Pathological Guidelines for Orthotopic Urinary Diversion in Women With Bladder Cancer: A Review of the Literature

Recurrent urethral tumor with neuroendocrine differentiation in a female patient after radical cystectomy for bladder cancer

Introduction

Urethral recurrence after radical cystectomy in female patients with bladder cancer is relatively uncommon. Recurrent bladder tumors with neuroendocrine differentiation are extremely rare.

Case presentation

A 71-year-old female patient who underwent radical cystectomy for bladder cancer presented with vaginal bleeding 19 months postoperatively. She was diagnosed with bladder cancer urethral recurrence. Urethral tumor en-bloc resection with the anterior vaginal wall was performed by combining abdominal and vaginal approaches. Pathological examination revealed a recurrent tumor of urothelial bladder cancer containing small-cell carcinoma components.

Conclusion

This case is the first report of a recurrent tumor with small-cell carcinoma in the female urethra after radical cystectomy for pure urothelial carcinoma.

Urethrectomy at the time of radical cystectomy for non-metastatic urothelial carcinoma of the bladder: a collaborative multicenter study

INTRODUCTION

The optimal management of the urethra in patients planned for radical cystectomy (RC) remains unclear. We sought to evaluate the impact of urethrectomy on perioperative and oncological outcomes in patients treated with RC for non-metastatic urothelial carcinoma of the bladder (UCB).

MATERIALS AND METHODS

We assessed the retrospective data from patients treated with RC for UCB of five European University Hospitals. Associations of urethrectomy with progression-free (PFS), cancer-free (CSS), and overall (OS) survivals were assessed in univariable and multivariable Cox regression models. We performed a subgroup analysis in patients at high risk for urethral recurrence (UR) (urethral invasion and/or bladder neck invasion and/or multifocality and/or prostatic urethra involvement).

RESULTS

A total of 887 non-metastatic UCB patients were included. Among them, 146 patients underwent urethrectomy at the time of RC. Urethrectomy was performed more often in patients with urethral invasion, T3/4 tumor stage, CIS, positive frozen section analysis of the urethra, and those who received neoadjuvant chemotherapy, underwent robotic RC, and/or received an ileal conduit urinary diversion (all p < 0.001). Estimated blood loss and the postoperative complication rate were comparable between patients who received an urethrectomy and those who did not. Urethrectomy during RC was not associated with PFS (HR 0.83, p = 0.17), CSS (HR 0.93, p = 0.67), or OS (HR 1.08, p = 0.58). In the subgroup of 276 patients at high risk for UR, urethrectomy at the time of RC decreased the risk of progression (HR 0.58, p = 0.04).

CONCLUSION

In our study, urethrectomy at the time of RC seems to benefit only patients at high risk for UR. Adequate risk assessment of UCB patients' history may allow for better clinical decision-making and patient counseling.

Role of radiotherapy in the management of bladder cancer: Recommendations of the French society for radiation oncology

We present the recommendations of the French society of oncological radiotherapy on the indications and techniques for external beam radiotherapy for bladder cancer.

Orthotopic bladder substitution: Surgical aspects and optimization of outcomes

Objectives

Orthotopic bladder substitution (OBS) is a management option for urinary diversion in men and women undergoing cystectomy. The aim of the procedure is to provide a functional continent urinary reservoir of adequate capacity, compliance and low pressure. We have provided a narrative review of the existing literature and highlighted areas where improvement and standardization can be recommended.

Methods

Literature search included database search for publications from January 1970 to November 2020, using keywords including OBS, bladder reconstruction, neobladder, radical cystectomy, robotic cystectomy, intracorporeal neobladder, surgical technique, patient selection and outcomes.

Results

Due to various factors including indications, operative technique and risk of complications, OBS is an enormous undertaking and commitment for patients, surgeons and health professionals involved in the care pathway. The main considerations for patient selection, the technical elements of the procedure and the rationale behind these are discussed. Previously considered to be a choice for a select few, the inclusion criteria have expanded over the last decade. Similarly, surgical techniques including the choice and configuration of bowel segments, construction of anastomosis and nerve or organ sparing procedures have evolved over the years. Minimally invasive laparoscopic and robotic assisted surgery has added further perspectives to the existing literature on OBS. Understanding the principles of operative techniques and assessing the best evidence to influence patient management is crucial as it has a major impact on clinical outcomes. Peri‐ and post‐operative care, focused on the prevention of complications and morbidity, affects long‐term functional and oncological outcomes, which ultimately dictates the quality of life.

