a radical cystectomy. This is a surgical procedure that’s designed to address high-grade, non-muscle invasive or muscle invasive bladder cancer. In today’s program, we’re going to learn more about who might be offered bladder removal surgery and the difference between open and robotic cystectomy as well as what’s involved in this life-saving yet life-altering procedure.

We’re delighted to welcome urologist and scientist, Dr. Matthew Mossanen from Brigham and Women’s Hospital in Massachusetts. Dr. Mossanen is a urologist at Brigham and Women’s and an assistant professor of surgery at Harvard Medical School. He’s a graduate of the University of California Los Angeles, UCLA, and received his medical degree from the David Geffen School of Medicine at UCLA. In 2020, Dr. Mossanen received one of BCAN’s patient-centered young investigator Awards to support his research.

Dr. Matthew Mossanen:

Well thank you very much for that wonderful introduction and thank you to BCAN.

This is a brief outline of what we’ll talk about. Of course, if there are questions, we’re happy to go over those at the end. This talk could probably take three days to do it justice, but I decided to put it into four sections. So step one, we’ll talk about the actual cystectomy, the operation, what it entails in terms of removal, so of the bladder and the nearby organs. We will divide it into male and female. We’ll talk briefly about organ sparing and when you can consider that, and the difference between open and robotic cystectomy.

The second part will be to talk about removal of lymph nodes, which is included in the cystectomy. And in step three we’ll talk about the reconstruction, which happens after the bladder and the lymph nodes are removed. We’ll go over some of the options that are commonly used. And then in the last part of the talk we’ll try to emphasize why this is such a life-saving yet life-altering operation that has a major recovery and requires careful consideration. So let’s go to the next slide.

So this is a key photo. This is the anatomy that’s involved. When doing a cystectomy, we’ll focus first on the picture on the right. So patients have kidneys connected to ureters. These are tubes that take all of the urine from the kidney and bring them down to the bladder. For female patients, the uterus and the ovaries are also near the bladder and can be removed during the surgery. Part of the vaginal wall known as an anterior vaginectomy can also be done.

Shifting gears for a second and looking at the male version on the left, you can see that in addition to kidneys, ureters and a bladder, the difference here is that there’s a prostate and seminal vesicles, and so the prostate and seminal vesicles are the parts that are removed during the male cystectomy. This is a picture that I often will draw in clinic just to help give patients some idea of what sort of anatomy is involved in and what we as surgeons look at when we’re reviewing scan. We can go to the next picture.

So this is a nice summary slide because I know there was a lot of discussion of anatomy and so the key thing to remember about a cystectomy is that it involves removal of the bladder, but also the nearby tissue and the organs that are removed as well. So to summarize, for men, this is the bladder and the prostate. For females, this can include the anterior vaginal wall, the uterus, the cervix, the fallopian tubes, and the ovaries.

Dr. Matthew Mossanen:

If we go to the next slide, I think it’s important to just discuss the concept of organ sparing. So remember, the goal of a cystectomy, that the most important goal is cancer control. Patients with bladder cancer have dangerous tumors that need to be removed. But quality of life is also an important consideration and preservation of sexual function can also be an important priority. So considering each patient’s unique case is the best way to bring up organ sparing. So if you’re talking to your surgeon, she or he will decide if that’s something that’s relevant and if it’s something that’s safe above all.

Oftentimes, the surgeon will consider nerve sparing in a male patient or in a female patient, you can talk about vaginal sparing options or preservation of the ovaries. It’s important to highlight that the details of the tumor, the patient’s goals of care and surgeon judgment are all factors that go into the decision If you’re eligible for an organ sparing cystectomy, but as the patient, it’s important to know that this is something you can discuss with your surgeon. Go to the next slide.

So this is a slide that lets you know there are two approaches to cystectomy. There’s an open cystectomy, which is done through a traditional incision, which usually goes from the belly button down to the pubic bone or a robotic cystectomy. In terms of cancer control and complications, these are about equal. There are some things that vary across the two approaches, but one of the most important things to know when it comes to a cystectomy is that the surgeon’s volume and experience often play an important role in their outcomes. So in other words, if the surgeon does most of their cystectomies robotically, then they’re most likely to have the best outcomes if it’s done robotically.

