Sparing Radical Cystectomy Research Articles

New concept in urologic surgery: The total extended genital sparing radical cystectomy in women

The aim of the study was to evaluate genital sparing radical cystectomy surgery in female patients from the point of view of both oncologic and functional outcomes (with emphasis on urinary and sexual outcomes) in a single high-volume center for the treatment of muscular invasive bladder cancer. Between January 2014 and January 2018, 14 female patients underwent radical cystectomy with preservation of genital organs (the entire vagina, uterus, fallopian tubes, ovaries) and orthotopic urinary neobladder (Padua neobladder). Inclusion criteria were recurrent T1G3 tumors; refractory tumors after BCG therapy without associated carcinoma in situ (CIS); T2 or T3a tumors entirely resected at endoscopic transurethral resection of the bladder and not involving urethra/bladder trigone. Exclusion criteria were: T3b or higher bladder cancer, associated CIS and involvement of urethra or bladder trigone. Oncological and histopathological outcomes (Overall Survival - OS, Recurrence Free Survival - RFS), urinary outcomes (day and night incontinence, intermittent catheterization use, Sandvik Score) and sexual outcomes (Female Sexual Function Index 19 FSFI-19) were considered. The average follow-up time was 56 months. Considering oncological outcomes, histologic examination reported urothelial carcinoma in 13/14 patients; 8/13 patients (61.5%) had high grade T1 stage, 3/13 patients (23%) had high grade T2 stage and finally 2/13 patients (15.5%) had high-grade T3 stage. One patient presented with embryonal rhabdomyosarcoma completely excised after surgery (PT2aN0M0). No patient developed local or metastatic recurrence (RFS 100%); OS was 100%. Considering urinary continence outcomes, 12/14 patients retained daytime and nighttime continence (85.5%); 2/14 (14.5%) complained of low stress urinary incontinence daily and nighttime urinary leakage. The Sandvik Score showed complete continence in 7/14 patients (50%); mild degree incontinence in 6/14 patients without use of incontinence devices (43%); moderate degree of incontinence in one patient (7%). The FSFI administered at 1 year from the surgery showed sexual desire in all patients (100%); subjective arousal, achievement of orgasm and sexual satisfaction in 12/14 patients (85.5%); sufficient lubrication in 11/14 patients (78.5%). Only one patient (7%) complained about dyspareunia during sexual intercourse. Our study aims to demonstrate that genital-sparing radical cystectomy is a safe surgery in terms of oncologic outcomes and, most importantly, that it is beneficial in terms of urinary and sexual function. Indeed, patients' quality of life together with their psychological and emotional health should be put on the same level as oncological safety. However, it is a treatment reserved for selected patients who are strongly motivated to preserve fertility and sexual function and thoroughly informed about the benefits and complications of such a procedure.

PD26-04 COMPARISON OF SEXUAL FUNCTION IN FEMALES AFTER REPRODUCTIVE ORGAN SPARING VERSUS NON-REPRODUCTIVE ORGAN SPARING RADICAL CYSTECTOMY

