Neobladder-vaginal Fistula Research Articles

Preliminary Functional Outcome Following Robotic Intracorporeal Orthotopic Ileal Neobladder Suspension with Round Ligaments in Women with Bladder Cancer

BackgroundChronic urinary retention (CUR) is a frequent complication after orthotopic neobladder (ONB) reconstruction in women. To decrease CUR, several open surgical modifications to provide back support to the ONB have been established on the basis of pelvic anatomical differences between females and males. ObjectiveTo illustrate our technique for robotic intracorporeal reconfiguration of ONB as integrated into our open surgical approach to provide back support to the ONB with round ligaments in women. Design, setting, and participantsFrom November 2017 to April 2021, 28 patients underwent robotic intracorporeal ONB with a minimum of 6 mo of follow-up at a single centre. Surgical procedureWe performed robotic radical cystectomy, pelvic lymphadenectomy, and a complete intracorporeal ONB suspended with round ligaments (rONB). Our surgical procedure is demonstrated in the accompanying video. MeasurementsDemographics and clinical and pathological data were collected. Perioperative and 90-d complications and 6-mo functional outcomes were compared for the rONB group (n = 12) and the patients receiving a traditional ONB (tONB; n = 16). Results and limitationsThe median total operative time was 305 min (interquartile range [IQR] 270–370) for tONB and 303 min (IQR 287–330) for rONB. The median estimated blood loss was 325 ml (IQR 200–700) for tONB and 350 ml (IQR 262–600) for rONB. Some 50% of the tONB group and 41.7% of the rONB group experienced low-grade complications. A total of 12.5% tONB and 8.3% rONB patients experienced high-grade complications with neobladder-vaginal fistula. The cumulative risk of CUR was 37.5% in the tONB group and 16.7% in the rONB group. This study is limited by the small sample size and the short follow-up period. ConclusionsWe established a feasible surgical technique for a robotic intracorporeal ONB configuration suspended with round ligaments. This may prevent the occurrence of emptying dysfunction in women. Patient summaryWe describe our stepwise technique for creating a new bladder within the body that is suspended with round ligaments. Patients undergoing removal of the bladder for bladder cancer may benefit from this technique in terms of better urinary function and the advantages of a robotic surgical approach.

Vaginal Complications after Radical Cystectomy for Bladder Cancer: A Systematic Review

To summarize the published literature regarding pelvic organ prolapse, dehiscence or evisceration, vaginal fistula, and dyspareunia after radical cystectomy and to describe the management approaches used to treat these conditions. Ovid MEDLINE, Ovid EMBASE, and Web of Science were systematically searched from January 1, 2001 to January 25, 2021 using a combination of search terms for bladder cancer and radical cystectomy with terms for four categories of vaginal complications (prolapse, fistula, evisceration/dehiscence, and dyspareunia). A total of 229 publications were identified, the final review included 28 publications. Neobladder vaginal fistula was evaluated in 17 publications, with an incidence rate of 3 - 6% at higher volume centers, often along the anterior vaginal wall at the location of the neobladder-urethral anastomosis. Sexual function was evaluated in 10 studies, 7 of which utilized validated instruments. Maintaining the anterior vaginal wall and the distal urethra appeared to be associated with improved sexual function. Pelvic organ prolapse was assessed in 5 studies, only 1 used a validated questionnaire and none included a validated objective measure of pelvic organ support. There is a need for more prospective studies, using standardized instruments and subjective outcome measures to better define the incidence of vaginal complications after radical cystectomy for bladder cancer, and to understand their impact on quality of life measures.

Surgical Outcomes of Transvaginal Neobladder-Vaginal Fistula Repair After Radical Cystectomy with Ileal Orthotopic Neobladder: A Case-Control Study.

