RU2257856C1 - Method for treating complicated forms of urinary bladder cancer - Google Patents

Abstract

FIELD: medicine, urology.

SUBSTANCE: one should perform radical cystectomy and chemotherapy, in case of prolonged hemorrhage one should tighten internal iliac artery being below the branching of the upper gluteal artery. Ureters should be crossed at the level of the upper cystic vessels. Then one should treat dorsal venous complex: one should isolate the complex followed by bandaging and suturing its elements. Distal urethral end should be sutured with uninterrupted suture. In women one should carry out radical cystectomy at resecting the uterus with adnexa and vaginal resection. In case of affected bladder's collum one should resect the urethra, as well. Uretherocutaneostoma should be formed as a ureter's cuff. One should perform systemic chemotherapy in adjuvant mode. One month later it is necessary to develop either orthotopic or heterotopic urinary reservoir. The method enables to prolong duration and quality of life in patients with complicated invasive forms of urinary bladder cancer.

EFFECT: higher efficiency of therapy.

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Description

The invention relates to medicine, to urology, and specifically to methods for treating complicated forms of bladder cancer.

Known methods of treating bladder cancer: chemotherapy, immunotherapy, radiation therapy, endoscopic methods of surgical treatment and radical surgery with various methods of urine diversion, as well as various combinations of these treatment methods at different stages of the disease. So, a common tactic for superficial bladder tumors is transurethral resection followed by chemotherapy or immunotherapy, radiation therapy [1; 2; 4; 7]. In the case of invasive forms of bladder cancer, they use, as the most appropriate, open operations - bladder resection, cystectomy with neoadjuvant and adjuvant chemotherapeutic effects, radiation therapy [4; 6; 7; 8]. However, cases of the complicated course of the disease often do not allow the use of chemotherapy methods (due to the development of ureterohydronephrosis on one or both sides) due to their pronounced toxicity to the body, endoscopic methods of treatment are also not applicable due to the large size of the tumor, intense bleeding from the tumor. At the moment, there is no single point of view on the treatment of this category of patients. The main objective of the treatment of complicated forms of bladder cancer is to eliminate the complications that have arisen, increase life expectancy, and maintain quality of life at the highest possible level [2]. So, in order to stop bleeding, methods of transurethral resection of the tumor, electro-vaporization are proposed [2; 4]. They use ligation and embolization of the internal iliac artery, stopping bleeding in the open bladder, palliative cystectomy [2; 4]. If the outflow from the upper urinary tract is disturbed, the most commonly used method is puncture nephrostomy, ureterocutaneostomy, Bricker operation, while leaving the bladder with a tumor [1; 2].

However, all the proposed methods, which are used symptomatically as necessary, are ineffective, if there is a large area of tumor lesion on the surface of the bladder and bleeding has already developed (transurethral resection, tumor vaporization), they give a small and short effect - ligation of the internal iliac artery, hemostasis in the open bladder, long enough and traumatic for debilitated patients - cystectomy with the simultaneous formation of intestinal reservoirs, or internal Thread urinary diversion and do not eliminate the risk of developing other complications and progression of tumor growth.

The closest to the achieved result is a method of treating complicated forms of bladder cancer, including radical cystectomy with various options for the derivation of urine of catheterized reservoirs (Brikker - wet stoma, Mainz-pouch - I, etc., dry stomas) followed by adjuvant chemotherapy or radiation therapy in the case of invasive forms of bladder cancer [4]. However, there are no specific dates for therapeutic measures and the choice of their types and sequence are not optimized, which ultimately reduces the provision of medical care at a symptomatic level, reducing the duration and quality of life of this category of patients ..

A new technical task is to increase the duration and quality of life of patients with complicated invasive forms of bladder cancer.

The stated technical problem is achieved by the use of a new method for the treatment of complicated bladder cancer, including radical cystectomy and subsequent chemotherapy, and when performing cystectomy, in case of continued bleeding, the ileal artery is ligated below the discharge of the superior gluteal artery, the ureters cross at the level of the superior vesical vessels and are treated dorsal venous complex, for which, under the control of vision, a complex is isolated with subsequent ligation and by crushing its elements, adequate hemostasis is achieved by flashing the distal end of the urethra with a continuous suture of the ligature, and in women, radical cystectomy is performed in the volume of removal together with the uterine bladder with appendages and vaginal resection, and in case of damage to the bladder neck, the ureterocutaneostomy is also formed ureteral cuffs, 5 mm above the skin surface, then, in a month, in the absence of contraindications, the patient is given systemic chemotherapy in the adjuvant mode, after 1 a month after the chemotherapy stage and if there are no signs of disease progression, the next stage of treatment is performed, which consists in creating an orthotopic or heterotopic urinary reservoir, moreover, for men, they usually perform orthotopic plastic surgery of the bladder, the type of plastic is selected depending on the patient’s constitution, ureter length, structure the ileum and sigmoid colon, and in women form heterotopic reservoirs with the formation of a wet or dry stoma reservoir and according to Bricker or create an ileo-colonic reservoir Indiana pouch.

Justification for a multi-stage treatment method

Among all malignant neoplasms, bladder cancer in Russia accounts for 2.4%. In 40% of patients with transitional cell carcinoma of the bladder, invasive forms of the disease are detected [2]. Invasive bladder cancer is accompanied by a number of serious, sometimes fatal complications such as:

recurring bleeding with the development of anemia

tamponade of the bladder cavity with blood clots

sprouting of the ureteral orifice with the development of ureterohydronephrosis on one or both sides

sprouting of the neck of the bladder with the development of infravesical obstruction

development of renal failure

Quite quickly, the tumor grows into neighboring organs: the prostate, urethra, intestines, affects the mouth of the ureters with the development of ureterohydronephrosis and chronic renal failure. In invasive forms of bladder cancer, surgical methods of treatment - radical cystectomy provides more than 10 year survival [1]. The long-term results of treatment of invasive bladder cancer depend on the stage, the degree of malignancy and the prevalence of the process, the peculiarities of the location of the tumor, its size, neoadjuvant and adjuvant therapy, as well as the choice of the surgical intervention itself. On average, according to several authors, a relapse-free course of the disease can be achieved in approximately 60-80% of patients after cystectomy. In the case of massive recurrent bleeding, neoadjuvant chemotherapy is not possible. With the ineffectiveness of organ-preserving methods, radical cystectomy is the method of choice in the fight against life-threatening bleeding. Thus, the indications for the proposed multi-stage method of treatment of bleeding-complicated forms of invasive bladder cancer are:

recurrent bladder bleeding in invasive cancer

large tumor or multifocal tumor growth

sprouting of the ureteral orifice with the development of ureterohydronephrosis on one or both sides

the presence of severe concomitant diseases.

Performing a radical cystectomy is aimed at eliminating the source of bleeding and the causes of obstruction of the ureters with the simultaneous removal of the tumor and pelvic lymph nodes. According to the results of the operation, the staging of the tumor process is accurately performed, and the time 1 month after the operation allows you to correct the development of body functions and systems that have developed as a result of complications. Adjuvant chemotherapy is performed to prevent the recurrence of the disease after radical cystectomy. Chemotherapy is carried out according to generally accepted schemes - for example, hemicitabine and cisplatin. Doses of hemicitabine 1000 mg / m ² and cisplatin 75 mg / m ² , the course of treatment consists of three 28 day cycles. 1 month after the completion of chemotherapy, in the absence of signs of relapse and in the absence of distant metastases, the third stage of treatment is performed - the formation of the urinary intestinal reservoir. In men, as a rule, an orthotopic reservoir forms (Camey, Studer, Reddy), in women - a heterotopic reservoir (according to Bricker or Indiana pouch).

Example. Patient S., 52 years old, was hospitalized in the department in the order of planned care with a diagnosis of Bladder cancer, bladder bleeding. At the time of admission, the duration of bleeding is more than 1 week, while a single urinary retention is noted. Urine was withdrawn in emergency order, the patient was prescribed hemostatic therapy, but the bleeding did not stop, and the patient turned to the urology department. When examined in the patient’s department of increased nutrition, the skin is pale with normal numbers of blood pressure, the pulse is 120 beats per 1 minute. According to the results of laboratory tests in the general analysis of urine - blood, in the general analysis of blood hemoglobin 96 g / l and the number of red blood cells 2.8 × 10 ¹² / l. A set of instrumental studies was carried out:

1. Ultrasound of the abdomen and pelvis

2. Bimanual palpation of the tumor

3. Cystoscopy

4. Transurethral ultrasound of the bladder

5. Biopsy of a bladder tumor

6. Cytology - smear imprint

7. Excretory urography.

Study 2, 3, 4, and 5 are performed simultaneously under general anesthesia.

According to the results of the studies, the diagnosis was established: Bladder cancer (smear imprint - atypical cells), multifocal localization with involvement of the left ureter in the process of the mouth with the formation of ureterohydronephrosis. Due to the size of the tumor and multiple foci of tumor growth, the TUR of the bladder tumor was not possible, neoadjuvant chemotherapy was also impossible due to a blocked left kidney and developed anemia, and hemostatic therapy using blood preparations did not bring any effect. With another tamponade with blood clots in the bladder, it was decided to perform a radical cystectomy. The operation was performed under endotracheal anesthesia. The volume was: radical cystectomy and pelvic lymphadenectomy; bilateral ureterocutaneostomy was chosen by the method of urine derivation. The duration of the operation is 2 hours 50 minutes, the volume of intraoperative blood loss was not more than 500 ml. The postoperative period was uneventful, blood counts returned to normal, and the left kidney functioned satisfactorily. According to the results of a histological examination of the removed material, the diagnosis: Moderately differentiated bladder cancer pT3aN1M0. 1 month after the operation, the patient's condition is satisfactory, laboratory parameters without deviation from the norm. A course of adjuvant chemotherapy was carried out according to the scheme: Gemicitabine + Cisplatin. Hemicitabine at a dose of 1000 mg / m ² was administered intravenously for 30-60 minutes in 400 ml of 0.9% NaCl solution on days 2, 8, 15 of each 28-day course.

Cisplatin at a dose of 75 mg / m ² was administered intravenously in 400 ml of a 0.9% NaCl solution with the rehydration of 800 ml of 5% glucose and the post-hydration of mannitol 400 ml in 1 day 28 day course. In total, 3 chemotherapy courses were carried out according to this scheme. Hospitalization for the second stage of surgical treatment after 6 months. According to the results of a comprehensive examination with MRI of the pelvic organs, isotope osteoscintigraphy, data for distant metastases and local recurrence of the disease were not detected. The patient was offered an operation to create an intestinal urinary reservoir, the patient agreed to reconstructive surgery. After preoperative preparation (special attention to the preparation of the intestine), orthotopic bladder plastic surgery was performed according to Camey. Features of the operation are the obligatory abandonment of the cystostomy catheter to prevent obstruction of mucus drainage in the early postoperative period, drainage with modeling drainages of the ureters, drainage of the abdominal cavity and cellular spaces of the pelvis. Adequate drainage - prevention of postoperative complications. Ureter modeling catheters were removed on day 14, a cystostomy catheter on day 16, and a urethral catheter on day 20. The postoperative period was uneventful. After removal of the catheters of the urinary reservoir, self-urination with episodes of nocturnal urinary incontinence was restored. The patient's condition is satisfactory, the patient began to work by profession.

This treatment method was used in 13 patients from July 1997 to April 2003. Four patients were operated on as an emergency. The age of patients in this group is 61.5 ± 5.9 years (from 53 to 66) in this group of 2 men and 2 women. Nine patients were operated on as planned care — all men. The age of patients in this group was 54.8 ± 8.5 years (from 43 to 64), all patients were of working age. Heterotopic plastic surgery (Bricker operation) was performed in three patients of both groups, and orthotopic plastic surgery was performed in 10 patients.

The presence of complications (bleeding, posthemorrhagic anemia, renal failure, chronic pyelonephritis, etc.), as well as concomitant diseases (cardiovascular system, chronic diseases of the gastrointestinal tract, chronic lung diseases) do not allow a course of systemic chemotherapy in neoadjuvant mode and large-scale reconstructive surgery. Therefore, the treatment of this group of patients is divided into 3 stages. The first stage is a radical cystectomy. The purpose of this stage is to remove the organ affected by the tumor, thereby eliminating the factors of development of complications. The main goal of this stage is to prolong the patient's life. In the postoperative period, normal indicators of organs and systems are restored, adequate staging of the tumor process is performed. The next stage - the conduct of systemic adjuvant chemotherapy - makes it possible to use cytostatic drugs in order to destroy malignant tumor micrometastases. The next step, the formation of the intestinal urinary reservoir, is aimed at improving the patient's quality of life.

