A 55 year old lady presented with history of pneumaturia and occasional passage of fecal matter per urethra since 8 days.She was a known case of carcinoma endometrium operated 18 years back with Total Abdominal Hysterectomy followed by chemotherapy and radiotherapy.She was asymptomatic for 10 years then she started leaking ? fecal matter per urethra.She was taken up for endoscopic intervention after which the fecal leakage stopped. She is a known case of diabetic-fairly controlled,hypertension on medications.She was investigated for cystoscopy(diagnostic) which revealed a fistula 2 cm away from the left ureteric orifice cranially and laterally.The fistulogram showed leakage of the contrast into the sigmoid colon. She was given option of open repair of colo-vesical fistula but she preferred an endoscopic approach over open repair.The patient was explained the chances of success and failure and then was taken up for endoscopic repair. She was kept on liquid diet before the planned surgery and also given Peglec for bowel preparation. On the day of surgery , the prophylactic antibiotics were administered and the cystoscopy was started. The fistula was identified in the same position.It was cauterised on all sides with ball electrode with resectoscope instrument. After cauterising the ureteric orifices were cannulated with ureteric catheters and the cauterised mucosa was re-inforced with Fibrin Glue(Mixture of Fibrinogen and thrombin-Tisseel by Baxter).A total of 4 ml quantity was required.The bladder was kept deflated after the injection. The sealing of the fistula tract was confirmed endoscopically and then Foleys catheter was introduced. The plan is to keep patient on NBM for 24 hours and further 24 hours on liquids and then ensure she will not suffer from constipation further.The bladder will be kept deflated for a period of 4 weeks.
Wednesday, April 28, 2010
Friday, April 23, 2010
Easy solution for the urethral stricture: Urethral stent insertion
A 48 year old gentleman came with recurrent stricture urethra-proximal bulbar region.He had undergone multiple endoscopic interventions-Optical Internal Urethrotomies and repeated dilatations. 
Patients flow before the surgery He was also a case of diabetes on oral hypoglycemic agents and thus prone for recurrent Urinary Tract Infections also. His investigations were within the normal limits.His Blood Sugar levels were fairly well controlled. Clinical examination revealed Balanitis Xerotica Obliterans as the cause of the urethral stricture. Retrograde urethrogram showed proximal bulbar stricture. 
He was given the options of Buccal Mucosal Graft Urethroplasty and urethral stents.The patient was wary of any surgery and opted for day care stent surgery. Memocath stent insertion was done for the patient.Intra-operative assessment of the stricture length was 5.5 cm reaching just near the External Urethral Sphicter.So a 7 cm Urethral stent was inserted just touching the sphincter proximally and covering extra 0/5 cm beyond the stricture distally.This was done keeping in mind the stricture length always extends 5-10 mm beyond the visible stricture(microscopic extension of the disease). After the surgery the patient went into post-obstructive diuresis( a phenomenon noted after relief of long standing obstruction) and so his stay was extended by 2 days and then he was discharged. His urinary stream was good and he was voding with Maximum Flow rate of 49 ml/sec.
Patients flow before the surgery He was also a case of diabetes on oral hypoglycemic agents and thus prone for recurrent Urinary Tract Infections also. His investigations were within the normal limits.His Blood Sugar levels were fairly well controlled. Clinical examination revealed Balanitis Xerotica Obliterans as the cause of the urethral stricture. Retrograde urethrogram showed proximal bulbar stricture. 
He was given the options of Buccal Mucosal Graft Urethroplasty and urethral stents.The patient was wary of any surgery and opted for day care stent surgery. Memocath stent insertion was done for the patient.Intra-operative assessment of the stricture length was 5.5 cm reaching just near the External Urethral Sphicter.So a 7 cm Urethral stent was inserted just touching the sphincter proximally and covering extra 0/5 cm beyond the stricture distally.This was done keeping in mind the stricture length always extends 5-10 mm beyond the visible stricture(microscopic extension of the disease). After the surgery the patient went into post-obstructive diuresis( a phenomenon noted after relief of long standing obstruction) and so his stay was extended by 2 days and then he was discharged. His urinary stream was good and he was voding with Maximum Flow rate of 49 ml/sec. 
Tuesday, April 20, 2010
General advice for patient with the kidney stone disease
General Advice for stone patient
Drinking advice:
• Balanced fluids
• 2.5-3.0 liters per day
• Diuresis 2.0-2.5 liters per day
• Specific gravity of urine <>
Drinking advice:
• Balanced fluids
• 2.5-3.0 liters per day
• Diuresis 2.0-2.5 liters per day
• Specific gravity of urine <>
Foods to be avoided: Cabbage,cauliflower,chicken,meat.fish,salty food,pickle,beer,berries,amla,chickoo,mushroom,brinjal,bhindi,tomatoes,eggs,cucumber,cashewnuts,milk(more than 2 glasses per day),lot of diary products
Foods to be taken: Pineapple juice,carrots,coconut water,karela,barley( preferrable made up of jowar),lime juice( donot take more than 1 ½ glasses per day),Horse gram(you can find out from Maharashtrian cuisine how to make items out of it),almonds,banana
Saturday, April 10, 2010
superficial bladder cancer: Trans Urethral Bladder Tumor Resection video
A 23 –year old gentleman presented with gross total hematuria since 1 month. He was a non-smoker and non- alcoholic. He did not have any comorbidities. The patient was investigated with imaging(ultrasonography) and blood biochemistry and hematological tests. The ultrasonography revealed 3 cm papillary growth in right lateral wall of the bladder and the urine cytology confirmed malignancy. He was taken up for endoscopy which confirmed the clinical diagnosis. With the help of resectoscope; the growth was resected .At the end of the procedure a deep cut was taken to include the muscularis propria to aid in staging of the disease and the further treatment. The final histology came as Ta Grade 2 The patient has been kept on 3 monthly follow-up with check cystoscopy.
Monday, April 5, 2010
Pin down that prostate problem
Recently, a 75-year old retired Air Force officer contacted me. The Bengaluru-based gentleman said he had a “good ten years left in me”. But he had been harbouring prostate cancer for the last five years and had been advised to leave it alone since it was slow growing. Alarmed, I asked him to rush to Hyderabad for further investigations, only to discover that the cancer had spread to his bones and abdomen. Unfortunately, even today the most common myth about prostate cancer is that since it’s slow growing, it is relatively harmless. However, this is not true. Changes in attitude, lifestyle and advances in medical technology have revolutionised the ageing process and men are leading active lifestyles well into their nineties. The Air Force officer once had a prostate cancer that was curable but his doctor had the wrong attitude. The cancer could end his life “prematurely”. Prostate cancer is most common in middle-aged men. Early detection is possible by a blood test called PSA (prostate specific antigen). PSA is a protein released specifically by the prostate gland into the blood stream. Basically, whenever there is an abnormal activity in the prostate gland, be it enlargement, infection or cancer, the prostate weeps in the form of PSA into the blood stream. If the PSA in the blood rises above 4 ng/ml then a prostate biopsy is essential to confirm the diagnosis. Very rarely the cancer can present as a bump in the prostate and therefore the PSA testing has to be combined by examination of the gland by a urologist. In the early stages, prostate cancer is normally without symptoms. Therefore, conducting a regular blood test for PSA and examination by a urologist should be routine for all men over the age of 50. When the disease is advanced, prostate cancer can cause difficulty in urination, infection and blood in urine. Till recently doctors were reluctant to offer treatment because of the side effects the treatment can cause. Any treatment given can affect both potency and the muscles that control urination. Laparoscopic robotic surgery and sophistication in radiation technology have minimised the complications and side effects and there is no reason why patients should not undergo a treatment to cure the prostate cancer. Recently, a new technique called HIFU (high intensity focused ultrasound) has been introduced in India. This uses high intensity ultrasound waves to destroy the cancerous gland. Since it is a nonsurgical procedure and does not involve radiation it avoids the trauma of surgery and side effects, thereby preserving the quality of life. Since the procedure is least traumatic it can be used on patients with heart ailments, diabetes and blood pressure. In conclusion, prostate cancer can be detected early by a blood test and examination by an urologist. It is advisable that men after the age of 50 should have a yearly prostate check even if they have no complaints. If cancer is detected early, can be cured by non-radiation and non-surgical proceduress.
The writer is the CEO of
Dr Ramayya’s UrologyNephrology Institute and Hospitals
Don’t ignore BED WETTING
Residual urine, high pressure on the kidneys and bladder irritability could be the first signs of kidney failure.
While working as a urologist, in England, a nurse casually asked me if bed wetting could be a serious problem. I said “Yes, it can be, but depends on the duration and age of the person.” She told me her father, an otherwise fit man, had recently started wetting the bed at night. But he was too embarrassed to see his family doctor. I asked her to bring him to me as soon as possible, since I knew from her description that he was probably dealing with a problem that might have affected the kidney. As expected, on examining the patient I found that a enlarged bladder was the reason behind the bed wetting. A subsequent ultrasound scan revealed swollen kidneys and further blood tests showed that he was in the early stages of kidney failure (accumulation of waste products in the body) which fortunately reversed once his bladder was emptied with a catheter. One of the fallouts of this was that his prostate had enlarged preventing his bladder from emptying. As a result the patient had to undergo laser prostate surgery to solve his problem. How does bed wetting and a failure to empty the bladder result in kidney failure? The kidneys situated on either side of the upper lumbar spine filter the blood. They help retain essential salts and proteins as the blood gushes through them at great speed and lets go of nearly two liters of water together with waste products. The blood isbrought into the kidney at great pressure to allow the filtration process. Once the filtration process is completed urine is produced and falls into the collecting system called calyces and pelvis, which are like funnels. The ureters are tubes, which then ease the urine into the bladder by a gentle wave like action called the peristalsis. For the filtration process to take place effectively the pressure has to be low in the collecting system and even lower in the ureters. Any disease in the bladder or in the outflow tract which creates a high pressure in the bladder to force open the gates can disrupt the filtering process resulting in kidney failure. This can happen in children due to faulty gates (vesico-ureteric reflux), blockage while passing urine called Posterior Urethral Valves and Congenital Urethral Stricture, a problem common among boys. It can also occur in adults due to interference in the nerve supply, due to neurological disease or spine injuries. Failure to empty bladder, transmission of high pressure to the kidneys can result in bladder irritability, which are the first signs of a serious kidney disease. Some children don’t grow out of bed wetting. This is usually of no consequence as they settle with time, but the problem still needs investigating to rule out bladder or kidney problem.
The writer is the CEO of
Dr Ramayya’s Urology, Nephrology Institute and Hospitals
While working as a urologist, in England, a nurse casually asked me if bed wetting could be a serious problem. I said “Yes, it can be, but depends on the duration and age of the person.” She told me her father, an otherwise fit man, had recently started wetting the bed at night. But he was too embarrassed to see his family doctor. I asked her to bring him to me as soon as possible, since I knew from her description that he was probably dealing with a problem that might have affected the kidney. As expected, on examining the patient I found that a enlarged bladder was the reason behind the bed wetting. A subsequent ultrasound scan revealed swollen kidneys and further blood tests showed that he was in the early stages of kidney failure (accumulation of waste products in the body) which fortunately reversed once his bladder was emptied with a catheter. One of the fallouts of this was that his prostate had enlarged preventing his bladder from emptying. As a result the patient had to undergo laser prostate surgery to solve his problem. How does bed wetting and a failure to empty the bladder result in kidney failure? The kidneys situated on either side of the upper lumbar spine filter the blood. They help retain essential salts and proteins as the blood gushes through them at great speed and lets go of nearly two liters of water together with waste products. The blood isbrought into the kidney at great pressure to allow the filtration process. Once the filtration process is completed urine is produced and falls into the collecting system called calyces and pelvis, which are like funnels. The ureters are tubes, which then ease the urine into the bladder by a gentle wave like action called the peristalsis. For the filtration process to take place effectively the pressure has to be low in the collecting system and even lower in the ureters. Any disease in the bladder or in the outflow tract which creates a high pressure in the bladder to force open the gates can disrupt the filtering process resulting in kidney failure. This can happen in children due to faulty gates (vesico-ureteric reflux), blockage while passing urine called Posterior Urethral Valves and Congenital Urethral Stricture, a problem common among boys. It can also occur in adults due to interference in the nerve supply, due to neurological disease or spine injuries. Failure to empty bladder, transmission of high pressure to the kidneys can result in bladder irritability, which are the first signs of a serious kidney disease. Some children don’t grow out of bed wetting. This is usually of no consequence as they settle with time, but the problem still needs investigating to rule out bladder or kidney problem.
The writer is the CEO of
Dr Ramayya’s Urology, Nephrology Institute and Hospitals
Don’t ignore that BLEEDING
The presence of blood in urine is indicative of a kidney stone or a tumour in the urinary tract.
Hematuria is the presence of blood, specifically red blood cells, in the urine. Whether the blood is visible only under a microscope or to the naked eye, hematuria is a sign that something is causing bleeding in the kidneys, ureters (tubes that carry urine to the bladder), prostate gland, bladder or urethra.
WHO IS AFFECTED
KINDS OF HEMATURIA
COMMON CAUSES
PINNING THE PROBLEM
The writer is the CEO of Dr Ramayya’s Urology, Nephrology Institute and Hospitals
Hematuria is the presence of blood, specifically red blood cells, in the urine. Whether the blood is visible only under a microscope or to the naked eye, hematuria is a sign that something is causing bleeding in the kidneys, ureters (tubes that carry urine to the bladder), prostate gland, bladder or urethra. Hematuria occurs in up to 10 per cent of the general population. The frequency of bleeding may differ. It can indicate various problems in men and women. Causes of this condition range from on-life threatening infections to the more serious kidney, bladder or prostate cancers.
KINDS OF HEMATURIAThere are two types of hematuria, microscopic and gross or macroscopic. In microscopic hematuria, the amount of blood in the urine is so small that it can only be seen under a microscope. A few experience microscopic hematuria that has no discernible cause (idiopathic hematuria). These people excrete a higher number of red blood cells. In gross hematuria the urine is pink, red, or dark brown and may contain small or large blood clots. The amount of blood does not necessarily indicate the seriousness of the problem. As little as 1 millilitre of blood can turn the urine red. Hematuria can also be caused due to jarring of the bladder while jogging or running long distance. This is known as ‘Joggers hematuria’. Reddish urine that is not caused by bleeding is called pseudohematuria. Excessive consumption of beets, berries, or rhubarb; food colouring, pain medication and certain laxatives can cause this.
COMMON CAUSES
Many conditions are associated with hematuria. The most common causes include enlarged prostate, kidney, ureter or bladder stones, kidney disease (Nephritis), prostate infection, trauma (e.g. a blow to the kidneys), tumours or cancer in the urinary system, urinary tract blockages or serious infection like tuberculosis, viral infections and sexually transmitted diseases.Hematuria can also be caused due to rare diseases and genetic disorders.