PurposeTo present surgical methods and outcomes in women with bladder cancer (BCa) requiring correction of neobladder-vaginal fistula (NVF) after radical cystectomy (RC) with ileal orthotopic neobladder (IONB).Materials and MethodsThe medical records of 163 women who underwent RC with IONB for BCa between January 2010 and December 2018 were retrospectively reviewed. The presence of NVF was confirmed by cystoscopy and/or voiding cystography. NVF repair was performed using a transvaginal approach, which included circumferential incision of the fistula tract, creation of a plane between the neobladder serosa and the vaginal epithelium, and multi-layered transvaginal closure.ResultsDuring a median follow-up of 47.9 months, NVF was identified in 12 (8.8%) of the 163 included women. Eight (66.7%) fistulas were located in the proximal anterior vaginal wall and four (33.3%) in the vaginal apex. Median time from RC to NVF repair was 3.4 months (range, 2.1–5.6 months), median NVF size was 6.0 mm (range, 4.0–22.0 mm), and median duration of urethral Foley catheter indwelling was 24.0 days (range, 15.0–43.0 days). Initial repair of NVF was successful in ten (83.3%) patients. Two (16.7%) patients who relapsed retained IONB through the subsequent operation. Two (16.7%) patients developed severe urinary incontinence after NVF repair, requiring anti-incontinence surgery with a synthetic transobturator mid-urethral sling.ConclusionThe transvaginal approach for NVF repair is feasible, yielding successful surgical outcomes. However, women should be counseled about the risks of relapse and urinary incontinence.

Neobladder-Vaginal Fistula: Surgical Management Techniques.

To describe the complexities of diagnosis and management of neobladder-vaginal fistula (NVF) following orthotopic urinary diversion in women. Multiple recent single-institution series confirm the variability of outcomes for NVF repairs and caution regarding comorbid stress urinary incontinence which may necessitate further interventions including conversion to alternate diversions. Although both abdominal and transvaginal approaches have been advocated for surgical management of NVF, contemporary series from reconstructive surgeons favor a vaginal approach to decrease overall operative morbidity. Patients should be carefully counseled regarding neobladder and sphincter function following fistula repair along with the risks of secondary urinary diversion.

PT009 - Surgical outcomes of transvaginal neobladder-vaginal fistula repair after radical cystectomy with ileal orthotopic neobladder in women

PT009 - Surgical outcomes of transvaginal neobladder-vaginal fistula repair after radical cystectomy with ileal orthotopic neobladder in women

Neovagina construction and continent cutaneous urinary reservoir using a previous orthotopic ileal neobladder

ABSTRACTStandard radical cystectomy (RC) in women involves removal of the distal ureters, bladder, proximal urethra, uterus, ovaries, and adjacent vagina. Furthermore, pelvic organ-preserving RC to treat selected women has become an accepted technique and may confer better postoperative sexual and urinary functions than standard RC, avoiding complications such as incontinence, prolapse, neobladder-vaginal fistula (NVF), and sexual dysfunction, without compromising oncological outcome.This article reports a different surgical approach: a patient who underwent a cutaneous continent reservoir and neovagina construction using a previous ileal orthotopic neobladder after RC. Patient presented no complications and she has no evidence of recurrent disease and is sexually active, with a satisfactory continent reservoir. This case is the first report of this procedure that was able to treat concomitant dyspareunia caused by short vagina and neobladder-vaginal fistula.In conclusion, standard radical cystectomy with no vaginal preservation can have a negative impact on quality of life. In the present case, we successfully treated neobladder fistula and short vagina by transforming a previous ileal orthotopic neobladder into two parts: a continent reservoir and a neovagina. However, to establish the best approach in such patients, more cases with long-term follow-up are needed.

Neobladder-Vaginal fistula: The University of Southern California experience.

The use of orthotropic neobladder (ONB) construction in women has increased in popularity. With increasing numbers so have complications distinct to this procedure. Neobladder vaginal fistula (NVF) is a rare but challenging complication. We present our experience correcting this problem. An IRB approved database of female patients with an ONB was retrospectively reviewed. Patients with a history of NVF were identified and charts reviewed. Our standard technique of radical cystectomy and orthotopic diversion in female patients includes interposition of omentum between the neobladder and anterior vaginal wall and sacrocolpopexy. Two hundred and forty-nine female patients underwent cystectomy and ONB construction between 1995 and 2015. Fourteen patients were diagnosed with a NVF (5.6% incidence). The average age and follow-up was 67 years and 33.7 months, respectively. Surgery for fistula closure was attempted in 13 patients. One repair was combined abdominal and transvaginal; the remaining 12 were performed transvaginally. Location of NVF was categorized as at the urethra-neobladder anastomosis (UNA, nine patients) and anterior vaginal wall (AVW, four patients). Eight patients had a successful fistula repair (61.5%) but only five patients ultimately retained their ONB (39%). Patients with a NVF pose a surgical challenge. Successful fistula repair does not necessarily result in adequate continence due to an incompetent outlet. NVF location at the UNA is the more common location and is more challenging in regard to successful resolution of the NVF as well as possible urinary incontinence post-NVF repair.

