UROLOGICAL ONCOLOGY

Orthotopic urinary diversion after cystectomy for bladder cancer: implications for cancer control and patterns of disease recurrence
Yossepowitch O, Dalbagni G, Golijanin D, Donat SM, Bochner BH, Herr HW, Fair WR, Russo P
Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
J Urol. 2003; 169:177-81

• Purpose: The impact of orthotopic urinary diversion on the quality of cystectomy and ensuing cancer control has not been adequately studied. We analyzed our experience with this clinical problem.
• Materials and Methods: The records of 214 patients who underwent cystectomy and orthotopic diversion for bladder cancer were retrospectively evaluated and compared with those of 269 treated with an ileal conduit. Analyzed end points included overall and cancer specific survival. We specifically assessed the patterns of relapse and their association with pathological findings at cystectomy in the neobladder group.
• Results: No cancer specific survival difference was identified in the neobladder and ileal conduit cohorts when adjusting for pathological stage. Patterns of relapse in 62 of the 214 patients with a neobladder (29%) included local recurrence in 23 (11%), distant recurrence in 19 (9%), and combined local and distant recurrence in 18 (8%). Urethral recurrence was rare (2%). Of 10 patients (4.6%) diagnosed with upper tract recurrence 6 and 4 initially had relapse in the ureteroenteric anastomosis and renal pelvis, respectively. Five of the 6 patients with anastomotic relapse had evidence of disease in the intramural or juxtavesical ureter that was removed en bloc with the cystectomy specimen. Only 1 patient required neobladder takedown after such anastomotic recurrence.
• Conclusions: These results indicate that neobladders do not compromise the quality of preceding cystectomy or interfere with management in the presence of local or distant disease relapse. Our data suggest that involvement of the intramural or juxtavesical ureteral segment at cystectomy irrespective of surgical margin status may identify patients at higher risk for anastomotic recurrence, which is associated with an ominous prognosis.
  
  
• Editorial Comment
  The authors compare the clinical causes of patients with bladder cancer after cystectomy and orthotopic neobladder vs. ileal conduit. However, this comparison is not really fair as the majority of patients with ileal conduit underwent cystectomy after systemic (neoadjuvant) chemotherapy.
  Rather than finding really new data from this comparison, the paper is important as it reflects the treatment standards of a very large and well-known referral center. Obviously, all patients in whom primary cystectomy is indicated will undergo a neobladder urinary diversion. If neoadjuvant chemotherapy is indicated, these patients usually receive an ileal conduit. From my point of view, this reflects a thorough and rational approach, which will suit the majority of patients very well.

Dr. Andreas Böhle
Professor and Vice-Director of Urology
Medical University of Luebeck
Luebeck, Germany