PINNING THE PROBLEM
Bleeding is classified by when it occurs during urination, which may indicate the location of the problem. If blood appears at the beginning of urination it indicates it is from the urethra or prostate, if it is present throughout urination (total hematuria) it is probably from the bladder, ureter, or kidneys. If blood appears at the end of urination it is indicative of a prostate disease. Family history may reveal inherited predispositions or problems associated with hematuria.When blood is discovered in the urine it is important to consult a urologist or nephrologist. Tests like urine culture, endoscopy, ultrasound scan or CT scan can then be ordered to diagnose the problem.
The writer is the CEO of Dr Ramayya’s Urology, Nephrology Institute and Hospitals
Sunday, April 4, 2010
Chasing the big `O'
About 43 per cent of women are sexually dissatisfied due to lack of arousal and elusive orgasms.
Recent
ly, a young couple walked into my clinic with worried expressions. The couple who had been married for just about a year were under pressure to conceive. But the 22-year-old woman had no sexual desires at all,
which was posing to be a problem. “Doctor, ever since my college days I don’t get aroused, and I thought it was incurable,” she said. And although she had mentioned this to her family doctor earlier, he had chosen to ignore the issue. The anxious couple was worried they wouldn’t be able to enjoy a ‘happy married life’. This couple was not alone. There are several couples, where the woman is sexually dissatisfied. But with the right help, this problem can soon be solved.
INCIDENCE
According to a survey by the American Medical Association, 43 per cent women in the 20 to 50 age group experience problems with arousal, orgasm and sexual satisfaction or in other words known as Female Sexual Dysfunction. While there is no recorded data in India,
the percentage of the problem could be the same.
DISSATISFACTION.
Urologis
ts, behavioural scientists,
and psychologists are looking at medical, cultural and psychological reasons for women’s sexual problems.
The female sexual response cycle consists of four stages — excitement (foreplay), plateau (intense excitement with increase in heart rate and vaginal and breast swelling), orgasm (intense vaginal
and pelvic muscle contraction) and resolution (decrease in heart rate, relaxation of muscles and psychological
need for security). Disruption in any of these phases can lead to dissatisfaction.
CAUSES
While there are many causes the exact reason is still unknown. Alcohol, depression, a partner who can’t be bothered, anxiety, stress, smoking, sexual abuse at a young age, urinary leak, dry vagina are some causes.
RECOGNISING THE PROBLEM
The American Foundation of Urologic Disease recognises four causes of female sexual dissatisfaction.
◗ Sexual desire problem
◗ Sexual arousal problem
◗ Orgasmic disorder
◗ Sexual pain disorder
While the first two are treated by a psychologist, the others are treated by a gynecologist.
TESTS
A vaginal plethysmography can evaluate the blood flow to the vagina, while a vaginal pH testing, commonly performed by gynecologists and urologists can be used to detect bacteria-causing vaginitis. A biothesiometer, a small cylindrical instrument, may be used to assess the sensitivity of the clitoris and labia to pressure and temperature. Readings are taken before and after the subject watches an erotic video.
TREATMENT:
Educating men and women on how to respond to a woman’s psychological and physical stimulatory needs is important. One of the methods used is Hormone replacement therapy (HRT) which aims at restoring hormone levels affected by age. A medical condition that causes diminished blood flow to the vagina must be addressed in light of female sexual dysfunction. There are solutions that can increase the blood flow by dilating clitoral blood vessels. There also a few handheld devices that can be used to increase blood
flow to improve sensitivity, lubrication, and the ability to experience orgasm.
The writer is the CEO of
Dr Ramayya’s Urology Nephrology Institute and Hospitals
Male Menopause Myth or Reality
With more and more senior citizens living longer, and seeking and demanding healthier more fulfilling lives, the past decade has seen major advances in the perception and medical understanding of changes in physical, mental and emotional health of older men which were previously dismissed as‘normal aging’. It is now possible to distinguish normal age related decline in male hormone (androgen) levels from a clinical condition where a variety of physical, mental and sexual symptoms are caused by low androgen levels – and are thus eminently treatable by androgen replacement therapy. The size of the problem is large; it has been estimated that up to 2.5% of men as young as 40 can be suffering from this, and the condition can be present in 30- 70% of men in their 70s. A survey in 2005 in the four metros found that almost 75% of men above 40 reported some features of hypogonadism (deficiency of sex hormones). The medical community has however, and with good reason, been a bit guarded in recommending casual or nonspecialist diagnosis and treatment. This is because on the one hand the signs and symptoms are subtle and there are no straight forward diagnostic tests with clear-cut normal and abnormal values, and on the other hand treatment can have potentially serious side effects if used indiscriminately or without proper monitoring.Typical symptoms include decreased energy and chronic fatigue, sleep disturbances, mood changes and difficulty concentrating, and reduced sexual drive. Specialist evaluation will show signs of decreased muscle mass, decreased bone density, increased visceral fat and hormonal abnormalities. All these symptoms can clearly also be due to other unrelated causes including financial and health related stress around retirement age, difficulty coping with changing relationships or death of a loved one etc. – all major events which can start impacting one’s quality of life at about the same time. Physical signs of androgen deficiency can similarly be mimicked by the tendency to put on weight in middle age, sedentary lifestyle, alcohol abuse and decreasing androgen levels due to something called the metabolic syndrome – a combination of inter-related disorders which increase the risk of heart disease, diabetes etc. The main features of metabolic syndrome are putting on weight around the waist, high blood pressure, low ‘good cholesterol’ and tendency for diabetes. Recent research has shown that metabolic syndrome and age-related hypogonadism can be both cause and effect of each other. Therefore the potential benefits of recognizing and treating ‘male menopause’ (or Symptomatic Late Onset Hypogonadism, to use the more accurate medical term) include not only improving the overall quality of life and sense of well being, but also prevent more well known killer diseases like heart disease, diabetes,blood pressure etc. That is why experts the world over are coming to the consensus that in the presence of typical symptoms and documented hypogonadism, hormone replacement therapy is valid and effective. There is also a cautionary note however: because the diagnosis requires astute clinical judgement and treatment can have potentially serious side effects (like heart and liver dysfunction and the theoretical risk of prostate cancer), hormone replacement therapy should only be started after excluding anyprostatic abnormality, And be carried out under specialist supervision and lifelong monitoring. Any concern about the prostate at any stage should warrant immediate urology referral. Male menopause is therefore very much a reality and can seriously compromise quality of life for ever increasing numbers of men in their sunset years. But with very effective treatment available we all need to believe that getting old may be natural but feeling old is now optional.The Writer is the
Clinical Director & Chief of Urology
Dr Ramayya's UrologyNephrology Institute and Hospitals Pvt. Ltd.