Treatment of Pelvic Floor Disorders Following Neobladder.

Radical cystectomy remains the gold standard treatment for organ-confined high-grade recurrent or muscle-invasive bladder cancer. Orthotopic neobladder urinary diversion following cystectomy represents an option for patients wishing for continent urinary diversion. Female patients who undergo radical cystectomy with orthotopic bladder substitution are at risk for developing both common and neobladder-specific disorders of the pelvic floor, including urinary incontinence, hypercontinence, vaginal prolapse, and neobladder-vaginal fistula. Each of these sequelae can have significant impact on the patient's quality of life. Due to the increased frequency of orthotopic neobladder creation in women, subspecialty urologists are more likely to confront such pelvic floor disorders in bladder cancer survivors. This review presents the most current information on the treatment of pelvic floor disorders after orthotopic bladder substitution.

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.

Transvaginal neobladder vaginal fistula repair after radical cystectomy with orthotopic urinary diversion in women.

We present the surgical management and outcomes of patients who underwent transvaginal neo-bladder vaginal fistula (NBVF) repair at our institution. Between 2002 and 2012, eight patients underwent transvaginal NBVF repair. The surgical management entailed placing a Foley catheter into the fistula tract. A circumferential incision was made around the fistula tract after which a plane between the serosa of the neobladder and the vaginal epithelium was created. Interrupted polyglycolic acid sutures were used to close the fistula. An additional layer of vaginal wall, Martius, or omental flap was interposed before vaginal wall closure. A urethral catheter was placed for a minimum of 14 days and removed after a negative cystogram and pelvic exam with retrograde neobladder filling without leakage. All patients presented with a fistula following radical cystectomy with orthotopic ileal neobladder. Two patients had failed two prior transvaginal fistula repairs. A unilateral Martius flap was used in five patients and an omental flap was used in one patient. The surgery was successful in all patients. After a mean follow up of 33 months [4-117], five patients underwent or are waiting to undergo management of stress urinary incontinence with bulking agents. No patient had a recurrent fistula. Management of NBVF is challenging but cure is possible using a transvaginal approach. Most patients will suffer from incontinence after the repair because of a short and incompetent urethra. Patients should be counseled about the high probability of requiring a secondary procedure to achieve continence.

Evaluation, Treatment and Management of Urinary Incontinence in Patients with Orthotopic Neobladder

Patients who undergo radical cystectomy for bladder cancer require reconstruction of the lower urinary tract. Orthotopic neobladder in carefully selected patients offers a more physiologic way of voiding. However, daytime and nighttime incontinence are commonly seen in male and female patients following surgery. Evaluation of incontinence requires careful history and physical exam to differentiate stress urinary incontinence from neobladder-vaginal fistula or poorly compliant neobladder with hypercontinence. Treatment of incontinence in patients with ONB may include: placement of retropubic sling, artificial urinary sphincter, or repair of fistula when present.

Mid-long-term follow-up of radical cystectomy with orthotopic ileal neobladder in women patients with bladder carcinoma

To assess the mid-long-term efficacies of orthotopic urinary diversion in women. From February 2003 to August 2012, 28 female patients with bladder cancer underwent radical cystectomy and orthotopic ileal neobladder.Open (n = 18) and laparoscopic (n = 9) procedures were performed.Ileal neobladder included 17 T-pouch and 11 modified Studer pouch reconstruction. The continence status, urodynamics, serum electrolyte and renal function were followed up. The mean follow-up period was 55 (8-114) months.Excellent continence was achieved during day-time in 82.1%, 92.3% and 90.5% cases at 6, 12 and 24 months postoperatively and in 53.6%, 88.5% and 90.5% cases at night respectively. The mean capacity of pouch was 282 ± 87, 345 ± 72 and 357 ± 75 ml at 6, 12 and 24 months postoperatively respectively. The mean filling pressure of pouch was 10.8 ± 3.2, 6.7 ± 2.6 and 6.2 ± 2.1 cmH₂O postoperatively respectively.One case of neobladder-vaginal fistula was cured by surgical repair. Another case of urethral stenosis responded well after regular dilation for 6 months.Renal function and electrolyte metabolism were stable in all cases. There was no instance of tumor recurrence or metastasis. Orthotopic urinary diversion in females has excellent long-term results with fewer complications so that it is highly recommended.

Highlights of 38th annual IUGA meeting with the Continence Foundation of Ireland, Dublin, Ireland, 2013

This year the 38th annual meeting of the InternationalUrogynecological Association (IUGA) took place in Dublin,Ireland, from 28 May to 1 June at the National ConventionCenter. The sun shone gloriously for the entire event,highlightingwhat a magnificent city Dublin is. DeclanKeaneandhiscochair,BarryO’Reilly,extendedaheartywelcometothe 1,549 delegates from more than 64 countries.This year saw two notable firsts for IUGA: the physiother-apy seminar, and the inaugural IUGA golf classic, played atRoyal Dublin Golf Club in Clontarf on the site of a famousbattle between the Irish and Viking invaders in the year 1014.Themeetingwasofficiallyopenedatthewelcomereceptionon Wednesday 28 May; however, for the many participants inthe physiotherapy seminar and workshops, the meeting wasalready in full swing. The workshops continue to be of a veryhigh standard and cover a large range of specialty interests.Undoubtedly, participation allows an “up-close and personal”learning experience, with the facility for delegates to interactinformally with international experts. The scientific programran from Thursday to Saturday and consisted of 199 presenta-tions, comprising oral, podium, poster, and video sessions.The winner of the best abstract was Carl Gustaf Nilsson ofFinland: “Long-termfollow-upoftheTVToperation:17yearsresults,” which concluded that the TVT procedure proves tobe safe and effective for at least 17 years [1].Alana Murphy was the winner of the best video presenta-tion; she presented two videos from Cleveland titled “Thighexploration for excision of a transobturator tape,” and“Transvaginal repair of a neobladder–vaginal fistula” [2, 3].The initial video highlighted the complex nature of dealingwith the specific mesh complication of thigh pain; the latterwas an instructional video highlighting the surgical techniquein repairing this type of fistula.Thenexttwoawardswereforfellowswiththebestpodi-um presentation and best oral poster. The prize for the bestpodium presentation went to Jaroslava Karbanova for thebodyofworktitled“Mediolateralvs.lateralepisiotomyandassociated intrapartal complications in primiparous wom-en.”Thisrandomizedcontroltrialof790primiparouswom-en found no difference between groups with respect to therate of obstetric anal sphincter injuries (OASIS) [4]. ThewinnerofthebestoralposterpresentationwasDanielaUlrich,who presented work she had undertaken in Melbourne, Aus-tralia,titled“Biomechanicalpropertiesofgelatin-coatedpoly-amide mesh seeded with human endometrial mesenchymalstem cells.” This study concluded that such meshes were lessstiff at 90 days of implantation, a property that may be desir-able in vaginal mesh [5].The State of the Art lecture—Titanic 101, the assistantsurgeon’sstory,” wasa moving, historicalaccount ofDr. JackSimpson,theassistantsurgeononboardtheill-fatedTitanic.Itwas presented by his great nephew, Mr. John Martin, FRCS,and was a combination of historical facts and personal detail,which transported usto the mid-Atlantic on the night of April14,1912.Ameasureoftheimpactofthelecturecouldbeseenin the rapt absorption on the faces in the auditorium.This year, Pamela Moali gave the Ulf Ulmsten Lecturetitled“Exposingthe science of prolapse meshes: a foundationfor future products.” It was a scientific extravaganza lookingat all biomechanic aspects of mesh and its evolution, with the