Conclusions

This concise overview of OBS literature highlights the importance of pre‐operative, peri‐operative, and post‐operative aspects with regards to the optimization of patient care. To achieve the best results, meticulous attention should be paid in all these areas, surgical and multi‐disciplinary. Patient education and counseling, with shared decision making are central to the success of the procedure.

Recommendations for planning and delivery of radical radiotherapy for localized urothelial carcinoma of the bladder

PURPOSE

Curative radio-chemotherapy is recognized as a standard treatment option for muscle-invasive bladder cancer (MIBC). Nevertheless, the technical aspects for MIBC radiotherapy are heterogeneous with a lack of practical recommendations.

METHODS AND MATERIALS

In 2018, a workshop identified the need for two cooperative groups to develop consistent, evidence-based guidelines for irradiation technique in the delivery of curative radiotherapy. Two radiation oncologists performed a review of the literature addressing several topics relative to radical bladder radiotherapy: planning computed tomography acquisition, target volume delineation, radiation schedules (total dose and fractionation) and dose delivery (including radiotherapy techniques, image-guided radiotherapy (IGRT) and adaptive treatment modalities). Searches for original and review articles in the PubMed and Google Scholar databases were conducted from January 1990 until March 2020. During a meeting conducted in October 2020, results on 32 topics were presented and discussed with a working group involving 15 radiation oncologists, 3 urologists and one medical oncologist. We applied the American Urological Association guideline development's method to define a consensus strategy.

RESULTS

A consensus was obtained for all 34 except 4 items. The group did not obtain an agreement on CT enhancement added value for planning, PTV margins definition for empty bladder and full bladder protocols, and for pelvic lymph-nodes irradiation. High quality evidence was shown in 6 items; 8 items were considered as low quality of evidence.

CONCLUSION

The current recommendations propose a homogenized modality of treatment both for routine clinical practice and for future clinical trials, following the best evidence to date, analyzed with a robust methodology. The XXX group formulates practical guidelines for the implementation of innovative techniques such as adaptive radiotherapy.

Prospective evaluation of definitive chemoradiotherapy with volumetric modulated arc therapy in patients with muscle invasive carcinoma of urinary bladder

Introduction

Concurrent chemoradiotherapy (CTRT) remains one of the treatment options in patients with muscle invasive bladder cancer (MIBC) unwilling/unsuitable for radical surgery. We evaluated the role of volumetric modulated arc therapy (VMAT) in MIBC patients treated with definitive CTRT.

Material and methods

25 patients of histologically proven transitional cell MIBC (T2–T4a, N0, M0) unwilling/unsuitable for radical surgery (after maximal transurethral resection of bladder tumour) were recruited in this prospective study. Primary clinical target volume (CTV) consisted of the gross tumour and whole bladder. Primary planning target volume (PTV) and nodal PTV were prescribed 60 Gy and 54 Gy (both in 30 fractions). Concurrent chemotherapy was cisplatin (40 mg/m²) weekly. Acute toxicities were assessed as per Common Terminology Criteria for Adverse Events (CTCAE) version 4.0. Survival estimates were done from the date of registration using the Kaplan-Meier method.

Results

Median age was 70 years (37–80 years). Median overall treatment time was 45 days (44–51). Median number of chemotherapy cycles was 5 (range 3–6). 5 (20%) and 4 (16%) patients respectively suffered from acute grade ≥ 2 gastrointestinal and grade ≥ 2 genitourinary toxicities during treatment. One patient each had grade 3 anaemia and neutropenia. At a median follow-up of 34 months (10–45 months), 3-year progression-free survival and overall survival were 65.6% and 81.2% respectively. 3-year distant metastasis-free survival was 90.5%. Bladder preservation rate at 3 years was 68%.

Conclusions

Definitive CTRT with VMAT is well tolerated in patients with MIBC unsuitable for surgery and yields decent survival and bladder preservation outcome.

