Local urethral recurrence after radical cystectomy and orthotopic bladder substitution in women: a prospective study

We prospectively studied the pathological outcome and incidence of urethral recurrence after radical cystectomy and orthotopic bladder substitution in women.

Between January 1995 and December 2001, 145 women with a mean age of 50 +/- 8.5 years underwent standard radical cystectomy and orthotopic substitution for bladder cancer. Histopathological examination of the cystectomy specimens was assessed by a single pathologist. Clinically evident pelvic lymphadenopathy, bladder neck and/or vaginal wall involvement, or positive intraoperative frozen section from the urethra were considered contraindications.

One patient died postoperatively of a massive pulmonary embolism. Followup was 12 to 97 months (mean 36, median 55.8). Pathological stage was P1, P2 (superficial muscle invasion), P3a (deep muscle invasion), P3b (perivesical fat infiltration) and P4a in 12, 29, 56, 44 and 4 patients, respectively. Grade was G1 in 61 patients, G2 in 62 and G3 in 22. Lymph nodes were positive in 28 cases and negative in 117. Histopathology of the trigone revealed carcinoma in situ in 11 cases and squamous metaplasia in 7, while results were free of disease in the remainder. At followup isolated urethral recurrence developed in 2 patients (1.4%), in whom definitive pathological findings showed P3a N1 (positive iliac lymph nodes) M0, grade 2 squamous cell carcinoma in 1 and P3b N0M0 tumor associated with trigonal carcinoma in situ in 1. Local pelvic recurrence developed in 18 patients, distant metastasis developed in 6 and the 2 conditions developed in 10. Oncological failure positively correlated with high stage, high grade and positive lymph nodes.

The rate of urethral recurrence after radical cystectomy and orthotopic bladder substitution in women is low and acceptable and, thus, it justifies the continued performance of this type of diversion. Proper selection of cases is mandatory. Close followup for oncological failure in this group of patients after cystectomy is necessary.