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Orthotopic Lower Urinary Tract Reconstruction in Women Using the Kock Ileal Neobladder: Updated Experience in 34 Patients
0022-5347/97/1582-0400$03.00/0 THEJOURNAL OF UROLOGY Copyright 0 1997 by AMERICAN UROLU(;ICAL ASSOCIATION, IN(..
Vol. 158,400-405,August 1997 Printed i n U.S.A.
ORTHOTOPIC LOWER URINARY TRACT RECONSTRUCTION IN WOMEN USING THE KOCK ILEAL NEOBLADDER: UPDATED EXPERIENCE IN 34 PATIENTS JOHN P. STEIN, GARY D. GROSSFELD, JOHN A. FREEMAN, DAVID ESRIG, DAVID A. GINSBERG, RICHARD J . COTE, EILA C. SKINNER, STUART D. BOYD, GARY LIESKOVSKY AND DONALD G. SKINNER From the Departments of Urology and Pathology. University of Southern California, Los Angeles, California
ABSTRACT
Purpose: Orthotopic lower urinary tract reconstruction has revolutionized urinary diversion following cystectomy. Initially performed solely in male patients, orthotopic diversion has now become a viable option in women. Currently, the orthotopic neobladder is the diversion of choice for women requiring lower urinary tract reconstruction a t o u r institution. We evaluate and update our clinical and functional experience with orthotopic reconstruction in female patients. Materials and Methods: Since June 1990, 34 women 31 to 86 years old (median age 67) have undergone orthotopic lower urinary tract reconstruction following cystectomy. Indications for cystectomy included transitional cell carcinoma in 29 patients, urachal adenocarcinoma in 1, mesenchymal tumor of endometrial origin in 1, cervical carcinoma in 1 and a fibrotic radiated bladder in 1. In addition, 1 woman underwent undiversion to the native urethra following a previous simple cystectomy and cutaneous diversion for eosinophilic cystitis. Data were analyzed according to postoperative early and late complications, survival, tumor recurrence, pathological evaluation of the cystectomy specimen, continence status, voiding pattern and patient satisfaction. The median followup in this group of patients was 30 months (range 17 to 70). Results: There were no perioperative deaths, and 4 early (11%) and 3 (9%) late complications. Four patients died, none with a urethral recurrence, including 3 of metastatic bladder cancer and 1 of unrelated causes. In another patient with a n extensive mesenchymal tumor of the uterus a sigmoid tumor recurred requiring conversion of the orthotopic reservoir to a cutaneous diversion. All of the remaining 29 patients are alive without evidence of disease. Intraoperative frozen section of the distal surgical margin (proximal urethra) accurately evaluated (confirmed by permanent section) the proximal urethra prospectively for tumor in all 29 specimens removed for transitional cell carcinoma, including 28 specimens (97%) without evidence of tumor and 1 specimen with carcinoma in situ. Complete daytime and nighttime continence was reported by 29 (88%)and 27 (82%) of 33 evaluable patients, respectively. A total of 28 patients (85%) void to completion, while 5 (15%) require some form of intermittent catheterization to empty the neobladder. Patient satisfaction is overwhelming. Conclusions: The excellent clinical and functional results demonstrated with further followup confirm our initial experience with orthotopic diversion in women. Careful selection of appropriate female candidates for orthotopic diversion is critical, and includes preoperative evaluation of the bladder neck and intraoperative frozen section analysis of the distal cystectomy margin. Furthermore, close monitoring of the retained urethra is mandatory in all women undergoing orthotopic diversion. We believe that the orthotopic neobladder is the urinary diversion of choice in women following cystectomy. KEY WORDS:bladder neoplasms, urinary diversion, women
As we enter the mid 199Os, urinary diversion has reached a new era. The ultimate goal of lower urinary tract reconstruction has become, not only a means to divert urine and Protect the upper urinary tract, but also to provide Patients with a continent means to store urine and allow for volitional voiding through the intact native urethra. These advances in urinary diversion have been made in an effort to provide patients a more normal life-style with a positive self-image Accepted for publication February 28, 1997.
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following removal of the bladder. We and others have been dedicated to the continued improvement and progress of lower urinary tract reconstruction, and currently believe that the orthotopic neobladder represents the most ideal form of urinary diversion.1-4 ~ ~ in 1986@ofihotopic ~ lower ~urinary tract i ~ reconstruction became the procedure of choice in select male patients undergoing cystectomy at our institution,z, 6 The excellent clinical and functional results achieved in these patients stimulated an effort to provide female subjects a similar form of diversion. Our initial clinical experience with orthotopic cu ~ ~ ~ ~~ ~ ~~ f ~ $ diversion in women1 was based on a better understanding of the continence mechanism in women,fi coupled with sound
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ORTHOTOPIC DIVERSION IN WOMEN
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pathological criteria that allow the clinician to select safely appropriate female candidates for this form of urinary diversion.i,x The clinical and functional results of our initial experience were excellent. We update our experience with the orthotopic neobladder in 34 women, which to our knowledge is the largest reported series in the literature. MATERIAL AND M E T H O D S
Patients. From June 1990 through March 1996,34 women 31 to 86 years old (median age 66) underwent orthotopic lower urinary tract reconstruction at the University of Southern California, including a Kock ileal neobladder in 33 (97%) and an ileocolonic neobladder in 1. En bloc anterior exenteration with bilateral pelvic lymphadenectomy was performed in 29 women (85%)for primary transitional cell carcinoma, in 1 for urachal mucinous adenocarcinoma and in 1 for squamous cell carcinoma of the bladder. One patient underwent total pelvic exenteration for squamous cell carcinoma of the cervix. In addition, 1 patient underwent simple cystectomy for a fibrotic radiated bladder, and 1 underwent undiversion to the native urethra following a previous cystectomy and cutaneous urinary diversion for eosinophilic cystitis 5 years previously. Patient selection. Three forms of urinary diversion were discussed with the patient in detail preoperatively, including an incontinent cutaneous form of diversion (ileal conduit), a continent cutaneous form of diversion (Kock ileal reservoir) and a n orthotopic form of diversion (ileal neobladder). All potential female candidates choosing orthotopic reconstruction underwent preoperative cystourethroscopy with evaluation of the bladder neck and urethra. All patients were marked preoperatively for a n appropriate stoma site and instructed on how to catheterize if necessary by the enterostomal therapy nurse. Furthermore, if tumor was demonstrated histologically on intraoperative frozen section of the distal cystectomy margin (proximal urethra), then orthotopic reconstruction would be abandoned and a n alternative cutaneous form of diversion performed according to patient preference as discussed preoperatively. Cystectomy. The technique of en bloc radical cystectomy with bilateral pelvic iliac lymphadenectomy in the female subject remains standard.1.9 However, several aspects of the anterior exenteration in women deserve specific mention. At the terminal stages of the cystectomy careful preparation of the urethra is critical to avoid injury to the continence mechanism. Minimal dissection should be performed in the region anterior to the urethra (fig. 1)to prevent injury to the rhabdosphincter region which extends from the proximal urethra to the membranous urethra. In addition, the pubourethral suspensory ligaments should be left intact. These ligaments provide support and help maintain a n intrapelvic neobladder position which may also contribute to the continence mechanism in women. Furthermore, no attempt is made to perform a sympathetic nerve sparing cystectomy in these women. In fact, we routinely sacrifice the autonomic sympathetic nerves extending from just above the aortic bifurcation, caudally off of the abdominal aorta, common iliacs and sacral promontory. In addition, the autonomic neurovascular bundles coursing along the lateral aspect of the uterus and vagina are removed down to the level of the bladder neck. This extensive dissection effectively denervates the bladder neck and proximal urethra, rendering them ineffective as far as a continence mechanism. We believe the rhabodospincter region and the corresponding innervation from branches off of the pudendal nerve provide continence in these The posterior dissection of the cystectomy is also critical to the successful outome of orthotopic diversion in women. After all tissue is swept off of the lateral aspect of the vagina, while developing the posterior pedicles, the posterior vagina is incised at the apex just distal to the cervix. This incision is
FIG. 1. View of female pelvis from overhead followin completion of anterior exenteration. Note that no dissection is pe3ormed anterior to urethra along pelvic floor, which helps prevent injury to rhabdosphincter region and corresponding innervation. which are critical to continence mechanism in women undergoing orthotopic diversion.
