The most common form of bladder cancer in the United States is urothelial carcinoma. Tobacco use is the most frequent risk factor, followed by occupational exposure to various carcinogenic materials such as automobile exhaust or industrial solvents. However, many patients develop bladder cancer without any identifiable risks.1 Other forms of bladder cancer, such as adenocarcinoma and squamous cell carcinoma, occur in distinct patient populations. Patients with chronic irritation from catheters, bladder stones, or schistosomiasis infection are at risk for the squamous cell variant, whereas those with urachal remnants or bladder exstrophy have an increased risk of adenocarcinoma. However, the aforementioned variant histology should not be confused with urothelial carcinoma with variant transformation.
Bladder cancer can be categorized into invasive and noninvasive types. Management of urothelial carcinoma varies greatly, depending on the depth of invasion. A complete transurethral resection of the bladder tumor, which allows for staging of the tumor, is the first step. The tumor should be completely removed, if possible, along with a sampling of the muscular bladder wall underlying the tumor. An exam under anesthesia should be performed for all patients with newly diagnosed bladder tumors. The exam under anesthesia can help determine clinical staging and whether there is fixation of the bladder to adjacent structures. Radiologic imaging of most bladder tumors is of limited benefit in determining the presence, grade, or size/stage of a bladder tumor. However, in the presence of a known bladder tumor, unilateral or bilateral hydronephrosis is an ominous sign of locally advanced disease (at least muscle-invasive bladder cancer).2 Computed tomography (CT) scans do provide valuable information regarding metastatic involvement of pelvic lymph nodes, liver, or lung. Historically, 25% of patients with preoperative CT scans demonstrating no evidence of lymphatic spread will actually have lymph node involvement during radical cystectomy and pelvic lymphadenectomy. The utility of a positron emission tomography (PET)-CT scan has emerged as an important imaging modality to minimize this rate to 5% to 10%. For patients who have disease invading into bladder muscle (T2), immediate (within 3 months of diagnosis) cystectomy with extended lymph node dissection offers the best chance of survival. Additionally, surgeons should send lymph node specimens in separate packets and not en bloc in an effort to increase nodal yield. Current long-term cure for those presenting with clinically localized disease has not significantly changed over the last two decades.3 The addition of neoadjuvant or adjuvant chemotherapy in those without discernible metastatic spread is gaining increasing acceptance and does provide a survival benefit.4 Patients with limited lymph node involvement may be cured with surgery alone, but those with extensive lymph node involvement have a dismal prognosis.
Patients have multiple reconstructive options, including continent and noncontinent urinary diversions. The orthotopic neobladder has emerged as a popular urinary diversion for patients without urethral involvement. This diversion type involves the detubularization of a segment of bowel, typically distal ileum, which is then refashioned into a pouch that is anastomosed to the proximal urethra (neobladder) or to the skin (continent cutaneous diversion). Detubularization decreases intrapouch filling pressure, which improves urinary storage capacity. In the case of a neobladder, the external sphincter is still intact, and voiding is achieved through sphincteric relaxation and a Valsalva maneuver. In the case of the continent cutaneous diversion, patients attain continence by utilizing a bowel segment (appendix or tapered small bowel) that has a high length-to-lumen ratio. The most common diversion is noncontinent, the ileal conduit, whereby a segment of distal ileum is isolated with one end brought out through the abdominal wall as a urostomy. Ileal conduits are preferred for renal insufficiency because urine is not “stored” and therefore has less time in contact with the absorptive surface of the ileal segment. Conduits are also used when the bladder is unresectable, but urinary diversion is necessary due to intractable bleeding, severe voiding pain, and hydronephrosis. Each segment of bowel that is used offers its own advantages and inherent complications.
Patients with non–muscle-invasive bladder cancer (confined to the bladder mucosa or submucosa) can be managed with transurethral resection alone and adjuvant intravesical (instilled into the bladder) chemotherapy/immunotherapy. The use of these intravesical agents is critical since patients with non–muscle-invasive bladder cancer are at risk for tumor recurrence and progression. Tumor grade is extremely important in assessing the risk of disease progression. Those patients with high-grade disease or recurrent tumors can be treated with intravesical agents such as bacille Calmette-Guérin or mitomycin C. These agents decrease risk of progression and recurrence, by induction of an effective immunologic antitumor response in the case of bacille Calmette-Guérin and through direct cytotoxicity for mitomycin C. Those patients at high risk of progression who fail conservative therapy should be offered cystectomy. Because upper tract recurrence is fairly common (up to 17% of patients with carcinoma in situ), surveillance must be performed with retrograde pyelograms or CT urograms.
Surgical Approaches and Complications
The typical surgical approach for cystectomy is a lower midline incision from just above the umbilicus to the pubic symphysis. This allows adequate exposure of the pelvic contents, iliac vessels, and lower abdominal cavity. The peritoneum between the median umbilical ligaments (urachal remnant) also is taken with the specimen. In men, the prostate is removed with the bladder. In women, the uterus, ovaries (in postmenopausal women), and anterior wall of the vagina are removed with the bladder. The vagina may be spared, depending on the location and extent of the tumor, but significantly more operative bleeding results. Robotic approaches for cystectomy are increasingly used, but the urinary diversion is still usually performed through an open incision. The benefits of the robotic portion are decreased blood loss during the pelvic dissection (due to pneumoperitoneum) and the shortening of the time that the abdomen is open. However, recent evidence (randomized controlled trials of open versus robot-assisted radical cystectomy) did not demonstrate any difference in oncologic efficacy or complication rates.
Complications of bladder cancer surgery involve bladder perforation during transurethral resection of the bladder tumor, which requires catheter drainage for several days if small (common) or open repair if large and intraperitoneal (rare). Cystectomy and urinary diversion may result in prolonged ileus, bowel obstruction, intestinal anastomotic leak, urine leak, or rectal injury. A urine leak from the ureteroileal anastomoses is a common cause of ileus, intra-abdominal urinoma, abscess formation, and wound dehiscence. Deep venous thrombosis is common after cystectomy5 due to the advanced age of most patients, proximity of the iliac veins to the resection and lymph node dissection, and the presence of malignancy. Pulmonary embolism is one of the leading causes of death in the perioperative period after radical cystectomy. The utility of subcutaneous heparin in the perioperative period can minimize the risk of venous thromboembolism.
Testicular cancer is the most common solid malignancy in men age 15 to 35 years.6 Most men are diagnosed with an asymptomatic enlarging mass (Fig. 40-1). A major risk for the development of testicular cancer is cryptorchidism. Although the debate continues over whether early surgical intervention to bring an undescended testis into the scrotum alters the future risk of cancer, it is generally accepted that doing so allows much easier monitoring for the development of a testicular mass.
Testicular cancer. Patients often present with advanced disease despite scrotal enlargement for several months.
Most neoplasms arise from the germ cells, although non–germ cell tumors arise from Leydig’s or Sertoli’s cells. The non–germ cell tumors are rare and generally follow a more benign course. Germ cell cancers are categorically divided into seminomatous and nonseminomatous forms that follow different treatment algorithms.
Since the vast majority of solid testicular masses are cancerous, any observed mass on physical examination and/or documented on ultrasound is malignant until proven otherwise. Initial studies must include tumor markers, including α-fetoprotein, β-human chorionic gonadotropin, and lactate dehydrogenase. Elevated tumor markers are found almost exclusively in nonseminomatous germ cell tumors, although up to 10% of patients with localized seminomas and 25% with metastatic seminomas will have a modest rise in β-human chorionic gonadotropin. Chest and abdominal imaging must be performed to evaluate for evidence of metastasis. The most common site of spread is the retroperitoneal lymph nodes extending from the common iliac vessels to the renal vessels, and abdominal imaging should be performed in all patients. There is no role for percutaneous biopsy of testicular masses due to (a) the risk of seeding the scrotal wall; (b) changing the natural retroperitoneal lymphatic drainage of the testicle (because the testes have a remarkably predictable pattern of lymphatic drainage); and (c) the propensity of a testicular mass being cancerous. In cases where metastatic disease to the testicle is suspected, an open testicular biopsy by delivery of the testicle through the inguinal canal is recommended. Lymphoma (especially among the elderly) may involve one or both testes. Often, evidence of lymphoma usually is present elsewhere in the body, although relapses may be isolated to the testes.
