Research Progress in Preoperative Evaluation of Lymph Node Metastasis of Bladder Cancer / 中国医学科学院学报

Bladder cancer is a common malignant tumor of the urinary system.The prognosis of patients with positive lymph nodes is worse than that of patients with negative lymph nodes.An accurate assessment of preoperative lymph node statushelps to make treatmentdecisions,such as the extent of pelvic lymphadenectomy and the use of neoadjuvant chemotherapy.Imaging examination and pathological examination are the primary methods used to assess the lymph node status of bladder cancer patients before surgery.However,these methods have low sensitivity and may lead to inaccuate staging of patients.We reviewed the research progress and made an outlook on the application of clinical diagnosis,imaging techniques,radiomics,and genomics in the preoperative evaluation of lymph node metastasis in bladder cancer patients at different stages.

Biochemical Relapse in Low-risk Prostate Cancer Treated with Radical Prostatectomy and Bilateral Pelvic Lymphadenectomy / Recaída bioquímica en cáncer de próstata de bajo riesgo tratado con prostatectomía radical y linfadenectomía pélvica bilateral

Introduction For low-risk prostate cancer (PCa), curative treatment with radical prostatectomy (RP) can be performed, reporting a biochemical relapse-free survival rate (bRFS) at 5 and 7 years of 90.1% and 88.3%, respectively. Prostatic specific antigen (PSA), pathological stage (pT), and positive margins (R1) are significant predictors of biochemical relapse (BR). Even though pelvic lymphadenectomy is not recommended during RP, in the literature, it is performed in 34% of these patients, finding 0.37% of positive lymph nodes (N1). In this study, we aim to evaluate the 10-year bRFS in patients with low-risk PCa who underwent RP and extended pelvic lymph node dissection (ePLND). Methodology All low-risk patients who underwent RP plus bilateral ePLND at the National Cancer Institute of Colombia between 2006 and 2019 were reviewed. Biochemical relapse was defined as 2 consecutive increasing levels of PSA > 0.2 ng/mL. A descriptive analysis was performed using the STATA 15 software (Stata Corp., College Station, TX, USA), and the Kaplan-Meier curves and uni and multivariate Cox proportional hazard models were used for the survival outcome analysis. The related regression coefficients were used for the hazard ratio (HR), and, for all comparisons, a two-sided p-value ˂ 0.05 was used to define statistical significance. Results Two hundred and two patients met the study criteria. The 10-year bRFS for the general population was 82.5%, statistically related to stage pT3 (p = 0.047), higher Gleason grade group (GG) (p ≤ 0.001), and R1 (p ≤ 0.001), but not with N1. A total of 3.9% of the patients had N1; of these, 75% had R1, 25% GG2, and 37% GG3. Among the N0 (non-lymph node metástasis in prostate cáncer) patients, 31% of the patients had R1, 41% GG2, and 13% GG3. Conclusions Our bRFS was 82.5% in low-risk patients who underwent RP and ePLND. With higher pT, GG, and presence of R1, the probability of BR increased. Those with pN1 (pathologicaly confirmed positive lymph nodes) were not associated with bRFS, with a pN1 detection rate of 3.9%. Details: In low-risk PCa, curative treatment with RP can be performed, reporting a bRFS rate at 5 and 7 years of 90.1% and 88.3%, respectively. Despite the fact that pelvic lymphadenectomy is not recommended during RP in clinical guidelines, in the literature, it is performed in 34% of these patients, finding 0.37% of N1. In this study, we report the 10-year bRFS in patients with low-risk PCa who underwent surgery.