Dr.Vishwambhar Nath
Saturday, April 3, 2010
Bladder cancer:Presentation two recently treated cases with review of the literature
A 23 –year old gentleman presented with gross total hematuria since 1 month. He was a non-smoker and non- alcoholic. He did not have any comorbidities. The patient was investigated with imaging(ultrasonography) and blood biochemistry and hematological tests. The ultrasonography revealed 3 cm papillary growth in right lateral wall of the bladder and the urine cytology confirmed malignancy. He was taken up for endoscopy which confirmed the clinical diagnosis. With the help of resectoscope; the growth was resected .At the end of the procedure a deep cut was taken to include the muscularis propria to aid in staging of the disease and the further treatment. The final histology came as Ta Grade 2 The patient has been kept on 3 monthly follow-up with check cystoscopy. Case 2: A 69 year old lady presented with difficulty in passing urine and a very weak stream. She had also complaints of dysuria. She was treated outside by urethral dilatation. As she was not benefitted she presented to us; ours being referral centre. On investigations there was a bladder mass on ultrasonography with corresponding urine cytology confirming the malignancy. The patient was taken up for pan- cystourethroscopy which revealed large growth on right lateral wall, posterior wall occupying whole trigone. The biopsy was taken from one of the edges taking care to include deep muscle. The growth as such was not amenable for endoscopic treatment(Trans Urethral Resection of Bladder Tumour). The final histopathology report came as High Grade Papillary Urothelial Carcinoma with lamina propria invasion and deep muscle invasion could not be commented upon. As the lesion was grade 3 with large size;a decision was taken up for radical cystectomy. All types of diversion were discussed with the patient and ileal conduit –the traditional diversion was opted for. The patient was successfully taken up for Radical cystectomy and ileal conduit and presently she is recuperating from the surgery. 
case 1: Radical cystectomy:excised bladder specimen showing mass in the bladder and the urethra held with the clamp We have discussed about these two cases as the bladder cancer can present in various stages and the treatment is also tailored upon the staging, the grading and the patients wellbeing (and sometimes choice - especially as far intestinal diversion is concerned ;if it doesnot compromise the oncological safety). Anatomy of the bladder 
The bladder is a hollow organ in the lower abdomen. It stores urine, the urine produced by the kidneys. Urine passes from each kidney into the bladder through a long cylindrical tube called a ureter. Urine leaves the bladder through another tube, the urethra. Understanding bladder cancer The wall of the bladder is lined with cells called transitional cells and squamous cells. More than 90 percent of bladder cancers begin in the transitional cells. This type of bladder cancer is called transitional cell carcinoma. 
Cancer that is only in cells in the lining of the bladder is called superficial bladder cancer. Cancer that begins as a superficial tumor may grow through the lining and into the muscular wall of the bladder. This is known as invasive cancer. Invasive cancer may extend through the bladder wall. It may grow into a nearby organ such as the uterus or vagina (in women) or the prostate gland (in men). It also may invade the wall of the abdomen. When bladder cancer spreads outside the bladder, cancer cells are often found in nearby lymph nodes. If the cancer has reached these nodes, cancer cells may have spread to other lymph nodes or other organs, such as the lungs, liver, or bones.Some of the lymphnode spread like para-aortic lymphnodes or nodes at the aortic bifurcation may denote the metastatic disease precluding surgery and indicating the need of chemotherapy rather than a curative option. When cancer spreads from its original place to another part of the body, the disease is metastatic bladder cancer. Less than 10% of the carcinomas are squamous cell carcinoma or adenocarcinoma. In underdeveloped nations, SCC is associated with bladder infection by Schistosoma haematobium(In india, this infection is found at the coastal belt of Maharashtra region) . Adenocarcinomas account for less than 2% of primary bladder tumors. These tumors are observed most commonly in exstrophic bladders and respond poorly to radiation and chemotherapy. Radical cystectomy is the treatment of choice. Small cell carcinomas are extremely aggressive tumors associated with a poor prognosis and are thought to arise from neuroendocrine stem cells. Pathophysiology The World Health Organization classifies bladder cancers as low grade (grade 1 and 2) or high grade (grade 3). Tumors are also classified by growth patterns: papillary (70%), sessile or mixed (20%), and nodular (10%). Carcinoma in situ (CIS) is a flat, noninvasive, high-grade urothelial carcinoma. The most significant prognostic factors for bladder cancer are grade, depth of invasion, and the presence of CIS. Upon presentation, 55-60% of patients have low-grade superficial disease, which is usually treated conservatively with transurethral resection and periodic cystoscopy. Forty to forty-five percent of patients have high-grade disease, of which 50% is muscle invasive and is typically treated with radical cystectomy. Bladder cancer: Who's at risk? No one knows the exact causes of bladder cancer. However, it is clear that this disease is not contagious. People who get bladder cancer are more likely than other people to have certain risk factors. Still, most people with known risk factors do not get bladder cancer, and many who do get this disease have none of these factors( so a clear cut cause and effect relationship may not be obtained in all cases). Doctors always find themselves in dilemma when a patient asks why he got the disease and ends up in answering a multifactorial cause for the cancer. Studies have found the following risk factors for bladder cancer: 1. Age. The chance of getting bladder cancer goes up as people get older. People under 40 rarely get this disease. 2. Sex: Men are likelier to get the disease than the females(3-4:1) 3. Tobacco. The use of tobacco is a major risk factor. Cigarette smokers are two to three times more likely than nonsmokers to get bladder cancer. Pipe and cigar smokers are also at increased risk. 
4. Occupation. Some workers have a higher risk of getting bladder cancer because of carcinogens in the workplace. Workers in the rubber, chemical, and leather industries are at risk. So are hairdressers, machinists, metal workers, printers, painters, textile workers, and truck drivers. 5. Infections. Being infected with certain parasites(like scistosomiasis) increases the risk of bladder cancer. 6. Treatment with cyclophosphamide or arsenic. These drugs are used to treat cancer and some other conditions. They raise the risk of bladder cancer. 7. Race. Whites get bladder cancer twice as often as African Americans and Hispanics. The lowest rates are among Asians. 8. Family history. People with family members who have bladder cancer are more likely to get the disease. Certain genes have been identified as the cause for the development or progress of the disease. Symptoms of bladder cancer Common symptoms of bladder cancer include: • Blood in the urine (making the urine slightly rusty to deep red), • Pain during urination • Frequency, or urgency. • Dysuria- especially if Carcinoma in Situ has been the cause • Weak stream: especially if bladder neck region is affected as in our second case. • Flank pain: In case of bladder tumor blocking one of the orifices the kidney can get swelled up(Hydro-ureteronephrosis) and the patient can have the flank pain because of that reason. These symptoms are not sure signs of bladder cancer. Infections, benign tumors, bladder stones, also can cause these symptoms. Anyone with these symptoms should see a doctor so that the doctor can diagnose and treat any problem as early as possible. Diagnosis of bladder cancer • Physical exam -- The doctor feels the abdomen and pelvis for tumors. The physical exam may include a rectal or vaginal exam; this is useful in advanced disease spreading to the pelvic wall precluding probably a complete resection(so called R0 resection). • Urine tests -- The laboratory checks the urine for blood, cytology. • Intravenous pyelogram/ CT UROGRAPHY: The radiologist injects the dye(radio-contrast one) to delieneate the kidneys and bladder region mainly for assessing the upper tracts. As the bladder cancer has a tendency for a field change (it may affect many regions of the genitourinary tract simultaneously or metachronously) the imaging can detect such changes. The CT urography/MRI is now-a-days more and more resorted to for its reliability in staging the local disease.It also vaguely indicates the lymphnode status 
• Cystoscopy – An endoscope is inserted into the bladder through the urethra to examine the lining of the bladder. The patient may need anesthesia for this procedure as the same sitting can be utilized for diagnosis/biopsy/complete resection of a superficial tumor. Staging The following is the TNM staging system for bladder cancer: • CIS - Carcinoma in situ, high-grade dysplasia, confined to the epithelium • Ta - Papillary tumor confined to the epithelium • T1 - Tumor invasion into the lamina propria • T2 - Tumor invasion into the muscularis propria • T3 - Tumor involvement of the perivesical fat • T4 - Tumor involvement of adjacent organs such as prostate, rectum, or pelvic sidewall • N+ - Lymph node metastasis • M+ - Metastasis More than 70% of all newly diagnosed bladder cancers are non–muscle invasive, approximately 50-70% are Ta, 20-30% are T1, and 10% are CIS. Approximately 5% of patients present with metastatic disease, which commonly involves the lymph nodes, lung, liver, bone, and central nervous system. Approximately 25% of affected patients have muscle-invasive disease at diagnosis. 
