Despite negative preoperative staging, pelvic lymphadenectomy and cystectomy for bladder cancer reveal a high percentage of unsuspected nodal metastases (24%) that have a 25% chance for long-term survival. This procedure also ensures a low pelvic recurrence rate even in lymph node-positive patients, and patients with locally advanced cancer have a 56% probability of 5-year recurrence-free survival.
This study demonstrates a high conduit related complication rate in long-term survivors and underlines the need for vigorous long-term followup. Only studies lasting more than 1 decade cover the entire morbidity spectrum.
After radical cystoprostatectomy and ileal orthotopic bladder substitution, attempted nerve sparing and age younger than 65 years are associated with improved urinary continence. Attempted nerve sparing has the greatest impact on daytime continence and age has the greatest impact on nighttime continence. Attempted nerve sparing and younger age are both associated with more frequent recovery of erectile function.
We report on 10 years of experience with an ileal low-pressure bladder substitute combined with an afferent tubular segment following cystectomy in 100 consecutive men. The median follow-up period was 30 months (range 3-108 months), with a 2.5-year minimum in survivors. A total of 42 patients died, 33 of these dying of bladder cancer. The early complication rate was 11%, including 2 deaths due to postoperative sepsis. In all, 14 patients required reoperation for late complications. The reservoir's median functional capacity increased to 500 ml at 12 months and was paralleled by improving continence: 92% by day (after 1 year) and 80% by night (after 2 years). Four ureteric strictures occurred. No coordinated, isolated pressure rise developed in the reservoir during voiding, which was accomplished by pelvic floor relaxation with abdominal straining, if necessary. Raised intraabdominal pressure acted equally on the reservoir and ureters, preventing reflux during voiding. This technique is straightforward, allows radical cancer surgery, and protects the upper tract. The favorable functional results are comparable with those achieved by similar techniques, but meticulous follow-up is essential.
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