Urological Surgery

Bladder cancer is one of the most common cancers in 6th rank globally, affecting approximately 131,000 adults in European Union and 74,000 adults in the United States each year. The organs through which urine is transported from kidneys and stored and expelled from the body constitute urinary system. Together with male reproductive system it is referred as Genito Urinary System which constitutes the main interest of Urology.

Genito Urinary System is composed of:

• In Women: Kidneys; Ureters, tubes that transport urine to the Bladder, where urine is stored and removed; Urethra, the tube that transports urine outside the body
• In Men: In addition to the organs in the female there are prostate and seminal vesicles below bladder; urethra; penis and testicles which constitute genitourinary system.

Thus, both in males and females, diseases of bladder are the concern of Urology.

Bladder cancer occurs 3 to 4 times more in men than it does in women; nevertheless, it is more often at an advanced stage in women than men when initially diagnosed.

Why Bladder Cancer is Diagnosed at An Advanced Stage in Women?

1. Blood in urine, hematuria, is the most prominent symptom of bladder cancer in both gender. However, many women mistake it as menstruation and do not refer urology.
2. Unfortunately, those worried about usually consult their gynecologists and thus urologists meet in a rather advanced stage of cancer.
3. Painful urination and frequent urination are among other symptoms of bladder cancer. These symptoms are frequently misconfused with infections of urinary tract and women diagnose themselves as cystitis. Thus, disease advances before an appointment with a urologist.
4. Bladder wall is thinner in women when compared to men. Bladder wall gets thicker with prostatic enlargement in the 5th and 6th decades in men, making cancer cells more difficult to invade deeper layers of bladder. On the other hand, as bladder wall in elder women gets thinner due to hormonal changes it is easier for cancer cells to penetrate deeper layers of bladder.

Treatment

Following initial diagnosis, a TUR BT (Trans Urethral Resection of Bladder Tumor) must be performed to excise the tumor and pathologic examination. This should be performed by an experienced urologic surgeon dealing with malignancy as bladder wall is thinner in women and the surgeon must not perforate the bladder to prevent spillage of cancer cells.

Radical cystectomy has to be performed if pathologic assessment yields a cancer invading the muscle layer of bladder (T2) or a high volume (T1) tumor. This surgery comprises complete removal of bladder together with distal part of ureters, uterus, ovaries, part of vagina in conjunction with lymph nodes adjacent to great vessels. After bladder removal, either a small segment of small intestine is utilized to conduct urine from kidneys to a collecting bag outside the body or a new bladder is constructed from a longer segment of small intestine. The first is named as Ileal Conduit and the latter is called Orthotopic Neobladder. In Orthotopic Neobladder surgery, given the condition that there is no renal and hepatic insufficiency and the cancer has not invaded urethra (the distal tube-like organ which transports urine from bladder) a sphere is constructed from a portion of small intestine that is attached to urethra. This provides a normal urine storage and urination; in this way keeps the patient from wearing an external urine collecting bag.