Radical Cystectomy and Orthotopic Neobladder with Prostate and Seminal Sparing in Young Patients with Transitional Cell Carcinoma (TCC) of the Bladder

Abstract

Introduction and Objectives: Radical cystectomy is considered the standard treatment for patients with invasive TCC of the bladder and for high grade, multifocal tumors refractory to conservative therapy. Preservation of sexual function, continence and fertility are important for surgery acceptance in young patients with this disease. The objectives of this study were to evaluate the results of our seminal and prostate sparing technique on cancer control, continence, potency and fertility in a selected group of young patients with TCC of the bladder. Materials and Methods: From March 2000 to November 2004, 312 radical cystectomies were performed on patients with bladder tumors. Fourteen patients (4.5%) met the eligibility criteria and were included in this study. Two patients were excluded from the group undergoing the seminal and prostate sparing procedure after the initial TUR because of the presence of TCC in the prostatic urethra. Twelve patients therefore had the operation, eleven of whom had superficial, recurrent, high grade tumors refractory to adjuvant immunotherapy (7) or chemotherapy (4) and one had a single invasive tumor. Staging was: T1G2 = 2, T1G3 = 6, Cis = 3, T2G3 = 1. The mean age was 52.5 years. Before surgery and during follow-up the EORTC Q-30 and the IIEF questionnaires were administered. The mean PSA was 1.8 ng/ml. Step 1 of the operation included TUR of the prostate maintaining the capsule intact. A frozen section of the peripheral prostatic chips was analyzed. The open surgical step consisted of a bilateral pelvic lymph node dissection and extraperitoneal radical cystectomy preserving the vas deferens, seminal vesicles and neuro-vascular bundles. Urinary diversion was performed with a modified Studer procedure in a “whale tail” shaped fashion (2 loops). The reservoir was anastomosed to the prostatic capsule with an interrupted suture on a 22 Fr catheter. Results: Mortality was 0. The mean operating time was 5.45 hours. The mean hospital stay was 17.3 days. The early post-operative complications were low: one patient had a bowel obstruction requiring reoperation. After a mean follow-up of 16 months no delayed complications were observed. No local or distant recurrences were observed and all the patients were alive. Day time continence was complete and immediate in all the patients (100%). One patient had night-time incontinence which lasted for 2 months. Erectile function was present in all the patients: the mean IIEF score was 23. The QoL measured by the EORTC Q-30 questionnaire returned to normal after 3–9 months. All patients had retrograde ejaculation; the sperm analysis from urine of 3 patients showed a mean of 8 million spermatozoa/ml. Conclusion: Radical cystectomy with seminal and prostatic capsule sparing and orthotopic neobladder is a good option for selected young patients with superficial and single localized invasive TCC of the bladder. Functional results are excellent. A longer follow-up is needed in order to confirm the present data.