Continent and incontinent urinary diversion, bladder sparing approaches

Czech version

Authors: A. Čermák; D. Pacík; V. Vít
Published in: Urol List 2012; 10(3): 34-43

Overview

Bladder cancer represents the second most common malignant disease in Europe. The invasive and locally advanced bladder cancers are both urological malignant diseases associated with high mortality rate. The standard surgical treatment for most patients with infiltrating bladder cancer without any marks of generalization includes radical cystectomy. Since radical cystectomy is an extensive surgery (mortality in European studies around 3.7%, early post-operative morbidity 30%) there is a tendency to replace it by less effective but also less demanding therapeutic modalities in elderly patients and patients in whom surgery represents a significant risk. The collective urinary tract has three functions: the one of transportation, storage and evacuation. The individual segments of urinary collective tract are morphologically and functionally inter-related. In case one of the segments is absent (urinary bladder in case of cystectomy, which ensures both storage and evacuation), its function has to be replaced artificially. This substitutive method is called urinary diversion. Ideally the substitution of bladder enables to secure both of its functions – storage and evacuation – in less ideal cases at least replacing the emptying function. Specific segments of gastrointestinal tract are used for urinary diversion. There are several techniques for urinary diversion available. The choice of technique in individual patients is based on objective parameters and surgeon’s preferences. The major objective of any approach is the preservation of physiologic renal function and smooth urinary evacuation if possible. Each choice should be considered individually, based on the objective parameters, including size, localization and biological potential of the tumour, anatomic factors, the overall patient status and comorbidities. The subjective factors include the individual centre and surgeon experience. Of great importance is also detailed and comprehensible discussion with the patient, who must be informed about the individual options, their risks and benefits.

Key words:
bladder cancer, radical cystectomy, urinary diversion, ureteroileostomy, sigma-rectum pouch, heterotopic bladder substitute, orthotopic bladder substitute

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