Even in the absence of enlarged lymph nodes on CT imaging (stage I), occult micrometastatic disease is often present (30% of the time), so adjuvant surgery, radiation, or chemotherapy is offered. However, active surveillance protocols have been gaining traction for both seminoma and nonseminomatous tumors. Retroperitoneal lymph node dissection (RPLND) is potentially curative in the setting of limited lymph node involvement and has been the preferred adjuvant treatment of those with stage I nonseminomatous disease. Alternatively, patients with stage I nonseminomatous tumors can also choose to receive two cycles of chemotherapy. Pure seminoma is exquisitely radiosensitive, and stage I, IIa, and IIb disease can be treated with external-beam radiation to the retroperitoneal nodes. However, a single dose of carboplatin for stage I seminoma was found to be just as effective as radiation therapy. Both forms of germ cell tumors, in the setting of disseminated disease or large bulky lymph nodes, are best treated with four cycles of chemotherapy. However, teratoma frequently is a component of retroperitoneal lymph node metastasis, and it is not responsive to chemotherapy or radiation and can demonstrate aggressive malignant degeneration. Postchemotherapy RPLND for residual masses can be challenging. Large bulky metastases may encase the great vessels, and vascular graft placement after resection occasionally is required.
Surgical Approach and Complications
For orchiectomy, an inguinal incision is made over the external ring and carried laterally over the internal ring. It is important to not violate the scrotal skin during orchiectomy, for fear (mostly theoretical) of altering the lymphatic drainage of the testis. For RPLND, a midline incision usually is made from the xiphoid process to the umbilicus for most patients with stage I disease. If it is in a setting of a postchemotherapy residual mass, the incision is extended down to the pubic symphysis. The use of robotic-assisted RPLND is rarely used for stage I nonseminomatous disease, although with increasing demand for minimally invasive surgery, one would anticipate that it will be the happy compromise for those who wish to avoid a major incision but are not interested in active surveillance or systemic chemotherapy.
Complications of testicular cancer surgery include scrotal hematoma formation, which can be prevented by meticulous hemostasis. Complications after RPLND include bowel obstruction; excessive bleeding, particularly from retrocaval lumber veins; and chylous ascites. Patients who undergo a full, bilateral RPLND often suffer from ejaculatory dysfunction due to the interruption of the descending postganglionic sympathetic nerve fibers that are involved in seminal emission. For this reason, right and left templates have been developed that limit bilateral dissection (especially below the inferior mesenteric artery) and preserve some of these nerves with a low risk of leaving residual microscopic cancer.7
Renal cell carcinoma (RCC) is a malignancy of the renal epithelium that can arise from any component of the nephron (Fig. 40-2). In 2012, there were over 64,000 new cases in the United States, with over 13,000 deaths.8 With the widespread use of imaging for many medical complaints, a stage migration has led to an increased incidence of small renal masses.9 Surprisingly, this has not led to lower mortality rates. Various histologic subtypes include clear cell, papillary (types I and II), chromophobe, collecting duct, and unclassified forms. Collecting duct and unclassified forms have dismal prognoses and do not routinely respond to systemic therapy. Benign lesions, common in the setting of a small renal mass, include oncocytomas and angiomyolipomas. Renal tumors are usually solid, but they also can be cystic. Simple cysts are very common and are not malignant, but more complex cysts may be malignant. The Bosniak classification system, based on septations, calcifications, and enhancement, is used to assess the likelihood of malignancy (Table 40-1).10
Table 40-1.Bosniak renal cyst computed tomography classification ||Download (.pdf) Table 40-1. Bosniak renal cyst computed tomography classification
|CATEGORY ||DESCRIPTION ||RISK OF MALIGNANCY/MANAGEMENT |
|I ||Thin-walled cyst with water density with no septations or calcifications. ||0%/nonsurgical |
|II ||Thin-walled cyst with few hairline septa that may contain fine or very limited thick calcifications. Also includes homogeneously hyperdense cysts <3 cm. ||0%/nonsurgical |
|II F (follow) ||Multiple hairline or slightly thickened septa without measurable enhancement. May contain nodular calcification. Also includes hyperdense cysts >3 cm. ||∼5%/should be followed for progression |
|III ||Irregular or smooth thickened walls or septa with measurable enhancement. ||∼50%/surgical |
|IV ||Same as III, but with enhancing solid components. ||∼100%/surgical |
Complex renal cyst. A right kidney with a Bosniak type 3 renal cyst. Note the enhancing septum (arrow). This cyst was removed and found to be a high-grade papillary renal cell carcinoma.
