RECONSTRUCTIVE UROLOGY

After cystectomy, is it justified to perform a bladder replacement for patients with lymph node positive bladder cancer?
Lebret T, Herve J-M, Yonneau L, Milinie V, Barre P, Lugagne P-M, Butreau M, Mignot L, Botto H
Department of Urology, Hopital Foch, Suresnes, France
Eur Urol. 2002; 42:344-349

• Purpose: After cystectomy for bladder cancer, when pelvic lymph nodes are positive, bladder replacement remains controversial. The aim of this study was to evaluate the outcome of patients who underwent neobladder replacement despite bladder cancer metastasis to the regional lymph nodes.
• Materials and Methods: From 1981 to 1997, a total of 504 consecutive cystectomies for bladder cancer were performed at our institution. For 150 patients, pelvic lymphadenectomy were positive, nevertheless 71 patients underwent a neobladder replacement (50 N1 and 21 N2). The distribution of patients by clinical stage, according to the TNM 97 classification, was 4 T1, 14 T2, 32 T3 and 21 T4. No patient showed signs of metastasis on diagnosis.
• Results: Five-year disease specific survival rate of the entire group (71 patients) was 46%. With a mean follow-up of 8.3 years (3.2-20 years), 25 patients (35%) were alive and free of disease (72% with day continence), five patients were alive with recurrence (three bone metastasis, one chest metastasis and one with local recurrence), 41 patients died, (three non-cystectomy related). Of the 46 patients who recurred, a total of eight patients had local recurrence. For five patients, a severe dysfunction of the plasty appeared: two needed definitive bladder drainage until they died, one patient became totally incontinent, one patient needed a conversion of the plasty to Bricker ileal conduit. For the remaining patient the tumor involvement provoked recto-plasty-cutaneous fistula. All these five patients died in the 6 months after the plasty dysfunction appeared.
• Conclusions: Although prognosis in bladder cancer metastasis to the regional lymph nodes has been reported to be poor, this study demonstrates that after cystectomy, it is justified to propose a neobladder replacement to well selected patients. Local recurrence only occurred in 11% of patients and there was no damage to enteroplasty function for nearly half of the patients, and considering benefit to the quality of life, orthotopic bladder substitution should be considered as the preferential diversion in this patient population.
  
  
• Editorial Comment
  Orthotopic bladder substitution to the urethra after cystectomy is meanwhile a standard procedure for both male and female patients. It offers the best and most natural solution of any kind of urinary diversion available today, if the surgical margins are negative. Initial concerns with regards to local recurrence, especially the side of the urethrointestinal anastomosis, proved to be insignificant compared to other forms of bladder substitution.
  There is, however, an ongoing discussion whether positive lymph nodes should be a contra-indication for orthotopic bladder substitution. As the authors of this paper have shown, a sizeable number of patients survive several years (46% of the patients survived at least 5 years in the hands of these authors). Should they be spared a bladder substitution to the urethra for the remaining years of their life, despite the positive effects on their quality of life?
  These authors, as well as others – e.g. Skinner et al from Los Angeles, Hautmann et al or our own group from the previous institution in Innsbruck – , have all shown a local recurrence rate around 10-12%, irrespective of the presence or the absence of microscopic lymph node metastasis. Of all patients that did recur locally, half had an undisturbed function of their continent reservoir for the remaining time of their life. Those developing a voiding dysfunction did so in the last 6 months of their life after they had a mean of 17 months life with a normal functioning bladder substitution.
  It seems therefore appropriate to conclude that continent urinary diversion is a possible option, and it should be regarded as a first line method of urinary diversion even in patients with microscopic lymph node metastasis of bladder cancer. One may even further conclude that if there are no macroscopic signs of lymph node involvement, why should you perform any frozen sections of lymph nodes during surgery? We know that frozen sections yield 20-25% false negative results and on the other hand they might not change decision-making at the time of surgery.

Dr. Arnulf Stenzl
Professor and Chairman of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany