الفهرس 
EPIDEMIOLOGY AND PATHOLOGY OF URINARY BLADDER CANCEROnly 14 pages are availabe for public view
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Abstract
B
ladder cancer is the fourth most common cancer in men and the eighth most common in women. It is primarily found in older persons, with approximately 80 percent of new cases occurring in persons 60 years or older. Bladder cancer is about three times more common in men (one in 27) than women (one in 85). It is more prevalent in white persons; however, because of delayed diagnosis, mortality rates are higher in black persons.
Radical cystectomy with pelvic lymphadenectomy is the standard treatment for muscle-invasive bladder cancer (stage T2 and above). Long-term, disease-free survival rates of up to 70 percent can be achieved if pathology shows no extravesical diseases.
Almost of patient undergo Radical cystectomy require urinary diversion. The goals of urinary diversion after cystectomy have evolved from simple diversion and protection of the upper tracts to functional and anatomic restoration as close as possible to the natural preoperative state.
Ileal conduit diversion remains the method most commonly used in conjunction with radical cystectomy for reconstructing the urinary tract. It is technically easier than continent reconstruction. However, several studies confirm a high incidence of upper urinary tract complications.
For continent urinary diversion, a tapered or stapled ileal segment or the appendix should be used as the outlet. Most reconstructive surgeons have abandoned the continent Kock ileal reservoir, largely because of the significant complication rate associated with the intussuscepted nipple valve.
The orthotopic reservoir should be considered today the gold standard with which other forms of diversion are compared. Orthotopic diversion can be safely offered to both male and female patients undergoing cystectomy. In addition, data suggest that an option of a neobladder diversion may decrease the physician’s reluctance to perform cystectomy earlier for bladder cancer at a more curable stage and increase the patient’s acceptance. With this form of diversion, it is thought that patients with bladder cancer as well as their physicians may be encouraged toward earlier and more aggressive forms of therapy with cystectomy, when cure and ultimately survival are greatest.
After urinary diversion close follow up to the patient help to detect early and late complications and give us the chance to manage any of these complications.
RC and subsequent urinary diversion has been assessed the most difficult surgical procedure in the field of urology. They are also the most difficult laparoscopic and robotic procedures to perform. The surgical mor¬bidity following RC is significant and, when strict reporting guidelines are used, much higher than pre¬viously published. Accurate reporting of postopera¬tive complications is essential for patient counseling, combined-modality treatment planning, clinical trial design, assessment of surgical success and for perioperative patient education.
In the long run, a conduit must be expected to develop complications in at least 60% of patients and almost 40% will require surgical reintervention. These complications can occur up to 20 years after surgery, emphasizing the need for more long-term studies to determine the full morbidity spectrum. This must be considered particu¬larly in regard to newer forms of urinary diversion. One might even raise the provocative question of whether the time honored gold standard of urinary diversion, the conduit is really golden, safe and simple.
Urinary diversion using segments of bowel is not inherently damaging to the kidneys. In general, renal function after construction of continent detubularized reservoirs compares favorably with ileal conduit diver¬sion, although the collected data is insufficient to recommend one form over another. There remains a long-term risk of renal deterioration, which is often asymptomatic, and thus close follow-up is necessary for all patients who have undergone urinary diversion in order to identify correctable causes early. Those with pre-existing renal pathology before surgery seem to be at greatest risk of postoperative renal deterioration. Serum creatinine is an imprecise measure of renal function; isotopic GFR measurement can detect renal function deterioration most accurately and at an early stage. Early interven¬tion for physical obstruction often results in a sustained improvement in renal function.
Appropriate patient selection and adherence to proper surgical technique are of paramount importance in preventing surgical complications of urinary diversion. Complications can be broadly divided into those related to bowel, conduit or reservoir, stoma and ureterointestinal anastomosis. Each type of urinary diversion has unique characteristics predisposing to certain surgical complications as well as similarities related to intestinal surgery. With conduit urinary diversions, problems related to the stoma such as stomal stenosis and parastomal hernia present not uncommonly. With continent cutaneous diversion, complications include difficulties with catheterizing of the efferent limb, formation of pouch stones and urinary leakage. With orthotopic neobladder formation, voiding dysfunction manifesting as incontinence or hypercontinence may present unique challenges in patient management. Increased surgical experience and technical refinements have led to decreasing surgical complication rates for all types of diversion in contemporary series.
Regarding complications, including UTIs, there is a lack of evidence concerning the best way to replace lower urinary tract integrity after cystectomy. Thus, additional research is required to determine the incidence of infectious and other complications in patients with different types of urinary diversion and the preferable treatment that should be instituted.
Evidence suggests an association between volume (rate of cystectomy operation) and outcome in cystectomy procedures for invasive bladder cancer. The challenge of optimum care for elderly patients with comorbidities is best mastered at a high-volume hospital by high-volume surgeons. This applies more so to the urinary diversion because although RC and urinary diversion are two steps of one operation, almost 75% of all complications stem from the diversion.