Introducción En el cáncer de próstata (CaP) de bajo riesgo se puede realizar un tratamiento curativo mediante prostatectomía radical (PR), con una tasa de supervivencia libre de recaída bioquímica (SLRb) a 5 y 7 años del 90,1% y el 88,3%, respectivamente. El antígeno prostático específico (PSA), el estadio patológico (pT) y los márgenes positivos (R1) son predictores significativos de recaída bioquímica (BR). Aunque la linfadenectomía pélvica no está recomendada durante la PR, en la literatura se realiza en el 34% de estos pacientes, encontrándose un 0,37% de ganglios linfáticos positivos (N1). En este estudio, nuestro objetivo es evaluar la SLB a 10 años en pacientes con CaP de bajo riesgo sometidos a PR y disección ganglionar pélvica extendida (DGLPe). Metodología Se revisaron todos los pacientes de bajo riesgo sometidos a PR más ePLND bilateral en el Instituto Nacional de Cancerología de Colombia entre 2006 y 2019. La recaída bioquímica se definió como 2 niveles crecientes consecutivos de PSA > 0,2 ng/mL. Se realizó un análisis descriptivo utilizando el software STATA 15 (Stata Corp., College Station, TX, USA), y se utilizaron las curvas de Kaplan-Meier y los modelos uni y multivariados de riesgos proporcionales de Cox para el análisis de resultados de supervivencia. Los coeficientes de regresión relacionados se utilizaron para la hazard ratio (HR), y, para todas las comparaciones, se utilizó un valor p de dos caras ˂ 0,05 para definir la significación estadística. Resultados Doscientos dos pacientes cumplieron los criterios del estudio. La bRFS a 10 años para la población general fue del 82,5%, estadísticamente relacionada con el estadio pT3 (p = 0,047), mayor grupo de grado Gleason (GG) (p ≤ 0,001), y R1 (p ≤ 0,001), pero no con N1. Un total del 3,9% de los pacientes tenían N1; de ellos, el 75% tenían R1, el 25% GG2, y el 37% GG3. Entre los pacientes N0 (metástasis no ganglionar en el cáncer de próstata), el 31% de los pacientes tenían R1, el 41% GG2 y el 13% GG3. Conclusiones Nuestra SSEb fue del 82,5% en los pacientes de bajo riesgo que se sometieron a RP y ePLND. A mayor pT, GG y presencia de R1, mayor probabilidad de RB. Aquellos con pN1 (ganglios linfáticos patológicamente confirmados como positivos) no se asociaron con la SSEb, con una tasa de detección de pN1 del 3,9%. Detalles: En el CaP de bajo riesgo se puede realizar tratamiento curativo con PR, reportando una tasa de SSEb a 5 y 7 años de 90,1% y 88,3%, respectivamente. A pesar de que la linfadenectomía pélvica no está recomendada durante la PR en las guías clínicas, en la literatura se realiza en el 34% de estos pacientes, encontrando un 0,37% de N1. En este estudio, reportamos la SLB a 10 años en pacientes con CaP de bajo riesgo sometidos a cirugía.

The Clinical Observation of Pelvic lymphadenoetomy and Vaginal Radical Trachelectomy Procedure in both the Effect and Reproductive Outcome for 16 Cases of Early-stage Cervical Cancer / 实用妇产科杂志

Objective:To investigate the clinical effectiveness and reproductive outcome of fertility-preserving surgery(pelvic lymphadenoetomy +Vaginal radical trachelectomy(VRT)in women with early stage cervical cancer.Methods:A perspective observation of 16 patients who had undergone pelvic lymphadenoetomy + VRT with early stage cervical cancer(study group) since Jan 2011 to Dec 2015 was carried out.30 patients who undergone laparoscopic radical hysterectomy(LRH) + pelvic lymphadenoetomy with early stage cervical cancer were set as the control group.The clinical efficiency were compared between the two groups,and the cumulative pregnancy rate and pregnancy outcome were followed up in study group.Results:There was no statistic difference in age,clinical staging,pathologicalgrade,LVSI,SCC expression,operating-time,pastoper ationfever,operative complications,tumor recurrence between the two groups(P＞0.05).Compare to control group,the index of amount of bleeding was fewer and the average hospital stay was shorter in study group(P ＜ 0.05),12 patients got pregnant and cumulative pregnancy 15 times within one year after operation,there were 4 mature delivery(33.3％) and 11 fetal loss(73.3％).Conclusions:For the young patients with early stage cervical cancer,pelvic lymphadenoetomy + VRT is the treatment procedure with the same clinical effectiveness with radical hysterectomy + pelvic lymphadenoetomy and has the advantage of fertility preserving,but the pregnancy and reproductive outcome need to be improved.

