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Bladder Removal Surgery Webinar

With Dr. Alex Kutikov, Fox Chase Cancer Center

You can read the entire Treating Bladder Cancer with Bladder Removal webinar transcript at the bottom of this page.

Year: 2021

Part 1: The Basics of Bladder Cancer

Video (10 min) | Transcript (PDF)

Part 2: The Basics of Radical Cystectomy (Bladder Removal) and Ileal Conduits

Video (22 min) | Transcript (PDF)

Part 3: The Basics of Neobladder and Indiana Pouch

Video (14 min) | Transcript (PDF)

Part 4: Question and Answer about Bladder Removal

Video (13 min) | Transcript (PDF)

Full Transcript

Stephanie Chisolm:

Welcome to Treating Bladder Cancer, Bladder Removal Surgery Part 1: Radical Cystectomy Options. This is the patient insight webinar from the Bladder Cancer Advocacy Network. We’d like to thank Bristol Myers Squibb, the EMD Serono/Pfizer partnership, Genentech, Astellas/Seattle Genetics partnership, Merck, Photocure and UroGen for their support of the patient insight webinar series. My name is Stephanie Chisolm and I’m the Director of Education and Research at BCAN. A radical cystectomy is the removal of a bladder to prevent the cancer from spreading to other parts of your body. It’s often recommended for treatment for someone who’s been diagnosed with bladder cancer. Today, we are delighted to have the chief of urology at the Fox Chase Cancer Center, Dr. Alexander Kutikov, with us. He’s going to help you learn more about what bladder removal is, when it’s recommended, how it’s done. One of the areas Dr. Kutikov will address is explaining the options to create a urinary diversion to allow for safe removal of the urine as part of that bladder removal process. Welcome, Dr. Kutikov. It’s a pleasure to have you here.

Dr. Alexander Kutikov:

The pleasure is all mine. Thank you, Stephanie, thank you BCAN for the invitation. A real privilege to be here and to share my thoughts about radical cystectomy, one of the biggest surgeries that are done in surgery and really a life changing one. But as hopefully I’ll communicate, it doesn’t have to be one that prevents folks from continuing their lives and living full lives. We’re going to talk about life after bladder removal and what bladder removal really entails. This is a journey and bladder cancer is a journey regardless of which path one takes. But bladder cancer, especially when the bladder is removed, is a long journey and is a hard journey. Bladder cancer affects over half a million Americans and every year about 84,000 get diagnosed, but some 600,000 live with bladder cancer. Unfortunately, around 17,000 succumb to bladder cancer every year. Bladder cancer starts in the inner lining of the bladder, in the mucosa. It’s like the inner lining of your cheek, and it takes many forms. There’s aggressive types, the high-grade types, there’s non aggressive types, the low-grade types.

Depending on the form that your bladder cancer takes, it really drives further management. Now, regardless of which path one takes, it’s challenging. For folks, the majority of folks who don’t have what’s called muscle invasive bladder cancer where their bladder cancer stays on the inner surface of the bladder, there’s lifelong scopes and scans and one has to carefully monitor this disease. The community of providers is working very hard on trying to better understand how to calibrate that monitoring and how to make people’s lives easier by having them have the scopes not as frequently as we currently do it. But although there’s been progress, there’s still lots of challenges. Then there is bladder cancer removal. Bladder cancer, about 25% of patients have muscle invasive bladder cancer where the bladder removal is needed and a urinary diversion is necessary. This is a space where many clinical questions remain unanswered and there is really a giant need to improve treatments and improve paradigms of care that we currently have now.

Except for some exceptions in the recent past, those really haven’t changed for many decades. A lot of us in the field really feel that for various cancers that for instance, we work on in general urinary oncology, this is arguably one of the ones that needs disruption the most. For instance, look at this slide. Over the last five decades, the red arrow shows mortality from bladder cancer. The death rate really has largely not changed despite all the innovation in medicine. We’re just starting to move the needle in bladder cancer, and we need to move it faster. To that end, this is the fourth most common cancer in men. The rates of bladder cancer, the frequency is about double that in men than in women. Despite it being such a relatively common cancer, it receives disproportionately a small fraction of cancer fundings. Thanks in part to BCAN, this has improved over the years, but still more bladder cancer research funding is needed. I really want to give a shout out to BCAN because this is just such a critical organization.

Dr. Alexander Kutikov:

Thanks to folks like Stephanie, it’s just so, so well run that over the years that I’ve been a urological oncologist, I’ve just seen BCAN grow and provides such great support to our patient community. Thank you BCAN for all that you do. We’re going to talk about the following things. I know we have about 40 minutes and I’m going to try to get through it all. But we’re going to talk about diagnosis and staging. We’re going to talk about bladder removal, also known as cystectomy. I’ll drill down into different urinary diversions and talk about sort of some of the issues that come up with these urinary diversions. I’ll talk about sexual dysfunction, because this is in a lot of folks minds, especially those that are sexually active who get diagnosed with bladder cancer. It becomes a significant obviously source of anxiety and concern. A lot of questions I get about open versus robotic approach to cystectomy, and I’ll speak a little bit about that. I also put in here a few slides on two things that I hear from patients often, “When is the artificial bladder coming? When can we get a bladder off the shelf and make a bladder substitute?”