Treatment • Ta, T1, and CIS Endoscopic treatment Transurethral resection of bladder tumor (TURBT) is the first-line treatment to diagnose, to stage, and to treat visible tumors. Patients with bulky, high-grade, or multifocal tumors should undergo a second procedure to ensure complete resection and accurate staging. Approximately 50% of stage T1 tumors are upgraded to muscle-invasive disease.This procedure is called as Relook TURBT and is usually undertaken after a period of 4 weeks to restage the disease Because bladder cancer is a polyclonal field change defect, continued surveillance is mandatory with IVP/CT Urography for upper tract affections. Radical cystectomy Muscle-invasive disease (T2 and greater) Radical cystoprostatectomy (men) Removes the bladder, prostate, and pelvic lymph nodes. a total urethrectomy involvement of the prostatic stroma High-grade T1 tumors that recur despite BCG have a 50% likelihood of progressing to muscle-invasive disease. Cystectomy performed prior to progression yields a 90% 5-year survival rate. The 5-year survival rate drops to 50-60% in muscle-invasive disease. Patients with not amenable for large superficial tumors( in our second case), prostatic urethra involvement, and BCG failure( these people have aggressive tumour) should also undergo radical cystectomy. Anterior pelvic exenteration (women) Perform this procedure in women diagnosed with muscle-invasive bladder cancer. The procedure involves removal of the bladder, urethra, uterus, ovaries, anterior vaginal wall, and pelvic lymph nodes. If no tumor involvement of the bladder neck is present, the urethra and anterior vaginal wall may be spared with the construction of an orthotopic neobladder. • In our second case as the bladder neck was involved and the anterior vaginal wall was appearing adherent the bladder neck, the proximal urethra with anterior vaginal wall was removed. The vagina was reconstructed using the posterior vaginal wall folding onto itself anteriorly making a vaginal stump. Pelvic lymphadenectomy Approximately 25% of patients undergoing radical cystectomy have lymph node metastases at the time of surgery. Bilateral pelvic lymphadenectomy (PLND) should be performed in conjunction with radical cystoprostatectomy and anterior pelvic exenteration. PLND adds prognostic information by appropriately staging the patient and may confer a therapeutic benefit. The boundaries of a standard PLND include the bifurcation of the common iliac artery and vein superiorly, the genitofemoral nerve laterally, the obturator fossa posteriorly, and the circumflex iliac vein (or node of Cloquet) inferiorly. Some surgeons routinely do extended lymphadenectomy till aortic bifurcation. There is some evidence(although no randomized controlled studies to show the benefit) that it gives the survival benefit After performing a cystectomy, a urinary diversion must be created from an intestinal segment. The various types of urinary diversions can be separated into the following continent and incontinent diversions: Conduit (incontinent diversion;): Conduits can be constructed from either ileum or colon. The ileal conduit is the most common incontinent diversion performed and has been used for more than 40 years with excellent reliability and minimal morbidity. A small segment of ileum (at least 15 cm proximal to the ileocecal valve) is taken out of gastrointestinal continuity but maintained on its mesentery, with care to preserve its blood supply. The gastrointestinal tract is restored with a small-bowel anastomosis. The ureters are anastomosed to an end or side of this intestinal segment and the other end is brought out as a stoma to the abdominal wall. Urine continuously collects in an external collection device worn over the stoma. 
We usually follow the Wallace technique where the ureters are anastomosed to the end of the ileal conduit. Indiana pouch (continent diversion): This is a continent urinary reservoir created from a detubularized right colon and an efferent limb of terminal ileum. The terminal ileum is plicated and brought to the abdominal wall. The ileocecal valve acts as a continence mechanism. The Indiana pouch is emptied with a clean intermittent catheterization 4-6 times per day. 
Neobladder (continent diversion; see image below): Various segments of intestine including ileum, ileum and colon, and sigmoid colon can be used to construct a reservoir. The ureters are implanted to the reservoir, and the reservoir is anastomosed to the urethra. This operation has been performed successfully in men for more than 20 years and, more recently, in women(Our experience with women has not been exactly good so we continue to offer traditional Ileal conduit for women.). The orthotopic neobladder most closely restores the natural storage and voiding function of the native bladder. Patients have volitional control of urination and void by Credes maneuver- pressing anterior abdominal wall/Valsalva. Contraindications to performing continent urinary diversions include renal and liver dysfunction,comorbidities,impaired dexterity(in case if a man/woman needs self catheterization to empty the bladder then it will be problematic for such patients with handicap) 
Laparoscopic and robotic surgery Recently, laparoscopic and robotic-assisted radical cystectomies have been performed in small numbers at select academic (PRIVATE HOSPITALS cannot afford ) centers. The urinary diversion is almost universally performed extracorporeally through a miniature laparotomy incision. Radiation therapy External beam radiation therapy has been shown to be inferior to radical cystectomy for the treatment of bladder cancer. The overall 5-year survival rate after treatment with external beam radiation is 20-40% compared to a 90% 5-year survival after cystectomy for organ-confined disease. Neoadjuvant external beam radiation therapy has been attempted for muscle-invasive bladder cancer, with no improvement in survival rate. In certain facilities, a bladder-preserving strategy for selective cases of urothelial carcinoma(small focal T2 disease away from ureteric orifices with good perforamce scale so as to tolerate the combination of radiotherapy and chemotherapy) is applied using a combination of external beam radiation, chemotherapy, and endoscopic resection. Survival rates associated with this approach are comparable with those of cystectomy in selected patients. This combination has a widespread application that is limited by the complexity of the protocol, its toxicity, and a high mortality rate. The advantage is bladder is preserved with similar survival rates but few patients ultimately require salvage cystectomy, which is associated with significantly increased morbidity and decreased options for urinary diversions.As the post-chemotherapy radical cystectomy is difficult surgery to perform for want of surgical planes and lot of post-chemotherapy/radiotherapy fibrosis •Segmental cystectomy: In some patients where the bladder growth is at the apex enblock segmental cystectomy can be done with pelvic lymphnode dissection.A very few patients qualify for the such surgery.Anyhow this surgery gives similar results like radical cystectomy. Post –TUR the patient may have blood in urine for few days or burning micturition which usually subsides on itself. Bladder cancer surgery may affect a person's sexual function. Because the surgeon removes the uterus and ovaries in a radical cystectomy, women are not able to get pregnant. Also, menopause occurs at once. Hot flashes and other symptoms of menopause caused by surgery may be more severe than those caused by natural menopause. Many women take hormone replacement therapy (HRT) to relieve these problems. If the surgeon removes part of the vagina during a radical cystectomy, sexual intercourse may be difficult because of short vaginal stump. In the past, nearly all men were impotent after radical cystectomy, but improvements in surgery have made it possible for some men to avoid this problem. The introduction of nerve sparing radical cystectomy tries to preserve the potency. Men who have had their prostate gland and seminal vesicles removed no longer produce semen, so they have dry orgasms. Men who wish to father children may consider sperm banking before surgery or sperm retrieval later on. Radiation therapy uses high-energy rays to kill cancer cells. Like surgery, radiation therapy is local therapy. It affects cancer cells only in the treated area. • External radiation:. Most people receiving external radiation are treated 5 days a week for 5 to 7 weeks as an outpatient. This schedule helps protect healthy cells and tissues by spreading out the total dose of radiation. • external radiation may permanently darken or "bronze" the skin in the treated area. Patients usually lose hair in the treated area and their skin may become erythematous, dry, tender, and itchy. • Radiation therapy to the abdomen may cause nausea, vomiting, diarrhea, or urinary discomfort. • Radiation therapy also may cause a decrease in the number of white blood