Review articleFollow-up strategies and management of recurrence in urologic oncology bladder cancer:: Invasive bladder cancer
Section snippets
Local recurrence
A local recurrence following cystectomy is defined as disease that recurs within the surgical bed or the regional pelvic lymph nodes. This includes involvement of the pelvic soft tissues and lymph nodes below the aortic bifurcation. Nodes above the aortic bifurcation or within the inguinal region typically are classified as distant metastatic disease. Urethral and upper tract recurrences are excluded in this portion of the discussion because they represent a different biologic process of
Distant recurrences
Despite optimal surgical intervention, up to 50% of patients undergoing cystectomy subsequently will relapse with distant disease [6], [15], [17], [18], [19], [20]. The important tumor characteristics associated with the development of a distant recurrence have been recognized since Jewett and Strong's early work [21] and are related to the depth of tumor invasion and the status of the regional lymph nodes. Recurrence rates at 5 years for less than or equal to P1, P2, P3, and P4 lesions are 15%
Natural history
The risk of upper tract recurrence (UTR) in the overall population of patients with invasive bladder cancer is relatively low at 2% to 4%, irrespective of diversion type [38], [39], [40], [41], [42], [43], [44], [45]. However, high-risk groups may be identified with tumors recurring in the renal pelvis (45%–80%), ureters (20%–29%), or in both sites concomitantly (12%–27%) [39], [40], [45], [46]. Median time to recurrence ranges from 22 to 40 months [38], [39], [40], [41], [45]. Surveillance
Natural history
The incidence of urethral recurrence after radical cystectomy is 8% to 17%, occurring at a median of 1 to 3 years after surgery [42], [59], [60], [61], [62]. Early detection is the key to successful treatment outcome, justifying the importance of regular urethral surveillance, particularly in the patient with pT4a bladder disease or associated CIS. Histologies other than TCCA uncommonly affect the urethra unless local extension from the primary bladder lesion exists. With the increased emphasis
Metabolic complications
Metabolic complications related to the use of bowel for the construction of urinary diversions are well documented [74]. Malabsorption related to the resection of bowel and reabsorption of secreted urinary constituents underlie the observed abnormalities. The specific segment of bowel used, the length of bowel incorporated, exposure to prior radiation therapy, overall renal function, and the contact time between urine and bowel all determine the type and extent of electrolyte and acid-base
Summary
A surveillance program following cystectomy should consider a patient's individual risk for the development of local and distant recurrences and any specific needs related to the urinary tract reconstruction performed (Table 1). Well-documented recurrence patterns following cystectomy are available from many large surgical series and provide the background information needed for tailoring follow-up based on pathologic criteria. Economic issues also must be considered, given that the health
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