You have accessJournal of UrologyCME1 Apr 2023PD26-04 COMPARISON OF SEXUAL FUNCTION IN FEMALES AFTER REPRODUCTIVE ORGAN SPARING VERSUS NON-REPRODUCTIVE ORGAN SPARING RADICAL CYSTECTOMY Sajya Singh, Natasha Gupta, Shirley Wang, Isabella Florissi, Max Kates, Trinity Bivalacqua, and Sunil Patel Sajya SinghSajya Singh More articles by this author , Natasha GuptaNatasha Gupta More articles by this author , Shirley WangShirley Wang More articles by this author , Isabella FlorissiIsabella Florissi More articles by this author , Max KatesMax Kates More articles by this author , Trinity BivalacquaTrinity Bivalacqua More articles by this author , and Sunil PatelSunil Patel More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003304.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Given recent data, reproductive organ sparing (ROS) radical cystectomy is a safe and effective treatment for bladder cancer in select women. In this study, we sought to better understand sexual function outcomes in females who underwent a ROS versus a non-reproductive organ sparing (non-ROS) radical cystectomy for the treatment of bladder cancer. METHODS: A cross-sectional questionnaire was administered in April 2022 to eligible participants selected from a retrospective single-institution cohort of female patients with a primary bladder malignancy who underwent radical cystectomy between 2016-2020. The study questionnaire included the short form of the Female Sexual Function Index (FSFI-6), a validated evaluation tool for diagnosing female sexual dysfunction (FSD) (score ≤19). Satisfaction with sex life was reported on a Likert scale with 5=dissatisfied and 1=satisfied. Bother with lack of sexual activity was reported as 4=a lot and 1=not at all. RESULTS: Among eligible patients (n=70), 45 women (64%) completed the questionnaire on average 3.1±1.0 and 3.4±1.4 years post-cystectomy for the ROS and non-ROS groups, respectively (p=0.59). Advanced-stage bladder cancer (≥pT3) was not statistically more prevalent in non-ROS (36%) compared to ROS patients (19%, p=0.25). Before surgery, significantly more women were sexually active in the ROS group (61%) than non-ROS (21%, p=0.01); however, post-cystectomy, this difference was not observed (29% vs. 21%, p=0.59). There was a trend towards more FSD among ROS patients by FSFI-6 (57% vs. 33%, p=0.49). In both the ROS and non-ROS groups, patients who were not sexually active reported low levels of bother regarding the absence of sexual activity (1.8±1.0 vs. 1.8±1.1, p=0.86). CONCLUSIONS: Within our limited cross-sectional cohort, we identified a higher prevalence of FSD in the ROS group, although this finding was not statistically significant. Consideration of patient-specific values when discussing post-operative sexual function is essential as most non-sexually active patients denied feeling concerned by a lack of sexual activity. Further research is needed to better understand the factors impacting post-cystectomy sexual function in women and to investigate interventions targeting the psychoeducational components of sexual health. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e736 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sajya Singh More articles by this author Natasha Gupta More articles by this author Shirley Wang More articles by this author Isabella Florissi More articles by this author Max Kates More articles by this author Trinity Bivalacqua More articles by this author Sunil Patel More articles by this author Expand All Advertisement PDF downloadLoading ...

Are quality of life and sexual functions remain same following nerve sparing, vas sparing, seminal vesicle sparing and partial prostate sparing radical cystectomy and orthotopic neobladder reconstruction: A prospective randomized trial

Are quality of life and sexual functions remain same following nerve sparing, vas sparing, seminal vesicle sparing and partial prostate sparing radical cystectomy and orthotopic neobladder reconstruction: A prospective randomized trial

Retrospective Study Genital Sparing Radical Cystectomy in Women: Oncological and Functional Results

Retrospective Study Genital Sparing Radical Cystectomy in Women: Oncological and Functional Results

V09-06 PROSTATE-CAPSULE SPARING RADICAL CYSTECTOMY WITH MODIFIED W-POUCH ORTHOTOPIC NEOBLADDER RECONSTRUCTION

You have accessJournal of UrologyCME1 May 2022V09-06 PROSTATE-CAPSULE SPARING RADICAL CYSTECTOMY WITH MODIFIED W-POUCH ORTHOTOPIC NEOBLADDER RECONSTRUCTION Christopher Dall, Charlotte Goldman, James Mason, Lisa Chuong, Keith Kowalczyk, Lambros Stamatakis, and Ross Krasnow Christopher DallChristopher Dall More articles by this author , Charlotte GoldmanCharlotte Goldman More articles by this author , James MasonJames Mason More articles by this author , Lisa ChuongLisa Chuong More articles by this author , Keith KowalczykKeith Kowalczyk More articles by this author , Lambros StamatakisLambros Stamatakis More articles by this author , and Ross KrasnowRoss Krasnow More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002617.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: For patients who undergo radical cystectomy (RC) with orthotopic neobladder, erectile dysfunction and urinary symptoms may have a large impact in quality of life. This video demonstrates our prostate-capsule sparing radical cystectomy (PSC-RC) surgical technique, which may improve these functional outcomes in appropriately selected patients. METHODS: In this video demonstration, we describe development of the posterior plane and dissection anterior to the seminal vesicles and vas deferens. The Space of Retzius is entered and the bladder mobilized anteriorly. The prostatic capsule is incised at the 11 o’clock and 1 o’clock positions and the prostate adenoma enucleated. The urethra is transected distally to the prostate adenoma. A modified W-pouch orthotopic neobladder is then created using 30 cm of dependent terminal ileum approximately 25-30cm proximal to the ileocecal valve. The ileum is first detubularized, followed by sewing of the posterior plate. The urethroenteric anastomosis is performed, following by closure of the anterior plate of the neobladder. The ureteroenteric anastomoses are then completed using the proximal and distal end of the neobladder pouch. RESULTS: Data presented in several papers indicates high levels of both daytime and nighttime continence. Satisfactory erectile function is similarly high. When compared to conventional RC, PSC-RC is associated with improved functional outcomes. In our patient series, oncologic outcomes are similar to conventional RC techniques with improved erectile and urinary function. CONCLUSIONS: PCS-RC is associated with improved erectile function and continence when compared to more conventional RC techniques. Our video describes a PCS-RC technique with modified W-pouch orthotopic neobladder reconstruction. Source of Funding:- © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e806 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Christopher Dall More articles by this author Charlotte Goldman More articles by this author James Mason More articles by this author Lisa Chuong More articles by this author Keith Kowalczyk More articles by this author Lambros Stamatakis More articles by this author Ross Krasnow More articles by this author Expand All Advertisement PDF DownloadLoading ...

V13-06 FEMALE ORGAN SPARING CYSTECTOMY AND ILEAL NEOBLADDER CREATION

You have accessJournal of UrologyBladder & Upper Tract Urothelial Oncology (V13)1 Sep 2021V13-06 FEMALE ORGAN SPARING CYSTECTOMY AND ILEAL NEOBLADDER CREATION John Pfail, John Sfakianos, and Peter Wiklund John PfailJohn Pfail More articles by this author , John SfakianosJohn Sfakianos More articles by this author , and Peter WiklundPeter Wiklund More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002100.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Female organ sparing cystectomy is feasible with satisfactory functional and oncologic outcomes with proper case selection. Presented here is a 47 year old female with cT3 bladder cancer treated previously with BCG and four cycles of neoadjuvant gemcitabine, cisplatin, and nivolumab. In the footage presented, she underwent organ sparing cystectomy with creation of an ileal neobladder. METHODS: Surgical video is displayed showing the technique for an organ sparing cystectomy with creation of ileal neobladder. Additionally, and not shown in the video, she underwent b/l extended pelvic lymph node dissection. Pre and postop patient characteristics are reviewed in the video. RESULTS: The final pathology was ypT3N2. There were 63 lymph nodes removed, of which 3 were positive. At 1.5 year follow up, this patient is sexually active with good satisfaction. She also has complete daytime and nighttime continence with 0 pad usage. Additionally, she has had no evidence of recurrence. CONCLUSIONS: Organ sparing radical cystectomy with the creation of an ileal neobladder is a feasible and well tolerated surgery which may allow females to remain sexually active with good satisfaction postoperatively. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1079-e1080 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information John Pfail More articles by this author John Sfakianos More articles by this author Peter Wiklund More articles by this author Expand All Advertisement Loading ...

Seminal Vesical Sparing Cystectomy for Bladder Cancer is Feasible with Good Functional Results without Impairing Oncological Outcomes: A Longitudinal Long-Term Propensity-Matched Single Center Study.

Seminal vesicle-sparing radical cystectomy has been reported to improve short-term functional results without compromising oncological outcomes. However, there is still a lack of data on long-term outcomes after seminal vesicle-sparing radical cystectomy. The aim of this study was to compare oncological and functional outcomes in patients after seminal vesicle-sparing vs nonseminal vesicle-sparing radical cystectomy. Oncological and functional outcomes of 470 consecutive patients after radical cystectomy and orthotopic ileal reservoir from 2000 to 2017 were evaluated. They were stratified into 6 groups according to nerve-sparing and seminal vesicle-sparing status as attempted during surgery: no sparing at all (55), unilateral nerve sparing (159), bilateral nerve sparing (132), unilateral seminal vesicle-sparing and unilateral nerve sparing (30), unilateral seminal vesicle sparing and bilateral nerve sparing (45), and bilateral seminal vesicle sparing (49) and used propensity modeling to adjust for preoperative differences. Median followup among the entire cohort was 64 months. Among the 6 groups, our analysis showed no difference in local recurrence-free survival (p=0.173). However, progression-free, cancer-specific and overall survival were more favorable in patients with seminal vesicle-sparing radical cystectomy (p <0.001, p=0.006 and p <0.001, respectively). Proportions of patients with erectile function recovery were higher in the seminal vesicle-sparing groups at all time points in all analyses, respectively, with pronounced earlier recovery in patients with bilateral seminal vesicle sparing. Importantly, patients with seminal vesicle sparing were significantly less in need of erectile aids to achieve erection and intercourse. Over the whole period, daytime urinary-continence was significantly better in the seminal vesicle sparing groups (OR 2.64 to 5.21). In a highly selected group of patients, seminal vesicle sparing radical cystectomy is oncologically safe and results in excellent functional outcomes that are reached at an earlier time point after surgery and remain superior over a longer period of time.

Effect of neurovascular bundle sparing radical cystectomy on post‐operative continence and sexual function: A systematic review and meta‐analysis

It is unclear whether the neurovascular bundle (NVB) sparing could improve post-operative urinary continence and potency. Furthermore, concern remains regarding the impact of nerve-sparing (NS) radical cystectomy (RC) on oncological outcomes. The primary objective of this meta-analysis was to evaluate whether in men undergoing NS RC could improve post-operative urinary continence and potency. The secondary objective was to assess whether NS RC could compromise the oncological control. A systematic search of the PubMed and Web of Science was performed in February 2020, yielding 1446 unique records. A total of 13 comparative cohort studies were included. Risk of bias in each study was assessed separately by two authors using the Newcastle-Ottawa Scale (NOS). Data from 921 participants in 12 studies were synthesized in the present meta-analysis. Meta-analysis revealed that NS compared with non-nerve sparing (NNS) results in improved post-operative potency, daytime continence, and nocturnal continence. RRs were 9.35 (P<.00001) in potency, 1.11 (P=.045) in daytime continence, and 1.33 (P=.002) in nocturnal continence, respectively. Furthermore, no differences were found in the included studies reporting oncological outcomes. RRs were 0.88 (P=.61) in local and/or distant recurrence between two groups. A sensitivity analysis of prospective studies indicated consistent results. This meta-analysis indicates that NS RC can improve post-operative potency, and daytime and nocturnal urinary continence, without compromising oncological control, compared with NNS RC in men.

SC294 - Sex sparing vs standard robot assisted radical cystectomy with intracorporeal padua ileal neobladder in female: perioperative, oncologic and functional outcomes

SC294 - Sex sparing vs standard robot assisted radical cystectomy with intracorporeal padua ileal neobladder in female: perioperative, oncologic and functional outcomes

PD41-02 SHORT SEGMENT ILEAL ORTHOTOPIC NEOBLADDER FOLLOWING RADICAL CYSTECTOMY FOR BLADDER CANCER: DOES SIZE MATTER?

