Orthotopic urinary diversion after cystectomy for bladder cancer: implications for cancer control and patterns of disease recurrence

Upper urinary tract tumour after radical cystectomy for transitional cell carcinoma of the bladder: an update on the risk factors, surveillance regimens and treatments

Urothelial carcinoma is characterized by multiple, multifocal recurrences throughout the genitourinary tract; approximately 3% of patients treated by radical cystectomy (RC) for invasive transitional cell carcinoma (TCC) of the bladder will subsequently develop a subsequent TCC in the upper urinary tract (UUT) urothelium. Metachronous upper UUT tumours (mUUT-TCC) typically occur as a late oncological event (>3 years after RC). The vast majority of mUUT-TCCs are detected only after the progression to tumour-related symptoms, e.g. haematuria, flank pain or pyelonephritis, despite strict adherence to surveillance protocols. Failure of imaging and cytology to detect most asymptomatic tumours has led to questions about the need for routine UUT surveillance. Some authors have advocated a more tailored approach to surveillance after RC, targeting high-risk patients and with limiting imaging in those patients at lowest risk of developing a subsequent UUT-TCC. mUUT-TCCs are most common in patients with TCC in the ureter or urethra, and with organ-confined bladder cancer. Although the prognosis is generally poor, long-term survival can be achieved in a subset of patients after radical nephroureterectomy (NU). Minimally invasive techniques, e.g. ureteroscopic and percutaneous resection, have been proposed as renal-sparing alternatives to radical surgery for patients with low-stage and -grade de novo UUT-TCC. However, oncological control of renal-sparing therapies in those with high-risk mUUT-TCC remains largely unconfirmed. Until oncological outcomes equivalent to the standard, radical NU, are reported in patients after RC, conservative treatment strategies should be avoided.

Upper Tract Urothelial Recurrence Following Radical Cystectomy for Transitional Cell Carcinoma of the Bladder: An Analysis of 1,069 Patients With 10-Year Followup

PURPOSE

Risk factors for upper tract recurrence following radical cystectomy for transitional cell carcinoma of the bladder are not yet well-defined. We reviewed our population of patients who underwent radical cystectomy to identify prognostic factors and clinical outcomes associated with upper tract recurrence.

MATERIALS AND METHODS

From our prospective database of 1,359 patients who underwent radical cystectomy we identified 1,069 patients treated for transitional cell carcinoma of the bladder between January 1985 and December 2001. Univariate analysis was completed to determine factors predictive of upper tract recurrence.

RESULTS

A total of 853 men and 216 women were followed for a median of 10.3 years (maximum 18.5). There were 27 (2.5%) upper tract recurrences diagnosed at a median of 3.3 years (range 0.4 to 9.3). Only urethral tumor involvement was predictive of upper tract recurrence. In men superficial transitional cell carcinoma of the prostatic urethra was associated with an increased risk of upper tract recurrence compared with prostatic stromal invasion or absence of prostatic transitional cell carcinoma (p <0.01). In women urethral transitional cell carcinoma was associated with an increased risk of upper tract recurrence (p = 0.01). Despite routine surveillance 78% of upper tract recurrence was detected after development of symptoms. Median survival following upper tract recurrence was 1.7 years (range 0.2 to 8.8). Detection of asymptomatic upper tract recurrence via surveillance did not predict lower nephroureterectomy tumor stage, absence of lymph node metastases or improved survival.

CONCLUSIONS

Patients with bladder cancer are at lifelong risk for late oncological recurrence in the upper tract urothelium. Patients with evidence of tumor involvement within the urethra are at highest risk. Surveillance regimens frequently fail to detect tumors before symptoms develop. However, radical nephroureterectomy can provide prolonged survival.

A pilot study of the assessment of the quality of life, functional results, and complications in patients with an ileal neobladder for invasive bladder cancer

OBJECTIVE

To assess the functional results, health-related quality of life (QOL) outcomes, and complications in patients with an ileal neobladder in comparison to those with cutaneous diversion (ileal conduit and cutaneostomy).