carried anteriorly along the lateral and anterior vaginal wall forming a circumferential incision. The anterorlateral vaginal wall is then grasped with a curved Kocher clamp, which provides counter traction, and facilitates dissection between the anterior vaginal wall and the bladder specimen. Development of this posterior plane and vascular pedicle is best performed sharply and carried just distal to the vesicourethral junction. Palpation of the Foley catheter balloon assists in identifying this region. This dissection effectively maintains a functional vagina. Furthermore, an intact anterior vaginal wall may lend additional support to the proximal urethra through a complex musculofascial support system that extends from the anterior vagina. The vaginal cuff is then closed at the apex and later suspended to Cooper’s ligament to prevent vaginal prolapse or the development of a n enterocele postoperatively. Alternatively, in the case of a deeply invasive posterior bladder tumor with concern of a n adequate surgical margin the anterior vaginal wall should be removed en bloc with the cystectomy specimen. ARer dividing the posterior vaginal apex, the lateral vaginal wall subsequently serves as the posterior pedicle and is divided distally, which leaves the anterior vaginal wall attached to the posterior bladder specimen. Again, the Foley catheter balloon facilitates identification of the vesicourethral junction. The surgical plane between the vesicourethral junction and the anterior vaginal wall is then developed distally at this location. A 1 cm. length of proximal urethra is mobilized while the remaining distal urethra is left intact with the anterior vaginal wall. The presence of extravesical disease away from the anterior vaginal wall, bladder neck or proximal urethra, as well as the presence of pelvic nodal metastases, did not preclude orthotopic lower urinary tract reconstruction. In addition, the specific histopathological type of pelvic tumor did not preclude orthotopic diversion as long as the aforementioned criteria for orthotopic reconstruction in women were maintained. Lower urinary tract reconstruction (Kock ileal reseruoir).
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ORTHOTOPIC DIVERSION IN WOMEN
The technique of constructing the Kock ileal reservoir with bilateral ureteroileal urethrostomy has been described previously and remains standard.'", 11 Depending on patient desire for sexual function postoperatively, vaginal reconstruction may be required.' Regardless, to prevent fistula formation a well vascularized omental pedicle graft should be secured to the levator ani muscles separating the reconstructed neobladder and vagina (fig. 2). Following completion of the mucosa-to-mucosa urethroenteric anastomosis, the neobladder is secured with a 3-Zero polyglycolic acid suture to the inferior aspect of the pubic symphysis. This maneuver maintains a tension-free urethroenteric anastomosis and ensures an intra-abdominal reservoir location. Followup. All patients are seen a t 4-month intervals postoperatively for the first year, 6-month intervals for the second year and annually thereafter. Followup consists of routine chemistry studies, including serum determination of blood urea nitrogen and creatinine. Radiographic evaluation of the neobladder (gravity cystogram) and upper urinary tract evaluation (either excretory urography or ultrasound) are performed a t 4 and 12 months postoperatively, and then annually thereafter. A thorough pelvic examination with particular attention to the anterior vaginal wall and urethroenteric anastomosis is performed a t each followup visit. In addition, a voided urine cytology specimen is obtained for surveillance purposes of the retained urethra. Panendoscopy of the urethra may be indicated when abnormal cells are reported on cytology, the pelvic examination is suspicious, or the patient reports any burning, bloody discharge or unusual sensation in the region of the urethra. To date, panendoscopy has not been required. Continence and voiding pattern. Continence status and voiding pattern were determined by questionnaires and personal interviews a t routine followup visits. Diurnal continence was evaluated according to the continence grading system of McGuire et a1,1* and defined as completely continent, incontinent with major effort and when upright, incontinent with minor effort only and incontinent without regard to effort, position or activity. Nighttime continence was de-
fined as either continent or incontinent requiring any form of protection. Voiding pattern was classified as able to void to completion without the need for catheterization or requiring any form of intermittent catheterization, either for residua] urine or unable to void requiring continuous intermittent catheterization. Data were analyzed according to early (within 30 days of surgery) and late complications, survival status, disease recurrence (urethral, pelvic or distant metastasis), pathological evaluation of the cystectomy specimen, continence status, voiding pattern and overall patient satisfaction. RESULTS
Early complications. Three patients (9%)suffered a total of 4 early complications (11%) which prolonged hospitalization or required reoperation. In 1patient a urine leak developed, requiring bilateral percutaneous nephrostomy tube placement, and a subsequent pulmonary embolus required full dose anticoagulation therapy. This women was discharged home 15 days postoperatively without further sequelae. Another patient, who received preoperative external beam radiation therapy (5,000 rad.) and underwent total pelvic exenteration for stage IIIB cervical cancer, suffered a prolonged postoperative ileus that was treated conservatively and she was discharged home on postoperative day 15. The third patient required an operation under local anesthesia to remove a retained portion of a Jackson-Pratt drain that broke while being removed. Hospital course was not prolonged and she was discharged home on hospital day 8. The average length of hospital stay for the remaining 31 patients was 8.5 days. Late complications. Late complications requiring rehospitalization or reoperation occurred in 3 patients (9%). In 2 patients a small bowel obstruction developed, requiring surgical exploration in 1and conservative treatment in 1. In the third woman a Kock pouch calculus developed, requiring outpatient endoscopic removal under local anesthesia. Survival and recurrence. There were no perioperative deaths. As of April 1996, 29 of the 34 patients (85%) were alive without evidence of disease and with an average followup of 30 months (range 17 to 70). Four patients died, including 3 of metastatic transitional cell carcinoma and 1of unrelated causes, and all without evidence of a pelvic or urethral recurrence. In addition, in 1 patient with an extensive mesenchymal tumor of the uterus a sigmoid tumor recurred 20 months postoperatively. This patient underwent exploratory celiotomy, en bloc resection of the tumor and sigmoid colon, and conversion of the orthotopic neobladder to a continent cutaneous Kock ileal reservoir. Pathological evaluation of cystectomy specimens. Detailed pathological examination was performed on all 29 cystectomy specimens removed for primary transitional cell carcinoma of the bladder. Of these 29 specimens 20 (69%) demonstrated grade 3 and 9 grade 4 histological tumors. Pathological staging of the primary tumor demonstrated 16 (5592'0organ confined ( P l , Pis, P2, P3a) lymph node negative tumors, 6 (21%) extravesical (P3b, P4) lymph node negative tumors and 6 (21%) lymph node positive tumors. One patient with lymph node positive disease had concomitant metastatic liver disease discovered a t the time of surgery. Carcinoma in situ with or without evidence of gross tumor was noted in 18 bladder specimens (62%),including 14 with multifocal and 4 with focal disease. Bladder neck (vesicourethral junction) involvement of tuFIG.2. Samttal section of female wlvis. Note that well vascular- mor was identified in 6 specimens (21%), and all demonized omentalpedicle graft is placed*between reconstructed vagina strated carcinoma in situ. Of these 6 cases 1 specimen (3%) and neobladder. Pedicle graft is secured to levator ani muscles to demonstrated concomitant carcinoma in situ of the proximal separate suture lines and helps prevent fistulization. Also note that vagina is closed at apex, Va will be suspended to Cooper+sliga- urethra. The remaining 5 patients with carcinoma in situ ment to prevent vaginal progpse or development ofenterocele post- involving the bladder neck were without evidence of tumor in operatively. the proximal urethra. No patient with an uninvolved bladder
ORTHOTOPIC DIVERSION IN WOMEN
neck demonstrated any evidence of urethral tumor involvement. In addition, intraoperative frozen section analysis of the distal surgical margin (proximal urethra) accurately predicted the final histological diagnosis of the proximal urethra in all 29 specimens, including 28 without evidence of tumor and 1with carcinoma in situ involving the proximal urethra. Continence. Continence status was evaluable in 33 of 34 patients. The patient with a sigmoid recurrence and who required conversion to a continent cutaneous diversion was excluded from analysis. Complete daytime continence was reported by 28 of 33 patients (85%).An 86-year-old woman required 2 courses of periurethral collagen injection 8 months postoperatively for incontinence (major effort only) and is currently completely continent. Daytime incontinence with major effort only was reported by the remaining 4 patients. Complete nighttime continence was reported by 27 of 33 patients (82%).Nighttime incontinence requiring some form of protection was reported by 6 patients, with no patient requiring more than 3 pads per night. Voidingpattern. Information regarding the voiding pattern was obtained in the aforementioned 33 patients. The ability to void to completion by Valsalva’s maneuver and relaxation of the pelvic floor muscles was reported by 28 patients (85%). Five patients require some form of intermittent selfcatheterization to empty the neobladder, of whom 2 catheterize twice daily for residual urine only and 3, who are unable to void, require continuous intermittent catheterization every 4 to 6 hours to empty the neobladder. One of these cases represents our early experience in which a Burch suspension procedure was performed simultaneous with lower urinary tract reconstruction, which we now realize only contributes to urinary retention. Satisfaction. All patients have been satisfied with the continence, voiding pattern, self-image and overall results of the procedure. In fact, the patient with a sigmoid recurrence who underwent conversion of the orthotopic neobladder to a cutaneous reservoir reported that, although she is currently continent, she much preferred the orthotopic form of diversion compared to the cutaneous form of diversion.
