Bladder substitution in women

Bladder substitution in women with transitional cell carcinoma (TCC) is not a universally accepted procedure. There are many concerns, one of which is the potential risk of metachronous and synchronous urethral transitional cell carcinoma involvement. Another concern is that voiding dysfunction may be more frequent than in male patients. The numbers of female patients who have had this procedure are still small, and follow-up data are relatively brief. Thus, the true role for orthotopic bladder substitution in the female is still being evaluated. This paper reviews the data on this type of surgery in women, with emphasis on urethral TCC risk and on voiding dysfunction. Early results from a number of institutions are encouraging, particularly in correctly selected patients. Based on more than 15 years experience in an albeit small number of patients, we believe that if there is a functional external sphincter and tumor margins can be safely cleared, this form of surgery offers patients the best opportunity to preserve quality of life following cystectomy.     

Bladder substitution in women

Bladder substitution in women with transitional cell carci-noma (TCC) is not a universally accepted procedure. There are many concerns, one of which is the potential risk of metachronous and synchronous urethral transitional cell carcinoma involvement. Another concern is that voiding dysfunction may be more frequent than in male patients. The numbers of female patients who have had this proce-dure are still small, and follow-up data are relatively brief. Thus, the true role for orthotopic bladder substitution in the female is still being evaluated. This paper reviews the data on this type of surgery in women, with emphasis on urethral TCC risk and on voiding dysfunction. Early results from a number of institutions are encouraging, particularly in correctly selected patients. Based on more than 15 years experience in an albeit small number of patients, we believe that if there is a functional external sphincter and tumor margins can be safely cleared, this form of surgery offers patients the best opportunity to preserve quality of life following cystectomy.     

Radical cystectomy (anterior exenteration) in the female patient

Anterior exenteration in the female patient can be performed accurately with a disciplined anatomic approach. The lymphadenectomy provides staging for the carcinoma. Excision of the uterus, a portion of the vagina, and the urethra reduces the potential for pelvic recurrence. Vaginal reconstruction and continent urinary diversion provide a better quality of life with maintenance of sexual function and urinary continence.     

Radical laparoscopic cystectomy

Radical laparoscopic cystectomy is being adopted by most groups with proven experience in laparoscopic surgery, especially by those who have already completed the learning curves in radical laparoscopic prostatectomy. It is still considered a highly complex technique, which has not yet been mastered in many Urology Units. In this article, we review the surgical technique and available literature on this approach, with special emphasis on its indications, advantages and most frequent morbidity.     

Bladder substitution

Preliminary data have shown that composite reservoirs consisting of gastric segments in combination with ileum or colon may reduce metabolic problems. Orthotopic neobladders are the most natural way to reconstruct the urinary bladder and are a safe option in selected male and female patients. Experimental and preliminary clinical data about new methods using autologous muscle transfer and tissue engineering are promising.     

Radical cystectomy in regionally advanced bladder cancer.

The distinction pathologically of invasive tumors confined to the muscularis propria from those that penetrate the bladder wall and invade the perivesical fat or adjacent organs is a critical prognostic determinant. Nodal metastases are evident in approximately one half of patients with tumors pathologically staged as P3b or greater. Five-year survival rates after radical cystectomy with or without preoperative irradiation for stage P3b tumors range from 17% to 46%. Long-term survival is the exception when bladder cancer invades the pelvic sidewall or adjacent structures, yet cystectomy can provide palliation and accurate staging and can be considered in the context of combination therapy. Supravesical diversion can provide palliation when there is nodal disease above the bifurcation or pelvic fixation. The optimal role of adjuvant chemotherapy in the treatment of regionally advanced bladder cancer is yet to be defined. Tannock has delineated the many serious pitfalls inherent in interpreting nonrandomized trials of new therapies (see also his article elsewhere in this issue). Randomized trials are currently under way to determine if survival can be improved with adjuvant or neoadjuvant chemotherapy and the most efficacious timing of chemotherapy administration. Clinicians should generally resist the tendency to treat all patients with these regimens until it is clear that we are truly improving the outcome of therapy and the quality of life for our patients.     

Surgical atlas: Orthotopic bladder substitution in women after cystectomy for bladder cancer

Orthotopic bladder substitution after cystectomy in women is feasible. The rate of continence is comparable to that in men who have been similarly treated. Over continence (which is common) is caused by posterior and caudal displacement of the neobladder. Prevention of this descent can reduce the incidence of this complication. Further follow-up is needed to evaluate the oncological outcome.     