If a surgeon has been doing open cystectomies and they’re more comfortable and have more experience with that approach, then the best option is for them to do it with an open approach because that’s how they’re most likely to have the best outcomes. You can talk to your surgeon more about which approach is best for you because there are also other factors at play which might help impact if a patient should have an open or robotic surgery such as prior surgery or prior radiation.

Dr. Matthew Mossanen:

So we’ve talked a little bit about the first part of a cystectomy just to recap, removal of the bladder with nearby tissue and the organs which differ in male and female patients. And we’ve talked a little bit about things like organ sparing and the two different approaches, open and robotic. So now we’re going to go to step two.

So a cystectomy involves removal of lymph nodes, which are right next to the bladder. This can be important to give valuable information on whether or not the cancer has spread and if it has, it can then guide the decision to give you additional treatment after surgery, such as with chemotherapy and or immunotherapy. There’s also evidence that if you can remove metastatic bladder cancer to the lymph nodes, it might help improve survival for that patient and give them a better long-term cancer-free outcome.

In either approach, robotic or open, the same lymph nodes are removed, so that doesn’t really make a difference. This is just the second step of the surgery. It’s important to note that some surgeons might do this at different parts of the operation before the bladder is removed or after the bladder is removed. That doesn’t really matter as long as the lymph nodes are removed. We can go to the next slide.

So the third part of the operation is the reconstruction. At this point, the surgeon has removed the bladder, the nearby organs and the lymph node tissue and now it’s time to reconstruct the urinary system. The concept is that the ureters, which were the tubes connected to the kidneys, which carry urine, are going to be sewn or attached to a piece of intestine that will somehow eventually make its way outside the body. And when we rebuild the urinary system, there are typically three options. We’ll go in detail into some of those options and it’s important to remember that BCAN actually has a wonderful library of information that goes into more detail if you are a patient that’s considering one of these urinary diversion options. So we’ll go to the next slide.

Dr. Matthew Mossanen:

Every patient and every case is unique. I want to emphasize that there are many factors that impact surgery, not only the cystectomy but the decision for a urinary diversion, a cancer diagnosis, so the actual stage of the tumor, the patient’s age, their overall health, their fitness level, if they’ve had prior surgery, if they’ve had prior radiation, of course the patient preference, what sort of urinary diversion they want to live with. And of course, again, surgeon judgment, which hopefully can be used to put all of this information together and then use shared decision making to figure out what the best option is. We can go to the next slide.

So just to emphasize, if you do have questions, there are many resources and BCAN is one of the most valuable for me and my patients. So I will often send them to the website as their surgeon, will have discussions, draw diagrams and go through all of their questions. And then of course I always invite patients to talk to other patients. So who better to answer questions than someone that’s lived it, someone that’s been through it and someone that uses that urinary diversion on a daily basis.

So the first option is an ileal conduit. It’s also called a urostomy or a stoma. There’s a small piece of intestine that comes just to the right of the belly button. That tube starts inside the belly but then comes through the abdominal wall and comes out through the skin and then attaches to a bag which you see in that circular picture and the urine drains into the bag. Many patients have ileal conduits, urinary stomas. You can go to the next slide.

So for those patients interested in a neobladder, the idea is that this would be connected to the urethra or the tube that exists that was previously connected to the bladder. There are many different types of neobladders. Neobladders can be done robotically or open, and it’s important that the surgeon have a discussion with you as to whether or not you’re a good candidate for this operation. Based on all of those factors that we discussed. Neobladders and ileal conduits are probably the most commonly used options out there for patients that are having reconstruction after cystectomy. In the next slide.

Dr. Matthew Mossanen:

This is an Indiana pouch and so this is a type of urinary construction where a patient will have a small pouch also made of intestine and a small channel usually through the belly button that they can stick a catheter through to drain out the urine. This is a little different than the urostomy where the urine just drains continuously into a bag or the neobladder where patients have to void the way they did before their bladder was removed. Among these three options, the best way to say it is you have to talk to your surgeon and if you want more information, talk to other patients. I’ll go to the next slide.

So we’ve talked about the three steps of the surgery. I think it’s important to emphasize that this is a major operation. There’s a risk of complications, there are little complications and big complications, and there’s a risk of getting readmitted to the hospital and it can be a long recovery that can take up months. The reason is because this is a major operation with the removal of organs and reconstruction using the intestines to rebuild the urinary system. So it’s important to be aware of that risk. In some of the work that we’ve done, there are many reasons why patients often need additional procedures or surgeries after this major operation. And you can see in this pie chart here, there are different issues that can happen where a patient might need another intervention. And this is just to let you know that what you’re going through is a major surgery. We’ll go to the next slide.