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ion performed anterior to the urethra. An elderly woman with incontinence 8 months postoperatively underwent 2 :ourses of periurethral collagen injection and is currently :ontinent. Furthermore, although adjuvant therapy for in:ontinence has been offered (periurethral collagen injection, )ladder neck suspension or sling procedure), all 4 women who report daytime incontinence with major effort only are jatisfied with the results and are not inconvenienced or im>aired by the urinary leakage to desire additional treatment 3t this time. Two important criteria must be fulfilled when considering any patient for orthotopic urinary diversion: 1) under no lcircumstances must the cancer operation be compromised by the reconstruction at the urethroenteric anastomosis, retained urethra or surgical margins and 2) the rhabdosphincter mechanism must remain intact to provide a continent means of storing urine. If these criteria can be safely maintained, the patient may then be considered an appropriate candidate for orthotopic urinary diversion. Recently, pathological criteria have been established which identify appropriate female candidates for orthotopic diversion.7.8 From an extensive analysis of female cystectomy specimens removed for transitional cell carcinoma of the bladder, we demonstrated that tumor involving the bladder neck is a n important risk factor for urethral tumor involvement.7 All cystectomy specimens with carcinoma involving the urethra had concomitant tumor involving the bladder neck. However, not all specimens with tumor involving the bladder neck demonstrated urethral tumor involvement. This is an important issue because, although bladder neck involvement with tumor is a risk factor for urethral tumor involvement, approximately 50% of patients with tumor involving the bladder neck will have a urethra free of tumor. In this situation the patient may be considered a n appropriate candidate for orthotopic diversion. Therefore, although bladder neck involvement with tumor is a risk factor for concomitant urethral tumor involvement, pathological evaluation of the proximal urethra is the most critical determinant for orthotopic diversion. These pathological guidelines were prospectively evaluated in 29 consecutive women undergoing orthotopic reconDISCUSSION struction for transitional cell carcinoma of the bladder in this The progressive development of urinary diversion has been series. All 23 cystectomy specimens without tumor involvethe result of persistent dedication by innovative and pioneer- ment of the bladder neck were also free of tumor at the ing surgeons to improve the treatment and quality of life of urethra. A total of 6 specimens demonstrated tumor involvepatients following cystectomy. This evolution has developed ment at the bladder neck, and only 1 of these 6 specimens along the 3 distinct paths of an incontinent cutaneous form of demonstrated urethral tumor involvement. These results diversion (ileal conduit), a continent cutaneous form of diver- support our previously established pathological criteria sion (Indiana and Kock pouches) and, most recently, a form of which identify the bladder neck as a risk factor for urethral diversion to the intact native urethra (orthotopic neoblad- tumor involvement. We have found the intraoperative frozen section of the der). We firmly believe the orthotopic neobladder currently represents the most ideal form of urinary diversion available distal surgical margin (proximal urethra) to be a n accurate and reliable method to evaluate the proximal urethra for in carefully selected male and female patients. The orthotopic neobladder most closely resembles the orig- urethral tumor involvement. Intraoperative frozen section inal bladder in location and function. Orthotopic diversion analysis accurately evaluated the proximal urethra in all 29 eliminates the need for a cutaneous stoma and the often specimens removed for transitional cell carcinoma, including plagued cutaneous continence mechanism, relying on the 28 cases without tumor involvement and 1 with carcinoma in intact rhabdosphincter mechanism for continence. Patients situ involving the urethra. In all 29 cases the frozen section retain a more natural micturition pattern and consciously result was correctly confirmed on permanent section of the void per urethra. In addition, we believe that the orthotopic cystectomy specimen. Currently, intraoperative frozen secneobladder provides a more normal life-style with an im- tion of the proximal urethra is the most decisive method to determine if a female patient may be an appropriate candiproved self-image compared to other forms of diversion. The excellent functional results in 34 women undergoing date for orthotopic diversion. Furthermore, because of the orthotopic neobladder diversion confirm our initial experi- risk of injuring the continence mechanism with preoperative ence with further followup. The majority of women are com- biopsy of the bladder neck and urethra, coupled with a conpletely continent (88%daytime) and void normally per ure- firmed method to evaluate reliably the proximal urethra thra without the need for catheterization. In many women (intraoperatively), we now rely solely on intraoperative complete continence is restored immediately following re- frozen section analysis of the proximal urethra for proper moval of the urethral catheter 3 weeks postoperatively and selection of women considering orthotopic lower urinary tract by 6 months most women obtain the maximum degree of reconstruction. To date, no patient has had a urethral recurrence with a continence. We attribute these results to the limited dissec-
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ORTHOTOPIC DIVERSION IN WOMEN
median followup of 30 months. These results are encourag- acceptance. Although long-term followup will be required to ing, since in our experience with male patients most urethral define the true risk of urethral recurrence in these women, tumors recur within the first 19 months following cystectomy we believe that female subjects considering orthotopic diverfor transitional cell carcinoma.'" Regardless, careful followup sion may be safely and appropriately selected using strict is mandatory to define the long-term risk of urethral recur- pathological criteria. We have found intraoperative frozen rence in this group of female patients. In addition, it must be section of the distal surgical margin (proximal urethra) to be shown that urethral recurrence can be diagnosed a t an early the most accurate and reliable method to determine if a curable stage. Currently, a thorough pelvic examination with women is an appropriate candidate for orthotopic diversion. particular attention to the anterior vaginal wall and a voided Orthotopic reconstruction is a viable option in most male and urine cytology are performed at each followup visit for sur- female patients, and signifies another important step forward in the evolution of urinary diversion. veillance purposes of the retained urethra. Although we have a better understanding of the