Most cases of RCC are sporadic, but many hereditary forms have been described. These syndromes frequently involve a germline mutation in a tumor suppressor gene. von Hippel-Lindau disease is associated with multiple tumors including clear cell RCC (Fig. 40-3). The involved gene, vhl, also frequently is mutated or hypermethylated in sporadic RCC.11 Other rare forms include Birt-Hogg-Dubé syndrome, where patients get oncocytomas or chromophobe tumors. Patients with hereditary papillary RCC and hereditary leiomyomatosis develop papillary RCC.
von Hippel-Lindau disease. A computed tomography image of a patient with von Hippel-Lindau disease and bilateral kidney tumors that are predominantly intrarenal. Note the numerous cysts in the head of the pancreas (arrow).
The most common sites of metastasis are the retroperitoneal lymph nodes and lungs, but liver, bone, and brain also are common sites of spread. Up to 20% to 30% of patients may present with metastatic disease, in which case, surgical debulking can improve survival, as shown in randomized controlled trials.12,13 Patients with all but the smallest renal masses should undergo testing for the presence of metastatic disease including chest CT, bone scan, and liver function tests.
Patients with localized disease may be cured with either partial or radical nephrectomy (Fig. 40-4). The oncologic efficacy of partial nephrectomy (nephron sparing) appears to be similar to that of radical nephrectomy. However, patients with larger tumors or with a more central tumor location may be at increased risk for surgical complications. Nephron-sparing surgery should be considered in all patients, if feasible, as those patients undergoing a radical nephrectomy are at risk for future chronic kidney disease.14 The lack of harm from nephrectomy due to malignancy has been extrapolated from the fact that kidney donors do not routinely develop renal insufficiency. However, kidney donors are a highly selected group, and patients with renal tumors are typically older and have more comorbidities. Additionally, the risk of contralateral RCC is 2% to 3% in most series,15 and a partial nephrectomy may prevent the future need for dialysis in case of a contralateral kidney tumor. While we should all strive to preserve as many nephrons as possible, we do not have level 1 evidence that supports the use of partial nephrectomy over radical nephrectomy for patients with small renal masses.
Partial nephrectomy. A kidney after partial resection for a small renal mass. Note the visible collecting system in the base of the defect (arrow).
Minimally invasive techniques for renal surgery have greatly changed the field of kidney cancer. Laparoscopic and robot-assisted laparoscopic renal surgery allows for more rapid convalescence and decreased narcotic requirements. While laparoscopic partial nephrectomy is challenging and is performed only in experienced hands due to its associated high rate of complications, the advent of robot-assisted surgery has changed the landscape. Surgeons are now capable of performing intracorporeal suturing with much greater ease. Ablative techniques such as cryoablation and radiofrequency ablation are also popular choices, especially among those who are poor surgical candidates. However, long-term results from these techniques are currently lacking due to their recent development. Active surveillance is another viable alternative for small renal masses, especially in patients with multiple comorbidities or advanced age. Most small renal masses are low grade with a slow growth rate, and patients very rarely progress to metastatic disease after limited follow-up of 2 to 3 years.16
Up to 10% of RCC invades the lumen of the renal vein or vena cava. The degree of venous extension directly impacts the surgical approach. Patients with thrombus below the level of the liver can be managed with cross-clamping above and below the thrombus and extraction from a cavotomy at the insertion of the renal vein (Fig. 40-5A). Usually, the thrombus is not adherent to the vessel wall. However, cross-clamping the vena cava above the hepatic veins can drastically reduce cardiac preload, and therefore, bypass techniques often are necessary. For thrombus above the hepatic veins, a multidisciplinary approach with either venovenous or cardiopulmonary bypass is necessary. In cases of invasion of the wall of the vena cava or atrium, deep hypothermic circulatory arrest may be used to give a completely bloodless field. Tumor thrombus embolization to the pulmonary artery is a rare but known complication during these cases and is associated with a high mortality rate (Fig. 40-5B). For cases of extensive tumor thrombus, intraoperative transesophageal echocardiography should be considered for monitoring and assessment of possible thrombus embolization. If a thrombus embolization occurs, a sternotomy/cardiopulmonary bypass with extraction of the thrombus may be life saving.
Inferior vena cava thrombus. A. A multidetector computed tomography image displaying a tumor thrombus extending above the diaphragm (arrow) arising from a right renal mass. B. An en bloc removal of a different right renal mass with a tumor thrombus that extended to the pulmonary artery. This patient is alive 6 years after surgery.
Patients undergoing resection of localized renal masses are at substantial risk of future recurrence. Many predictive features have been recognized, but the most widely accepted prognostic findings are tumor stage, grade, and size, each of which exerts an independent effect on recurrence. Isolated solitary recurrences, either local or distant, can be resected with long-term disease-free rates approaching 50%.17
Surgical Approach and Complications
Nephrectomy, either partial or radical, can be performed through a number of surgical approaches. Flank incisions over the eleventh or twelfth ribs from the anterior axillary line to the lateral border of the rectus muscle provide access to the kidney without entering the peritoneum. However, entry into the pleura is not uncommon. If small, the pleurotomy usually can be closed without need for a chest tube. The anterior subcostal approach also is used for nephrectomy. There is no risk for pleural entry, but this incision is transperitoneal, so ileus is somewhat more likely. Laparoscopic nephrectomy is now common, and robot-assisted laparoscopic partial nephrectomy is gaining significant traction in the management of small renal masses. For large tumors, particularly on the right side where the liver makes exposure of the tumor more difficult, a thoracoabdominal approach is very helpful. In these cases, the flank incision is made over the tenth rib and carried further posterior and anterior than a typical flank incision. The chest and abdominal cavities are intentionally entered for maximum exposure, and the diaphragm is partially divided in a circumferential fashion, which allows cephalad retraction of the liver. A chest tube is used postoperatively. The adrenal gland is no longer routinely removed unless the tumor is adherent to it. The benefit of lymph node dissection when the nodes are not clinically involved is uncertain.
Complications of radical nephrectomy include bleeding, pneumothorax, splenic injury, liver injury, and pancreatic tail injury. Partial nephrectomy has the added risks of delayed bleeding and urine leak. Ileus is not common when the peritoneal cavity is not entered.
Prostate cancer is the most common nonskin malignancy in men, with an incidence of approximately 200,000 per year. Yearly screening consisting of digital rectal exam and serum prostate-specific antigen (PSA) testing has been a topic of much debate. The U.S. Preventive Services Task Force has advised against the routine use of prostate cancer screening. The American Urological Association has advised for screening for men 55 to 69 years of age. Patients of African American descent or those with a family history of prostate cancer should be considered for screening at an earlier age (as early as 40). Men with abnormal digital rectal exams or PSA elevation have an indication for prostate biopsy to determine the presence of the disease. With the advent of PSA screening, prostate cancer has experienced a stage migration, with most cases now discovered locally confined within the prostate. The majority of patients with prostate cancer will not die of the disease by 10 to 15 years, whether it is treated at diagnosis or not. However, those undergoing initial treatment have improved cancer-specific survival.18
Prostate cancer is graded according to the Gleason scoring system.19 A primary and secondary score are assigned based on the most common and second most common histologic patterns. Grades range from 1 for the most differentiated to 5 for the least. The grades are added to give the Gleason score. In current practice, scores below 6 are almost never assigned. Gleason score, preoperative PSA level, and digital rectal exam are used to estimate the likelihood of whether the cancer is localized, locally advanced, or metastatic. Prostate cancer with a high Gleason score (8 to 10) or a high PSA level (>20) is much more likely to have spread, often at a micrometastatic level. After definitive treatment, an increasing PSA is indicative of recurrent cancer.
