Orthotopic bladder reconstruction in women

The feasibility of performing orthotopic bladder reconstruction in women after radical cystectomy for transitional cell bladder carcinoma is gaining increasing acceptance. Traditionally, it was generally believed that this type of operation in women was not indicated for two main reasons: 1) scepticism about the possibility of preserving urinary continence after removal of the bladder neck; and 2) concern over performing incomplete radical cancer surgery and, therefore, of possible local recurrence if part of the bladder neck were spared. On the contrary, more recent studies indicate that retention of the bladder neck is not essential to the preservation of continence because continence is mainly assured by the external urethral sphincter, with its component of striated, slow-twitch variety muscle fibres, situated in the mid-urethra. Sparing this area, together with the creation of a detubularized high compliance reservoir, assures, as for men, a good functional result. Also, local recurrence incidence may be reduced to a minimum by careful selection of patients, excluding cases of neoplasm infiltration into the cervico-urethral area through preoperative and frozen section biopsies, and opting for external drainage in cases of high stage and grade tumors. Finally, urethral mucosectomy can prove useful to further reduce the risk of recurrence, especially in cases of associated carcinoma in situ. Based on these assumptions, the authors have reported their experience of 10 cases of orthotopic neobladder reconstruction in women, performed between 1983 and 1995. The first four were performed without detubularization of the isolated intestinal segment (Camey I technique), the last 6 with detubularization of the ileum (2 using the Camey 2 technique, and 4 adopting a personal, stapled technique: Simplified Ileal Bladder). Of the 6 detubularized cases, 5 have had good functional results (complete diurnal continence, and nocturnal continence supported by one or two scheduled voidings); one case shows posterior sagging of the neobladder which has caused a high postvoiding residual and the subsequent necessity for intermittent self-catheterization. Systematic use of neobladder suspension to the periosteum of the pubis (Cooper's ligament) can obviate the complication. There has been one case of local recurrence, accompanied, however, by distant metastases, in a patient presenting a high stage primary tumor upon whom reconstruction was performed given her young age. The authors believe that the use of strict selection criteria and of careful surgical dissection techniques can allow, even in women, for orthotopic bladder reconstruction following cystectomy with positive results regarding continence and excellent cancer control.