Voiding Function in Women with Orthotopic Neobladder Urinary Diversion

Most long-term morbidity after radical cystectomy is related to the urinary diversion or reconstruction. While there are benefits to an orthotopic neobladder, there can be a substantial risk of voiding dysfunction in women. We examine the prevalence of postoperative voiding complications in women who underwent orthotopic neobladder diversion. We identified all women who underwent radical cystectomy and orthotopic neobladder for bladder cancer at our institution from 1996 to 2011 (51) and included patients with regular clinic followup (49). The presence and severity of incontinence and hypercontinence were evaluated at routine clinic visits. Unadjusted analyses were performed to measure the association between patient variables and voiding symptoms, with p < 0.05 considered significant. Daytime incontinence, nighttime incontinence and hypercontinence were reported by 43%, 55% and 31% of women, respectively. A neobladder-vaginal fistula developed in 3 women (6%). On unadjusted analysis having daytime incontinence was associated with a concurrent or previous hysterectomy (p = 0.031), but not with age, disease stage, preoperative incontinence, year of surgery or sparing the vaginal wall. The severity of daytime incontinence was associated with preoperative incontinence only (p = 0.02). The presence and severity of nighttime incontinence were associated with patient age only (p = 0.013, p = 0.005, respectively). Hypercontinence was not associated with any variable. Among women with orthotopic neobladder after radical cystectomy we identified a significant prevalence of voiding dysfunction. We recommend preoperative discussion of these possible complications with any woman interested in orthotopic neobladder to establish realistic expectations. For properly selected women who understand these risks, orthotopic neobladder may be an appropriate diversion choice.

Vaginal repair of neobladder–vaginal fistula: a case report and review of the literature

Neobladder substitution after radical cystectomy for invasive cancer has become commonplace as it preserves normal volitional voiding through the native urethra and avoids urinary diversion. Neobladder-vaginal fistula (NVF) is a rare postoperative complication of this procedure that results in decreased quality of life. We describe a case of vaginal repair of a NVF and present a review of the literature.

Riparazione Trans-Vaginale di Fistola Neovescico-Vaginale

Introduction Neobladder vaginal fistula is a known complication after cystectomy and orthotopic neobladder in women. The exact incidence is still unknown, even if in some of the largest series is reported in about 5% of female patients. We present our personal experience with a case of neobladder vaginal fistula. Methods A fifty-year old woman affected by T2G3 bladder cancer underwent radical cystectomy and orthotopic neobladder in December 2007. Definitive pathological examination revealed pT3aN0G3 urothelial cancer with squamous aspects. Two cycles of neoadjuvant chemotherapy were administered before cystectomy. Three weeks after cystectomy, a retrograde cystography revealed a fistula between vagina and neobladder. At first, the patient was treated conservatively, keeping the urethral catheter for two months. Cystographies, repeated every month, recorded a reduction in size of the fistula but not the complete closure. A surgical correction was planned. Preoperative cystoscopy showed the neobladder opening of the fistula on the posterior wall. Then a transvaginal approach with fistula excision and a two layer cross suture were performed. Results At the cystography performed 1 month after surgical repair no fistula was detected, and the patient was completely dry. At 3 months follow-up the patient was completely dry. Conclusion The development of a neobladder-vaginal fistula is a significant, even if infrequent, complication after cystectomy. In our case, we performed a transvaginal approach without tissue interposition, with good results. Such procedure is easy and effective and, in our opinion, can be tempted as first line surgical treatment.

Cierre de fístula neovésico-vaginal en paciente con neovejiga tipo studer mediante abordaje transvaginal con interposición de colgajo de Martius

We report a case of neobladder-vaginal fistula in a patient, and its closure using a Martius flap interposition.A 51-year-old patient required cystectomy and Studer's neobladder for invasive bladder adenocarcinoma. After urethral catheter removal she presented constant leakage and was diagnosed by cystoscopy of neobladder-vaginal fistula.This complication was successfully treated using a vaginal approach with closure in two layers and interposition of a Martius flap.Neobladder is a rare indication in women, as it is the eventuality of presenting this type of fistula. The adequate approach to treat it is still controversial. In our experience and after reviewing literature we think vaginal closure using a Martius flap interposition is a good technique to treat a neobladder-vaginal fistula.

Functional and oncological outcomes after orthotopic neobladder reconstruction in women

