Orthotopic bladder substitution in women: nontraditional applications

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.

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).

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.

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.