Partial cystectomy - Clinical Tree

Introduction

Partial cystectomy is an uncommonly performed procedure with oncologic and functional indications that determine surgical approach. Because of the risk of tumor spillage with urothelial cancers, it is rarely indicated in the management of this malignancy, but the approach can be utilized for less common bladder tumors or the excision of bladder diverticula for functional reasons. The robotic approach is particularly suited to partial cystectomy due to the enhanced surgical view compared to open surgery and significantly improved dexterity over traditional laparoscopic surgery, particularly for bladder closure.

KEY STEPS

1.
Access, pneumoperitoneum, port placement
2.
Bladder mobilization ± ureteric mobilization
Urachal remnant/tumor
1.
Bladder filling, cystotomy, and tumor excision
2.
Bladder closure
3.
Excision of remaining urachus and umbilicus
4.
Closure of rectus sheath and overlying fat
Bladder diverticula
1.
Partial filling of bladder and diverticulum
2.
Mobilization of diverticulum from adjacent structures
3.
Ligation of diverticular neck (for malignant indications)
4.
Disconnection of diverticulum from bladder
5.
Bladder closure

Indications and contraindications for robotic-assisted partial cystectomy (RAPC)

An overview of the indications is provided in Table 28.1 .

TABLE 28.1

Indications for Partial Cystectomy

Bladder	Diverticulum	Urachus
Malignant Conditions
Urothelial cancer Variant histology: adenocarcinoma, squamous carcinoma, and neuroendocrine carcinoma
Rare malignancies: spindle cell carcinoma or sarcoma Diverticulum cancer: urothelial cancer, rarely squamous carcinoma and adenocarcinoma	Adenocarcinoma
Benign Conditions
Tumors: paraganglioma and pheochromocytoma but also leiomyoma or fibrous histiocytoma Other: colovesical fistula repair, vesicovaginal fistula repair, and less commonly for cavernous hemangiomas, ulcerative interstitial cystitis, and localized endometriosis of the bladder	Congenital or acquired benign diverticula	Infected urachal remnants: patent urachus, urachal cyst, urachal sinus, and vesicourachal diverticulum

Pathologies of the urinary bladder

Bladder cancer

Partial cystectomy is rarely indicated in the management of urothelial cancer due to the risk of tumor spillage and the development of implantation tumors. Chemoradiation provides a reasonable alternative in those patients not fit for or who refuse radical cystectomy. However, patients with urothelial malignancy within a bladder diverticulum may be suitable for this approach. Furthermore, those with variant histology, such as adenocarcinoma, squamous carcinoma, and neuroendocrine carcinoma, have lower risk of implantation tumors and are more suitable for partial cystectomy. Rare malignant indications also include other histological subtypes, such as spindle cell carcinoma or sarcoma. Although data are sparse, there is some evidence in the literature that partial instead of radical cystectomy in well-selected patients with variant histology does not impair survival. In carefully selected patients, partial cystectomy has functional and morbidity related advantages over radical cystectomy ( Table 28.2 ).

TABLE 28.2

Advantages and Relative Indications of Partial Cystectomy Over Radical Cystectomy

Advantages	Relative Indications
Preservation of functionally continent native urinary reservoir Reduced morbidity (suited for high-risk patients and palliative situations) Potency sparing in males Continence sparing No separate urinary diversion with requisite small bowel resection and anastomosis	Patient choice Preservation of native bladder function Palliation of severe local symptoms High-risk surgical patients

Among patients who recur following partial cystectomy, salvage cystectomy offers similar survival to primary radical cystectomy for organ-confined disease. The inclusion of partial cystectomy in novel trimodal therapy protocols and innovations in surgical technique offers some promise to improve patient outcomes but should be considered experimental.

The role of pelvic lymph node dissection (PLND) as part of the primary treatment and its extent is controversial. In patients with urothelial cancer, there is some evidence that PLND at the time of partial cystectomy is associated with a lower cancer specific mortality rate and improved overall survival. ^,

However, for the treatment of urachal carcinoma, there is no clear evidence that lymphadenectomy is of any benefit. ^, Some evidence suggests that PLND, even in the presence of lymphadenopathy on imaging, is of no benefit, whereas other evidence suggests a survival benefit of up to 25% at 5 years. ^, ^, Because of the low incidence of urachal adenocarcinoma, sufficient evidence for consensus opinion will be difficult to achieve.

Benign bladder tumors

Although conventional transurethral resection is regarded as the gold standard for benign bladder tumors, partial cystectomy is considered the most effective treatment for certain benign bladder tumors, such as bladder paraganglioma, pheochromocytoma, leiomyoma, and fibrous histiocytoma.

Other benign indications

Partial cystectomy may also be performed as part of more extensive pelvic surgery, including colovesical fistula repair, vesicovaginal fistula repair, and less commonly for cavernous hemangiomas, ulcerative interstitial cystitis, and bladder endometriosis.

Bladder diverticulum

Diverticulectomy is most commonly performed for functional reasons but may rarely be indicated in patients with isolated malignancy within a bladder diverticulum.

Acquired bladder diverticula predominantly develop in adult males due to bladder outlet obstruction secondary to prostatic hyperplasia or urethral stricture. Less commonly, they may arise in male or female patients with neurogenic bladder (detrusor-sphincter-dyssynergia). Congenital diverticula are rare.

Chronic urinary stasis within bladder diverticula, especially in those with a narrow rather than wide neck, can result in bladder calculi and subsequent infections, leading to squamous metaplasia and risk of malignancy. Radical cystectomy remains the gold standard for cancer within a bladder diverticulum; however, in highly selected cases, partial cystectomy with or without multimodal therapy for high-risk tumors remains a more conservative alternative approach.

Pathologies of the urachus

After birth, the urachus becomes a fibrous cord known as the median umbilical ligament. If remnants of the allantois remain within the ligament, they may develop into cysts and epithelial or mesenchymal neoplasms. Four structural anomalies may arise: patent urachus, urachal cyst, urachal sinus, and vesicourachal diverticulum.

Urachal tumors

Urachal tumors, both benign and malignant, are rare, but the predominant type is adenocarcinoma.

Malignant urachal neoplasms account for less than 1% of all bladder cancers ^, and are generally treated by partial cystectomy with en bloc resection of the median umbilical ligament and umbilicus.

Benign urachal neoplasms are extremely rare and include fibromas, adenomas, fibroadenomas, fibromyomas, and hamartomas; however, they are important in that they mimic urachal malignancy.

Infected urachal remnants

All anomalies mentioned above are prone to infection. Early recognition and treatment for infected urachal remnants lowers the risk of bladder fistula or cyst rupture, both of which can elicit peritonitis, abscess, and sepsis. Surgical excision of urachal remnants in adults is not only preventive against recurrent infection but also reduces risk of malignant transformation.

Preoperative assessment

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