AGAINST BLADDER SPARING: SURGERY 457

This article highlights the recent advances now attainable with orthotopic urinary diversion following radical cystectomy for inva- sive bladder cancer. Montie specifically addresses the most common forms of bladder preserving strategies available today, including transurethral resection and combination strategies using systemic chemotherapy and external beam radiation as well as intravesical therapy in a salvage setting for late recurrences. A comparison between cystectomy and bladder preserving strategies is made with an emphasis on the limitations of these current strategies with respect to local control and pelvic recurrences. As noted in the article, uncertainties with respect to proper patient selection, fate of the retained bladder and limited long-term outcomes are justification for the use of bladder preservation outside of an experimental protocol in only a few select patients. Clearly radical cystectomy provides the best opportunity for eradication of the primary tumor. Furthermore, with the evolution of improved surgical techniques and specifi- cally with reports of acceptable long-term complication rates in pa- tients with orthotopic urinary diversion, the quality of life following cystectomy is expected to be quite acceptable.’ However, properly designed studies to define more accurately the quality of life after radical extirpative surgical procedures in combination with conti- nent diversion are still forthcoming.

Nevertheless, predicting the lethal potential of a muscle invasive bladder cancer remains a n inexact science. Clearly, local therapy alone is woefully inadequate for a large percentage of patients with invasive bladder cancer and the fact remains that deaths from blad- der cancers have remained stable or slightly increased during the last several years among men in the United States.* Therefore, this

review really demonstrates “the good, the bad, and the ugly” with respect to our current status with invasive cancer. On one hand, significant strides have been made towards improved quality of life through improved surgical techniques with reconstruction which closely approximates normal function in most cases. The bad news includes the lack of proved efficacy in trials using combined multi- modality approaches, including chemotherapy and radiotherapy in an adjuvant or neoadjuvant setting. And finally, the ugly reflects the ultimate progression of disease and cancer mortality which remain significant problems and in many cases appear to be independent of successful local control. However, the future appears bright, and strategies to impact morbidity and mortality from bladder cancer include chemoprevention, early detection, enhanced molecular stag- ing and more effective chemotherapy in combination with continued refinements in our surgical techniques.

Michael S. Cookson Department of Urologic Surgery Vanderbilt University Medical Center Nashville, Tennessee

1. Gburck, B. M., Lieber, M. M. and Blute, M. L.: Comparison of Studer ileal neobladder and ileal conduit urinary diversion with respect to perioperative outcome and late complications. J. Urol., 160 721, 1998.

2. Lamm, D. L.: Bladder cancer: twenty years of progress and the challenges that remain. CA, 4 8 263, 1998.