continence mechanism in women," the precise etiology in the female REFERENCES subject undergoing orthotopic diversion is still lacking. We suspect multiple factors contribute to the continence mecha1. Stein. J . P., Stenzl, A.. Esria, D., Freeman, J. A., Boyd, S. D Lieskovsky, G., Cote, R. J, Bennett, C., Colleselli, K., Draxl: nism in women undergoing orthotopic diversion, including a H., Janetschek, G., Poisel, S., Bartsch, G. and Skinner, D. G.: complex urethral support (musculofascial)system, as well as Lower urinary tract reconstruction following cystectomy in the rhabdosphincter mechanism. The urethral support mechwomen using the Kock ileal reservoir with bilateral uretanism is an elaborate musculofascial system which includes eroileal urethrostomy: initial clinical experience. J. Urol., 152: connective support bundles extending from the anterior vag1404, 1994. inal wall that surround and support the proximal and mid 2. Elmajian, D. A,, Stein, J. P., Esrig, D., Freeman, J. A., Skinner, urethra in a sling-like fashion. In addition, the pubourethral E. C., Boyd, S. D., Lieskovsky, G. and Skinner, D. G.: The Kock ligaments also help maintain the proximal urethra and the ileal neobladder. Updated experience in 295 male patients. neobladder in an intra-abdominal position. We believe that J . Urol., 156: 920, 1996. this musculofascial support system, coupled with a low pres3. Hautmann, R. E., Miller, K., Steiner, U. and Wenderoth, U.: The ileal neobladder: 6 years of experience with more than 200 sure reservoir, help maintain continence in women undergopatients. J . Urol., 150: 40, 1993. ing orthotopic diversion. 4. Studer, U. E., Danuser, H., Merz, V. W., Springer, J. P. and The rhabdosphincter region, which extends from the proxZingg, E. J.: Experience in 100 patients with an ileal low imal to the membranous urethra along with its correspondpressure bladder substitute combined with an afferent tubular ing innervation (branches off of the pudendal nerve), is beisoperistaltic segment. J. Urol., 154: 49, 1995. lieved ta be critical in maintaining urinary continence in 5. Skinner, D. G., Boyd, S. D., Lieskovsky, G., Bennett, C. and these female subjects.6.14 Extensive fluorourodynamic studHopwood, B.: Lower urinary tract reconstlvction following ies in women undergoing orthotopic diversion have identified cystectomy: experience and results in 126 patients using the this region as the area that provides continence.14 Although Kock ileal reservoir with bilateral ureteroileal urethrostomy. J. Urol., 146: 756, 1991. some authors have suggested that a sympathetic nerve spar6 Colleselli, K., Strasser, H., Moriggl, B., Stenzl, A., Poisel, S. and ing cystectomy is important in maintaining continence in Bartsch, G.: Hemi-Kock to the female urethra: anatomical w0men,15-~~ we make no attempt to perform a nerve sparing approach to the continence mechanism of the female urethra. cystectomy and remove all autonomic sympathetic innervaJ . Urol.. part 2, 151: 500A. abstract 1089, 1994. tion from just above the aortic bifurcation down to the proxI . Stein, J . P:, Cote, R. J., Freeman, J . A., Esrig, D., Elmajian, imal urethra. In addition, we routinely sacrifice the sympaD. A,, Groshen, S., Skinner, E. C., Boyd, S. D., Lieskovsky, G. thetic neurovascular bundle coursing along the lateral aspect and Skinner, D. G.: Indcations for lower urinary tract reconof the uterus and vagina. Some controversy exists regarding struction in women following cystectomy for bladder cancer: a innervation of the female urethral smooth muscle whether it pathological review of female cystectomy specimens. J. Urol., 154. 1329, 1995. is primarily sympathetic or combined sympathetic and para8. Stenzl, A,, Draxl, H., Posch, B., Colleselli, K., Falk, M. and sympathetic. We are aware of the fact that it is practically Bartsch, G.: The risk of urethral tumors in female bladder impossible to denervate the urethra completely and some cancer: can the urethra be used for orthotopic reconstruction of fibers intimately accompany the blood supply, yet we and the lower urinary tract? J . Urol., 153: 950, 1995. others believe that this extensive dissection effectively re9. Skinner, D. G. and Lieskovsky, G.: Technique of radical cystecsults in the removal of most of the peripheral sympathetic tomy. In: Diagnosis and Management of Genitourinary Caninnervation of the smooth muscle of the proximal urethra. cer. Philadelphia: W. B. Saunders, Co., chapt. 42, pp. 607-621, while sparing the parasympathetic supply.1S This sympa1988. thetic smooth muscle denervation may result in a flaccid 10. Skinner, D. G., Boyd, S. D. and Lieskovsky, G.: Technique of continent lower urinary tract reconstruction with Kock pouch portion of the proximal urethra and the characteristic balurethrostomy following cystectomy. Videotape available from looning or dilatation of this portion of the urethra seen on Marketing Communications, 3M Medical-Surgical Division, fluorourodynamic evaluation.14 In addition, this peripheral St. Paul, Minnesota. denervation may render the proximal urethra to be less effective as far a s a continence mechanism in women undergo- 11. Boyd, S. D., Skinner, E., Lieskovsky, G. and Skinner, D. G.: Continent and orthotopic urinary diversion following radical ing orthotopic diversion. We believe that the continence in cystectomy. Should these reconstlvctive procedures now be these women is maintained primarily by the pudendal innerconsidered standard of care? Surg. Oncol. Clin. N. Amer., 4 vation of the distal two-thirds of the urethra, the rhab277, 1995. dosphincter region, as well as the parasympathetic innerva- 12. McGuire, E. J., Fitzpatrick, C. C., Wan, J., Bloom, D., tion that is spared. Sanvordenker, J., Ritchey, M. and Gormley, E. A,: Clinical
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CONCLUSIONS
We present encouraging clinical and functional data with intermediate followup in women undergoing orthotopic lower urinary tract reconstruction following cystectomy for a pelvic malignancy. Orthotopic diversion in women may be performed with few postoperative complications, excellent con~tinence results, a normal voiding pattern and high patient
assessment of urethral sphincter function. J. Urol., 1 5 0 1452, 1993. 13. Freeman, J . A., Tarter, T. T., Esrig, D., Stein, J. P., Elmajian, D. A., Chen, S-C., Groshen, S., Lieskovsky, G. and Skinner, D. G.: Urethral recurrence in patients with orthotopic ileal neobladders. J . Urol., 156 1615, 1996. 14. Grossfeld, G. D., Stein, J. P., Bennett, C . J., Ginsberg, D. A., Boyd, S. D., Lieskovsky, G. and Skinner, D. G.: Lower urinary tract reconstruction in the female using the Kock ileal reservoir with bilateral ureteroileal urethrostomy: update of conti-
ORTHOTOPIC DIVERSION IN WOMEN nence results and flurourodynamic findings. Urology, 48: 383, 1996. 15. Stenzl, A,, Colleselli, K., Poisel, S., Feichtinger, H., Pontasch, H. and Bartsch, G.: Rationale and technique of nerve sparing radical cystectomy before a n orthotopic neobladder procedure in women. J. Urol., 154: 2044, 1995. 16. Cancnni, A,, de Carli, P., Fattahi, H., Pompeo, V., Cantiani, R.
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and von Heland, M.: Orthotopic ileal neobladder in female patients after radical cystectomy: 2-year experience. J. Urol., part 2, 153: 956, 1995. 17. Hautmann, R. E., Paiss, T. and de Petriconi, R.: The ileal neobladder in women: 9 years of experience with 18 patients. J. Urol., 155: 76, 1996. 18. Tanagho, E. A,: Personal communication, 1997.
Vol. 158,400-405,August 1997 Printed i n U.S.A.
ORTHOTOPIC LOWER URINARY TRACT RECONSTRUCTION IN WOMEN USING THE KOCK ILEAL NEOBLADDER: UPDATED EXPERIENCE IN 34 PATIENTS JOHN P. STEIN, GARY D. GROSSFELD, JOHN A. FREEMAN, DAVID ESRIG, DAVID A. GINSBERG, RICHARD J . COTE, EILA C. SKINNER, STUART D. BOYD, GARY LIESKOVSKY AND DONALD G. SKINNER From the Departments of Urology and Pathology. University of Southern California, Los Angeles, California
ABSTRACT
Purpose: Orthotopic lower urinary tract reconstruction has revolutionized urinary diversion following cystectomy. Initially performed solely in male patients, orthotopic diversion has now become a viable option in women. Currently, the orthotopic neobladder is the diversion of choice for women requiring lower urinary tract reconstruction a t o u r institution. We evaluate and update our clinical and functional experience with orthotopic reconstruction in female patients. Materials and Methods: Since June 1990, 34 women 31 to 86 years old (median age 67) have undergone orthotopic lower urinary tract reconstruction following cystectomy. Indications for cystectomy included transitional cell carcinoma in 29 patients, urachal adenocarcinoma in 1, mesenchymal tumor of endometrial origin in 1, cervical carcinoma in 1 and a fibrotic radiated bladder in 1. In addition, 1 woman underwent undiversion to the native urethra following a previous simple cystectomy and cutaneous diversion for eosinophilic cystitis. Data were analyzed according to postoperative early and late complications, survival, tumor recurrence, pathological evaluation of the cystectomy specimen, continence status, voiding pattern and patient satisfaction. The median followup in this group of patients was 30 months (range 17 to 70). Results: There were no perioperative deaths, and 4 early (11%) and 3 (9%) late complications. Four patients died, none with a urethral recurrence, including 3 of metastatic bladder cancer and 1 of unrelated causes. In another patient with a n extensive mesenchymal tumor of the uterus a sigmoid tumor recurred requiring conversion of the orthotopic reservoir to a cutaneous diversion. All of the remaining 29 patients are alive without evidence of disease. Intraoperative frozen section of the distal surgical margin (proximal urethra) accurately evaluated (confirmed by permanent section) the proximal urethra prospectively for tumor in all 29 specimens removed for transitional cell carcinoma, including 28 specimens (97%) without evidence of tumor and 1 specimen with carcinoma in situ. Complete daytime and nighttime continence was reported by 29 (88%)and 27 (82%) of 33 evaluable patients, respectively. A total of 28 patients (85%) void to completion, while 5 (15%) require some form of intermittent catheterization to empty the neobladder. Patient satisfaction is overwhelming. Conclusions: The excellent clinical and functional results demonstrated with further followup confirm our initial experience with orthotopic diversion in women. Careful selection of appropriate female candidates for orthotopic diversion is critical, and includes preoperative evaluation of the bladder neck and intraoperative frozen section analysis of the distal cystectomy margin. Furthermore, close monitoring of the retained urethra is mandatory in all women undergoing orthotopic diversion. We believe that the orthotopic neobladder is the urinary diversion of choice in women following cystectomy. KEY WORDS:bladder neoplasms, urinary diversion, women
As we enter the mid 199Os, urinary diversion has reached a new era. The ultimate goal of lower urinary tract reconstruction has become, not only a means to divert urine and Protect the upper urinary tract, but also to provide Patients with a continent means to store urine and allow for volitional voiding through the intact native urethra. These advances in urinary diversion have been made in an effort to provide patients a more normal life-style with a positive self-image Accepted for publication February 28, 1997.
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following removal of the bladder. We and others have been dedicated to the continued improvement and progress of lower urinary tract reconstruction, and currently believe that the orthotopic neobladder represents the most ideal form of urinary diversion.1-4 ~ ~ in 1986@ofihotopic ~ lower ~urinary tract i ~ reconstruction became the procedure of choice in select male patients undergoing cystectomy at our institution,z, 6 The excellent clinical and functional results achieved in these patients stimulated an effort to provide female subjects a similar form of diversion. Our initial clinical experience with orthotopic cu ~ ~ ~ ~~ ~ ~~ f ~ $ diversion in women1 was based on a better understanding of the continence mechanism in women,fi coupled with sound
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pathological criteria that allow the clinician to select safely appropriate female candidates for this form of urinary diversion.i,x The clinical and functional results of our initial experience were excellent. We update our experience with the orthotopic neobladder in 34 women, which to our knowledge is the largest reported series in the literature. MATERIAL AND M E T H O D S
Patients. From June 1990 through March 1996,34 women 31 to 86 years old (median age 66) underwent orthotopic lower urinary tract reconstruction at the University of Southern California, including a Kock ileal neobladder in 33 (97%) and an ileocolonic neobladder in 1. En bloc anterior exenteration with bilateral pelvic lymphadenectomy was performed in 29 women (85%)for primary transitional cell carcinoma, in 1 for urachal mucinous adenocarcinoma and in 1 for squamous cell carcinoma of the bladder. One patient underwent total pelvic exenteration for squamous cell carcinoma of the cervix. In addition, 1 patient underwent simple cystectomy for a fibrotic radiated bladder, and 1 underwent undiversion to the native urethra following a previous cystectomy and cutaneous urinary diversion for eosinophilic cystitis 5 years previously. Patient selection. Three forms of urinary diversion were discussed with the patient in detail preoperatively, including an incontinent cutaneous form of diversion (ileal conduit), a continent cutaneous form of diversion (Kock ileal reservoir) and a n orthotopic form of diversion (ileal neobladder). All potential female candidates choosing orthotopic reconstruction underwent preoperative cystourethroscopy with evaluation of the bladder neck and urethra. All patients were marked preoperatively for a n appropriate stoma site and instructed on how to catheterize if necessary by the enterostomal therapy nurse. Furthermore, if tumor was demonstrated histologically on intraoperative frozen section of the distal cystectomy margin (proximal urethra), then orthotopic reconstruction would be abandoned and a n alternative cutaneous form of diversion performed according to patient preference as discussed preoperatively. Cystectomy. The technique of en bloc radical cystectomy with bilateral pelvic iliac lymphadenectomy in the female subject remains standard.1.9 However, several aspects of the anterior exenteration in women deserve specific mention. At the terminal stages of the cystectomy careful preparation of the urethra is critical to avoid injury to the continence mechanism. Minimal dissection should be performed in the region anterior to the urethra (fig. 1)to prevent injury to the rhabdosphincter region which extends from the proximal urethra to the membranous urethra. In addition, the pubourethral suspensory ligaments should be left intact. These ligaments provide support and help maintain a n intrapelvic neobladder position which may also contribute to the continence mechanism in women. Furthermore, no attempt is made to perform a sympathetic nerve sparing cystectomy in these women. In fact, we routinely sacrifice the autonomic sympathetic nerves extending from just above the aortic bifurcation, caudally off of the abdominal aorta, common iliacs and sacral promontory. In addition, the autonomic neurovascular bundles coursing along the lateral aspect of the uterus and vagina are removed down to the level of the bladder neck. This extensive dissection effectively denervates the bladder neck and proximal urethra, rendering them ineffective as far as a continence mechanism. We believe the rhabodospincter region and the corresponding innervation from branches off of the pudendal nerve provide continence in these The posterior dissection of the cystectomy is also critical to the successful outome of orthotopic diversion in women. After all tissue is swept off of the lateral aspect of the vagina, while developing the posterior pedicles, the posterior vagina is incised at the apex just distal to the cervix. This incision is
FIG. 1. View of female pelvis from overhead followin completion of anterior exenteration. Note that no dissection is pe3ormed anterior to urethra along pelvic floor, which helps prevent injury to rhabdosphincter region and corresponding innervation. which are critical to continence mechanism in women undergoing orthotopic diversion.