Radical Cystectomy in Female Patients - Improving Outcomes

PURPOSE OF REVIEW

To review the methods of improving surgical, oncological, and functional outcomes in women with bladder cancer treated with radical cystectomy.

RECENT FINDINGS

Οrthotopic urinary diversion (ONB) is a safe option for well-selected women as it combines high rates of daytime and nighttime continence with exceptional oncologic outcomes. It is considered safe even for patients with limited lymph node disease and trigone involvement, as long as a preoperative biopsy of the bladder neck or an intraoperative frozen section analysis of distal urethral margin rules out malignant disease. Nerve-sparing techniques have shown promising results. For well-selected patients with early invasive disease, sparing of internal genitalia has proven to be oncologically safe. Yet, generally accepted and evidence-based oncological and functional follow-up schemes for women after radical cystectomy are still lacking. Properly designed prospective studies are needed with adequate number of participants in order to safely conclude about a broader use of pelvic organ-sparing cystectomy.

Treatment and outcomes of urethral recurrence after orthotopic neobladder replacement in patients with bladder cancer - practice in a single centre

Objectives

To report on the treatment of urethral recurrence after orthotopic urinary diversion at our institution.

Methods

We retrospectively reviewed clinical information of urethral recurrence in patients who underwent radical cystectomy and orthotopic urinary diversion between January 1998 and January 2013.

Results

Of 341 patients, 282 presented for follow-up (median follow-up: 56 months; range: 1–174 months). Eight patients developed local recurrence of urothelial cancer after radical cystectomy. The rate of urethral recurrence (1.4%) in female patients who underwent orthotopic urinary diversion was lower than in male patients (3.3%). The median (range) time to recurrence was 33 (6–120) months after radical cystectomy and orthotopic urinary diversion. Recurrences were treated by transurethral resection of tumour, urethrectomy, neobladder resection, revision of urinary diversion, adjuvant chemotherapy, or radiation therapy, based on individual circumstances. Survival analysis showed that 5-year cancer-specific survival was significantly higher in patients with urethral recurrence alone (83.3%), compared with patients with other recurrences, including pelvic/abdomen recurrence and distant metastasis (26.8%).

Conclusions

En bloc urethrectomy and revision of urinary diversion remain the principle surgical choices. Selection of transurethral tumour resection was based on tumour stage and was used in carefully chosen patients. Cancer-specific survival might depend on multidisciplinary therapy.

Management of Voiding Dysfunction After Female Neobladder Creation

PURPOSE OF REVIEW

Functional complications after orthotopic neobladder urinary diversion (ONB), including urinary incontinence and urinary retention, present unique challenges. The purpose of this review is to outline contemporary treatment options for voiding dysfunction after ONB in females.

RECENT FINDINGS

Meticulous surgical technique in the form of urethral nerve-sparing has been shown to play an important role in maintaining continence, as has sparing the uterus when possible. Data supporting the effectiveness of lifestyle measures, urethral bulking, pubovaginal slings, and transobturator slings in the treatment of urinary incontinence are widely variable and limited to case reports. Urinary retention is still most effectively managed with self-catheterization. Voiding dysfunction after ONB can be devastating. Recent advances focus on improving surgical techniques to decrease the risk of incontinence and retention, as post-operative management options are limited.

Radical cystectomy: do we need standardization?

INTRODUCTION

The first series of radical cystectomy with a definition of surgical landmarks was published in 1949 and was characterized by a high perioperative mortality and a 5-year survival rate around 50%. Decades later, nevertheless many surgical progresses were made and the perioperative mortality dropped to 2,5%, this had not lead to an improvement of long term survival rates, also because a standardization of the procedure is still missing. Areas covered: Radical cystectomy is performed with different surgical techniques obmitting a standardization. The comparability of many studies is therefore difficult or havely compromised. A paragon with other diciplines was made emphazing that there high surgical quality is defined, measured and controlled. A systematic literature search was made selecting finally 76 article adressing this issue. Expert commentary: Surgical guidelines in uro-oncology are vague and a definition of surgical quality is missing. A view outside of the box could be very helpful. This is a plea for a change.

