Urethra-sparing cystectomy and orthotopic urinary diversion in women with malignant pelvic tumors

Abstract

Background: To the authors' knowledge, few data exist regarding the functional and oncologic outcome of pelvic tumors in women with urethra-sparing cystectomy and orthotopic urinary diversion to the urethra.

Patients and methods: The combined data of 102 women age 28-79 (mean, 59 yrs) years who underwent a urethra-sparing cystectomy and orthotopic urinary diversion for either primary bladder cancer (96 patients), carcinoma of the uterine cervix (2 patients), carcinoma of the vagina (1 patient), primary fallopian tube carcinoma (1 patient), uterine sarcoma (1 patient), or rectal carcinoma (1 patient) were reviewed. The histology of the 96 primary bladder tumors was 81 transitional cell carcinomas (TCC), 8 adenocarcinomas, 5 squamous cell carcinomas, 1 small cell carcinoma, and 1 unclassified. Follow-up ranged from 1.5-100 months (mean, 26 mos; median, 24 mos). In all patients, the bladder neck and up to 1 cm in length of the adjacent urethra were removed with the bladder. An ileal orthotopic neobladder procedure was performed if staging biopsies of the bladder neck and intraoperative frozen section of the urethral margin revealed no tumor.

Results: 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. Three pelvic recurrences occurred, two tumors of the inner genitalia and one adenocarcinoma of the bladder, none of them in the area of the urethra or its supplying autonomic nerves. Daytime continence was 82%; nocturnal continence was 72%. Twelve (12%) patients were unable to empty their bladders completely and needed some form of catheterization.

Conclusions: The functional and oncologic outcome of female patients with an orthotopic urinary diversion to a remnant urethra was found to be comparable to that found in large studies on males. An orthotopic neobladder proved to be an oncologically safe option for women with pelvic tumors and was found to provide quality of life when there was adherence to previously defined selection criteria.