METHODS

Between September 1992 and February 2003, we consecutively performed an ileal neobladder (the Studer method) in 30 patients and cutaneous diversion in 38 patients. In August 2004, questionnaires were mailed to 54 patients. The questionnaire included the validated health-related quality of life (QOL) questionnaire, SF-36 General Health Survey, and a urinary incontinence questionnaire. We also evaluated the functional results in patients with an ileal neobladder and the postoperative complications in patients with both urinary diversions.

RESULTS

The data from 41 patients (21 ileal neobladder procedures and 20 cutaneous diversions) were available for the analysis. No differences in the overall QOL were observed between the two groups. Complete daytime and night-time urinary continence was achieved in the 21 patients (100%) and 13 patients (61.9%), respectively. The mean value of the maximum flow rate was 15 +/- 12 mL/min in the 21 neobladder patients. There were 19 early complications in 18 patients (60.0%) and seven late complications in six patients (20.0%) with an ileal neobladder. However, there were 15 early complications in 14 patients (36.8%) and eight late complications in six patients (15.8%) with cutaneous diversions.

CONCLUSION

The findings regarding the health-related QOL and the frequency of complications in the neobladder group and those in the cutaneous diversion group were similar. However, the functional results and the status of urinary continence in the neobladder patients were satisfactory.

Entérocystoplastie de substitution chez l'homme (Hautmann exclu) : principes et applications techniques

Orthotopic urinary reservoir using a bowel segment has become the most favoured form of diversion after radical cystectomy. Ideal neobladder has to (i) store the urine with a low pressure bladder substitute, (ii) protect the upper urinary tract and (iii) provide a better quality of life enabling volitional voiding. A lot of techniques have bee described to construct a reservoir, however, all of them are based on the principle of intestinal loop detubulation. Many intestinal segments have been used, but ileum seems to be preferred in Europe. The upper urinary tract is mainly protected by a low neobladder pressure, rather than an additional antireflux flap-valve-type implantation technique which may increase the risk of uretero-enteric stricture. No significant difference in functional outcome can be observed among the several techniques. In selected cases, orthotopic bladder replacement is well tolerated and feasible and appears to be the gold standard after cystectomy.

Surgical treatment for urethral recurrence after ileal neobladder reconstruction in patients with bladder cancer

OBJECTIVE

To report a retrospective study evaluating the management of superficial urethral recurrence after ileal neobladder construction in patients with bladder cancer.

PATIENTS AND METHODS

In 77 consecutive patients with ileal neobladder after radical cystectomy for invasive bladder cancer, urethral recurrence was evaluated and transurethral resection (TUR) used as an initial treatment for superficial urethral recurrence. Urethrectomy with urinary re-diversion was performed when further recurrence developed.

RESULTS

Four patients (5%) presented with a superficial urethral recurrence and all four were treated by TUR as initial therapy. One patient has had no evidence of recurrence after initial TUR, although the other three patients were later treated with salvage urethrectomy due to repeated urethral recurrence. As a result, the stage of urethral recurrence advanced from pTa to pT1-pT2 in two of the three patients. For urinary re-diversion, one patient had a conversion from a Studer pouch to an ileal conduit, using the afferent limb, and the other two were converted from a Hautmann pouch to a continent reservoir using the Appe-Mainz procedure. There was no evidence of metastasis or local recurrence in any of the four patients.

CONCLUSION

Urethral preservation at initial therapy for superficial recurrence might be reasonable, and sequential urethrectomy after attempted urethral preservation might be strategically feasible. Urinary re-diversion from a neobladder to a catheterizable continent reservoir using the appendix would be a good choice and maintains the quality of life.

Assessment of Long-Term Quality of Life Using the FACT-BL Questionnaire in Patients with an Ileal Conduit, Continent Reservoir, or Orthotopic Neobladder

OBJECTIVE

To assess and compare quality of life (QOL) of patients followed for a long time who underwent an ileal conduit (IC), continent reservoir (CR) or ileal neobladder (NB) using FACT-BL, a bladder-cancer-specific questionnaire.

