RECONSTRUCTIVE UROLOGY

Nerve-sparing radical cystectomy and orthotopic bladder replacement in female patients
Bhatta Dhar N, Kessler TM, Mills RD, Burkhard F, Studer UE
Department of Urology, University of Bern, Bern, Switzerland
Eur Urol. 2007; 52: 1006-14

• Objectives: Orthotopic diversion, initially performed solely in men, has now become a viable option in women. Approximately 15 yr ago, at several centres, urethra-sparing cystectomy and orthotopic diversion were initiated in women with bladder cancer. Several studies have since addressed both the oncologic and functional outcomes of this procedure.
• Methods: We describe our surgical technique of cystectomy and orthotopic urinary diversion in female patients, with an emphasis on how we preserve the neurovascular bundle.
• Results and Conclusions: An improved understanding of the anatomic neurovascular and fascial planes related to the rhabdosphincter has facilitated identification of elements needed for orthotopic diversion in female patients. The technique of en bloc anterior exenteration includes the anterior portion of the vagina; however, preservation of the rhabdosphincter and its autonomic nerve supply necessitates specific modifications of the standard operation. The video provides a detailed description of our surgical technique with attention to anatomic details necessary to avoid damage to the proximal urethra and to preserve the autonomic innervation of the rhabdosphincter.
  Autonomic nerve preservation reconfirmed
  
  
• Editorial Comment
  This is another detailed description and rationale for an orthotopic bladder substitution in female patients undergoing radical cystectomy. There is a plethora of literature now about the use of urinary continence diversion to the urethra in female patients. Whereas almost all contributions agree that such a diversion can and should be authored to female patients there is still no agreement whether better functional results can be achieved with a preservation of autonomic nerves running to the remnant isolated urethra. This contribution by well-known experts clearly favor preservation of autonomic nerves for two reasons: sexual activity, especially in younger women has been more or less neglected for many years but seems to be important (reference 16 and 17 in the manuscript), this group has formerly demonstrated that preservation of autonomic nerves also contributes to continence. It is therefore not only important to preserve autonomic nerves in the younger patients, although sexually active, but to preserve autonomic nerve in elderly patients as well, those patients that are in danger of having a borderline continence postoperatively. A better sensitivity of the remnant urethra will be better for the “first drop incontinence” due to better reaction of urine entering the urethra and resulting in reflex contraction in the pelvic floor but also will help in achieving better results with postoperative physical therapy for urinary incontinence (1).
  Not everything concerning the function of autonomic nerves with regards to clitoral and vaginal function, secretion of pelvic glands, function and long-term fate of urethral smooth musculature, and interaction with rhabdosphincter and pelvic floor musculature is known to date. However, with increasing knowledge we know that it is important to preserve at least part of the ganglions and nerve fibers of pelvic autonomic nerves to increase the quality of life for these patients in the long-term. In addition, it is the long-term quality of life where functional outcome is important contrary to oncological outcome, which in the first few years seems to be dominant as quality of life studies have shown.

Reference
1. Di Gangi Herms AM, Veit R, Reisenauer C, Herms A, Grodd W, Enck P, Stenzl A, Birbaumer N: Functional imaging of stress urinary incontinence. Neuroimage. 2006; 29: 267-75.

Dr. Arnulf Stenzl &
Dr. Karl-Dietrich Sievert
Department of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany