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Actos Lawsuit : The bladder is the container in the body that stores urine. The other term for bladder is “vesical,” which is derived from the Latin word vesicular. The bladder is a soft, round structure that is located in the pelvis. The pubic bone is in front of the bladder; the rectum in men or the uterus in women is behind the bladder. Urine drains into the bladder through an opening on each side at the bottom of the bladder. Urine is stored in the bladder until a person is ready to urinate. In order to urinate, the muscle in the bladder wall squeezes, push­ing the urine out of the bladder through the urethra. In women, the urethra is short, only approximately 1 inch long. In men, it is much longer because it has to pass through the prostate and then the penis before finally opening at the tip of the penis.

In the middle of the abdomen, just beneath the lower ribs, are the kidneys. The kidneys filter the blood to produce urine. The urine that the kidneys produce exits the kidney through the renal pelvis and flows into the ureters. The ureters are soft, muscular tubes that are about the width of a pencil. They carry the urine from the kidneys down to the bladder, where they open into the base of the bladder.

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The adult bladder normally holds approximately 400 ml of urine. The bladder wall has three separate layers. The innermost layer that is in contact with the urine is a thin layer called the urothelium. The middle layer is made of muscle fibers that can squeeze. When the muscles contract, they increase the pressure inside the bladder, squeezing the urine out of the bladder. The outermost layer is a thin but protective layer called serosa.

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The bladder has two functions. The first is the storage of urine, and the second is the emptying of urine. In an infant, the bladder constantly fills and empties without any control by the brain. During toilet training, the brain learns to control the bladder, enabling it to hold (store) the urine until a time when it is socially accept­able to urinate. Emptying is the second function that the bladder must perform. In infancy, before toilet train­ing, this is actually the most important function of the bladder.

Although most of us take these two processes for granted, either one or both can malfunction. If the stor­age function fails, the bladder can become very small and contracted, holding just a tiny amount of urine before it needs to empty. In contrast, it may become floppy and dilated, holding several liters of urine before it is ready to empty. It can also become “overactive,” causing feelings of urgency and the need to urinate more than eight times per day. When the actual emptying function goes wrong, the bladder may only partially empty each time, leaving a high remaining amount of urine (the so-called postvoid residual). The bladder muscle may also weaken to the point where one is completely unable to urinate. This is called urinary retention.

When storing urine, the bladder must do so at a low pressure. This allows the new urine made in the kidneys to flow downward into the bladder. A safe bladder pres­sure is less than 40 cm H2O. When the pressures are higher than this, the urine may “back up” in the kidneys. High pressures in the kidneys over a long period of time may damage the kidneys. During urination, the bladder must squeeze to force the urine out. The pressure in the bladder at these times may be much higher than 40 cm H₂O, but it does not usually damage the kidneys.

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Actos Lawsuit News- 1/26/2012: Surgery can be as effective in elderly patients as in younger patients, but it does have a higher rate of postoperative complications in older individuals who have other medical problems (comorbidities). Elderly people are particularly sensitive to long-term complications, lilce the metabolic dis­turbances that can follow urinary diversion. In those aged 80 or older, the role of radical cystectomy is controversial. Although newer surgical techniques and improvements in care, before and after the operation, make this an option for increasing numbers of older patients, several studies suggest that its benefit is at best quite minimal, even in relatively fit octogenarians. You need to carefully weigh the benefits and risks of radical cystectomy with your multidisciplinary team before going through such an aggressive operation.

Because bladder cancer surgery can cause serious side effects and debilitation that requires significant healing time and energy, older patients usually tolerate neoadjuvant chemotherapy (given before surgery) better than adjuvant chemotherapy (given after surgery). On the other hand, because not all bladder cancer patients need chemotherapy, giving it after surgery (adjuvant therapy) offers the advantages of treating only those patients who absolutely need it. You should discuss the advantages and disadvantages of both approaches with your multi­disciplinary team.

With regard to choice of chemotherapy, healthy older patients can receive the same regimens as their younger counterparts, including those that are anthracycline-based, like MVAC (see Chapter 3). However, older patients are at increased risk of developing congestive heart failure from these regimens, and gemcitabine-cisplatin is probably a better choice, especially in those with a significant cardiac risk for anthracyclines. Recent studies have shown this regimen to be just as effective as MVAC but with fewer- side effects.

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Managing chemotherapy-associated toxicity with appropri­ate supportive care is crucial in the elderly population to give them the best chance of cure and survival or to provide the best palliation. Reducing tire dose of chemotherapy (or radiation therapy) based purely on chronological age may seriously affect the effectiveness of treatment. Those with metastatic disease may tolerate single-agent chemotherapy better, but tire presence of severe comorbidities, age-related frailly, or underlying severe psychosocial problems may be obstacles, even for these treatment plans. As in younger patients, trimodal therapy with bladder preservation may be an option for selected older individuals with bladder cancer (see Chapter 3). It is an aggressive treatment approach that involves radiation therapy, chemotherapy, and surgery. If an older person is too frail to undergo radical cystectomy, he or she is usually too frail to get trimodal therapy. There are a few exceptions to this general rule, and it is essential that you weigh all of the risks and benefits with your multidisciplinary care team. In frail patients, radiation therapy is sometimes used to control the symptoms of bladder cancer, but it is rarely curative.

The fatigue that usually accompanies radiation therapy can be quite profound in the elderly, even in those who are fit. Often, the logistical details (like daily travel to the hospi­tal for a 6-week course of treatment) are the hardest for older people. It is important that you discuss these potential problems with your family and social worker before starting radiation therapy. Anemia (low red blood cell count) is common in the elderly, especially the frail elderly. It decreases the effectiveness of chemotherapy and often causes fatigue, falls, cognitive decline (for example, dementia, disorientation or confusion), and heart problems. Therefore it is essential that anemia be recognized and corrected with red blood cell transfusions or the appropriate use of erythropoiesis-stimulating agents.

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Kidney function declines as we age. Some of the medicines that older patients take to treat both their cancer (for example, cisplatin, carboplatin, methotrexate, zoledronic acid, nonsteroidal anti-inflammatory drugs) and noncancer- related problems might make this worse. The dehydration that often accompanies cancer and its treatment can put additional stress on the kidneys. Fortunately, it is often possible to minimize these effects by carefully selecting and dosing appropriate drugs, managing “polypharmacy,” and preventing dehydration. Fatigue is a near universal complaint of older cancer patients. It is particularly a problem for those who are socially isolated or depend on others to help them with activities of daily living. It is not necessarily related to depression, but it can be. Depression is quite common in the elderly. In contrast to younger patients who often respond to a cancer diagnosis with anxiety, depression is the more common disorder in older cancer patients. With proper support and medical attention, many of these patients can safely receive anticancer treatment.

fter receiving the diagnosis of cancer, many patients report that they hear very little else their doctor tells them. Although this information will be repeated and clarified over the ensuing visits with your physician, it can also be empowering to find out more information on your own. When searching for information about any healthcare topic, you should look for two criteria. First, the information should be published by a reliable source. Articles or reviews by experts are often the high­est quality resources. Second, the information should be written at an appropriate level for the reader. Very technical writing may not be appropriate for everyone, whereas some patients may want more detailed scientific information. The following resources meet these criteria, are either expert written or reviewed, and offer varying levels of scientific detail.

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Actos Lawsuit : There are two broad types of cancers in the bladder: primary and metastatic. Primary bladder cancers are those that begin in the bladder itself. Metastatic cancers are those that originated in another organ and then spread to the bladder. Other tumors can get into the bladder through the bloodstream, through the lymphatic system, or by directly extending from a nearby organ, such as the prostate or the cervix.

Cancers originating in the bladder are far more common than cancers that spread to the bladder from another loca­tion. There are several types of primary tumors. Recall that transitional cell cancer accounts for at least 90% of all bladder cancers. Transitional cell tumors can be classi­fied as (1) papillary, (2) sessile, or (3) a mix of both types. Papillary tumors look like a piece of cauliflower attached to the wall by a short stalk; sessile tumors look flat and are broad-based. Almost 70% of transitional cell tumors are papillary types, which tend to have a better prognosis than sessile tumors. Less common types of bladder can­cer include squamous cell cancer, adenocarcinoma, and urachal carcinoma.

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Squamous cell carcinoma accounts for 3% to 7% of bladder cancers in the United States; however, in Egypt it accounts for 75% of the bladder cancers. There is a parasitic infection called schistosomiasis that is very common in Egypt. Infection with this parasite strongly predisposes a person to the development of squamous cell cancer. The parasite burrows into the wall of the bladder, which chronically irritates the bladder. Over many years, this chronic irritation can lead to the devel­opment of bladder cancer, most often squamous cell cancer. Other conditions that cause chronic irritation also predispose to this type of tumor. Chronic indwelling catheters, for example, can irritate the bladder and pre­dispose someone to this tumor. Squamous cell carci­noma does not tend to spread to the lymph nodes like transitional cell cancer does, although it does tend to spread aggressively directly through the bladder into neighboring structures. Because it is so locally aggres­sive and relatively resistant to chemotherapy or radia­tion, it usually has a worse prognosis than transitional cell cancers.

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Adenocarcinoma of the bladder is quite uncommon, accounting for approximately 2% of all bladder cancers in the United States. These tumors are also associated with chronic irritation. They tend to be high-grade aggressive tumors and are therefore usually associated with a worse prognosis. Urachal carcinoma is a specific type of adenocarci­noma of the bladder, but it is unique in that it does not originate in the lining of the bladder. These develop from the outer surface of the bladder, extending toward the inside of the bladder. They can then metastasize to the lymph nodes, the liver, lung, and bone.

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Actos Lawsuit: Pain post-op is initially treated often via the epidural catheter. Intravenous medication may be given as an alternative and switched to oral pain meds once the individual is tolerating liquids. Many physicians order a PCA (patient controlled anesthesia) in which the patient pushes a button that releases pain medication via an intravenous line into the blood stream. Maximal amounts of drug administered are carefully controlled by settings on the PCA to allow safe, effective analgesia.