I’ll talk to the research that’s been done in that space, and we’ll talk about the major effort that’s happening in the field about saving the bladder. There is no better bladder than your own, so how can we save the bladder in those people who generally need bladder removal? Then we’ll do some questions. Let’s talk about diagnosis and staging. This is done with endoscopic procedures with what’s called the resectoscope. Where we go in, and through the bladder, we actually sample the tumor, we resect the tumor, and we try to sample the wall, the inner wall of the bladder. This is the muscle of the bladder. When we talk about muscle invasive disease, we talk about disease that’s invading through the inner lining and into the wall of the bladder. Cysview is something that a lot of folks have not heard about, and this is what’s called Blue Light Cystoscopy. Let’s see if I can get this to play. Here we go. Blue Light Cystoscopy is a way to get a better assessment of the bladder.

You’ll see in this video, which is a video of a cystoscope going into the urethra, here we’re going through the male urethra. That was the prostate, and now we’re in the bladder. This is a bladder that looks relatively normal. At the top of this bladder here, you see a bubble. This is the bubble that we brought in there with the fluid. It’s distended by irrigation fluid, and the little bubbles coalesce into one big bubble at the top. You’ll see that the bladder looks relatively normal, but when we do find an area of tumor, which in this bladder is actually what’s called on the anterior wall, and an often missed tumor in patients, because as you can see, it’s hard for the cystoscope to see up there. But in a second, you’ll see my hand sort of pushing the bladder wall through the belly and kind of show in the scope the tumor, a very important technique to do. You can see that with Cysview, with this Blue Light Cystoscopy, you can see the tumor jump out much better than it does just with regular white light cystoscopy.

The Basics of Radical Cystectomy and Ileal Conduit

Dr. Alexander Kutikov:

As I’ll show you in a minute, there’s basically small other little tumors that you can readily see that will sometimes jump out at you that you would have otherwise missed with regular cystoscopy. An important technique, important to find centers that offer this technique, because this is an important step. Especially for patients with highly recurrent bladder cancer, it allows one to get a clean slate on the bladder before giving intravesical therapy. But we’re here to really talk about cystectomy, and let’s talk a little bit about anatomy. This is what’s called the retroperitoneum, which is a fancy word for the organs that live behind the bowel sack. This is kind of the anatomy that we’re used to seeing, and this lives behind it. These are the kidneys. These are the ureters, the tubes that go from the kidneys to the bladder. This is the bladder, and this is the prostate in the male. We’ll talk about female urological anatomy in a minute. The inner lining of the bladder is the same as the inner lining of the ureters and the same as the inner lining of the kidneys.

Dr. Alexander Kutikov:

When we talk about urothelial carcinoma, which is basically the main type of cancer that bladder cancer patients have, that is the same lining that lines the ureters and the kidneys. So patients with bladder cancer are at risk of developing tumors along their ureters and inside of the kidney. It’s very important for those people that are being monitored for bladder cancer, whether they had or didn’t have a bladder removal, is to have routine imaging of their upper tract. The upper tract, we basically call the kidneys and the ureters. These blue and red pipes are the great vessels. This is the aorta that brings blood away from the heart and goes down to the legs. The blue are the veins. This is the iliac veins and the vena cava. These yellow nodes and little yellow channels is the lymphatic system. What the lymphatic system does in the healthy state, is that it traffics the immune system to appropriate areas of the body. Just like if you have a sore throat, you get a lymph node that’s enlarged in your neck.

Well, many cancers, including bladder cancer, hijack this lymphatic system and use it as a highway for cancer to spread. When a bladder is removed, and along with the bladder removal in males, the prostate is removed … We’ll talk about sort of what organs are removed during during a female cystectomy in a minute, because it’s really changing. But when bladder removal is done, it’s important to also harvest lymph nodes in the pelvis, and it serves a dual purpose. It serves a diagnostic purpose. It allows us to know where things stand and whether the cancer has spread. Then it also serves, some believe, a therapeutic purpose. Where if in some patients who have a low volume of lymph node positive disease, sometimes we can get a very long disease free interval and potentially even a cure. These lymph nodes that are shown here are removed during cystectomy on both sides. When we talk about urinary diversion, we talk about having to get the urine out once the bladder has been removed.

These ureters are cut and they obviously need to be plugged into something in order for the urine to leave the body. Some patients ask a great question, “Why can’t you just take the ureters and put them to the skin and put a bag on it and not use anything else to plug the ureters in?” That actually can be done. It’s called cutaneous ureterostomy. The problem with that is that they don’t stay open. They stricture and they close down. Also the appliance to collect urine is very difficult to keep on a cutaneous ureterostomy, because it basically leaks under the adhesive on the appliance and it’s very difficult to take care of. We actually use the gastrointestinal track to help us divert the urine. Let’s talk about the gastrointestinal tract. Basically, you have the stomach, which is here. Then the stomach leads to the small bowel, which is the duodenum to jejunum. This last part of the small bowel right here is called the ileum. This ileum leads into the colon. This is the right colon, this is a transverse colon, this is the descending colon, and the sigmoid colon, and this is the rectum.

