الفهرس 
Techniques and Subtypes of Orthotopic Bladder SubstitutionOnly 14 pages are availabe for public view
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Abstract
T
he term urethral recurrence is therefore somewhat misleading as it suggests failure of definitive treatment of the bladder cancer as the cause of the urethral lesion. Rather, most urethral tumors probably represent simply another occurrence of the transitional cell carcinoma in the remaining urothelium (Campbell’s Urology, 2007).
Only tumor infiltration of the prostatic stroma and diffuse carcinoma in situ of the prostatic urethra are primary risk factors. Even the traditional preoperative biopsy of the prostatic urethra is not necessary any more today. The high speed biopsy of the resection margin of the urethra during the cystectomy facilitates the decision whether it can remain in place and a neobladder can be constructed (Hautmann et al., 2006).
The form of urinary diversion is an independent and significant predictor of UR (Stein et al.,2005).
Iselin et al., and Studer et al., reported urethral recurrence in 2.8 % and 6 % respectively, of patients undergoing ileal neobladder construction with negative frozen urethral sections at cystoprostatectomy (Moore et al., 2007).
High tumor recurrence rate stems from old reports of cystectomy series with cutaneous diversions, in which it has been reported to be as high as 18% (Varol et al.,2004).
This value is much lower (approximately 4%) in patients with orthotopic bladder substitutes and sufficient long-term follow-up because they are carefully screened with preoperative or intra-operative urethral biopsies to exclude any malignancy at the future anastomotic site(Leissne et al.,1999).
The low local tumor recurrence rate of 11% and the recurrence rate of2–5% in the urethra support the trend towards orthotopic urinary diversion (Gschwend,2003).
Freeman and his colleges found that urethral recurrence was 5% in orthotopic neo-bladder patients versus 24% in the blind-ending urethra after heterotopic urinary diversion.
The risk of UR in patients with orthotopic diversion is 0.4–4%, which is lower than the 8–10% risk of series with mostly cutaneous diversions. Freeman et al. observed in 436 radical cystectomies for UC that 5 (2.9%) of 174 patients with orthotopic diversion had UR versus 29 (11.1%) of 262 with cutaneous diversion. They said that continued exposure to urine or an unknown biological phenomenon gave orthotopic diversion a protective effect. Other authors suggested that the association of lower UR rate with orthotopic diversion was most probably a result of patient selection (Hassan et al.,2004).
Stein et al.evaluated the incidence of UR in 397 (51%) patients who underwent orthotopic diversion and with cutaneous diversion. They found these two groups demographically and clinically well matched. So, with no apparent selection bias, 6 (4%) patients with orthotopic and 29 (8%) with cutaneous diversion (p = 0.02) had UR. Type of urinary diversion was an independent and significant predictor of UR (Stein et al., 2005).
In a study by Taylor et al, 6 recurrences were treated with various methods, including transurethral resection, urethrectomy with conversion of neobladder to continent catheterizable diversion, and chemotherapy. At the last follow-up, four of these six patients were alive without disease, one was alive with disease, and one had died from disease (Taylor et al., 2009).
Endoscopic treatment was Successful for superficial urethral recurrences and intraurethral Bacille Calmette-Guérin treatment of urethral carcinoma in situ. Urethrectomy and takedown of the neobladder are indicated in cases of tumor multiplicity or infiltrating tumors. In these cases, the isoperistaltic proximal limb of a Studer neobladder may be used as the ileal conduit (Huguet et al.,2003).
Leissner et al. managed 4 urethral recurrences by transurethral resection in 2 patients pTaG3/pT1G3) who were disease-free at 59 months, by local radiotherapy in 1 who died of metastatic disease at 28 months and in 1 with urethrectomy who was disease-free at 13 months (Leissner
et al., 1999).
After diagnosis of urethral recurrence, the range of treatment options must be considered. Urethrectomy is the obvious choice for patients with a cutaneous urinary diversion or for local invasive recurrence after a neobladder. However, patients with a properly functioning orthotopic neobladder are understandably reluctant to undergo conversion to an alternate form of urinary diversion (Sherwood and Sagalowsky, 2006).
Varol et al., reported on intraurethral instillation of BCG for male patients with urethral tumor after orthotopic neobladder diversion. Routine urethral wash cytology was performed every 6 months during the first 2 years of follow-up. Of the 15 cases, 14 were diagnosed based on positive cytology, and gross hematuria was present in 1. Patients received intraurethral BCG (3 times the usual dose mixed in 150 ml of 0.9% saline) in the following sequence via a special multi-hole catheter and balloon occlusion at the junction of the neobladder and urethra: 100 ml infused over 75 minutes, keeping the infusion pressure less than 20 cm of water; 25 ml are instilled into the urethra with the meatus occluded for 25 minutes; and 25 ml are infused as a small urethral catheter is withdrawn from the urethra (Varol et al., 2004).
Treatment was considered successful in 83% (5 of 6) of patients with CIS. However, it is noteworthy that subsequent biopsy was positive in only 9 cases. Thus, cases judged to represent CIS on the basis of the urethral cytology alone might be overdiagnosis. The true success rate for the intraurethral treatment may have been much lower. Treatment failed in 4 cases of papillary or invasive recurrence and urethrectomy was ultimately recommended. There were Endoscopic management with or without intraurethral treatments has been attempted in some cases of superficial TCC that recur after orthotopic diversion (Varol et al., 2004).
The ideal treatment for tumor recurrence in the urethra is total urethrectomy. Attempts for subtotal urethrectomy (with meatal sparing) for facilitating the use of prosthesis has been accompanied by a high rate of tumor recurrence in glandular part of the urethra (Clark et al., 2004).
Figure (22): Algorithm for the treatment of recurrence after othotopic neobladder (Hautmann and Simon, 1999).
The urethrectomy is the treatment of choice in patients withUR.InsurfaceURsandlow-gradeconservativeendoscopictreatmentmaybeanoptioninpatientswith orthotopicdiversion (Huguet, 2012).
Urethral recurrence post radical cystectomy is a relatively rare phenomenon, occurring in 8% to 10% of patients.
Orthotopicneobladder substitution is now considered the diversion of choice for the majority of patients, both male and female, undergoing radical cystectomy and is the procedure with which all other types of diversion must be compared.
A comprehensible discussion with the patient about all options for urinary diversion as well as the potential short- and long-term risks and the beneficial effects of each type of diversion is mandatory for improved postoperative compliance and functional outcomes.
Intraoperative frozen section analysis of the distal urethral margin is necessary to reduce the risk of recurrence.
Currently, the only absolute contraindication to creation of an orthotopic reservoir is biopsy-proven urothelial carcinoma of the anterior urethra or on frozen section analysis of the surgical margins (Mooreet al.,2007).
Neobladder reconstruction is a time-consuming and technically demanding procedure but inherits important advantages like improved body image, sexual function and continence (Hobisch et al., 2001).
Hautmann et al.,evaluated whether the willingness of the surgeon to offer an orthotopic diversion and the desire of the patient to undergo neobladder construction may lead to earlier performance of cystectomy and result in improved cancer-related outcomes (Hautmann and Paiss, 1998).
In female patients there is evidence now that using an orthotopic neobladder after cancer-related cystectomy does not compromiseoncologic outcome as long as we adhere to predefined anatomic and functional pathologic guidelines (Stein et al.,2009).
Maybe some of the remaining questions could be answered by pooling data from other large volume centres and creating a multi-institutional database, as has been suggested by the authors. Because single-institutional data even from high volume centres frequently suffer from statistical under-powering in case of rare events like urethral or upper tract recurrence, this intention is strongly encouraged.