Surgical principles

The usual procedure is cystoprostatectomy in male patients or anterior bladder exenteration in female patients, with dissection of local lymph nodes. Bladder resection is associated with urinary diversion— most commonly, a non-refluxing ileal conduit and urinary bag. Complications include loss of sexual potency in the male and loss of the vagina in the female. It is important for patients to have advice from a specialized stoma therapist before surgery.

In specialist centres, excellent results can be achieved in selected patients treated by radical cystectomy with continent diversion based on urinary tract reconstruction by ileocystostoplasty. This can produce urinary continence and, in experienced centres, the surgical complication rates are less than 10% and operative mortality less than 2%.

Radical radiotherapy based on CT scan has led to increased precision and more accurate dosimetry. Usually, the entire bladder is treated to encompass the risk of subclinical disease at other sites in the urothelium. The technique uses either three or four fields and the common fractionation regimens include treatment to a dose of 64 Gy in 32 fractions over 62 weeks or 55 Gy in 20 fractions over 4 weeks. Most patients suffer some side-effects during radiotherapy, such as increased frequency of micturition, dysuria, and, occasionally, strangury requiring analgesics. There may also be proctitis associated with diarrhoea. Chronic side-effects of this type are uncommon.

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