And important area of research for me and something that I feel very strongly about is that if anybody is going to be undergoing a cystectomy, it’s important that they quit smoking. So this is some research that we did and you can see there are two lines here. And the main takeaway is that for patients that are active smokers, there’s a higher risk of complications. And so that happens and increases as patients age. So if you’re headed towards a cystectomy and you are an active smoker, quitting is one of the most powerful and important things you can do before your surgery. We’ll go to the next slide.

Dr. Matthew Mossanen:

So a question that often comes up is how many of these do you do and what kind of experience do you have? And so thinking about that for any surgeon, it’s important to highlight I think these two papers that came out many years ago but showed essentially that higher volume hospitals have better outcomes, lower mortality rates. So one of the key things to think about is that for cystectomy patients, seeing a surgeon that is high volume, in other words, operates frequently and does these often is very important.

If you go to the next slide and take this one step further, if we look at the surgeon volume, that’s probably something within the hospital that explains where those outcomes are coming from. So in this picture, what you see is that as a surgeon does more cystectomies, the outcomes are improved and the mortality rate is lower. No matter what approach your surgeon uses, making sure that they do this operation often is important. I’ll go to the next slide and recap what we were able to talk about today.

So we focused on the anatomy of a cystectomy, which is the removal of a bladder and nearby organs which differ in male and female patients. We touched briefly on organ sparing, which can be discussed with the surgeon on a case-by-case basis. Open and robotic approaches are likely equivalent and it just depends on the experience of the surgeon. Removal of lymph nodes is an important part of the surgery that gives valuable information and can improve your overall outcome. There are multiple reconstruction options available, but they use intestine to rebuild the urinary tract. And remember, this is a major surgery. It takes multiple hours to complete and months to recover from. So be patient with yourselves and make sure you have plenty of help and use all the resources available at your disposal. And one of the best ones is this platform that you’re on right now, which is BCAN. So with that, I want to thank Stephanie and BCAN for this wonderful opportunity to talk a little bit about something that I’m passionate about and involved in.

And at this point I’m happy to go over any questions from any of the participants about cystectomy or bladder cancer.

Stephanie Chisolm:

Thank you so much, Dr. Mossanen. That was fabulous and really nicely done. A great explanation of the various procedures. And we do have a number of questions, but I thought of a couple too while I was listening to you. So do you have a preference? Are you a robotic surgeon or an open surgeon?

Dr. Matthew Mossanen:

That’s a good question. I kind of do it on availability, where I have the next available slot. Patients will often ask me what the main differences are. Open surgery might be a little bit quicker, robotic surgery might be a little bit longer, but have less blood loss. I like open surgery, it’s how I was trained. I also enjoy robotic surgery, so I think I’m mixed on it. I think the previous generation was all open surgeons. I think the upcoming generation is going to be mostly robotic surgeons, so we’ll see how the story unfolds. But the good news for patients just to emphasize is it’s probably equivalent. They’re probably both good. It’s more about the person doing the cutting and sewing than the tools they’re using.

Stephanie Chisolm:

Sure, absolutely. I always sort of joke and say, well, if you’re Jaguar had an issue, you wouldn’t take it to the mechanic on the corner. You would take it to the Jaguar dealer that does this all the time. And we need to make sure that we take good care of our health and go to the right people. So we had a bunch of excellent questions. I’m really interested in the difference, if any, between a radical cystectomy neobladder surgery between men and women. The question was about whether women have more problems than men do. Is there an issue with that in terms of gender?

Dr. Matthew Mossanen:

One of the complications that can happen after a female neobladder surgery is that the neobladder could form a fistula with the vagina. And so the woman could have leakage of urine through the vaginal canal, and that’s a really serious problem.

For male patients, it’s not very common to have leakage into any of the adjacent structures. And so you could say that women might be at risk for something more significant because the vagina is near that location. Some surgeons might do vaginal sparing to avoid any possibility of forming a connection between a hole in the vagina that’s getting sewn and a hole in the neobladder that’s getting sewn.