METHODS

One hundred and forty-seven patients underwent radical cystectomy and urinary diversion for bladder cancer from 1987 to 2002 at our institution. Of them, 79 (54%) patients were asked to participate in this study. Forty-nine patients (20 IC, 14 CR and 15 NB) returned the answered questionnaire for a survey response rate of 62%. Mean follow-up was 83.0 months.

RESULTS

Four categories (physical, social/familial, emotional and functional well-being) in FACT-G were equally favorable in these groups. Patients with IC had less trouble controlling urine but had a worse image on altered body appearance compared with NB patients. Interest in sex was extremely low in all patients and capability of maintaining an erection was also low in 39 male patients. The mean total value of FACT-BL in IC, CR and NB patients was 106.3+/-16.4, 104.0+/-14.2, and 110.9+/-18.0, respectively, showing no significant difference. Ten (77%) of 13 IC, seven (78%) of nine CR and six (86%) of seven NB patients answered that they would choose the same type of diversion if they had the choice again.

CONCLUSIONS

The type of urinary diversion does not appear to be associated with a different QOL by general cancer-related assessment. Urinary function and body image are affected and related to the method used to reconstruct the urinary system.

Cystectomy for transitional cell carcinoma of the bladder: results of a surgery only series in the neobladder era

PURPOSE

We studied the effect of radical cystectomy for transitional cell carcinoma of the bladder on survival and failure patterns when the 2 surgical standards cystectomy and neobladder were combined, when possible.

MATERIALS AND METHODS

A consecutive series of patients undergoing radical cystectomy with pelvic lymph node dissection for transitional cell carcinoma of the bladder with curative intent was analyzed. Patients with neoadjuvant radiotherapy/chemotherapy were excluded. Pathological characteristics based on the 2002 TNM system, recurrence-free/overall survival and metastatic patterns were determined.

RESULTS

A total of 788 patients with a mean age +/- SD of 65 +/- 10 years and a mean followup of 53.5 months who underwent surgery between 1986 and 2003 were analyzed. A neobladder was constructed in 75.4% of patients. Ten-year recurrence-free and overall survival rates were 59.1% and 44.9%, respectively. Positive lymph nodes were present in 143 patients (18%). The rate of recurrence-free survival at 5 years was 82.5% for pT2a pN0, 61.9% for pT2b and pT3a pN0, and 53.1% for pT3b pN0 disease. Local and distant failure rates were 4% and 9.5% for organ confined tumors, 15.9% and 19.2% for nonorgan confined tumors, and 20.4% and 45.1% in patients with positive lymph nodes, respectively.

CONCLUSIONS

In patients with organ confined, lymph node negative transitional cell carcinoma excellent survival data can be achieved as long as the tumor is limited to the inner half of the detrusor. These data on a large group of patients support early aggressive surgical management for invasive bladder cancer. The results of this surgery only series may serve as a reference for other treatment modalities for bladder cancer.

The Role of Imaging in the Surveillance of Urologic Malignancies

Urologic malignancies are common, accounting for approximately 25% of all new cancer cases in the United States. Patients with urologic malignancies require long-term surveillance to detect progression or recurrence as early as possible. The urologist is faced with the task of balancing patient safety and cost-effectiveness, while finding the most practical follow-up regimen. For each urologic malignancy, this article reviews the commonly used radiologic techniques for surveillance and offers recommended follow-up schedules.

Tumor Recurrence in the Remnant Urothelium of Females Undergoing Radical Cystectomy for Transitional Cell Carcinoma of the Bladder: Long-Term Results From a Single Center

PURPOSE

We analyzed the risk factors and incidence of secondary TCC of the remnant urothelium in women following radical cystectomy for TCC of the bladder.