Effects of Drainage on Pelvic Lymphocyst After Laparoscopic Radical Hysterectomy Combined with Pelvic Lymphadenectomy / 中国微创外科杂志

Objective To explore the influence of no drainage on pelvic lymphocyst following laparoscopic radical hysterectomy and pelvic lymphadenectomy . Methods A total of 105 patients with cervical cancer undergoing laparoscopic radical hysterectomy and pelvic lymphadenectomy in this hospital from January 2012 to February 2016 were divided into either non-drainage group (50 cases) or drainage group (55 cases) according to whether the pelvic drainage tube was placed after surgery .Comparative analyses on the incidence of postoperative complications such as pelvic lymphocyst were made between the two groups . Results No significant difference in lymphocyst rate was found between the two groups [27.3%(15/55) vs.24.0%(12/50), χ2 =0.147, P=0.702].The incidence of pelvic infection was lower in the non-drainage group (2.0%, 1/50) than that in the drainage group (14.5%, 8/55), but the difference was not statistically significant (χ2 =3.781, P=0.052).Other postoperative complications including urinary retention , urinary fistula, and deep venous thrombosis of lower limb had no statistical differences between the two groups (P>0.05). Conclusions Drainage after radical hysterectomy and pelvic lymphadenectomy for cervical cancer does not make a difference to the incidence of lymphocyst .Non-drainaging doesn ’ t increase the risk of infection .

Prevention of lymphocele development in gynecologic cancers by the electrothermal bipolar vessel sealing device / 부인종양

OBJECTIVE: A number of new techniques have been developed to prevent lymphocele formation after pelvic lymphadenectomy in gynecologic cancers. We assessed whether the electrothermal bipolar vessel sealing device (EBVSD) could decrease the incidence of postoperative lymphocele secondary to pelvic lymphadenectomy. METHODS: A total of 321 patients with gynecologic cancer underwent pelvic lymphadenectomy from 2005 to 2011. Pelvic lymphadenectomy without EBVSD was performed in 134 patients, and pelvic lymphadenectomy with EBVSD was performed in 187 patients. We retrospectively compared the incidence of lymphocele and symptoms between both groups. RESULTS: Four to 8 weeks after operation, 108 cases of lymphocele (34%) were detected by computed tomography scan examination. The incidence of lymphocele after pelvic lymphadenectomy was 56% (75/134) in the tie ligation group, and 18% (33/187) in the EBVSD group. We found a statistically significant difference in the incidence of lymphocele between both groups (p<0.01). To detect the independent risk factor for lymphocele development, we performed multivariate analysis with logistic regression for three variables (device, number of dissected lymph nodes, and operation time). Among these variables, we found a significant difference (p<0.001) for only one device. CONCLUSION: Use of the EBVSD during gynecological cancer operation is useful for preventing the development of lymphocele secondary to pelvic lymphadenectomy.

Preservación de la fertilidad en estadios iniciales de cáncer de cuello uterino

La incidencia de cáncer cervical ha aumentado en mujeres jóvenes, en quienes se requiere prestar atención a la preservación de la fertilidad. Se presenta dos casos de pacientes con cáncer temprano de cuello uterino, en estadios iniciales IA2 e IB1 sin metástasis en ganglios pélvicos, y se analiza nuestra experiencia en la aplicación de la técnica quirúrgica de traquelectomía radical abdominal, de manera de preservar la fertilidad.

The incidence of cervical cancer has increased in young women in whom it is important to preserve fertility. Two cases of patients with early cervical cancer stages IA2 e IB1 and no pelvic lymph nodes metastasis are presented, and experience with abdominal radical trachelectomy in order to preserve fertility is analized.

¿Preservación de la fertilidad en cáncer de cérvix?: es possible

El cáncer de cérvix es la causa más común de muerte por cáncer ginecológico en el mundo. Debido al incremento del diagnóstico de esta enfermedad en estadios tempranos en mujeres en edad fértil, hacemos énfasis en los nuevos conceptos de preservación de la fertilidad y tratamiento quirúrgico mínimamente invasivo. El cono frío de cérvix con o sin linfadenectomía pélvica representa un esquema de tratamiento adecuado para el manejo de cáncer de cérvix en estadio IA1-2 en pacientes que desean conservar su fertilidad. Sin embargo, su potencial curativo no ha sido explorado extensamente en lo que concierne a la enfermedad en estadios IB1. En el Instituto Nacional de Enfermedades Neoplásicas (INEN), desde hace cinco años se ha iniciado el manejo individualizado de estas pacientes por la mayor demanda de pacientes jóvenes, quienes desean preservar la fertilidad, con el consentimiento informado de las pacientes y con resultados óptimos hasta la actualidad. Se presenta cuatro casos de cáncer de cérvix en estadios IA2 y IB1 con factores patológicos de riesgo bajo, en quienes se planteó cirugía conservadora para la preservación de la fertilidad. Se les realizó cono frío del cérvix y linfadenectomía pélvica bilateral laparoscópica. Los resultados demostraron que la cirugía conservadora en estadios tempranos de cáncer de cérvix de riesgo bajo es factible en mujeres jóvenes, logrando preservar su fertilidad, con las mismas tasas de curación que la cirugía radical.