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Ureter (including Pyeloplasty) and Bladder Reconstruction (including fistula), Augmentation, Substitution, Diversion II (PD41)1 Apr 2020PD41-02 SHORT SEGMENT ILEAL ORTHOTOPIC NEOBLADDER FOLLOWING RADICAL CYSTECTOMY FOR BLADDER CANCER: DOES SIZE MATTER? Anthony Devasia*, Arun George, Ramani Kumar, and Chandra Singh Anthony Devasia*Anthony Devasia* More articles by this author , Arun GeorgeArun George More articles by this author , Ramani KumarRamani Kumar More articles by this author , and Chandra SinghChandra Singh More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000921.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Orthotopic neobladder is a diversion that is increasingly used following cystectomy for bladder cancer. The standard length of ileum used is 60 cm. We evaluated the functional outcomes of a short segment (35+5cm) ileal neobladder. METHODS: Following at least one side nerve sparing radical cystectomy for bladder cancer, orthotopic ileal neobladder was constructed using 35 cm of ileum for the pouch with an additional 5cm chimney. Preoperatively all patients were taught pelvic floor excercises and advised to perform them several times a day while awaiting surgery. Postoperatively frequent voiding was advised with alarm regulated voids at night keeping the voided volume to <400ml.Data was retrieved from our electronic database. Pouch capacity, voiding, continence, erectile function, upper tracts and biochemistry were assessed RESULTS: Of a total of 39 males who underwent the procedure from 2003 to 2019, an N pouch was constructed in 34. The mean age was 50.7 (SD 10.5)years and the mean follow up was 54 months. At 1 month, continence was 59% and at 3 months, 82.4% were fully continent with occasional nocturnal leak. By 6 months, all were continent not requiring pads with a rare leak of a few drops in a few, only at night. All men voided spontaneously without the need for clean catheterisation with a mean Q max of 22 ml/sec (SD 12), voided volume of 273ml (SD 109) and a residue of 30 ml(SD 23). There was no metabolic abnormality and renal function remained stable in all with no upper tract dilatation. Spontaneous erections were seen in 44% and 17% required PDE5 inhibitors. Six received chemotherapy (neoadjuvant 5, adjuvant 1). Two, in their late sixties who were fully continent for several years developed mild worsening of continence that improved after restarting pelvic floor exercises. Five years post operatively, one developed a calculus on the suture at the urethral anastomosis causing a ball valve effect, resulting in poor flow. The flow was restored after removal of the calculus. Thirty three (84.6%)were tumor free at the last review and 6 expired with late recurrence and metastases CONCLUSIONS: Orthotopic neobladder with a short segment of ileum (35+5) had good outcomes in terms of voiding to completion, continence and capacity, with biochemical and upper tract preservation in a carefully selected group. Source of Funding: nil © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e821-e821 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Anthony Devasia* More articles by this author Arun George More articles by this author Ramani Kumar More articles by this author Chandra Singh More articles by this author Expand All Advertisement PDF downloadLoading ...

Quality of Life in Patients with Continent Urinary Diversion after Radical Cystectomy in Upper Egypt

Background: Quality of life (QOL) assessment after radical cystectomy (RC) and urinary diversion (UD) is a crucial element of a fully evaluated patient-reported outcomes and gauging the impact and success of the diversion surgery. There has been long-standing interest in health-related quality of life (HRQOL) evaluation and research among patients who receive UD. Objective: To compare ureterocolic versus orthotopic neobladder (ONB) urinary diversions in terms of their QOL. Patient and method: This retrospective, multicenter study included 128 patients with muscle invasive bladder cancer (MIBC) who underwent RC and UD through the period from January 2011 to June 2016. The patients were divided into two groups: (ONB) 78 patients and uretrosigmoidostomy group 50 patients. HRQOL was evaluated with Functional Assessment of Cancer Therapy–Bladder Cancer (FACT-BL) Questionnaire, while Sexual Health Inventory for Men (SHIM) Questionnaire was used to assess the erectile function of males. Results: The mean patients’ age was 54.0 ± 7.9 years old in the ONB group and 57 ± 8.5 years old in ureterosigmoidostomy group. Patients in the ONB group were younger than those in the ureterosigmoidostomy group. There were diff erences in the physical, social and functional well-being that were significantly higher in patients in the ONB. Regarding the sexual function, there were significant differences between patients who underwent nerve sparing RC and non-nerve sparing RC. Conclusions: Findings suggest that patients with an ONB have marginal QOL advantages over ureterosigmoidostomy.