MATERIALS AND METHODS

A total of 85 women with a mean age of 64.5 years with clinically localized TCC of the bladder underwent radical cystectomy between 1992 and 2004. Orthotopic bladder substitution was performed in 46 females, while 39 underwent nonorthotopic urinary diversion. Of the entire cohort 22 (26%) patients underwent cystectomy for multifocal or recurrent TCC. Followup examinations were performed at 6-month intervals.

RESULTS

Mean followup in the entire cohort was 49.8 months (median 42). Intraoperative frozen sections obtained from the urethra and distal ureters were negative for TCC and CIS in all patients. Four women (4.7%) had TCC in the remnant urothelium at a mean of 56 months postoperatively. These patients had undergone cystectomy for multifocal or recurrent TCC (4 of 22 or 18%). No secondary TCC was seen in the 63 patients with solitary invasive or nonrecurrent bladder cancer (p <0.05). Urethral recurrence was found in 2 patients (4.3%) 65 and 36 months after orthotopic neobladder surgery, respectively. In the orthotopic group 1 patient (2.1%) had an upper urinary tract tumor 76 months after surgery, while in the nonorthotopic group 1 (2.5%) was found to have an upper urinary tract tumor 48 months postoperatively.

CONCLUSIONS

Recurrent or multifocal TCC may represent a risk factor for secondary TCC of the remnant urothelium after cystectomy. In our series all recurrent tumors were late recurrences (more than 36 months postoperatively). Because the rate of urethral recurrence in the current series corresponds to that reported in men (2% to 6%), urethra sparing cystectomy with orthotopic bladder replacement does not appear to compromise the oncological outcome in women.

Continent urinary diversion

During the last decade continent urinary diversion, especially orthotopic bladder substitution has become increasingly popular following radical cystectomy for bladder cancer. In general, if sphincter sparing surgery is possible, orthotopic bladder substitution is performed, if not then continent catheterisable reservoirs are a viable option. Strict patient selection criteria and improved surgical technique have had a positive influence on outcome, not only on survival but also on quality of life issues. It is becoming increasingly obvious, that a nerve sparing surgical technique not only improves sexual function but also continence. In addition, the length of the intestinal segment has an influence on continence and the degree of metabolic consequences, which are discussed in detail. Postoperative surveillance and instruction of patients is of utmost value for good functional results. Overall patient satisfaction and quality of life seem comparable in the various types of continent urinary diversions, and improved when compared to a urinary stoma. Continent urinary diversion offers a good quality of life with few long-term complications and should be considered the treatment of choice in the majority of patients, independent of sex.

Lokalrezidiv nach radikaler Zystektomie bei Harnblasenkarzinom

The prognosis for patients with local recurrence following cystectomy for urothelial bladder cancer is poor. Only a small proportion of patients with good performance status are candidates for any form of therapy at all. Clinical experience shows that local recurrence is often accompanied or followed by systemic tumor spread. Therefore, palliative systemic chemotherapy is the cornerstone of treatment. Local radiotherapy or local tumor resection is reserved for subgroups of patients and to ease local symptoms or complications. Only a few patients are candidates for multimodal therapeutic approaches with curative intent. Despite such efforts, the survival of patients with local recurrence is limited in nearly all cases.

Urethral recurrence after cystoprostatectomy: Implications for urinary diversion and monitoring

OBJECTIVES

To review our cystoprostatectomy (CP) database to determine the urethral recurrence rate. Urethral recurrence after CP has been reported to occur in up to 10% of patients. Recent data have suggested a much lower incidence. This has important implications when considering the type of urinary diversion and postoperative monitoring.

METHODS

We retrospectively analyzed our single-surgeon, consecutive CP series and determined the urethral recurrence rate and prognostic factors for recurrence. Urethrectomy was performed at CP if the prostatic apical margin was positive for carcinoma. All patients were followed up quarterly for 2 years and then semiannually. Urethral wash cytology was obtained if the patient had an ileal conduit. Cytology and cystoscopy were performed if they had an orthotopic neobladder.

