Orthotopic bladder reconstruction in women--what we have learned over the last decade

Approximately 10 years ago protocols for urethra-sparing cystectomy and orthotopic urinary diversion to the urethra in female patients with bladder cancer were initiated at several centers. Long-term data regarding the oncological and functional outcome are the subject of this review. Studies regarding the relationship between primary bladder cancer and secondary urethral tumors in women revealed in most studies a lower risk for women than for men in most studies. In a recent meta-analysis the incidence of urethral tumors was 6.8% in 5657 male and 3.6% in 841 female patients with transitional cell cancer of the bladder. Anatomical and functional studies revealed that smooth musculature can be found in the entire length of the female urethra. The rhabdosphincter which is the important structure for postoperative continence in low pressure intestinal reservoirs is in the midportion of the urethra which will not be touched during urethra-sparing surgery. A recent study looked at the oncological and functional results of 102 women with orthotopic urinary diversion after a follow-up ranging from one and half to 100 months (mean 26, median 24 months). There was no perioperative mortality, and an early and late complication rate requiring secondary intervention in 5 (5%) and 12 (12%) patients. With 88 of 102 patients alive and 83 of 102 patients disease free, a disease specific survival of 74% and a disease free survival of 63% was estimated at 5 years. No pelvic recurrence was seen in 81 patients with TCC. Daytime continence was 82%; nocturnal continence was 72%. Twelve patients (12%) were unable to empty their bladders completely and needed some form of catheterization. Increasing experience in recent years confirms the initial preliminary results showing that sparing the urethra at cystectomy will not compromise oncological outcome and can be satisfactorily used for orthotopic reconstruction of the lower urinary tract. Both diurnal and nocturnal continence and clean intermittent catheterization rates after 6 months justify the use of orthotopic neobladders as the procedure of choice in the majority of female patients with bladder neoplasms.