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Published byHillary Gilbert Modified over 9 years ago
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Hassan Farsi, Anmar Nassir, Hesham Saada, Rami Salawi
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Bladder caner 63,210 new cases Male to female 3:1 All cancer cases Men 4 th common cancer 6.6% Women 9 th common cancer 2.4% % Age middle-aged and elderly people.
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Bladder Cancer - Pathology TCC >90% SCC 5-7% chronic irritation stones, foleycatheter Schistosomiasis] ADENOCARCINOMA 1-2% urachal carcinoma, cystitis glandularis Rule out metastatic source. STAGING Superficial versus Infiltrating Tumor Localized versus Locally Extensive or Metastatic
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INDICATIONS of RADICAL CYSTECTOMY Muscle-invasive bladder cancer Recurrent T1 disease or CIS unresponsive to intra-vesical chemotherapy Palliative procedure when the symptoms of the disease are severe Severe hematuria Severe frequency
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Indications of Urinary Diversion Dangerous bladder Bladder cancer Pelvic Malignancy Useless bladder Neurogenic Contracted (T.B,B.Irrad) Vesicle fistula Absent bladder Congenital anomalies (Ectopia ) Abol-enein,H 2000
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Goals of Continent Urinary Diversion Construction of a complaint reservoir Detubularisation and Double folding Protection of the upper tracts Controlled reservoir emptying (continence) Abol-enein,H 2000
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Ideal Orthotopic Bladder Substitute Technical simplicity Constructed from a minimal bowel length Complaint Protects the upper tract. Continent. Minimal metabolic and nutritional consequences Abol-enein,H 2000
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REFLUXING OR ANTIREFLUXING ANASTOMOSIS Considerable controversy Potential advantage of anti reflux as long as it does not add a risk of obstruction. Ghoneim, 2002 No Explicit evidence of its necessity Anti refluxing Uretero-intestinal anastomosis in low pressure high capacity reservoir is unnecessary. Prospective controlled randomized study is required Pantuk,2000 & Hohnfeller,2002
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To assess our experience and results of patients undergoing: Radical Cystectomy and Orthotopic Neobladder Reconstruction
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MATERIALES & METHODS
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Number23 Mean Age58.8 Y Sex22 Males 1 Female Duration Of Follow Up26 (6-39) months Patient
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Method Radical Cystectomy & W-Neobladder. Ureteral re-implantation: SLEMT (Abol-Enein & Ghoneim,1993)=8 Pts Our modification of studier hyperperstaltic ileal limb,15 Pts 2 short ileal limbs (each,5-cm long) instead of one (regular studer limb).
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Patient selection ( Exclusion criteria) Renal profileSCr: >180 cCr: <45ml/min Hepatic dysfunctionx Unfit for surgery and Psychiatric patient x frozen section from the cut urethral margin and /or pelvic LN +ve
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SLEMT Radical Cystectomy & W-Neobladder. 5cm two long chimney with direct anastomosis
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Post Operative Evaluation Histopathologcal examination of the Cystectomy specimens Follow up evaluation on regular intervals Renal profiles CBC UA and Cx U/S and /or IVU Pouchogram when indicated CT Bone scan Endoscopy AUG
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RESULTS
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TUMOR CHARACTERISTICS (HISTOPATHOLOGY RESULTS) TUMOR CHARACTERISTICS histopathNo. patients Cell typeTCC19 SCC4 GradeLG9 HG14 LN-ve23 +ve0
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Age Distribution AgeNo. patients% <4000% 41-50418% 51-601148% 61-70834% >7000%
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Early Complications Type of complication Mortality DVT URINARY LEAKAGE BROKEN URETERAL STENS Prolonged ileus
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Renal and electrolytes profiles SCr Na K CL HCO3 RefluxingAnti Reflux
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Continence Status Continence status Day timecontinent Stress incont Total incont Night timecontinent Noct enuresis Total incont
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Voiding pattern TimeNumber of frequency No. patients% Day time Night time
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Late Complications Local recurrence &/or distance Mets Ureteral stricture Urine retention (mucus) Total urinary incont
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Radiographic Evaluation Radiology FLUNo. patients% IVU/US Ascending Urothrogram /Pouchogram
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Preoperative Bladder tumour
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I V U
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Pouchogrphy+VCUG SLEMT
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Pouchogrphy + VCUG + IVU 5cm Two Long Chimney With Direct Anastomosis
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Early Post Op Urethroileal Leakage 2 wk More Foleys catheter drainage 3 wk post operative
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Early Post Op Broken Unrecognized External Ureteral Stent SLEMT EASY CYSTOSCOPY + STENT REMOVAL EASY LOCALIZATION OF BOTH URETERAL ORIFICE
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Early Post Op Broken External Ureteral Stent 5cm Two Long Chimney With Direct Anastomosis Antegrade insertion of Guide wire then Cystoscopy and URS and removal of DJ Stent
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Uretero-Ileal Anastomosis Stricture
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Reflux 5cm two long chimney with direct anastomosis
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Conclusions Radical Cystectomy, followed by the construction of orthotopic W-shaped ileal Neobladder results in a near-normal- functioning orthotopic reservoir that can be safely offered to Suitable patients. Well designed Prospective controlled randomized study regarding refluxing and anti-refluxing anastomosis is required.
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