RESULTS

A total of 226 men had undergone radical CP. The mean age for all patients was 69 years. Eight (3.5%) had undergone urethrectomy at CP. The mean follow-up was 42 months for the remaining 218 patients, of whom 108 had an orthotopic neobladder and 110 had supravesical diversion. Of the 218 patients, 8 (3.7%) developed urethral recurrence, 7 (6.4%) in the 110 who had undergone supravesical diversion and 1 in the 108 (0.9%) who had an orthotopic neobladder. Seven patients underwent urethrectomy for the recurrence and had no evidence of disease at last follow-up. One patient died of metastatic transitional cell carcinoma at 61 months.

CONCLUSIONS

In our series, the risk of urethral recurrence after radical CP was low. The risk was substantially lower for patients who had an orthotopic neobladder. Our results show that urethrectomy at CP is rarely necessary because the proximal urethral margin is usually free of cancer. An orthotopic neobladder can therefore be safely considered in most patients. Delayed urethrectomy can be safely performed in those few patients with isolated urethral recurrence without compromising their survival.

The “B-Bladder”—an Ileocolonic Neobladder with a Chimney: Surgical Technique and Long-Term Results

OBJECTIVES

A modified version of the "Le Bag" ileocolonic neobladder with a "Studer"-like ileal chimney (B-bladder) is presented. The surgical technique, perioperative complications, and long-term results, including cancer control and continence, are described.

METHODS

Twenty-nine patients underwent radical cystectomy and urinary diversion to an orthotopic ileocolonic neobladder with an ileal chimney. All operations were done by a single surgeon. Preoperative, perioperative and postoperative data were recorded. Median duration of follow-up was 3.4 years.

RESULTS

The operation was technically successful in all cases. Late complications included recurrent urinary tract infection (17%) and uretero-neobladder anastomotic stricture (3%), both at acceptable rates. Postoperative daytime continence was excellent. Cancer control was satisfactory during follow-up; 11 patients (38%) died of disease progression with distant metastases. Median survival was 71.1 months.

CONCLUSIONS

The B-bladder maintains the simplicity of preparation of the original "Le-Bag" neobladder while gaining the advantages of ureteral anastomosis to an ileal chimney. The incidence of perioperative complications is low and long-term results with regard to cancer control, continence, and complications are excellent.

Standardization of radical cystectomy and pelvic lymph node dissection for bladder cancer: a collaborative group report

PURPOSE

We propose standards for radical cystectomy and pelvic lymph node dissection in the surgical treatment of patients with invasive bladder cancer.

MATERIALS AND METHODS

We compiled the consecutive cystectomy experience of 16 experienced surgeons during the last 3 years (2000 to 2002) from 4 institutions. We evaluated patient, tumor and surgical variables of margin status, extent of pelvic node dissection, number of nodes examined and surgeon volume associated with bladder cancer outcomes.

RESULTS

A total of 1,091 cystectomy cases were evaluated. Surgical margins and number of nodes retrieved correlated with patient age, prior treatments, pathological tumor stage and extent of node dissection, but not surgeon volume.

CONCLUSIONS

Standards for radical cystectomy can be established and achieved by experienced surgeons operating on patients presenting with diverse clinical situations.

Modified ureterosigmoidostomy (Mainz II): a long-term follow-up

OBJECTIVE

To assess the long-term results in patients treated using a modified ureterosigmoidostomy (Mainz II).

PATIENTS AND METHODS

Between 1994 and 1999, 17 patients had their lower urinary tract reconstructed by a ureterosigmoidostomy, modified by reconfiguring the rectum to make a low-pressure reservoir (Mainz II). All patients were followed on a standard protocol. Data were extracted from the database and from a review of the case-notes. In 12 patients the procedure was with a radical cystectomy for carcinoma. Five had a failed conventional ureterosigmoidostomy for bladder exstrophy and therefore proceeded to a Mainz II. The data on continence and complications were retrieved for a retrospective analysis; the mean (range) follow-up was 6.4 (4-8.6) years.