Systematic Review on the Fate of the Remnant Urothelium after Radical Cystectomy

CONTEXT

Urothelial carcinoma is considered a pan-urothelial disease. As such, the remnant urothelium in the upper urinary tract and urethra following radical cystectomy (RC) remains at risk for secondary urothelial tumors (SUTs).

OBJECTIVE

To describe the incidence, diagnosis, treatment, and outcomes of patients with SUTs after RC.

EVIDENCE ACQUISITION

A systematic search was conducted using PubMed database according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to identify studies between 1970 and 2016 reporting on malignant diseases of the urothelium after RC for bladder cancer. The search strategy separated between upper and lower tract urothelial tumors.

EVIDENCE SYNTHESIS

Of a total of 1069 studies, 57 were considered for evidence synthesis. SUTs occured in approximately 4-10% of patients after RC. Carcinoma in situ of the bladder, a history of nonmuscle invasive bladder cancer, and tumor involvement of the distal ureter are the strongest risk factors for secondary upper tract tumors. Risk factors for secondary urethral tumors represent urothelial malignancy in the prostatic urethra/prostate and bladder neck (in women), nonorthotopic diversions, and positive findings on permanent sections. The majority of patients (84%) with SUTs, presented with urothelial recurrence without evidence of metastasis. Of those, 84.0% were treated with surgery, 10.5% with systemic chemotherapy and/or radiotherapy, and 5.6% with topical chemotherapy and/or immunotherapy. After a median follow-up of 91 mo (range: 26-155), 65.9% of patients died of disease and 21.5% died of other causes. Detection and treatment of SUTs at an asymptomatic stage can reduce the risks of cancer-specfific and overall mortality by 30%. A limitation of the study is that the available data were retrospective.

CONCLUSIONS

SUTs are rare oncological events and most patients have an adverse prognosis despite absence of distant disease at diagnosis. Therefore, surveillance of the remnant urothelium should be implemented for patients with histological features of panurothelial disease as it may improve timely detection and treatment.

PATIENT SUMMARY

Secondary tumors of the renal pelvis, ureters, and urethra occur in approximately 4-10% of patients after radical removal of the bladder for bladder cancer. These patients' prognoses are reduced, likely due to delayed diagnosis. Therefore, routine surveillance might be important to detect tumors at an early stage.

Evidence from the 'PROspective MulticEnTer RadIcal Cystectomy Series 2011 (PROMETRICS 2011)' study: how are preoperative patient characteristics associated with urinary diversion type after radical cystectomy for bladder cancer?

PURPOSE

The aim of this study was to examine preoperative patients' characteristics associated with the urinary diversion (UD) type (continent vs. incontinent) after radical cystectomy (RC) and UD-associated postoperative complications.

MATERIALS

In 2011, 679 bladder cancer patients underwent RC at 18 European tertiary care centers. Data were prospectively collected within the 'PROspective MulticEnTer RadIcal Cystectomy Series 2011' (PROMETRICS 2011). Logistic regression models assessed the impact of preoperative characteristics on UD type and evaluated diversion-related complication rates.

RESULTS

Of 570 eligible patients, 28.8, 2.6, 59.3, and 9.3% received orthotopic neobladders, continent cutaneous pouches, ileal conduits, and ureterocutaneostomies, respectively. In multivariable analyses, female sex (odds ratio [OR] 3.9; p = 0.002), American Society of Anesthesiologists score ≥3 (OR 2.3; p = 0.02), an age-adjusted Charlson Comorbidity Index ≥3 (OR 4.1; p < 0.001), and a positive biopsy of the prostatic urethra in the last transurethral resection of the bladder prior to RC (OR 4.9; p = 0.03) were independently associated with incontinent UD. There were no significant differences in 30- and/or 90-day complication rates between the UD types. Perioperative transfusion rates and 90-day mortality were significantly associated with incontinent UD (p < 0.001, respectively). Limitations included the small sample size and a certain level of heterogeneity in the application of clinical pathways between the different participating centers.

CONCLUSIONS

Within this prospective contemporary cohort of European RC patients treated at tertiary care centers, the majority of patients received an incontinent UD. Female sex and pre-existing comorbidities were associated with receiving an incontinent UD. The risk of overall complications did not vary according to UD type.

Treatment and Outcomes of Urethral Recurrence of Urinary Bladder Cancer in Women after Radical Cystectomy and Orthotopic Neobladder: A Series of 12 Cases

Introduction: The incidence, treatment, and outcome of urethral recurrence (UR) after radical cystectomy (RC) for muscle-invasive bladder cancer with orthotopic neobladder in women have rarely been addressed in the literature. Patients and Methods: A total of 12 patients (median age at recurrence: 60 years) who experienced UR after RC with an orthotopic neobladder were selected for this study from a cohort of 456 women from participating institutions. The primary clinical and pathological characteristics at RC, including the manifestation of the UR and its treatment and outcome, were reviewed. Results: The primary bladder tumors in the 12 patients were urothelial carcinoma in 8 patients, squamous cell carcinoma and adenocarcinoma in 1 patient each, and mixed histology in 2 patients. Three patients (25%) had lymph node-positive disease at RC. The median time from RC to the detection of UR was 8 months (range 4-55). Eight recurrences manifested with clinical symptoms and 4 were detected during follow-up or during a diagnostic work-up for clinical symptoms caused by distant metastases. Treatment modalities were surgery, chemotherapy, radiotherapy, and bacillus Calmette-Guérin urethral instillations. Nine patients died of cancer. The median survival after the diagnosis of UR was 6 months. Conclusions: UR after RC with an orthotopic neobladder in females is rare. Solitary, noninvasive recurrences have a favorable prognosis when detected early. Invasive recurrences are often associated with local and distant metastases and have a poor prognosis.

A feasibility study of peritoneum preservation in radical cystectomy with extraperitonealization of orthotopic neobladder for invasive high-grade bladder cancer: a preliminary analysis

OBJECTIVE

To describe a technique for radical cystectomy with extraperitonealization of orthotopic neobladder (RCEN) that reduces bowel-related complications by preservation of the peritoneum.

MATERIALS AND METHODS

Fifteen patients with non-metastatic bladder cancer underwent RCEN by a peritoneum preserving technique. The study included 13 patients with T1 high-grade bladder cancer and 2 with T2a bladder cancer. To compare perioperative outcomes including bowel-related complications, we also reviewed 15 patients who underwent traditional cystectomy with ileal Studer neobladder who were matched for age, sex, body mass index, American Society of Anesthesiologists (ASA) score, tumor stage, tumor grade, tumor size, and location. Female genital organs were preserved in five female patients who underwent the RCEN technique.

RESULTS

There was no significant difference between the two cohorts (RECN vs. traditional technique) with respect to age, body mass index, ASA score, or tumor characteristics. The mean operative time was similar between the two groups. The patients who underwent RECN exhibited earlier recovery of normal gas pattern on plain abdominal X-ray during the postoperative period and an earlier resumption of normal diet. The mean hospital stay was shorter in the RECN group than the traditional group.

CONCLUSIONS

The RECN technique preserving the whole peritoneum is a feasible approach that significantly reduces bowel-related complications in selected patients.

ICUD-EAU International Consultation on Bladder Cancer 2012: Radical cystectomy and bladder preservation for muscle-invasive urothelial carcinoma of the bladder

CONTEXT

New guidelines of the International Consultation on Urological Diseases for the treatment of muscle-invasive bladder cancer (MIBC) have recently been published.

OBJECTIVE

To provide a comprehensive overview of the current role of radical cystectomy (RC) in MIBC.

EVIDENCE ACQUISITION

A detailed Medline analysis was performed for original articles addressing the role of RC with regard to indication, timing, surgical extent, perioperative morbidity, oncologic outcome, and follow-up. The analysis also included radiation-based bladder-preserving strategies.

EVIDENCE SYNTHESIS

The major findings are presented in an evidence-based fashion and are based on large retrospective unicenter and multicenter series with some prospective data.

