Part 1 Continent Diversions: The New Gold Standards of Ileoanal Reservoir and Neobladder
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Familial adenomatous polyposis is an inherited disorder in which the affected person's large intestine contains multiple polyps. The polyps have a virtually 100% chance of malignant degeneration. Familial polyposis occurs across the world at an incidence of 1:10,000 to 1:20,000 in the population.6,7 Conversely, CUC occurs mostly in the Scandinavian countries, Great Britain, and North America at a rate of 1 to 15 cases per 100,000 population or 1 in 160 people.8,9 Because of the substantially lower occurrence of FAP, not as many persons undergo IAR surgery for the disorder.
Ileoanal reservoir surgery is used in persons suffering from only one form of inflammatory bowel disease - CUC, a condition that affects the inner lining of the large intestine. The bleeding, pain, mucus, and other symptoms can be treated definitively if the diseased tissue is surgically removed - that is, by total colectomy. Chronic ulcerative colitis is also associated with a higher incidence of colon cancer development. About 5% of persons with ulcerative colitis develop colon cancer.10 The risk of malignant degeneration over time is eradicated when the entire large intestine is removed. Because CUC sufferers are often younger persons, the IAR offers eradication of a horrible disease state along with preservation of their native anal sphincters.
Ileoanal reservoir surgery is not performed in people with Crohn's disease because the disease potentially affects the entire gastro-intestinal tract, including the ileum. Some research suggests that complications (eg, anal complications) are associated with people who were later diagnosed with Crohn's disease.11 When people have indeterminate colitis (IC), it is not certain whether their disease is CUC or Crohn's.12 The challenge for future care is to develop better diagnostic tests to truly rule out Crohn's disease. Therefore, in a person with IC, the choice of pouch surgery as an option is left to the colorectal surgeon and the patient.3
Bladder cancer is the fourth most common cancer in men, the eighth most common cancer in women, and the sixth most common cause of cancer deaths in the US.13 The American Cancer Society estimates that in 2004, approximately 60,240 new cases of bladder cancer (44,640 men and 15,600 women) will be diagnosed in the US.13 Bladder cancer affects twice as many men as women. The incidence of bladder cancer rises dramatically with age among men and women in all populations. Rates among people 70 years old and older are about 15 to 20 times higher than those age 30 to 54 years.14 The disease is most often linked with cigarette smoking,15 which is known to increase a person's risk of bladder cancer by at least threefold. The length of time of smoking appears to be the most important predictor of that risk.16
Occupational exposures also contribute to bladder cancer, particularly a group of chemicals known as arylamines; therefore, occupations with exposure to arylamines, (dye workers, rubber workers, leather workers, truck drivers, painters, and aluminum workers) are at higher risk. Other risk factors include exposure to certain drugs like arsenic and cyclophosphamide, frequent urinary tract infections, and infections from the parasite, schistosomiasis.17
The most common histologic type of bladder tumor is the "transitional" cell or "urothelial" cell form. Eighty percent of bladder tumors are "superficial"; they do not invade the bladder wall. As long as it is superficial, the tumor can be controlled by periodic surveillance, instillation of intravesical chemotherapy, and/or transuretheral resection of the bladder tumor (TURBT).
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