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  • Ureterointestinal anastomosis in urinary diversion – current opinion.
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Please enable cookies in your browser to get the full Trove experience. Skip to content Skip to search. Webster, B. Published Oxford : Isis Medical Media, Language English. Other Authors Webster, G. George D. Goldwasser, B. Benad M. Physical Description ix, p.

Subjects Urinary diversion. Urinary organs -- Surgery. Notes Includes index and bibliographic references. Dewey Number View online Borrow Buy Freely available Show 0 more links Clinicians should inform patients about potential changes in sexual function resulting from bladder cancer treatment and should refer them to appropriate medical professionals for treatment of sexual dysfunction when indicated.

While the data is scant, there is a known harmful impact of pelvic radiation on sexual function in both men and women. Bowel symptoms can include loose stools, diarrhea, hematochezia, or tenesmus. Metabolic and nutritional issues can also result from urinary diversions. Use of the distal ileum may also lead to inadequate absorption of vitamin B12 intrinsic factor complex resulting in megaloblastic anemia or neurological symptoms. There is also a risk for electrolyte abnormalities due to reabsorption of excreted metabolites, with hyperchloremic hypokalemic metabolic acidosis representing the most common abnormality for ileal and colonic segments.

Robotic Cystectomy with Total-intracorporeal Urinary Diversion

Patients need to be informed that medications may be necessary to correct these abnormalities. Several studies have noted a risk of decline in long-term renal function in patients undergoing cystectomy. Utilizing a multidisciplinary approach, clinicians should offer cisplatin-based neoadjuvant chemotherapy to eligible radical cystectomy patients prior to cystectomy.

The Panel advocates cisplatin-based chemotherapy prior to radical cystectomy based predominantly on two large phase III randomized trials that evaluated the effects of NAC versus no NAC on mortality. After an initial reported median follow up of four years, the difference was not statistically significant HR 0. Several other trials were unable to show significant differences in survival; however, many of them used regimens that are no longer used in clinical practice.

Multiple retrospective studies have evaluated predictive biomarkers for response to NAC for MIBC, but none have been prospectively validated. One prospective trial testing MVAC prior to cystectomy in high-risk organ confined bladder cancer with p53 alterations by immunohistochemistry did not find any association with outcome.

However, these have not been prospectively tested and validated, and thus, the Panel does not recommend any at this time. Several retrospective cohort studies suggest that there may not be a significant difference in outcome between GC and MVAC, although these studies cannot be considered as conclusive evidence. The optimal duration of NAC remains undefined.

Spontaneous rupture of continent cutaneous urinary diversion after 25 years

Most studies have evaluated three to four cycles of preoperative chemotherapy over about three months, although several smaller studies have tested shortened intensified regimens using six to eight weeks of chemotherapy. Cisplatin eligibility is a major determinant of candidacy for NAC. New York Heart Association Class III-IV heart failure marked or severe limitation in activity is felt to be exclusionary due to the volume of intravenous fluid required for safe cisplatin administration. Cisplatin-induced peripheral neuropathy is increased in patients with pre-existing sensory neuropathy and may preclude treatment.

Clinicians should not prescribe carboplatin-based neoadjuvant chemotherapy for clinically resectable stage cT2-T4aN0 bladder cancer. Patients ineligible for cisplatin-based neoadjuvant chemotherapy should proceed to definitive locoregional therapy. Expert Opinion.

Downstaging rates in these series appear lower than with cisplatin-based chemotherapy, and comparative data is lacking with either radical cystectomy alone or neoadjuvant cisplatin-based combinations.

AUA Announces Update to its Overactive Bladder Clinical Practice Guideline

In the metastatic setting, carboplatin-based combinations are felt to be inferior based on the results of small randomized trials. Frequent multidisciplinary collaboration between medical oncologists and urologists is critical for timely implementation of integrated therapy. Further delay may decrease the therapeutic benefit of systemic therapy.

No single randomized clinical trial has demonstrated a significant improvement in overall survival with AC.

Four trials reported AC with an associated decreased risk of mortality versus no AC, but no trial reported a statistically significant benefit. The largest trial randomized patients to either immediate adjuvant cisplatin-based combination chemotherapy with either MVAC, dose intensified MVAC, or gemcitabine and cisplatin versus treatment at relapse.

However, immediate treatment did prolong progression-free survival by an estimated 1. All of the AC trials were terminated early, and therefore are underpowered to provide sufficient evidence to state definitively the benefit of AC in MIBC. However, meta-analyses have suggested a possible benefit, albeit based on data of variable quality. In patients who are non-cisplatin-eligible, consideration of referral to clinical trials is reasonable. Clinicians should offer radical cystectomy with bilateral pelvic lymphadenectomy for surgically eligible patients with resectable non-metastatic M0 muscle-invasive bladder cancer.