Cervical cancer is the most frequent cause of death by gynecologic cancer in the world. Due to increased diagnosis of early stage disease in childbearing age women new concepts in fertility preservation and minimally invasive surgical treatment are emphasized. Cervical cold conization with or without pelvic lymphadenectomy is appropriate treatment for stage IA1-2 cervical cancer in patients who desire fertility. However curative potential has not been extensively explored concerning to IB1 stage disease. In the past five years individualized treatment of these patients has been started at Instituto Nacional de Enfermedades Neoplasicas (INEN) due to increased demand of young patients who wish to preserve fertility, with informed consent of patients and good current results. Four cases of stages IA2 y IB1 cervical cancer with low-risk pathology factors with conservative surgery for fertility preservation are presented. Cervical cold conization and bilateral laparoscopic pelvic lymphadenectomy was performed. Results demonstrated that conservative surgery in low risk early stages cervical cancer is feasible in young women, with fertility preservation and same cure rates as radical surgery.

An Analysis of the Risk Factors and Management of Lymphocele after Pelvic Lymphadenectomy in Patients with Gynecologic Malignancies / Journal of the Korean Cancer Association, 대한암학회지

OBJECTIVES: The incidence and risk factors of lymphocele development after pelvic lymphadenectomy were evaluated and its management investigated. MATERIALS AND METHODS: This retrospective study was carried out on 264 patients who received a pelvic lymphadenectomy, between March 1999 and February 2003, due to gynecologic cancer. The patients were classified into two groups; the lymphocele (n=50) and non-lymphocele groups (n=214), as confirmed by ultrasonography, CT scan and MRI. Each group was compared by cancer type and stage, BMI, preoperative Hb, use of pre/postoperative chemotherapy or radiotherapy, number of resected pelvic lymph nodes and the volume of postoperative drainage from a Hemovac(R) pelvic drain. RESULTS: Of the 264 patients tested, 15 of 105 cervical cancer (14%), 22 of 115 ovarian cancer (19%) and 11 of 40 endometrial cancer patients (27%), a total of 50 patients (18%), developed lymphoceles. In the lymphocele group (n=50), 13 patients were diagnosed with complicated lymphocele. The BMI and number of resected pelvic lymph nodes were found to be higher in the lymphocele than in the non-lymphocele group (23.94+/-3.38 vs. 22.52+/-3.00, p=0.00 and 26.80+/-14.82 vs. 22.96+/-10.18, p=0.03, respectively), and showed statistical significance. The occurrence of lymphoceles was lower without postoperative radiotherapy (p=0.01). CONCLUSION: Among the 264 patients, a total of 50 patients (18%) developed lymphoceles. The BMI and number of resected lymph nodes were higher in the lymphocele group, and the use of postoperative radiotherapy was associated with a higher risk of lymphoceles. Thirteen of the 50 patients that developed lymphoceles (n=50) required treatment for lymphocele-related complications.

Laparoscopic radical trachelectomy combined with laparoscopic pelvic lymphadenectomy in the treatment of early-stage cervical carcinoma: A report of 6 cases / 中国微创外科杂志

Objective To evaluate the feasibility of laparoscopic radical trachelectomy combined with laparoscopic pelvic lymphadenectomy in the treatment of early-stage cervical carcinoma.Methods Six women with early-stage cervical carcinoma demanding the preservation of child-bearing potentials were treated from April 2003 to April 2005.Laparoscopic pelvic lymphadenectomy was carried out for frozen-section examinations.Once a negative finding was established,the ureter was divided and the cardinal ligament was severed,with the uterine arteries and the round ligament preserved.Then transvaginal procedures of amputation of cervix,resection of superior vagina 2 cm in length,and corpus-vagina anastomosis were performed.Results The operation time was 75~150 min(mean,120 min),and the estimated blood loss was 100~250 ml(mean,150 ml).No complications were found.Normal menses was recorded 1 month after operation.Follow-up for 5~24 months(mean,14.6 months) found no recurrence in all the 6 patients.Conclusions Laparoscopic radical trachelectomy combined with pelvic lymphadenectomy is a feasible method for early-stage cervical carcinoma in patients with child-bearing demands.