cells (neutropenia), cells that help protect the body against infection. If the blood counts are low, the radiation oncologist may start Granulocyte Stimulating Factor and withhold the radiation therapy till the neutropenis recovers. • For both men and women, radiation treatment for bladder cancer can affect sexuality. Women may experience vaginal dryness, and men may have difficulty with erections. Medical Care The treatment of non–muscle-invasive (Ta, T1, CIS) and muscle-invasive bladder cancer should be differentiated. Treatments within each category include both surgical and medical approaches. • Non–muscle-invasive disease (Ta, T1, CIS) o Intravesical immunotherapy (Bacillus Calmette-Guérin [BCG] immunotherapy) BCG immunotherapy is used in the treatment of Ta(high grade), T1(all grades), and CIS urothelial carcinoma of the bladder and may help to decrease the rate of recurrence and progression. BCG immunotherapy is the most effective intravesical therapy and involves a live attenuated strain of Mycobacterium bovis. BCG induces a nonspecific, cytokine-mediated immune response to foreign protein. Because BCG is a live attenuated organism, it can cause an acute disseminated tuberculosis like illness if it enters the bloodstream (BCG sepsis), possibly resulting in death. Therefore, the use of BCG is contraindicated in patients with gross hematuria.The patient should be under surveillance after the BCG instillation.The procedure should be avoided if during the catheter introduction during the instillation causes bleeding BCG typically causes mild systemic symptoms that resolve within 24-48 hours after intravesical instillation. BCG can also cause granulomatous cystitis or prostatitis with bladder contraction. Typically, BCG is administered weekly for 6 weeks. Another 6-week course may be administered if a repeat cystoscopy reveals tumor persistence or recurrence. Interferon alpha or gamma has been used in the treatment of stages Ta, T1 and CIS urothelial carcinoma, either as a single agent therapy or in combination with BCG. Its role has primarily been in post-BCG failure with early promising results. Although BCG with interferon has shown a 42% response with tolerable side effects after BCG failure, no evidence has indicated that re-treating with BCG with interferon is superior to re-treating with BCG alone. oIntravesical chemotherapy Valrubicin has recently been approved as intravesical chemotherapy for CIS that is refractory to BCG. In patients whose conditions do not respond to BCG, the overall response rate to valrubicin is approximately 20%, and some patients can delay time to cystectomy. Other forms of adjuvant intravesical chemotherapy for bladder cancer mitomycin-C, doxorubicin, and epirubicin. There has been evidence to suggest that immediate peri-operative instillation of the mitomicin may prevent recurrence upto 40% of the cases. •Muscle-invasive disease (T2 and greater) o Adjuvant and neoadjuvant chemotherapy Neoadjuvant chemotherapy prior to either radical cystectomy or external beam radiotherapy is controversial. The Southwestern Oncology Group (SWOG) conducted a multicenter randomized prospective study that compared neoadjuvant therapy using a methotrexate, vinblastine, doxorubicin (Adriamycin), and cisplatin (MVAC) combination with surgery alone. The group concluded that neoadjuvant therapy conferred a treatment benefit compared with surgery alone. oChemotherapeutic agents for metastatic disease MVAC is the standard treatment of metastatic bladder cancer. MVAC has an objective response rate of 57-70%, a complete response rate of 15-20%, and a 2-year survival rate of 15-20%. Gemcitabine and cisplatin (GC) is a newer regimen and has been shown to be as efficacious as MVAC, but with less toxicity. GC is now considered a first-line treatment agent for bladder cancer. Prognosis: • As many as 50% of patients with muscle-invasive bladder cancer may have occult metastases that become clinically apparent within 5 years of initial diagnosis. • Most patients with overt metastatic disease die within 2 years despite chemotherapy. • Approximately 25-30% of patients with only limited regional lymph node metastasis discovered during cystectomy and pelvic lymph node dissection may survive beyond 5 years. Surveillance: Several reviews have been performed to assess the myriad urine markers proposed for bladder cancer surveillance. While FISH and NMP-22 are promising, the clinical evidence is insufficient to warrant the substitution of the cystoscopic follow-up scheme with any of the currently available urine marker tests.NMP-22 may have a role in low grade bladder cancers where cytology sometimes shows nothing.
case 1: Radical cystectomy:excised bladder specimen showing mass in the bladder and the urethra held with the clamp We have discussed about these two cases as the bladder cancer can present in various stages and the treatment is also tailored upon the staging, the grading and the patients wellbeing (and sometimes choice - especially as far intestinal diversion is concerned ;if it doesnot compromise the oncological safety). Anatomy of the bladder 
The bladder is a hollow organ in the lower abdomen. It stores urine, the urine produced by the kidneys. Urine passes from each kidney into the bladder through a long cylindrical tube called a ureter. Urine leaves the bladder through another tube, the urethra. Understanding bladder cancer The wall of the bladder is lined with cells called transitional cells and squamous cells. More than 90 percent of bladder cancers begin in the transitional cells. This type of bladder cancer is called transitional cell carcinoma. 
Cancer that is only in cells in the lining of the bladder is called superficial bladder cancer. Cancer that begins as a superficial tumor may grow through the lining and into the muscular wall of the bladder. This is known as invasive cancer. Invasive cancer may extend through the bladder wall. It may grow into a nearby organ such as the uterus or vagina (in women) or the prostate gland (in men). It also may invade the wall of the abdomen. When bladder cancer spreads outside the bladder, cancer cells are often found in nearby lymph nodes. If the cancer has reached these nodes, cancer cells may have spread to other lymph nodes or other organs, such as the lungs, liver, or bones.Some of the lymphnode spread like para-aortic lymphnodes or nodes at the aortic bifurcation may denote the metastatic disease precluding surgery and indicating the need of chemotherapy rather than a curative option. When cancer spreads from its original place to another part of the body, the disease is metastatic bladder cancer. Less than 10% of the carcinomas are squamous cell carcinoma or adenocarcinoma. In underdeveloped nations, SCC is associated with bladder infection by Schistosoma haematobium(In india, this infection is found at the coastal belt of Maharashtra region) . Adenocarcinomas account for less than 2% of primary bladder tumors. These tumors are observed most commonly in exstrophic bladders and respond poorly to radiation and chemotherapy. Radical cystectomy is the treatment of choice. Small cell carcinomas are extremely aggressive tumors associated with a poor prognosis and are thought to arise from neuroendocrine stem cells. Pathophysiology The World Health Organization classifies bladder cancers as low grade (grade 1 and 2) or high grade (grade 3). Tumors are also classified by growth patterns: papillary (70%), sessile or mixed (20%), and nodular (10%). Carcinoma in situ (CIS) is a flat, noninvasive, high-grade urothelial carcinoma. The most significant prognostic factors for bladder cancer are grade, depth of invasion, and the presence of CIS. Upon presentation, 55-60% of patients have low-grade superficial disease, which is usually treated conservatively with transurethral resection and periodic cystoscopy. Forty to forty-five percent of patients have high-grade disease, of which 50% is muscle invasive and is typically treated with radical cystectomy. Bladder cancer: Who's at risk? No one knows the exact causes of bladder cancer. However, it is clear that this disease is not contagious. People who get bladder cancer are more likely than other people to have certain risk factors. Still, most people with known risk factors do not get bladder cancer, and many who do get this disease have none of these factors( so a clear cut cause and effect relationship may not be obtained in all cases). Doctors always find themselves in dilemma when a patient asks why he got the disease and ends up in answering a multifactorial cause for the cancer. Studies have found the following risk factors for bladder cancer: 1. Age. The chance of getting bladder cancer goes up as people get older. People under 40 rarely get this disease. 2. Sex: Men are likelier to get the disease than the females(3-4:1) 3. Tobacco. The use of tobacco is a major risk factor. Cigarette smokers are two to three times more likely than nonsmokers to get bladder cancer. Pipe and cigar smokers are also at increased risk. 