During the post-o you will meet regularly with an enterostomy nurse who will teach you the mechanics of caring for an ostomy and handling the ostomy appliance.period, Gradually, your pain will diminish, strength will increase, and diet will be advanced. Drains placed intraoperatively to siphon off any excess fluids from the abdomen will be removed when no longer needed. During difficult dissection, small intestines may be inadvertently opened. These injuries are usually immediately recognized and repaired without difficulty. During removal of the bladder, the rectum may be entered. Assuming the patient has had a complete bowel prep prior to surgery, the rectum is usually readily repaired.

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During removal of the pelvic lymph nodes, entry into a major vein or artery may result in significant blood loss. Smaller, inconsequential veins or branches into larger veins are usually ligated with a suture or cauterized shut. Larger veins and arteries require repair with a fine vascular suture and needle. Troublesome bleeding can also occur during removal of the bladder and from deep in the pelvis after the bladder and prostate are removed. Bleeding is stopped through suture ligation, vascular clips, or cautery.

An abscess is a pocket of pus located deep within the body. It may form from a bowel or urine leak, and generally will require drainage since antibiotics alone may not resolve it. If percutaneous drainage (drainage through the skin) is possible, the radiologist will drain the abscess. If this is not possible, the urologist will need to open the incision or make a new incision to allow the pus to be drained. A sizable abscess will generally not be cured without proper drainage. Left untreated, an abscess can result in sepsis, a life threatening bacterial infection.

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When the bowel is reconnected after removing the section for the urinary diversion, healing may not be adequate and bowel contents may leak into the abdomen. A bowel leak often will present as a failure of the bowel to return to normal function, resulting in a distended abdomen with poor bowel sounds. Distention, ileus (poor bowel function) may occur after the bowels are working well and feeding has been going on for some time. Evaluation is usually accomplished with CT Scan and oral contrast. Immediate surgical correction may be necessary. Left untreated, a bowel leak will generally lead to an abscess or possibly a fistula (a drainage tract from the bowel which may extend out through the incision or drain). The incidence of bowel leak is increased if bowel has been exposed to prior radiation, most often from radiation used to treat prostate cancer in men and uterine cancer in women.

When a piece of bowel is separated from the intestine to create the new urinary drainage system, the remaining bowel must be reanastomosed (brought back together). This may be accomplished via sewing the bowel together or through the use of staples. Sometimes the opening of the bowel connection may be obstructed secondary to swelling. If an obstruction does not clear after a reasonable time, reoperation may be required.

During a standard radical cystectomy in the male, the fine nerves which run along the base of the prostate to the penis are severed, resulting in loss of erections (impotence). If the individual having surgery still has good erections and is sexually active, these nerves can be attempted to be saved by modifying the surgery. Saving the nerves is more difficult to do, it takes more time, and is not always successful.

Our use of the term or terms Actos Lawsuit is for descriptive purposes only. There is no relationship between the owners of this website and the maker of the product discussed in this post. Our use of the words Recall, Class Action Lawsuit and other similar words related to an event do not necessarily mean that this event has occurred. Refer to the website of the United States Food and Drug Administration for information on drug or medical device recalls. If a Class Action Lawsuit is formed in relation to the product discussed in this post we will provide that information at the time the Class Action is formed. A Class Action Lawsuit is not required to exist for you to file a lawsuit if you have been injured by the product discussed in this post.

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Actos Lawsuit : Bladder cancer is a malignant overgrowth of the cells of the bladder. Most commonly, the growth occurs in cells that are in the urothelium. The lining of most hollow spaces in the body is made of epithelial cells. The lining of the inside of your cheek, for instance, is an epithelial cell lining. Also, the lining of your stomach, bowels, gallbladder, and—you guessed it—the bladder is made of epithelial cells. Each organ has its own subset of epithelial cells. In the bladder, the lining cells are called transitional epithelial cells. The cancer that grows from these cells is then called transitional cell cancer; 90% to 95% of all bladder cancers are of this type. If the cancer grows from a different type of cell in the bladder, it is given a different name. Other types of uncommon cancers in the bladder include squamous cell carcinoma and adenocarcinoma (carcinoma is another word for cancer). A very rare type of bladder cancer that occurs only in children is called rhabdomyosarcoma.

It is also possible that cancer in the bladder did not begin there but spread to the bladder from somewhere else. The bladder is an uncommon place for other tumors to “seed” (or metastasize), but it does occasionally occur. Although metastases are uncommon, tumors can occa­sionally grow directly into the bladder from an adjacent organ, such as the prostate, colon, rectum, or cervix.

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Cancer is one of the major causes of death and disease throughout the world. If all types of cancer are combined, it ranks as the second leading cause of death in the United States today behind heart disease. As treatments for heart disease continue to improve, it has been esti­mated that within the next 5 to 10 years cancer will become the leading cause of death in the United States and other developed countries.

Bladder cancer is the fourth most common type of cancer in men and the eighth most common in women. The American Cancer Society estimated that in 2009, there would be about 70,980 new cases of bladder cancer diagnosed in the United States. In 2009, 14,330 deaths were expected from bladder cancer. In spite of the increased incidence of bladder cancer over the years, the rate of people dying from bladder cancer has decreased over the past 20 years.

From 1998 to 2000, the median age at diagnosis was 63 years of age. 90% of patients were 55 years of age and older at the time of diagnosis. The chance of a man developing bladder cancer at any time during his life is about 1 in 27, whereas it is 1 in 84 for a woman. Thus bladder cancer is 3 times more common in men than in women. The incidence of bladder cancer increases with age in both sexes, meaning that an older individual is more likely to acquire bladder cancer than a younger person. It is twice as common in white American men as it is in African American men and 1.5 times more common in white American women as it is in African American women. Hispanic Americans also have about half the rates of bladder cancer as do white Americans. Bladder cancer is more common in the United States and Great Britain than in Japan or Finland.

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cancer is more common in white Americans, African Americans tend to have more advanced disease when they first present to the doctor. This may be because of an underreporting of more superficial tumors, delays in diagnosis, or a tendency toward more aggressive tumors in this group. As would be expected from the tendency toward more advanced disease, 5-year survival rates are 71% for African American men versus 84% for white men, and 71% for African American women ver­sus 76% for white women.

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Actos Lawsuit: For many years, it was believed lymph node dissection served mainly to provide prognostic information. Knowing whether nodes have cancer was valuable information which could be used to determine if chemotherapy was warranted after surgery. More recently, a number of studies have shown that doing a nodal dissection may prove to be therapeutic as well, resulting in a reduction of risk for recurrence and improvement in survival. The ureters may not be long enough to bring out to the skin surface at the same location for one drainage bag. In addition, the ureters are small and easily compressed, and therefore would be subject to obstruction when brought out directly.

Transitional cell cancer extending into the urethra of a female patient or the prostatic urethra of a male patient would generally require urethrectomy at the time of cystectomy. Urethrectomy requires more dissection, potential for bleeding and infection, and possibly increased post operative drainage. It should therefore be performed only when necessary. Cancer located close to the bladder neck may raise the odds of cancer developing in a urethra which is left behind. The status of the urethra can be followed post cystectomy with washings sent for cytology. If cancer subsequently develops, a urethrectomy can be accomplished as a separate operation long after cystectomy has been done.

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At the conclusion of surgery, generally while still in the operating room, the endotracheal tube is removed when the patient is awake enough to breathe on his own. The patient will then be brought to the recovery room where he will be carefully observed by trained nurses in conjunction with the anesthesiologist and urologist. The individual is kept in the recovery room until conscious, breathing on his own and stable. Recovery room stays may be short, on the order of 30 minutes, or may extend to several hours, depending on how the individual is doing. If doing well, the patient will then be transferred to a floor in the hospital. If the individual’s surgery was particularly complicated, extended, or if the individual is unstable (irregular heart beat, low blood pressure, inability to be taken off the respirator), or if the individual has significant medical problems or has experienced a complication from surgery, transfer to an ICU (intensive care unit) may be warranted. In the ICU, there exists a much higher ratio of nurses to patients than on a standard postoperative floor, allowing for constant surveillance and care for critical patients. Also, if a respirator is required postoperatively, initial treatment in an ICU is usually necessary.

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After transfer to the floor from the recovery room, the patient is often kept on bed rest for the rest of the day. The nasogastric tube is left in and placed to gentle suction to remove excess stomach fluids. Initially, nothing is allowed by mouth other than ice chips or sips of water. Adequate fluids and some nutrition are given via an intravenous catheter. By the following day, patients are often out of bed and sometimes walking with assistance. Sequential stockings on the lower legs are removed while ambulating, and discontinued once the individual is able to move about well. Traditionally, nasogastric tubes have been left in until the bowel activity returns (generally 3-4 days). This is generally heralded by the passing of flatus (gas) or the presence of active bowel sounds, which will be checked by your urologist with a stethoscope. Recent studies have indicated nasogastric drainage for this length of time may not be necessary and may impede normal breathing, leading to other problems. Some urologists are therefore removing the tubes earlier. Feeding is gradually introduced however, once bowel activity has returned.

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Actos Lawsuit :Another potential serious pulmonary problem is called pulmonary embolus. A pulmonary embolus causes damage to the lung by a blood clot which forms in another area of the body, travels through the veins of the body and ends in the lungs. Blood clots can form in the pelvic veins as a result of surgery. They can also form in the lower extremities because of prolonged bed rest and immobility after surgery. Compression stockings used during and after surgery until mobility resumes help to prevent clots in the legs. Getting the individual out of bed and ambulating as soon as possible after surgery are important to prevent clots from forming. In addition, subcutaneous heparin (a medication that stops clotting) can be given during the post-operative period to lessen the possibility of pulmonary embolus without a substantial increase in post-operative bleeding.

The symptoms of a pulmonary embolus are shortness of breath and pain in the chest with breathing. Clinical signs include a rapid heart beat and poor oxygenation of the blood. Diagnosis is confirmed with a ventilation-perfusion scan. This study will demonstrate a lack of blood flow in various parts of the lung which have good air flow (a finding consistent with a vascular blockage by a clot). In many institutions, a CT angiogram of the lungs has become the preferred study because of the speed of the study and its enhanced accuracy. An individual must not be allergic to IV contrast, nor have significant renal insufficiency if this test is to be ordered. Pulmonary emboli are usually treated with supportive measures such as supplemental oxygen and anti-coagulation of the blood to prevent further clots from forming and migrating. If a large clot has formed and continues to embolize to the lung, a small filter device may be placed in the main vein of the abdomen (the inferior vena cava) to prevent further clots from traveling to the lungs.