During the observation period, 4 patients of both groups died - 1 patient in the group operated in emergency care. The cause of death of the patient - the progression of the underlying disease - occurred 13 months after reconstructive surgery. In the group of patients operated on in the order of planned care, 3 patients died. Cause of death:

- mesenteric vascular thrombosis with the development of necrosis of the small and large intestine and transplant (14th day after surgery);

- acute myocardial infarction - 36 months after reconstructive surgery;

- acute pyelonephritis (the death of a patient in another country and is clarified according to relatives).

Currently, the clinic has 9 patients. In 8 patients, orthotopic and in one patient heterotopic reservoirs. All patients are observed with a frequency of 1 time in 3 months, with mandatory laboratory tests (general blood and urine tests, biochemical blood tests), ultrasound examinations (liver, kidneys, pelvic organs). Urodynamic studies (uroflowmetry, cystomanometry) are performed. Episodes of daytime urinary incontinence are noted by 5 (62.5%) patients, however, no more than 1 pads are changed per day. Night incontinence is noted by 6 (75%) patients, but at the same time, most of the excreted urine is controlled by patients both day and night. A patient with a heterotopic reservoir uses a cutaneous urinary device. Erectile function is not preserved in any patient. All patients assess their quality of life as satisfactory.

Thus, the proposed method, representing the optimal combination of therapeutic measures in the sequence proposed by the applicants, improves the quality and duration of life and can be recommended for use in medical practice as an algorithm for treating this category of patients.

List of sources

1. Pereverzev A.S., Petrov S.B. Bladder tumors. Kharkiv. "Fact", 2002.

2. Matveev B.P., Figurin K.M., Koryakin O.B. Bladder cancer Moscow. Verdana, 2001.

3. S.Kh. Al-Shukri, Tkachuk V.N. Tumors of the urinary tract. St. Petersburg. Peter, 2000 .-- S. 86 - 130.

4. Kogan M.I., Perepechay V.A. Modern diagnosis and surgery of bladder cancer. Rostov-on-Don. RMSU, 2002.

5. Kaprin A.D. Modern concept for the treatment of bladder cancer / Attending physician. - 1999. - No. 5.

6. Komyakov B.K., Gorelov S.I., Novikov A.I., Gorelov A.I. et al. Immediate results of radical surgery for bladder cancer / Urology. - No. 2. - 2002. - P.16-19.

7. Matveev B.P., Figurin K.M., Toktomushev A.K. The results of organ-preserving therapy for invasive bladder cancer / Urology. - No. 3. - 2002. - P.3-5.

8. Hinman F. Operational urology. M. "GEOTAR-MED", 2001.

9. Matveev B.P. Guide to Oncourology. Moscow. - 2003. - S.195-407.

Claims (1)

A method for the treatment of complicated bladder cancer, including radical cystectomy and chemotherapy, characterized in that when cystectomy is performed in case of continued bleeding, the internal iliac artery is ligated below the outlet of the superior gluteal artery, the ureters cross at the level of the superior vesical vessels and process the dorsal venous complex, for what, under the control of vision, a complex is isolated with subsequent dressing and stitching of its elements, adequate hemostasis is achieved by the distal end of the urethra with a continuous suture of the ligature, moreover, in women, radical cystectomy is performed in the volume of removal together with the bladder of the uterus with appendages and resection of the vagina, and in case of damage to the neck of the bladder, the urethra and ureterocutaneostomy are formed in the form of a ureter cuff that rises above the skin surface by 5 mm, then a month later, in the absence of contraindications, the patient is given systemic chemotherapy in the adjuvant mode, 1 month after the chemotherapy stage and in the absence of The signs of disease progression perform the next stage of treatment, which consists in creating an orthotopic or heterotopic urinary reservoir, and in men, mostly orthotopic plastic surgery of the bladder is performed, the type of plastic is selected depending on the patient’s constitution, ureter length, ileal and sigmoid colon structure, and heterotopic reservoirs of women are formed with the formation of a wet or dry reservoir stom according to Bricker or create an ileal colonic p reservoir Indiana pouch.