carried anteriorly along the lateral and anterior vaginal wall forming a circumferential incision. The anterorlateral vaginal wall is then grasped with a curved Kocher clamp, which provides counter traction, and facilitates dissection between the anterior vaginal wall and the bladder specimen. Development of this posterior plane and vascular pedicle is best performed sharply and carried just distal to the vesicourethral junction. Palpation of the Foley catheter balloon assists in identifying this region. This dissection effectively maintains a functional vagina. Furthermore, an intact anterior vaginal wall may lend additional support to the proximal urethra through a complex musculofascial support system that extends from the anterior vagina. The vaginal cuff is then closed at the apex and later suspended to Cooper’s ligament to prevent vaginal prolapse or the development of a n enterocele postoperatively. Alternatively, in the case of a deeply invasive posterior bladder tumor with concern of a n adequate surgical margin the anterior vaginal wall should be removed en bloc with the cystectomy specimen. ARer dividing the posterior vaginal apex, the lateral vaginal wall subsequently serves as the posterior pedicle and is divided distally, which leaves the anterior vaginal wall attached to the posterior bladder specimen. Again, the Foley catheter balloon facilitates identification of the vesicourethral junction. The surgical plane between the vesicourethral junction and the anterior vaginal wall is then developed distally at this location. A 1 cm. length of proximal urethra is mobilized while the remaining distal urethra is left intact with the anterior vaginal wall. The presence of extravesical disease away from the anterior vaginal wall, bladder neck or proximal urethra, as well as the presence of pelvic nodal metastases, did not preclude orthotopic lower urinary tract reconstruction. In addition, the specific histopathological type of pelvic tumor did not preclude orthotopic diversion as long as the aforementioned criteria for orthotopic reconstruction in women were maintained. Lower urinary tract reconstruction (Kock ileal reseruoir).
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The technique of constructing the Kock ileal reservoir with bilateral ureteroileal urethrostomy has been described previously and remains standard.'", 11 Depending on patient desire for sexual function postoperatively, vaginal reconstruction may be required.' Regardless, to prevent fistula formation a well vascularized omental pedicle graft should be secured to the levator ani muscles separating the reconstructed neobladder and vagina (fig. 2). Following completion of the mucosa-to-mucosa urethroenteric anastomosis, the neobladder is secured with a 3-Zero polyglycolic acid suture to the inferior aspect of the pubic symphysis. This maneuver maintains a tension-free urethroenteric anastomosis and ensures an intra-abdominal reservoir location. Followup. All patients are seen a t 4-month intervals postoperatively for the first year, 6-month intervals for the second year and annually thereafter. Followup consists of routine chemistry studies, including serum determination of blood urea nitrogen and creatinine. Radiographic evaluation of the neobladder (gravity cystogram) and upper urinary tract evaluation (either excretory urography or ultrasound) are performed a t 4 and 12 months postoperatively, and then annually thereafter. A thorough pelvic examination with particular attention to the anterior vaginal wall and urethroenteric anastomosis is performed a t each followup visit. In addition, a voided urine cytology specimen is obtained for surveillance purposes of the retained urethra. Panendoscopy of the urethra may be indicated when abnormal cells are reported on cytology, the pelvic examination is suspicious, or the patient reports any burning, bloody discharge or unusual sensation in the region of the urethra. To date, panendoscopy has not been required. Continence and voiding pattern. Continence status and voiding pattern were determined by questionnaires and personal interviews a t routine followup visits. Diurnal continence was evaluated according to the continence grading system of McGuire et a1,1* and defined as completely continent, incontinent with major effort and when upright, incontinent with minor effort only and incontinent without regard to effort, position or activity. Nighttime continence was de-
fined as either continent or incontinent requiring any form of protection. Voiding pattern was classified as able to void to completion without the need for catheterization or requiring any form of intermittent catheterization, either for residua] urine or unable to void requiring continuous intermittent catheterization. Data were analyzed according to early (within 30 days of surgery) and late complications, survival status, disease recurrence (urethral, pelvic or distant metastasis), pathological evaluation of the cystectomy specimen, continence status, voiding pattern and overall patient satisfaction. RESULTS
Early complications. Three patients (9%)suffered a total of 4 early complications (11%) which prolonged hospitalization or required reoperation. In 1patient a urine leak developed, requiring bilateral percutaneous nephrostomy tube placement, and a subsequent pulmonary embolus required full dose anticoagulation therapy. This women was discharged home 15 days postoperatively without further sequelae. Another patient, who received preoperative external beam radiation therapy (5,000 rad.) and underwent total pelvic exenteration for stage IIIB cervical cancer, suffered a prolonged postoperative ileus that was treated conservatively and she was discharged home on postoperative day 15. The third patient required an operation under local anesthesia to remove a retained portion of a Jackson-Pratt drain that broke while being removed. Hospital course was not prolonged and she was discharged home on hospital day 8. The average length of hospital stay for the remaining 31 patients was 8.5 days. Late complications. Late complications requiring rehospitalization or reoperation occurred in 3 patients (9%). In 2 patients a small bowel obstruction developed, requiring surgical exploration in 1and conservative treatment in 1. In the third woman a Kock pouch calculus developed, requiring outpatient endoscopic removal under local anesthesia. Survival and recurrence. There were no perioperative deaths. As of April 1996, 29 of the 34 patients (85%) were alive without evidence of disease and with an average followup of 30 months (range 17 to 70). Four patients died, including 3 of metastatic transitional cell carcinoma and 1of unrelated causes, and all without evidence of a pelvic or urethral recurrence. In addition, in 1 patient with an extensive mesenchymal tumor of the uterus a sigmoid tumor recurred 20 months postoperatively. This patient underwent exploratory celiotomy, en bloc resection of the tumor and sigmoid colon, and conversion of the orthotopic neobladder to a continent cutaneous Kock ileal reservoir. Pathological evaluation of cystectomy specimens. Detailed pathological examination was performed on all 29 cystectomy specimens removed for primary transitional cell carcinoma of the bladder. Of these 29 specimens 20 (69%) demonstrated grade 3 and 9 grade 4 histological tumors. Pathological staging of the primary tumor demonstrated 16 (5592'0organ confined ( P l , Pis, P2, P3a) lymph node negative tumors, 6 (21%) extravesical (P3b, P4) lymph node negative tumors and 6 (21%) lymph node positive tumors. One patient with lymph node positive disease had concomitant metastatic liver disease discovered a t the time of surgery. Carcinoma in situ with or without evidence of gross tumor was noted in 18 bladder specimens (62%),including 14 with multifocal and 4 with focal disease. Bladder neck (vesicourethral junction) involvement of tuFIG.2. Samttal section of female wlvis. Note that well vascular- mor was identified in 6 specimens (21%), and all demonized omentalpedicle graft is placed*between reconstructed vagina strated carcinoma in situ. Of these 6 cases 1 specimen (3%) and neobladder. Pedicle graft is secured to levator ani muscles to demonstrated concomitant carcinoma in situ of the proximal separate suture lines and helps prevent fistulization. Also note that vagina is closed at apex, Va will be suspended to Cooper+sliga- urethra. The remaining 5 patients with carcinoma in situ ment to prevent vaginal progpse or development ofenterocele post- involving the bladder neck were without evidence of tumor in operatively. the proximal urethra. No patient with an uninvolved bladder
ORTHOTOPIC DIVERSION IN WOMEN
neck demonstrated any evidence of urethral tumor involvement. In addition, intraoperative frozen section analysis of the distal surgical margin (proximal urethra) accurately predicted the final histological diagnosis of the proximal urethra in all 29 specimens, including 28 without evidence of tumor and 1with carcinoma in situ involving the proximal urethra. Continence. Continence status was evaluable in 33 of 34 patients. The patient with a sigmoid recurrence and who required conversion to a continent cutaneous diversion was excluded from analysis. Complete daytime continence was reported by 28 of 33 patients (85%).An 86-year-old woman required 2 courses of periurethral collagen injection 8 months postoperatively for incontinence (major effort only) and is currently completely continent. Daytime incontinence with major effort only was reported by the remaining 4 patients. Complete nighttime continence was reported by 27 of 33 patients (82%).Nighttime incontinence requiring some form of protection was reported by 6 patients, with no patient requiring more than 3 pads per night. Voidingpattern. Information regarding the voiding pattern was obtained in the aforementioned 33 patients. The ability to void to completion by Valsalva’s maneuver and relaxation of the pelvic floor muscles was reported by 28 patients (85%). Five patients require some form of intermittent selfcatheterization to empty the neobladder, of whom 2 catheterize twice daily for residual urine only and 3, who are unable to void, require continuous intermittent catheterization every 4 to 6 hours to empty the neobladder. One of these cases represents our early experience in which a Burch suspension procedure was performed simultaneous with lower urinary tract reconstruction, which we now realize only contributes to urinary retention. Satisfaction. All patients have been satisfied with the continence, voiding pattern, self-image and overall results of the procedure. In fact, the patient with a sigmoid recurrence who underwent conversion of the orthotopic neobladder to a cutaneous reservoir reported that, although she is currently continent, she much preferred the orthotopic form of diversion compared to the cutaneous form of diversion.