Complete resection of a small muscle invasive bladder cancer at times can eradicate the cancer. However, diligent follow up with repeat biopsies and repeat resections will be necessary as recurrent disease and further progression are likely. Combination therapy with tumor resection, chemotherapy, and radiation is an additional option, which has proven to be effective in some individuals.

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Recently, a number of clinical studies have demonstrated that in select individuals with muscle invasive bladder cancer, utilization of three modes of therapy can be effective in controlling invasive bladder cancer. ¹ These bladder preservation protocols have found those individuals that do best have smaller, invasive bladder cancers that can be completely resected. Resection is followed by radiation, which is then followed by chemotherapy. Those that fail the initial treatment go on to cystectomy. Long term bladder preservation in some studies is achieved in approximately 40%.

It should be noted however, this high rate of success may be contingent on choosing patients with less serious disease than the average patient undergoing cystectomy. Platinum based chemotherapy appears to offer the best results; however, the best combination regimen of chemotherapy is still being studied. Individuals with large, invasive canccrs and those with associated CIS or hydronephrosis secondary to cancer are not considered good candidates for bladder preserving therapy. Side effects of therapy are predominately the effects of chemotherapy, and include nausea, vomiting, diarrhea, fatigue, and sepsis secondary to lowered immunity.

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After removal of the bladder, an approximately 6 inch piece of small intestine from the ileum (the final section of small intestine) is surgically separated from the rest of the small intestine. This section of bowel is used to create an ileal loop diversion. The ileum is the best section of small bowel to use since it has the lowest rate of electrolyte (body salts) disturbances afterwards. The ileum from which this section is removed is reconnected via suturing or staples.

The future ileal loop is flushed clean and the base of the loop is sewn shut. The ends of both ureters are then carefully sewn to a small opening made close to the base of the ileal loop. The opposite end of the ileal loop is brought out through the skin and secured. The end of the loop is everted and tied down to the skin to create a raised stoma. Usually, small plastic tubes called stents are placed through the ileal loop, up the ureters, with their ends curling in the kidneys. These stents are temporary, generally left in for several weeks. Stents serve the purpose of decreasing urinary leakage at the anastomosis (the connection of the ureter to the ileal loop) and serve to allow the anastomosis to heal in an open fashion, thereby reducing the incidence of scarring. The ileal loop is the simplest and quickest form of urinary diversion. Post-operative complications are infrequent. Given these advantages, it remains the most common form of urinary diversion.

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Actos Lawsuit :There are several long-term complications specifically related to the fact that urine comes in contact with the intestinal portion of the diversion. Metabolic complications, such as acidosis, can occur but are often not clinically significant. The risk for clinically significant acidosis is higher in patients with continent urinary diversion because there is more intestinal surface area that comes in contact with the urine. Your physician will periodically monitor you for metabolic changes simply by checking lab tests. The majority of metabolic disturbances can be treated with dietary supplementation. Five to 10 percent of patients with urinary diversion form urinary stones at some point in their life, and approximately the same number experience repeated bouts of urinary tract infection or pyelonephritis.

Continent urinary diversions have several complications that are unique compared with that of the ileal conduit. Patients with continent catheterizable diversion over time can experience leakage of urine from their catheterizable channel. Scar tissue can also form at the site of the cath­eterizable channel, causing difficulty with catheterization. Both problems generally require a secondary procedure to revise this portion of the diversion. Men and women with orthotopic urinary reconstructions can experience both urinary incontinence and urinary retention. The incidence of incontinence is greater in men than in women, but the incidence of urinary retention is greater in women. Urinary retention is often managed with clean intermittent catheterization, which consists of self-passage of a urinary catheter via the urethra several times a day to empty the diversion. If the idea of self-catheterization is unpalatable to you, this is something you should keep in mind when considering your choice of urinary diversion.

Each intravesical (within the bladder) agent used for the treatment of bladder cancer has its own side-effect profile, but they all cause some degree of lower urinary tract symptoms during and for several weeks after treatment. These symptoms can vary from mild to severe from individual to individual and consist of painful urination, urinary frequency, and urinary urgency. These symptoms are very similar to a urinary tract infection but are actually caused by bladder inflammation and irritation from the intravesical therapy. Mitomycin C can cause a skin rash (usually on the hands) that generally resolves when ther­apy is discontinued.

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Although bacillus Calmette-Guerin (BCG) therapy is highly effective in treating non-muscle- invasive bladder cancer, some patients experience a certain degree of side effects related to treatment. Lower urinary tract symptoms can occur in as many as 80-90 percent of those treated. Less common side effects include blood in the urine, fevers, fatigue, and nausea. If you experience significant symptoms, your urologist can decrease the BCG dose, which makes treatment tolerable for many more patients. Because BCG is a live, attenuated vaccine (made from live organisms that have lost their virulence but still produce an immune response), it can cause severe infections in very rare circumstances. Infections associated with a high fever may require complete discontinuation of the BCG and antibiotic therapy for up to 6 months. When BCG is instilled into a patient’s bladder who has severe cystitis, or after traumatic catheterization, it may be absorbed directly into the blood vessels causing a severe infection, called BCG sepsis. Fortunately, BCG sepsis is rare, occurring in less than 1 percent of those treated.