CONCLUSIONS

Open RC is the standard treatment for locoregional control of MIBC. Delay of RC is associated with reduced cancer-specific survival. In males, standard RC includes the removal of the bladder, prostate, seminal vesicles, and distal ureters; in females, RC includes an anterior pelvic exenteration including the bladder, entire urethra and adjacent vagina, uterus, and distal ureters. A procedure sparing the urethra and the urethra-supplying autonomous nerves can be performed in case of a planned orthotopic neobladder. Further technical variations (ie, seminal-sparing or vaginal-sparing techniques) aimed at improving functional outcomes must be weighed against the risk of a positive margin. Laparoscopic surgery is promising, but long-term data are required prior to accepting it as an option equivalent to the open procedure. Lymphadenectomy should remove all lymphatic tissue around the common iliac, external iliac, internal iliac, and obturator region bilaterally. Complications after RC should be reported according to the modified Clavien grading system. In selected patients with MIBC, bladder-preserving therapy with cystectomy reserved for tumor recurrence represents a safe and effective alternative to immediate RC.

Australian & New Zealand Faculty of Radiation Oncology Genito-Urinary Group: 2011 consensus guidelines for curative radiotherapy for urothelial carcinoma of the bladder

Curative radiotherapy, with or without concurrent chemotherapy, is recognized as a standard treatment option for muscle-invasive bladder cancer. It is commonly used for two distinct groups of patients: either for those medically unfit for surgery, or as part of a 'bladder preserving' management plan incorporating the possibility of salvage cystectomy. However, in both situations, the approach to radiotherapy varies widely around the world. The Australian and New Zealand Faculty of Radiation Oncology Genito-Urinary Group recognised a need to develop consistent, evidence-based guidelines for patient selection and radiotherapy technique in the delivery of curative radiotherapy. Following a workshop convened in May 2009, a working party collated opinions and conducted a wide literature appraisal linking each recommendation with the best available evidence. This process was subject to ongoing re-presentation to the Faculty of Radiation Oncology Genito-Urinary Group members prior to final endorsement. These Guidelines include patient selection, radiation target delineation, dose and fractionation schedules, normal tissue constraints and investigational techniques. Particular emphasis is given to the rationale for the target volumes described. These Guidelines provide a consensus-based framework for the delivery of curative radiotherapy for muscle-invasive bladder cancer. Widespread input from radiation oncologists treating bladder cancer ensures that these techniques are feasible in practice. We recommend these Guidelines be adopted widely in order to encourage a uniformly high standard of radiotherapy in this setting, and to allow for better comparison of outcomes.

Ileal neobladder in women with bladder cancer: cancer control and functional aspects

PURPOSE OF REVIEW

Radical cystectomy and urinary diversion is the accepted standard of care for invasive bladder cancer. Although orthotopic neobladder is the preferred method of urinary diversion in men, less experience is available for women. Recent studies and reports on this subject are summarized and reviewed.

RECENT FINDINGS

Urethra-sparing cystectomy in women and orthotopic urinary diversion can be performed safely in appropriately selected women with invasive bladder cancer. Excellent oncological outcomes can be expected with a minimal risk of urethral recurrence in case of negative frozen section of the proximal urethra. Orthotopic neobladder diversion offers excellent clinical and functional results, and should be the diversion of choice in most women following cystectomy. Female sexual dysfunction can be avoided in patients who received neurovascular preservation, although quality of life declined in women who had undergone non-nerve-sparing radical cystectomy.

SUMMARY

Urethra-sparing cystectomy does not compromise the oncologic outcome in women with bladder cancer. The excellent functional outcome and voiding pattern with orthotopic urinary diversion argues in favor of this technique as the preferred method for lower urinary tract reconstruction after radical cystectomy. Nerve-sparing radical cystectomy preserves female sexual function and improves quality of life.

Improving selection of appropriate urinary diversion following radical cystectomy for bladder cancer

Radical cystectomy represents the gold-standard of treatment for invasive bladder cancer. Following cystectomy, various options for urinary diversion may be offered to patients. This article represents an overview of the history of urinary diversion, explains the current selection criteria used at one of the most experienced bladder cancer centers worldwide, and provides an update on the current understanding of continence mechanisms. Furthermore, we review the current literature on quality of life for patients with different forms of urinary diversion. Excellent functional results can be achieved with continent forms of urinary diversion. It is important to consider the relative and absolute contraindications when choosing any form of urinary diversion. Proper patient selection and thorough standardized preoperative counseling is critical in achieving optimal results.