Bladder substitution in children

In spite of all the difficulties, cystoplasty, particularly with the ileocecal segment, has proved rewarding. Undiversion is easily accomplished in this way. Most patients are outwardly well and happy. Reflux usually does no harm in the near term, especially if infection can be prevented, and bladder pressures are not elevated. However, we believe that we are close to being able to prevent reflux in a reliable manner. If this is the case, the ileocecal segment or hemi-Kock pouch may clearly become the optimal choice for bladder substitution in patients with reflux or ureteral obstruction, as well as those with short ureters or very small bladders, or as a standard method of undiversion. We have also employed the intussuscepted ileum as the antireflux mechanism in patients undergoing bladder substitution using a patch of small bowel as in the hemi-Kock. This technique allows one to leave the cecum and ileocecal valve in situ, reducing the risk of chronic postoperative diarrhea. In addition, small bowel is proving to be more compliant on the average than large bowel segments when used in bladder reconstruction. Whether the ileocecal segment or the hemi-Kock cystoplasty has a permanent place in undiversion and in the treatment of chronic or pharmacoresistant noncompliant bladder, neuropathic or otherwise, the techniques learned are making total replacement of the bladder with bowel segments a more attractive and feasible undertaking. The pool of patients susceptible to such maneuvers is a large one.     

Radical cystectomy with ileoneocystoplasty

There were examined 32 patients with cancer of bladder, to whom radical cystectomy with ileoneocystoplasty in the author's modification was performed. Operative intervention was done for the transitional cell carcinoma of bladder in T2-T4 stage. The method of the bladder formation using resection of the ileum segment 40-60 cm in length was adduced. The intestinal segment was transsected along the side opposite to mesentery, the transplant was placed in U-like fashion, the posterior wall of bladder was formed sewing together medial edges, anastomosis between bladder and ureter was performed. In 17 patients postoperative complications had occurred, mainly of septic-purulent character. Postoperative mortality was 9.4%. Radical cystectomy with ileoneocystoplasty is an effective method of medico-social rehabilitation of patients, which secures restoration of urodynamics of upper urinary ways and urination.     

高龄膀胱癌患者全膀胱切除术19例报告

目的探讨高龄（≥75岁）浸润性膀胱癌患者行全膀胱切除术的可行性及疗效。方法1985年1月至2002年1月收治高龄（≥75岁）浸润性膀胱癌行全膀胱切除术患者19例，均为男性，平均年龄78岁。从手术时间、术中输血、术后并发症、生存率等方而与同期202例浸润性膀胱癌（〈75岁，对照组）行全膀胱切除术患者进行比较。结果高龄组平均手术时间414min，平均术中输血1550ml，平均术后住院时间24d，对照组分别为366min，1200ml，19d，2组比较差异无统计学意义（P〉0．05）。高龄组和对照组术后近期并发症分别为9例（47．4％）、28例（13．9％），P〈0．05。高龄组13例获随访，1、5年生存率分别为66．7％（8／12）、50．0％（3／6）。对照组138例获得随访，1、5年生存率分别为90．4％（113／125）、68．4％（52／76）。高龄组患者1年生存率明显低于对照组（P〈0．05），而5年生存率比较差异无统计学意义（P〉0．05）。结论全膀胱切除术可以安全地应用于适当选择的高龄患者，年龄不应成为高龄浸润性膀胱癌患者行根治性全膀胱切除术的排除标准。     

Bladder cancer in men and women treated by radiation therapy and/or radical cystectomy

Four-hundred fifty-one patients with bladder cancer, 348 men and 103 women, were treated by radiation therapy and/or radical cystectomy during the last two decades at Memorial Sloan-Kettering Cancer Center. Radical cystectomy alone was the treatment in 98 men and 39 women. Radical radiation therapy to an average tumor dose of 6,000 rad in six weeks was given to 79 men and 30 women ± one year before salvage cystectomy was done for recurrent or persistent tumors. Planned preoperative irradiation was delivered to the true pelvis either 4,000 rad in four weeks in 95 men and 24 women or 2,000 rad in one week in 76 men and 10 women ± six weeks and two days, respectively, before radical cystectomy. Over-all survival and recurrence results in both sexes were similar; 40 per cent of men and 36 per cent of women were alive at five years without recurrence, 45 per cent of men and 48 per cent of women died in five or more years with local and/or distant recurrences, and 21 per cent of men and 15 per cent of women died before five years from causes other than cancer recurrence. Higher five-year survival for high clinical stage B₂ to D₁ tumors was noted similarly in the irradiated men (30 per cent) and women (37 per cent) than in the cystectomy alone patients (19 per cent in men and 4 per cent in women). Similar survival rates (52 to 57 per cent) were observed in men and women with low clinical stage O to B1 tumors treated with or without irradiation.     

Radical cystectomy and adjuvant chemotherapy

Seventy-one radical cystectomies were performed at the University of Tennessee from June, 1976, through December, 1983. The operative mortality rate was 1.5 per cent. The early and late complication rate was 21 and 15 per cent, respectively. Single agent cisplatin was used as adjuvant chemotherapy in patients at high risk for development of metastatic disease and did not alter the poor survival of this group of patients.