There are many different chemotherapy drugs and combination of drugs that are used to treat bladder cancer. Each drug has its own side-effect profile. A complete listing of all of these side effects is beyond the scope of this chapter. However, this section will summarize the general side effects that you may experience with chemotherapy. When discus sing a particular chemotherapy regimen with your oncologist, it is important thatyou ask about the specific side effects of each medication so you know exactly what to expect over the course of your treatment.

Just as with, surgery, the general side effects of chemotherapy can be broken down into short term (acute) and long term (chronic). The ma j or short-term side effects of chemotherapy are nausea and vomiting, fatigue, loss of appetite, weight loss, hair loss, and reduction in various blood counts. The acute effects start shortly after administration of chemotherapy and can wax and wane over the course of your treatment. Often, over the course of your treatment you will start to feel better toward the end of a cycle as the side effects of the medication wear off. Dealing with the acute side effects can be physically and emotionally draining. You should discuss side effects with your physician and healthcare providers because they often have many tips to help alleviate such symptoms.

During the course of chemotherapy your blood counts will be closely monitored. Chemotherapy can cause decreases in many important blood cells, including red blood cells (anemia) and white blood cells (leukopenia). If your blood counts fall too low, you may require hospitalization. A significant concern with leukopenia is die increased risk of infection. Depending on how severe your leukopenia is, your physician may place you on antibiotics to limit infections and also give you certain medications to help promote the production of white blood cells. Similarly, ifyou become too anemic, a blood transfusion may be required to boost your red blood cell count. It is important to remain positive and remember most of these side effects resolve fairly quickly once your chemotherapy is completed.

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Long-term side effects of chemotherapy include chronic anemia, neuropathy (nerve damage), sterility or infertility, and an increased risk of certain cancers. In most instances the chronic anemia resolves with time as your body recovers. If you are planning on having children, men should bank sperm before starting chemotherapy and women should consult their gynecologist about the potential risks of pregnancy after chemotherapy. Unfortunately, it is difficult to predict the course of neuropathy in many patients. Some nerve damage slowly resolves with time, whereas other nerve damage can be permanent. Neuropathic symptoms can run the spectrum from numbness and tingling, sharp pain, and burning sensations. There are medications to help alleviate these symptoms, and your oncologist may want you to seek consultation with a neurologist in the case of severe symptoms. Although it seems counterintuitive, chemotherapy may actually incre ase your risk for developing another malignancy. Fortunately, this rarely happens (likely only 1-2 percent of patients who receive chemotherapy). Your oncologist will be aware of such risks and will monitor you after treatment for potential recurrence of the primary cancer and for any development of secondary cancers.

Just like chemotherapy and surgery, radiation has both acute (during or shortly after treatment) and chronic (up to many years after treatment) side effects. Acute side effects from radiation include lower urinary tract symptoms, diarrhea, fatigue, bloody urine and stool, and decreased white blood cell counts. Decreased white blood cell counts tend not to be as severe as that seen with chemotherapy. The other symptoms listed above typically resolve with time after therapy, but some patients may experience intermittent bladder and rectal bleeding even years after their initial treatment.

Chronic side effects of radiation therapy include erectile dysfunction, occasional rectal bleeding or bloody urine, and decreased bladder function. In the same manner that the nerves that supply erections can be inj’ured during surgery, often to provide adequate radiation coverage these nerves may be damaged. Similarly to surgery, the degree of erectile dysfunction one might experience after treatment is directly related to a patient’s age and current level of functioning. Because the radiation is directed at your bladder, side effects to the bladder itself are not uncommon. You many occasionally experience blood in your urine many years after your initial treatment. It is important to discuss this with your physician to ensure the bleeding is related to the radiation and not a recurrence of bladder cancer. Direct radiation to the bladder can also decrease bladder function. Radiation can result in bladder fibrosis, causing decreased bladder compliance and significant voiding dysfunction in approximately 5 percent of patients.

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Actos Lawsuit : While still awake, you will be transferred onto the operating room table and secured on it. If an epidural has not already been placed, one may be inserted. You may have an additional intravenous line placed. Next, your anesthesiologist will have you breathe through a mask placed over your nose and mouth. You will be given a mixture of agents which will allow you to become relaxed. Further anesthetics will result in an unconscious state. At this time, an endotracheal tube will be passed down your windpipe to provide oxygen, which is delivered automatically by a respirator, controlled by the anesthesiologist. The anesthesiologist will continuously monitor your heart rate, blood pressure, electrocardiogram, and tissue oxygenation throughout your operation. Fluid balance may also be measured via an intravenous line passed close to your heart. Urine output will be followed. Antibiotics will be infused intravenously.

Usually, compression stockings will be secured around your legs. These stockings periodically squeeze the legs to prevent blood from becoming stagnant, lowering the risk of blood clots forming in your legs, which can occur when you lie completely motionless for extended periods of time. A nasogastric tube will be passed through your nostril down your esophagus into the stomach, draining the stomach secretions during and after the surgery. A grounding pad will be placed on your side to allow for the safe use of electric current which is used to sometimes cut tissue and often in the cauterization of small bleeding vessels to stop bleeding.