RESULTS

Ten of those with bladder cancer and one in the revision group were continent. Two patients in the revision group had sufficiently severe nocturnal incontinence to require conversion to a colonic conduit. Seven of the 17 patients had hyperchloraemic acidosis, one had pyelonephritis and one had renal stones. There were no anastomotic neoplasms.

CONCLUSION

The Mainz II has a good outcome if used as the primary procedure. In patients with an existing ureterosigmoidostomy who are incontinent, detubularization of the rectosigmoid alone is unlikely to restore continence.

Incidence and location of prostate and urothelial carcinoma in prostates from cystoprostatectomies: implications for possible apical sparing surgery

PURPOSE

Prostatic carcinoma (Pca) at cystoprostatectomy is usually an incidental finding with the majority thought to be clinically insignificant. Most studies have not specifically addressed the location of Pca or the incidence and location of in situ or invasive urothelial carcinoma (Uca) in prostates of cystoprostatectomy specimens. The frequency of involvement of the apex with these processes has clinical implications. Specifically urinary continence following orthotopic diversion may be enhanced by prostate apical sparing. In this study the pathological features of Pca and Uca, and the frequency of apical involvement were investigated in prostates from cystoprostatectomy specimens.

MATERIALS AND METHODS

Whole mounted prostates from 121 consecutive cystoprostatectomy specimens were analyzed. Pca location, tumor volume, grade, stage, surgical margin and pelvic lymph node status of Pcas were assessed. Clinically insignificant Pcas had a volume of less than 0.5 cc without Gleason pattern 4, extracapsular extension, seminal vesicle invasion, lymph node involvement or positive surgical margins. Prostate involvement by Uca or urothelial carcinoma in situ (CIS)/severe dysplasia and its location were assessed.

RESULTS

Of 121 prostates 50 (41%) had unsuspected Pca, of which 24 (48%) were clinically significant. Of Pcas 30 of 50 (60%) involved the apex, including 19 of 24 (79%) that were significant and 11 of 26 (42%) that were insignificant. Of 121 prostates 58 (48%) had Uca involving the prostatic stroma, noninvasive Uca or urothelial CIS/severe dysplasia in the prostatic urethra or periurethral ducts, of which 19 (33%) had apical involvement. Overall only 32 of 121 patients (26%) had no Pca or prostate Uca/CIS and only 45 (37%) had no clinically significant Pca or Uca/CIS in the prostate. However, 74 of the 121 patients (61%) had no prostatic apical involvement by Pca or Uca/CIS and 85 (70%) had no apical involvement by clinically significant Pca or Uca/CIS. Patients with prostatic apical involvement by invasive or in situ Uca uniformly had involvement of more proximal (toward the base) portions of the prostate.

CONCLUSIONS

The majority of prostates from cystoprostatectomies had no involvement of the prostatic apex by Uca or clinically significant Pca. Hence, most patients may be candidates for prostate apical sparing. However, involvement of the apex by Uca in any patient raises concern about procedures that leave portions of the prostate urethra after cystectomy in an effort to improve continence. In candidates for orthotopic neobladder reconstruction removing all of the prostatic urethra and sparing the remainder of the prostatic apex may allow improved preservation of urinary continence with an acceptable low risk of clinical Pca progression. Whether future strategies for preoperative exclusion of apical Pca and intraoperative assessment of more proximal prostate to help exclude apical urothelial disease may identify patients suitable for prostatic apical sparing remains to be determined. The impact on functional outcomes and cancer control also require additional study.

Local Urethral Recurrence After Radical Cystectomy and Orthotopic Bladder Substitution in Women:: A Prospective Study

PURPOSE

We prospectively studied the pathological outcome and incidence of urethral recurrence after radical cystectomy and orthotopic bladder substitution in women.

MATERIALS AND METHODS

Between January 1995 and December 2001, 145 women with a mean age of 50 +/- 8.5 years underwent standard radical cystectomy and orthotopic substitution for bladder cancer. Histopathological examination of the cystectomy specimens was assessed by a single pathologist. Clinically evident pelvic lymphadenopathy, bladder neck and/or vaginal wall involvement, or positive intraoperative frozen section from the urethra were considered contraindications.

