RECONSTRUCTIVE UROLOGY

Orthotopic bladder substitution in women: nontraditional applications
Lee CT, Hafez KS, Sheffield JH, Joshi DP, Montie JE
Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
J Urol. 2004; 171: 1585-8

• Purpose: Orthotopic urinary diversion is a feasible and optimal technique for many women undergoing cystectomy. Although successful outcomes have been achieved, groups at most centers have strict selection criteria. We evaluated our experience with female orthotopic diversion in traditional and nontraditional candidates.
• Materials and Methods: From September 1, 1995 to February 6, 2003 53 females with a mean age of 62 years underwent orthotopic bladder substitution. Median followup was 24 months. Clinicopathological parameters were evaluated in traditional and nontraditional patients. The nontraditional subset comprised 22 women older than 70 years (12) or had a history of pelvic radiation (2), neoadjuvant chemotherapy (6) or stress incontinence (2).
• Results: The entire group had a mean operative time, blood loss and hospital stay of 6.2 hours, 1,135 ml and 8.2 days, respectively. Tumor was organ confined in 38 and extravesical in 14 patients with bladder cancer. Complications were detected in 20 patients, including 9 who were traditional (23%) and 11 who were nontraditional (50%). Daytime and nighttime continence was reported by 46 (87%) and 45 (85%) patients, respectively, of whom 11 (21%) required intermittent catheterization. Of the patients with cancer 42 were disease-free, 2 were alive with disease and 6 died of disease. The nontraditional subset was older (p < 0.0003) and had shorter followup (p = 0.05), a higher American Society of Anesthesiologists score (p = 0.01) and a shorter overall survival (p = 0.001) than the traditional group. Continence was seen in 19 of 22 nontraditional patients (86%) and 4 (18%) required intermittent catheterization.
• Conclusions: Orthotopic neobladder diversion offers excellent clinical and functional results, and should be the diversion of choice in most women following cystectomy. A subset of less favorable candidates can also successfully undergo orthotopic substitution with a tolerable toxicity profile.
  
  
• Editorial Comment
  In this paper the authors confirm previous studies on a successful use of orthotopic neobladder in a wide range of female patients. Despite extravesical disease, an age older than 70 years, a history of pelvic radiation, neoadjuvant chemotherapy, or preoperative stress incontinence, these patients had a continence rate of 86% and an intermittent catheterization rate of 18%. None of the patients had a urethral recurrence after a median follow up of 24 months.
  This study reinforces previous suggestions that an orthotopic bladder substitution in women undergoing radical cystectomy is not only feasible but also applicable to a majority with localized bladder tumors. Not everybody might agree with the technique of surgery by the authors, which might be the reason for a higher rate of urinary retention compared to other reports, but undoubtedly this paper shows that unfavorable factors must be a contraindication for an orthotopic neobladder.

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