Editing Cystectomy (section)

==== Urethral Involvement ====
*'''<span style="color:#ff0000">Males</span>'''
**'''<span style="color:#ff0000">Urethral recurrence</span>'''
***Epidemiology
****Overall risk of urethral recurrence following cystectomy is ≈7% at 5 years and 9% at 10 years.
****Recurrences are observed at a median of 2 years after cystectomy (range 0.2-13 years)
*** '''<span style="color:#ff0000">Risk factors</span>'''
****'''<span style="color:#ff0000">Involvement of the prostatic urethra</span>''' 
*****Absolute risk increase 6% at 5 years (11% men with any prostate involvement vs. 5% men without any prostate tumour involvement
****** '''Patients with documented prostatic mucosal, ductal, or stromal invasion [found at TURBT of the primary tumour] should be counselled about the increased risk of urethral recurrence if the urethra is left in situ to help them weigh that risk against any perceived advantage of an orthotopic diversion'''
*****'''Extent of prostatic tumor involvement correlates with the risk of subsequent urethral recurrence.'''
****** 5-year risk of urethral recurrence 18% pT2 (stromal invasion) vs. 12% CIS or pT1 (mucosa and ductal prostatic urethral involvement)
******* Isolated prostatic stromal involvement is unusual in the absence of nodal disease
******'''In general, those with prostatic stromal invasion are counseled to undergo neoadjuvant chemotherapy'''
*******In those who are not candidates for neoadjuvant chemotherapy or who have persistent prostatic urethral involvement, at surgery a concomitant urethrectomy and cutaneous form of diversion are recommended. 
**** Other risk factors with mixed results
*****Presence of papillary tumours
*****Multifocality
*****Trigone or bladder neck involvement
*****CIS 
******'''The presence of [bladder] CIS or a multifocal tumor should not preclude orthotopic diversion'''
**** '''Some evidence suggests that orthotopic diversion itself may provide some protection against urethral recurrence'''
*****Close surveillance of the urethra is mandatory if a neobladder procedure is performed, with periodic urethral wash cytology and urethroscopy as indicated.
* '''<span style="color:#ff0000">Females</span>'''
** '''<span style="color:#ff0000">Risk factors for urethral involvement (3):</span>'''
**# '''<span style="color:#ff0000">Tumour involving bladder neck</span>'''
**#* In one study, ≈50% of women with bladder neck tumors had a normal (tumor-free) proximal urethra. No patient with a normal bladder neck demonstrated tumor involvement of the urethra. In all cases, intraoperative frozen-section analysis of the proximal urethra correlated with and was correctly confirmed by final permanent section. These results suggest that one may depend on the intraoperative frozen section to determine the feasibility of orthotopic diversion.
**# '''<span style="color:#ff0000">Tumour invading anterior vaginal wall</span>'''
**#* '''Vaginal wall involvement is best evaluated on bimanual examination under anesthesia at the time of TURBT or cystectomy.'''
**#* Anterior vaginal wall involvement by a posterior-based bladder tumor or bladder neck or urethra involvement is a contraindication to urethra sparing and orthotopic bladder replacement because one cannot get an adequate distal vaginal margin and urethra margin
**#'''<span style="color:#ff0000">Inguinal lymphadenopathy</span>'''