4. Occupation. Some workers have a higher risk of getting bladder cancer because of carcinogens in the workplace. Workers in the rubber, chemical, and leather industries are at risk. So are hairdressers, machinists, metal workers, printers, painters, textile workers, and truck drivers. 5. Infections. Being infected with certain parasites(like scistosomiasis) increases the risk of bladder cancer. 6. Treatment with cyclophosphamide or arsenic. These drugs are used to treat cancer and some other conditions. They raise the risk of bladder cancer. 7. Race. Whites get bladder cancer twice as often as African Americans and Hispanics. The lowest rates are among Asians. 8. Family history. People with family members who have bladder cancer are more likely to get the disease. Certain genes have been identified as the cause for the development or progress of the disease. Symptoms of bladder cancer Common symptoms of bladder cancer include: • Blood in the urine (making the urine slightly rusty to deep red), • Pain during urination • Frequency, or urgency. • Dysuria- especially if Carcinoma in Situ has been the cause • Weak stream: especially if bladder neck region is affected as in our second case. • Flank pain: In case of bladder tumor blocking one of the orifices the kidney can get swelled up(Hydro-ureteronephrosis) and the patient can have the flank pain because of that reason. These symptoms are not sure signs of bladder cancer. Infections, benign tumors, bladder stones, also can cause these symptoms. Anyone with these symptoms should see a doctor so that the doctor can diagnose and treat any problem as early as possible. Diagnosis of bladder cancer • Physical exam -- The doctor feels the abdomen and pelvis for tumors. The physical exam may include a rectal or vaginal exam; this is useful in advanced disease spreading to the pelvic wall precluding probably a complete resection(so called R0 resection). • Urine tests -- The laboratory checks the urine for blood, cytology. • Intravenous pyelogram/ CT UROGRAPHY: The radiologist injects the dye(radio-contrast one) to delieneate the kidneys and bladder region mainly for assessing the upper tracts. As the bladder cancer has a tendency for a field change (it may affect many regions of the genitourinary tract simultaneously or metachronously) the imaging can detect such changes. The CT urography/MRI is now-a-days more and more resorted to for its reliability in staging the local disease.It also vaguely indicates the lymphnode status 
• Cystoscopy – An endoscope is inserted into the bladder through the urethra to examine the lining of the bladder. The patient may need anesthesia for this procedure as the same sitting can be utilized for diagnosis/biopsy/complete resection of a superficial tumor. Staging The following is the TNM staging system for bladder cancer: • CIS - Carcinoma in situ, high-grade dysplasia, confined to the epithelium • Ta - Papillary tumor confined to the epithelium • T1 - Tumor invasion into the lamina propria • T2 - Tumor invasion into the muscularis propria • T3 - Tumor involvement of the perivesical fat • T4 - Tumor involvement of adjacent organs such as prostate, rectum, or pelvic sidewall • N+ - Lymph node metastasis • M+ - Metastasis More than 70% of all newly diagnosed bladder cancers are non–muscle invasive, approximately 50-70% are Ta, 20-30% are T1, and 10% are CIS. Approximately 5% of patients present with metastatic disease, which commonly involves the lymph nodes, lung, liver, bone, and central nervous system. Approximately 25% of affected patients have muscle-invasive disease at diagnosis. 
Treatment • Ta, T1, and CIS Endoscopic treatment Transurethral resection of bladder tumor (TURBT) is the first-line treatment to diagnose, to stage, and to treat visible tumors. Patients with bulky, high-grade, or multifocal tumors should undergo a second procedure to ensure complete resection and accurate staging. Approximately 50% of stage T1 tumors are upgraded to muscle-invasive disease.This procedure is called as Relook TURBT and is usually undertaken after a period of 4 weeks to restage the disease Because bladder cancer is a polyclonal field change defect, continued surveillance is mandatory with IVP/CT Urography for upper tract affections. Radical cystectomy Muscle-invasive disease (T2 and greater) Radical cystoprostatectomy (men) Removes the bladder, prostate, and pelvic lymph nodes. a total urethrectomy involvement of the prostatic stroma High-grade T1 tumors that recur despite BCG have a 50% likelihood of progressing to muscle-invasive disease. Cystectomy performed prior to progression yields a 90% 5-year survival rate. The 5-year survival rate drops to 50-60% in muscle-invasive disease. Patients with not amenable for large superficial tumors( in our second case), prostatic urethra involvement, and BCG failure( these people have aggressive tumour) should also undergo radical cystectomy. Anterior pelvic exenteration (women) Perform this procedure in women diagnosed with muscle-invasive bladder cancer. The procedure involves removal of the bladder, urethra, uterus, ovaries, anterior vaginal wall, and pelvic lymph nodes. If no tumor involvement of the bladder neck is present, the urethra and anterior vaginal wall may be spared with the construction of an orthotopic neobladder. • In our second case as the bladder neck was involved and the anterior vaginal wall was appearing adherent the bladder neck, the proximal urethra with anterior vaginal wall was removed. The vagina was reconstructed using the posterior vaginal wall folding onto itself anteriorly making a vaginal stump. Pelvic lymphadenectomy Approximately 25% of patients undergoing radical cystectomy have lymph node metastases at the time of surgery. Bilateral pelvic lymphadenectomy (PLND) should be performed in conjunction with radical cystoprostatectomy and anterior pelvic exenteration. PLND adds prognostic information by appropriately staging the patient and may confer a therapeutic benefit. The boundaries of a standard PLND include the bifurcation of the common iliac artery and vein superiorly, the genitofemoral nerve laterally, the obturator fossa posteriorly, and the circumflex iliac vein (or node of Cloquet) inferiorly. Some surgeons routinely do extended lymphadenectomy till aortic bifurcation. There is some evidence(although no randomized controlled studies to show the benefit) that it gives the survival benefit After performing a cystectomy, a urinary diversion must be created from an intestinal segment. The various types of urinary diversions can be separated into the following continent and incontinent diversions: Conduit (incontinent diversion;): Conduits can be constructed from either ileum or colon. The ileal conduit is the most common incontinent diversion performed and has been used for more than 40 years with excellent reliability and minimal morbidity. A small segment of ileum (at least 15 cm proximal to the ileocecal valve) is taken out of gastrointestinal continuity but maintained on its mesentery, with care to preserve its blood supply. The gastrointestinal tract is restored with a small-bowel anastomosis. The ureters are anastomosed to an end or side of this intestinal segment and the other end is brought out as a stoma to the abdominal wall. Urine continuously collects in an external collection device worn over the stoma. 
We usually follow the Wallace technique where the ureters are anastomosed to the end of the ileal conduit. Indiana pouch (continent diversion): This is a continent urinary reservoir created from a detubularized right colon and an efferent limb of terminal ileum. The terminal ileum is plicated and brought to the abdominal wall. The ileocecal valve acts as a continence mechanism. The Indiana pouch is emptied with a clean intermittent catheterization 4-6 times per day. 