Dr. Alexander Kutikov:

That’s the GI tract, and it’s really the main urine diversions are performed using the ileum. Because the ileum is actually part of the bowel that it doesn’t do as much absorption, which is what you want when you’re trying to store urine. You don’t want things to go back into the body. We also, for Indiana pouches that I’ll show you, we use the colon. These are the three main urinary diversions for bladder removal. There is the ileal conduit, which is right here. We basically take a small segment of the small bowel, we disconnect it from the remainder of the small bowel. We’re reconnect the small bowel, so obviously the gastrointestinal track is in continuity. Then we plug in the ureters into this ileal conduit. It’s a conduit for urine to leave the body. We’ll talk a little bit about this in a minute, but basically this end of the ileal conduit comes out of the body wall, and that’s how urine collects on the body wall into an appliance. This diversion is called the neobladder.

Dr. Alexander Kutikov:

It’s taking a longer segment of the small bowel, about 60 centimeters, and sewing it into a first of all, detubularising it. Which is important because the bowel kind of has this peristaltic motion, and it’s going to push urine in a certain direction. You want to disrupt that motion, so you detubularise it, and then you sew it into a spherical reservoir about the same volume as one’s bladder. You have this thing called the chimney, which actually does peristalse and it pushes the urine this way away from the kidneys into the neobladder. Then the neobladder is sewn to the urethra. Both men and women can have this diversion, and they urinate out of the urethra. They don’t have an appliance, they don’t have a bag. This is definitely an option for some patients. We’ll talk a little bit in a minute about what the trade-offs are. Why shouldn’t everybody get this? This is called an Indiana pouch. This is a pouch that’s made out of that right colon. This is a colon pouch.

Although this pouch, there is a stoma here, and you can even, in younger patients, put it in the belly button where you can hide it in ones belly button and their umbilicus, patients have to catheterize themselves through the belly button or through a small stoma on the side to get the urine out. Again, it’s a good option for the right patient, and we’ll talk a little bit about who selects these and why choose one versus another. Let’s talk about the ileal conduit first. This is certainly the type of urinary diversion that gets employed by most patients and surgeons. A lot of patients come in for a cystectomy at an older age. They’re frail, they have other medical problems, and this is the simplest diversion to perform and this is associated with the least complications. But even those younger patients who have to have a bladder removal and who are candidates for other diversions, sometimes choose this one because sometimes this one is not associated with some risks that a neobladder or an Indiana pouch can expose the patients to. We’ll talk about sort of what those risks are. What are the big risks for folks who have ileal conduit?

Dr. Alexander Kutikov:

One of the biggest hassles for somebody who has an ileal conduit is having a parastomal hernia. Which is basically bowel sneaking next to the opening that one used to create an ileal conduit in the abdominal wall, and what’s called a fascia. Fascia is kind of the leather that keeps one together, and you have to make a hole in it in order to pull through the ileal conduit. This is what it looks like. This is what an ileal conduit, the tip over that of that conduit looks like on one’s skin. Basically a bulge here next to it can happen over months and years and can, a, be problematic where bowels can get stuck in there. But more commonly can just cause a bulge and it’d be uncomfortable to patients and make it difficult to have the appliance fit. This is a significant issue in patients with ileal conduit, and it happens in about a quarter of patients, about 25%.

Recently, this is just this last year, there was a prospective randomized trial that was done in Sweden, where surgeons put in mesh, put in prophylactic hernia mesh at the time of bladder cancer surgery in order to try to prevent these hernias. Now, why wasn’t this done before? Because there were concerns. There were concerns that you’re putting a foreign material, mesh, during a surgery where you have urine in the field and you actually have bowel content in the field because you’re opening the bowel and reconnecting it. People were worried about infections, but this was a prospective randomized trial, which is what’s called level one evidence in medicine. Which is as good as it gets. Over a two year study period, there was no increase in complications, no increase in length of stay or other really clinically relevant negative outcomes. Really patients did just as well, whether they got this mesh or not. The rate of hernias, the rate of parastomal hernias with this mesh was cut down in more than half. It went from 20 … It wasn’t perfect. Still 11% of patients got it but it went down to a rate of 23% to 11%.

Dr. Alexander Kutikov:

Again, this is, they had half the patients getting bladder removal walk through a door where they didn’t get mesh, and they had half the patients walk through a door where they got mesh and the compared results. There was a market reduction. Many centers, including our center at Fox Chase, we’re now offering this prophylactic mesh to our patients and find it quite helpful. I showed you this. This is an incision from an open radical cystectomy and ileal conduit. We’ll talk about robotic cystectomies, but let me just show you what that looks like. There’s a couple of ways to do robotic cystectomy (robotic bladder removal). One is to take the bladder out robotically and then have small incisions that basically where you took it out, you still have to open the abdomen to remove the specimen. Through that small incision, you do the bowel work and the ureter work. What’s been happening recently is that people have been trying to do all that work with the robot without actually opening. We’ll show there’s a lot of sort of discussion controversy around that approach. But in the right hands, that’s a fine operation.