Surveillance strategies after definitive therapy of invasive bladder cancer

Following definitive therapy for muscle invasive bladder cancer, patients remain at risk for local and distant recurrence. Additionally, recurrences can result from formation of new tumours elsewhere in the urinary tract. We review patterns of recurrence and the prognosis associated with recurrence. Optimal surveillance strategies are discussed.

Oncological and functional outcomes of radical cystectomy and orthotopic bladder replacement in women

OBJECTIVE

To report oncological and functional results in women undergoing radical cystectomy and orthotopic bladder replacement.

MATERIALS AND METHODS

The charts of all women undergoing bladder replacement after radical cystectomy at UCSF through April 2008 were reviewed. Pathologic characteristics, survival (overall and disease-specific), and urinary functional outcomes are reported. Survival was estimated using Kaplan-Meier methods, and Cox proportional hazards regression analyses were performed to determine factors associated with incontinence, retention, and mortality.

RESULTS

Fifty-six women with a mean follow-up of 35 months were analyzed. The cancer recurrence rate was 32%. Kaplan-Meier estimated 5-year recurrence-free, cancer-specific, and overall survival were 54%, 57%, and 47%, respectively. Pathologic lymph node status (HR 14.2, P <.001) and age at diagnosis (HR 1.7, P = .04) were the only clinical or pathologic characteristics significantly associated with survival. The overall continence rate (no pads) was 57%. Hypercontinence occurred in 24% of patients.

CONCLUSIONS

With careful patient selection and usage of urethral frozen section, rates of local recurrence are low. Overall rates of incontinence (43%) and hypercontinence (24%) are similar to those previously reported. When pathologically organ-confined, women have an excellent disease-specific survival. Orthotopic bladder replacement is a safe and effective form of urinary diversion after radical cystectomy in women.

Current trends in the management of bladder cancer

This article provides a review of bladder cancer etiology, diagnosis, and management for WOC nurses. Bladder cancer incidence continues to rise yearly in the United States, and patients with bladder cancer comprise some of the most challenging cases in urologic oncology. Nurses are involved with all aspects of the processes of care for the patient with bladder cancer, from initial diagnosis and treatment to postsurgical care and follow-up. For nonmuscle invasive bladder cancer, treatment includes transurethral resection followed by intravesical chemotherapy or immunotherapy to prevent recurrence or progression. Radical cystectomy along with chemotherapy protocols provides a survival advantage for muscle invasive bladder cancer, although the timing of chemotherapy remains controversial. Numerous factors are considered when determining the type of urinary diversion used at the time of radical cystectomy, but patient, family, surgeon, and nursing input are essential for preserving an optimal health-related quality of life and reducing morbidity. Patients with metastatic bladder cancer are generally treated with a cisplatin-based chemotherapy but continue to have a poor prognosis. Newer therapies involving novel molecular-targeted agents provide hope for the future for patients with metastatic disease.

Clinical experience in a modified Roux-Y-shaped sigmoid neobladder: assessment of complications and voiding patterns in 43 patients

OBJECTIVE

To evaluate the complications and urinary voiding patterns in patients with a new Roux-Y-shaped continent neobladder, using a modified sigmoid pouch.

PATIENTS AND METHODS

Between June 2003 and July 2008, 43 patients (26 men and 17 women, mean age 69.5 years) underwent a modified Roux-Y-shaped sigmoid continent neobladder reconstruction after radical cystectomy. The surgical procedures involved the construction of a Roux-Y-shaped sigmoid pouch, making an antifeces-refluxing valve into the sigmoid urine reservoir and ureterosigmoidostomy using the Leadbetter method. This pouch method has not been described before. The patients' clinical, biochemical, radiological and urodynamic variables were assessed.

RESULTS

During the mean (range) follow-up of 24 (6-65) months, there were no deaths related to the procedure. In 16% of the patients, early complications occurred, whereas 12% had late complications. There were no cases with local recurrence and metastasis. Routine electrolyte evaluation revealed a slight metabolic acidosis in six patients (14%). Hypovitaminosis B(12) did not occur in any patients. All patients were continent in the daytime and night-time continence was poor in eight patients (19%). The mean (sd, range) neobladder capacity and residual urine volume was 330 (110, 120-410) mL and 48 (26, 25-80) mL, respectively. Moreover, the maximum urinary flow rate was 9.2-25.3 mL/s.

