In most urologists' view, the principle treatment of MIBl is radical cystectomy combined with urinary diversion. Three types of urinary diversion are used, dependent on the patient's age, co-morbidity, mental status and extent of the disease.
12. Ileal conduit (IC) with an incontinent urostomia at the abdominal wall, which has to be covered by a plastic bag for urine collection.
13. Heterotopic bladder replacement (HBR). A continent reservoir is constructed from a bowel segment. The patients have to catheterize themselves at regular intervals through an abdominal stoma.
14. Orthotopic bladder replacement (OBR). A similar reservoir as in alternative 2 is anastomized with the remaining urethra, thus enabling a more 'natural' urine passage, and hopefully continence.
The typical morbidities after radical cystectomy are erectile dysfunction and disturbed sexual life on the one hand, and urinary leakage and stoma problems on the other.3-6 Change of body image and disturbed sexuality may be followed by decreased self-esteem.
High-dose radiotherapy is another therapeutic option which in non-randomized series seems to result in similar survival rates comparable to patients with small tumours (T2).7 An important condition for a favourable outcome of such an approach is the feasibility of qualified follow-up combined with salvage cystectomy if necessary. Typical radiotherapy related side-effects are diarrhoea due to the irradiated bowel, irritative symptoms from the bladder, dryness of the vagina and erectile dysfunction.
No large (>100 patients) prospective QL study has been reported in MIBl, but such results will be available in a few years' time. Several cross-sectional studies have been compared QL after the different types of urinary diversion and after radiotherapy. Three treatment-related dimensions have been assessed by specific modules: urinary symptoms, stoma problems, and sexuality. However, one has to consider that some of these domains may be affected already before any treatment is applied due to the disease itself, high age and/or co-morbidity.
Dependent on age and co-morbidity, 64% of the patients with MIBC recorded erectile dysfunction present before any treatment was given, and 51% recorded decreased libido.8 Urinary symptoms were present in 2661% of the patients with muscle-invasive bladder cancer before the start of any treatment.
Overall reduced sexual life represents the most frequently reported problem after cystectomy experienced by almost all patients, independent of the type of urinary diversion. Nerve-sparing operation techniques have been introduced in selected cases to reduce the incidence of this side-effect. Forty to fifty percent of patients with ileal conduit (IC) will experience stoma problems. Gerharz et al., supported by Okoda et al., demonstrated significant differences in patients with IC as compared to those with heterotopic bladder replacement (HBR) as to important specific dimensions and single item of global QL (Table 1).9,10 HBR seemed to be combined with more favourable outcomes. On the other hand, no significant difference
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