To review our experience with orthotopic neobladder reconstruction (ONR) in women, highlighting functional and oncological outcomes, as ONR has been used increasingly for urinary diversion in women after radical cystectomy (RC), largely due to a better understanding of the natural history of urothelial cell carcinoma (UCC) and of the anatomy underlying the female continence mechanism, but defining the safety and long-term efficacy of ONR remain important to expanding its use. We identified 59 women who had RC with ONR between 1995 and 2006 at the Mayo Clinic. Their records were reviewed for clinicopathological demographics, and functional and oncological outcomes. The median (range) age at surgery of the women was 62 (20-82) years, and the median follow-up was 29.2 (1-141) months. Fifty-three women had RC for malignant disease, including UCC in 47. Five women (8.5%) required resection of the anterior vaginal wall during surgery, while 39 (66%) had concurrent hysterectomy. One patient had a positive surgical margin, at the left distal ureter, on final pathology. Thirteen (22%) patients had perioperative complications, including two (3%) who required reoperation. In addition, three patients (5%) developed a neobladder-vaginal fistula after RC with ONR, requiring surgical repair. At the last follow-up, daytime urinary continence (defined as needing no pads) was reported by 44/49 (90%) patients, while 28/49 (57%) had achieved continence at night. Seventeen (31%) patients required intermittent self-catheterization to facilitate emptying of the neobladder. Fifteen (28%) women had recurrence of disease, at a median of 8 (2-36) months after ONR, including seven (13%) who developed a pelvic recurrence. Twelve (20%) patients died during the follow-up, with four (8%) dying from UCC at a median of 14 (11-65) months after surgery. ONR provides a safe and effective option for urinary diversion in women, with oncological and functional outcomes similar to those for men. Thus, the technique remains a preferred option for urinary diversion in appropriately selected women treated with RC.

Vesicovaginal Fistula Repair with Rectus Abdominus Myofascial Interposition Flap

Complex, recurrent vesicovaginal fistulas (VVFs) can be very challenging to repair and often require interposition of nonirradiated, well-vascularized tissue between the urinary system and vagina. We report our experience using a rectus abdominus myofascial (RAM) interposition flap for VVF repair. A retrospective analysis was performed to identify patients who had undergone VVF repair with RAM interposition. Data were collected focusing on preoperative patient characteristics, etiology of VVF, intraoperative parameters, including surgical techniques, and postoperative patient outcomes. We used a RAM interposition flap for VVF repair in 5 patients. All VVFs had developed postoperatively; no patient had received radiotherapy. VVF developed after total abdominal hysterectomy (TAH) or radical cystectomy in 3 and 2 cases, respectively. Both cases of VVF after radical cystectomy occurred in conjunction with orthotopic diversion (neobladder-vaginal fistula). In 3 patients with post-TAH VVF, a total of five previous failed repairs were attempted before RAM interposition. In 1 patient with a neobladder-vaginal fistula, who had received adjuvant chemotherapy, RAM interposition failed, and the patient ultimately required cutaneous urinary diversion after two subsequent failed attempts at repair (68 months of follow-up). The remaining 4 patients (80%) had no evidence of recurrent VVF or voiding abnormalities at a mean follow-up of 19 months (range 8 to 32). Rectus abdominus muscle can be a successful interposition flap during repair of complex, recurrent VVF. In our experience, this has been successful in most cases, particularly in younger patients with nonmalignant processes.

Preservation of the anterior vaginal wall during female radical cystectomy with orthotopic urinary diversion: technique and results.

Orthotopic urinary reconstruction has been shown to be a viable option in women undergoing radical cystectomy. However, due to anatomical differences and technical considerations orthotopic diversion has been performed in a relatively small number of patients. We examined our technique of vaginal wall preservation during female radical cystectomy and orthotopic neobladder construction. We reviewed the records of all patients who underwent radical cystectomy between January 1994 and December 2001. Of these 542 patients we identified 94 females, of whom 25 (27%) underwent orthotopic neobladder substitution. We reviewed perioperative major and minor complications, postoperative care, followup and pathological results. Overall 21 of the 25 patients (84%) underwent anterior vaginal wall sparing. Five patients (24%) had minor complications, there were no major perioperative complications and no patients required transfusion. Median estimated blood loss in this group was 575 ml. (range 200 to 1,250). A single neobladder-vaginal fistula developed in a patient early in our series in whom the anterior vaginal wall was incised and repaired during dissection. Of the 21 patients 15 (72%) were continent. Pathological specimens revealed a negative posterior bladder wall and urethral margins in all cases. At a median followup of 12 months 1 patient had local recurrence. Anterior vaginal wall preservation in female radical cystectomy with orthotopic neobladder substitution is technically feasible, maintains vaginal length and support, has an acceptable complication rate and can achieve negative margins. Prospective evaluation is needed to assess the long-term impact on functional outcomes and cancer control.