CONCLUSION

The modified Roux-Y-shaped sigmoid neobladder replacement provides a new simple surgical procedure with low complication rates. The procedure offers comparatively satisfactory daytime continence with low postvoid residual urine volumes and voiding patterns. This technique is a valid alternative to continent urinary diversion.

Orthotopic ileal neobladder reconstruction in patients with recurring bladder cancer after renal transplantation--a report of two cases and a review of the literature

Renal transplant recipients have a high risk of developing multiple and invasive urothelial tumors because of long-term immunosuppression and infections with oncogenic viruses in China. However, treatment of renal transplant recipients who developed invasive bladder tumor is challenging. We aimed to evaluate the efficacy and safety of orthotopic ileal neobladder reconstruction following radical cystectomy in renal transplant recipients. Orthotopic ileal neobladder reconstruction and preservation of the transplanted kidney were performed in two patients after one and 36 months of transplantation, respectively. One recipient was lacking a bladder because of prior cystectomy before the transplantation, and the other developed multiple and invasive bladder cancer after the transplantation. During the 14-month and seven-yr follow-up postoperation, no serious complications occurred except slight hydronephrosis in one patient. No rejection and graft dysfunction occurred in both patients with reduced dosage of immunosuppressants, and serum creatinine as a marker of renal function remained stable. Urinary continence was satisfactory during the day and night with voluntary voiding. Our experience showed that radical cystectomy and orthotopic ileal neobladder reconstruction in transplant patients with stable renal function is a safe and effective way to provide better quality of life, satisfactory urinary diversion and preservation of renal function simultaneously.

Bladder cancer survivals in New South Wales, Australia: why do women have poorer survival than men?

OBJECTIVE

To investigate factors that most influenced survival from bladder cancer in New South Wales, Australia (NSW) and to consider the impact of changes in coding practices on the reporting the of bladder cancer outcomes.

PATIENTS AND METHODS

All NSW cases of bladder cancer diagnosed between 1980 and 2003 were followed to the end of 2004 (17 923 cases). Survival analysis was undertaken using Kaplan-Meier unadjusted disease-specific survival and adjusted disease-specific survival using Cox proportional hazards regression modelling. This analysis was unique in that it modelled the effect of sex, age, country of birth, socio-economic status (SES), histological type, extent of disease and period of diagnosis on survival from bladder cancer in NSW.

RESULTS

After adjusting for sex, age, extent of disease, SES, period of diagnosis and histological type, the likelihood of death was 11% (95% confidence interval, CI 5-18%) higher in females than in males, with case fatality most influenced by age at diagnosis, extent of disease, and histological type. When the analysis was repeated for cases with a method 6 (i.e. coding undertaken in the registry after examination of the pathology report, which would enhance accuracy), the likelihood of death was 13% (95% CI 5-21%) higher in females than in males.

CONCLUSIONS

The NSW analysis controls for variability in coding, extent of disease at diagnosis and histological type of cancer. The analysis shows significantly lower survival from bladder cancer in NSW women compared with men, with no improvement in survival from 1980 to 2003. Possible reasons for the lower survivals in women, the lack of improvement in survival and coding differences in jurisdictions are discussed.

Urethral recurrence in a woman after continent orthotopic urinary diversion for bladder cancer

We describe a 55-year-old woman with a urethral recurrence of transitional cell carcinoma of her bladder 4 years after she underwent radical cystectomy with negative margins and no evidence of invasion of the bladder neck, anterior vaginal wall, or proximal urethra. This was the first urethral recurrence in an appropriately selected female patient at our institution. This report emphasizes the need for long-term follow-up in patients after radical cystectomy and the need for guidelines for appropriate selection of female patients for continent orthotopic urinary diversion.

[Perspectives in urinary diversion]

"Perspectives in Urinary Diversion" was the title of a presentation held during the opening session of the 56th annual meeting of the German Urological Association in Hamburg on September 21, 2006. It focused on the balance between obstruction and reflux of ureters implanted in diverted intestinal segments, the choice of intestinal segments for orthotopic pouches, orthotopic diversion in the female, the status of rectal diversions, and alternatives to the use of intestinal segments.