Bladder reconstruction in the surgical management of bladder cancer

As the preceding discussion has demonstrated, a number of ingenious yet relatively practical approaches have been proposed for urinary reconstruction following partial or total cystectomy for bladder cancer. Ileal conduit diversion and ureterosigmoidostomy are the only procedures for which there is adequate clinical experience to judge their relative advantages and disadvantages. Neither is an ideal form of diversion but both are practical solutions to the problem of urinary drainage following radical cystectomy. Until effective alternatives are developed, these procedures will remain the standard therapies in the management of bladder cancer. The ideal bladder substitute which needs to be developed must be continent, able to evacuate completely, have minimal physiologic consequences, and be stomaless. Ureteroiliourethrostomy comes closest to fulfilling these criteria, but there is persistent skepticism about the ability of the ileal bladder to empty effectively. Further clinical trials of this procedure are necessary before any definitive statements are possible regarding its eventual role in patients with bladder cancer. The major consideration in urinary reconstruction in the management of bladder cancer is the possibility of tumor recurrence in an adjacent urinary segment. Partial rather than total bladder reconstruction is usually precluded by this factor, but may be feasible in carefully selected patients. Staged urinary reconstruction, such as initial conduit diversion and later reestablishment of urinary continuity once tumor recurrence has been ruled out, is an attractive but relatively untried solution to this problem. The quality of life of the patient must improve to an extent which warrants the operative risks involved. To minimize these risks, a flexible, reliable, and uncomplicated procedure must be developed and must withstand prolonged clinical scrutiny. Advances in urinary reconstruction in the management of bladder cancer are eagerly anticipated by surgeons and patients alike.