Again, we’ll jump to the deliverables of robotics in bladder cancer, but unlike some other spaces, especially spaces that I work in, like prostate cancer and kidney cancer, where really robotics is a game changer, in bladder cancer, there’s a lot more controversy on whether it is a superior approach to a small incision such as this. We’ll talk about that in a minute. This is what it looks like soon postoperatively, a small open incision. Here’s the ileal conduit. These are stents. These are stents that are coming out of the stoma, and I’m going to show you those in the minute. They come out of the stoma like this. These stents really go all the way up to the kidneys and they help with these connections that we make from the kidneys to the ileal conduit. As I’ll show you, that’s another source of complications after these bladder removal operations. The one thing I do want to talk about is incisional hernias. These are hernias through the cut, and a lot of folks are coming to these surgeries not sort of after chemotherapy and some nourishment issues and incisional hernias are quite common.

Dr. Alexander Kutikov:

15% of the time that they happen, in about 9% of the time, at least in the experience that we published, they have to be repaired. That’s another risk that bladder cancer patients face and what we actually looked at our center. At least when we did the robotic approach by making a small incision to do the extracorporeal work for doing the bowels, the hernia rates were, not statistically significantly higher, but actually a bit higher. At least not better. We were hoping maybe robotics solves that issue with bladder removal, and it doesn’t look like it does, at least with the standard approach with robotics. The one thing that predisposes one to a hernia like this, if your belly, when you’re sitting up and you have a bulge what’s called diastasis recti, which is under your breastplate. Where your belly starts, you see a bulge when you’re sitting up, that’s called diastasis recti. If you have that, your chances of developing an incisional hernia for any surgery is about 50% higher. This is what the bladder removal patient sees when they come out of surgery.

They have the appliance on the stoma and they have a drain. The drain sort of allows one to have a window into the belly. Usually, these drains come out before one leaves the hospital. Although some surgeons in some instances you do have to go home with the drain. The drain site, if it gets removed, sometimes leaks for a while. Which is just the bruise fluid, it’s called peritoneal fluid. But because everything is so inflamed inside, your body produces a lot of it. Sometimes that drain site leaks quite a bit, and sometimes actually needs an appliance bag just for the drain site for a few days and sometimes even for a few weeks. Also, both in men and in women, you can have leakage of this fluid that this drain is picking up. Then after it’s removed, you might have some fluid coming out of the penis or out of the urethra remanent or the vagina in women. That sometimes is disconcerting, but it’s something that’s often expected and obviously speak to your surgeon, but not something that need to be overly concerned about because that’s very common.

Dr. Alexander Kutikov:

These are the stents, I showed you that. The stents are used to prevent strictures, prevent this area where the urinary tract is sewn into the gastrointestinal track from shutting down. The stents stay there anywhere from one to three weeks, depending on your surgeon’s preference. When they get removed in the office, it’s not a painful procedure. The stents are there to allow this area to heal. The removal of the stents and the stents clogging up before is sort of a common source of urinary tract infection. About 30% of patients get a urinary tract infection around the time of cystectomy and whenever you manipulate those stents, sometimes that’s when it happens. Even though we’ll give you antibiotics a lot of us in practice before, during and after stent removal, sometimes we still can’t prevent these infections. One of the very common complications of bladder removal surgeries is to have a urinary tract infection. Which it sounds like not a huge deal, but it actually, around the time of cystectomy, it is a big deal. A lot of times you need a readmission to the hospital.

It sets once recovery back, you get exhausted, sometimes need IV antibiotics, you have high fevers, even sepsis. We haven’t figured out a perfect way to prevent them, but the stents sort of sometimes contribute to them. If this area’s strictured, then your kidney gets hydronephrotic. In the past, in large series, this happened anywhere from five to 15% of the time. There is now techniques, there’s sort of been a disruption in this space where this technological SPY fluorescent imaging has been used to look at the blood supply. This is a picture from one of the surgeries of Fox Chase, where you can see this is the left ureter through the SPY camera. You can see kind of the bright vascularized area of the ureter go all the way down to the tip. Whereas here, this area is gray. If this area was connected to the ileal conduit, it would’ve likely strictured because of the blood supply is not good. I’m not showing you sort of interoperative pictures, because I know some folks don’t want to see those. But I’ll tell you that it looks identical through white light, through surgeon’s eyes.

Dr. Alexander Kutikov:

You can’t tell the difference between these. This spy technology allows you to visualize the blood supply. You can do this both through open and robotic cystectomies. The trick here is just to cut back this ureter. Sometimes it makes the surgery a little bit more challenging because there’s sort of plumbing and length issues, but almost always it’s possible. That way it helps prevent strictures. There’s been a couple of publications now, and I’ve adopted this in my practice several years ago and I find it extremely helpful to cut down on the rate of urethral strictures. Which are really complications that set patients back and make recovery much more challenging. What other complications briefly? There’re recurrent infections. I mean, other infections right after surgery, but about a quarter of patients have urinary tract infections after the receiver urinary diversion. These data are from 15 years of followup for pioneers in cystectomy like Studer, where they follow their patients diligently for decades. These are the numbers.