P147 - Prospective randomized comparison of quality of life and sexual function between ileal neobladder versus sigmoid neobladder reconstruction following nerve sparing, vas sparing, seminal vesicle sparing and partial prostate sparing radical cystectomy

P147 - Prospective randomized comparison of quality of life and sexual function between ileal neobladder versus sigmoid neobladder reconstruction following nerve sparing, vas sparing, seminal vesicle sparing and partial prostate sparing radical cystectomy

Early Oncological and Functional Outcomes of Prostate Capsule Sparing Cystectomy Compared with Standard Radical Cystectomy

Introduction and Objectives: A comparative study of standard radical cystectomy and prostate capsule sparing radical cystectomy regarding functional and oncological outcomes. Materials and Methods: A randomized study of 96 patients with transitional cell carcinoma of the bladder (December 2014 - June 2016) was done. We excluded cases with preoperative T4 staging, lymphadenopathy, prostatic specific antigen > 4 ng/dl, and cases with positive biopsies from the bladder neck, trigone, and/or prostatic urethra. Patients were divided into 2 groups, Group 1: standard radical cystectomy with orthotopic diversion (n = 51), Group 2: prostate capsule sparing cystectomy with orthotopic diversion (n = 45). Preoperative transrectal ultrasound and prostatic biopsies were done in Group 2 to exclude prostate cancer. We compared the urinary continence and erectile function in both groups after 6 months, 1, and 2 years. Results: There was no significant difference between the groups regarding preoperative demographic data, tumor stage, grade, site by cystoscopy, and biopsy. Intraoperative monitoring showed no significant differences regarding blood loss, surgical complications, or operative time (2.5 ± 0.48 vs. 2.4 ± 0.45 h). There was a significantly higher percentage of continence and potency in Group 2 than in Group 1. Sixteen cases (35.6%) in Group 2 but only 4 cases (7.8%) in Group 1 developed large post-voiding residual urine and needed intermittent self-catheterization cleaning (p = 0.001). The tumor recurrence rate was not significantly different between the groups after 2 years (p = 0.3). Conclusion: Prostate capsule sparing cystectomy is a good option in selected cases with better continence and potency and without compromising oncological outcomes after 2 years.

987 - Prospective randomized comparison of quality of life and sexual function between ileal neobladder versus sigmoid neobladder reconstruction following nerve sparing, vas sparing, seminal vesicle sparing and partial prostate sparing radical cystectomy

987 - Prospective randomized comparison of quality of life and sexual function between ileal neobladder versus sigmoid neobladder reconstruction following nerve sparing, vas sparing, seminal vesicle sparing and partial prostate sparing radical cystectomy

Chronic urinary retention after radical cystectomy and orthotopic neobladder in women: Risk factors and relation to time