Stephanie Chisolm:

Sure. So if somebody, say a woman, wanted to also preserve sexual function, nerve sparing would be important as well for women. And then she should speak to her doctor about just how much of the vagina might need to be altered because of this.

Dr. Matthew Mossanen:

So you can remove part of the vagina or you can… And that would be the anterior wall. So when we say that, it’s that the bladder is sitting on top of the vagina, so when you take out the bladder, you’re also removing a strip of the vagina and then folding it closed or sewing it closed. So in some cases, rather than remove the roof of the vagina, you can actually just leave it intact and take out the bladder. But it depends on tumor features, prior surgery, patient preferences, but that’s something that can be considered with cystectomy.

Stephanie Chisolm:

Okay. And then it’s also, would you comment a little bit in terms of when patients who do, excuse me, have their bladder removed for females, if they had issues later on with sexuality and sexual function with intercourse, what would you recommend to them? How would they go and get therapy?

Dr. Matthew Mossanen:

I have patients that I’ve sent to pelvic floor physical therapy before and they’ve found it very helpful. I’m also fortunate enough to work with a very skilled PA that has a lot of experience with cystectomy patients and she’s a valuable resource to them. So the combination of those two things and then case by case basis, we figure out what the patient needs.

I do try to make sure that any female patient and also male patients, that they know they can talk to another patient that’s gone through all this because I have found that it’s sometimes helpful to talk to somebody who has lived it. And so I think BCAN has lots of opportunities for that. But I also have a small group of patients that are always willing to talk to other patients over the years.

Stephanie Chisolm:

Right. Our Survivor to Survivor program can help connect you to somebody who has the type of diversion you’re considering. So I definitely encourage you to visit bcan.org and look for the Survivor to Survivor program if you’re interested in doing something like that. I have dropped a couple of links in the chat feature to some of the additional resources that we do have available about cystectomy. So let me go back to the questions that were submitted.

“I was treated at Brigham and Women’s and had a cystectomy two years ago and doing very well. I’m grateful for the excellent care I received. My question is, can you speak to what are the longer-term issues post-surgery that we should be aware of? Hernias, fistulas differences as you already touched on briefly for men and women.”

Dr. Matthew Mossanen:

Yeah, hernia is always an issue for the urinary stoma. Getting a parastomal hernia or a hernia near the stoma is a problem that can be seen commonly. For the neobladders, leakage can be a problem for both men and women, and so learning to self-catheterize and often needing diapers while urinary control is sort of recovered and you relearn how to use your neobladder is common. Fistulas can happen. Strictures is also an issue that can happen where you sew in those little tubes into the piece of intestine, it can scar down and that can be an issue. Those are some of the main things that we see. I think when we talk about preservation of sexual function, an important question that we always start with is what is your baseline sexual function? For example, for a man, we’ll talk about how well erections work and then go from there in order to discuss nerve sparing. I think was there another part to that question that I answered?

Stephanie Chisolm:

No, but I think one of the things I think would probably be helpful, could you explain what a fistula is? Because I’m not sure if people haven’t had one that they would know what that is. It’s a complicated term that I don’t know that everybody understands.

Dr. Matthew Mossanen:

Yeah, that’s a good question. So a fistula is an abnormal connection between two places. So you have a bladder that connects to the outside world, but sometimes the urine can have an abnormal tunnel to another part of the body so that urine leaks through there. And so for women after a neobladder construction, it’s possible to have a fistula to the vagina, that would be an abnormal connection between those two structures.

Stephanie Chisolm:

Okay, thank you. That was really helpful to understand. So do any patients have partial cystectomies and what’s the difference between a partial or a total cystectomy or a radical cystectomy as they call it, and who would be eligible for a partial cystectomy if it’s even done?

Dr. Matthew Mossanen:

You can consider a partial cystectomy based on the anatomy of the bladder and the cancer diagnosis. For more advanced stage bladder cancers, we don’t usually consider a partial cystectomy for cancer reasons. You can consider a partial cystectomy under specific situations because our concern would be that you remove a tumor, but the rest of the bladder is also at risk for cancer that can then come back or spread. So patients with cancer in a diverticulum, you could consider that for example. And a diverticulum is basically a cave in the bladder. So that’s one scenario that could be discussed. But again, that’s a complicated question, so I think it would depend case by case basis.