25% of recurrent infections, urinary stones and these complications usually occur beyond on five and 10 years. Impaired kidney function due to obstruction or ureter reflux happens in about a third of patients. We always got to watch kidney function after these diversion. Stomal complications, we talked about that. Up to 25% may have bowel complications. Which is you’re cutting the bowel, you’re reconnecting it, and things like small bowel obstruction, fistula formation, diarrhea, are very difficult sort of problems to tackle and very difficult for patients. But these are the kinds of the most feared complications by surgeons and patients. Usually manageable, but definitely sort of very frustrating for everybody involved. 30% of patients get readmitted. If you count all the complications, these are surgeries. Regardless of what center you look at, and some of the busier centers are most honest about sort of reporting their complications, greater than 60% complication rate. I tell my patients, there’s only about a 40% chance and potentially less that you get through the surgery without any issues, without any glitches.

The Basics of Neobladder and Indiana Pouch

Dr. Alexander Kutikov:

We’ve got to brace ourselves that there are going to be some bumps in the road, and this is why it’s important to partner with a center and a surgeon whom you trust. Because this is not a single event, the bladder removal surgery, this is a process. This is a journey that you got to go through together. The vast majority of issues that arise can be handled non-operatively, but some do require a second surgery. Let’s see how are we doing on time? We’re doing okay. Let’s see. Let’s see if I can get through some of these other diversions after bladder removal. This is a neobladder. A neobladder urinary diversion, again, uses a larger segment of small bowel. It basically creates a reservoir where the patients can urinate through their urethra. Some people ask me what a neobladder looks like during surgery. I put a slide there. If you don’t want to see a picture from inside a surgery, I would just turn away from the screen now, and I’ll just keep it up for 10, 15 seconds. But here’s what a neobladder looks like interoperatively.

This is the small bowel opened up, detubularised and kind of sewn together. This is a Studer neobladder, which most people use and that’s what I use in practice. This is where the neobladder has kind of folded on itself and now the ureters are being sewn in into the neobladder. That’s what it looks like during bladder removal surgery. But let’s talk about why somebody would choose a neobladder and why not. There’re trade-offs. First, one needs to understand that there is chance of incontinence. I quote patients approximately 10% chance of daytime incontinence. When somebody coughs, sneezes, picks up something heavy, stand up too fast, you can leak some urine and need a pad or it depends. Hopefully those chances are even less, but you got to sort of use the 10% risk as the risk to make your decision. That’s daytime. Nighttime is more difficult to predict. In all of us who have their native bladder, what happens is, when our bladder fills, when we’re sleeping, our sphincter, our muscle that keeps the urine in, tightens automatically. That’s a spinal reflex.

Dr. Alexander Kutikov:

There’s basically our bladder sends a signal to our spinal cord to tighten the sphincter. In patients who have a neobladder, that obviously doesn’t happen because there was no signal from the bladder to tighten the sphincter. About 20% of patients who have neobladders leak at night, when they are the deep sleepers and they’re dry during the day. But when they fall asleep, their sphincter loosens up and they don’t have the reflux to tighten it, and they leak at night. It can be a frustrating problem. It may require other surgeries or a lot of times people sort of just handle it and either put a condom catheter or it depends, but it can be frustrating. That’s a risk that one has to sort of understand before getting into a neobladder. Hypercontinence, this is another risk. Hypercontinence, it’s the opposite problem, you can’t empty your neobladder. What happens then? You need to catheterize and you would need to catheterize for the rest of one’s life. Sometimes this is the deal breaker about a neobladder, although, and then the risks are five to 10%. In women they’re much higher, 20 to 30%.

But sometimes this is a little bit of a deal-breaker for folks. They just don’t want to risk that. But also perioperative complication. Recovery, this is a bigger surgery. There is multiple drains that are coming out of you. You’re walking around, you’re waiting for this bladder to heal. For our elderly and frail patients, we usually don’t spend too much time discussing this because they’re not great candidates. We’re trying to get them through one of the biggest operations that we do in surgery and adding another layer of complexity, like a neobladder, is just not a great idea.

Dr. Alexander Kutikov:

What about if you signed up for a neobladder? Do you always get one? Well, most of the time you do. But I tell patients there’s three scenarios where we may need to walk away from a neobladder using a game time decision. I tell them it’s when the urethra has some cancer on it. It’s always very important to send a margin, a urethra margin at the time of the neobladder surgery and for the pathologist to tell the surgeons that that edge is clean. Because if there is cancer in the urethra, you can’t obviously take more urethra because you will lose the continence mechanism and you can’t leave cancer behind. That’s one possibility. The other possibility is that sometimes when somebody becomes unstable during bladder removal surgery, something is happening with their heart, with their lungs. It’s very rare, especially for patients who are good neobladder candidates. But sometimes the anesthesiologists can tell the surgeon that, “Hey, we really need to get this patient off the table.” Neobladder just takes more time than an ilial conduit. That’s a very unusual sort of scenario.

