Surgery for invasive bladder cancer.

Bladder substitution, in whole or in part, represents a growing field within the specialty of surgery. The principles and procedures associated with bladder augmentation are well established and include the use of spatulated, rather than intact, bowel segments and appreciation of the importance of adequate protection of the augmented bladder from urinary extravasation by means of both the suprapubic and ureteral catheter drainage. The principles pertinent to continent urinary diversion by means of total bladder replacement have not been as well defined. Problems still exist with each of the described procedures. There has yet to be an operative technique that will allow for orthotopic micturition that is free from the difficulty of enuresis. With those operations employing a continent abdominal stoma requiring intermittent catheterization, the competence of the continence mechanism is not assured in every case. Nevertheless, the psychologic advantages of freedom from urinary collection devices can stimulate patients to seek out total bladder substitution when facing cystectomy. An additional large patient group already diverted by means of urinary conduits is seeking conversion to total bladder substitution. It is certain that this large patient population will stimulate the operative technique of bladder substitution so that we will have a dependable procedure to employ in future years.