RESULTS

One patient died postoperatively of a massive pulmonary embolism. Followup was 12 to 97 months (mean 36, median 55.8). Pathological stage was P1, P2 (superficial muscle invasion), P3a (deep muscle invasion), P3b (perivesical fat infiltration) and P4a in 12, 29, 56, 44 and 4 patients, respectively. Grade was G1 in 61 patients, G2 in 62 and G3 in 22. Lymph nodes were positive in 28 cases and negative in 117. Histopathology of the trigone revealed carcinoma in situ in 11 cases and squamous metaplasia in 7, while results were free of disease in the remainder. At followup isolated urethral recurrence developed in 2 patients (1.4%), in whom definitive pathological findings showed P3a N1 (positive iliac lymph nodes) M0, grade 2 squamous cell carcinoma in 1 and P3b N0M0 tumor associated with trigonal carcinoma in situ in 1. Local pelvic recurrence developed in 18 patients, distant metastasis developed in 6 and the 2 conditions developed in 10. Oncological failure positively correlated with high stage, high grade and positive lymph nodes.

CONCLUSIONS

The rate of urethral recurrence after radical cystectomy and orthotopic bladder substitution in women is low and acceptable and, thus, it justifies the continued performance of this type of diversion. Proper selection of cases is mandatory. Close followup for oncological failure in this group of patients after cystectomy is necessary.

Follow-up strategies and management of recurrence in urologic oncology bladder cancer:

A surveillance program following cystectomy should consider a patient's individual risk for the development of local and distant recurrences and any specific needs related to the urinary tract reconstruction performed (Table 1). Well-documented recurrence patterns following cystectomy are available from many large surgical series and provide the background information needed for tailoring follow-up based on pathologic criteria. Economic issues also must be considered, given that the health care-related expenses of treating and following patients with bladder cancer is twice as much as that expended for the treatment of prostate cancer. Because of the ever-increasing fiscal constraints placed on clinicians, risk-adjusted follow-up strategies are reasonable, but will require prospective evaluation to validate their appropriateness.

Bladder substitution

PURPOSE OF REVIEW

Radical cystectomy and urinary diversion is the accepted standard of care for invasive bladder cancer, with orthotopic neobladders as the preferred method of bladder substitution in male and female patients. Last year's studies and reports on this subject are summarized and reviewed.

RECENT FINDINGS

Today, most patients considered candidates for radical cystectomy, independent of sex, are potential candidates for orthotopic bladder substitution. It has been shown that orthotopic bladder replacement is well tolerated and feasible even in selected patients with locally advanced tumors with or without positive nodes. The complication rates for orthotopic bladder substitutes are similar to, or lower than, the morbidity rates after conduit formation or continent cutaneous diversion. It has been shown that an afferent tubular segment without any antireflux flap-valve-type implantation techniques protects the upper urinary tract adequately for more than a decade. The true impact of the chosen type of urinary diversion on distress symptoms, quality of life and patients' well-being among survivors of bladder cancer remains controversial and requires further clinical investigation.

SUMMARY

The excellent functional outcome and voiding pattern with orthotopic bladder substitution, even in the long-term, argues in favor of this technique as the preferred method for lower urinary tract reconstruction following radical cystectomy for invasive bladder cancer.

Bladder cancer

Bladder cancer is a significant public health problem responsible for more than 130,000 deaths annually worldwide. Disease prevalence is also remarkable, with more than 500,000 patients carrying the diagnosis in the United States alone. Significant progress has been made in understanding the underlying molecular and genetic events in bladder cancer. However, there remains a great need for the development of reliable markers that can provide clinically useful information regarding diagnosis and prognosis and to facilitate the selection of appropriate therapy in the individual patient. Ongoing and future investigation is anticipated to refine treatment of patients with high-risk superficial disease, to determine the role of neoadjuvant and adjuvant chemotherapy for high-risk invasive disease, and to improve the efficacy of chemotherapy for patients with metastatic bladder cancer.