Your abdomen will be prepared for surgery by shaving any hair and prepping the skin with an antiseptic solution. Female patients will have the vagina prepped with antiseptics as well. The surgical field will then be draped with sterile towels and sheets to prevent contamination from surrounding non-sterilized areas. Your upper body may be kept warm with a warming blanket. Your surgical nurse, surgeon, and assistant will all have thoroughly cleaned their hands and arms (scrubbed) and will then don a sterile gown and gloves. Their hair will be covered with a surgical cap, and they will be wearing masks over their mouths to prevent any contamination of the sterilized surgical field.

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After transfer to the floor from the recovery room, the patient is often kept on bed rest for the rest of the day. The nasogastric tube is left in and placed to gentle suction to remove excess stomach fluids. Initially, nothing is allowed by mouth other than ice chips or sips of water. Adequate fluids and some nutrition are given via an intravenous catheter. By the following day, patients are often out of bed and sometimes walking with assistance. Sequential stockings on the lower legs are removed while ambulating, and discontinued once the individual is able to move about well. Traditionally, nasogastric tubes have been left in until the bowel activity returns (generally 3-4 days). This is generally heralded by the passing of flatus (gas) or the presence of active bowel sounds, which will be checked by your urologist with a stethoscope. Recent studies have indicated nasogastric drainage for this length of time may not be necessary and may impede normal breathing, leading to other problems. Some urologists are therefore removing the tubes earlier. Feeding is gradually introduced however, once bowel activity has returned.

The patient will be encouraged to do deep breathing exercises to prevent lung collapse. This process is generally assisted with a small device called a spirometer. If the individual has a history of lung disease or is congested post-operatively, respiratory treatments with inhaled medication may be instituted and provided by a respiratory therapist.

Pain post-op is initially treated often via the epidural catheter. Intravenous medication may be given as an alternative and switched to oral pain meds once the individual is tolerating liquids. Many physicians order a PCA (patient controlled anesthesia) in which the patient pushes a button that releases pain medication via an intravenous line into the blood stream. Maximal amounts of drug administered are carefully controlled by settings on the PCA to allow safe, effective analgesia.

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Bowel leak: When the bowel is reconnected after removing the section for the urinary diversion, healing may not be adequate and bowel contents may leak into the abdomen. A bowel leak often will present as a failure of the bowel to return to normal function, resulting in a distended abdomen with poor bowel sounds. Distention, ileus (poor bowel function) may occur after the bowels are working well and feeding has been going on for some time. Evaluation is usually accomplished with CT Scan and oral contrast. Immediate surgical correction may be necessary. Left untreated, a bowel leak will generally lead to an abscess or possibly a fistula (a drainage tract from the bowel which may extend out through the incision or drain). The incidence of bowel leak is increased if bowel has been exposed to prior radiation, most often from radiation used to treat prostate cancer in men and uterine cancer in women.

Bowel obstruction: When a piece of bowel is separated from the intestine to create the new urinary drainage system, the remaining bowel must be reanastomosed (brought back together). This may be accomplished via sewing the bowel together or through the use of staples. Sometimes the opening of the bowel connection may be obstructed secondary to swelling. If an obstruction does not clear after a reasonable time, reoperation may be required.

Our use of the term or terms Actos Lawsuit is for descriptive purposes only. There is no relationship between the owners of this website and the maker of the product discussed in this post. Our use of the words Recall, Class Action Lawsuit and other similar words related to an event do not necessarily mean that this event has occurred. Refer to the website of the United States Food and Drug Administration for information on drug or medical device recalls. If a Class Action Lawsuit is formed in relation to the product discussed in this post we will provide that information at the time the Class Action is formed. A Class Action Lawsuit is not required to exist for you to file a lawsuit if you have been injured by the product discussed in this post.

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Actos Lawsuit : A continent urinary reservoir can be reconstructed using small or large bowel. Unlike noncontinent diversions, larger segments (up to 60 cm [2 feet]) of bowel are configured into a pouch that can store urine. There are two main types of continent diversions: orthotopic and continent-cutaneous. An orthotopic continent diversion is one in which the newly reconstructed pouch is reconnected back to your urethra and voiding occurs in much the same manner as before cystectomy. Continent-cutaneous diversions use a small channel made of bowel that is brought up through the skin on the abdominal wall. Unlike the noncontinent diversions, this type of diversion does not constandy drain urine but instead collects it in the pouch. Several times a day a catheter is passed through this channel in the sldn to empty the urine from the reservoir. Although these diversions allow for urinary continence, which most replicates normal function, they are associated with increased complication rates and require much more effort to maintain compared to the ileal conduit. Additionally, multiple studies have not shown that quality of life is significantly improved with continent diversion compared to noncontinent diversion.

