Considerations for orthotopic diversions in women

This article overviews current controversies in the field of orthotopic bladder substitution (OBS) in women.

For patients scheduled for OBS, current evidence suggests that a preoperatively obtained biopsy of the bladder neck is equivalent to performance of an intraoperative frozen section analysis of the distal urethral margin. Women with lymph node tumor or bladder trigone involvement are not at higher risk for urethral recurrence and can, therefore, undergo OBS. Current evidence is not supportive of any type of antirefluxive implantation technique for the protection of the upper tract in patients with ileal neobladder. Facilitating access to the upper tract is important for straightforward follow-up of patients. Although recent studies have shown that robotic urinary diversion with intracorporeal neobladder is technically feasible, they have failed to show that functional outcomes after robotic urinary diversion are superior to open surgery. In order to prevent the formation of neobladder-vaginal fistula an omental transfer with interposition between the reconstructed anterior vaginal wall and the posterior neobladder should be considered.

Surgical meticulousness, but not the technique itself, is important for improved functional outcomes of patients with urinary diversion. Novel surgical techniques need to concentrate around the question of how to improve surgical meticulousness during the preparation of critical anatomical structures at radical pelvic surgery.