21 Urinary Bladder Cancer

Urinary Bladder Cancer

7

THE GEC ESTRO HANDBOOK OF BRACHYTHERAPY | Part II: Clinical Practice Version 1 - 21/04/2015

Twisting of catheters over each other preventing parallelism can be avoided by placing intravesical Teflon spacers (24) (fig 22.8). Before the catheters exit the inner part of the bladder, the cathe- ters first pass through the spacers. The spacers are attached with a cord to the Foley-balloon catheter and can be removed as soon as the irradiation catheters have been removed after the treat- ment. The spacers are removed together with the Foley-balloon catheter. The spacers are not only necessary to prevent twisting of the catheters, but can also be used to define the length of the target length. If no spacers are used, the target length is marked by metal mark- ers, implanted in the bladder wall at both ends of the target area. To prevent stone formation, the markers should not be clipped to the mucosa surface, but implanted into the muscle. For sites very low in the trigone, it may be better to make a loop than two parallel lines, to be able to cover the target adequately.

localised by the light from the cystoscope that can be observed from the outer wall view. By slightly pressing from the outside on the bladder with laparoscopic instruments, the position of the tumour area can be checked from the cystoscopic view (Fig 22.9). By verifying the position of the tumour area from both sides proper placement of the catheters is guaranteed.

Fig 22.9: Upper panel: Light emission from cystoscope, visible outside the bladder. Three catheters placed with the robotic arm. Lower panel: Cystoscopic view of the TURB scar. Manip- ulation outside the bladder is visible cystoscopically Picture kindly provided by Dr. G. Smits, Rijnstate Hospital, Arnhem, The Netherlands

Fig 22.8 : Intravesical spacers to maintain source separation of the implanted bladder brachytherapy catheters.

Afterloading catheters of sufficient length (50 cm) are needed to bridge the distance from skin to bladder and back outside the patient and still to have enough length to allow for connecting to the afterloader. The catheters should be guided preferentially through the ab- dominal wall, including the abdominal wall fascia, and not through the laparotomy scar. To reduce the risk of kinking when the fascia is sutured together, the catheters should not leave the abdomen too close to a median incision. Finally the catheters are fixed on the skin with buttons and the catheter is cut open. Another method to fix the catheters is by using perforated gas- tric tubes at both extra-abdominal ends of the loop. To prevent kinking in the course of treatment it is advisable to place a syn- thetic or metallic guide wire in the catheters. 8.4 The minimal invasive laparoscopic technique In 2009 the Arnhem group developed an implantation technique using laparoscopy. Later this technique was developed toward a robot-assisted approach. This allows minimal invasive surgery with four 1 cm incisions in the abdominal wall for the inser- tion of instruments. By using a cystoscope introduced through the urethra into the bladder, an endoscopic view of the location and extension of the residual tumour (or the scar) is obtained. Minimal manipulation is sometimes necessary to reach the out- er bladder wall, while a light emitted by the cystoscope exposes the affected part of the bladder. This provides a full view of the bladder wall from both sides. The position of the tumour area is

Needles with catheters attached to them are implanted through the skin into the abdominal cave where they are taken over by the instruments operated by the urologist. The catheters have a needle attached at one side of the catheter to be controlled by the laparoscopic instruments (Fig 22.10). The needles are inserted from the outer side of the bladder, through the muscular bladder wall, reappearing again at the surface beyond the tumour area (Fig 22.9). The cystoscopic view ensures that the needle followed by the catheter remains intramural and does not enter intravesi- cally. As with the suprapubic approach, usually 2- 4 catheters are needed to cover the target area completely. If a partial cystecto- my is performed, 2 catheters are placed along the vesical scar. After that the catheters are guided to pass through the abdom- inal wall to be fixed on the skin with buttons. Finally titanium surgical clips are fixed next to the catheter insertion points on the bladder outer surface to mark the CTV area properly.

Fig 22.10: Specially designed catheter with needle for laparoscopic use.