The other scenario is where we find more disease. Again, this is a discussion with you and your surgeon before surgery, but sometimes we decide that if there is a frank lymph node positive disease or there’s sort of diseases concerning, then we’ll go with a simpler operation in order to recover faster and get to subsequent therapy faster. All right. Let’s talk a little bit about Indiana pouch. Remember I told you about this right colon. That’s what we use, and we make a catheterizable channel that you catheterize. Sometimes you can put in a belly button, but sometimes you turn this around and put the stoma around here. This is a good option for patients who don’t want a bag, who don’t want an appliance, but whose pelvis has been remediated or they have sort of a degree of malignancy where you can’t offer them a neobladder. And for whom it’s very important not to have an appliance. This is a good diversion. Sometimes we offer to women who really don’t want to self catheterize because catheterizing for women can be difficult, especially as they lose their dexterity with age.

Dr. Alexander Kutikov:

As the body ages, it becomes more and more difficult to catheterize the urethra. This is a diversion sometimes that we use associated with quite high complication rates associated with infection risks. I offer it to my patients, but this is not something we rush to do before really discussing with patients and making sure that this is what they want. Let’s talk about sexual dysfunction. This is a little bit of a conversation, and I know we don’t have a lot of time, but this is a conversation about what needs to be removed from the female pelvis when one does a cystectomy. On this picture, this is the woman is facing this way. This is her back, and this is the pubic symphysis, this is the rectum, and this is the bladder and urethra. Classically, what’s removed is the anterior vagina, the anterior wall of the vagina, the uterus. Here are the ovaries and the fallopian tubes are removed as well. Kind of this is what’s called an anterior exenteration. What’s really we understand better, is that we don’t always have to remove all that, especially women who are active.

By not removing the uterus, we can prevent some degree of prolapse, which can happen when you remove these public structures. For some women we offer, depending on the location of their disease, but if there is really no concern for disease that’s really budding the vagina, to really offer a vaginal and the uterus sparing cystectomy. We offer that more and more these days and it’s a discussion whether to take their ovaries and fallopian tubes depending on menopausal status, depending on patient’s age. We usually discuss with the patient’s gynecological colleagues about their opinions regarding that. If it’s a vaginal sparing cystectomy, generally sexual function is largely preserved. Even when the anterior vagina is resected, there can be some dyspareunia, there can be some pain with intercourse, but usually patients can still be sexually active. For male patients, we remove the prostate, the seminal vesicles, and the bladder. Ejaculations are dry. These are the nerves. These are the nerves that innovate the corporal bodies of the penis.

Dr. Alexander Kutikov:

Even if there’s nerve sparing cystectomies that are done, the erections are quite poor, but sensation is intact, is always intact. Things like an orgasm that’s one-on-ones brain. Those functions are intact so people can be intimate but the erections are poor after cystectomy, generally. Not in everybody, but generally. There are ways to get erections back. Usually the oral medications don’t work, but there’s injections, there’s a lot of options for men who are interested to stay sexually active. So an important conversation to have with one’s surgeon. We’re running out of time. I will rush through these slides a bit because I want to take questions. But open versus robotic cystectomy, what I’ll leave you with is, it doesn’t matter. Choose a surgeon and choose a busy surgeon who knows what they’re doing and use their preference. There’s been some concerns about robotic cystectomy recently where the robot is this platform where you use this device to sort of give you 3D visualization and degrees of freedom when moving the instruments. But there were some concerns that after this paper in the gynecological surgery with cervical cancer, where the results were far inferior with the robotic surgery.

But thankfully, in urological oncology, and there was an FDA warning about it, but in urologic surgery, although concerns were raised over the years about recurrence patterns, because the belly is insufflate and some of this urine can get aerosolized, and there were some different recurrence patterns that we were seeing with robotic surgery versus open surgery. Then that there were more strictures with robotic surgery. There’s a recent report with these newer techniques. But in the experienced hands, there were two trials that were now done that we basically don’t see robotics to be an inferior operation. Whether it’s superior operation, it is very much debated and at least right now there’s really no evidence for that. A lot of us busy robotic surgeons that I do a lot of robotic surgery, but cystectomy, I did it for five years robotically and I went back to doing it with a classic open incision because I do think the onus is on robotic cystectomy to show superiority before we totally shift that way. It really hasn’t happened yet here. But it’s not the driver, it’s the car. Choose a surgeon and use their most preferred method.

Dr. Alexander Kutikov:

But certainly both bladder removal procedures are considered now the standard of care and the recovery is very similar from one versus another, especially if the surgeons use small incisions to do the open cystectomy bladder removal. It really is a little bit of dealer’s choice and just use a center and a surgeon that you prefer. For instance, at Fox Chase, we do both. We do both open and robotic cystectomy. I want to spend two minutes because this comes up all the time. What about artificial bladder? When are people are going to make a bladder? We’ve had an artificial heart since 1982. Why there is no artificial bladder? It’s not for lack of effort. People have tried. It’s just a very difficult problem to tackle. Urine encrusts these synthetic devices and the connections tend to fail, and people get bad infections with prosthetic devices in the urinary tract. These are kind of the best data that we have. There’s been really a lack of effort in the space since the ’90s. With modern materials, I think that effort needs to be renewed, but it’s something that I’m very interested in, but it’s certainly this has largely been abandoned.

