Urology>>>>>Bladder Cancer
Question 9#

A 69-year-old woman has been diagnosed with muscle-invasive bladder cancer and is considering undergoing radical cystectomy with formation of an orthotopic neobladder. Her GFR is 52 mL/min and she has marked right-sided hydronephrosis. Which of the following statements is TRUE?

A) She should be counselled that orthotopic neobladder is contraindicated in her case in view of the low GFR and presence of hydronephrosis
B) Quality of life studies of patients with orthotopic diversion have uniformly shown that patients with continent diversions have a better quality of life than those with ileal conduits
C) Her pre-operative counselling can be facilitated by results of several randomised controlled studies which have become available in the past few years comparing neobladder to ileal conduit and other types of urinary diversion
D) If she had pre-existing significant stress incontinence, this would be a relative contra-indication for neobladder formation

Correct Answer is D

Comment:

Answer D

Patients with significantly decreased renal function are at increased risk of developing chronic acidosis and metabolic abnormalities with a continent diversion. This is due to the reabsorption of electrolytes by the bowel mucosa. There is no exact renal function cut-off below which continent urinary reconstruction should not be performed, but as a general guide, one should generally avoid it if the GFR is <50 mL/min. Abnormal GFR, hydronephrosis, previous bowel surgery with or without adjuvant chemotherapy and/or external beam radiation to the pelvis are not absolute but relative contra-indications for a neobladder. Involvement of the bladder neck is considered an absolute contraindication in both sexes. Quality of life surveys have not shown one type of urinary diversion to be superior over another. Most patients are reasonably well adapted socially, physically and psychologically to their diversion. The key to this adaptation is appropriate and realistic preoperative education. Quality of life surveys have often been underpowered or affected by selection bias. Most such studies in patients with continent urinary diversion suffer from major methodological problems. Unfortunately, there is not a single RCT within the field of urinary diversion. Almost all studies are of Level 3 evidence good-quality retrospective studies, or case series, or Level 4 evidence including expert opinion.