The most common site of spread of prostate cancer is the pelvic lymph nodes and bone. For patients with high-risk disease based on clinical stage, grade on biopsy, and PSA level, staging includes bone scan and CT imaging to evaluate for bony metastases or pelvic lymphadenopathy. Multiple treatment options are available for men with localized disease, including radical prostatectomy (retropubic, perineal, or robotic-assisted laparoscopic approaches), brachytherapy, and external-beam radiation therapy. For low-risk disease, the efficacy of each treatment modality is thought to be similar. For low-risk disease, radical prostatectomy (open or robotic) can be performed with unilateral or bilateral cavernosal nerve sparing to limit postoperative erectile dysfunction (ED). For high-risk disease, either non–nerve-sparing surgery or external-beam radiation therapy plus androgen deprivation may be performed. The associated morbidity of each treatment differs, and it is important to discuss the side effects with patients. Irritative voiding and bowel symptoms are common after radiation therapy, with ED being a late side effect. Radical prostatectomy is associated with early incontinence and ED (depending on nerve sparing). Incontinence improves significantly with time, with <1% of men in experienced hands suffering severe long-term problems with urinary control. Likewise, ED improves with time. The large majority of younger men (<55 years of age) regain erectile function, often with the aid of oral medications, if both cavernosal nerves are spared.20 Older men or those with no nerves or one nerve spared have lower rates of erectile function.
Active surveillance has emerged as a safe and viable option for men with anticipated survival of <10 years, low Gleason score (6), early-stage disease (cT1c), and small-volume disease as determined by biopsy. Patients should be monitored closely with digital rectal exam, PSA testing, and repeat biopsy at 1 to 2 years to assess the possible progression of disease. Once prostate cancer has spread, it is no longer curable. Medications that lower serum testosterone or that block the androgen receptor are able to control the disease, often for years, but the cancer inevitably becomes resistant to this treatment. Nevertheless, patients with noncurable prostate cancer can live many years, and a large number die of causes other than prostate cancer.
Surgical Approach and Complications
The approach for an open radical retropubic prostatectomy uses a lower midline incision from the pubic symphysis to approximately 5 cm below the umbilicus. The peritoneum is not entered. Lymph nodes are removed between the external iliac vein and obturator vessels bilaterally, although this may be omitted in cases where the probability of involvement is very low. Some regularly perform a wider dissection that may improve staging, although any therapeutic benefit is uncertain. The cavernosal nerves lay immediately posterolateral to the prostatic capsule. They may be spared if the cancer is not likely to penetrate the capsule on that side, which is a function of preoperative parameters such as biopsy results, PSA, and clinical examination. Robot-assisted laparoscopic radical prostatectomy has superseded laparoscopic prostatectomy due to the learning curve and increased agility that facilitates intracorporeal suturing. Benefits over open radical retropubic prostatectomy include lower blood loss and faster convalescence. Some claim faster return of continence and lower ED rates, but these findings have not yet been widely demonstrated.
Complications of prostatectomy depend on approach. Retropubic approaches may result in urine leaks, lymphocele, and very rarely, rectal or ureteral injury. Robotic prostatectomy uses a transperitoneal approach that can occasionally result in ileus, particularly in cases of a urine leak from the vesicourethral anastomosis. All approaches carry a small risk of urinary incontinence and a more substantial risk of ED.