Radical cystectomy with orthotopic ileal neobladder:comparison of laparoscopy vs open surgery / 中华泌尿外科杂志

Objective To compare the therapeutic effect of laparoscopic radical cystectomy with orthotopic ileal neobladder (LRC-INB) vs open radical cystectomy (ORC-INB). Methods A total of 81 patients were evaluated including 33 undergoing LRC-INB (group A) and 48,ORC-INB (group B) from June 1994 to September 2004 at our institution.The parameters for analysis included operative time,surgical method,blood loss,therapeutic effect,complications and hospital stay.Statistics included t-test and chi-square analysis (P

Laparoscopic Radical Hysterectomy and Pelvic Lymphadenectomy for Uterine Malignancy:Report of 11 Cases / 中国微创外科杂志

0.05).The mean follow-up of the two groups was(11.0?3.2) months and(12.0?2.8) months respectively;no evidence of recurrence was detected during the period. Conclusion Laparoscopy is minimally invasive,safe and effective for uterine malignancy.

Tumor diameter, tumor volume, cervical stromal invasion as prognostic factors in early stage cancer of the cervix

The surgical specimens of ninety-eight patients with cervical carcinoma Stage IB to IIA who underwent radical hysterectomy with pelvic lymphadenectomy at the Philippine General Hospital from February, 1990 to August, 1992 were examined tod etermine tumor diameter, tumor volume, and cervical stromal invasion for the purpose of determining 1) the interrelationship of tumor diameter, tumor volume and cervical stromal invasion; 2) the use of the above factors to predict lymph node metastasis and tumor recurrence; 3) the use of these three prognostic variables plus lumph node metastasis to predict recurrence rate; 4) to detemine the relationship between lymph node involvement and recurrence rateUsing multivariate dicriminant analysis, the following were noted: 1) There is a very significant positive relationship among the three prognostic factors, 2) Among the three variables, only tumor diameter and stromal invasion were significant in predicting lymph node metastasis. 3) All these three variables - tumor diameter, tumor volume and cervical stromal invasion have significant relationship with tumor recurrence. 4) The presence of lymph node involvement, when added to the three variables mentioned, contributed significantly in predicting recurrence rate. Using chi-square test, 5) the presence of lymph node metastasis significantly correlates with tunor recurrence.

Pelvic Drainage Following Radical Hysterectomy with Pelvic Lymphadenectomy for Cervical Cancer: Is it Necessary? / 대한부인종양콜포스코피학회잡지

OBJECTIVES: This study was to determine whether drainage after radical hysterectomy and bilateral pelvic lymphadenectomy can reduce the risk of postoperative morbidity as compared with no drainage. METHODS: 165 patients with stage Ia2 to Ilb underwent radical hysterectomy and bilateral pelvic lymphadenectomy between January 1995 and May 1997, and those medical records were analyzed, Closed suction drains were placed in group I (n 102), not in group II (n 67). All surgeries were perforrned by the same surgeon in a uniform method. RESULTS: The characteristics of two groups were similar for mean age, preoperative weight, total protein, serum albumin, tumor cell histology, invasion depth, and tumor stage. There was no difference in mean operation time in two groups. But mean estimated blood loss was more in group I than group lI(p0.05). Rehospitalization rate was higher in group I than in group II. CONCLUSION: Pelvic drainage didn't reduce the postoperative febrile morbidity and lymphocyst formation. Therefore the author could not find any necessity to perform the drainage following radical hysterectomy and pelvic lymphadenectomy.

