الفهرس 
Surgical Anatomy Of The Urinary SystemOnly 14 pages are availabe for public view
 |  | from | 137 |  |  |
| | | from | 137 | | |
Abstract
Guidelines for surveillance of patients undergoing nephrectomy have been published from several authors during the last decade. No consensus currently exists on surveillance guidelines after radical or partial nephrectomy for renal cell carcinoma.The emphasis on follow-up should be during the first 3-5yr after nephrectomy.
First assessment is recommended at 4-6wk and includes physical examination to exclude surgical complications, serum creatinine to assess the remaining kidney function, and hemoglobin to assess recovery of operative blood loss. If alkaline phosphatase is abnormal preoperatively, repeat measurements are recommended to exclude residual tumor or distant metastasis.
Patients with pT1-T2 tumours should be evaluated with clinical assessment and chest x-ray every 6 mo during the first 3 yr and yearly thereafter.
Patients with pT3 tumours, clinical assessment and chest x-ray should be performed every 6 mo for the first 3 yr and yearly thereafter.
Abdominal CT scan may not be recommended for pathologic stages T1and T2, while most studies support scanning to be performed every 6 mo for the first 2-3 yr and then every2-3yr for patients with pT3 tumours.
Although surveillance may be more intense during the first3 yr after surgery, patients who have been operated for RCC should be followed lifelong.
RCC can metastasize to every part of the body. Metastases most commonly appear in the lungs (38-80% of patients with metastasis), bone (most often in the axial skeleton; 20-49% of patients), liver (9-40% of patients), adrenal glands (8-11% of patients), brain (2-15% patients), and skin and subcutaneous tissue (2-13% of patients).
Recommendations for surveillance follo-wing therapy for upper tract TCC include a spectrum of many scenarios, taking into account the natural history of the tumor which is based largely on grade and stage, and the form of therapy the patient underwent.
All patients should be assessed at 3-month intervals the first year after they are rendered tumor free by endoscopic or open surgical approaches. Then at 6-month intervals for 2-3yrs, then yearly thereafter.
Evaluation should include history taking, physical examination, urinalysis, urine cytology (especially for high grade) and urethro-cystoscopy because of the high risk of bladder recurrences in patients treated both conservatively and with nephroureterectomy.
Patients who have undergone nephroure-terectomy, whether open or laparoscopic, will need to be followed for potential recurrences within any remaining ipsilateral urothelium; at the bladder, prostatic urethra, and contralateral ureter; and for distant metastatic disease. For assessment of the contralateral ureter yearly intravenous urography is usually sufficient. However, retrograde pyelography may be necessary if the patient is not a candidate for injection of contrast medium or if intravenous urography is not diagnostic.
If an organ-sparing approach is chosen, the ipsilateral urinary tract must be assessed endoscope-cally as well as the remainder of the urinary tract. the frequency and duration of the follow-up assessments depend largely on the grade and stage of the lesion, but they are usually every 6 months for several years and annually thereafter.
For follow up of non muscle invasive bladder cancer (Ta, T1, CIS), Surveillance stra-tegies for recurrence have historically relied on the diagnostic combination of cystoscopy and urinary cytology. In clinical practice, only 40% of patients actually comply with a standard surveillance protocol.
Most protocols include this combination every 3 months for 18 to 24 months after the initial diagnosis, then every 6 months for the following 2 years, and then annually, resetting the clock with each newly identified tumor.
Cystoscopy is the hallmark of surveillance. The optimum schedule is controversial but may be individualized based on risk.
Patients with solitary low-grade Ta lesions whose initial 3-month surveillance cystoscopy is normal and who have negative cytology can have surveillance on a less aggressive schedule. Annual cystoscopy is probably reasonable, and cessation may be considered in 5 years. Patients with high-grade tumors (including CIS) warrant quarterly cystoscopy for 1 to 2yrs, semiannual cystoscopy for 1 to 2yrs, and annual cystoscopic evaluation for life.
Upper tract imaging is not necessary for low-grade tumors but should be performed at diagnosis and every 1 to 2yrs for high-grade tumors.
Cytology is usually performed at the time of each cystoscopy. Its specificity is very high, but its sensitivity is suboptimal and a negative cytology does not assure the absence of any grade bladder cancer.
Patients with superficial bladder cancer may be candidates for cystoprostatectomy under certain circumstances like, (a) Failure after two courses of intravesical chemotherapy or immunotherapy, (b) Prostatic involvement, (c) Persistent high-grade lesions, (d) Uncontrollable recurrence of Ta disease not amenable to transurethral resection, (e) Persistence of tumor in nonfunctioning bladder.
For follow up of invasive bladder cancer, A surveillance protocol designed to identify local and distant recurrences should include a routine physical examination that focuses on the pelvic and rectal evaluations and laboratory and radiographic studies. CT and MRI provide adequate views of the abdomen and pelvis with CT urography also available to provide detailed imaging of the collecting system.
Variables associated with the subsequent development of a local recurrence include pathologic stage of the primary tumor and the presence of regional lymph node involvement. Other variables reported to be associated with local recurrence risk include the extent of the lymph node dissection performed and whether perioperative chemotherapy was received.
The important tumor characteristics associated with the development of a distant recurrence are related to the depth of tumor invasion and the status of the regional lymph nodes.
Eighty to ninety percent of distant recurrences will be identified within 3 years, although late recurrences beyond 10 years following surgery have been noted. The likely sites of involvement are bone, lung, and liver, with brain, skin, vagina, and the peritoneal cavity affected less frequently.
In selected patients with invasive carcinoma, standard therapy may not provide optimal or acceptable management. Intercurrent illnesses that are against the use of radical cystectomy as well as the patient’s preferences in an era of increasing interest in conservative surgical inter-vention and organ preservation programs have driven the search for alternative methods of treating muscle-invasive carcinoma. These approaches range from TUR to the development of complex bladder preservation regimens employing endoscopic surgery, systemic chemotherapy, and radiation therapy.
Combined-modality bladder preservation protocols have been proposed as an alternative to radical cystectomy, motivated by two components: (1) Many patients with invasive bladder cancer have micrometastatic disease at the time of presentation. These patients, when asymptomatic, may not derive significant benefit from local intervention without concomitant systemic therapy. (2) Removal of the bladder in the asymptomatic patient with metastatic disease is not necessary, does not enhance quality of life, and delays the delivery of potentially valuable systemic therapy.