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ion performed anterior to the urethra. An elderly woman with incontinence 8 months postoperatively underwent 2 :ourses of periurethral collagen injection and is currently :ontinent. Furthermore, although adjuvant therapy for in:ontinence has been offered (periurethral collagen injection, )ladder neck suspension or sling procedure), all 4 women who report daytime incontinence with major effort only are jatisfied with the results and are not inconvenienced or im>aired by the urinary leakage to desire additional treatment 3t this time. Two important criteria must be fulfilled when considering any patient for orthotopic urinary diversion: 1) under no lcircumstances must the cancer operation be compromised by the reconstruction at the urethroenteric anastomosis, retained urethra or surgical margins and 2) the rhabdosphincter mechanism must remain intact to provide a continent means of storing urine. If these criteria can be safely maintained, the patient may then be considered an appropriate candidate for orthotopic urinary diversion. Recently, pathological criteria have been established which identify appropriate female candidates for orthotopic diversion.7.8 From an extensive analysis of female cystectomy specimens removed for transitional cell carcinoma of the bladder, we demonstrated that tumor involving the bladder neck is a n important risk factor for urethral tumor involvement.7 All cystectomy specimens with carcinoma involving the urethra had concomitant tumor involving the bladder neck. However, not all specimens with tumor involving the bladder neck demonstrated urethral tumor involvement. This is an important issue because, although bladder neck involvement with tumor is a risk factor for urethral tumor involvement, approximately 50% of patients with tumor involving the bladder neck will have a urethra free of tumor. In this situation the patient may be considered a n appropriate candidate for orthotopic diversion. Therefore, although bladder neck involvement with tumor is a risk factor for concomitant urethral tumor involvement, pathological evaluation of the proximal urethra is the most critical determinant for orthotopic diversion. These pathological guidelines were prospectively evaluated in 29 consecutive women undergoing orthotopic reconDISCUSSION struction for transitional cell carcinoma of the bladder in this The progressive development of urinary diversion has been series. All 23 cystectomy specimens without tumor involvethe result of persistent dedication by innovative and pioneer- ment of the bladder neck were also free of tumor at the ing surgeons to improve the treatment and quality of life of urethra. A total of 6 specimens demonstrated tumor involvepatients following cystectomy. This evolution has developed ment at the bladder neck, and only 1 of these 6 specimens along the 3 distinct paths of an incontinent cutaneous form of demonstrated urethral tumor involvement. These results diversion (ileal conduit), a continent cutaneous form of diver- support our previously established pathological criteria sion (Indiana and Kock pouches) and, most recently, a form of which identify the bladder neck as a risk factor for urethral diversion to the intact native urethra (orthotopic neoblad- tumor involvement. We have found the intraoperative frozen section of the der). We firmly believe the orthotopic neobladder currently represents the most ideal form of urinary diversion available distal surgical margin (proximal urethra) to be a n accurate and reliable method to evaluate the proximal urethra for in carefully selected male and female patients. The orthotopic neobladder most closely resembles the orig- urethral tumor involvement. Intraoperative frozen section inal bladder in location and function. Orthotopic diversion analysis accurately evaluated the proximal urethra in all 29 eliminates the need for a cutaneous stoma and the often specimens removed for transitional cell carcinoma, including plagued cutaneous continence mechanism, relying on the 28 cases without tumor involvement and 1 with carcinoma in intact rhabdosphincter mechanism for continence. Patients situ involving the urethra. In all 29 cases the frozen section retain a more natural micturition pattern and consciously result was correctly confirmed on permanent section of the void per urethra. In addition, we believe that the orthotopic cystectomy specimen. Currently, intraoperative frozen secneobladder provides a more normal life-style with an im- tion of the proximal urethra is the most decisive method to determine if a female patient may be an appropriate candiproved self-image compared to other forms of diversion. The excellent functional results in 34 women undergoing date for orthotopic diversion. Furthermore, because of the orthotopic neobladder diversion confirm our initial experi- risk of injuring the continence mechanism with preoperative ence with further followup. The majority of women are com- biopsy of the bladder neck and urethra, coupled with a conpletely continent (88%daytime) and void normally per ure- firmed method to evaluate reliably the proximal urethra thra without the need for catheterization. In many women (intraoperatively), we now rely solely on intraoperative complete continence is restored immediately following re- frozen section analysis of the proximal urethra for proper moval of the urethral catheter 3 weeks postoperatively and selection of women considering orthotopic lower urinary tract by 6 months most women obtain the maximum degree of reconstruction. To date, no patient has had a urethral recurrence with a continence. We attribute these results to the limited dissec-
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ORTHOTOPIC DIVERSION IN WOMEN
median followup of 30 months. These results are encourag- acceptance. Although long-term followup will be required to ing, since in our experience with male patients most urethral define the true risk of urethral recurrence in these women, tumors recur within the first 19 months following cystectomy we believe that female subjects considering orthotopic diverfor transitional cell carcinoma.'" Regardless, careful followup sion may be safely and appropriately selected using strict is mandatory to define the long-term risk of urethral recur- pathological criteria. We have found intraoperative frozen rence in this group of female patients. In addition, it must be section of the distal surgical margin (proximal urethra) to be shown that urethral recurrence can be diagnosed a t an early the most accurate and reliable method to determine if a curable stage. Currently, a thorough pelvic examination with women is an appropriate candidate for orthotopic diversion. particular attention to the anterior vaginal wall and a voided Orthotopic reconstruction is a viable option in most male and urine cytology are performed at each followup visit for sur- female patients, and signifies another important step forward in the evolution of urinary diversion. veillance purposes of the retained urethra. Although we have a better understanding of the continence mechanism in women," the precise etiology in the female REFERENCES subject undergoing orthotopic diversion is still lacking. We suspect multiple factors contribute to the continence