However, the AHRQ review found that these trials had methodological issues as well as bias in terms of survival comparisons; none evaluated QOL. When performing a standard radical cystectomy, clinicians should remove the bladder, prostate, and seminal vesicles in males and should remove the bladder, uterus, fallopian tubes, ovaries, and anterior vaginal wall in females. Radical cystectomy involves removal of the bladder cystectomy along with the organs at highest risk of harboring tumors that extend beyond the bladder. Thus, in males, this includes the prostate and seminal vesicles, and in females it includes the anterior vaginal wall, uterus, cervix, fallopian tubes, and ovaries.

This is based on Clinical Principle and can be modified as specified below in selected patients see statement Preoperative counseling should be performed for patients who have cancer at the bladder neck or prostatic urethra in men in regards to its possible necessity.

Urinary Diversion, Second Edition: Scientific Foundations and Clinical Practice Karl J. Kreder, III

This can be assessed with a frozen section or final pathology performed at the time of radical cystectomy. Clinicians should discuss and consider sexual function preserving procedures for patients with organ-confined disease and absence of bladder neck, urethra, and prostate male involvement. Preservation of sexual function is safe and feasible in many patients undergoing radical cystectomy. In all patients who desire sexual function preservation and are sexually active, a nerve-sparing procedure should be discussed and offered as long as it will not compromise oncologic control.

Preservation of the ovaries has not been associated with bladder cancer recurrence, and in patients with no known hereditary risk of ovarian or breast cancer, oophorectomy may not be necessary. Data on the safety of prostate preservation is based on limited observational data, indicating the need for improved data on oncologic outcomes and to guide its use and understand efficacy for preserving sexual function.

In patients undergoing radical cystectomy, ileal conduit, continent cutaneous, and orthotopic neobladder urinary diversions should all be discussed. Discussing the pros and cons of each approach is an important component of preoperative education. The Panel emphasized that clinicians should first determine whether or not a patient is a candidate for each of the diversion options, and patients should be counseled regarding all three categories of urinary diversion, if not contraindicated. The suitability of the appropriate bowel segments is a critical determining factor for creation of either a continent cutaneous reservoir or ileal neobladder.

If there is limited available bowel or the patient is unwilling to perform self-catheterization, then an ileal conduit may be the most appropriate diversion. If ileum is not available, then a colon conduit or continent cutaneous diversion may be the preferred diversion choice.

Patients should understand that the ileal conduit is the most commonly utilized urinary diversion type. It is an incontinent diversion using a short segment of distal ileum; preservation of the most distal 15 cm can reduce issues related to absorption of B12, fat soluble vitamins, and bile salts. While there are several different techniques, the principle of connecting a segment of detubularized and folded bowel to the urethra is a common principle. The main rationale for this approach is to mimic as closely as possible the functional aspects and body image of a native bladder.

The last diversion type is the continent cutaneous reservoir. While there are many techniques for creating continent catheterizable reservoirs, the goal is to create a low-pressure reservoir from detubularized bowel with a continent catheterizable channel to the skin that will avoid involuntary efflux of urine. This type of reservoir is used in patients who want to avoid a stomal appliance and preserve continence but either are not candidates for or do not desire a neobladder.

In patients receiving an orthotopic urinary diversion, clinicians must verify a negative urethral margin. Pathologic assessment of urethral margin status at the time of surgery is a best practice to determine if a patient is eligible for an orthotopic diversion. Although prostate involvement is the most significant risk factor for cancer in the urethra, it should not preclude orthotopic diversion, provided that intraoperative frozen section analysis of the urethral margin is without evidence of tumor.

Clinicians should attempt to optimize patient performance status in the perioperative setting.


Given the significant risk of morbidity and prolonged recovery time associated with radical cystectomy, the Panel recommends perioperative patient optimization in accordance with enhanced recovery pathway principles. A substantial percentage of patients with MIBC are malnourished at the time of diagnosis, and preoperative malnutrition is associated with a significant increase in the risk of postoperative mortality.

In addition, all patients undergoing treatment for bladder cancer should receive smoking cessation counseling. This is based on multiple studies supporting the importance of smoking cessation prior to cystectomy, both for reducing postoperative complications and improving long-term oncologic control. While data from prospective RCTs supports not using a bowel preparation prior to colorectal surgery, there is also some data suggesting a potential benefit in the setting of colorectal resection.

During and immediately following surgery, a restrictive transfusion strategy should be utilized in the absence of coronary artery disease or other mitigating factors following American Association of Blood Bank guidelines.