Resection Specimens

Obviously there are important surgical differences between the sexes. Radical surgery for bladder cancer in the male comprises cystoprostatectomy, with urethrectomy if there is prostatic urethra involvement, and in the female an anterior exenteration (bladder, uterus and adnexae - see Chapter 34). With surgical and anaesthetic advances, operative mortality from radical cystectomy has fallen from 20% to < 1%.

In the male, the bladder is approached through a midline lower abdominal incision. The urachus and vasa deferentia are identified and ligated. A pelvic lymphadenectomy is performed and the ureters identified and divided close to the bladder. Ureteric margins are ideally submitted separately from the main resection specimen for pathological assessment. The bladder, prostate and seminal vesicles are separated from the rectum and the puboprostatic ligaments divided. The urethral sphincter is then divided unless a urethrectomy is being considered.

Simple cystectomy is quite a rare operation, typically performed for benign conditions such as interstitial cystitis or neurogenic bladder complicated by chronic infection. It involves bladder removal with maintenance of the urethra in women or the prostate and seminal vesicles in men.

The need for an alternative urinary drainage system following cystectomy has raised difficulties of acceptance for many patients. However, new developments in surgical techniques mean several options are now available:

1. urinary diversion and intestinal conduit formation; an isolated segment of small or large intestine (usually ileum) is anastomosed to both ureters and a stoma formed on the anterior abdominal wall. Drainage is continuous into a worn device.

2. continent cutaneous diversion (e.g., Indiana pouch, which uses the ileocaecal valve as a continence mechanism); requires intermittent self-catheterisation.

3. continent orthotopic reservoir; a "neobladder" is formed from an ileal or ileocolonic segment and sutured directly onto the urethra; usually confined to men but also possible in women with an intact urethra.

4. ureterosigmoidostomy (sigma rectum pouch); the ureters are anastomosed directly onto a detubularised segment of sigmoid colon still in continuity, i.e., remains in contact with faeces. This avoids the need for a stoma or self-catheterisation but results in the frequent passage of liquid faeces.

5. rarely, cutaneous ureterostomy.

Long-term complications following these procedures include stenosis, adenomatous polyps and tumour formation (usually adenocarcinoma). These may necessitate subsequent resection.

Partial cystectomy is infrequently performed, but may be indicated for a solitary urothelial carcinoma at the bladder dome or for tumour arising in a urachal remnant or diverticulum. Excision of a benign bladder diverticulum may be performed intravesically, extravesically or, if small, transurethrally.

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