It was abandoned because tissue engineering was really holding much promise and there was all these papers that were coming out where we were looking like we were very close, especially in animal models. But then when we did these trials in patients, there were many problems and these bladders just did not take. This was not a new bladder, this was just trying to make a bladder bigger in some patients who were born congenitally with non-functioning bladders. There was a company that was started that tried to make a synthetic ilial conduit by using cells from the patient and using a scaffold and growing an ileal conduit. This was Tengion, Inc. that unfortunately went into bankruptcy in 2014. Let’s stop here because I can talk a little bit about sort of how to save the bladder, but that’s a larger talk. But what I’ll tell you is, we’re not there either. This is a study that we just published showing that even when we try to save the bladder and it looks very good on cystoscopy, 25% of the time, we actually miss muscle-invasive disease.

Question and Answer

Stephanie Chisolm:

I deeply thank you so much. Dr. Kutikov, that was phenomenal and I think you really did such a great job of explaining all of those complications and everything else. I think the underlying message that I heard, and I hope that the participants here is kind of you wouldn’t take your Jaguar to the mechanic on the corner. You go to somebody that does bladder removal on a regular basis. You really want to go to somebody who has that experience if you’re going to have the surgery, because it is complicated. You don’t want them to say, “I read about that in a journal once.” Then, “Sure, I can do that. I’m a doctor.” You want to go with somebody who has an awareness of what the problems are so you can circumvent them certainly. I think that that came through very closely and very clearly. Let’s get to some of the questions. We have a kind of a unique question. There’s a participant with only one kidney and their GFR is holding at 27. I guess they’re indicating that they’re going to have a cystectomy. If they choose to have the stoma and need dialysis, I think this is a good recommendation in terms of getting in the team approach. Because dialysis can be run by the nephrologist, correct? Is it possible to do dialysis when you only have a stoma?

Dr. Alexander Kutikov:

Yeah. Hemodialysis, the stoma won’t affect your hemodialysis. I think the question is asking whether they can do peritoneal dialysis, which is basically putting dialysis fluid in the belly and having an exchange and do what a kidney does, but filter the toxins through the peritoneum. It’s a great question. I think it’s a real discussion with your nephrologist and your surgeon. It’s a big risk that will not be possible because of adhesions. Regardless of what kind of surgery whether it’s stoma or neobladder or an Indiana pouch, there can be adhesions that sort of prevent the peritoneal fluid from, lack of a better word, sloshing around the belly and exchanging. There will be pockets of scar where it will prevent one from getting peritoneal dialysis. It’s a great question. There’s a big wildcard there whether that’s possible or not. A lot of people will do a little bit of hand waving to say, probably not, but something that can be tried. But generally, it’s not a go-to. It’s generally, once you have a lot of abdominal surgery, not a great candidate for peritoneal dialysis, but never say never. I mean, it’s a discussion.

Stephanie Chisolm:

Okay. Good point. When you’re doing a neobladder operation, what would cause the surgeon to not be able to spare the nerves. Everybody goes in with good intentions, but what are some of the complications that come up that mean that you’re not able to do that nerve sparing procedure?

Dr. Alexander Kutikov:

Right. This gets to the question of, how good is nerve sparing during cystectomy and how effective it is in preserving erections. For instance, for prostatectomy, when we just take out the prostate, the nerves are very much localized right around the periphery of the prostate. That nerve sparing tends to work quite well. The problem with these nerves, is they sort of spread around the bladder and despite all efforts to spare the nerves, sometimes the erections just suffer greatly. Obviously there’s scenarios where nerve sparing is abandoned, like there’s disease that’s sort of encasing the nerves, there’s radiation scarring those kinds of things. But even if the nerves are spared, one needs to be counseled appropriately that it is no guarantee that one will have erection. Now, there are certainly patients after cystectomies who have a relatively good erections. But even in the best of hands, there’s a big wild card of whether that nerve sparing will be effective. Now, again, as I mentioned in my talk, it doesn’t have to be the end of personal life. Even without erections, one can be intimate. There’s lots of ways to get erections back. But this is really some of the predictors of erectile function are really age, ability to nerve spare, function before surgery. Those kinds of things need to be integrated and really need to be discussed on an individual basis with a patient.

Stephanie Chisolm:

BCAN has done a couple of programs, specifically relating to sexuality for both men and women, and they’re on our bcan.org website. That’s a good point. Okay. I understand the repair of parastomal hernias is very involved with the potential for long-term post-op stay, nearly equivalent to the radical cystectomy itself. Please discuss what’s involved in repairing these hernias especially if you don’t use the mesh to begin with.

