Nov. 1, 2000 GAINESVILLE, Fla.---As if battling cancer weren't harrowing enough, some patients who have undergone radiation therapy to fight the disease develop an unwanted complication long after the treatment is over: bladder problems that eventually require surgery to remove the organ.
Other patients find themselves facing bladder removal but for other reasons -- severe incontinence, for example, or benign diseases that cause the bladder to malfunction.
Now University of Florida surgeons have improved the technique for removing the bladder, an advance that is likely to help patients who often are too ill to undergo the standard surgical approach. The new method is described in a paper published in the October issue of The Journal of Urology, a publication of the American Urological Association.
Many patients with serious bladder problems simply undergo urinary diversion, surgery to reroute urine to an internal reservoir patients can empty themselves, or to a piece of bowel that funnels it to an external bag, bypassing the bladder.
"In many cases the bladder is left behind because these patients often are quite sick and removal of the bladder is quite extensive surgery," said Zev Wajsman, professor of surgery at UF's College of Medicine and chief of urologic oncology at the UF Shands Cancer Center.
But two out of three people whose bladders are not taken out at the time of surgery go on to develop serious complications; as many as 20 percent of them eventually require an operation to remove the organ, a procedure known as a cystectomy, Wajsman said.
"We developed a modification of the technique that makes this surgery much safer and much faster," Wajsman said. "And by doing the removal of bladder at time of urinary diversion, it prevents complications in the future, such as severe infection down the road, severe pain, bleeding from the bladder and, mainly, the frequent need to urinate, bladder spasm and fever. It's quite a significant help for these patients."
UF surgeons revised what is called a "simple" cystectomy - in contrast to its "radical" counterpart. Their modified technique uses specific kinds of incisions and alternative anatomical paths to the bladder, removing the organ while sparing adjacent structures, including the prostate, seminal vesicles and urethra in men, and the vagina, uterus and urethra in women.
The surgeons operated on 12 women and seven men who had crippling symptoms after the patients failed to respond to an average of five conservative treatments. The majority of these patients had undergone previous surgeries and pelvic radiation. In 13 cases, cystectomy was performed at the time of urinary diversion; the six other patients underwent cystectomy because of complications caused by a retained nonfunctional bladder.
Researchers tracked the group for 15 months after surgery. In all cases, patients' symptoms were dramatically alleviated and no problems developed that were directly attributable to the simple cystectomy.
The modified approach adds only 30 minutes to surgery time when performed at the time of urinary diversion and minimizes blood loss, Wajsman said. And because it is well tolerated by patients, the method ideally should be performed at the time of urinary diversion, to avoid later problems, he said.
"Simple cystectomy involves significantly lower surgical stress and a lower risk of complications than radical cystectomy," wrote the paper's authors, who in addition to Wajsman included Dr. Endre Z. Neulander, a postdoctoral fellow in urologic oncology; Dr. Inoel Rivera, an assistant professor of urology; and Dr. Nicole Eisenbrown, a urologic resident.
"The standard procedure is more extensive and as a consequence more complicated, more so after tissues have been radiated," said Dr. Julio M. Pow-Sang, a professor of surgery at the University of South Florida who also leads the Genito-Urinary Oncology Program at H. Lee Moffitt Cancer Center in Tampa. "The [new] procedure is much simpler."
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