indication

T1 tumors at high risk of progression (high grade, multifocality, CIS, and tumor size, )

In all T1 patients failing intravesical therapy

muscle-invasive bladder cancer T2-T4a, N0-Nx, M0

BCG-resistant Tis extensive papillary disease

performance status and age influence the choice of primary therapy, as well as type of urinary diversion with cystectomy being reserved for younger patients without concomitant disease and better performance status

Timing and delay of cystectomy

delay of treatment beyond 90 days of primary diagnosis caused a significant increase in extravesical disease (81 vs 52%)

Before cystectomy, the patient should be counselled adequately

regarding all possible alternatives, and the final decision should be based on a consensus between

patient and surgeon.

Technique and extent

prostate and seminal urothelial cancer in the prostate was detected in 33% in23-54% of patients a prostate cancer is found

uterus and adnexa in women spare seminal vesicles and the

prostatic capsule

Role of Lymphadenectomy provides insight into the local extent In limited nodal burden increase

survival

dissection of regional lymph nodes.

There is a substantial amount of literature about the extent of lymphadenectomy.

Yet, data regarding its clinical significance are controversial

In retrospective studies extended lymphadenectomy (removal of the

obturator, internal, external, common iliac and presacral nodes as well as

nodes at the aortic bifurcation) has been reported to improve survival

standard lymph node dissection

genitofemoral nerve laterally internal iliac artery medially Cooper ligament caudally, and the crossing of the ureter at

the common iliac artery cranially

Ileal Conduit

It is simplest type of conduit diversion to perform and isassociated with the fewest intraoperative and immediatepostoperative complications

Colon Conduit

transverse colon is used when one wants to be surethat the segment of conduit employed has not been irradiated

sigmoid conduit is a good choice in patients undergoing a pelvic exenteration who will have a colostomy

Contra-indications continent urinary diversion

• Debilitating neurological and psychiatric illnesses.

• Limited life expectancy.• Impaired liver or renal function.• Transitional cell carcinoma of the

urethral margin or other surgical margins