PurposeTo investigate the long-term cumulative incidence of chronic urinary retention (CUR) after radical cystectomy (RC) and orthotopic neobladder (ONB) in women and the possible risk factors. Material and methodsWe retrospectively analyzed a prospectively evaluated cohort of women for whom RC and ONB were performed. Patients in CUR were evaluated for the cumulative incidence of CUR using Kaplan-Meier curve and for the possible risk factors using log rank and Cox regression analysis. ResultsA total of 234 women with mean age ± SD of 52.3 ± 9 years and a median (range) of follow-up of 92 (12–247) months were included. The incidence of CUR increased with time, where 12 (5.2%), 21 (8.97%), 35 (14.9%), 53 (22.6%), and 56 (24%) patients started clean intermittent catheterization in 1, 2, 2 to 5 years, 5 to 10 years, and after 10 years of follow-up, respectively. In univariate and multivariate analysis, diabetes mellitus and urethral Kock pouch were independent predictors of CUR development (HR [95% CI] = 2.45 [1.2–5.1], and 2.1 [1.05–4.2], P = 0.01 and 0.03, respectively). Genital- sparing RC and surgical modification to provide pouch back support were independent factors that reduce CUR development (HR [95% CI] = 9.3 [1.25–69.9], and 2.1 [1.19–3.9], P = 0.02 and 0.01, respectively). ConclusionThe incidence of CUR after RC and ONB in women increases with time even after 10 years of follow-up. Presence of diabetes mellitus increases the risk of CUR development. Genital-sparing RC and modification to prevent CUR reduced the likelihood of CUR development.

Sexual Sparing Robot-Assisted Radical Cystectomy in Female: Technique Step-by-Step

Introduction and Objective: Anterior pelvic exenteration is often synonym of radical cystectomy (RC) in women, including removal of bladder, urethra, ovaries, fallopian tubes, uterus, and part of the vagina. However, preservation of the gynecologic organs is possible in selected women. After 100 minimally invasive RCs (60 laparoscopic and 40 robotic), we describe the technique of “Sexual-sparing robot-assisted radical cystectomy” (RARC) in a female. Methods: Sexual sparing RC is offered to sexually active, relatively young women affected by low stage clinical localized muscle-invasive bladder cancer (≤T2b, N0, M0), unifocal tumor away from bladder base, and with free internal genital organs. We report the technique of RARC in a female with preservation of genital organs. Results: A four robotic arm configuration is adopted. A bilateral extended pelvic lymph node dissection is performed: the proximal limit is the ureter cross over the common iliac a.; laterally the genitofemural-n. and psoas m.; caudally Cloquet's node; and medially peritoneal sheet, umbilical a. and lateral edge of the bladder. Ureters are dissected down to the ureterovesical junction at level of uterine a. crossing. Ureters are divided and distal ureteral margins are sent bilaterally for frozen section. Vascular pedicles are sealed and sectioned with articulable vessel sealing forceps (Caiman Vessels Sealers; Aesculpa BBraun) or ultrasonic forceps (SonoSurg G2; Olympus). Space between the uterus and the bladder is dissected. A vaginal spatula facilitates dissection along the vaginal wall. The anterior vagina is opened and the plane between the vagina and the bladder is developed. A limited portion of anterior vaginal wall close to the trigone is resected en bloc with the bladder 1 cm above the bladder neck. Dissection is performed along the anterolateral paravaginal plane, no further dorsal than the 2 or 10 o'clock position to preserve the paravaginal fibers and nerves. The bladder is taken down with monopolar cautery. The urethra is identified and dissected. The catheter is removed and a clip is placed to avoid tumor spillage before urethra transection. Retrieval bag is inserted through the vagina opening and bladder is removed under vision. Vagina is then closed in two continuous layers. Conclusions: Sexual sparing RARC performed when possible with orthotopic neobladder offers intact body image and lowers decrease of sexual function and normal voiding function. Those elements play an extremely important role on patient's psychology, sexuality, and potential fertility. Robotic surgery is the perfect tool to perform such a complex minimally invasive technique. No competing financial interests exist. Runtime of video: 7 mins

Orthotopic genital sparing radical cystectomy in pre-menopausal women with muscle-invasive bladder carcinoma: A prospective study.