Neobladder (continent diversion; see image below): Various segments of intestine including ileum, ileum and colon, and sigmoid colon can be used to construct a reservoir. The ureters are implanted to the reservoir, and the reservoir is anastomosed to the urethra. This operation has been performed successfully in men for more than 20 years and, more recently, in women(Our experience with women has not been exactly good so we continue to offer traditional Ileal conduit for women.). The orthotopic neobladder most closely restores the natural storage and voiding function of the native bladder. Patients have volitional control of urination and void by Credes maneuver- pressing anterior abdominal wall/Valsalva. Contraindications to performing continent urinary diversions include renal and liver dysfunction,comorbidities,impaired dexterity(in case if a man/woman needs self catheterization to empty the bladder then it will be problematic for such patients with handicap) 
Laparoscopic and robotic surgery Recently, laparoscopic and robotic-assisted radical cystectomies have been performed in small numbers at select academic (PRIVATE HOSPITALS cannot afford ) centers. The urinary diversion is almost universally performed extracorporeally through a miniature laparotomy incision. Radiation therapy External beam radiation therapy has been shown to be inferior to radical cystectomy for the treatment of bladder cancer. The overall 5-year survival rate after treatment with external beam radiation is 20-40% compared to a 90% 5-year survival after cystectomy for organ-confined disease. Neoadjuvant external beam radiation therapy has been attempted for muscle-invasive bladder cancer, with no improvement in survival rate. In certain facilities, a bladder-preserving strategy for selective cases of urothelial carcinoma(small focal T2 disease away from ureteric orifices with good perforamce scale so as to tolerate the combination of radiotherapy and chemotherapy) is applied using a combination of external beam radiation, chemotherapy, and endoscopic resection. Survival rates associated with this approach are comparable with those of cystectomy in selected patients. This combination has a widespread application that is limited by the complexity of the protocol, its toxicity, and a high mortality rate. The advantage is bladder is preserved with similar survival rates but few patients ultimately require salvage cystectomy, which is associated with significantly increased morbidity and decreased options for urinary diversions.As the post-chemotherapy radical cystectomy is difficult surgery to perform for want of surgical planes and lot of post-chemotherapy/radiotherapy fibrosis •Segmental cystectomy: In some patients where the bladder growth is at the apex enblock segmental cystectomy can be done with pelvic lymphnode dissection.A very few patients qualify for the such surgery.Anyhow this surgery gives similar results like radical cystectomy. Post –TUR the patient may have blood in urine for few days or burning micturition which usually subsides on itself. Bladder cancer surgery may affect a person's sexual function. Because the surgeon removes the uterus and ovaries in a radical cystectomy, women are not able to get pregnant. Also, menopause occurs at once. Hot flashes and other symptoms of menopause caused by surgery may be more severe than those caused by natural menopause. Many women take hormone replacement therapy (HRT) to relieve these problems. If the surgeon removes part of the vagina during a radical cystectomy, sexual intercourse may be difficult because of short vaginal stump. In the past, nearly all men were impotent after radical cystectomy, but improvements in surgery have made it possible for some men to avoid this problem. The introduction of nerve sparing radical cystectomy tries to preserve the potency. Men who have had their prostate gland and seminal vesicles removed no longer produce semen, so they have dry orgasms. Men who wish to father children may consider sperm banking before surgery or sperm retrieval later on. Radiation therapy uses high-energy rays to kill cancer cells. Like surgery, radiation therapy is local therapy. It affects cancer cells only in the treated area. • External radiation:. Most people receiving external radiation are treated 5 days a week for 5 to 7 weeks as an outpatient. This schedule helps protect healthy cells and tissues by spreading out the total dose of radiation. • external radiation may permanently darken or "bronze" the skin in the treated area. Patients usually lose hair in the treated area and their skin may become erythematous, dry, tender, and itchy. • Radiation therapy to the abdomen may cause nausea, vomiting, diarrhea, or urinary discomfort. • Radiation therapy also may cause a decrease in the number of white blood cells (neutropenia), cells that help protect the body against infection. If the blood counts are low, the radiation oncologist may start Granulocyte Stimulating Factor and withhold the radiation therapy till the neutropenis recovers. • For both men and women, radiation treatment for bladder cancer can affect sexuality. Women may experience vaginal dryness, and men may have difficulty with erections. Medical Care The treatment of non–muscle-invasive (Ta, T1, CIS) and muscle-invasive bladder cancer should be differentiated. Treatments within each category include both surgical and medical approaches. • Non–muscle-invasive disease (Ta, T1, CIS) o Intravesical immunotherapy (Bacillus Calmette-Guérin [BCG] immunotherapy) BCG immunotherapy is used in the treatment of Ta(high grade), T1(all grades), and CIS urothelial carcinoma of the bladder and may help to decrease the rate of recurrence and progression. BCG immunotherapy is the most effective intravesical therapy and involves a live attenuated strain of Mycobacterium bovis. BCG induces a nonspecific, cytokine-mediated immune response to foreign protein. Because BCG is a live attenuated organism, it can cause an acute disseminated tuberculosis like illness if it enters the bloodstream (BCG sepsis), possibly resulting in death. Therefore, the use of BCG is contraindicated in patients with gross hematuria.The patient should be under surveillance after the BCG instillation.The procedure should be avoided if during the catheter introduction during the instillation causes bleeding BCG typically causes mild systemic symptoms that resolve within 24-48 hours after intravesical instillation. BCG can also cause granulomatous cystitis or prostatitis with bladder contraction. Typically, BCG is administered weekly for 6 weeks. Another 6-week course may be administered if a repeat cystoscopy reveals tumor persistence or recurrence. Interferon alpha or gamma has been used in the treatment of stages Ta, T1 and CIS urothelial carcinoma, either as a single agent therapy or in combination with BCG. Its role has primarily been in post-BCG failure with early promising results. Although BCG with interferon has shown a 42% response with tolerable side effects after BCG failure, no evidence has indicated that re-treating with BCG with interferon is superior to re-treating with BCG alone. oIntravesical chemotherapy Valrubicin has recently been approved as intravesical chemotherapy for CIS that is refractory to BCG. In patients whose conditions do not respond to BCG, the overall response rate to valrubicin is approximately 20%, and some patients can delay time to cystectomy. Other forms of adjuvant intravesical chemotherapy for bladder cancer mitomycin-C, doxorubicin, and epirubicin. There has been evidence to suggest that immediate peri-operative instillation of the mitomicin may prevent recurrence upto 40% of the cases. •Muscle-invasive disease (T2 and greater) o Adjuvant and neoadjuvant chemotherapy Neoadjuvant chemotherapy prior to either radical cystectomy or external beam radiotherapy is controversial. The Southwestern Oncology Group (SWOG) conducted a multicenter randomized prospective study that compared neoadjuvant therapy using a methotrexate, vinblastine, doxorubicin (Adriamycin), and cisplatin (MVAC) combination with surgery alone. The group concluded that neoadjuvant therapy conferred a treatment benefit compared with surgery alone. oChemotherapeutic agents for metastatic disease MVAC is the standard treatment of metastatic bladder cancer. MVAC has an objective response rate of 57-70%, a complete response rate of 15-20%, and a 2-year survival rate of 15-20%. Gemcitabine and cisplatin (GC) is a newer regimen and has been shown to be as efficacious as MVAC, but with less toxicity. GC is now considered a first-line treatment agent for bladder cancer. Prognosis: • As many as 50% of patients with muscle-invasive bladder cancer may have occult metastases that become clinically apparent within 5 years of initial diagnosis. • Most patients with overt metastatic disease die within 2 years despite chemotherapy. • Approximately 25-30% of patients with only limited regional lymph node metastasis discovered during cystectomy and pelvic lymph node dissection may survive beyond 5 years. Surveillance: Several reviews have been performed to assess the myriad urine markers proposed for bladder cancer surveillance. While FISH and NMP-22 are promising, the clinical evidence is insufficient to warrant the substitution of the cystoscopic follow-up scheme with any of the currently available urine marker tests.NMP-22 may have a role in low grade bladder cancers where cytology sometimes shows nothing.
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