The Analysis of Lymph Node Metastases and Survival Rates in Transitional Cell Carcinoma of Urinary Bladder / 대한비뇨기과학회지

PURPOSE: The incidence of lymph node metastases in patients undergoing radical cystectomy varies between 15% and 25%, and is related to the depth of invasion of primary tumor. Pelvic lymphadenectomy provides accurate staging information as well as therapeutic benefit in a selected group of patients without increased morbidity. We analyzed the incidence of lymph node metastases and survival rates in the patients with pathologically proven lymph node metastases to reassess the role of pelvic lymphadenectomy in the patients with transitional cell carcinoma of urinary bladder. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 215 patients with transitional cell carcinoma treated by radical cystectomy and pelvic lymphadenectomy from 1976 to 1996 who were followed for a mean 31.7 months and analyzed the incidence of pathologically proven lymph node metastases and survival rates according to pathological stage, histologic grade and cell morphology. RESULTS: Patient distribution according to pathological stage was 18 for pTa, 51 pT1, 44 pT2 36 pT3a, 42 pT3b, and 24 pT4. Mean follow up was 31.7 months. The overall 5-year survival rate was 67.9%. The 5-year survival rates according to pathological stage were 93.6% for pTa and pT1, 72.4% pT2, 47.2% pT3a, 52.2% pT3b, 49.6% pT4 The 5-year survival rates according to histologic grade were 100.0% for grade l, 80.1% grade ll, 57.0% grade lll. The overall incidence of lymph node metastases was 14%(30/215). The 5-year survival rates according to lymph nodes metastases were 72.5% for pN0, 30.3% pN1 and the 2-year survival rate was 41.5% for pN2. The incidence of lymph node metastases was 0% for pTa and pT1, 2.3% pT2, 11.1% pT3a, 38.1% pT3b, 37.5% pT4 and 0% for grade l, 7.2% grade ll, 19.0% grade lll. The 5-year survival rates according to pathological stage and lymph nodes metastases were 75.9% for pT3a or less with pN0,58.4% for pT3b or more with pN0, 26.7% for pT3b or more with pN1 or pN2. CONCLUSIONS: Lymph node metastases was a significant prognostic factor for transitional cell carcinoma of the urinary bladder. The incidence of lymph node metastases increased as pathological stage and histologic grade increased. Radical cystectomy with pelvic lymphadenectomy might be beneficial for a few patients with bladder confined tumor with lymph node metastases. Adjuvant therapy is recommended for transitional cell carcinoma of the urinary bladder with lymph node metastases for improved survival.

Laparoscopic Pelvic Lymphadenectomy in Cervical Cancer / 대한부인종양콜포스코피학회잡지

We performed laparoscopic pelvic lymphadenectomy in 7 patients with squamous cell carcinoma in the uterine cervix. Among them, 5 cases were subsently laparotomy with radical hysterectomy. The others, one case was performed Laparoscpic pelvic lymphadenectomy as Staging Procedure and the other was laparoscopically assisted radical vaginal hysterectomy with pelvic lymphadenectomy without complication. The following results were obtained 1. Total number of pelvic nodes obtained at laparoscopy in 7 cases were 104 2. Averege number of pelvic nodes obtained at laparoscopy were 14.2+/-6.38(7-23) 3. Average number of additional pelvic nodes obtained at laparotomy were 10.4+/-279(7-13) 4. % yield by laparoscopy/laparoscopy+laparotomy was 71/123(58%) 5. No positive metastatic lymph nodes were missed by laparartomy 6. Average time, blood loss at laparoscopic lymphadenectomy was 172.1min and 304.3ml, seperately 7. surgical staging procedure was performed at Case 3 8. Laparoscopic Pelvic lym phadenectomy with radieal vaginal hysterectomy (type II radical) was done in Case 5. without Laparotomy or complication.

Radical Cystectomy with Pelvic Lymphadenectomy in Bladder Tumor: Review of 14 Cases / 대한비뇨기과학회지

A clinical observation was made on 14 patients of bladder tumor who were treated by radical cystectomy with pelvic lymphadenectomy in the Department of Urology, Catholic Medical College during the period from March, 1984 to July, 1986. Metastases to pelvic lymph node were proved histologically in 3 cases among 14 cases. Operative pathologic staging demonstrated an understanding error of 36 per cent, an overstaging error of 28 per cent and an accuracy of 36 per cent. The addition of a meticulous pelvic lymph node dissection did not increase the mortality or morbidity compared to simpler procedures. Results of this study support the early aggressive use of radical cystectomy with pelvic lymphadenectomy and urinary diversion in the management of patients with bladder cancer.