ABSTRACT
When concomitant disease exists, this presents a surgical dilemma as to the appropriate timing and staging of surgical therapy. Present day complex oncologic urologic procedures such as radical cystectomy require opening the gastrointestinal tract for construction of a neobladder. Performing both urologic and vascular procedures simultaneously may potentially increase the risk o f graft infection.1 Also, combined procedures of this magnitude may result in unacceptable morbidity and increased mortality. Conversely, staging of the two procedures risks interval progres sion of the neoplastic process or rupture of the aneurysm.2 This patient population, most of whom are elderly, are then subjected to two major intraabdominal procedures usually within a three-month period during which the morbidity and mortality is cumulative. In addition, the retroperitoneal dissection required for either the oncologic or aortic procedure renders the second procedure technically more diffi cult. One may also elect not to treat a small aortic aneurysm (< 5 cm in diameter). However, an increased risk of aneurysm rupture has been reported after laparotomy, thoracotomy and sternotomy. Nora has observed that in patients with concomitant colon cancer and aortic aneurysms, when the aneurysm was not resected, there were no long-term survivors.3 Finally, a stent-graft approach to the aortic aneurysm, which could be performed before or after the urologic procedure, is now feasible. However, any technical failure, graft migration or endoleak which would require an open operation would be particularly problematic and potentially compromise the subse quent urologic procedure or injure a previously constructed urinary diversion.4
