OncoLog, Volume 53, Number 11, November 2008 Page: 6
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bladder training to master control and continence; how-
ever, it most closely approximates the "normal" way of
voiding. According to Dr. Dinney, patients who have
neo-bladders benefit greatly from the assistance of support
groups and specialized nursing.
Treatment decisions
Primary treatment
The decision about whether to use neoadjuvant chemo-
therapy is largely a medical one. It is strongly recommended
for the subset of patients who by identified criteria more like-
ly harbor occult disease and therefore are at a high risk for
recurrence. "For those patients, it's a major determinant of
survival," said Dr. Millikan.
For patients who do not have adverse indicators, neoadju-
vant therapy can still be considered by the physician and
patient. Some patients and physicians prefer to use chemo-
therapy along with surgery to minimize risk of recurrence.
When a patient's physiologic reserve is adequate to tolerate
both approaches, this is a reasonable decision. "Because che-
motherapy provides a small advantage, it must be weighed
against the side effects," said Dr. Grossman. "This is signifi-
cant therapy, and chemotherapy and surgery back-to-back
can be quite intensive, so comorbidities are a significant
factor." If the patient is expected to tolerate only one of the
two treatments well, surgery alone should be chosen, as it
offers the best chance of cure.
Another approach for some patients is to proceed with
the surgery and decide afterward about adjuvant chemo-
therapy, based on the operative findings and postoperative
pathologic examination of the bladder. However, response
to chemotherapy-often a strong prognostic indicator-
cannot be observed if the chemotherapy is given after the
bladder and tumor are removed.
According to Dr. Grossman, bladder cancer is a very lethal
disease when it becomes advanced, so it is crucial to undertake
treatment with a view to minimizing that possibility. Where
there are treatment choices to be made, it is important to help
patients understand all of their risks and options, to help them
arrive at the best choice for their individual situation.
Urinary diversion
The surgeon discusses all options for diversion with the
patient preoperatively and learns the patient's preferences.
While patient preferences can usually be met, the final deci-
sion is usually made intraoperatively by the surgeon, based
on the extent of surgery necessary to remove the cancer.
"For example, the creation of a neo-bladder is not among
the options for patients in whom we're not able to spare
the urethra," Dr. Dinney said.
According to Ouida Lenaine Westney, M.D., a recon-
structive surgeon and an associate professor in the Depart-
ment of Urology, other medical factors may also preclude the
creation of a neo-bladder. Renal insufficiency and compro-
mised liver function are two contraindications because theneo-bladder is constructed from intestine, which (unlike
bladder tissue) reabsorbs toxins such as creatinine. Likewise,
the bowel segment that will be used must be healthy, and
therefore patients with extensive bowel disease such as celiac
disease or inflammatory bowel disease may not be able to
have a neo-bladder or Indiana pouch.
Beyond medical considerations, Dr. Westney said the pa-
tient's lifestyle and desires play a big part in the diversion deci-
sion as well. For example, many patients do not want to deal
with urostomy's external urine collection bag, which can be
embarrassing for them. On the other hand, some patients are
very averse to the idea of a catheter, which is the method of
emptying an Indiana pouch (4-6 times per day) and which may
have to be used on occasion with neo-bladders, especially in
the early months. Some degree of hand-eye coordination and
manual dexterity are required to handle a catheter, and Dr.
Westney suggests that such capacities be assessed preoperative-
ly. For both types of continent diversion, patients must be able
to catheterize and irrigate the internal pouch to prevent mucus
buildup and stone formation. Neo-bladders may not be the best
option for patients who feel unable (or do not want) to under-
take bladder training, which is necessary for continence and
normal voiding with neo-bladders. Patients who have signifi-
cant comorbidities or physical limitations are examples.
According to Dr. Millikan, an important consideration
regarding radical cystectomy and urinary diversion is the
available surgical experience. Ultimately, the patient will
benefit most if such an operation is performed by a surgeon
with a great deal of experience doing it. Even though bladder
cancer is relatively common (the U.S. National Cancer In-
stitute estimates more than 68,000 new cases and 14,000
deaths in 2008), invasive tumors are rare, so the surgery is
uncommon outside of major cities and treatment centers. eColin P. N. Dinney, M.D.
Chairman, Department of Urology
Professor, Departments of Urology and Cancer Biology
Monteleone Family Foundation Disringuished Professorship
for Research of Bladder and Kidney Cancers
H. Barton Grossman, M.D.
Deputy Chairman, Department of Urology
Professor, Departments of Urology and Cancer Biology
Monteleone Family Foundation Distinguished Professorship
for Research of Bladder and Kidney Cancers
Randall E. Millikan, M.D., Ph.D.
Associate Professor, Department of Genitourinary
N medical OowloxOuida Lenaine Westney, M.D.
Associate Professor, Department of Urology
Fellowship Director, Urinary Tract and Pelvic
Reconstruction6 OncoLog " November 2008
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University of Texas M.D. Anderson Cancer Center. OncoLog, Volume 53, Number 11, November 2008, periodical, November 2008; Houston, Texas. (https://texashistory.unt.edu/ark:/67531/metapth903079/m1/6/: accessed July 18, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu.; crediting UNT Libraries Government Documents Department.