mecha1. Stein. J . P., Stenzl, A.. Esria, D., Freeman, J. A., Boyd, S. D Lieskovsky, G., Cote, R. J, Bennett, C., Colleselli, K., Draxl: nism in women undergoing orthotopic diversion, including a H., Janetschek, G., Poisel, S., Bartsch, G. and Skinner, D. G.: complex urethral support (musculofascial)system, as well as Lower urinary tract reconstruction following cystectomy in the rhabdosphincter mechanism. The urethral support mechwomen using the Kock ileal reservoir with bilateral uretanism is an elaborate musculofascial system which includes eroileal urethrostomy: initial clinical experience. J. Urol., 152: connective support bundles extending from the anterior vag1404, 1994. inal wall that surround and support the proximal and mid 2. Elmajian, D. A,, Stein, J. P., Esrig, D., Freeman, J. A., Skinner, urethra in a sling-like fashion. In addition, the pubourethral E. C., Boyd, S. D., Lieskovsky, G. and Skinner, D. G.: The Kock ligaments also help maintain the proximal urethra and the ileal neobladder. Updated experience in 295 male patients. neobladder in an intra-abdominal position. We believe that J . Urol., 156: 920, 1996. this musculofascial support system, coupled with a low pres3. Hautmann, R. E., Miller, K., Steiner, U. and Wenderoth, U.: The ileal neobladder: 6 years of experience with more than 200 sure reservoir, help maintain continence in women undergopatients. J . Urol., 150: 40, 1993. ing orthotopic diversion. 4. Studer, U. E., Danuser, H., Merz, V. W., Springer, J. P. and The rhabdosphincter region, which extends from the proxZingg, E. J.: Experience in 100 patients with an ileal low imal to the membranous urethra along with its correspondpressure bladder substitute combined with an afferent tubular ing innervation (branches off of the pudendal nerve), is beisoperistaltic segment. J. Urol., 154: 49, 1995. lieved ta be critical in maintaining urinary continence in 5. Skinner, D. G., Boyd, S. D., Lieskovsky, G., Bennett, C. and these female subjects.6.14 Extensive fluorourodynamic studHopwood, B.: Lower urinary tract reconstlvction following ies in women undergoing orthotopic diversion have identified cystectomy: experience and results in 126 patients using the this region as the area that provides continence.14 Although Kock ileal reservoir with bilateral ureteroileal urethrostomy. J. Urol., 146: 756, 1991. some authors have suggested that a sympathetic nerve spar6 Colleselli, K., Strasser, H., Moriggl, B., Stenzl, A., Poisel, S. and ing cystectomy is important in maintaining continence in Bartsch, G.: Hemi-Kock to the female urethra: anatomical w0men,15-~~ we make no attempt to perform a nerve sparing approach to the continence mechanism of the female urethra. cystectomy and remove all autonomic sympathetic innervaJ . Urol.. part 2, 151: 500A. abstract 1089, 1994. tion from just above the aortic bifurcation down to the proxI . Stein, J . P:, Cote, R. J., Freeman, J . A., Esrig, D., Elmajian, imal urethra. In addition, we routinely sacrifice the sympaD. A,, Groshen, S., Skinner, E. C., Boyd, S. D., Lieskovsky, G. thetic neurovascular bundle coursing along the lateral aspect and Skinner, D. G.: Indcations for lower urinary tract reconof the uterus and vagina. Some controversy exists regarding struction in women following cystectomy for bladder cancer: a innervation of the female urethral smooth muscle whether it pathological review of female cystectomy specimens. J. Urol., 154. 1329, 1995. is primarily sympathetic or combined sympathetic and para8. Stenzl, A,, Draxl, H., Posch, B., Colleselli, K., Falk, M. and sympathetic. We are aware of the fact that it is practically Bartsch, G.: The risk of urethral tumors in female bladder impossible to denervate the urethra completely and some cancer: can the urethra be used for orthotopic reconstruction of fibers intimately accompany the blood supply, yet we and the lower urinary tract? J . Urol., 153: 950, 1995. others believe that this extensive dissection effectively re9. Skinner, D. G. and Lieskovsky, G.: Technique of radical cystecsults in the removal of most of the peripheral sympathetic tomy. In: Diagnosis and Management of Genitourinary Caninnervation of the smooth muscle of the proximal urethra. cer. Philadelphia: W. B. Saunders, Co., chapt. 42, pp. 607-621, while sparing the parasympathetic supply.1S This sympa1988. thetic smooth muscle denervation may result in a flaccid 10. Skinner, D. G., Boyd, S. D. and Lieskovsky, G.: Technique of continent lower urinary tract reconstruction with Kock pouch portion of the proximal urethra and the characteristic balurethrostomy following cystectomy. Videotape available from looning or dilatation of this portion of the urethra seen on Marketing Communications, 3M Medical-Surgical Division, fluorourodynamic evaluation.14 In addition, this peripheral St. Paul, Minnesota. denervation may render the proximal urethra to be less effective as far a s a continence mechanism in women undergo- 11. Boyd, S. D., Skinner, E., Lieskovsky, G. and Skinner, D. G.: Continent and orthotopic urinary diversion following radical ing orthotopic diversion. We believe that the continence in cystectomy. Should these reconstlvctive procedures now be these women is maintained primarily by the pudendal innerconsidered standard of care? Surg. Oncol. Clin. N. Amer., 4 vation of the distal two-thirds of the urethra, the rhab277, 1995. dosphincter region, as well as the parasympathetic innerva- 12. McGuire, E. J., Fitzpatrick, C. C., Wan, J., Bloom, D., tion that is spared. Sanvordenker, J., Ritchey, M. and Gormley, E. A,: Clinical
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CONCLUSIONS
We present encouraging clinical and functional data with intermediate followup in women undergoing orthotopic lower urinary tract reconstruction following cystectomy for a pelvic malignancy. Orthotopic diversion in women may be performed with few postoperative complications, excellent con~tinence results, a normal voiding pattern and high patient
assessment of urethral sphincter function. J. Urol., 1 5 0 1452, 1993. 13. Freeman, J . A., Tarter, T. T., Esrig, D., Stein, J. P., Elmajian, D. A., Chen, S-C., Groshen, S., Lieskovsky, G. and Skinner, D. G.: Urethral recurrence in patients with orthotopic ileal neobladders. J . Urol., 156 1615, 1996. 14. Grossfeld, G. D., Stein, J. P., Bennett, C . J., Ginsberg, D. A., Boyd, S. D., Lieskovsky, G. and Skinner, D. G.: Lower urinary tract reconstruction in the female using the Kock ileal reservoir with bilateral ureteroileal urethrostomy: update of conti-
ORTHOTOPIC DIVERSION IN WOMEN nence results and flurourodynamic findings. Urology, 48: 383, 1996. 15. Stenzl, A,, Colleselli, K., Poisel, S., Feichtinger, H., Pontasch, H. and Bartsch, G.: Rationale and technique of nerve sparing radical cystectomy before a n orthotopic neobladder procedure in women. J. Urol., 154: 2044, 1995. 16. Cancnni, A,, de Carli, P., Fattahi, H., Pompeo, V., Cantiani, R.
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and von Heland, M.: Orthotopic ileal neobladder in female patients after radical cystectomy: 2-year experience. J. Urol., part 2, 153: 956, 1995. 17. Hautmann, R. E., Paiss, T. and de Petriconi, R.: The ileal neobladder in women: 9 years of experience with 18 patients. J. Urol., 155: 76, 1996. 18. Tanagho, E. A,: Personal communication, 1997.