Introduction:Invasive cancer bladder is a life-threatening disease that is best treated with radical cystectomy and a suitable urinary diversion. The aim of this study was to evaluate the oncological outcome, voiding and sexual functions after genital sparing radical cystectomy with orthotopic bladder reconstruction in pre-menopausal women with bladder cancer.Materials and Methods:18 pre-menopausal women who underwent radical cystectomy and orthotopic urinary diversion with preservation of genital organs were included for this study. The patients were followed-up clinically and radiologically to assess their oncological outcome in addition to their voiding and sexual function.Results:Mean age of the patients was 37.8 years, and the median follow-up after surgery was 70 months. One patient was lost to follow-up at 12 months post-operatively. The surgery was completed as planned in all patients, with a mean operative time of 290 min and an average blood loss of 750 mL. 14 patients were able to void satisfactorily, being continent day and night, while four patients needed clean intermittent catheterization. Sexual life remained unchanged in 15 cases, while three patients reported dysparunea. Till the last follow-up, there was no local recurrence while distant metastases were detected in three cases, two of whom died.Conclusions:Genital sparing cystectomy is a valid option for managing carefully selected women with muscle-invasive bladder cancer with good functional and sexual outcomes.

Sparing radical cystectomy - How much is enough?

Radical cystectomy in females is increasingly being followed by orthotopic urinary diversion. This is particularly true when it comes to young patients. Wisahi et al. [1] from Egypt describe a small series of such patients with Bilharziosis associated bladder cancer. The results presented match well with those presented in other series [2–4]. Nerve-sparing radical cystectomy has been shown to be the most important determinant for subsequent neobladder function and sexual quality of life. Preservation of the uterus as proposed herein allows for very extensive nerve sparing. Moreover, dorsal stability is provided for the neobladder, which is also considered helpful in preventing obstruction. However, even with this approach still 3 women require CIC in this group. One may argue that other unknown factors could also be influential. Neobladder type itself does not appear as important as the actual radical cystectomy. Several groups have shown this before [2–4]. More importantly the authors have shown excellent sexual function. In very young women even pregnancy may be feasible. Leaving the uterus behind nevertheless is a risk factor for any later instrumentation to the internal genitalia. Injury to the neobladder is inadvertent if no urologist is part of the surgery team in such cases [5]. Overall survival was excellent in this group of women with two-thirds of them living more than 10 years. Aggressive early surgery may thus be warranted even in very young women affected by invasive bladder cancer. In developing countries such as Egypt or India clinicians are frequently challenged with young bladder cancer patients requiring radical cystectomy. The article published in this issue of the journal is particularly relevant to them.

Orthotopic genital sparing radical cystectomy in pre-menopausal women with muscle-invasive bladder carcinoma: A prospective study

Orthotopic genital sparing radical cystectomy in pre-menopausal women with muscle-invasive bladder carcinoma: A prospective study

Survival up to 5-15 years in young women following genital sparing radical cystectomy and neobladder: oncological outcome and quality of life. Single-surgeon and single-institution experience.

IntroductionThis is an observational retrospective study utilising long term patient follow–up for 15 years to determine the survival and quality of life in women (age range 20–54 years) after having been treated for carcinoma of the bladder by radical cystectomy with preservation of genital organs.Material and methodsThe study included 13 female patients with urothelial carcinoma of the bladder treated with genital sparing radical cystectomy during the period of 1995 until 2006. They had orthotopic ileal neobladder. Follow–up included recurrence–free survival, metastases–free survival, overall survival, continence, and sexual function.ResultsGenital sparing cystectomy was done in 13 women. Seven women were between the ages of 20–37, and 6 women were aged 38–54. Overall survival of 10–15 years was 61.53%, survival from 5 to 9 years was 38.46%. The procedure was done in 9 women with a muscle–invasive tumor of stage T2– T3a. Non–muscle invasive T1 tumor was present in four patients. Quality of life was assessed by continence, which was good in 10/13 patients. Three women needed CIC. Sexual function was tested by female sexual function index >20–30 and was scored at 84.61%.ConclusionsThe study provides evidence of safety and efficacy of radical cystectomy with sparing of genital organs in women aged 20 to 54 with urothelial carcinoma of the bladder. Oncological outcome for 5–15 years was good; continence and sexual function were good. This procedure should be considered when surgical approach appears to be feasible. The limitation of our findings is the small sample size of this case series.