Stephanie Chisolm:

Sure. And they’re not very common?

Dr. Matthew Mossanen:

Not very common. That’s right.

Stephanie Chisolm:

This person said, “I have my second high grade tumor in three years. My case goes to tumor board on Friday. Do you think removal of my bladder will be an option?”

Dr. Matthew Mossanen:

It’s hard to know without details on treatment and more specifics, but I think the idea is that we typically think of cystectomy in patients that have stage two or greater, which is muscle invasion, invasion of the bladder wall muscle. But that question is important because it highlights that patients which have recurrent high grade tumors, despite multiple treatments in the bladder, can also be eligible for cystectomy. And so the answer to that question is probably yes, depending on additional details, but there are a lot of alternatives to cystectomy and it’s important to mention that in addition to cystectomy, you can try radiation for specific cases or other types of intravesical or inside the bladder therapies.

Stephanie Chisolm:

All right. This next question’s a little bit confusing. “What is the life expectation for each procedure?” And maybe just talk about perhaps some of the complications because I don’t know that… Is there a difference between life expectancy with an ileal conduit versus a neobladder or an Indiana Pouch?

Dr. Matthew Mossanen:

There shouldn’t be. That’s a really good question. There shouldn’t be a difference from the urinary diversion. That’s sort of a reshaping of the intestine to store and transport urine. So the main way that we determine the cancer outcome is with what was removed, what was in the bladder. So the cancer staging is what drives the ultimate outcome. In terms of complications and which diversion, for older patients with multiple medical problems that might not heal in the best way, we think about an ileal conduit. For a healthy fit patient that might be younger, that still lives a very active lifestyle and is not ready for a urostomy bag, we would lean towards a neobladder.

That doesn’t mean that you can’t have a fifty-year-old that wants a conduit or perhaps a seventy-year-old that really wants a neobladder. This is just the idea is that every case is different and it kind of depends not just on the cancer, but on the overall patient health and wellbeing and then what their preferences are for how they want to live their lifestyle. I will say that I have a lot of patients with urostomies and neobladders that do all kinds of activities. They do yoga, they ride motorcycles, they play golf, they fish. And so keeping in mind the kind of activities you want to do after surgery and sharing that with your surgeon is an important way to help you figure out what the best choice for you is.

Stephanie Chisolm:

Right? Yeah. You can play pickleball with an ileal conduit.

Dr. Matthew Mossanen:

Definitely.

Stephanie Chisolm:

As you can also with a neobladder or an Indiana Pouch. So if that’s in your future, that’s definitely something to bring up to your doctor.

Dr. Matthew Mossanen:

I will actually add one thing to that. I did have a patient that was trying to figure out which one they wanted, very fit, and so the patient actually put on a urostomy bag before the surgery and kind of took it for a test drive and did some yoga poses and kind of stretched and just got a feel for it. And I thought that was a very creative way to figure out what life would be like with his stoma.

Stephanie Chisolm:

Sort of do the Costco model, try it before you buy it. Right? Okay. So you talked about the difference between the length of robotic surgery versus open surgery, but can you give us a best guess? I know each situation is unique, but in general, how many hours are we talking for the surgery?

Dr. Matthew Mossanen:

Maybe an hour, maybe an hour and a half. Kind of depends on the patient’s anatomy, but it’s typically okay to think that robotic surgery will take a little bit longer, but the incisions are a little bit smaller. The recovery depends on multiple factors. And so when the patient is ready to go home is usually driven by when they’re eating and passing gas and their pain is under control. And so once they have good eating, good bowel function, they’re ready to go. So those are kind of the key things we think about.

I don’t know, I think it’s usually a surgeon is more used to doing one or the other or they do a little bit of both. It’s important for the patient to just bring it up with a surgeon if they have any questions about it. But the long-term cancer outcomes are the same.

Stephanie Chisolm:

So Dr. Mossanen, I remember that you had started cystectomy bootcamp a while ago. Do you still do that and what’s involved in that? So bootcamp is more like prior to you going through surgery, you get yourself ready. Do you still do that?