Sexual dysfunction after pelvic surgery can have a major impact on quality of life for both men and women. In recent years radical cystectomy with the aim of preserving sexual function has been explored in both men and women. Patients with evidence of cancer invading through the bladder wall either on preoperative imaging or at the time of surgery are not ideal candidates for this type of procedure. In men this entails sparing of die nerves involved with potency that run along and underneath the prostate. In doing so, sexual potency may be preserved in a significant percentage of men. More recently, some surgeons have explored the possibility of preserving a portion of the prostate or seminal vesicles, which are traditionally removed at the time of surgery. Preservation of these structures also decreases the risk of erectile dysfunction after surgery by not damaging the nerves that run in close proximity to diem. Preservation of a portion of the prostate at the time of surgery also may improve continence in men undergoing an orthotopic bladder reconstruction.

Although nerve sparing can be performed with little risk of decreased cancer control in appropriately selected patients, prostate- and seminal vesicle-sparing surgery are more controversial because there is potential for an increased risk of cancer recurrence and also die potential for leaving undiagnosed prostate cancer behind. In women, sexual function preserving radical cystectomy has also been explored. This involves preservation of the nerves important in both clitoral engorgement and sensation. Preserving organs traditionally removed at the time of surgery, including the uterus, fallopian tube, ovaries, and portion of vagina, may also allow for improved sexual function after surgery. It should be remembered that die first goal of surgery is cancer control, and organ- and nerve-sparing procedures may not be appropriate in all cases.

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Radical cystectomy is one of the biggest and most complex procedures performed by urologists. In addition to its complexity from a technical standpoint, you will likely have many questions not only related to cancer control but also to quality of life after surgery. Cystectomy can affect your quality of life from both an emotional and physical standpoint. After surgery, you may face specific physical adjustments to die urinary diversion, possible changes in sexual function, and changes in bowel habits and function. Specific side effects and complications related to cystectomy and urinary diversion are discussed in Chapter 4. An essential aspect to enhanced quality of life after surgery is to be proactive in the decision-making process before surgery. Ask your surgeon many questions before surgery, because knowing what to expect after surgery will ease this transition. A cancer diagnosis is a difficult time for anyone, and thoughts and questions will race through your head faster than you can remember them. Write them down as you think of them, so you can have a complete discussion at the time of consultation with your physician.

As stated previously this is a big surgery, and your surgeon may have you see other specialists before your procedure to ensure you are in the best medical condition to undergo surgery. You may be admitted to the hospital the day before your scheduled surgery for any remaining tests and to prepare your bowel for surgery. In the last decade, however, medicine has become increasingly more outpatient based, and many surgeons have eliminated the preoperative admission and have you report to the hospital the morning of surgery. Your surgeon will most likely have you only consume clear liquid on the day before surgery to clear out your GI tract, which allows for a technically easier urinary diversion and may also decrease your risk of complications. Along this same line, most surgeons will have you do some form of bowel preparation the day or two leading up to surgery. This is also used to cleanse your GI tract before surgery.

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Immediately after surgery you will generally stay in the hospital 5-10 days. Postoperative practice varies from surgeon to surgeon, but most leave a small drain in the abdomen to monitor for leakage of urine from the newly created diversion and intestinal contents from the reconnected bowel. If there is no evidence of an internal leak, the drain routinely is removed at the bedside (with minimal discomfort) before discharge from the hospital. Your surgeon may also leave a nasogastric tube in for the first day or so after surgery. This is a tube that goes from your nose to your stomach and keeps your stomach decompressed, which prevents abdominal bloating and vomiting.

Generally, starting on the day after surgery you will be out of bed and with assistance from the hospital staff will start walking. It is very important to begin walking as soon as possible because it will make you feel better, will help with early return ofbowel function, and will decreasethe chances of developing blood clots in your legs and pelvic veins. You will also be instructed on breathing exercises while in bed and sitting to help expand your lungs after surgery and to prevent pneumonia. One of the major obstacles before discharge is return ofbowel function and resumption of a regular diet. Your GI tract can be slow to return to normal function, largely related to the bowel work required for the urinary diversion. This will take time, and it is important to not force your diet too soon after surgery because this will increase your chances of nausea and vomiting. In general, your body will tell you when you are ready to eat.

Use your time in the hospital to learn as much as you can about your urinary diversion. Most centers in which cystectomies are performed have an enterostomal therapist with expertise in taking care of patients with urinary diversions. If you have a new ileal conduit, they will go over the general maintenance of the abdominal stoma and urinary appliance bags. This will make you more comfortable and confident in dealing with your diversion at the time of discharge from the hospital. Upon discharge from the hospital, your surgeon will give you precise instructions regarding physical activity, exercise, and resumption of sexual intercourse. It is important to follow these instructions carefully to ensure a smooth postoperative recovery.

Our use of the term or terms Actos Lawsuit is for descriptive purposes only. There is no relationship between the owners of this website and the maker of the product discussed in this post. Our use of the words Recall, Class Action Lawsuit and other similar words related to an event do not necessarily mean that this event has occurred. Refer to the website of the United States Food and Drug Administration for information on drug or medical device recalls. If a Class Action Lawsuit is formed in relation to the product discussed in this post we will provide that information at the time the Class Action is formed. A Class Action Lawsuit is not required to exist for you to file a lawsuit if you have been injured by the product discussed in this post.

To keep up to date on Actos Lawsuit visit our site often.

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