• Carcinoma in situ (CIS)
• Superficial invasive TCC
• Muscle Invasive TCC

Once a bladder tumor has penetrated into the muscle layer, the ability to completely resect it via TURB becomes more difficult if not impossible. It is often difficult to know from the resected specimen if the entire tumor has been eradicated. Moreover, because such a deeply penetrating tumor would necessitate a deeper resection, there is a correspondingly greater risk of perforation of the bladder as well as major injury to adjacent organs. Finally, as there is an increased possibility that the tumor has either spread to adjacent organs or even metastasized to distant organs, a diagnosis of muscle invasive TCC warrants a thorough evaluation with multiple radiographic tests.

In general the treatment of muscle invasive bladder cancer without evidence of metastatic spread is the complete removal of the bladder, or a radical cystectomy. Because the bladder is so close to other pelvic organs-the prostate and seminal vesicles in men, as well as the uterus and ovaries in women-this operation would also include their removal, leading to sterility in both. This is an aggressive treatment for an aggressive stage of bladder cancer. The objective of this operation is to eradicate this cancer completely. Pertinent issues are the side effects of this operation, as well as changes in quality of life.

Because the original or "native" bladder will be removed, it is important to consider how the urinary system can be reconstructed so that the urine can be excreted safely and effectively while best maintaining an individual's quality of life. These "reconstructions" are performed during the same operation immediately following the cystectomy. There are several options with regard to urinary excretion following removal of the bladder, each of which will depend on specific criteria that will deem the patient a potential candidate. These criteria include an individual's overall health status and their ability to tolerate a major operation; level of overall motivation and active participation in their own care; and extent of local cancer spread. Each reconstruction necessitates removal of a segment of large or small intestine, to which the remaining ureters will be connected. The following is a brief description of 3 reconstructive operations for urinary excretion:

• URINARY CONDUIT: This reconstruction includes removing an approximately 6 inch segment of small intestine, which will remain on its vascular stalk to insure a continuous blood supply. The gap in the remaining small intestines is reconnected, and one of the open ends of the removed 6 inch segment is sewn closed. The 2 remaining ureters will be connected to the free segment of intestine or "conduit" at the side of the closed end. Finally, the open end of the segment is connected to the skin as an opening, or stoma, at the lower aspect of the abdomen. Urine will continuously drain from the stoma, so it is necessary to wear an appliance to collect it. The appliance sac will need to be emptied manually approximately 3-4 times per day. At nighttime, individuals can connect their appliance sac to a larger collection bag, precluding the need to empty their urine during sleep. The urinary conduit is the simplest of the 3 reconstructions, and has the lowest rate of complications.

• CATHETERIZABLE STOMA: A modification of the urinary conduit, the catheterizable stoma enables an individual to excrete urine from their stoma without the need for an external appliance. The stoma is modified into a one-way valve so that urine cannot leak out. In addition, a larger segment of small or large intestine is removed, and fashioned into a reservoir or "pouch" for holding approximately 3-4 cups of urine. By inserting a rubber catheter into the stoma, urine is easily drained from the reservoir. This reconstruction requires individuals to have a level of dexterity and self-motivation to perform the catheterization at multiple times each day. Unlike the urinary conduit, individuals cannot connect their stoma to a larger drainage sac at night, but rather must awaken to empty their reservoir potentially at multiple times.

• NEOBLADDER: The most technically complex reconstruction, the neobladder literally means "new bladder". This results in no stoma, but rather connects the intestinal reservoir to the urethra. The neobladder leads to the least amount of disruption to both urinary function and cosmetic appearance. This operation is far more complex for several reasons. First, the connection of the reservoir to the urethra is technically more difficult since it is deep within the pelvis. The complexity of this connection may lead to complications such as scarring leading to urinary retention; or internal leakage leading to urine collections that can become infected. Second, because the removal of the bladder includes part of the urinary sphincter responsible for continence, it is possible that there will be significant urinary leakage or incontinence. On the other hand, because the intestinal reservoir does not have the same innervation and musculature as does the bladder, the ability of the reservoir to contract and therefore excrete the urine is fairly limited. Because of this potential outcome, individuals must be motivated in and capable of performing self-catheterization through their native(original) urethra. Nevertheless, in most cases careful training and rehabilitation teach individuals to exert internal abdominal pressures in order to excrete urine. Finally, it should be noted that the extent of local bladder cancer may impact on the safety and efficacy of this reconstruction from a cancer-control standpoint. For example, if a muscle invasive bladder tumor is located at the base of the bladder where the urethra begins, it may be necessary to remove some or all of the urethra to ensure cancer eradication. In this case no connection could be made, precluding the neobladder as an option.

Below are photographs and schematic drawings:

typical appearance of the stoma	the urinary conduit and its stoma

This is the internal view of a catheterizable stoma. Note the large pouch sewn from a removed segment of large intestine. In this case the catheterizable stoma is formed from the appendix. Note the ureters inserting into the pouch.

Here is the internal view of a neobladder. Bowel has been made into a pouch and the ureters are connected above, while the pouch itself is connected to the urethra.