Dr. Matthew Mossanen:

That’s a great question. The short answer is yes. So I really believe that the time before cystectomy is valuable. Patients are either waiting for their surgery or they’re getting chemo. And so we have a program at our institution where patients can do an educational class on Zoom with the nurses that will take care of them after surgery. They can also do some zoom exercises with an exercise physiologist. They practice some stretching, strength training, some conditioning, and try to use the four weeks before cystectomy to kind of get a little bit more fit. We also give them some nutrition shakes to help sort of boost up their nutrition ’cause their appetite is not great after a cystectomy. It takes a while to recover normal eating. And of course quit smoking. It’s the number one thing.

But yeah, so we do have a pre habilitation program and I know there’s a lot of great programs out there at other institutions and things that are being studied that are on the horizon. But yeah, you can always ask your surgeon if there’s any programs that they can recommend or refer you to for nutrition, for exercise, for a number of things to help prepare you better.

Stephanie Chisolm:

I understand that the Indiana Pouch does require a unique perspective. They’re creating a little internal pouch, just like a neo-bladder and connecting it with a stoma usually behind the belly button. Do you do those on a regular basis or is that just a few… I hear different stories that not everybody does those.

Dr. Matthew Mossanen:

I have not done it in years. We don’t do it that often. It has to be the right patient. It’s not a commonly done operation, but it can be done. We can do it if we needed to. The most common one I do is the ileal conduit, and that’s just probably a reflection of the patient population that I see. Bladder cancer patients tend to be in their seventies and have multiple or many medical problems. And so for those patients, typically the first choice is a urostomy. But for any patient in their fifties or sixties young, fit, that really wants to have an active lifestyle and avoid the bag, we’ll often go into a lot of detail about a neobladder.

Stephanie Chisolm:

Okay. Well here’s a good question. When the bladder is removed, what happens to where it was, the space?

Dr. Matthew Mossanen:

A lot of people ask that question. That comes up… The intestines just kind of slide down into that space. So the pelvis is filled with the intestine, and kind of slides down. Right now in the normal picture, a normal anatomy, the intestine are sitting on top of the bladder. So when the bladder comes out, the intestine just filled the space.

Stephanie Chisolm:

And in any of the diversions, they’re using a piece of intestine. And does that impact a person’s nutritional status because they’re missing sometimes a bigger piece than others?

Dr. Matthew Mossanen:

We try to use a piece that will minimize that. There are some blood tests that we do after surgery to monitor certain vitamin levels. Your surgeon usually checks those and it’s possible that you can eat supplementation. But in general, the amount that we remove allows you to be able to extract food nutritiously and be able to eat the regular foods that you were before your cystectomy. But it’s because we use a specific part of the intestine.

Stephanie Chisolm:

Okay, here’s a participant who, a woman who had a neobladder one and a half years ago for high recurrence low grade bladder cancer. “My urether was also and replaced with intestine. I developed incontinence overflow, then went to self-cathing. Docs now think I have a stricture in my urethra. I have catheter prep for urethra reconstruction. How common are urethral strictures post-cystectomy.”

Dr. Matthew Mossanen:

Okay. There are a lot of steps to that question. So how common are urethral strictures? So, yes.

Stephanie Chisolm:

Or she said urethral in there, but it might also been ureteral.

Dr. Matthew Mossanen:

Maybe it was the ureter… So ureteral. I think it’s probably the ureteral, but the ureter, and this is also important, a lot of patients will say ureter and mean urethra or urethra-

Stephanie Chisolm:

Correct.

Dr. Matthew Mossanen:

We’ll just say that it’s ureteral. The ureters carry the urine from the kidneys down to the bladder. They’re very small tubes. They’re about the size of a straw and they can often get scar tissue and need to be reconstructed. That’s common. If it’s the urethra, which is the tube that goes to the outside world, it’s not that common, but it can happen.

Stephanie Chisolm:

Right. And yes. Okay. So next question, and I think this is a good one. “Is chemotherapy always recommended before having a cystectomy?” That’s known as neoadjuvant chemotherapy. What does it do and is that standard practice?

Dr. Matthew Mossanen:

Where I work, I will not feel comfortable taking a patient for cystectomy until they’ve seen medical oncology, especially if it’s muscle invasive. So for any patient with muscle invasive bladder cancer, they absolutely should see a medical oncologist to discuss neoadjuvant chemotherapy. There are a number of reasons for that. One, it can improve their outcomes. Two, a medical oncologist is extremely qualified to discuss the risks and benefits of neoadjuvant chemotherapy. Three, very few patients are able to get chemotherapy after surgery because it’s a long recovery. That being said, for non-muscle invasive tumors, there’s no defined rule or standard role for neoadjuvant chemotherapy.