Dr. Alexander Kutikov:

Right. This is exactly why a lot of us have enthusiasm for doing the mesh after bladder removal upfront. It makes the surgery a bit longer, but it sort of prevents this issue down the road, that again, happens in 25% of folks. Yes, it’s an involved operation and I’m very fortunate to have a general surgery colleague who’s very adept at doing these at Fox Chase. But it takes an experienced surgeon who sort of understands the logistics. A lot of times it can be done laparoscopically and actually kind of get all the adhesions and get all the scarring off and get the bow out of the hernia and actually put a good mesh there. But yeah, this is a very nuanced operation that needs an experienced hernia surgeon to do, because it’s easy to make it too tight and actually obstruct the ileal conduit, which can have a lot of problems. It’s easy to damage the bowel and have these prolonged hospital stays and have a lot of problems. I would really, especially here seek a center that has a lot of experience in fixing these because they’re operations that require quite a bit of expertise.

Stephanie Chisolm:

Do the inguinal hernias add to the rate of post radical cystectomy hernias or contribute to other complications in general?

Dr. Alexander Kutikov:

Yes. Once you remove the bladder, what we call occult hernia, sometimes folks have these hernias. They’re really not clinically symptomatic, and it’s very hard to even diagnose them, but once you move the bladder, where all of a sudden the bowel snakes into this hernia defect in the groin, and you can develop them after cystectomy. Now, we take them … Usually those are relatively simple to fix and those are outpatient procedures. But a challenge comes up if somebody has a large hernia or symptomatic hernia before cystectomy. Again, this needs a multidisciplinary approach where it can be fixed. You sort of have choices. You can fix it before cystectomy. You can just fix it during cystectomy. You can fix it after cystectomy or forego fixing it altogether and just monitor it. Again, that really sort of needs an individualized approach. It depends on the size of hernia. It depends on how symptomatic it is. It’s important. Usually, at least in my practice, I work with that hernia surgeon who helps me with the parastomal hernias, and we kind of figure out a plan for each patient. Sometimes the plan is different just depending on the circumstances.

Stephanie Chisolm:

Excellent. Great. Thank you. I think we have time for a couple more questions. For people with a metastasis to a nearby lymph gland, is removal off the table since now we’re already dealing with systemic cancer, or is that still an option down the road with other treatments?

Dr. Alexander Kutikov:

Terrific question. When somebody has a lymph node positive disease, a cystectomy is still an option. Cystectomy shouldn’t be done upfront. This is definitely something where a patient at most centers who’ll receive chemotherapy first. I’ll speak to our center. This is, approaches differ and there are sort of risks to each approach here. But at our center, we generally give chemotherapy and then we gauge the response. In the right patients, when the response is favorable, we actually offer surgery. Now, it’s a discussion. It’s a discussion whether the patient would want to go through surgery when the risks of kind of systemic progression are quite high. But again, a very sort of individualized decision. But especially the younger patients with great responses generally proceed with cystectomy.

Stephanie Chisolm:

One of the programs we do have on our website is a couple of things where some of our experts are also talking about prehabilitation and preparing for cystectomy. I’m going to kind of blend this question with something else. In terms of getting ready to go back to their normal activities, sometimes bladder cancer patients are a little bit older. They may have other comorbidity. What’s the typical time for getting back to their normal everyday activities. Is there something they should avoid doing when they’ve had a cystectomy? Is there anything you recommend for getting yourself ready for anybody who’s on this call who is awaiting a cystectomy in terms of making sure that you’re going to have the best outcomes by preparing your body? What is there to do out there?

Dr. Alexander Kutikov:

Yeah. It’s really important and terrific question that I probably won’t do justice in just a few minutes, but I’ll tell folks this. The one thing I do want to communicate is, this is an incredibly challenging period in people’s lives. I mean, this is one of the hardest things that really humans go through. I mean, a cystectomy isn’t just a giant operation, in the postoperative course, it’s fraught with issues. Before one gets wind back in their sails, it can be months. I mean, sometimes it’s weeks, but you got to be prepared for months. I tell folks it’s physical exhaustion, sort of dovetailed with an emotional exhaustion. There are people that have never been depressed in their life, and this is the first time that they really feel profoundly depressed. It’s important to sort of make sure that you’re self-aware and that you seek help. Most centers that do these surgeries have support and will get you through this very dark time. It really is. That what I really encourage folks to remember that no matter how sort of difficult the situation is, the clouds always lift. Sometimes it takes three or four months. What’s challenging is that physically you can see the surgeons back and see the nurses back, and everybody says you look great.

You feel terrific. Then you go home and you just don’t feel like your old self. You feel like you’ll never get your energy back. You feel like you’ll never have sort of the kind of the love for life that you had before surgery. You will, it just really takes a long time. Yes, the prehab and there’s lots of efforts to try to kind of redirect the arc of this recovery and quicken it. But sometimes it’s very difficult and the best thing is to really surround yourself with as good of a support group as you can have, and try to be as active as possible and just give it time and give yourself sort of time to recover from this just very large operation.

Stephanie Chisolm:

Great. Well, Dr. Kutikov, this has been phenomenal. We appreciate you sharing your experience with the entire bladder cancer community.

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