I don’t know how to say it, but for patients with non-muscle invasive bladder cancer that has come back after BCG or other chemotherapies, there are a number of trials that are in progress that are looking at alternatives to cystectomy as a way to preserve the bladder. So stay tuned because there’s literally been an explosion of trials out there that are looking at alternatives to this exact operation. So it’s really exciting and it’s still evolving. But that’s a great question. See a medical oncologist or ask your urologist if they think it’s appropriate for you to have a consultation if there’s any question.

Stephanie Chisolm:

Yeah, here’s a good question because I hear about peristomal hernias a lot from patients who especially have had ileal conduits. “Are you aware of any newer or better approaches regarding repairing a peristomal hernia since those recurrences are so common?”

Dr. Matthew Mossanen:

So we refer our patients to one of usually two general surgeons here that do a lot of those repairs. So just like we said with the cystectomy and those slides where it matters that the hospital does a lot of them and the surgeon does a lot of them, same thing with peristomal hernia repairs. So I tend to send them to some general surgery colleagues that have a lot of experience. They tend to use mesh to repair everything. And the biggest risk factor, one of the biggest risk factors for getting a peristomal hernia is having a hernia in another part of your body even prior to the cystectomy. So a male patient with an inguinal hernia that gets a urostomy is at a higher risk for getting a hernia near the urostomy.

Stephanie Chisolm:

Okay, great. Well, here’s a question, but I’m not quite sure and I think this is what I’m going to interpret it as. “My most recent high-grade tumor is near the muscle, but no invasion. Prior intravascular treatments were very damaging and my bladder capacity is so small.” Would this person, even though they don’t have muscle invasion, be a candidate if they were tired of a small bladder for having bladder surgery?

Dr. Matthew Mossanen:

I think that’s a really good question and I’m sorry to that patient for having that problem. That’s tough. Thinking about bladder function is an important decision when considering cystectomy. So if you have cancer that’s typically not treated with a cystectomy, but you put that cancer in the setting of poor bladder function or not great quality of life because of bladder issues or urinary issues, you might be a good patient, a good candidate for a cystectomy. So I have had some men with really bad urinary problems and then dangerous bladder cancer and after their cystectomy, they actually had a better quality of life because they weren’t going to the bathroom that often. So it’s unique case by case, but certainly something to consider if you have poor bladder function.

Stephanie Chisolm:

Right. And so when somebody’s going for an ileal conduit, they would meet with the wound and ostomy nurse to determine the best place for putting the stoma, for one thing. They also will be educated about the appliance, the wafers that go around it and how you attach the bag and everything else. So there was a question that was related to leaking on an ileal conduit, but I think that’s mostly related to the bag seal. So you would always refer a patient to the wound and ostomy nurse for how you deal with that?

Dr. Matthew Mossanen:

They all have to see the wound and ostomy nurse before surgery for the marking and then before surgery, I always take a look at it when they’re… right before they roll back surgery, I have them kind of sit down and stand up just so I can get a sense of where it is. But leaking, especially in the first couple of weeks is very common because you’re learning how to put on the wafer, you’re learning how to put on the barrier paste, and there are all these things you’re learning. So it can sometimes be a little discouraging to patients, but I try to reassure them that eventually you’re going to wake up, you’re going to brush your teeth, you’re going to fix your bag, you’re going to head out the door. So it’ll eventually become second nature.

Stephanie Chisolm:

Great. “For men with muscle invasion of the bladder, how common are removal of both the bladder and prostate?” Is that like a standard procedure, they just take both out so close?

Dr. Matthew Mossanen:

It is. It is. Yeah, the standard approach is to take out the prostate with the bladder. Is rare, case by case. If someone’s really interested in nerve sparing, we can do a nerve sparing cystectomy. And I think that’s probably as much detail as they’re asking for. But asking about organ sparing is something that usually depends a lot on the patient’s function and their cancer stage.

Stephanie Chisolm:

Dr. Mossanen, this has been a delight. I appreciate it. We’re looking forward to many more webinars with you. We know we have one that we have to schedule, so we’re looking forward to setting those up. Thank you so much for joining us this evening. I appreciate it. And thank you all for coming. Bye-Bye.

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